Prospective PED-study of intravitreal aflibercept for refractory vascularized pigment epithelium detachment due to age-related macular degeneration: morphologic characteristics of non-responders in optical coherence tomography.

PURPOSE: The aim of this study was to investigate the outcomes of a fixed intravitreal aflibercept regimen in patients with vascular pigment epithelium detachment (vPED) secondary to age-related macular degeneration with refractory subretinal fluid. METHODS: A prospective, interventional case series involved 20 eyes of 20 patients with refractory subretinal fluid and vPED treated with at least three injections of intravitreal anti-VEGF prior to study inclusion. After study inclusion, patients were treated with three injections of intravitreal aflibercept 2 mg/0.05 mL monthly followed by injections every 8 weeks. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) were evaluated at all visits. Fluorescein angiography and indocyanine green angiography were performed at baseline and quarterly. Primary outcomes were effectivity of a fixed treatment as measured in change in BCVA, PED greatest linear diameter (GLD), and PED height from baseline to month 12. In an additional post hoc analysis, vPED patients were differentiated into two groups: (1) vPED lesions that showed persistence of subretinal fluid throughout 1 year of treatment and (2) vPED lesions that showed complete resolution of subretinal fluid at least at one of the monthly performed OCT volume scans. Reflectivity values were determined in the subretinal pigment epithelium (RPE) compartment in OCT scans at baseline, month 6 and 12. RESULTS: A total of 18 patients completed the study protocol. The mean age was 74.8 ± 10.6 years, and six patients were female. The median BCVA of all patients was 72.0 ± 8.0 EDTRS letters at baseline and 72.5 ± 9.5 EDTRS letters at 12-month follow-up (p = 0.7420). The median PED height in all patients as measured in the OCT images significantly decreased from 372.0 ± 140.0 µm to 149.0 ± 142.0 µm after 12 months of treatment (p = 0.0020). Persistent subretinal fluid was present at every OCT control in six patients (group 1). Twelve patients showed resolution of subretinal fluid at least at one OCT control (group 2). Reflectivity values in the sub-RPE compartment in OCT scans were 41.48 ± 4.48 (group 1) and 42.62 ± 12.34 (group 2) at baseline (p = 0.854) and 65.88 ± 6.74 and 50.87 ± 14.11 at month 12 (p = 0.038). CONCLUSIONS: Intravitreal aflibercept in refractory vPED leads to a significant reduction in PED height and disease activity as well as preservation of BCVA over 1 year. Persistent subretinal fluid was present in PED lesions with high values of reflectivity under the RPE, suggesting both a diffusion barrier and an increasing fibrovascular maturization of the choroidal neovascularization. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03370380.

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.

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.

Quantification of changes in foveal capillary architecture caused by idiopathic epiretinal membrane using OCT angiography.

PURPOSE: To quantify the extent and depth of distortion of the foveal capillary architecture due to traction of an idiopathic epiretinal membrane (ERM) using optical coherence tomography angiography (OCT-A). METHODS: Multimodal imaging including OCT-A (Angiovue, Optovue) was performed in 42 eyes with idiopathic ERM (72.4 years ±6.8). Best corrected visual acuity (BCVA), OCT-A vessel density of the foveal (VDfo) and parafoveal (VDp) region were assessed. Based on 6 × 6-mm2 OCT-A images, a macular vessel density ratio (MVR = VDfo/VDp) was calculated for the superficial (s), deep (d) and full-thickness (f) slabs to assess a depth-resolved, non-invasive evaluation of foveal distortion. The acquired data were subdivided in a patient group with mild and significant BCVA reduction due to ERM. Data was compared to age-matched healthy controls. RESULTS: In all three slabs, MVR was significantly smaller in the control group in comparison with the ERM group: MVRs: 0.63 ± 0.1 vs 0.83 ± 0.1 (p > 0.001); MVRd: 0.60 ± 0.1 vs 0.73 ± 0.1 (p < 0.001); MVRf: 0.68 ± 0.1 vs 0.82 ± 0.1 (p < 0.001). Group 1 (BCVA <0.4 LogMar) showed a significantly higher MVR in comparison with the control group in the superficial plexus only: MVRs: 0.64 ± 0.1 vs 0.78 ± 0.1 (p < 0.001); MVRd: 0.60 ± 0.1 vs 0.65 ± 0.2 (p = 0.3); MVRf: 0.68 ± 0.1 vs 0.77 ± 0.1 (p = 0.01). However, group 2 (BCVA > = 0.4 LogMar) showed a significantly higher MVR in all three slabs: MVRs: 0.64 ± 0.1 vs 0.86 ± 0.1 (p < 0.001); MVRd: 0.60 ± 0.1 vs 0.77 ± 0.2 (p < 0.001); MVRf: 0.68 ± 0.1 vs 0.85 ± 0.1 (p < 0.001). CONCLUSION: Assessing MVR using OCT-A may serve as a tool to quantify the extent and depth of distortion of the foveal capillary architecture due to traction of ERM. BCVA reduction appears to be associated with extent and depth of distortion.

Signal reduction in choriocapillaris and segmentation errors in spectral domain OCT angiography caused by soft drusen.

PURPOSE: To analyze signal reduction in choriocapillaris (CC) and segmentation errors in spectral domain optical coherence tomography angiography (OCT-A) caused by soft drusen due to age-related macular degeneration (AMD). METHODS: Twenty-four eyes of 24 patients underwent multimodal retinal imaging including central 3 × 3mm2 OCT-A (AngioVue, Optovue). Three drusen per study eye were randomly chosen and evaluated regarding drusen height, diameter, and accuracy of OCT-A layer segmentation in lesion proximity. Structural en-face OCT CC images were graded qualitatively and quantitatively regarding signal loss underneath the individual drusen area. Those drusen that showed no distinct signal loss in structural en-face OCT CC images were further evaluated in OCT-A. CC decorrelation signal index was measured within a 30-µm OCT-A CC slab in the exact area of drusen affection. Data were compared to healthy age-matched control subjects. Accuracy of layer segmentation, OCT CC data, and OCT-A CC data were correlated to morphological drusen parameters. RESULTS: Mean drusen height and diameter were 91.57 ± 19.5µm and 315.17 ± 116.7µm. OCT-A layer segmentation of the inner plexiform layer (IPL) was disturbed by more than 50 µm in proximity to 26 drusen (36.1%). In these patients, drusen height was significantly higher compared to those with accurate IPL segmentation (p = 0.0126). Sixty-six out of 72 drusen (91.7%) caused a distinct signal loss in the structural en-face OCT CC image. Drusen height and drusen diameter were significantly higher in this group compared to the six drusen with a sufficient signal (p = 0.0276, p = 0.0025). CC decorrelation signal index measured in the area of these six drusen without OCT signal loss (8.3%) was reduced compared to age-matched healthy controls (73.6 vs. 100.1; p = 0.001). CONCLUSIONS: Signal attenuation in CC slabs and segmentation errors of the IPL depend on drusen morphology. Both are frequent artifacts in OCT-A imaging in patients with soft drusen and must be considered during image analysis.

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.

[Traumatic Lacrimal Duct Stenosis: Demographics and Success Rate of Surgical Procedures for Secondary Treatment]. / Traumatische Tränenwegsstenosen: Epidemiologie und Erfolgsraten nach sekundärer operativer Intervention.

BACKGROUND: Traumatic lacrimal duct stenosis can be the result of sharp trauma of the eyelid, indirect trauma or surgery in the nasoorbital region, as well as burns, chemotherapy and radiation of the facial region. The aim of the study is to present the demographics, patient satisfaction, and course of different surgical procedures for secondary treatment of traumatic lacrimal duct stenosis. METHODS: We retrospectively reviewed the medical records of 50 patients who required surgery for traumatic lacrimal duct stenosis from 2009 to 2011 at the University Eye Hospital in Muenster. The evaluation included the following criteria: age, sex, duration of symptoms, complication rate and the rate of recurrence. We systematically evaluated the medical data and asked the patients about the recent symptoms via telephone questionnaire. RESULTS: 60 eyes of 50 patients were included (18 women; 32 men; age: 51.8 ± 17.1 years); 34 eyes (56.7 %) had already had operations of the lacrimal system. The success rate was 58.1 %. The mean postoperative follow-up was 52.3 ± 10.7 months. In 11 cases (18.3 %), a dakryocystorhinostomy (DCR) was necessary. CONCLUSION: Traumatic lacrimal stenosis is more common in men, and has a poorer prognosis than lacrimal duct stenosis from other causes.

[Diurnal Fluctuations of Intraocular Pressure, Blood Pressure, and Ocular Perfusion Pressure in Glaucoma Patients]. / Schwankungen des Augeninnendrucks, Blutdrucks und okulären Perfusionsdrucks bei Glaukompatienten.

BACKGROUND: An elevated intraocular pressure remains the main risk factor for the development and progression of glaucoma but other factors such as fluctuations of the intraocular pressure, the blood pressure, and the ocular perfusion pressure are gaining in importance. The influence of the anti-glaucomatous therapies on these parameters is barely investigated. This study investigates 1) a correlation between the fluctuations of the intraocular pressure, the blood pressure and the ocular perfusion pressure with the severity of the glaucoma damage and 2) if these parameters can be influenced by different anti-glaucomatous therapies. MATERIAL AND METHODS: Data from 121 glaucoma patients who had been hospitalised for 24-hour measurements of the intraocular pressure and blood pressure between 2003 and 2012 were analysed retrospectively. The patients were divided into groups by the severity of the glaucoma damage and by their anti-glaucomatous therapy. Mean values for the intraocular pressure, the blood pressure and the ocular perfusion pressure were calculated and correlated with the individual groups. The statistical analysis was performed with SPSS21.0 using Kruskal-Wallis and Mann-Whitney U tests for the comparison of the groups. RESULTS with p < 0.05 were considered statistically significant. RESULTS: The severity of the glaucoma damage correlated significantly with higher mean values of the intraocular pressure and its fluctuations, as well as with a nocturnal decrease of the blood pressure and low mean values of the ocular perfusion pressure (p < 0.0001). The anti-glaucomatous therapy decreased the intraocular pressure to normal values. A monotherapy with carboanhydrase inhibitors correlated with the lowest fluctuations of the ocular perfusion pressure while a quadri-therapy was associated with higher values of the intraocular pressure and its fluctuations. The anti-glaucomatous therapy did not show an association with the blood pressure or the ocular perfusion pressure. CONCLUSION: Glaucoma is negatively influenced by high intraocular pressure, nocturnal blood pressure decreases and ocular perfusion pressure fluctuations. A monotherapy with carboanhydrase inhibitors seems to be sufficient to decrease fluctuations of the intraocular pressure. Patients with a quadri-therapy should be monitored regularly as they present high values of intraocular pressure and its fluctuations. A hospitalisation of the patients with 24-hour measurements of the intraocular pressure and blood pressure provides information needed to improve the therapy or decide about surgical interventions.

[Effect of Hypericin on the Function of the Neuroretina: An Electroretinographic Study]. / Einfluss von Hypericin auf die isolierte pigmentepithelfreie Netzhaut: Eine elektroretinografische Untersuchung.

BACKGROUND: Hypericin is an important component of the Saint John's wort (Hypericum perforatum). It is assumed to inhibit intracellular signalling cascades, which contribute to neoangiogenesis. The phototoxic effect of hypericin on the retina was investigated in human retinal pigment epithelium (RPE); hypericin induces oxidative stress and has also been described to be an inhibitor of Ca(2+) influx channel in cultured RPE cells. The aim of our study is to evaluate the effect of hypericine on the function of the neuroretina. METHODS: Isolated bovine retinas were perfused with an oxygen saturated nutrient solution (1 mL/min). We exposed the retina to a flashlight of 6.3 mlx every 5 min. The electroretinogram (ERG) was recorded as a transretinal potential using Ag/AgCl electrodes. ERGs were monitored before, during and after hypericin exposure. RESULTS: In three independent experiments we investigated the effect of hypericin on the amplitude of the b-wave. In our experiments we observed a significant reduction of the amplitude of the b-wave to 87.1 ± 3.5 % (p = 0.02). This reduction was in all our experiments partially reversible. After hypericin wash-out the b-wave amplitude did not recover completely and did not return to the initial value (91.0 ± 5.1 %; not significant). We did not observe a significant effect of hypericin on the implicit time of the b-wave. CONCLUSION: This study shows for the first time that hypericin influences retinal signal transduction, suggesting that hypericin impairs not only the RPE, but also affects retinal signalling and function.

[Microsurgical Treatment of Canalicular Stenosis: Long-Term Follow-Up]. / Verlauf von Kanalikulusstenosen nach mikroskopischer Kanalikuluschirurgie.

PURPOSE: Studies about the indication and the functional prognosis of microsurgical treatment of canalicular stenosis (CR) are rare. In this study we determined the cause, recurrence and success rates of CR and compared our results with the results in the literature. METHODS: We retrospectively reviewed the medical records of 22 patients who required a microsurgical treatment of canalicular stenosis (CR) from 2009 to 2011. We systematically evaluated the medical data and asked the patients about the recent symptoms via telephone questionnaire. RESULTS: 22 patients were included (73 % women; 27 % men; age: 52.8 ± 19.9 years), 12 (55 %) patients had already had operations. The mean postoperative follow-up was 45 ± 9.2 months. The patients were followed for a minimum of 30 months. The success rate was 58 %. CONCLUSION: In some cases like long localised canalicular stenosis and especially after traumatic lacerations of the lacrimal canaliculi, a microsurgical treatment of canalicular stenosis is required. The aim of this procedure is to restore the lacrimal mucosa continuity so that a spontaneous lacrimal drainage is possible. The success rate of CR in our study was 58 %.

Characterisation of reticular pseudodrusen and their central target aspect in multi-spectral, confocal scanning laser ophthalmoscopy.

BACKGROUND: To analyse reticular pseudodrusen (RPD) in patients with age-related macular degeneration (AMD) using multi-spectral (MS), confocal scanning laser ophthalmoscopy (cSLO). METHODS: cSLO images (blue fundus autofluorescence [FAF; exc., λ = 488; em., λ = 500-700 nm], near-infrared reflectance [IR; λ = 820 nm], MS [blue reflectance (BR) λ = 488 nm, green reflectance (GR) λ = 515 nm, IR λ = 820 nm], as well as colour fundus photographs (CFP) were taken of 200 eyes from 100 AMD patients suspected to show RPD on the basis of funduscopy or previous fundus imaging. FAF and IR images were graded by two independent readers. If both readers concordantly confirmed the presence of RPD in both modalities, eyes were subsequently also graded for RPD in MS, BR, GR, green-blue enhanced mode (GBE), and CFP. Besides, FAF, IR, and MS images were evaluated for the presence of a target aspect, which represents a common feature of RPD lesions. RESULTS: The presence of RPD was confirmed using FAF and IR images by both readers in 130 eyes of 76 patients. In those eyes, both readers concordantly diagnosed RPD in MS images in 124 (95.4%) eyes (BR: 52 [40.0%], GR: 63 [48.5%], GBE: 101 [77.7%], CF: 27 [20.8%]). Cohen kappa statistics revealed excellent inter-observer agreement for MS (0.95) and GBE (0.85), substantial agreement for BR (0.75), GR (0.78), and moderate agreement for CFP (0.59). A target aspect within RPD lesions was detected in 45 of 130 (35.0%) included eyes using FAF and IR. The presence of a target aspect improved the recognition of RPD lesions in all modalities. If a target aspect was present, RPD were diagnosed in 45 eyes (100%) using MS (GBE: 42 eyes [93.3%], BR: 30 eyes [66.7%], GR: 37 eyes [82.2%], CFP: 17 eyes [37.8%]). Using MS cSLO, a target aspect could be identified in 75 of 130 (57.7%) included eyes. CONCLUSIONS: MS cSLO imaging is equivalent to FAF and IR in identifying RPD in AMD patients. Higher identification rates in BR and GR of those RPD lesions featuring a target aspect confirm the current hypothesis of RPD localisation and its progression further into the photoreceptor layers. MS seems to be more sensitive in identifying a central target aspect in RPD lesions compared to blue FAF and IR.

[Alterations of intraocular pressure in comparison of self- and external-administered topical antiglaucomatosa during diurnal intraocular pressure measurements]. / Vergleichende Analyse intraokularer Druckwerte zwischen Fremd- und Eigenapplikation topischer Antiglaukomatosa bei stationärem Tagestensioprofil.

BACKGROUND: The correct self-administration of topical antiglaucomatous eye drops is important for the success of glaucoma treatment. Individual impairment, like increased age, decreased visual acuity, impaired visual-field perception or the frequency of drug appliance may influence a correct application technique and the patients compliance and therewith intraocular pressure (IOP). The aim of this study was to explore alterations of IOP due to self versus external administration (by trained medical personnel) of topical antiglaucomatous eye drops due to impairing factors. MATERIAL AND METHODS: A prospective analysis was undertaken of 123 patients with primary chronic open-angle glaucoma receiving a diurnal intraocular pressure (DIP) measurement over 72 hours at our department. During the first 24 hours, the application of topical eye drops was self-administered by patients (SA), while the application of eye drops within the following 48 hours was performed by trained medical personnel (EA). Alterations of mean intraocular pressure (MIP) and diurnal fluctuations (DF) between EA and SA were analysed with regard to initial IOP, restrictions of visual field perception, visual acuity, age, general health status and frequency of daily eye drop administration. RESULTS: Overall comparable MIP in SA and EA was seen. 19.2-43.9 % of the patients with an initial IOP ≥ 11 mmHg showed beneficial effects of EA with lowering of IOP under 15.5 mmHg. 27.6 % of the patients showed lowering of DF < 5 mmHg due to EA. EA influenced DF beneficially in cases of poor visual acuity (≤ 0.1, - 0.8 mmHg) and frequent drop administration (- 0.75 mmHg). CONCLUSIONS: Subpopulations of investigated patients showed lowering of MIP due to EA, although EA showed no MIP lowering effects in comparison with SA in general. Glaucoma-impaired patients show decreased DF by EA. Particularly beneficial influences to DF by EA were observed due to impaired visual acuity and frequent drop administration. We recommend a 72-hour DIP to evaluate individual parameters influencing the success of topical glaucomatous treatment. The benefit of EA in patients with certain impairments should be the subject of further investigations.

Automatic inference of ICD-10 codes from German ophthalmologic physicians' letters using natural language processing.

Physicians' letters are the optimal source of diagnoses for registries. However, most registries demand for diagnosis codes such as ICD-10. We herein describe an algorithm that infers ICD-10 codes from German ophthalmologic physicians' letters. We assess the method in three German eye hospitals. Our algorithm is based on the nearest-neighbor method as well as on a large thesaurus for ICD-10 codes. This thesaurus was embedded into a Word2Vec space created from anonymized physicians' reports of the first hospital. For evaluation, each of the three hospitals sent all diagnoses taken from 100 letters. The inferred ICD-10 codes were evaluated for correctness by the senders. A total of 3332 natural language terms had been sent in (812 hospital one, 1473 hospital two, 1047 hospital three). A total of 526 non-diagnoses were excluded upfront. 2806 ICD-10 codes were inferred (771 hospital one, 1226 hospital two, 809 hospital three). In the first hospital, 98% were fully correct and 99% correct at the level of the superordinate disease concept. The percentages in hospital two were 69% and 86%. The respective numbers for hospital three were 69% and 91%. Our simple method is capable of inferring ICD-10 codes for German natural language diagnoses, especially when the embedding space has been built with physicians' letters from the same hospital. The method may yield sufficient accuracy for many tasks in the multi-centric setting and can easily be adapted to other languages/specialities.

Skin metastases in metastatic uveal melanoma: GNAQ/GNA11 mutational analysis as a valuable tool.

BACKGROUND: Uveal melanomas represent 3.1% of all melanomas, with a high potential of metastatic disease of up to 50%, where the median survival time is 6 months. Though liver metastases dominate as the primary site for metastasis, the existence of primary skin metastases is still under discussion but has been reported in only a few studies. OBJECTIVES: We present two cases in which patients with a known history of uveal melanoma developed melanoma skin metastases. METHODS: Mutational analysis was performed to clarify the origin of the metastases (uvea or skin). RESULTS: The analyses revealed GNA11 mutations, which are typical for uveal melanoma. These cases strongly suggest the skin to be the primary site of uveal melanoma. CONCLUSIONS: Knowledge about the mutational status of uveal melanomas opens the opportunity for future targeted therapies that directly interact with the mutation and its activated signal cascades. First trials in uveal melanoma have shown promising results with MEK inhibitors.

[Impact of age on success rate of lacrimal duct irrigation with silicone tube intubation in connatal lacrimal duct stenosis]. / Einfluss des Operationszeitpunktes auf den langfristigen Erfolg von Tränenwegsoperationen mit Schlauchintubation bei kindlicher Tränenwegsstenose.

BACKGROUND: Irrigation of the lacrimal duct with silicone tube intubation (TWS/S) remains the preferred treatment in persisting connatal lacrimal duct stenosis (kTWS). The timepoint of operation is however discussed controversely. On the one hand, it is recommended to wait for spontaneous opening of the lacrimal duct within the first year of life, on the other hand a later operation may trigger inflammatory changes within the lacrimal duct system influencing the success rate of the operation negatively. The aim of this study was to analyze the best time point of operation regarding the long-term success rate of the operation. PATIENTS/MATERIALS AND METHODS: 411 lacrimal ducts of 316 children with kTWS between 0 and 48 months of age (164 male, 156 female), who had undergone TWS with S because of kTWS at a tertiary eye care centre between 2007-2011 were included in this study. The children were divided into 6 groups of age (0-6, 7-12, 13-18, 19-24, 24-36, > 36 months) at the time of operation. The operative success was retrospectively evaluated after 36 months. The groups were compared and differences in late success rate analyzed statistically. RESULTS: The average success of operation of TWS/S in kTWS was 89 % (366 of 411 lacrimal ducts). The success rate of operation differed between the groups. If operated at the age of 0-6 months the operation was successful in 94 %, at the age 7-12 months in 91 %, between 13-18 months in 90.5 %, from 19-24 months in 88 %, and from 25-36 months in only 84.5 %. The success rate was therewith at the age of 25-36 months significantly lower than at the age of 0-6 months (p < 0.05). CONCLUSION: TWS/S in kTWS has overall a very high rate of success. The success of the operation decreases however in correlation with age at time of operation and shows with > 25 months significantly poorer results than at 0-6 months. The choice of the best time point for operation merits further investigation.

Light conditions influence optic nerve OCT angiography parameter in healthy subjects with neutral pupils.

Optical coherence tomography angiography measurements are influenced by a range of environmental factors as blood pressure and physical fitness. The present study aimed to evaluate the effects of light and dark exposure in eyes with neutral and mydriatic pupils on vessel density in the macular and optic nerve head regions, as measured using optical coherence tomography angiography (OCTA). 55 eyes of 55 healthy volunteers (28 patients with neutral pupils; 27.18 ± 4.33 years) were examined using a high-speed and high-resolution spectral-domain OCT XR Avanti system with a split-spectrum amplitude de-correlation angiography algorithm. OCTA imaging was performed after dark adaptation and after exposure to light. The vessel density data of the superficial and deep retinal macular and optic nerve head region OCT-angiogram were analyzed for these two light conditions. Through Bonferroni correction for multiple testing, the p- value was adapted from 0.05 to 0.017. In eyes with neutral pupils, a significant increase was found in the capillary region of the optic nerve head region (p = 0.002), comparing dark- and light-adaptation. In the macular region of eyes with neutral (p = 0.718) and mydriatic pupils (p = 0.043), no significant differences were observed, as were any in the optic nerve head region of the mydriatic eyes (p = 0.797). This observation suggests that light conditions could be a possible factor influencing OCTA measurements. After dark exposure, vessel density data were significantly different between eyes with neutral and mydriatic pupils (nerve head region: p < 0.0001, superficial macula: p < 0.0001, deep macula: p = 0.0025). These data warn for the effect of mydriatic drops on vessel density measurements.

[Current situation of electronic medical records in ophthalmological departments in Germany]. / Status der elektronischen Dokumentation in ophthalmologischen Hauptabteilungen in Deutschland.

BACKGROUND: Electronic medical records are required in ophthalmology clinics to be integrated into digital care networks and efficient clinical registry databases. AIM OF THE WORK: To assess the prevalence and methods of electronic medical recordkeeping in inpatient ophthalmological care in Germany. MATERIAL AND METHODS: An online questionnaire was sent to all German university eye hospitals and ophthalmology departments in June 2021. It included 13 open and closed option questions concerning current practices of digital recordkeeping, including the structure of data storage and the recording of billing-relevant codes in the departments. RESULTS: A total of 44 (44%) out of 100 clinics responded. Patient documentation was completely digital in 15 (34%) clinics and partly digital and paper-based in the remaining 29 (66%). A total of 16 different constellations of documentation programs were specified. The most frequently used programs were Orbis (27%) (Dedalus HealthCare, Bonn, Germany), FIDUS (18%) (Arztservice Wente, Darmstadt, Germany), and SAP/i.s.h.med (16%) (SAP Deutschland, Walldorf, Germany; Cerner Deutschland, Berlin, Germany) and 3 clinics indicated primary use of paper records. Structured documentation of findings was performed in 61% of the departments, while 23% used a semistructured manner and 15% used a nonstructured format. Electronic documents are stored as DICOM (Digital Imaging and Communications in Medicine) documents 20% of the clinics and as PDF (Portable Document Format) files in 34% of the clinics while 23% store scanned printouts. DISCUSSION: Methods of medical record keeping in German eye clinics are heterogeneous, with paper-based documentation continuing to play an important role. This, as well as the high number of different electronic medical record software pose important challenges in terms of interoperability and secondary use of clinical data.

[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.