[Diagnostics of diseases of the optic nerve head in times of artificial intelligence and big data]. / Diagnostik von Erkrankungen des Sehnervenkopfes in Zeiten von künstlicher Intelligenz und Big Data.

BACKGROUND: The use of artificial intelligence (AI) interesting for automated image segmentation, analysis and classification, among others and has already been described for various fields of ophthalmology. OBJECTIVE: This manuscript provides an overview of current approaches and advances in the application of big data and AI in various diseases of the optic nerve head. MATERIAL AND METHODS: A PubMed search was performed. Studies were searched for that answered clinical questions using big data approaches or classical machine learning methods in the analysis of multimodal imaging of the optic nerve head. RESULTS: Big data can help to answer clinical questions in common diseases such as glaucoma. The AI is applied for the segmentation of multimodal imaging of the optic nerve head as well as for the classification of diseases, such as glaucoma or optic disc edema on this imaging data. CONCLUSION: With the help of big data and AI, relationships can be recognized more easily and the diagnostics and course assessment of diseases of the optic nerve head can be facilitated or automated. A prerequisite for clinical application is a CE marking as a medical device in Europe and approval by the Food and Drug Administration in the USA.

["Flipped classroom"-A future concept for student teaching in ophthalmology?] / "Flipped classroom" ­ Ein Zukunftskonzept für die studentische Lehre in der Augenheilkunde?

BACKGROUND: "Flipped classroom" is a didactic teaching concept in which learning contents are prepared by self-study with arranged tools before the classroom session. The concept offers the advantage of a uniform knowledge base for the students at the beginning of the course and also the advantage of a greater theoretical knowledge, which creates more opportunities for practical exercises, application and consolidation in the subsequent joint teaching units. This study describes the establishment and application of such a model in student teaching in ophthalmology and analyzes the student's evaluation. METHODOLOGY: For the winter term 2018/2019, a new teaching module was designed and established in a cooperation between the department of ophthalmology and the Institute for Education and Study Affairs (IfAS) at the medical faculty of the University of Münster. A uniform training of the lecturers as well as a preparation of the students for the restructuring took place. After the course the evaluation of the students was recorded and evaluated using a standardized online evaluation. RESULTS: Between the winter semester 2018/2019 and the winter semester 2019/2020, an average of 112.3 ± 4.0 students were taught with the "flipped classroom" model. Of these 93.7% were able to give an assessment. In the previous semesters with the old teaching concept (summer semester 2015 to summer semester 2018), the average number of students was 115.4 ± 15.1 with an assessment rate of 93.3%. The new teaching concept achieved on average a better assessment than the old module. CONCLUSION: With a "flipped classroom" space and flexibility can be generated for a more individual course preparation and at the same time a higher practical part. Further studies are needed to analyze whether this also enables a sustainable transfer of knowledge.

[Artificial intelligence in management of macular edema : Opportunities and challenges]. / Künstliche Intelligenz zum Management von Makulaödemen : Chancen und Herausforderungen.

Macular edema occurs in a wide variety of ophthalmological diseases. The diagnostics and treatment are an important part of modern ophthalmology. Due to the continuous development, artificial intelligence (AI) offers many opportunities to improve the management of macular edema. This article provides the readership with an overview of this interesting topic.

[FIDUSweb version 2.0 : An electronic platform to establish a cooperative university eye network]. / FIDUSweb in der Version 2.0 : Möglichkeiten einer elektronischen Plattform zur Etablierung eines kooperativen, universitären Augennetzwerks.

BACKGROUND: Due to the increasing digitalization in ophthalmology, increasingly more documentation and diagnostic data are becoming electronically available. In order to improve patient care beyond sectoral boundaries, electronic cooperation portals were introduced in Münster and Homburg, which serve the networking with ophthalmologists in private practice. METHOD: This article reports on the implementation of an electronic cooperation portal at the University Eye Hospitals in Münster and Homburg in 2015 and 2016. RESULTS: The FIDUSweb represents a data protection-compliant cooperation portal that can be easily set up. By implementing it as a web portal all terminal equipment and also electronic patient files can be networked. Particularly important functions are the transmission of medical reports in real time, appointment booking functions, the transmission of imaging data and shared treatment documentation. CONCLUSION: Cross-sectoral care can greatly benefit from the use of the FIDUSweb, especially in digital and multimodal ophthalmology.

Impact of integrated multiple image averaging on OCT angiography image quality and quantitative parameters.

PURPOSE: Multiple image averaging (MIA) is a new approach to improve OCT angiography (OCTA) imaging. The aim of this work was to analyze the impact of MIA on image quality and quantitative OCTA parameters. METHODS: Twenty eyes from 20 healthy volunteers (55.65 ± 14.8 years) were prospectively enrolled. Imaging was performed using two commercially available OCTA devices (Canon OCT HS-100, Optovue AngioVue) using a uniform imaging protocol. Each participant had two single scans of the macula (3 × 3mm, Canon and Optovue) as well as five continuous single scan imaging procedures (3 × 3mm each) using the Canon device. Three out of five of these images with highest quality were manually chosen and then automatically processed by the Canon device using MIA. The superficial retinal plexus of the single scans and of MIA images was analyzed with regard to the device' own image quality scores (IQS), peak signal-to-noise ratio (PSNR), the size of the foveolar avascular zone (FAZ), and vessel density (VD). Image acquisition times were recorded. Parameters were compared between the devices and the different imaging protocols. RESULTS: Average acquisition time was significantly higher for the MIA compared with the single measurements (29.09 ± 10.19 seconds (s) (MIA) vs. 5.56 ± 2.17 s (Canon single scan) vs. 20.28 ± 6.81 s (Optovue) (p < 0.001)). IQS showed no significant differences between the devices and between the recording protocols. PSNR was 12.38 ± 0.20 (Canon single scan), 13.01 ± 0.36 (Canon MIA), and 14.34 ± 0.60 (Optovue) (p < 0.001 between the groups). Mean FAZ area in Canon single scans was 0.29 ± 0.06 mm2, 0.27 ± 0.07 mm2 using MIA, and 0.27 ± 0.08 mm2 using the Optovue device. There was no significant difference between mean FAZ measurements before and after averaging (Canon single scan vs. MIA, p = 0.168). VD of the parafoveal area using MIA was significantly lower compared with both single scans (p < 0.001). CONCLUSIONS: MIA can improve PSNR, but it also reduces imaging speed and significantly affects VD measurements. Therefore, when comparing OCTA data, the use of uniform imaging protocols is required.

Automated OCT angiography image quality assessment using a deep learning algorithm.

PURPOSE: To expedite and to standardize the process of image quality assessment in optical coherence tomography angiography (OCTA) using a specialized deep learning algorithm (DLA). METHODS: Two hundred randomly chosen en-face macular OCTA images of the central 3 × 3 mm2 superficial vascular plexus were evaluated retrospectively by an OCTA experienced reader. Images were defined either as sufficient (group 1, n = 100) or insufficient image quality (group 2, n = 100) based on Motion Artifact Score (MAS) and Segmentation Accuracy Score (SAS). Subsequently, a pre-trained multi-layer deep convolutional neural network (DCNN) was trained and validated with 160 of these en-face OCTA scans (group 1: 80; group 2: 80). Training accuracy, validation accuracy, and cross-entropy were computed. The DLA was tested in detecting 40 untrained OCTA images (group 1: 20; group 2: 20). An insufficient image quality probability score (IPS) and a sufficient image quality probability score (SPS) were calculated. RESULTS: Training accuracy was 97%, validation accuracy 100%, and cross entropy 0.12. A total of 90% (18/20) of the OCTA images with insufficient image quality and 90% (18/20) with sufficient image quality were correctly classified by the DLA. Mean IPS was 0.88 ± 0.21, and mean SPS was 0.84 ± 0.19. Discrimination between both groups was highly significant (p < 0.001). Sensitivity of the DLA was 90.0%, specificity 90.0%, and accuracy 90.0%. Coefficients of variation were 0.96 ± 1.9% (insufficient quality) and 1.14 ± 1.6% (sufficient quality). CONCLUSIONS: Deep learning (DL) appears to be a potential approach to automatically distinguish between sufficient and insufficient OCTA image quality. DL may contribute to establish image quality standards in this recent imaging modality.

[Analysis of real-life data on treatment quality in patients with exudative age-related macular degeneration (AMD) and vein occlusion at a German university eye hospital]. / Real-Life-Daten-Analyse der Therapiequalität bei Patienten mit exsudativer altersabhängiger Makuladegeneration (AMD) und venösen Gefäßverschlüssen an einer deutschen Universitätsaugenklinik.

PURPOSE: Real-life data provide an insight into the reality of patient care under everyday conditions. Digitization in ophthalmology has led to a structured documentation of patient data. This makes it possible to automate the retrieval of a huge amount of real-life data by developing suitable query algorithms. METHODS: Using an automated query from fully electronic patient documentation, real-life therapy data were obtained in patients with intravitreal operative drug delivery (IVOM) in age-related macular degeneration (AMD) and vein occlusion (VO). Among other things, injection frequency, frequency of visits and best-corrected visual acuity over a total of 4 years of treatment were recorded. The influence of factors, such as patient age, distance to the clinic and type of insurance on the quality of care were also investigated. Treatment-naïve and pretreated patients were analyzed. RESULTS: In the first year AMD patients received an average of 4.59 ± 2.00 injections with 10.29 ± 4.47 visits, in the second year 3.83 ± 2.23 injections with 7.72 ± 5.78 visits, in the third year 3.40 ± 2.18 injections with 7.19 ± 5.44 visits and in the fourth year 3.11 ± 2.29 injections with 6.46 ± 6.20 visits. The VO patients received an average of 4.17 ± 2.15 injections with 9.60 ± 4.88 visits in the first year, 3.31 ± 2.03 injections with 7.75 ± 4.88 visits in the second year, 2.94 ± 2.00 injections with 6.55 ± 4.77 visits in the third year and 3.03 ± 1.94 injections with 7.18 ± 5.26 visits in the fourth year. The course of the visual acuity was relatively stable over 4 years. With repect to the quality of care, a younger patient age and a closer distance to the clinic seemed to have a positive influence. CONCLUSION: The study results show a positive trend towards an improved quality of care in intravitreal injection therapy in patients with AMD and VO. The age of the patient and the place of residence are factors influencing the therapy.

Inferior shoulder dislocation after shortening osteotomy of the humerus. A case report.

We present a case of a post-surgical complete dislocation after excessive proximal humeral shortening osteotomy performed in a patient operated on for atrophic non-union of a proximal humeral fracture. This complication has not been previously reported. The dislocation occurred due to extensive laxity of the soft tissue envelope, predominantly the deltoid muscle, as well as rotator cuff tear. The reconstructive procedure consisted of vertical duplication of the capsule, reinforcement of the repair with coracoacromial ligament, tenodesis of the long head of the biceps tendon to the conjoined tendon and distal transfer of the deltoid muscle. The repair was reinforced with transarticular Steinmann pins. 15 months after surgery, there is an inferior subdislocation present, with full reduction in active abduction. Patient is pain-free at rest, and pain grade 4 in VAS scale in activity with loading.

Prevalences of segmentation errors and motion artifacts in OCT-angiography differ among retinal diseases.

PURPOSE: To assess the prevalences of segmentation errors and motion artifacts in optical coherence tomography angiography (OCT-A) in different retinal diseases METHODS: In a retrospective analysis, multimodal retinal imaging including OCT-A was performed in one eye of 57 healthy controls (50.96 ± 22.4 years) and 149 patients (66.42 ± 14.1 years) affected by different chorioretinal diseases: early/intermediate age-related macular degeneration (AMD; n = 26), neovascular AMD (nAMD; n = 22), geographic atrophy due to AMD (GA; n = 6), glaucoma (n = 28), central serous chorioretinopathy (CSC; n = 14), epiretinal membrane (EM; n = 26), retinal vein occlusion (RVO; n = 11), and retinitis pigmentosa (RP; n = 16). Central 3 × 3 mm2 OCT-A imaging was performed with active eye-tracking (AngioVue, Optovue). Best-corrected visual acuity (BCVA) and signal strength index (SSI) were recorded. Images were independently evaluated by two graders using the OCT-A motion artifact score (MAS; scores I-IV) as well as a newly introduced segmentation accuracy score (SAS; score I-IIB). RESULTS: Mean SSI was 63.67 ± 9.2 showing a negative correlation with increasing age (rSp = - 0.42, p < 0.001, n = 206). In the healthy cohort, mean MAS was 1.45 ± 0.8 and segmentation was accurate (SAS I) in all eyes. In eyes with retinal pathologies, mean MAS was 2.1 ± 0.9 (p < 0.001). Lowest MAS was observed in GA (2.67 ± 0.5) and RVO (2.45 ± 1.1). Compared to an accurate segmentation in 100% in healthy subjects, 34.2% (n = 51) of all patients showed highest segmentation quality (p < 0.001). 63.8% showed segmentation errors in more than 5% of all single b-scans in one (SAS IIA, n = 58) or at least two (SAS IIB, n = 40) segmentation boundaries. Highest percentages of inaccurate segmentation (SAS IIA or IIB) were observed in the nAMD group (90.1%). The inner plexiform layer was the segmentation boundary most prone to inaccurate segmentation in all pathologies compared to the inner limiting membrane (ILM) and retinal pigment epithelium (RPE) segmentation layer. Incorrect ILM segmentation was only seen in patients with EM. CONCLUSIONS: Prior to both qualitative and quantitative analysis, OCT-A images must be carefully reviewed as motion artifacts and segmentation errors in current OCT-A technology are frequent particularly in pathologically altered maculae.

[Deep learning and neuronal networks in ophthalmology : Applications in the field of optical coherence tomography]. / "Deep Learning" und neuronale Netzwerke in der Augenheilkunde : Einsatzmöglichkeiten im Bereich der optischen Kohärenztomographie.

Deep learning is increasingly becoming the focus of various imaging methods in medicine. Due to the large number of different imaging modalities, ophthalmology is particularly suitable for this field of application. This article gives a general overview on the topic of deep learning and its current applications in the field of optical coherence tomography. For the benefit of the reader it focuses on the clinical rather than the technical aspects.

[Spontaneous intraocular hemorrhage under oral anticoagulation : Apixaban in comparison to phenprocoumon]. / Spontane intraokulare Blutungen unter oraler Antikoagulation : Apixaban im Vergleich zu Phenprocoumon.

BACKGROUND: To determine and compare the frequency of intraocular hemorrhage in patients who underwent oral anticoagulation with apixaban or phenprocoumon. METHODS: A retrospective analysis of patients under oral anticoagulant medication (apixaban or phenprocoumon) seen between January 2015 and June 2015 at the department of ophthalmology, University of Muenster Medical Center was performed. Vitreal or retinal hemorrhage in addition to clinical information including age, gender, best corrected visual acuity, concomitant diseases, concomitant medication and therapy were obtained. Bleeding frequency in both groups was compared using Fisher's exact test. RESULTS: A total of 172 patients were included with a mean age = 74.0 ± 10.6 years, 57.0% (n = 98) male and 43.0% (n = 74) female. In the phenprocoumon group 147 patients (3.4%, n = 5) developed a retinal or vitreal hemorrhage. In the apxiban group 25 patients (36%, n = 9) developed a retinal or vitreal hemorrhage. There was a significant correlation between the group and bleeding risk (p < 0.001). CONCLUSION: There was a significant correlation between medication (apixaban vs. phenprocoumon) and bleeding risk in this study population. Further studies with more patients especially in patients with a high risk of hemorhage, age-related macular degeneration (AMD) and proliferative diabetic retinopathy are needed.

Age-related delay in visual and auditory evoked responses is mediated by white- and grey-matter differences.

Slowing is a common feature of ageing, yet a direct relationship between neural slowing and brain atrophy is yet to be established in healthy humans. We combine magnetoencephalographic (MEG) measures of neural processing speed with magnetic resonance imaging (MRI) measures of white and grey matter in a large population-derived cohort to investigate the relationship between age-related structural differences and visual evoked field (VEF) and auditory evoked field (AEF) delay across two different tasks. Here we use a novel technique to show that VEFs exhibit a constant delay, whereas AEFs exhibit delay that accumulates over time. White-matter (WM) microstructure in the optic radiation partially mediates visual delay, suggesting increased transmission time, whereas grey matter (GM) in auditory cortex partially mediates auditory delay, suggesting less efficient local processing. Our results demonstrate that age has dissociable effects on neural processing speed, and that these effects relate to different types of brain atrophy.

Impact of eye-tracking technology on OCT-angiography imaging quality in age-related macular degeneration.

OBJECTIVE: To evaluate the impact of eye-tracking (ET) technology on optical coherence tomography angiography (OCT-A) image quality and manifestation of motion artifacts in patients with age-related macular degeneration (AMD). METHODS: In a prospective trial, multimodal retinal imaging including OCT-A was performed in 30 patients (78.97 ± 9.7 years) affected by different stages of AMD. Central 3 × 3 mm2 OCT-A imaging was performed four times consecutively in each patient, twice with active, and twice with inactive ET. Parameters for image evaluation were signal strength index (SSI), variability of foveal vessel density (VD), acquisition time, presence of motion artifacts caused by eye movement (blink lines, displacement) and by software correction of eye movement (quilting, stretch artifacts, vessel doubling). Images were evaluated by two independent readers with subsequent senior reader arbitration for presence of artifacts, and an OCT-A motion artifact score (MAS) was calculated. RESULTS: Eight patients had early and eight patients had intermediate stages of AMD. Four patients had an atrophic late stage and ten patients an exudative stage of the disease. SSI was 53.55 with inactive and 57.18 with active ET (p = 0.0005). Coefficients of variability of VD between the first and second measurement were 8.9% with inactive and 5.7% with active ET. Mean image acquisition time was 15.97 s (active ET: 22.88 s, p < 0.001). Presence of motion artifacts was significantly higher with inactive ET (mean MAS 3.27 vs. 1.93; p < 0.0001). MAS correlated with AMD disease stage [p = 0.0031 (inactive ET) and p < 0.0001 (active ET)] and with SSI (p = 0.0072 and p = 0.0006). CONCLUSIONS: In patients with AMD, active ET technology offers an improved image quality in OCT-A imaging regarding presence of motion artifacts at the expense of higher acquisition time.

Decoding auditory attention to instruments in polyphonic music using single-trial EEG classification.

OBJECTIVE: Polyphonic music (music consisting of several instruments playing in parallel) is an intuitive way of embedding multiple information streams. The different instruments in a musical piece form concurrent information streams that seamlessly integrate into a coherent and hedonistically appealing entity. Here, we explore polyphonic music as a novel stimulation approach for use in a brain-computer interface. APPROACH: In a multi-streamed oddball experiment, we had participants shift selective attention to one out of three different instruments in music audio clips. Each instrument formed an oddball stream with its own specific standard stimuli (a repetitive musical pattern) and oddballs (deviating musical pattern). MAIN RESULTS: Contrasting attended versus unattended instruments, ERP analysis shows subject- and instrument-specific responses including P300 and early auditory components. The attended instrument can be classified offline with a mean accuracy of 91% across 11 participants. SIGNIFICANCE: This is a proof of concept that attention paid to a particular instrument in polyphonic music can be inferred from ongoing EEG, a finding that is potentially relevant for both brain-computer interface and music research.

Gaze-independent brain-computer interfaces based on covert attention and feature attention.

There is evidence that conventional visual brain-computer interfaces (BCIs) based on event-related potentials cannot be operated efficiently when eye movements are not allowed. To overcome this limitation, the aim of this study was to develop a visual speller that does not require eye movements. Three different variants of a two-stage visual speller based on covert spatial attention and non-spatial feature attention (i.e. attention to colour and form) were tested in an online experiment with 13 healthy participants. All participants achieved highly accurate BCI control. They could select one out of thirty symbols (chance level 3.3%) with mean accuracies of 88%-97% for the different spellers. The best results were obtained for a speller that was operated using non-spatial feature attention only. These results show that, using feature attention, it is possible to realize high-accuracy, fast-paced visual spellers that have a large vocabulary and are independent of eye gaze.

[Acetabular roof remodeling after varus derotation osteotomy in congenital hip dysplasia]. / Przebudowa stropu panewki stawu biodrowego po osteotomii detorsyjno-dewalgizujacej w leczeniu rozwojowej dysplazji stawu biodrowego.

The aim of this paper was to evaluate the acetabular roof remodelling process and changes of the Wiberg angle after proximal femur varus drotational osteotomy up to skeletal maturity. The analysis included 33 patients after 48 osteotomies (in 15 patients on both sides). The age at the time of surgery ranged from 1.0 to 9.8 years, mean 4.7 years. Follow-up time ranged from 7.6 to 15.9 years, mean 12.0 years. Statistical analysis showed significant differences in acetabular index, Sharp's angle, acetabular ratio and Wiberg's angle between early post-operative x-rays and radiograms taken at the last follow-up. Comparison not only of the remodelling dynamics, but also final radiological measurements confirm the necessity for surgical of severely dysplastic acetabular roof, especially in older age groups.

[The influence of the amount of variation of cervical-thoracic angle on the hip status and radiological results of the treatment of developmental hip dysplasia by torsion osteotomy]. / Wplyw wartosci waryzacji kata szyjkowo-trzonowego na przebudowe stawu biodrowego i radiologiczne wyniki leczenia rozwojowej dysplazji stawu biodrowego osteotomia detorsyjno-dewalgizujaca.

The aim of this paper was to determine the differences in hip remodeling and final outcomes of hip dysplasia treatment by fixing a certain amount of varus during varus-detorsion osteotomy of the proximal femur. The analysis included 33 children who underwent 48 osteotomies. During final follow-up at skeletal maturity it was found that the amount of varus fixed during the osteotomy influenced significantly femur remodeling and some containment measurements. However it played only slight part in acetabular remodeling. The outcomes at final follow-up proved significantly better in the group in whom a greater amount of varus was fixed.

[Proximal femur remodeling after proximal femur varus-derotational osteotomy in treatment of developmental dysplasia of the hip]. / Przebudowa blizszego konca kosci udowej po osteotomii detorsyjno-dewalgizujacej w leczeniu rozwojowej dysplazji stawu biodrowego.

The aim of this paper was to assess proximal femur remodelling after proximal femur varus-derotational osteotomy in treatment of developmental dysplasia of the hip up to skeletal maturity. The analysis included 48 osteotomies performed in 33 children between 1st and 10th year of life. The follow-up period was on average 12 years. Supported by statistical evaluation the analysis showed persistent increase of the neck-shaft angle after proximal femur varus-derotational osteotomy, especially in the younger age groups. It also correlated strongly with the amount of varus fixed at the time of operation. On other hand femoral antetorsion corrected during surgery remained unchanged till skeletal maturity.

[Surgical resection of primary soft-tissue sarcoma of the extremities]. / Chirurgiczne leczenie oszczedzajace w przypadku miesaków tkanek miekkich konczyn.

We evaluated 5 patients who had soft tissue sarcoma of the extremity treated by limb sparing surgery. All tumors were adjacent to bone, with no features of infiltration. According to the Surgical Staging System, all tumors were IIB. The mean follow-up was 13 months. To achieve wide resections of the tumors in such cases we recommend resections of the tumor with part of the bone, which is in direct contact with the tumor. Wide resection margins were achieved in all patients and none had local recurrence during the observation period.