A custom virtual reality training solution for ophthalmologic surgical clinical trials.

We present a summary of the development and clinical use of two custom designed high-fidelity virtual-reality simulator training platforms. This simulator development program began in 2016 to support the phase III clinical trial Archway (ClinicalTrials.gov identifier, NCT03677934) intended to evaluate the Port Delivery System (PDS) developed by Genentech Inc. and has also been used to support additional clinical trials. The two simulators address two specific ophthalmic surgical procedures required for the successful use of PDS and provide state-of-the-art physical simulation models and graphics. The simulators incorporate customized active haptic feedback input devices that approximate different hand pieces including a custom hand piece specifically designed for PDS implantation. We further describe the specific challenges of the procedure and the development of corresponding training strategies realized within the simulation platform.

A comparison of robotic and manual surgery for internal limiting membrane peeling.

PURPOSE: To compare the Preceyes Surgical Robotic System (Eindhoven, Netherlands) to manual internal limiting membrane (ILM) peeling using the Eyesi surgical simulator (VRmagic, Mannheim, Germany) as the operative platform. METHODS: A comparative study was carried out with surgeons initially performing ILM peeling manually and then with the robot. Twenty-three vitreoretinal surgeons agreed to participate and all consented to the use of their surgical data from the Eyesi surgical simulator. Surgeons were given a 5-min demonstration of the devices and were allowed to practice for 10 min before attempting the membrane peel. Initially, the peel was performed manually and afterwards, this was repeated using the robot-controlled forceps. Surgical simulator outcome measures were compared between approaches. RESULTS: The average time required for the procedure was 5 min for the manual approach and 9 min with the robot (paired t test, p = 0.002). Intraocular instrument movement was reduced by half with the robot. On average 344 mm was required to complete the ILM peeling with the robot compared with 600 mm using the manual approach (paired t test, p = 0.002). There were fewer macular retinal hemorrhages with the robot: 53 with manual surgery, 32 with the robot (Mann-Whitney U test, p = 0.035). Retinal injuries were eliminated with the robot. CONCLUSIONS: Intraocular robotic surgery is still in its infancy and validation work is needed to understand the potential benefits and limitations of emerging technologies. Safety enhancements over current techniques may be possible and could lead to the broader adoption of robotic intraocular surgery in the future.

Unusual Primary Ocular Manifestation of Sarcoidosis.

A 23-year-old male patient presented with very mild visual disturbances, but a distinct prominence of the optic discs, more pronounced in the right than in the left eye. The ophthalmic symptoms initially seemed trivial, but a large-scale interdisciplinary workup later identified them as the presenting symptoms of sarcoidosis affecting lung and eyes. A standard steroid monotherapy successfully caused regression of the ophthalmic findings.

Key Factors to Improve the Outcome of Retinal Reattachment Surgery in Proliferative Vitreoretinopathy and Proliferative Diabetic Retinopathy.

INTRODUCTION: For management of complicated retinal detachments, a pars plana vitrectomy with temporary silicone oil (SO) fill is the method of choice. According to literature, the retinal redetachment rate varies between <10% and >70% with around 36% in our own group (retrospective data analysis, n = 119 eyes). METHODS: The main goal was to reduce the retinal redetachment rate. Standard operating procedures (SOPs) and evaluation protocols (EVALPs) were developed to prospectively analyse risk factors. Lab analysis of SO was performed, and the role of surgical experience was evaluated and investigated with Eyesi®. RESULTS: We achieved a significant reduction of the retinal redetachment rate (to 6.80%, n = 101, p = 0.002). After surgery with SO injection, neither further membrane peeling (in 16.5%) nor retinal laser coagulation (in 100%) during revision surgery had a significant effect on the reattachment rate (p = 0.167, p = 0.23), while extensive additional laser coagulation reduced visual acuity (p = 0.01). A 3-port approach had to be set up to complete SO removal. A difference in success rate depending on surgical experience was confirmed, and the performance in Eyesi correlated with that in the patients' eye. CONCLUSIONS: A SOP- and EVALP-based management and new strategies to secure the surgical performance seem to be essential for successful surgery.

Design and Synthesis of Enantiomerically Pure Decahydroquinoxalines as Potent and Selective κ-Opioid Receptor Agonists with Anti-Inflammatory Activity in Vivo.

In order to develop novel κ agonists restricted to the periphery, a diastereo- and enantioselective synthesis of (4aR,5S,8aS)-configured decahydroquinoxalines 5-8 was developed. Physicochemical and pharmacological properties were fine-tuned by structural modifications in the arylacetamide and amine part of the pharmacophore as well as in the amine part outside the pharmacophore. The decahydroquinoxalines 5-8 show single-digit nanomolar to subnanomolar κ-opioid receptor affinity, full κ agonistic activity in the [35S]GTPγS assay, and high selectivity over µ, δ, σ1, and σ2 receptors as well as the PCP binding site of the NMDA receptor. Several analogues were selective for the periphery. The anti-inflammatory activity of 5-8 after topical application was investigated in two mouse models of dermatitis. The methanesulfonamide 8a containing the (S)-configured hydroxypyrrolidine ring was identified as a potent (Ki = 0.63 nM) and highly selective κ agonist (EC50 = 1.8 nM) selective for the periphery with dose-dependent anti-inflammatory activity in acute and chronic skin inflammation.

Clinical Efficacy of Simulated Vitreoretinal Surgery to Prepare Surgeons for the Upcoming Intervention in the Operating Room.

PURPOSE: To evaluate the efficacy of the virtual reality training simulator Eyesi to prepare surgeons for performing pars plana vitrectomies and its potential to predict the surgeons' performance. METHODS: In a preparation phase, four participating vitreoretinal surgeons performed repeated simulator training with predefined tasks. If a surgeon was assigned to perform a vitrectomy for the management of complex retinal detachment after a surgical break of at least 60 hours it was randomly decided whether a warmup training on the simulator was required (n = 9) or not (n = 12). Performance at the simulator was measured using the built-in scoring metrics. The surgical performance was determined by two blinded observers who analyzed the video-recorded interventions. One of them repeated the analysis to check for intra-observer consistency. The surgical performance of the interventions with and without simulator training was compared. In addition, for the surgeries with simulator training, the simulator performance was compared to the performance in the operating room. RESULTS: Comparing each surgeon's performance with and without warmup trainingshowed a significant effect of warmup training onto the final outcome in the operating room. For the surgeries that were preceeded by the warmup procedure, the performance at the simulator was compared with the operating room performance. We found that there is a significant relation. The governing factor of low scores in the simulator were iatrogenic retinal holes, bleedings and lens damage. Surgeons who caused minor damage in the simulation also performed well in the operating room. CONCLUSIONS: Despite the large variation of conditions, the effect of a warmup training as well as a relation between the performance at the simulator and in the operating room was found with statistical significance. Simulator training is able to serve as a warmup to increase the average performance.

Evaluation of gadolinium-EOB-DTPA uptake after portal vein embolization: value of an increased flip angle.

BACKGROUND: The optimal sequence for Gd-EOB-DTPA uptake measurement in the liver with the purpose of liver function measurement is still not defined. PURPOSE: To prospectively evaluate the effect of an increased flip angle (FA) of a T1-weighted fat-saturated 3D sequence for the measurement of hepatocyte uptake of Gd-EOB-DTPA magnetic resonance imaging (MRI) after right portal vein embolization (PVE). MATERIAL AND METHODS: Ten patients who received a PVE prior to an extended hemihepatectomy were examined 14 days after PVE using Gd-EOB-DTPA enhanced MRI of the liver using the standard FA of 10° and the increased FA of 30°. RESULTS: Relative enhancement of the right liver lobe (RLL) was 0.52 ± 0.12 for 10° and 1.41 ± 0.39 for 30°. Relative enhancement of the left liver lobe (LLL) was 0.58 ± 0.11 for 10° and 2.05 ± 0.61 for 30°. Relative enhancement of the RLL was significantly higher for 30° than for 10° (P = 0.009) and significantly higher in the 30° than in the 10° sequences (P = 0.005) for the LLL. CONCLUSION: A flip angle of 30° increases the contrast between liver partitions with and without portal venous embolization. Thereby, the sensitivity for differences in uptake intensity is increased. This could be of value for a more exact determination of differences in regional liver function and, consequently, the estimation of the future remnant liver function.

Beyond scale-free small-world networks: cortical columns for quick brains.

We study to what extent cortical columns with their particular wiring boost neural computation. Upon a vast survey of columnar networks performing various real-world cognitive tasks, we detect no signs of enhancement. It is on a mesoscopic--intercolumnar--scale that the existence of columns, largely irrespective of their inner organization, enhances the speed of information transfer and minimizes the total wiring length required to bind distributed columnar computations towards spatiotemporally coherent results. We suggest that brain efficiency may be related to a doubly fractal connectivity law, resulting in networks with efficiency properties beyond those by scale-free networks.

Interactions of ghrelin signaling pathways with the GH neuroendocrine axis: a new and experimentally tested model.

Growth hormone (GH) is secreted in a pulsatile fashion from the pituitary gland into the circulation. Release is governed by two hypothalamic neuropeptides, growth hormone-releasing hormone (GHRH) and somatostatin (SRIF), resulting in secretion episodes with a periodicity of 3.3 h in the male rat. Ghrelin is an additional recently identified potent GH-secretagogue. However, its in vivo interactions with the GH neuroendocrine axis remain to be elucidated. Moreover, two different sites of ghrelin synthesis are involved, the stomach and the hypothalamus. We used our previously developed core model of GH oscillations and added the sites of ghrelin action at the pituitary and in the hypothalamus. With this extended model, we simulated the effects of central and peripheral ghrelin injections, monitored the GH profile and compared it with existing experimental results. Systemically administered ghrelin elicits a GH pulse independent of SRIF, but only in the presence of GHRH. The peripheral ghrelin signal is mediated to the brain via the vagus nerve, where it augments the release of GHRH and stimulates the secretion of neuropeptide-Y (NPY). By contrast, centrally administered ghrelin initiates a GH pulse by increasing the GHRH level and by antagonizing the SRIF block at the pituitary. In addition, NPY neurons are activated, which trigger a delayed SRIF surge. The major novel features of the present model are a) the role played by NPY, and b) the dissimilar functions of ghrelin in the hypothalamus and at the pituitary. Furthermore, the predictions of the model were experimentally examined and confirmed.

EYESi ophthalmoscope - a simulator for indirect ophthalmoscopic examinations.

We present a training simulator for indirect ophthalmoscopy. An optical tracking system is used to reconstruct the position of a lens mockup and a model of the patient's face. Refraction and illumination are computed in real-time and displayed on a head-mounted display using augmented reality. A case database completes the training system which allows to practise the examination and to study clinical patterns.

Phenothiazine as a redox-active DNA base substitute: comparison with phenothiazine-modified uridine.

Phenothiazine can be incorporated as a redox-active probe into DNA in two conceptually different ways: the non-nucleosidic DNA base surrogate exhibits similar properties to 10-methylphenothiazine but with no preferential base-pairing properties, whereas the phenothiazine-modified uridine has different optical and electrochemical properties, but exhibits preferred Watson-Crick base pairing with adenine.

Real-time Marker-based Tracking of a Non-rigid Object.

Real-time tracking of non-rigid objects for use in interfaces of VR-simulators is presented. Markers are attached to the objects and observed by several cameras with integrated image-processing hardware which extracts relevant marker data (centroid, area & color) in real-time. Data from the different cameras is then matched in the host PC to reconstruct the 3D positions. We present two approaches to this special matching problem because standard image feature based algorithms are not feasible for marker-based tracking. A model of the deformation is extracted from the reconstructed 3D point cloud and the simulation model is updated accordingly. Experiments with a prototype of a deformable eye interface for the ophthalmosurgical simulator EYESI show that latency, robustness and accuracy of the deformation tracking are adequate for application in VR simulators. The approach is extensible to other types of simulators where deformable tissue has to be tracked.

Perylene-3,4:9,10-tetracarboxylic acid bisimide dye as an artificial DNA base surrogate.

A phosphoramidite of the perylene bisimide dye was synthesized as a DNA building block that allows incorporation of this chromophore as an artificial nucleoside surrogate either at the 5'-terminus or at internal positions of duplex DNA. The internally incorporated perylene bisimide chromophore shows strong interactions with the DNA base stack; the 5'-terminally attached perylene bisimide is able to induce dimerization of two whole DNA duplexes.

The geometry of the flux cone of a metabolic network.

The analysis of metabolic networks has become a major topic in biotechnology in recent years. Applications range from the enhanced production of selected outputs to the prediction of genotype-phenotype relationships. The concepts used are based on the assumption of a pseudo steady-state of the network, so that for each metabolite inputs and outputs are balanced. The stoichiometric network analysis expands the steady state into a combination of nonredundant subnetworks with positive coefficients called extremal currents. Based on the unidirectional representation of the system these subnetworks form a convex cone in the flux-space. A modification of this approach allowing for reversible reactions led to the definition of elementary modes. Extreme pathways are obtained with the same method but splitting up internal reactions into forward and backward rates. In this study, we explore the relationship between these concepts. Due to the combinatorial explosion of the number of elementary modes in large networks, we promote a further set of metabolic routes, which we call the minimal generating set. It is the smallest subset of elementary modes required to describe all steady states of the system. For large-scale networks, the size of this set is of several magnitudes smaller than that of elementary modes and of extreme pathways.

1-ethynylpyrene-modified guanine and cytosine as optical labels for DNA hybridization.

1-ethynylpyrene shows remarkable absorption changes upon DNA hybridization when it is covalently attached to the 8-position of guanine. An absorption band at approximately 420 nm is only present in the duplex, exhibits thermal melting behaviour and provides the basis for a molecular beacon together with 1-ethynylpyrene-modified cytosine.

Reductive electron transfer in phenothiazine-modified DNA is dependent on the base sequence.

A new DNA assay has been designed, prepared and applied for the chemical investigation of reductive electron transfer through the DNA. It consists of 5-(10-methyl-phenothiazin-3-yl)-2'-deoxyuridine (Ptz-dU, 1) as the photoexcitable electron injector and 5-bromo-2'-deoxyuridine (Br-dU) as the electron trap. The Ptz-dU-modified oligonucleotides were synthesised by means of a Suzuki-Miyaura cross-coupling protocol and subsequent automated phosphoramidite chemistry. Br-dU represents a kinetic electron trap, since it undergoes a chemical modification after its one-electron reduction that can be analysed by piperidine-induced strand cleavage. The quantification of the strand cleavage yields from irradiation experiments reveals important information about the electron-transfer efficiency. The performed DNA studies focused on the base sequence dependence of the electron-transfer efficiency with respect to the proposal that C*- and T*- act as intermediate electron carriers during electron hopping. From our observations it became evident that excess-electron transfer is highly sequence dependent and occurs more efficiently over T-A base pairs than over C-G base pairs.

Construction of an associative memory using unstable periodic orbits of a chaotic attractor.

Unstable periodic orbits are the skeleton of a chaotic attractor. We constructed an associative memory based on the chaotic attractor of an artificial neural network, which associates input patterns to unstable periodic orbits. By processing an input, the system is driven out of the ground state to one of the pre-defined disjunctive areas of the attractor. Each of these areas is associated with a different unstable periodic orbit. We call an input pattern learned if the control mechanism keeps the system on the unstable periodic orbit during the response. Otherwise, the system relaxes back to the ground state on a chaotic trajectory. The major benefits of this memory device are its high capacity and low-energy consumption. In addition, new information can be simply added by linking a new input to a new unstable periodic orbit.

Collective bursting in layer IV. Synchronization by small thalamic inputs and recurrent connections.

Layer IV is believed to be the cortical signal amplifier, for example, of thalamic signals. A previous spiny stellate recurrent network model of this layer is made more realistic by the addition of inhibitory basket neurons. We study the persistence and characteristics of previously observed collective firing behavior, and investigate what additional features would need to be implemented to generate in vivo type neuronal firing. It is shown that neuronal activity is only coarsely synchronized within the network. By applying methods of noise-cleaning, it emerges that the firing of individual neurons is of low-dimensional hyperchaotic nature, as found in the analysis of measured cat in vivo spike trains. In order to reproduce in vivo firing patterns, it is sufficient to have time-varying thalamic input. Conclusions from low-dimensional hyperchaotic behavior of network-embedded neurons are drawn. We interpret observed in vivo pattern-sharpening features of stimuli and outline possible connections to epilepsy. From our results, it follows that emergent global behavior is likely to be the result of the interaction between comparably simple neuronal components, driven by input specificity.