[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.

[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.

[Current recommendations on optic neuritis]. / Aktuelle Empfehlungen zur Neuritis nervi optici.

BACKGROUND: The diagnostics and therapy of optic neuritis are complex and require interdisciplinary cooperation. AIM: Compact, up-to-date recommendations for the clinician appear to be desirable. MATERIAL AND METHODS: A selective literature search including the authors' professional experience was carried out. An algorithm for the practical approach to optic neuritis was derived from the best available evidence. RESULTS: Our recommendation distinguishes between compulsory and optional investigations. Differential diagnostic cues with regard to atypical optic neuritis and other optic neuropathies are shown. Standard therapy patterns and means of escalation are suggested. Indications for referral are presented. CONCLUSION: The algorithm suggested in this article provides ophthalmologists with an effective orientation aid for the complete treatment procedure of optic neuritis.

[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.

[Functional diagnostic options for advanced and end stage glaucoma]. / Funktionsdiagnostische Möglichkeiten bei fortgeschrittenem oder präterminalem Glaukom.

The visual functional diagnostics for patients with advanced glaucomatous optic neuropathy are subject to challenge. Reduced visual acuity, instable fixation and extensive scotomata frequently lead to incorrect results within the central 30° or 24° field. Static automatic perimetry (SAP) in particular is often hampered by extended examination time and fatigue especially in older patients. Focusing of the examination towards the central 10° field using a dense test grid (2° distance between stimulus locations) allows a more exact assessment of the small remaining central island. Tailoring the examination area towards the central 10° field may be useful even in cases with a mean deviation (MD) of 15 dB. In cases of advanced visual field loss kinetic perimetry is superior to static perimetry for various reasons: sharply demarcated visual field defects can be comparatively easily delineated (edge detection); the results are more reliable because fixation can be easily controlled and fatigue is much less pronounced in this interactive examination procedure. However, manual kinetic visual field testing within the central 5° using the conventional Goldmann perimeter is almost impossible due to technical reasons. Semi-automated kinetic perimetry, presenting moving stimuli along interactively defined vectors is a useful tool under these circumstances. The standardized presentation of kinetic stimuli is also feasible within the pericentral region and has particular advantages also with regard to follow-up examinations. On the other hand, detection and delineation of small visual field remnants are comparatively difficult to handle with this kind of vector-based kinetic perimetry.

[Conventional perimetry. Antiquated or indispensable for functional glaucoma diagnostics?]. / Konventionelle Perimetrie. Antiquiert oder unverzichtbar für die funktionelle Glaukomdiagnostik?

Despite its relatively long history conventional perimetry has preserved its role in (glaucoma) diagnostics by the continuous advancement of technical equipment, examination strategies and new methods for analysis and visualization of progression. A high standardization in execution and evaluation of visual field examination can now be obtained by the increasing use of computer technology. Standardized protocols become increasingly more useful especially in cases of chronic diseases, such as glaucoma where several suitable diagnostic methods must be applied over a long time period. For the assessment of functional deterioration several (numeric) perimetric indices are available in addition to clinical evaluation. The use of fast threshold estimating strategies and locally condensed grids are promising tools for early detection of the functional manifestation or progression of (glaucomatous) loss of visual field. In cases of advanced (glaucomatous) visual field loss, perimetry with (computer generated) moving stimuli (semi-automated kinetic perimetry) allows an efficient, standardized and patient-friendly edge detection of scotoma borders. This method is also very well suited for expert opinions and ability testing. The assessment by morphological or morphometric, hydrodynamic and other functional parameters serve as complementary diagnostic aids or as elementary tools for plausibility control.

[Current state of pupil-based diagnostics for glaucomatous optic neuropathy]. / Aktueller Stand der pupillenbasierten Diagnostik der glaukomatösen Optikusneuropathie.

There are considerable differences between pupillary reactions to light in glaucoma patients and healthy subjects which can be identified by various techniques. These methods are based on the early asymmetry of the afferent conduction in the visual pathway, on the examination of the visual field by focal light stimuli or on visual stimuli in analogy with multifocal electrophysiological tests. Latest findings in pupillary research also suggest a possible use of the intrinsically photosensitive (melanopsin expressing) retinal ganglion cells in glaucoma diagnostics. The current results of pupillary experiments in glaucoma patients are encouraging for further research in this field because suitable objective screening methods for glaucoma are continually being sought.

[Stereometric parameters of the optic disc. Comparison between a simultaneous non-mydriatic stereoscopic fundus camera (KOWA WX 3D) and the Heidelberg scanning laser ophthalmoscope (HRT IIII)]. / Stereometrische Parameter der Papillentopographie. Vergleich einer simultan-stereoskopischen Non-Mydriasis-Funduskamera (KOWA WX 3D) mit dem Heidelberg Retina Tomograph (HRT III).

BACKGROUND: The Heidelberg retina tomograph (HRTIII, Heidelberg Engineering, Germany) in conjunction with the Moorfields regression analysis (MRA) allows monitoring for the progression of early damage to the optic nerve suspicious of early stage glaucoma. The confocal scanning laser ophthalmoscope provides clinicians with an objective and reproducible analysis of morphological parameters of the optic disc. Margins of the optic disc are approximated with a contour line to calculate the stereometric parameters leading to interobserver and intraobserver variability of the MRA. New devices enabling 3D fundus photography might be an alternative to the established HRT. It was the goal of this study to compare the methods by assessing the differences in the topographic parameters obtained by the HRT and the Kowa nonmyd WX 3D (2D/3D non-mydriatic retinal camera, Kowa, Japan) in a representative sample. METHODS: This retrospective study included 45 eyes of normal patients, 40 eyes of patients with macropapillae and 45 eyes of glaucoma patients. Each patient underwent an HRT examination and fundus photography with the Kowa nonmyd WX 3D on the same day. Excluded from the study were eyes with hazy media (cornea, lens, vitreous) or refractive anomalies higher than >4 dpt or astigmatisms >2 dpt. Eyes with previous refractive surgery history or other retinal diseases affecting the optic nerve were also excluded from the study. Bland-Altman plots were used for statistical evaluation. Distribution of parameters was described by 95% confidence intervals (CI). RESULTS: In normal eyes (n=45) a mean difference in the disc area of 0.33 mm(2) was found (95 % confidence interval CI: 0.22-0.43), in the cup-disc ratio (CDR) of 0.02 (95% CI: -0.06-0.14), in the cup volume of 0.03 mm(3) (95% CI: -0.04-0.01), in the rim volume of 0.04 mm(3) (95%-CI: -0.04-0.13) and in the maximum cup depth of 0.28 mm (95 %-CI: 0.34-0.23). All differences, except for the rim volume, were statistically significant (p<0.05). Patients exhibiting a macropapilla (n=40) displayed a mean difference of 0.03 mm(2) (95 % CI: -0.18-0.11) for the disc area, a difference in CDR of 0.09 (95% CI: -0.05-0.13), a difference in maximum cup depth of 0.28 mm (95% CI: 0.23-0.34) and a cup volume of 0.14 mm(3) (95%-CI: 0.10-0.18). In addition, there were no significant differences in rim volume (difference: -0.02 mm(3), 95% CI: -0.07-0.12) or in disc area. In glaucomatous eyes (n=45), the mean difference for cup area was 0.33 mm(2) (95% CI: 0.22-0.43), an area of 0.09 mm(2) (95% CI: 0.06-0.13) for the CDR, -0.03 mm(3) (95 % CI: -0.09-0.02) for the cup volume and 0.08 mm(3) (95% CI: 0.03-0.13) for the rim volume. Mean maximum cup depth difference was 0.25 mm (95% CI: 0.20-0.31). Mean differences in CDR, maximum cup depth and cup area were all statistically significant. The mean differences did not exceed the interobserver and intraobserver variability found in HRT measurements of other studies. CONCLUSIONS: To the best of our knowledge this study is the first comparing optic disc parameters of HRT and 3D photography. Mean differences in stereometric parameters did not exceed the known interobserver and intraobserver variability. The combination of non-mydriatic fundus photography and optic disc analysis is a very attractive and time-saving method. However, before progression of early glaucoma can be monitored or suspected glaucoma can be appraised over longer time periods, further studies are needed to clarify test and retest variability.

[Recommendations for a standardized perimetry within the framework of epilepsy surgery]. / Empfehlungen für eine standardisierte Perimetrie im Rahmen epilepsiechirurgischer Eingriffe.

Epilepsy surgery aims to achieve a seizure-free outcome and to gain relevant socio-medicinal prospects for the patients. After successful temporal lobe resection eligibility for driving is established during the seizure-free period. However, extended postoperative homonymous visual field defects can preclude from driving. This article will give an overview of the objectives of postoperative perimetry, particularly with respect to the visual field criteria for driving and neurosurgical outcome evaluation. A literature review details the perimetry methods applied in neurosurgical outcome studies. Based on a discussion of methodological difficulties of visual field testing, suggestions for a uniform procedure for perimetric examinations are developed. Only a strict standardization with special consideration of the postoperative interval, examination strategies and quantification of the area of field lost allows meaningful comparisons between operation techniques, surgical approaches, target areas and surgical centres.

[Operative treatment of osseous pull out of the extensor tendon using a hook plate]. / Die Versorgung der dorsalen Endphalanxbasisfraktur der Langfinger mittels Hakenplatte.

OBJECTIVE: Anatomical reposition and stabilization of dorsal distal phalanx fractures with a hook plate. INDICATIONS: Dislocated mallet fractures type Doyle IVb with dislocation of the fragment by more than 2 mm and/or tilting of the fragment as well as dislocation of the dorsal distal phalanx fractures type Doyle IVc. CONTRAINDICATIONS: Florid inflammation of and injuries to the soft tissues in the operation area. SURGICAL TECHNIQUE: Dorsal approach to the distal interphalangeal joint (Y-, S-, H-shaped). Preparation of the fragment, cleaning the fracture gap, repositioning of the fragment, mounting of the plate, placing the screw. Controlling by image converter. Suture of the skin; tape. POSTOPERATIVE MANAGEMENT: Stack splint for 4 weeks. After week 3, start with exercising of the distal interphalangeal joint within the splint. Physiotherapy is usually not required. Full exertion after 6-8 weeks is possible. The period of inability to work is dependent on the patient's occupation. Due to the danger of perforation and infection, it is recommended that the plate be removed after 3-6 months. RESULTS: From February 2002 to September 2009, 77 mallet fractures type Doyle IVb and IVc were operatively stabilized with a hook plate. In a retrospective study, 59 patients were followed up at a mean interval of 38.3 (3-69) months after the operation. Wound healing problems or inflammation were not observed. Visible disturbances of nail growth were macroscopically seen in 11.9%. Results were very good in 35 patients (59.3%), good in 16 patients (27.1%), sufficient in 5 patients (8.5%), satisfying in 1 patient (1.7%), and insufficient in 2 patients (3.4%).

[A topodiagnostically characteristic visual field defect]. / Ein topodiagnostisch wegweisender Gesichtsfeldausfall.

A 69-year-old female patient presented with unilateral optic nerve atrophy and visual loss. The visual field examination showed not only a subtotal visual field loss in the affected eye but also a visual field defect in the other eye which was classified as an anterior junction syndrome. Cranial MRI revealed a tuberculum sellae meningioma which was treated surgically.

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

In 2009 the DIN 58220 norms for determination of visual acuity were revised. The new rules came into force on 1(st) November 2009. The new regulations on expert assessment of visual acuity (DIN norm 58220, part 3) are particularly important for ophthalmologists because as a result of the revisions the approach to testing visual acuity in patients with low acuity must be changed in the future. The background and potential problems will be presented and a simple solution for the lower acuity range will be suggested. Parts 5 (general test of vision) and 6 (driving-related vision test) of DIN 58220 remain practically unchanged. Part 7 of DIN 58220 is newly introduced, in which regulations for testing mesopic contrast vision with and without glare are defined for the first time.

[Quality demands on the assessment of colour vision]. / Qualitätsanforderungen an die Untersuchung des Farbsinns.

Assessing colour vision comprises a wide spectrum of methods, many of which are practical and highly informative. Given this methodological variety this review aims to help select the most appropriate test and how to correctly execute it, thus achieving the highest quality.Some aspects of the physiology of colour vision are covered as far as is necessary for a basic understanding of colour testing methodology and possible pitfalls. For congenital colour anomalies most pertinent are questions of occupational aptitude. For acquired colour deficiencies assessing colour vision supplements diagnostics of the retina and the visual pathway, allowing both early diagnosis and/or monitoring. For both these fields colour tests provide different kinds of evidence and need to be adequately selected. Methodical artefacts due to both equipment design properties and testing procedures are highlighted so they can be avoided. A form is presented for recording colour examination results commensurate with quality objectives. Finally, a tabular overview of 19 common colour vision tests is provided.

A mathematical description of nerve fiber bundle trajectories and their variability in the human retina.

We developed a mathematical model wherein retinal nerve fiber trajectories can be described and the corresponding inter-subject variability analyzed. The model was based on traced nerve fiber bundle trajectories extracted from 55 fundus photographs of 55 human subjects. The model resembled the typical retinal nerve fiber layer course within 20 degrees eccentricity. Depending on the location of the visual field test point, the standard deviation of the calculated corresponding angular location at the optic nerve head circumference ranged from less than 1 degrees to 18 degrees , with an average of 8.8 degrees .

[Fulminant process of an orbital Mucoracea infection]. / Fulminanter Verlauf einer orbitalen Mucoracea-Infektion.

Rhinoorbitocerebral mucormycosis is a rare invasive fungal infection that is fatal when untreated. We describe an immunosuppressed patient with chronic lymphatic leukaemia who developed a severe rhinoorbitocerebral mucormycosis after allogeneic bone marrow transplantation. Due to the potentially fulminant course and fatal outcome, radical excision of the necrotic area in combination with antifungal therapy is necessary in the presence of suspicious clinical signs of mucormycosis despite a lack of histopathologic confirmation.

The use of semi-automated kinetic perimetry (SKP) to monitor advanced glaucomatous visual field loss.

PURPOSE: (i) To compare visual field (VF) results obtained with semi-automated kinetic perimetry (SKP) and automated static perimetry (ASP) in patients with advanced glaucomatous VF loss, (ii) to evaluate test-retest reliability of SKP and ASP and (iii) to assess patients' preference for SKP and ASP. METHODS: Twenty eyes of 20 patients (11 male, 9 female, aged 38 to 83 years) with advanced glaucomatous VF loss (stage III or IV according to the Aulhorn classification). Each of the 20 patients were examined in 4 sessions every 3 months with SKP (Goldmann stimulus III4e, I4e and at least one additional dimmer stimulus, within the 90 degrees visual field) and ASP within the 30 degrees VF, employing a threshold-related, supra-threshold test strategy with high spatial resolution for the same instrument (Octopus 101 perimeter, Haag-Streit Inc., Koeniz, Switzerland). RESULTS: Visual field areas (VFA) were compared by analyses of covariance (ANCOVA) with co-variable time, patient effect and their interaction. Test-retest reliability was assessed by ratios (R) of intersection and union of VFA: The mean VFA within the 30 degrees of VF at baseline was 2,344 square degrees (deg(2)) with SKP (Goldmann stimulus III4e) and 1,844 deg(2) with ASP. The patients showed stable visual fields for both SKP and ASP. Comparison of SKP with ASP of the same sessions revealed a median ratio of intersection and union of VFA of 0.78 with the III4e stimulus and of 0.79 with the I4e stimulus. When follow-up SKPs were compared with baseline SKPs the median of the ratios was between 0.80 and 0.93 for the different isopters. The corresponding ratio of ASP's follow-up and baseline VFs was 0.81 (with the size III static stimulus). Nineteen of 20 patients preferred kinetic perimetry to static perimetry. CONCLUSIONS: The comparability between SKP and ASP is satisfactory and within the range of the test-retest reliability of ASP. SKP shows slightly better test-retest reliability than ASP. The majority of patients with advanced glaucomatous visual field loss prefer SKP instead of ASP. SKP is a valuable alternative to ASP in monitoring advanced glaucomatous visual field loss.

The pupillary light reflex pathway: cytoarchitectonic probabilistic maps in hemianopic patients.

OBJECTIVE: The anatomy of the human pupillary light reflex (PLR) pathway is a matter of debate. The aim of this study was twofold: namely, to investigate the association of a relative afferent pupillary defect (RAPD) in acquired suprageniculate lesions with the location and extent of the cerebral lesions. Further, we suggest a new strategy of lesion analysis by combining established techniques with the stereotaxic probabilistic cytoarchitectonic atlas developed by the Jülich group. METHODS: Twenty-three patients with homonymous visual field defects participated in this study. The RAPD was quantified clinically by two independent examiners with graded neutral density filters (swinging flashlight test). Using MRI in each individual, cerebral regions commonly affected in patients with a RAPD but spared in patients without a RAPD were determined and subsequently assessed by using cytoarchitectonic probabilistic maps. RESULTS: A RAPD was present in 10/23 patients. Comparison of patients showing a RAPD vs those not showing a RAPD revealed that a region including the course of the optic radiation at its early beginning in the temporal white matter is commonly associated with a RAPD. CONCLUSIONS: It was demonstrated that the pupillary light reflex (PLR) depends on the input of suprageniculate neurons, thus supporting the involvement of a cortical pathway also. The site of integration of cortical signals in relation to the PLR into the pupillomotor pathway may be located suprageniculately in the vicinity of the lateral geniculate nucleus. Moreover, the suggested combination of established lesion analysis techniques with the probabilistic cytoarchitectonic atlas turned out to be a very helpful amelioration of stroke data analyses.