New digital methods: remodelling the harms tangent scale setting.

PURPOSE: The aim of this study is to present a feasibility study to evaluate and compare a self-constructed, digital-based tangent scale using the Harms tangent screen test for the examination of patients' strabismus angles. METHODS: The documented strabismus angles of 10 patients were measured at nine gaze-positions and compared using the Harms tangent screen test (Harms Screen) and a self-constructed digital screen test (Digital Screen). The primary outcome is the difference in the measured angles between both methods. Secondary outcomes include the duration of the examinations and the diagnostic conclusion based on the results of the measurements. RESULTS: The datasets from 10 of 13 patients were used for comparisons (median age 52 years; females 5; males 5). All measurements showed a mean of 1.77° (SD 2.95°) in horizontal deviations and 1.11° (SD 2.23°) in vertical deviations. The two methods showed differences (> 5°) in 12 cases (13.3%) for horizontal angle measurements and in four cases (4.4%) for vertical angle measurements. The median examination time was 238 s (range 60-430 s) for the Harms Screen and 150 s (range 120-600 s) for the Digital Screen tests. The diagnostic conclusions were identical for both methods. CONCLUSIONS: The feasibility of the experimental digital setup in principle is shown. Despite some deviations in the measured strabismus angles, the resulting diagnosis of the paresis was identical. The new method showed a reduction of examination time.

Early postoperative changes of the foveal surface in epiretinal membranes: comparison of 23-gauge macular surgery with air vs. balanced salt solution.

OBJECTIVE: To analyze the foveal surface using binary image analysis after spectral-domain optical coherence tomography (SD-OCT) following 23-gauge macular surgery in epiretinal membranes (ERM) using either air tamponade (AIR) or balanced salt solution (BSS). METHODS: One hundred twenty-four eyes (124 patients) with ERM that had undergone membrane peeling with installation of air or BSS were analyzed retrospectively. Ophthalmic examination was performed at baseline and 3 months. OUTCOME MEASURES: The foveal area and surface symmetry, area matched thickness, area matched contour, and best-corrected visual acuity (BCVA). The OCT images were analyzed after binary conversion with ImageJ software. RESULTS: Eighty eyes (80 patients) of 124 screened patients were included (AIR group: 39 patients, BSS group: 41 patients). Median follow-up time was 14 weeks (range, 9-19 weeks). Three months after surgery, the median horizontal area decreased significantly in both groups (p < 0.0001). At follow-up, the foveal surface symmetry values for the BSS group (median, 22.73 µm, range, 0-153) were significantly lower than for the AIR group (median, 23.95 µm, range, 0-160.43) (p < 0.0001). The area-matched thickness increased significantly in both groups (p < 0.001). The AIR group showed a significant increase of the area matched contour for the nasal located measurement-areas N1 (p < 0.0003), N2 (p < 0.0079), N3 (p < 0.007). The BSS group showed a significant increase of the area-matched contour for the measurement areas N1 (p < 0.019), N2 (p < 0.0014), and N4 (p < 0.022). After surgery, median BCVA for both groups increased significantly to 0.3 logMAR. CONCLUSIONS: The analysis of early contour changes after ERM surgery was technically possible. Long-term data have to be looked at before the clinical impact of this methodology can be estimated. Although there were no big differences between both groups (AIR vs. BSS), this could change within a longer and more representative follow-up.

Critical evaluation of the usability of augmented reality ophthalmoscopy for the training of inexperienced examiners.

PURPOSE: To measure the value of augmented reality technology usage to teach the medical students performing binocular indirect ophthalmoscopy. METHODS: Thirty-seven medical students were randomly assigned to the training of binocular indirect ophthalmoscopy either in the conventional way or with augmented reality ophthalmoscopy (ARO). For testing student's skills, they had to examine a real person using a conventional ophthalmoscopy system and draw the optic disk. They also had to fill out a questionnaire. Subjective and objective evaluations were performed. RESULTS: Thirty-seven students were randomly assigned to two groups. Eighteen students were trained with conventional ophthalmoscopy and 19 students with ARO. The questionnaires showed no differences. Performing an objective analysis, the median ophthalmoscopy training score for the conventional ophthalmoscopy group was 1.2 (range, 0.67-2) and showed a significant difference (P < 0.0033) to the ARO group (median 2; range, 0.67-2). CONCLUSION: The study provides evidence that a single ARO training is efficient to improve ophthalmoscopy skills. As the objective analysis showed, the ARO group had a significantly superior performance. Our study also indicates that subjective evaluation of the fundus drawings without systematic analysis is prone to errors.

A new digitised screen test for strabismus measurement.

PURPOSE: Our study presents a digitised tangent screen test for ocular motility analysis according to the Harms and Hess tests (measurement of the squint angle in all fields of vision). This test uses an image beamer to display the tangent screen, a position sensor to measure the patient's head orientation, and a distance sensor to measure the fixation distance. Digital measurement of head orientation allows for a test procedure that eliminates the conventional requirement for a light pointer in the patient's hand. Thus, the digital screen test is presented, and the uncertainty of the measurement system is evaluated. METHODS: A mathematical relationship was given between the measured squint angles, as well as the angle of diagnostic gaze direction, and the influence quantities on their measurement uncertainty. The individual uncertainties resulted from deviations in the measured values by the position and distance sensors, the calibration of the projection image of the beamer in length units, and the finite image resolution of the beamer. The individual standard uncertainties of the influence quantities were determined. The combined standard measurement uncertainties of the squint and gaze direction angles were given based on the model equation of the error propagation law at the tangent table according to Harms at a test distance of 2.5 m. The patient's uncertainty contribution to the mobility analysis was not considered. RESULTS: The combined standard uncertainty of the measurement system (coverage factor k = 2 for 95% confidence level) for the squint angle is ≤ 0.43° for the angle of diagnostic gaze direction ≤ 3.13° at the test distance of 2.5 m. The individual standard uncertainties of the influence quantities on the angles are (k = 1): 1.55°/1.01° (horizontal/vertical angle of the position sensor), 0.19° (distance sensor), 0.06° (calibration of the projection image of the beamer), and 0.02° (image resolution of the beamer). The maximum valid test distance of the digital screen test is 3.8 m. CONCLUSION: The digital screen test is compact and can be used at different locations. Compared to the traditional test, the time required for examination via the digitised test is less; additionally, its documentation is simplified. The measurement uncertainty of the diagnostic gaze direction angle is dominated by the sensor drift of the position sensor in the horizontal direction (yaw angle) and is due to the sensor technology. However, this drift error does not affect the squint angle measurement result nor its measurement uncertainty because the measurement principle used here is based on the congruence between the position cross and the fixation object and the confusion principle and compensates for the drift error. The measurement uncertainties of the determined measurement system are the lower limits of the uncertainties in the clinical use of the digital screen test if there are no effects due to significant patient deviations.

Comparison of spherical and aspherical intraocular lenses with decentration and tilt error using a physical model of human contrast vision and an image quality metric.

PURPOSE: In this study, two intraocular lenses (spherical IOL SA60AT and aspherical IOL SN60WF) are examined in an eye model under conditions of misalignment (defocus, decentration and tilt). The lenses are rated using the contrast sensitivity function (CSF) based on Barten's physical model. The square root integral (SQRI) method is used as a quality criterion comparable to the subjective image quality assessment of the human eye. METHODS: The IOLs to be tested are decentered from 0 to 1mm and tilted from -5 to +5 degrees in the Navarro eye model (optimized for far-point 6m and pupil aperture 3mm). The defocus of the IOLs is ±0.1mm at the anterior chamber depth (ACD). The optical modulation transfer function (MTF) is simulated with a ray tracing program. The SQRI is calculated using this MTF and the Barten CSF model (for in-focus at aperture 3 and 4.5mm and for defocus at 3mm). RESULTS: With increasing decentration, the spherical IOL shows a significantly smaller loss of quality for both apertures compared to the aspherical lens. With an aperture of 4.5mm, the image quality of the aspherical IOL is better for small decentration and tilt. The loss of quality of the spherical IOL increases with increasing tilt in both directions. In contrast, the image quality of the aspherical IOL is reduced under decentration for certain tilt values. For ACD-0.1mm, both IOLs behave similarly to the in-focus situation. For ACD+0.1mm, the influence of tilt without decentration is small for both IOLs. With increasing decentration, the quality loss of the aspherical IOL is similar to that in-focus and greater than that of the spherical lens. CONCLUSION: In general, under the same conditions the spherical SA60AT displays a lower tolerance in loss of quality of subjective vision with lens alignment errors, in comparison to the aspherical SN60WF, limited by certain combinations of decentration and tilt according to this study. This study shows a way to evaluate IOLs based on the subjective visual performance of the eye.

The Cosine Similarity Technique: A new method for smart EXCIMER laser control.

PURPOSE: To introduce additional steps towards smart laser control in eye surgery, with the use of the cosine similarity technique to analyze the spectra of organic polymers obtained using non-contact photoacoustic spectroscopy (NCPAS). METHODS: The experiments were performed with two organic polymers: polyethylene and polyamide. A 193 nm excimer laser was used for photoablation at a repetition rate of 200Hz. The resulting acoustic signal of the ablation process was recorded by a capacitor microphone and then preamplified and digitized. For each specimen, four measurements with 1000 single pulses were taken. The cosine similarity technique was then used to compare the spectra of the polymers. The performance of the discrimination technique was evaluated by receiver operating characteristic analysis. RESULTS: It was possible to correctly recognize a material with a probability of approximately 98% using the cosine similarity technique at a laser repetition rate and recording rate of 200 Hz, which represents the acoustic signal of one laser pulse. CONCLUSIONS: The determination of materials with the cosine similarity method (CSM) is a fast, precise and promising approach towards smart laser control. Additional steps could include the design of a database containing generic spectra, using higher repetition rates, and the combination of NCPAS results with the position of the laser beam.

Design, Implementation and Operation of a Reading Center Platform for Clinical Studies.

Clinical reading centers provide expertise for consistent, centralized analysis of medical data gathered in a distributed context. Accordingly, appropriate software solutions are required for the involved communication and data management processes. In this work, an analysis of general requirements and essential architectural and software design considerations for reading center information systems is provided. The identified patterns have been applied to the implementation of the reading center platform which is currently operated at the Center of Ophthalmology of the University Hospital of Tübingen.

Quality and learning curve of handheld versus stand-alone non-mydriatic cameras.

PURPOSE: Nowadays, complex digital imaging systems allow detailed retinal imaging without dilating patients' pupils. These so-called non-mydriatic cameras have advantages in common circumstances (eg, for screening or emergency purposes) but present limitations in terms of image quality and field of view. We compare the usefulness of two non-mydriatic camera systems (ie, a handheld versus a stand-alone device) for fundus imaging. The primary outcome was image quality. The secondary outcomes were learning effects and quality grade-influencing factors. METHODS: The imaging procedures followed standard protocol and were all performed by the same investigator. Camera 1 (DRS®) was a stand-alone system, while Camera 2 (Smartscope® PRO) was a mobile system. In order to evaluate possible learning effects, we selected an examiner with no prior training in the use of these systems. The images were graded separately by two experienced and "blinded" ophthalmologists following a defined protocol. RESULTS: In total, 211 people were enrolled. Quality grade comparisons showed significantly better grades for Camera 1. Both systems achieved better quality grades for macular images than for disc-centered images. No remarkable learning effects could be demonstrated. CONCLUSIONS: Both camera systems are useful for fundus imaging. The greater mobility of Camera 2 was associated with lower image quality. For screening scenarios or telemedicine, it must be determined whether image quality or mobility is more important.

Human Vision-Motivated Algorithm Allows Consistent Retinal Vessel Classification Based on Local Color Contrast for Advancing General Diagnostic Exams.

PURPOSE: Abnormalities of blood vessel anatomy, morphology, and ratio can serve as important diagnostic markers for retinal diseases such as AMD or diabetic retinopathy. Large cohort studies demand automated and quantitative image analysis of vascular abnormalities. Therefore, we developed an analytical software tool to enable automated standardized classification of blood vessels supporting clinical reading. METHODS: A dataset of 61 images was collected from a total of 33 women and 8 men with a median age of 38 years. The pupils were not dilated, and images were taken after dark adaption. In contrast to current methods in which classification is based on vessel profile intensity averages, and similar to human vision, local color contrast was chosen as a discriminator to allow artery vein discrimination and arterial-venous ratio (AVR) calculation without vessel tracking. RESULTS: With 83% ± 1 standard error of the mean for our dataset, we achieved best classification for weighted lightness information from a combination of the red, green, and blue channels. Tested on an independent dataset, our method reached 89% correct classification, which, when benchmarked against conventional ophthalmologic classification, shows significantly improved classification scores. CONCLUSIONS: Our study demonstrates that vessel classification based on local color contrast can cope with inter- or intraimage lightness variability and allows consistent AVR calculation. We offer an open-source implementation of this method upon request, which can be integrated into existing tool sets and applied to general diagnostic exams.

Grid laser photocoagulation for macular oedema due to branch retinal vein occlusion in the age of bevacizumab? Results of a prospective study with crossover design.

BACKGROUND AND AIM: To investigate the long term effectiveness of grid laser photocoagulation (GLP) versus intravitreal bevacizumab (BEV) in macular oedema (MO) secondary to branch retinal vein occlusion (BRVO), and to evaluate the treatment courses after treatments were switched. METHODS: In this prospective interventional consecutive case series, previously untreated eyes with perfused MO were enclosed over a period of 16 months for BEV and for 29 months for GLP. The follow-up period was 1 year. Patients with persistent MO after 12 months of BEV were offered GLP and vice versa, and were followed-up for another 12 months. RESULTS: Both BEV (23 eyes) and GLP (21 eyes) caused a significant (p<0.05) reduction in central retinal thickness (CRT) at 12 months although this was delayed with GLP. However, BEV revealed a significantly better best corrected visual acuity (BCVA) compared with GLP (0.2 vs 0.5 logMAR; p<0.04). Switching therapy for non-responders revealed a reduced CRT at another 12 months, although this was not significant. CONCLUSIONS: Functionally and anatomically, BEV appears to be more effective than GLP for the therapy of MO due to BRVO. BCVA is significantly better after 1 year and the anatomical response of the MO is faster. Furthermore, non-responders with persistent MO despite BEV or GLP treatment might benefit from switching therapy.

A new technique for treating posttraumatic aniridia with aphakia: first results of haptic fixation of a foldable intraocular lens on a foldable and custom-tailored iris prosthesis.

We describe a new surgical technique for treating traumatic aniridia with aphakia and its results in a small consecutive case series. We attached a 3-piece acrylic intraocular lens through the haptics to a customized silicone iris prosthesis. The combined implant was inserted through a 5-mm incision and fixated with a transscleral suture in the ciliary sulcus using a knotless technique (Z suture). In all patients, the combined implant stayed firmly fixed within the sulcus and showed a stable and centered position without any tilt or torque during follow-up. Thus, managing posttraumatic aniridia with aphakia by means of haptic fixation of a foldable intraocular lens on a custom-tailored iris prosthesis is a promising approach for visual rehabilitation and cosmetic improvement.