[ChatGPT and the German board examination for ophthalmology: an evaluation]. / ChatGPT und die deutsche Facharztprüfung für Augenheilkunde: eine Evaluierung.

PURPOSE: In recent years artificial intelligence (AI), as a new segment of computer science, has also become increasingly more important in medicine. The aim of this project was to investigate whether the current version of ChatGPT (ChatGPT 4.0) is able to answer open questions that could be asked in the context of a German board examination in ophthalmology. METHODS: After excluding image-based questions, 10 questions from 15 different chapters/topics were selected from the textbook 1000 questions in ophthalmology (1000 Fragen Augenheilkunde 2nd edition, 2014). ChatGPT was instructed by means of a so-called prompt to assume the role of a board certified ophthalmologist and to concentrate on the essentials when answering. A human expert with considerable expertise in the respective topic, evaluated the answers regarding their correctness, relevance and internal coherence. Additionally, the overall performance was rated by school grades and assessed whether the answers would have been sufficient to pass the ophthalmology board examination. RESULTS: The ChatGPT would have passed the board examination in 12 out of 15 topics. The overall performance, however, was limited with only 53.3% completely correct answers. While the correctness of the results in the different topics was highly variable (uveitis and lens/cataract 100%; optics and refraction 20%), the answers always had a high thematic fit (70%) and internal coherence (71%). CONCLUSION: The fact that ChatGPT 4.0 would have passed the specialist examination in 12 out of 15 topics is remarkable considering the fact that this AI was not specifically trained for medical questions; however, there is a considerable performance variability between the topics, with some serious shortcomings that currently rule out its safe use in clinical practice.

Ocular Syphilis: Experience over 11 Years at a German Ophthalmology Reference Centre.

BACKGROUND: In accordance with worldwide data, the Robert Koch Institute (RKI) has reported a constant increase of syphilis cases in Germany over the past decade. METHODS: We analysed the data of all patients, referred to a Department of Ophthalmology in a tertiary referral centre in Düsseldorf, Germany between 2008 and 2019, who were tested for syphilis. The epidemiologic, demographic, clinical, diagnostic and therapeutic data were retrieved from the records and evaluated in a retrospective, descriptive, non-comparative study. RESULTS: Syphilis serology was positive in 32/1840 (1.7%) patients, and was evenly distributed over this period. 26 (81.3%) were male, 19 (59.4%) belonged to a risk group. Ocular syphilis was the primary diagnosis for 29 patients (90.6%). The most frequent manifestation was uveitis (n = 20, 62.5%). By the end of therapy, 19 patients (59.4%) had an improved visual acuity. CONCLUSION: The incidence of ocular syphilis cases has remained stable over the last decade.

Retinal vascular occlusion in pregnancy: three case reports and a review of the literature.

BACKGROUND: Retinal arterial occlusive events in young patients are rare. However, because of physiological multifactorial adaptations during pregnancy, retinal vascular occlusive disease may occur spontaneously. In addition, a patent foramen ovale is a risk factor for an ischemic thromboembolic event. Since fluorescein angiography, a central tool in the evaluation of these occlusions, should be avoided during pregnancy, optical coherence tomography angiography, a novel technique, offers a good opportunity for visualizing vascular perfusion of retinal tissue. CASE PRESENTATION: Here we present a case series of three patients (Caucasian, nonsmoker) who visited our clinic owing to acute visual impairment and central scotoma. Using regular optical coherence tomography and optical coherence tomography angiography, retinal vascular occlusions were detected, thus initiating the evaluation of systemic risk factors. We report two patients (30 and 32 years old) who developed cilioretinal artery occlusion but whose etiology differed: one was of thromboembolic origin associated with patent foramen ovale, while the other was caused by hemodynamic blockade secondary to central retinal vein occlusion. In both cases, optical coherence tomography angiography revealed reperfusion of the cilioretinal artery occlusion. However, transient ischemia led to retinal atrophy after a few weeks. In the third patient (32 years old), 8 weeks after onset of scotoma, optical coherence tomography angiography revealed atrophy of the middle layers and impaired perfusion in the deep capillary plexus, and thus a paracentral acute middle maculopathy was diagnosed. All patients regained normal visual acuity and had otherwise uncomplicated pregnancies, and laboratory blood tests did not reveal any defects or alterations. CONCLUSIONS: As shown here, optical coherence tomography angiography enables risk-free imaging of retinal vessel perfusion during pregnancy. Together with regular optical coherence tomography, it allows one to predict functional outcome according to the existing retinal occlusion-related atrophy.

[Current and future effects of climate change on ophthalmology]. / Aktuelle und zukünftige Auswirkungen des Klimawandels auf die Augenheilkunde.

BACKGROUND AND OBJECTIVES: Climate change is also an increasingly important issue in the healthcare system. Due to its anatomical and physiological nature, the eye is directly exposed to environmental influences and changes in a special way. METHODS: The current literature is used to illustrate the effects of climate-induced changes and the respective influences on the eye. A PubMed search (cut-off date 3 October 2021) using the search terms "climate change" or "planetary health" or "global health" and in each case "ophthalmology" or "eye" or "ocular" was used to determine the development of the number of publications between 2011 and 2021. RESULTS: Measurable effects of climate change are already evident in a wide variety of ophthalmological fields. The significance of this topic, for instance, is reflected in a relatively constant increase in the number of publications and an almost tenfold increase in the number of publications per year from 2011 to 2021. CONCLUSION: The impact of climate change on eye diseases and on the field of ophthalmology is multifaceted and could be expected to intensify in the coming years. Therefore, the interrelationships need to be further investigated in future studies, preferably on a large scale.

A randomized, open-label, multicenter study of switching to brolucizumab with or without a loading dose for patients with suboptimal anatomically controlled neovascular age-related macular degeneration-the FALCON study.

BACKGROUND: Treatment initiation with brolucizumab, a new potent anti-vascular endothelial growth factor (VEGF) agent, is typically performed with three monthly injections (loading dose) and has been well studied in treatment-naïve patients. However, no clinical data are available yet on whether or not anti-VEGF pretreated patients also benefit from a loading dose. In the clinical setting, different heterogeneous treatment patterns are used as no clinical trial has addressed this so far in a head-to-head comparison. Therefore, the FALCON study is investigating whether patients with unsatisfactory response to previous anti-VEGF treatments benefit from a loading dose at the switch to brolucizumab treatment. METHODS: FALCON is a 52-week, two-arm, randomized, open-label, multicenter, multinational study in patients with residually active neovascular age-related macular degeneration (nAMD) who will be randomized 1:1 and started with brolucizumab 6 mg loading (three monthly loading doses) or brolucizumab 6 mg non-loading (one initial injection) and consecutive treatment every 12 weeks, respectively. The primary objective is to demonstrate non-inferiority of the non-loading vs. loading arm in mean change of best-corrected visual acuity (BCVA) from baseline to the mean value at week 40 to week 52. Secondary objectives include the assessment of anatomical outcomes, treatment intervals, safety and tolerability. RESULTS: FALCON will be the first study to assess treatment initiation with an anti-VEGF agent in a switch situation with or without loading dose in patients with nAMD. CONCLUSIONS: The results will support the optimization of treatment of patients with previous unsatisfactory anti-VEGF response. Therefore, we expect to see an impact on current clinical practice which has been established for more than a decade. TRIAL REGISTRATION: Clinicaltrials.gov: NCT04679935, date of registration-22-Dec 2020; EUDRACT number: 2019-004763-53, date of registration-03 Dec 2019.

Frequently assessed and used prognostic factors for outcome after macular hole surgery: which is better?

BACKGROUND: The aim of this retrospective study was to evaluate commonly used clinical and OCT-morphological parameters, including perifoveal pseudocysts, as prognostic factors for postoperative outcome after macular hole surgery in a retinal referral clinic in North Rhine-Westphalia, Germany. METHODS AND MATERIAL: This was a retrospective analysis of all patients who underwent surgery because of idiopathic MH between 2011 and 2017 in Augenklinik Tausendfensterhaus, Duisburg, Germany. Statistical evaluation of clinical and OCT-based parameters, including the areas of intraretinal pseudocysts, was conducted. The main statistical outcomes were surgical success and visual acuity. Only parameters with a highly significant correlation to the outcome parameters (postoperative visual acuity (VA); surgical success) in univariate analysis were entered in linear and logistic regression analyses. RESULTS: A total of 189 eyes of 178 patients (71.4% female; mean age 67.5 ± 8.2 a) who underwent surgery because of MH were included. The overall closure rate was 86.8%. The mean best corrected VA increased from 0.7 ± 0.3 logMAR before surgery to 0.5 ± 0.3 logMAR (p < 0.0001). While several clinical and OCT-based parameters as well as calculated indices showed a significant correlation with the outcome measures, the regression analysis showed that the minimum linear diameter was the only parameter that both predicted surgical success (p = 0.015) and was correlated with postoperative VA (p < 0.001). CONCLUSION: The minimum linear diameter serves as an easily assessed prognostic factor with the best predictive properties. This result is of great importance for clinical practice, as it simplifies the postsurgical prognosis.

[Atypical optic neuritis: the importance of a comprehensive diagnostic work-up]. / Atypische Neuritis nervi optici (NNO): Bedeutung einer umfassenden Abklärung.

A 65-year-old woman was referred for sudden bilateral loss of vision. She was vaccinated a few days earlier. The ophthalmological examination showed a massive optic disc swelling on both eyes. Magnetic resonance imaging (MRI) revealed suspected bilateral optic neuritis without cerebral involvement or transverse myelitis. After serological detection of anti-MOG (myelin oligodendrocyte glycoprotein) antibodies, the patient was treated with high-dose corticosteroid pulse therapy until vision recovered. Discussion: an atypical optic neuritis may indicate a neuromyelitis optica spectrum disorder (NMOSD), which should be further characterized by determination of Aquaporin 4(AQP4)-IgG and MOG-IgG.

Prevalence, incidence, and risk factors of primary open-angle glaucoma - a cohort study based on longitudinal data from a German public health insurance.

BACKGROUND: This study estimates the prevalence and incidence rates of primary open -angle glaucoma (POAG) as well as risk factors based on a dataset from the largest German health insurance company. METHODS: A random sample of 250,000 persons at age 50+ of the Allgemeine Ortskrankenkasse (AOK) from 2010 to 2013 was used. Selected risk factors of POAG incidence were analyzed using multivariate Cox proportional hazard models. RESULTS: The age-standardized prevalence of POAG at age 50+ in 2010 was 2.79% (95%-CI: 2.72-2.85%). The age-standardized total incidence rate was 0.38 (0.36-0.39) per 100 person-years. Sex differences were significant for total prevalence and total incidence rates, with higher prevalence and incidence rates for women compared to men. The Cox model revealed a strong age effect, a significantly 19% higher incidence for women (p ≤ 0.001), injuries of the eye and orbit (175%, p ≤ 0.001), degeneration of iris and ciliary body (155%, p = 0.022), myopia (155%, p ≤ 0.001), retinal vascular occlusions (134%, p ≤ 0.001), hypertension (13%, p ≤ 0.001) and diabetes mellitus (23%, p ≤ 0.001). CONCLUSION: Health claims data are an important data source for estimating POAG occurrence and help overcome the problems of small sample sizes. These results may help to understand the causal pathways of POAG and to develop intervention strategies to increase the awareness of patients and physicians with the aim of reducing POAG incidence.

[Biomechanical investigations on accommodation of the eye]. / Biomechanische Untersuchungen zur Akkommodation des Auges.

BACKGROUND: The biomechanics of accommodation are of particular interest in terms of the causes of presbyopia and the function of intraocular lenses. OBJECTIVE: The aim of the present article is to model the mechanism of accommodation in detail. MATERIALS AND METHODS: The state of the art of applying biomechanical models to accommodation is presented, which enables the accommodation process to be understood. RESULTS AND CONCLUSION: The established models, which are based on the Helmholtz theory, can explain the accommodation process in a plausible manner. These models thereby also enable further investigations on the genesis of presbyopia as well as on the development of accommodative intraocular lenses and implants. However, measurements are always necessary to compare the simulation results with reality, and to provide input and material data as well as geometric dimensions of components of the eye.

[German ophthalmology in developing countries : Partnerships with eye clinics in developing countries - an initiative of the German Ophthalmological Society]. / Deutsche Augenheilkunde in Entwicklungsländern : Partnerschaften mit Augenkliniken in Entwicklungsländern ­ eine Initiative der Deutschen Ophthalmologischen Gesellschaft.

In 1999 the global initiative "Vision 2020 - The Right to Sight" was established by the World Health Organization (WHO), the International Agency for the Prevention of Blindness (IAPB) and several non-governmental organizations (NGOs) with the goal of reducing avoidable blindness. Based on this initiative, the working group "International Ophthalmology" of the German Ophthalmological Society (DOG), which was established in 1994, was converted into a DOG section with the same name in 2004 and represents one of the core components of the DOG; however, even before there were a number of established partnerships of German and African eye hospitals. The first cooperation of this kind was the partnership between the Department of Ophthalmology, Ludwig-Maximilians University Munich and the University of Nairobi, Kenya, which was founded in 1978. As a result of this cooperation, the Department of Ophthalmology in Nairobi has evolved into one of the major centers of ophthalmological training and ophthalmic care in East Africa. Since then a number of similar cooperation projects between several hospitals and numerous further projects (e. g. in Myanmar) have been implemented and some of these are presented in this manuscript.

[In vivo imaging of the corneal nerve plexus : From single image to large scale map]. / In-vivo-Bildgebung des kornealen Nervenplexus : Vom Einzelbild zur großflächigen Darstellung.

The sub-basal nerve plexus (SNP) of the cornea provides the possibility of in vivo and non-invasive examination of peripheral nerve structures by corneal confocal microscopy (CCM). Thus morphological alterations of the SNP can be directly detected and quantified. A single CCM image is insufficient for a well-founded diagnosis because of the inhomogeneous distribution of the nerve fibers; therefore, there is a demand for techniques for large area imaging of the SNP. This article provides an overview of published approaches to the problem. Current developmental work at the Karlsruhe Institute of Technology and the University of Rostock Eye Clinic is expected to lead to a simplified handling of the technology and a further improvement in the image quality.

[Morphometric characterization of the subbasal nerve plexus : Detection and analysis of networks of nerve fibers]. / Morphometrische Charakterisierung des subbasalen Nervenplexus : Detektion und Analyse von Nervenfasernetzwerken.

Confocal laser scanning microscopy is a versatile tool in medical research and enables noninvasive in vivo imaging of the corneal subbasal nerve plexus. The aim of this work is to provide a structured overview about the detection and quantification of nerve fibers of the subbasal nerve plexus from images acquired by confocal laser scanning microscopy. Relevant steps are explained and potential factors influencing the quality of the results are pointed out. Information obtained from the quantification of subbasal nerve fiber structure can be potentially used as clinical parameters in the context of diagnostics and therapy control of diabetic neuropathy.

Demographics of patients receiving Intravitreal anti-VEGF treatment in real-world practice: healthcare research data versus randomized controlled trials.

BACKGROUND: While randomized controlled trials (RCTs) are based on strict inclusion/exclusion criteria, non-interventional studies (NISs) might provide additional information to guide management in patients more representative to the real-world setting. The aim of this study was to compare baseline characteristics of patients receiving intravitreal treatment in the NIS OCEAN with those from published RCTs. METHODS: The ongoing OCEAN study enrolled patients treated with ranibizumab for neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME) or branch/central retinal vein occlusion (B/CRVO). Baseline patient characteristics were compared by indication within the OCEAN cohort. Furthermore, the characteristics were set in reference to those of published RCTs in the same indications. Confidence intervals (CIs) were calculated and assessed for statistically significant differences as indicated by non-overlapping CIs. RESULTS: Patient characteristics in the NIS OCEAN were evaluated for 3,614 patients with nAMD, 1,211 with DME, 204 with BRVO and 121 with CRVO. Between these groups, significant differences in mean age, gender distributions, and mean baseline VA were seen, reflecting known differences between the indications. Compared to the patient characteristics of published RCTs (trials selected by literature search: nAMD: 13 RCTs, DME: 9, RVO: 5), the OCEAN patients' mean age was significantly higher in every indication. The gender distributions across the trials were comparable, with only few differences between OCEAN and the RCTs. Regarding the mean baseline VA, notable differences were found in nAMD and in DME, with VA significantly higher in some RCTs and lower in others. CONCLUSIONS: The described differences underline the complementarity of NISs and RCTs. OCEAN covers a broader spectrum and more variability of patients than do RCTs. As baseline values may have impact on the treatment response (ceiling effect), there is an ongoing need for research in all patient subgroups. Country-specific assessments of patient populations can better reflect the real-world situation. NISs can deliver insights that RCTs may not, as NISs can include non-typical patients, patients with comorbidities, a broader age spectrum and patients of various disease stages. TRIAL REGISTRATION: The NIS OCEAN was registered on www.clinicaltrials.gov (identifier: NCT02194803 ).

Femtosecond laser cutting of human corneas for the subbasal nerve plexus evaluation.

Assessment of various morphological parameters of the corneal subbasal nerve plexus is a valuable method of documenting the structural and presumably functional integrity of the corneal innervation in health and disease. The aim of this work is to establish a rapid, reliable and reproducible method for visualization of the human corneal SBP using femtosecond laser cut corneal tissue sections. Trephined healthy corneal buttons were fixed and processed using TissueSurgeon-a femtosecond laser based microtome, to obtain thick tissue sections of the corneal epithelium and anterior stroma cut parallel to the ocular surface within approximately 15 min. A near infrared femtosecond laser was focused on to the cornea approximately 70-90 µm from the anterior surface to induce material separation using TissueSurgeon. The obtained corneal sections were stained following standard immunohistochemical procedures with anti-neuronal ß-III tubulin antibody for visualization of the corneal nerves. Sections that contained the epithelium and approximately 20-30 µm of anterior stroma yielded excellent visualisation of the SBP with minimal optical interference from underlying stromal nerves. In conclusion, the results of this study have demonstrated that femtosecond laser cutting of the human cornea offers greater speed, ease and reliability than standard tissue preparation methods for obtaining high quality thick sections of the anterior cornea cut parallel to the ocular surface.

Comparative quantitative assessment of the human corneal sub-basal nerve plexus by in vivo confocal microscopy and histological staining.

PurposeThis study was designed to compare and contrast quantitative data of the human corneal sub-basal nerve plexus (SBP) evaluated by two different methods: in vivo confocal microscopy (IVCM), and immunohistochemical staining of ex vivo donor corneas.MethodsSeven parameters of the SBP in large-scale IVCM mosaicking images from healthy subjects were compared with the identical parameters in ex vivo donor corneas stained by ß-III-tubulin immunohistochemistry. Corneal nerve fiber length (CNFL), corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), average weighted corneal nerve fiber tortuosity (CNFTo), corneal nerve connection points (CNCP), average corneal nerve single-fiber length (CNSFL), and average weighted corneal nerve fiber thickness (CNFTh) were calculated using a dedicated, published algorithm and compared.ResultsOur experiments showed significantly higher values for CNFL (50.2 vs 21.4 mm/mm2), CNFD (1358.8 vs 277.3 nerve fibers/mm2), CNBD (847.6 vs 163.5 branches/mm2), CNFTo (0.095 vs 0.081 µm-1), and CNCP (49.4 vs 21.6 connections/mm2) in histologically staining specimens compared with IVCM images. In contrast, CNSFL values were higher in IVCM images than in histological specimens (32.1 vs 74.1 µm). No significant difference was observed in CNFTh (2.22 vs 2.20 µm) between the two groups.ConclusionsThe results of this study have shown that IVCM has an inherently lower resolution compared with ex vivo immunohistochemical staining of the corneal SBP and that this limitation leads to a systematic underestimation of several SBP parameters. Despite this shortcoming, IVCM is a vital clinical tool for in vivo characterization, quantitative clinical imaging, and evaluation of the human corneal SBP.

[Magnetic Resonance Microscopy of the Accommodative Apparatus]. / Magnetresonanzmikroskopie des Akkommodationsapparats.

Magnetic resonance microscopy (MRM) at ultra-high magnetic fields allows acquisition of high resolution MR images in the micrometre range. The use of ultra-high magnetic fields opens the possibility of user-independent and artefact-free detailed characterisation of the anatomical tissue of the human eye, which is not achievable with classical imaging techniques. This article correlates MRM of the anterior eye segment and the accommodative apparatus at 9.4 Tesla with conventional histology.

[Finite Element Modelling of the Eye for the Investigation of Accommodation]. / Finite-Elemente-Modellierung des Auges zur Untersuchung der Akkommodation.

Background: Accommodation research increasingly uses engineering methods. This article presents the use of the finite element method in accommodation research. Material and Methods: Geometry, material data and boundary conditions are prerequisites for the application of the finite element method. Published data on geometry and materials are reviewed. It is shown how boundary conditions are important and how they influence the results. Results: Two dimensional and three dimensional models of the anterior chamber of the eye are presented. With simple two dimensional models, it is shown that realistic results for the accommodation amplitude can always be achieved. More complex three dimensional models of the accommodation mechanism - including the ciliary muscle - require further investigations of the material data and of the morphology of the ciliary muscle, if they are to achieve realistic results for accommodation. Discussion and Conclusion: The efficiency and the limitations of the finite element method are especially clear for accommodation. Application of the method requires extensive preparation, including acquisition of geometric and material data and experimental validation. However, a validated model can be used as a basis for parametric studies, by systematically varying material data and geometric dimensions. This allows systematic investigation of how essential input parameters influence the results.