[Development and first results of fast and cost-effective examination methods for an ophthalmological screening within the National Cohort]. / Entwicklung und erste Anwendungserfahrungen einer schnellen und kostengünstigen ophthalmologischen Untersuchung für die Nationale Kohorte.

BACKGROUND: For an implemented ophthalmological screening within a German long-term cohort study (National Cohort) simple and effective methods for an examination of visual acuity and for non-mydriatic retina photografies should be evaluated. Furthermore standard operating-procedures (SOP) should be developed. METHODS: In the years 2011 and 2012 pinhole visual acuity measurements and automated retina photographies (DRS, CenterVue S. p. a., Padua, Italy) were made at three different epidemiological study centers within Germany. Furthermore, anterior segment images were taken by the camera. Standard operating procedures (SOP) regarding the ophthalmological screening were developed and evaluated within the study. The main question was whether it is possible to implement the screening methods within the National Cohort. Further main outcomes were quality and interpretability of the taken images. RESULTS: 457 subjects (914 eyes) were examined within the investigation. Median VA was 0.8 for right and left eyes (p > 0.42). Image quality of the photographies was good in 491 cases (54 %), fair in 239 cases (26 %) and bad in 179 cases (20 %). The usability of the images was without limitations in 686 cases (75 %), limited in 152 cases (17 %) and not given in 71 cases (8 %). Increasing age of the subjects was slightly correlated with decreasing image quality (r = 0.26) and decreasing image usability (r = 0.2). Anterior segment photographies were usable in 176 eyes (56 %). CONCLUSION: The developed screening method fulfilled the specifications of the National Cohort. The used pinhole visual acuity examination was fast and cheap. Image quality and usability of the retina photographies could be improved with prolonged pupil recovery times. The quality of the anterior segment images could not fulfill the expectations and were taken out of the further examinations of the ophthalmological screening. The written SOP showed good acceptance within the investigators' daily routine. The ophthalmological screening within the National Cohort generates information (e. g., pathologies of the vessels or of the retina) which are useful not only from an ophthalmological point of view.

[New DIN and ISO norms for determination of visual acuity]. / Neue DIN- und ISO-Normen zur Sehschärfebestimmung.

Recently, three international norms (ISO) for visual acuity assessment were revised. The DIN EN ISO 8596:2018 stipulates the Landolt C eye chart as the standard optotype and specifies display characteristics. An informative annex lists clinical optotypes for the first time. These include the ETDRS chart, Snellen chart and pediatric optotypes; however, these clinical optotypes do not have the same status as the Landolt C chart, since even with identical font size and stroke width they may differ in recognizability. The technical report ISO/TR 19498:2015 complements DIN EN ISO 8596. A scientifically appropriate procedure is described, which enables a quantitative correlation of clinical optotypes with the Landolt C chart. The DIN EN ISO 10938:2016 describes the required optical quality of optotypes. For the first time, electronic devices are explicitly approved for standardized visual acuity tests. Consequently, according to this amendment electronic devices may be used for acuity assessment for ophthalmological expert opinions according to DIN 58220, part 3.

[Photopic contrast sensitivity. Local contrast perception]. / Photopisches Kontrastsehen. Ortliche Kontrastempfindlichkeit.

Contrast perception is an important visual function. Contrast sensitivity (CS) is affected by to optical reasons (aberrations, scatter, diffraction) or neural dysfunction (e.g., glaucoma, optic nerve diseases). In clinical practice the measurement of CS is relevant for disease monitoring, expert opinions, roadworthiness assessment, and recruitment screening. Furthermore, CS testing is often required in studies assessing optical quality, e.g., cataract or refractive surgery. Adding an appropriate glare source allows measurement of the glare-induced loss of CS (disability glare). Compared to high-contrast acuity, CS is more variable and strongly depends on the type of test, illumination, test strategy, and contrast definition; ceiling effects are quite common among many tests. Maximal standardization is important, especially for follow-up exams. In summary, CS testing cannot be regarded as a routine test. The present report by the DOG commission for quality management of psychophysical assessment covers the physiological background, testing principles, and strategies and presents a tabular overview of common tests.

[Morning glory disc anomaly und frontonasal dysplasia]. / Morning-glory-Papille und frontonasale Dysplasie.

Morning glory disc anomaly (MGDA) is a rare congenital malformation of the optic disc, which can be associated with midline craniofacial abnormalities, such as basal encephalocele. A female neonate presented with MGDA in the right eye, pendular nystagmus, hypertelorism, a flattened nasal root and cleft lip and palate. MRI revealed a basal encephalocele, agenesis of the corpus callosum and ventricular enlargement. MGDA combined with midline facial clefting should always lead to the suspicion of a basal encephalocele.

[Contrast vision-definitions, conversions, and equivalence tables]. / Kontrastsehen ­ Definitionen, Umrechnungen und Äquivalenztabelle.

Human contrast vision and its quantitative assessment are gaining more attention. Publications on this topic can be confusing due to the overabundance of differing definitions and quantification of contrast vision. As a case in point, in Germany, contrast ratios as required for certain driving licenses and the DIN-defined contrast ratio are reciprocal. In this article, the five most important definitions of luminance contrast and contrast vision (Michelson, Weber, contrast ratios, logCS) are presented. We detail the specific domains for them, give formulae to convert between all of them and provide a table with equivalent values. We recommend the unit logCS wherever possible.

[Conventional techniques of visual field examination: part 4 Static perimetry: interpretation--perimetric indices--follow-up--perimetry in childhood]. / Konventionelle Perimetrie Teil 4: Statische Perimetrie: Befundauswertung--Indizes--Verlaufskontrolle--Perimetrie im Kindesalter.

Visual field examination with fixed stimuli was first realized in manual static profile perimetry. The transition from a linear stimulus alignment along a profile section towards a two-dimensional arrangement introduced the era of static grid perimetry. Application of computer technology nowadays allows automation and standardization of this procedure, which enables the examiner to select the necessary visual field area, the adequate grid, and the optimal strategy for an estimation of differential luminance sensitivity. Furthermore, the computer independently takes over the recording, visualization, and processing of the perimetric procedure. This contribution discusses conventional static visual field examinations since these are widely used, easily accessible, well established for practical application, and standardized. This paper (part 4) explicitly focuses on the correct interpretation of automated static strategies of visual field examinations. Furthermore the classification and scoring of visual field defects as well as quality control, progression analysis, and perimetry in childhood are addressed. This manuscript is based on three preceding parts, which were published in previous issues of this journal [27, 28, 29].

[Integrated approach to the promotion of young academics in vision research at a European level]. / Integrativer Ansatz zur Nachwuchsförderung in der Sehforschung auf europäischer Ebene.

The European Commission predicts a dramatic dearth of researchers and doctors in the near future. At the same time, highly qualified and motivated human resources form the only guarantee for further development of scientific knowledge for research and clinical application. This situation calls for an integrated approach to the promotion of young academics in vision research at a European level. The Marie Curie Program of the European Union is an ideal tool, which can be used particularly efficiently in vision research to promote international networking and dedicated advancement of young academics. The exemplary chances and opportunities of this strategy can be demonstrated by six specific measures of the University Eye Hospital in Tübingen. In particular, strictly defined medical areas will need to fully exploit their innovation potential in the future in order to secure their position in the global research area or even to expand it. New organizational concepts and long-term career options as well as a clear commitment to cutting-edge performance are the prerequisites for effective promotion of young academics.

[Conventional perimetry. Part 3: Static perimetry: grid--strategy--visualisation]. / Konventionelle Perimetrie. Teil 3: Statische Perimetrie: Raster--Strategien--Befunddarstellung.

Methods for visual field examination using static strategies began with manual static profile perimetry. The transition from a linear stimulus alignment along the profile section to a two-dimensional grid arrangement introduced the era of static grid perimetry. The use of computers makes it possible to automate and standardise this process, allowing the examiner to choose the visual field area, an adequate grid and the optimal strategy, while leaving the processing, visualisation and recording completely observer-independent. This contribution is based only on conventional static procedures for visual field examination (the use of white on white perimetry) as this technique is easily accessible, standardised and well established in everyday practice.

Does visual restitution training change absolute homonymous visual field defects? A fundus controlled study.

AIM: To examine whether visual restitution training (VRT) is able to change absolute homonymous field defect, assessed with fundus controlled microperimetry, in patients with hemianopia. METHODS: 17 patients with stable homonymous visual field defects before and after a 6 month VRT period were investigated with a specialised microperimetric method using a scanning laser ophthalmoscope (SLO). Fixation was controlled by SLO fundus monitoring. The size of the field defect was quantified by calculating the ratio of the number of absolute defects and the number of test points; the training effect E was defined as the difference between these two ratios before and after training. A shift of the entire vertical visual field border by 1 degrees would result in an E value of 0.14. RESULTS: The mean training effect of all right eyes was E = 0.025 (SD 0.052) and all left eyes E = 0.008 (SD 0.034). In one eye, a slight non-homonymous improvement along the horizontal meridian occurred. CONCLUSIONS: In one patient, a slight improvement along the horizontal meridian was found in one eye. In none of the patients was an explicit homonymous change of the absolute field defect border observed after training.

[Conventional perimetry I: introduction--basics]. / Konventionelle Perimetrie. Teil I: Einführung--Grundbegriffe.

Evaluation of visual field findings is an essential ophthalmological task. Applying psychophysical principles enables non-invasive (topo-)diagnostics in case of unexplained visual loss or suspected lesions of the visual pathways. Furthermore, any kind of expert opinion or ability test depends critically on adequate visual field findings. Repeated examinations allow the functional follow-up of a disease and judgement of therapeutic efficiency. This paper is explicitly focused on conventional strategies of visual field examination, since these are widespread, easily accessible, standardized and well established in everyday practice. Part 1 of this continuing education series will mainly impart basic concepts in perimetry and psychophysics. It will also consider indications and the necessary general setup of a perimetric examination. Furthermore, a concept of scotoma classification is explained.

[Conventional techniques of visual field examination Part 2: confrontation visual field testing -- kinetic perimetry]. / Konventionelle Perimetrie Teil 2: Konfrontationsperimetrie -- Kinetische Perimetrie.

Evaluation of visual field findings is an essential ophthalmological task. Applying psychophysical principles enables noninvasive (topo-)diagnosis in cases of unexplained visual loss or suspected lesions of the visual pathway. Furthermore, any kind of expert opinion or ability test critically depends on adequate visual field findings. Repeated examinations allow functional follow-up of a disease and assessment of therapeutic efficiency. This paper explicitly focuses on conventional strategies since these are widespread, easily accessible, standardized, and well established in everyday practice over years. Standardized white-on-white perimetry with moving targets (kinetic perimetry) is the major topic of this paper (part 2) in addition to "rough"/preliminary confrontation visual field testing. This review series is aimed at imparting basic concepts in perimetry and psychophysics to ophthalmologists and also addresses interested physicians from other disciplines.

Detection and follow-up of homonymous visual field defects - perimetric essentials for evaluation of spontaneous recovery.

Clinical detection and follow-up of homonymous visual field defects require appropriate perimetric procedures: since postgeniculate lesions are usually characterised by absolute scotomata, time consuming threshold methods can be replaced by supraliminal strategies with comparatively high stimulus densities. Compared with equidistant rectangular grids, a centripetal stimulus condensation represents the physiological conditions more adequately and thus is more effective. It allows one to differentiate central changes of the visual field, like macular sparing or splitting, which also interfere with reading performance. This procedure requires test points to be located to either side of the vertical meridian, rather than directly on it. Multimodal assessment of visual subfunctions (using static, kinetic or colour test points, random dot patterns or optokinetic stimulation) specifies the effect of the lesion in different channels or regions of the visual pathways. Automation of perimetric procedures and continuous monitoring of fixation are important tools, enhancing the quality of examination and follow-up. The above mentioned psychophysical techniques for detection of functional defects and documentation of eventual recovery, as well as matching neuroimaging findings, are demonstrated by illustrative cases.

Hyperexcitatory activity in visual cortex in homonymous hemianopia after stroke.

OBJECTIVES: Damage to and destruction of neural afferents result in a disruption of sensory input, which causes reduced activity in the corresponding cortical areas. Conversely, there is also evidence that lesions in the sensory pathway induce changes in the intracortical connectivity resulting in augmented cortical activity due to disinhibition. As disinhibition is assumed to be involved in the reconfiguration of neural networks, its appearance after brain lesions might be relevant for the restitution of impaired brain functions. METHODS: The effects of lesions in the visual pathway on the activity in visual cortex were studied using magnetoencephalography. In order to compare the neural activity affected by the lesion with the activity associated with intact visual processing, only patients with unilateral, post-chiasmatic lesions resulting in homonymous hemianopia were examined. RESULTS: Stimulation within the scotoma resulted in reduced magnetic activity compared to the stimulation of the intact hemifield. Increased activity was observed when the border region of the scotoma was stimulated. CONCLUSIONS: It is concluded that the magnetic hyperactivity reflects cortical disinhibition induced by lesions in the visual system. Furthermore, the possible role of cortical disinhibition as a basis for cortical reorganization and as a precondition for the recovery of impaired visual functions is discussed.

Progress in the genetics of glaucoma.

The term glaucoma describes a heterogeneous group of optic neuropathies that lead to optic nerve atrophy and permanent loss of vision. It is the second most prevalent cause of bilateral blindness in the Western world and affects over 60 million people worldwide. The hereditary forms of glaucoma are genetically heterogeneous. Different forms of glaucoma can be distinguished: the primary open-angle glaucoma of adult onset is the most common, representing approximately half of all cases. The juvenile-onset open-angle glaucoma is an uncommon autosomal dominant form of glaucoma with manifestation predominantly before the fourth decade of life. The primary congenital glaucoma is a clinical and genetic entity clearly distinct from the juvenile form, following an autosomal recessive mode of inheritance. At least eight loci have been linked to glaucoma (GLC1A-F, GLC3A/B) and three genes have been identified to date: MYOC, CYP1B1 and OPTN. In the last decade, there has been much progress in finding new genes, detecting disease-related mutations and determining allele frequencies within populations of different ethnical backgrounds, but little is known about the function of the mutated gene products and the underlying pathogenic mechanisms. This chapter attempts to summarize the current knowledge regarding glaucoma-associated genes.

Combined cataract-glaucoma operation and its complications with the 7-S-intraocular lens.

The new generation of intraocular lenses placed in the sulcus or in the bag allows implantation even in glaucoma patients under certain conditions. Patients with intraocular pressure between 25 and 30 mm Hg underwent Argon laser trabeculoplasty before implantation. In patients with regulated intraocular pressure between 15 and 20 mm Hg not even an iridectomy was performed implanting the 7-S posterior chamber lens. An average degree of the intraocular pressure of 1.5 mm Hg was found after 6 months. Preoperative endothelial cell counting facilitates the indication for implanting an intraocular lens.

Models for the description of angioscotomas.

To describe small scotomas in visual field examinations several statistical models are proposed and applied to the evaluation of angioscotoma in 13 ophthalmologically normal subjects. A special perimetric grid is used where thresholds can be estimated along a line of narrow-spaced test points which crosses the predicted location of the retinal vessel. A two-stage analysis employs single estimations to fit a threshold curve by means of a special parametric description of the luminance difference sensitivity threshold as a function of stimulus position. An alternative model incorporates the threshold as a function of position into the probabilistic description of the binary response (stimulus seen/not seen).

Preretinopic changes in the colour vision of juvenile diabetics.

AIMS: To examine the colour vision of juvenile patients suffering from diabetes mellitus without retinopathy in relation to metabolic and ophthalmic state. METHODS: Metameric matches, both Rayleigh (red/green) and Moreland (blue/green) were used to test the colour vision yearly of 10 juvenile patients. The patients were monitored over 4 years, and during the final year, their blood glucose level was determined directly after testing colour vision. An ophthalmic examination was performed on the day of colour vision testing and blood and urine were analysed regularly throughout the 4 years. Their results are compared with an aged matched control group of 20 subjects, seven of whom were retested after 9-16 months. RESULTS: After 4 years, the colour vision results show an enlarged matching range for the Moreland match, as well as a smaller increase in the matching range for the Rayleigh match. No significant correlation was found between blood glucose at the time of testing and any of the variables measured. CONCLUSION: The pattern of colour vision deficits in metameric matching shown by juvenile diabetics is consistent with postreceptoral alterations of the inner retina, at this preretinopic stage of disease. Duration of diabetes is correlated with both colour vision changes and morphological alteration of the retina.

Development of brightness matching and colour vision deficits in juvenile diabetics.

We studied hue discrimination and brightness matching throughout the spectrum in ten juvenile patients suffering from diabetes mellitus (Type I) with no (eight patients) or mild (two patients) retinopathy. In addition, the FM 100-Hue test was performed. The data were collected once every year over 5 years. Over the 5 years, the diabetics show a continual change in the shape of their brightness matching function. Wavelength discrimination ability remains quite stable with time at the long end of the spectrum but is variable at short wavelengths. FM-100 error scores remain similar over the period tested, at a level slightly higher than that of a control group. Additional experiments show that the sensitivity of the S-cone in the diabetic group is similar to that of controls. The results can be explained by an early relative reduction in the sensitivity of post-receptoral processes in juvenile diabetics.

Reaction time in automated kinetic perimetry: effects of stimulus luminance, eccentricity, and movement direction.

PURPOSE: To determine the effects of stimulus eccentricity and luminance level on the reaction time (RT) of young normal volunteers during automated kinetic campimetry. METHODS: We used a specially designed video-campimetric device equipped with a continuous infrared (IR) pupillographic fixation control (Tübingen Computer Campimeter) and recorded reaction times upon presenting horizontally moving small circular stimuli (size 26'; constant angular velocity 2 degrees /s) starting at 16 locations within the central 30 degrees -radius of the visual field. Two different levels of stimulus luminance were used (41.6 cd/m(2) and 110 cd/m(2)), while background luminance was 10 cd/m(2). Each stimulus was presented a total of six times in a randomized order. Subjects were 12 healthy young individuals (aged 21-30 years) with normal ophthalmic examinations. An analysis of variance (ANOVA) was performed on the data. RESULTS: RTs showed considerable inter- and intra-individual variation with individual least squares means (LSM, fitted values of a linear model) ranging from 305 to 454 ms, and residual standard deviation (R.S.D.) 66 ms. Reaction times did not differ significantly as a function of stimulus direction (P>0.6). Higher luminance levels produced significantly reduced reaction times for all stimulus locations and directions (mean reduction: 16 ms; P<0.0001). Reaction times increased with increasing eccentricity, in the mean by 1.8 ms per degree of visual angle, from 365+/-4 ms (S.E.M.) foveally, to 407+/-2 ms at 30 degrees eccentricity; (P<0.0001). CONCLUSIONS: Automated kinetic perimetry should be designed to cope with significant, variable interindividual response characteristics. Other stimulus related factors, such as eccentricity or luminance level, have a significant but comparatively small effect on reaction time within the central 30 degrees -radius visual field in healthy young individuals.

Brightness matching and colour discrimination in young diabetics without retinopathy.

This study used the methods of the Farnsworth-Munsell 100-hue test (FM-100), heterochromatic brightness matching (HBM) and wavelength discrimination to test the sensitivity and colour vision of 20 juvenile diabetics with no (16) or very mild (4) retinopathy. Their results were compared to an age-matched control group. The FM-100 results showed a significant increase in error scores throughout the spectrum in comparison to the controls. This deterioration in colour vision was confirmed in the results for the wavelength discrimination task, tested between 440 and 640 nm, where the just noticeable difference in colour was, in general, larger for the diabetic group than the control group. Only at 460 nm were the results of the diabetics similar to those of the controls. The diabetic group were also less sensitive than the control group in the HBM task between 480 and 600 nm. The results show that a deficit in sensitivity and colour vision occurs in diabetics before the onset of a clinically visible retinopathy.