[Photo-based examination for diabetic eye pathologies in a German ophthalmological practice without personal doctor-patient contact]. / Fotobasierte Untersuchung auf diabetische Augenveränderungen in einer deutschen Augenarztpraxis ohne direkten Arzt-Patienten-Kontakt.

BACKGROUND: An increasing number of patients suffering from diabetes require regular ophthalmological check-ups to diagnose and/or treat potential diabetic retinal disease. Some countries have already implemented systematic fundus assessments including artificial intelligence-based programs in order to detect sight-threatening retinopathy. The aim of this study was to improve the detection of diabetic fundus changes in Germany without examination by a doctor and to create an easy access to ophthalmological examinations. MATERIAL AND METHODS: In this prospective monocentric study 93 patients in need for a routine check-up for diabetic retinopathy were included. The study participants took up an offer of an examination (visual examination, non-mydriatic camera-based fundus examination) without doctor-patient contact. Patient satisfaction with the organization and examinations was assessed using a questionnaire. RESULTS: The mean age was 53.5 years (SD 13.6 years, 49.5% female) and 17 eyes (18.3%) showed a diabetic retinopathy which was detected using a camera-based examination. Within the small sample, no patient had to repeat the examination due to poor image quality. All categories of the questionnaire showed a good to very good satisfaction, indicating a high acceptance of the other examination form that took place at the ophthalmologist's premises. CONCLUSION: In our study in an ophthalmological practice a high level of acceptance among the patients interested in the screening for diabetic retinopathy without any direct patient-doctor contact was achieved. Our study shows a very good acceptance and feasibility. Future use of artificial intelligence in clinical practice may help to be able to screen many more patients as in this study imaging quality was very good.

Optimal Patient Adherence and Long-Term Treatment Outcomes of Neovascular Age-Related Macular Degeneration in Real-Life.

PURPOSE: To report on long-term real-life outcomes of anti-vascular endothelial growth factor (anti-VEGF) therapy in neovascular age-related macular degeneration (nAMD) with optimal patient adherence. METHODS: For this retrospective monocenter study, we identified 3217 eyes of 2793 patients that received a minimum of three intravitreal anti-VEGF injections for nAMD therapy between 2006 and 2014 at the University Eye Hospital Munich. From those, we included eyes with treatment-naïve nAMD, follow-up (FU) of ≥60 months and continuous adherence during FU. Primary measures were corrected visual acuity (VA), number of injections and visits as well as treatment regimen. RESULTS: We included 161 eyes of 125 patients with a mean FU of 8.0 ± 2.3 years. Mean VA at baseline was 60.1 letters (Snellen equivalent, 20/63). After the third year, mean VA declined constantly by 2-3 letters per year. After 5 and 8 years, 26.1% and 42.1% had lost at least 3 lines from baseline. Mean cumulative number of injections was 5.3 after the first year, and 23.9, 38.1, 48.5 after 5, 8, and 10 years. "Treat and extent" regimen with higher injection frequency correlated with better function. At time of last FU, 69.8% of eyes were under active treatment. Eyes with ≥70 letters at baseline correlated with better VA at the end of FU. CONCLUSIONS: Despite optimal patient adherence, visual function declined progressively in real-life nAMD therapy over long-term. The highest impact on treatment success is given by an early treatment start with individual but intensive anti-VEGF therapy.

The Role and Views of Ophthalmologists During the COVID-19 Pandemic.

PURPOSE: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic forced ophthalmologists to adjust their working conditions to ensure patient and staff safety, while still providing effective and timely treatment. This international survey among ophthalmologists was initiated to capture what actions ophthalmologists were taking and what their opinions were on the risks of infection in their workplace, the delay in treatment, the use of telemedicine and telephone for appointments, and the regional specifications and measures implemented by the respective authorities. METHODS: An open-source web tool was used to develop an online survey, to which ophthalmologists worldwide were invited via e-mail using international mailing lists (Media Mice, Singapore; Texere Publishing Inc, USA; CGO Gerling) and incentivized using a lottery. The physicians provided their level of agreement relating to the offered statements and gave free answers to the questions regarding the actions taken (conducted November 5th 2020 to December 20th 2020). RESULTS: After 91,000 invitations, responses were collected from 1122 ophthalmologists. Despite the use of large international mailing lists, mainly doctors from Europe participated. Half of the participants expressed great concern about possible SARS-CoV-2 infection in their patients. A significant number of younger ophthalmologists (≤50 years: 76.9%, n = 313; >50 years: 69.6%, n = 181) feared the delays that COVID-19 could cause to treatment. Reductions in patient numbers were broadly observed, with more ophthalmologists of younger age reporting greater declines. Nearly all ophthalmologists indicated that they provided disinfectant and the majority also used masks and questionnaires for screening. For 60.3% (n = 412) of ophthalmologists, telephone calls reduced the risk of 'no-shows'; 71.6% (n = 497) disagreed that telemedical evaluation is possible without slit lamp findings and fundus photos; and 57.0% of participants felt content with the governmental measures during the COVID-19 pandemic. CONCLUSION: The COVID-19 pandemic has significantly influenced the work of ophthalmologists. Based on the limited response rate, certain statements were only possible to evaluate for the European Union: with a noticeable reduction in patient numbers, delay in treatment was a major worry. Measures to protect and reassure patients should be undertaken, especially regarding those with vision-threatening diseases requiring treatment.

Big data simulations for capacity improvement in a general ophthalmology clinic.

PURPOSE: Long total waiting times (TWT) experienced by patients during a clinic visit have a significant adverse effect on patient's satisfaction. Our aim was to use big data simulations of a patient scheduling calendar and its effect on TWT in a general ophthalmology clinic. Based on the simulation, we implemented changes to the calendar and verified their effect on TWT in clinical practice. DESIGN AND METHODS: For this retrospective simulation study, we generated a discrete event simulation (DES) model based on clinical timepoints of 4.401 visits to our clinic. All data points were exported from our clinical warehouse for further processing. If not available from the electronic health record, manual time measurements of the process were used. Various patient scheduling models were simulated and evaluated based on their reduction of TWT. The most promising model was implemented into clinical practice in 2017. RESULTS: During validation of our simulation model, we achieved a high agreement of mean TWT between the real data (229 ± 100 min) and the corresponding simulated data (225 ± 112 min). This indicates a high quality of the simulation model. Following the simulations, a patient scheduling calendar was introduced, which, compared with the old calendar, provided block intervals and extended time windows for patients. The simulated TWT of this model was 153 min. After implementation in clinical practice, TWT per patient in our general ophthalmology clinic has been reduced from 229 ± 100 to 183 ± 89 min. CONCLUSION: By implementing a big data simulation model, we have achieved a cost-neutral reduction of the mean TWT by 21%. Big data simulation enables users to evaluate variations to an existing system before implementation into clinical practice. Various models for improving patient flow or reducing capacity loads can be evaluated cost-effectively.

Enlargement rate of geographic atrophy before and after secondary CNV conversion with associated anti-VEGF treatment.

BACKGROUND: To study the enlargement rate of primary geographic atrophy (GA) before and after diagnosis of a secondary choroidal neovascularization (CNV) treated with anti-vascular endothelial growth factor (VEGF) therapy. METHODS: Five hundred twenty-two consecutive eyes with primary GA were screened for the development of a complicating secondary CNV. Geographic atrophy was measured on blue autofluorescence (BAF) by two readers and calculated into mean growth rate before and after CNV diagnosis. RESULTS: Ten eyes of six patients were included in the study (six study eyes with GA complicated by CNV, four GA only partner eyes). Follow-up was 1.42 ± 0.48 years before and 3.64 ± 2.73 years after CNV. There was no significant difference between mean growth rate before and after CNV (1.58 ± 0.99 vs. 1.39 ± 0.65 mm2/year; p = 0.44) or between study and partner eyes (p = 0.86). Over a mean time of 3.64 ± 2.73 years, a mean of 8.3 ± 2.8 anti-VEGF injections were given. No correlation between the amount of anti-VEGF injections and change in growth rate could be observed (r = 0.58; p = 0.23). CONCLUSION: In this pilot study, primary GA enlargement did not seem to be influenced by a secondary CNV. No association between the intensity of anti-VEGF treatment and changes in atrophy enlargement rates were found. Further studies with larger sample sizes are warranted.

Evaluation of Functional Outcomes and OCT-Biomarkers after Intravitreal Dexamethasone Implant for Postoperative Cystoid Macular Edema in Vitrectomized Eyes.

PURPOSE: To evaluate the efficacy of dexamethasone implant (DEX) for the treatment of postoperative cystoid macular edema (PCME) in vitrectomized eyes and to investigate visual and morphological OCT predictive factors. METHODS: In this retrospective study, eyes with PCME after vitrectomy were treated with at least one DEX injection and were observed over 12 months. Indications for surgery were epiretinal membrane (ERM) or rhegmatogenous retinal detachment (RRD) without macular involvement. Prior treatments, if any, were noted. Best corrected visual acuity (BCVA), central foveal thickness (CFT), and OCT morphology including the presence of intraretinal cysts/fluid or subretinal fluid (IRF/SRF) and ellipsoid zone (EZ) continuity were evaluated. Correlations between OCT measures and visual outcomes were analyzed by the generalized estimating equations procedure. RESULTS: Forty-six eyes with ERM and 15 eyes with RRD were enrolled. The ERM group was more likely to gain BCVA than RRD (odds ratio (OR), 1.168; 95% confidence interval (CI), 1.003-1.360; p=0.046). The absence of SRF (OR, 0.860; 95% CI, 0.743-0.995; p=0.043) was predictive of worse BCVA, whereas the integrity of EZ (OR, 1.094; 95% CI, 0.951-1.257; p=0.209) or naïve status (OR, 0.946; 95% CI, 0.871-1.137, p=0.853) was not. Eyes with a worse baseline BCVA were more likely to gain >1 line after 12 months (OR, 1.485; 95% CI, 1.171-1.884; p=0.001). CONCLUSION: The efficacy of the treatment of PCME in vitrectomized eyes seems to be affected by baseline BCVA, the absence of SRF, and the indication for surgery. Naïve status appears not to play any significant role in the prediction of BCVA. This trial is registered with DRKS00018955.

Impact of Sub-Retinal Fluid on the Long-Term Incidence of Macular Atrophy in Neovascular Age-related Macular Degeneration under Treat & Extend Anti-Vascular Endothelial Growth Factor Inhibitors.

Sub-retinal fluid (SRF) has been discussed as a protective factor against macular atrophy in eyes with neovascular age-related macular degeneration (nAMD).To gauge the impact of SRF on macular atrophy, a database of 310 nAMD eyes was screened for eyes manifesting an SRF-only phenotype under treat & extend anti-VEGF treatment, defined as nAMD expressing CNV exudation beyond the three monthly anti-VEGF loading doses by SRF only without any signs of exudative intra-retinal fluid (IRF) for ≥3 years. Incidence of macular atrophy and treatment responses were evaluated on multimodal imaging, including optical coherence tomography (OCT), blue autofluorescence (BAF) and near-infrared (NIR) confocal scanning laser ophthalmoscopy and fluorescence and indocyanine green angiography (FAG/ICGA). In total, 27 eyes (8.7%) of 26 patients with a mean follow-up of 4.2 ± 0.9 (3-5) years met the inclusion criteria. Mean age was 72 ± 6 (range: 61-86) years. The SRF only phenotype was seen from baseline in 14 eyes (52%), and in 13 eyes (48%) after a mean 1.0 ± 1.3 (1-3) injections. In years 1 to 5, mean 7.5, 5.9, 6.1, 6.1 and 7.0 anti-VEGF injections were given (p = 0.33). Cumulative macular atrophy incidence was 11.5% at year 1, 15.4% throughout years 2 to 4, and 22.4% at year 5. In conclusion, eyes manifesting activity by SRF only in treat & extend anti-VEGF regimen for nAMD seem to exhibit rather low rates of macular atrophy during long-term follow-up. SRF might be an indicator of a more benign form of nAMD.

Response of neovascular central serous chorioretinopathy to an extended upload of anti-VEGF agents.

PURPOSE: To determine the anatomical and functional outcomes of an extended 6-month intravitreal anti-vascular endothelial growth factor (anti-VEGF) upload in choroidal neovascularization (CNV) secondary to chronic central serous chorioretinopathy (CSCR). METHODS: A retrospective database analysis was performed applying the following inclusion criteria: (1) diagnosis of CSCR, (2) diagnosis of secondary CNV, and (3) treatment of at least six consecutive injections of anti-VEGF. Outcome measures included the change of central retinal subfield thickness, remodeling of the pigment epithelium detachments, and change in visual function. RESULTS: Twenty-one eyes of 21 patients were included. Mean patient age was 65 ± 8.3 years, and 35% of the patients (n = 8) were female. Mean disease duration before diagnosis of CNV was 48 ± 25.3 months. Mean central retinal thickness decreased from 346 ± 61 to 257 ± 57 µm (p < 0.01) after the sixth injection while mean visual acuity improved from 0.65 ± 0.35 to 0.49 ± 0.29 (logMAR; p < 0.01). Of note, an extended upload of six as opposed to three injections yielded an additional mean central retinal thickness reduction (280 ± 46 µm vs. 257 ± 57 µm, p = 0.038). Significant CNV remodeling was observed as a decrease in pigment epithelium detachment (PED) vertical (p = 0.021) and horizontal diameter (p = 0.024) as well as PED height (p < 0.01). CONCLUSION: An extended anti-VEGF upload of six consecutive injections seems to be effective in inducing CNV remodeling and fluid resorption in CNV complicating chronic CSCR.

One- and two-year visual outcomes from the Moorfields age-related macular degeneration database: a retrospective cohort study and an open science resource.

OBJECTIVES: To analyse treatment outcomes and share clinical data from a large, single-centre, well-curated database (8174 eyes/6664 patients with 120 756 single entries) of patients with neovascular age-related macular degeneration (AMD) treated with anti-vascular endothelial growth factor (VEGF). By making our depersonalised raw data openly available, we aim to stimulate further research in AMD, as well as set a precedent for future work in this area. SETTING: Retrospective, comparative, non-randomised electronic medical record (EMR) database cohort study of the UK Moorfields AMD database with data extracted between 2008 and 2018. PARTICIPANTS: Including one eye per patient, 3357 eyes/patients (61% female). Extraction criteria were ≥1 ranibizumab or aflibercept injection, entry of 'AMD' in the diagnosis field of the EMR and a minimum of 1 year of follow-up. Exclusion criteria were unknown date of first injection and treatment outside of routine clinical care at Moorfields before the first recorded injection in the database. MAIN OUTCOME MEASURES: Primary outcome measure was change in VA at 1 and 2 years from baseline as measured in Early Treatment Diabetic Retinopathy Study letters. Secondary outcomes were the number of injections and predictive factors for VA gain. RESULTS: Mean VA gain at 1 year and 2 years were +5.5 (95% CI 5.0 to 6.0) and +4.9 (95% CI 4.2 to 5.6) letters, respectively. Fifty-four per cent of eyes gained ≥5 letters at 2 years, 63% had stable VA (±≤14 letters), 44% of eyes maintained good VA (≥70 letters). Patients received a mean of 7.7 (95% CI 7.6 to 7.8) injections during year 1 and 13.0 (95% CI 12.8 to 13.2) injections over 2 years. Younger age, lower baseline VA and more injections were associated with higher VA gain at 2 years. CONCLUSION: This study benchmarks high quality EMR study results of real life AMD treatment and promotes open science in clinical AMD research by making the underlying data publicly available.

Evaluation of a computed-tomography-based assessment scheme in treatment decision-making for isolated orbital floor fractures.

INTRODUCTION: Treatment decisions for fractures of the orbital floor are based on clinical appearance, ophthalmological examination, and computed tomography (CT) scans. In extensive fractures, decisions are easily made between conservative and surgical treatment. However, objective parameters are rare in inconclusive cases. MATERIALS AND METHODS: Our retrospective study included 106 patients with unilateral isolated orbital floor fractures. Correlations between preoperative ophthalmological examinations and specific CT parameters were performed. RESULTS: The defect size of the fracture appeared to be significantly associated with the presence of diplopia. CT-morphological parameters and preoperative ophthalmological results showed statistical significance for diplopia and incarceration of inferior rectus muscle (IRM), diplopia and displacement of IRM, decreased mobility and incarceration of IRM, and decreased mobility and displacement of IRM. DISCUSSION: Our clinical assessment scheme for CT scans of orbital floor fractures is aimed at facilitating treatment decision making using four CT-based variables. As critical size defects of the orbital floor of ≥2 cm2 are likely to cause clinically significant posterior displacement of the globe, resulting in enophthalmos, the proposed parameters offer a readily accessible and easy to evaluate scheme that helps to identify patients in need of surgical intervention.

Differences in corneal clinical findings after standard and accelerated cross-linking in patients with progressive keratoconus.

BACKGROUND: The purpose of this study was to identify differences in clinical corneal findings after standard and accelerated epithelial off cross-linking (CXL) during a long-term follow-up. METHODS: Two hundred forty-one patients (184 male) were included in this monocentric, retrospective, non-randomized and unmasked study. One hundred forty-eight eyes were treated with the accelerated protocol and 138 with the standard protocol with epithelial off CXL, if diagnosed with keratoconus and a progression in Kmax of more than one dioptre during the preceding 6 months, plus a minimal pachymetry measurement of 400 µm in keratometry (Pentacam, Oculus GmbH, Wetzlar, Germany). Exclusion criteria were previous surgery, other corneal conditions or age above 50 years. Follow-up time was 36 months with clinical examination and keratometry at every visit. Outcome measures were the observed rate of corneal changes, differences between treatment groups and correlation with keratometry measurements. RESULTS: In patients with accelerated CXL, significantly more clear corneas were seen at three (p = 0.015) and six (p = 0.002) months after surgery than following the standard protocol. The rate of clear corneas dropped from 52.2% pre-operation (OP) to a minimum of 19.3% after 6 months in the standard protocol group compared with 50.7% clear corneas pre-OP and a minimum of 40.8% in the accelerated group. In the standard protocol group, more striae were found 3 months after intervention than in the accelerated group (p = 0.05). CONCLUSIONS: In patients with accelerated CXL, fewer morphological corneal changes were observed than after conventional CXL. However, rarely, corneal changes persisted for a long time.