Georg Mossböck

Impact of dose rate on clinical course in uveal melanoma after brachytherapy with ruthenium-106.

Background and Purpose:It has been suggested that the actual dose rate of an irradiating source may be a distinct influencing factor for the biological effect after brachytherapy with ruthenium-106 for uveal melanoma. The purpose of this study was to investigate a hypothesized impact of the dose rate on the clinical and echographic course after brachytherapy.Patients and Methods:In total, 45 patients were included in this retrospective study. According to the actual dose rate, two groups were defined: group 1 with a dose rate < 4 Gy/h and group 2 with a dose rate ≥ 4 Gy/h. Regarding age, tumor height, basal diameter, scleral and apical dose, differences between the groups were not significant. Clinical parameters, including early and late side effects, and echographic courses were compared.Results:A significantly lower metastatic rate was found in group 2. Using univariate Cox proportional hazards regression, only dose rate predicted metastatic spread significantly (p < 0.05), while in a multivariate analysis, using age at the time of treatment, greatest tumor height and greatest basal diameter as covariates, the variable dose rate was of borderline significance (p = 0.077). Patients in group 2 had more early side effects and more pronounced visual decline, but these differences were of borderline significance with p-values of 0.072 and 0.064, respectively.Conclusion:These data suggest that a higher dose rate may confer a lower risk for metastatic spread, but may be associated with more side effects and more pronounced visual decline.Hintergrund und Ziel:Es wurde vermutet, dass die Dosisrate einer Strahlenquelle einen maßgeblichen Faktor für den biologischen Effekt nach Brachytherapie mit Ruthenium-106 beim uvealen Melanom darstellt. Ziel dieser Studie war die Untersuchung des Einflusses der Dosisrate auf den klinischen und echographischen Verlauf nach Brachytherapie.Patienten und Methodik:Insgesamt wurden 45 Patienten in diese retrospektive Studie eingeschlossen. Entsprechend der Dosisrate zum Zeitpunkt der Brachytherapie wurden zwei Gruppen definiert: Gruppe 1 mit einer Dosisrate < 4 Gy/h und Gruppe 2 mit einer Dosisrate ≥ 4 Gy/h. Bezüglich des Alters, der Tumorhöhe, des basalen Durchmessers sowie der Sklerakontakt- und apikalen Dosis bestand kein signifikanter Unterschied zwischen den beiden Gruppen. Klinische Parameter inklusive früher und später Nebenwirkungen sowie der echographische Verlauf wurden verglichen.Ergebnisse:Es fand sich eine signifikant niedrigere Metastasierungsrate in Gruppe 2. Mit der univariaten Cox-Regression zeigte sich nur für die Dosisrate ein signifikanter Zusammenhang (p < 0,05), während der Zusammenhang in der multivariaten Analyse mit Alter, größter Tumorhöhe und größtem Tumordurchmesser als Kovariablen grenzwertig war (p = 0,077). Patienten der Gruppe 2 hatten eine höhere Rate an frühen Nebenwirkungen und einen größeren Visusverlust, wobei die Unterschiede grenzwertig signifikant waren (p = 0,072 bzw. p = 0,064).Schlussfolgerung:Diese Daten lassen vermuten, dass eine höhere Dosisrate ein niedrigeres Metastasierungsrisiko aufweist, aber mit einer höheren Rate an Nebenwirkungen und größerem Visusverlust assoziiert ist.

Myopia and glaucoma

SummaryThe question is whether there is an increased risk to develop glaucoma in co-existing myopia. The different kinds of glaucoma dealing with this problem are described. The highly myopic eye with increased axial length shows many structural changes. Especially the changes of the optic nerve head in a highly myopic eye make it very difficult to differentiate between a beginning glaucoma and a normal structure or to define a progression of glaucomatous changes. The visual field defects are often close to fixation and may reduce visual acuity and therefore the quality of life of these usually younger patients. An increase of the thickness of the lens induced by senile cataract, drugs or diabetes mellitus, a forward shift of the lens or the iris-lens-diaphragm will lead to refractive myopia and may provoke an angle closure glaucoma. Pigmentary glaucoma occurs in younger patients in connection with low or medium myopia and more rapidly destroys the optic nerve head due to higher intraocular pressure values in comparison to the primary open-angle glaucoma. After refractive surgeries of myopic eyes one has to expect different kinds of glaucoma (steroid induced, pupillary block, angle closure). Due to the increased risk to develop glaucoma patients especially with high myopia are advised to consult their ophthalmologist on a regular basis.ZusammenfassungEs stellt sich die Frage, ob ein erhöhtes Risiko besteht an einem Glaukom zu erkranken, wenn gleichzeitig eine Kurzsichtigkeit vorliegt. Es werden die damit in Zusammenhang stehenden unterschiedlichen Glaukomformen beschrieben. Das hochmyope Auge bei Achsenmyopie ist strukturell in Sinne eines Myopiesyndroms pathologisch verändert. Die myopen Veränderungen des Sehnervenkopfes machen eine Beurteilung betreffend einen Glaukomschaden oder dessen Progression besonders schwierig. Aufgrund der Zentrumsnähe sind die Gesichtsfeldausfälle sehschärfenbedrohend und reduzieren somit die Lebensqualität dieser meist jüngeren PatientInnen. Eine Dickenzunahme der Linse (grauer Star, Medikamente, Diabetes mellitus) sowie eine Verlagerung der Linse oder des Iris-Linsendiaphragmas nach vorne verursachen eine Brechungsmyopie und können zu einem Winkelblockglaukom führen. Das bei jüngeren PatientInnen mit geringer bis mittelgradiger Myopie verbundene Pigmentglaukom ist wegen der sehr hohen Augendruckwerte als Papillentöter gefürchtet. Nach operativen Eingriffen gegen die Myopie ist ebenso mit unterschiedlichen Glaukomformen (Steroidglaukom, Pupillarblock-Winkelblockglaukom) zu rechnen. Aufgrund eines bestehenden höheren Glaukomrisikos sollen PatientInnen besonders mit hoher Myopie regelmäßig einen Augenarzt konsultieren.

Das Grazer Modell der Facharztausbildung, Teil 2: Der erste Nachtdienst (mit Tabellen)

ZusammenfassungHintergrundZiel dieser Arbeit ist es entsprechend den Richtlinien des International Council of Ophthalmology (ICO)Fertigkeiten (wie z. B. die Brillenkorrektur eines Sehfehlers) als Minimalstandard für ein Curriculum im jeweiligen Land zu definieren.Material und MethodeAn Hand der Anforderungen eines Nachtdienstes in einer Augenambulanz werden die Erfordernisse in der Ausbildung eines gerade die Ausbildung beginnenden Assistenten (Assistentin) abgeleitet und in einzelne aufeinander aufbauende Schritte zerlegt.Als Grundvoraussetzungen für den ersten Journaldienst sind ein ausführliches Eingangsgespräch, die Untersuchung an einem standardisierten Patienten, begleitende Evaluierung für eine(n) Assistenten (in).Antheoretischen Kenntnissen sind die Klinik und Therapie der Notfälle, Entzündungen der äußeren Augenabschnitte und des hinteren Augensegmentes sowie der Verletzungen wichtig. Die Differentialdiagnose des roten Auges sowie die Ursachen eines akuten sowie langsamen Visusverlustes sollten gekonnt werden. Nebendiagnostischen Fertigkeiten wie die Untersuchung an der Spaltlampe, die Tonometrie und die Beurteilung des Fundus mit dem Kontaktglas und der Volk-Lupe sollten die Gesichtsfelduntersuchung mittels Fingerperimetrie sowie idealerweise die kinetische Perimetrie am Goldmann-Perimeter selbständig durchgeführt werden können. Die Diagnose eines Tränenröhrchenabrisses, die Differentialdiagnose von akuten Doppelbildern oder die Diagnose eines intraokularen Fremdkörpers sollte mit den adäquaten Untersuchungsmethoden (Abdecktest, Rot-Grün Test, Tränenwegsspülung bzw. a. p.-Röntgen, Comberg-Röntgen und CT) gestellt werden können. Die Entscheidung, in welchen Fällen der Oberarzt (Hauptdienst) beigezogen werden soll (z. B. bei einer Tränenwegsverletzung, bei Verdacht einer intraokularen Infektion oder einer perforierenden Augenverletzung), ist ein entscheidendes Lernziel für die Phase der ersten Journaldienste (die ersten Monate der Facharztausbildung).SchlussfolgerungDie Tabellen (wie z. B. die des ersten Dienstes) sollen eine Art Checkliste darstellen, damit die Basis andiagnostischen Methoden undtherapeutischen Fertigkeiten bereits in den ersten Monaten der Facharztausbildung erlernt werden und im Dienst weiter praktiziert werden können. (Die angeführten Tabellen sind beispielhaft und unvollständig und sollen im Rahmen der Ausbildung von jungen Assistenten weiter entwickelt werden.)SummaryBackgroundAim of this paper is to provide the resident with the basic knowledge and skills for his (her) first 6 months of residency according to the guidelines of the International Council of Ophthalmology.At the end of these first 6 months of training the resident should be able to triage and manage ocular emergencies, the most important corneal and conjunctival inflammations and should have basic knowledge in neuro-ophthalmology.MethodAt the very beginning the resident learns to perform the medical history and basic refraction of a simple refractive error. He (she) should be able to perform basic anterior segment investigations (slit lamp biomicroscopy, tonometry) and direct and indirect ophthalmoscopy. In order to differentiate between different types of optic neuropathies the resident learns to perform Goldman perimetry. He should know the reasons for a rapid or slow impairment of visual function, the most common causes of inflammation of the cornea, conjunctiva and iris.He (she) can perform minor external and adnexal surgical procedures (foreign body removal, closure of skin, conjunctival and lid lacertions), treat chemical burns, diagnose and treat an acute closure glaucoma, and recognise endophthalmitis, canalicular lacerations and orbital fractures with eye movement disorders.ConclusionThe tables of this paper should act as a checklist for more or less experienced residents or the tutor. Knowledge, diagnostic and therapeutic skills are learned and checked step by step.

The configuration of the vitreomacular interface determines the pattern of pseudophakic cystoid macular oedema

monly the source of information was an ophthalmologist (54%). There were significant genderrelated differences in the results: 89% of the women and 71% of the men had had their IOP measured sometime, women attended regular IOP measurements twice as often as men (60% versus 30% respectively), 22% of the men visited an ophthalmologist regularly and the same proportion were aware of therapy recommendation, whereas the corresponding percentages among women were 51% and 42%. The lesser likelihood of men to visit a physician may be a general trend, i.e. according to a report from the Finnish National Institute for Health and Welfare, 18% of men and 13% of women among the age group of 55–64 years had not visited a physician during the previous year (Helld an & Helakorpi 2015). The percentage of those who had had their IOP measured did not differ significantly between the two lower and the two higher level education sub-categories or between age groups. However, there were regional differences concerning IOP measurements: those from the Southwest Finland had had their IOP measured significantly more often than those from Northern Savo (86% versus 77% respectively), and those from a town with a university hospital more often than citizens of smaller outlying municipalities (86% versus 78% respectively). The availability of health services and information on glaucoma risks and care in local media might account for these kinds of differences. Even if an individual is suffering from glaucoma, the value of IOP is frequently in normal range and therefore tonometry as the only method is not sufficient for glaucoma screening. A campaign should be launched to encourage better awareness of the need and importance of regular eye inspections, especially among elderly men. All patients with glaucoma should be encouraged to inform their relatives of their increased risk for glaucoma and thus of the importance of having regular eye check-ups.

Role of rs1533428 and rs12994401 in patients with Primary Open Angle Glaucoma in an European population

Purpose: Genetic factors have been shown to play a remarkable role in the pathophysiology of glaucoma. Recently, two polymorphisms (rs1533428 and rs12994401) on chromosome 2p were found to be strongly associated with POAG in an Afro-Caribbean population in Barbados, West Indies. As data with regard to the role of these polymorphisms in a Caucasian population are lacking, the present study was set to investigate a hypothetical association between these polymorphisms and POAG in a Caucasian population. Methods: In total 723 participants were included in this study comprising 366 patients with POAG and 357 control subjects from the southern part of Austria. Genotyping of rs1533428 and rs12994401 was performed using polymerase chain reaction. Results: Allelic frequencies and genotype distributions of rs1533428 and rs12994401 did not show statistical significance between patients with POAG and control subjects (p < 0.05). Presence of the rs1533428 T-allele was associated with an odds ratio of 0.95 (95% CI: 0.76–1.19; p = 0.69) for POAG, while the rs12994401 T-allele was associated with an odds ratio of 0.94 (95% CI: 0.73–1.21; p = 0.65) for POAG. Conclusion: Our data suggest that rs1533428 and rs12994401 themselves are unlikely major risk factors for POAG in a Central European population.

Role of interleukin 6-174G>C polymorphism in primary open-angle glaucoma

Purpose. In addition to its proinflammatory effects, interleukin (IL)–6 also possesses antiapoptotic properties. Recently, IL-6 has been reported to protect retinal ganglion cells from pressure-induced apoptosis, indicating a possible role in the pathogenesis of primary open-angle glaucoma (POAG). A common polymorphism in the promoter region of IL-6 gene at position -174 characterized by a substitution from G to C has been found to decrease transcription rate of IL-6. The aim of our study was to investigate a hypothesized association between IL-6-174G>C polymorphism and POAG in Caucasian patients. Methods. The present case-control study comprised 191 unrelated patients with POAG and 191 control subjects, matched for age and sex. Genotyping of the IL-6-174G>C polymorphism was done using polymerase chain reaction. Results. Allelic frequencies and genotype distribution of IL-6-174G>C did not significantly differ between patients with POAG and control subjects (p>0.05). Presence of the IL-6-174C allele was associated with a nonsignificant odds ratio of 0.78 (95% confidence interval 0.46–1.32; p=0.78) for POAG. Conclusions. Our findings suggest that the functional IL-6-174G>C polymorphism itself is unlikely a major risk factor for POAG.

Transpupillare Thermotherapie (TTT), Ruthenium 106 Brachytherapie oder Leksell® Gamma Knife Radiochirurgie. Eine Standortbestimmung

ZusammenfassungDie Publikation soll den Stellenwert von neuen Therapiekonzepten wie transpupillare Thermotherapie (TTT) oder einzeitige Leksell Gamma Knife Radiochirurgie vor dem Hintergrund einer etablierten Therapie wie der Ruthenium 106 Brachytherapie beleuchten.Patienten und MethodikVon den seit 1985 bulbuserhaltend an der Univ.-Augenklinik Graz behandelten Patienten wurden ausgewertet: 58 Patienten mit kleinen und mittelgroßen Aderhautmelanomen und Ruthenium 106 Brachytherapie, 60 Patienten mit mittelgroßen und großen Melanomen und Leksell Gamma Knife® Radiochirurgie und 28 Patienten mit transpupillarer Thermotherapie (TTT).ErgebnisseNach Ruthenium 106 Brachytherapie konnten 43/47 Augen erhalten werden, 2 Augen mussten auf Grund eines Rezidivs enukleiert werden, nach Leksell Gamma Knife® Therapie wurden 51/60 Augen erhalten, 4 wurden auf Grand eines Rezidivs und 5 wegen eines hämorrhagischen Glaukoms entfernt. Nach Thermotherapie wurden 23/28 Augen erhalten, 5 mussten auf Grund eines Rezidivs enukleiert werden.DiskussionDie transpupillare Thermotherapie ist bei juxtapapillären Tumoren und einer maximalen Prominenz von 3 mm Therapie der Wahl an unserer Klinik, die Ruthenium 106 Brachytherapie bei Tumoren der mittleren Peripherie und des Ziliarkörpers und einer Prominenz bis zu 5 (6) mm, wir ziehen die Gamma Knife Radiochirurgie bei makulären und juxtamakulären Tumoren bzw. Tumoren bis zu einer maximalen Prominenz von 10 mm anderen Therapiekonzepten vor. Die Ergebnisse der einzelnen Therapien sind nur bedingt miteinander vergleichbar, da bei der Thermotherapie flache Tumore in zentraler Lokalisation, bei der Leksell Gamma Knife Therapie z. T. hoch prominente Tumoren mit großen Tumorvolumina behandelt werden.SummaryThis paper deals with new globe preserving therapies like transpupillary thermotherapy (TTT) and single fraction Leksell® Gamma Knife radiosurgery as well as widly accepted therapies like Ruthenium 106 brachytherapy.Patients and methodsSince 1985 58 patients suffering from small to medium sized uveal melanomas have been treated with Ruthenium 106, 60 patients underwent Leksell Gamma Knife Radiosurgery and 28 mainly small posteriorly located uveal melanomas were treated with transpupillary thermotherapy (TTT).ResultsRuthenium 106 brachytherapy could achieve globe preservation in 43 out of 47 eyes, in 60 eyes treated with the Leksell® Gamma Knife as an alternative therapy to enucleation 51 could be retained, 5 eyes were removed due to neovascular glaucoma and 4 eyes due to recurrant tumor growth. After thermotherapy 23/28 globes could be preserved, 5 eyes had to be enucleated due to regrowth.DiscussionTranspupillary thermotherapy (TTT) is our treatment of choice in small melanomas of the posterior pole up to 3 mm prominence, we prefer Ruthenium 106 in medium sized tumors located in the midperiphery of the fundus and ciliary body. Single fraction Leksell Gamma Knife® Radiosurgery is our treatment of choice in macular melanomas and tumors with a maximum tumor prominence of 10 mm. These different therapeutic modalities can hardly be compared as tumors of different sizes (volumes) and locations had been treated.

Intraocular Pressure Contact Lenses – Suitable for Everyday Use Yet?

The importance of intraocular pressure (IOP) as a relevant and treatable risk factor for the development or progression of glaucoma is evident. In managing this disease, to take only a single or a few measurements of this crucial parameter is definitely suboptimal. Technical research has developed contact lenses with embedded structures that are able to measure the IOP or surrogates over a longer period of time. One such system measures changes of the peripheral corneal curvature by means of strain gauges, and another measures the IOP by means of a piezoresistant membrane. Comfort is increased by wireless data transmission and miniaturisation of devices that do not influence visual acuity or daily/nightly activities. The safety and tolerability of the Triggerfish® contact lens is good and proved by several clinical observational studies. Missing are studies that confirm the reliability and reproducibility of the results. So far, no device can be recommended for everyday use in an ophthalmological office.

Triglycerides and Open Angle Glaucoma – A Meta-analysis with meta-regression

Although intraocular pressure is the main the risk factor for the development of glaucoma, other risk factors such as vascular dysfunction might play an additional pathogenic role. Hypertriglyceridemia, which may lead to vascular dysfunction, has been implicated in the development of glaucoma. The objective of this meta-analysis was to investigate the association of triglyceride levels with the risk of glaucoma in case-control studies. Seventeen case-control studies were included investigating the difference in triglyceride levels in patients with glaucoma (N = 1 391) compared to subjects without glaucoma (N = 25 575). In random effects meta-analysis, the pooled mean triglyceride level across all studies and patients with and without glaucoma was 132.9 mg/dL (95%CI: 124.0–141.7). Patients with glaucoma had significantly higher mean triglyceride levels than patients without glaucoma (absolute difference = 14.2 mg/dL, 95%CI: 5.8–22.5, p < 0.0001). A considerable amount of heterogeneity of included studies was observed (I2 = 66.2%, heterogeneity χ2 = 47.4 on 16 degrees of freedom, p < 0.0001). In conclusion, this meta-analysis of case-control studies found that patients with glaucoma had higher mean triglyceride levels than patients without glaucoma. This finding is consistent with the concept that hypertriglyceridemia represents an additional risk factor for glaucoma. Whether this association is causal and/or might be modified by glaucoma medications remains to be investigated.