Publications by authors named "Andreas Frings"

59 Publications

The Vision Correction Questionnaire (VCQ): An electronic patient reported outcome measure for refractive surgery.

J Cataract Refract Surg 2022 Jul 20. Epub 2022 Jul 20.

The Refractive Surgery Service, Moorfields Eye Hospital, London, UK.

Purpose: To develop a psychometrically robust electronic patient outcome measure (ePROM) for refractive surgery.

Setting: Moorfields Eye Hospital, London, United Kingdom.

Design: A questionnaire development study.

Methods: Items were derived in 6 domains (spectacle dependence, visual quality, eye comfort, functional freedom, emotional wellbeing, and satisfaction with treatment) from existing Rasch adjusted instruments, patient and surgeon feedback, and refinement in semi-structured interviews before administration to a field test cohort (n=360) of patients undergoing routine refractive surgery. Spectacle dependence and satisfaction with treatment items were used to provide descriptive statistical information only. Contemporary criteria for item reduction and Rasch modelling were applied to the remaining domains. The finalised questionnaire was then administered to a second patient cohort (n=120) before and after surgery to assess sensitivity to change.

Results: A 5-item scale derived for emotional wellbeing was unidimensional and a good fit to the Rasch model with ordered category response profiles, adequate precision (person separation 2.22 logits, reliability coefficient 0.83), and no misfitting items. Mean logit scores were 0.91 higher after treatment (effect size 1.26) suggesting a positive impact on emotional wellbeing. Functional scales could not be derived for visual quality, eye comfort or functional freedom. Single item ratings for visual quality and eye comfort were retained in our final 11-item questionnaire.

Conclusons: This short ePROM should integrate well with routine clinical care and clinical trials in refractive surgery. The Rasch adjusted emotional wellbeing scale may help quantify the way patients feel about refractive surgery, with the remaining items providing useful descriptive information.
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http://dx.doi.org/10.1097/j.jcrs.0000000000001018DOI Listing
July 2022

Effect of Postoperative Ocular Residual Astigmatism (ORA) on Treatment Outcome After Myopic Laser in situ Keratomileusis (LASIK).

Clin Ophthalmol 2022 23;16:2079-2092. Epub 2022 Jun 23.

Department of Ophthalmology, Heinrich-Heine-University Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany.

Purpose: To analyze the impact of postoperative ocular residual astigmatism (ORA) on refraction, visual acuity and subjective satisfaction after myopic laser-in-situ-keratomileusis (LASIK) by a comprehensive analysis, which includes clinically relevant data and patient-reported outcomes.

Material And Methods: To evaluate the influence of ORA, comparison groups were built following Archer et al. Myopic patients were subdivided by the fraction ORA/MRC (matched and not matched for MRC) (MRC = manifest refractive cylinder), ORA magnitude and CA magnitude in high ORA eyes (CA = corneal astigmatism). Refractive and visual data were analyzed via retrospective cross-sectional analysis for multiple parameters. The subjective satisfaction was analyzed retrospectively 3-4 years after having LASIK via patient reported outcome analysis.

Results: Refractive outcome: Only when grouped by ORA magnitude only, high ORA eyes resulted in approximately twice as cylinder magnitude compared to eyes with preoperative lower ORA. Furthermore, there appeared to be no statistically significant differences in any case. Visual outcome: There appeared to be no statistically significant differences for visual acuity parameters (safety index, efficacy index). Patient reported outcome: When grouped by the rate of ORA/MRC not matching for MRC, there were statistically significant differences in the subjective satisfaction (p = 0.006) and the postoperative side effects (p = 0.001, p = 0.01, p = 0.006), those differences appeared less strong when matched for MRC treated and result better for a higher ratio of ORA/MRC.

Conclusion: Patients with postoperatively high ORA report on higher satisfaction with treatment results than patients with postoperatively low ORA. This did not correlate with differences in the refractive nor visual outcome. As a matter of fact, there is a discrepancy between the objective analysis results and the subjective satisfaction of patients.
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http://dx.doi.org/10.2147/OPTH.S352410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9236448PMC
June 2022

Spectrum and resistance in bacterial infections of the ocular surface in a German tertiary referral center 2009-2019.

Graefes Arch Clin Exp Ophthalmol 2022 Jun 10. Epub 2022 Jun 10.

Department of Ophthalmology, Heinrich-Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.

Purpose: Aim of this study was to evaluate the frequencies, trends, and antibiotic resistance of bacteria collected from ocular surface or contact lens material in a German tertiary referral center from 2009 to 2019.

Methods: Microbiological data from 2009 to 2019 was analyzed. Culture-dependent microbial identification and analysis of antibiotic sensitivity was completed by the Institute of Microbiology. Statistical analysis of age- and sex-specific differences as well as changes in the microbial spectrum and resistance over the study period was performed with GraphPad Prism 9.0 applying nonparametric tests (level of significance: p ≦ 0.05).

Results: A total of 6361 specimens were analyzed. Positivity rate was 18.6%. Sixty-three percent (n = 680) of the bacterial isolates were derived from ocular surface and 37% (n = 399) from contact lens material. The ratio of gram-negative bacteria was significantly higher in contact lens material. Multiresistant bacteria showed a significant increase with patient age (p < 0.0001). An overall increase in resistance to levofloxacin (p = 0.0239) was detected. Only 2.4% and 3.1% isolates were resistant to a combination of moxifloxacin and gentamicin, respectively, levofloxacin and gentamicin.

Conclusions: The reported bacterial spectrum is similar to comparable centers. Our data show that it should not be assumed that the newest classes of antibiotics have the best efficacy or lowest resistance levels. In suspected bacterial conjunctivitis, we propose using gentamicin as first-line therapy. In therapy refractive cases and in involvement of the cornea, we recommend a combination of gentamicin and ofloxacin or moxifloxacin. Overall, the evaluated organisms showed good sensitivity to the regularly used antibiotics.
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http://dx.doi.org/10.1007/s00417-022-05721-7DOI Listing
June 2022

Prediction model of free flaps in microkeratome-assisted LASIK.

PLoS One 2021 1;16(9):e0255525. Epub 2021 Sep 1.

Department of Ophthalmology, University Hospital Hamburg Eppendorf, Hamburg, Germany.

Purpose: To identify mechanical factors, as well as patients' biometric and surgeons' experience factors that correlate with the FF incidence in microkeratome (MK)-assisted LASIK and to construct a predictive model based on these parameters.

Methods: 55,700 consecutive LASIK treatments of 28,506 patients between January 2017 and April 2020 done by 50 surgeons in 10 centers, all with Sub Bowman Keratome (SBK) and 90μ head (OUP) were analyzed retrospectively for the incidence of FF and their correlation to mean keratometry, central corneal thickness, MK ring height and stop, as well as surgeons' experience. A prediction model was built and tested for sensitivity and specificity.

Results: The incidence of FF using the SBK MK was 0.276%. Risk factors were low central corneal thickness, very flat (-1) or very thick (+2) ring height, and higher stop values (p<0.001). Mean keratometry and low surgeon experience were not correlated to FF incidence. A prediction model with a cut-off FF risk of 0.274%, a 76% specificity, and a 73% sensitivity was applied.

Conclusions: Free flaps are rarely seen in modern MK LASIK. However, the incidence of this complication using the SBK MK increases using higher stop values, very thick and very thin MK rings, and in eyes with thin corneas.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255525PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8409612PMC
November 2021

Comparison of Syringes With Intravitreal Anti-VEGF Drugs: Particle Burden and Protein Aggregates in Brolucizumab, Aflibercept and Bevacizumab.

Transl Vis Sci Technol 2021 08;10(9):21

Department of Pharmacy, Pharmaceutical Technology and Biopharmaceutics, Ludwig-Maximilians-University Munich, Germany.

Purpose: In a benchwork particle counting analytical evaluation, the number and type of particles in intravitreal injection formulations of three different agents against vascular endothelial growth factor were investigated.

Methods: Commercially available ready-to-use aflibercept and brolucizumab glass syringes, vials containing bevacizumab (off-label use in ophthalmology), and repackaged ready-to-use plastic syringes containing bevacizumab were tested without filtration. Total visible, subvisible, and nanoparticles numbers and size distributions were quantified using light obscuration, flow imaging, resonant mass measurement (RMM), tunable resistive pulse sensing, and dynamic light scattering.

Results: Repackaged bevacizumab showed overall low particle numbers, aflibercept showed high numbers of micrometer sized particles but low nanoparticle numbers, brolucizumab showed low to moderate numbers of micrometer sized particles but high nanoparticle numbers. RMM measurements identified particles in the nanometer range as either proteinaceous or silicon oil; the nature of the other particles was not further evaluated.

Conclusions: Repackaged bevacizumab shows no inferior particle quality compared to ready-to-use products. It is relevant to study nanoparticle load of the products as the micrometer-sized particle numbers do not in all cases correlate to nanoparticle counts. Particularly for the high concentration product Beovu (brolucizumab), high nanoparticle numbers were found despite low numbers of micrometer sized particles. Silicone oil droplets did not account for high particle numbers as the measured numbers were low.

Translational Relevance: Different side effects are registered in different frequencies with different intravitreal anti-VEGF-drugs and syringes, which are applied by injection by small 30G needles through the sclera directly to the intravitreal cavity. The study of nanoparticles and silicone oil droplets may be able to contribute to narrowing down the causes.
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http://dx.doi.org/10.1167/tvst.10.9.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375009PMC
August 2021

Intraoperative OCT - Real-World User Evaluation in Routine Surgery.

Klin Monbl Augenheilkd 2021 Jun 20;238(6):693-699. Epub 2021 May 20.

Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Deutschland.

Background: In recent years, great progress has been made in intraoperative imaging using optical coherence tomography (iOCT). There are now several commercially available iOCT systems that allow high-resolution imaging of all structures of the eye without interrupting surgery. This real-time visualisation can provide additional information to conventional surgical microscopy, but is relatively expensive. The aim of our study was to find out how often OCT integrated into the surgical microscope is used by trained surgeons, or to what extent they consider that iOCT is relevant for intraoperative procedures.

Patients And Methods: A prospective monocentric analysis was conducted of the field of application and user-friendliness of the EnFocus Ultra-Deep OCT (Leica Microsystems), a mobile device combination of surgical microscope and OCT. The use and benefit were investigated of iOCT, which was not mandatory. Standardised documentation and evaluation using a questionnaire was performed by the respective surgeon (n = 5) immediately after surgery.

Results: Over a period of 25 working days, 118 procedures were performed in the operating theatre equipped with the microscope-OCT combination. The iOCT was used in 24.6% of the 118 procedures performed. iOCT was regarded as crucial to the intraoperative procedure in 3 of the 29 patients. In one patient, it was possible to check graft orientation during a DMEK operation in a very opaque cornea and, in the second patient, to visualise the correct positioning of an iris diaphragm in the capsular bag. In the third patient, the risk of developing a pseudoforamen was assessed, and this led to the decision not to perform a full gliosis peel.

Conclusion: Experienced surgeons in a university eye hospital with a full surgical spectrum considered that intraoperative OCT was decisive for the course of surgery in only a few selected surgical situations, e.g. in case of limited corneal transparency. The impact of the use of iOCT on post-operative outcome quality still needs to be evaluated by larger prospective studies. On the basis of this survey, the cost-benefit ratio is still unclear.
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http://dx.doi.org/10.1055/a-1389-5815DOI Listing
June 2021

Quality of life in stable and progressive 'early-stage' keratoconus patients.

Acta Ophthalmol 2021 Mar 10;99(2):e196-e201. Epub 2020 Sep 10.

Department of Ophthalmology, UKE - University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany.

Purpose: To analyse the vision-related quality of life (vr-QoL) in stable and progressive keratoconus (KC) patients with a still good visual acuity.

Methods: Combined prospective/cross-sectional study design. The Refractive Status and Vision Profile (RSVP) and the National Eye Institute Visual Functioning - 25 (NEI-25) questionnaire were used in 16 emmetropic, 32 myopic and 56 KC patients, whereby KC patients with a stable (n = 26) and patients with a progressive stage (n = 30) and some of them before and after corneal cross-linking (CXL; n = 10) were included. All patients had a DCVA in at least one eye of ≥0.7 (decimal chart).

Results: The analyses revealed a minor decline of the vr-QoL from emmetropes to myopes to early KC patients with a stable disease. Nonetheless, sociological subscales (i.e. 'social functioning', 'role difficulties' and 'dependency') did not display statistically significant differences comparing these groups. In progressive KC, we could demonstrate a statistically significant decline also of these sociological subscales, which did not improve after CXL.

Conclusion: Due to a still high and almost unaffected vr-QoL in early KC patients and the distinct decline after progression without rehabilitation after CXL, a reconsideration of current strategies to perform CXL only after a progression is diagnosed should be re-evaluated.
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http://dx.doi.org/10.1111/aos.14564DOI Listing
March 2021

Gender-Specific Differences in Signs and Symptoms of Dry Eye Disease.

Curr Eye Res 2021 03 19;46(3):294-301. Epub 2020 Aug 19.

Department of Ophthalmology, University Hospital Duesseldorf , Düsseldorf, Germany.

Introduction: Dry eye disease (DED) is a multifactorial disease of the ocular surface characterized by loss of homeostasis of the tear film. Epidemiological studies suggest it occurs more frequently in women than men. The aim of this retrospective analysis was to determine whether patients with DED show gender-specific differences in symptoms and signs.

Material And Methods: A retrospective analysis of 107 patients was conducted at the Department of Ophthalmology of the University of Düsseldorf - Germany. After completing the OSDI questionnaire, the patients underwent objective refraction and were asked about the following symptoms: burning, itching, foreign body sensation, epiphora, sticky eyes, pain, red eyes and swollen eyelids. Furthermore, they underwent an evaluation of the following signs: lipid layer thickness, non-invasive break-up-time (NI-BUT), conjunctival hyperemia, lid parallel conjunctival folds, meibography, Schirmer test and tear meniscus height, ocular surface staining, expressibility of meibomian glands.

Results: Of the 107 patients (56.2 ± 17.3 years) 75 were women and 32 men. Women reported significantly more often eyelid swelling ( = .03) and showed a tendency to complain more about red eyes ( = .051), while men tended to complain more often about epiphora ( = .053). In an age-matched sample taken from the cohort, significant differences were found for OSDI-scores ( = .025) showing women reporting more symptoms compared to men, while men showed more conjunctival hyperaemia ( = .004) than women. Women showed a significant thicker lipid layer ( = .0009) in the full cohort, but not in the age-matched sample ( = .43).

Conclusion: Although the majority of the investigated parameters did not show gender-specific differences, women reported higher OSDI scores. These findings could be explained by an increased frequency of neuropathic symptoms or ocular surface sensitivity in women or higher resilience of men to consult an ophthalmologist. Sex may have an effect on the clinical characteristics of DED, but further studies are needed to confirm these findings.
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http://dx.doi.org/10.1080/02713683.2020.1801758DOI Listing
March 2021

Pyramidal Aberrometry in Wavefront-Guided Myopic LASIK.

J Refract Surg 2020 Jul;36(7):442-448

Purpose: To evaluate measurement repeatability and clinical results for pyramidal aberrometry in routine myopic wavefront-guided laser in situ keratomileusis (LASIK).

Methods: Results from 265 consecutive eyes treated with myopic wavefront-guided LASIK using the Amaris 1050RS Excimer Laser and Peramis pyramidal aberrometer (SCHWIND eye-tech-solutions GmbH) were reviewed. Limits of repeatability were calculated for the aberrometric refraction spherical equivalent and higher order aberrations for the Peramis aberrometer using results from three consecutive scans acquired preoperatively and postoperatively for the first 100 eyes treated.

Results: The 95% limits of repeatability for pyramidal aberrometric measurement were: 0.3 diopters (D) for sphere, 0.2 D for cylinder, and 0.1 D (dioptric equivalent) for 3rd and 4th order aberration indices. A total of 95% of eyes were within ±0.50 D of the manifest refraction spherical equivalent target postoperatively. Uncorrected distance visual acuity was 20/20 or better in 96% of 232 eyes with a plano refraction target outcome. A total of 97% of eyes had a refraction cylinder of 0.50 D or less. No eyes lost one or more line of corrected distance visual acuity.

Conclusions: These data demonstrate good measurement repeatability, safety, and efficacy for pyramidal aberrometry in routine myopic LASIK. [J Refract Surg. 2020;36(7):442-448.].
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http://dx.doi.org/10.3928/1081597X-20200519-03DOI Listing
July 2020

Hidradenitis Suppurativa is Associated with Symptoms of Keratoconjunctivitis Sicca.

Curr Eye Res 2021 01 7;46(1):23-30. Epub 2020 Jun 7.

Department of Dermatology, Venereology and Allergology, University Hospital Würzburg , Würzburg, Germany.

Aim Of The Study: Hidradenitis suppurativa (HS) and psoriasis vulgaris (PSO) are chronic inflammatory dermatoses in which proinflammatory cytokines, such as IL-17, play a central role. The prevalence of keratoconjunctivitis sicca (KCS) is commonly higher in PSO than in healthy individuals. This study was thus set up to investigate the prevalence of KCS among patients with HS.

Materials And Methods: In a cross-sectional study standardized tear film parameters and symptom-oriented questionnaires (OSDI, SPEED) were analyzed in a total of 71 subjects (HS n = 20, PSO n = 20, healthy controls n = 31). Additionally, IL-17 and MMP-9 in the tear film were analyzed. These parameters were correlated to the clinical severity of the skin disease. PSO patients served as inflammatory control group.

Results: There were statistically significant differences in OSDI ( = .003) and SPEED (p ≤ 0.001) between HS and the control group, but not between PSO and controls. For HS, there was a statistically significant correlation between symptoms (OSDI) and the severity of HS according to Hurley stage ( = .023). Tear film concentrations showed significantly increased levels of IL-17 ( = .018), but not MMP-9, in PSO alone compared to the control group.

Conclusion: Data show that subjective complaints of KCS may be associated with HS and correlate with the severity of the respective Hurley stage, but do not involve alterations of tear film MMP-9 and IL-17. Clinicians should remain mindful that ocular complications in HS are often more vague than in psoriatic patients, but dry eye symptoms might be detrimental for the patients' quality of life.
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http://dx.doi.org/10.1080/02713683.2020.1775259DOI Listing
January 2021

Issues with Intravitreal Administration of Anti-VEGF Drugs.

Clin Ophthalmol 2020 23;14:897-904. Epub 2020 Mar 23.

Department of Ophthalmology, Heinrich Heine University, Duesseldorf, Germany.

Purpose: To provide an update of summary of risk factors and side effects of long-term use and contamination of intravitreal anti-VEGF injections.

Methods: We reviewed relevant publications of the topic of contamination of anti-VEGF injections and long-term side effects due to this reason.

Results: Due to the long-term use of anti-VEGF drugs and the higher number of injections worldwide, various studies have shown side effects in recent years, ranging from increased intraocular pressure to visual disturbing silicone oil vesicles in the vitreous cavity. Several studies have demonstrated that both the drug and the processing, storage, environmental factors and the material and design of the syringes have a decisive influence on these side effects.

Conclusion: The risks of deposits from syringes in the eye can be significantly reduced by various optimizations in transport, storage and syringe and cannula selection.
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http://dx.doi.org/10.2147/OPTH.S207978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101474PMC
March 2020

Diffractive trifocal lens implantation with or without excimer laser enhancement: is a touch-up procedure a negative predictor for refractive and subjective outcome?

Graefes Arch Clin Exp Ophthalmol 2020 May 19;258(5):1115-1121. Epub 2020 Feb 19.

Department of Ophthalmology, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.

Purpose: To investigate the refractive results of a LASIK enhancement and its impact on treatment safety, efficacy, predictability and patient reported outcome in eyes after clear lens extraction and diffractive trifocal lens implantation.

Methods: A retrospective cohort multicentre study of Care Vision Refractive Centres in Germany compared two groups of patients. Group 1 consisted of eyes that had non-toric MIOL surgery only, whereas group 2 had a consecutive laser enhancement after 3 months follow-up. Refractive and subjective results of the two groups were compared. Patient reported outcome measurements were assessed by using a 30-item questionnaire with four subscales. (Spectacle Dependence, Eye Comfort, Freedom and Looking/Feeling Well). Refractive results were reported following standard reporting in refractive surgery.

Results: 139 eyes of 79 patients were included in which either MIOL surgery or MIOL surgery plus LASIK enhancement had been performed between January and December 2017. UDVA reached 0.1logMAR (0.8; 20/25) in 94% in group 2 and 85% in group 1. Compared to preoperative CDVA no change in Snellen lines of CDVA was shown in 89% in group 1 and in 93% in group 2. Spectacle dependence (P = 0.41), eye comfort (P = 0.15), freedom (P = 0.48) and looking/feeling well (P = 0.45) showed no statistically significant difference between both the groups.

Conclusions: In patients with residual ametropia after MIOL implantation, LASIK provides a reliable, safe and efficient way to achieve the desired refractive outcome and patient satisfaction. We recommend performing Laser enhancement at 3 months after MIOL implantation (Bioptics) in trifocal MIOL patients that benefit from improvement of residual ametropia.
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http://dx.doi.org/10.1007/s00417-020-04628-5DOI Listing
May 2020

[Photorefractive Keratectomy (PRK) as a Procedure for Correction of Residual Refractive Errors after Radial Keratotomy].

Klin Monbl Augenheilkd 2020 Aug 2;237(8):961-967. Epub 2019 Jul 2.

Ophthalmology, St. Petka Eye Clinic, Varna, Bulgaria.

Background: A large number of myopic patients were treated by radial keratotomy (RK) in recent years. Despite being effective in many cases, the refractive results of this surgical intervention proved to be of limited predictability, and it frequently resulted in over- or under-correction in the long term. In this study, we discuss the intermediate and long-term results of a topography-guided photorefractive keratotomy (PRK) in a consecutive series of patients who were previously treated for myopia by radial keratotomy.

Materials And Methods: In this retrospective case series, we examined the refraction and visual acuity in a consecutive series of patients-16 eyes-who were treated by PRK for residual refractive errors after radial keratotomy in the past. Mean follow up was 41 months (min. 9, max. 96).

Results: All treated eyes showed an improvement in uncorrected visual acuity, and 56% had an improvement in corrected visual acuity. No serious or sight-threatening complications were recorded. Refraction was stable throughout the study period in all patients.

Conclusions: In this case series, photorefractive keratotomy was shown to be an effective treatment method for secondary ametropia after radial keratotomy. Apart from the correct planning and execution of the PRK, it is of critical importance to inform the patients about the limitations and the anticipated refractive result of the procedure.
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http://dx.doi.org/10.1055/a-0901-7544DOI Listing
August 2020

Analysis of excimer laser treatment outcomes and corresponding angle κ in hyperopic astigmatism.

J Cataract Refract Surg 2019 07;45(7):952-958

Care Vision Nuremberg, Nuremberg, Germany; Care Vision Hamburg, Hamburg, Germany; University Hamburg, Department of Ophthalmology, Hamburg, Germany.

Purpose: To investigate the prevalence of preoperative, intraoperative, and postoperative angle κ in hyperopic eyes and its effect on the refractive outcomes of excimer laser vision correction.

Setting: University Hospital Hamburg and Care Vision Refractive Centers, Germany.

Design: Retrospective multicenter study.

Methods: Hyperopic patients after laser in situ keratomileusis and before retreatment because of hyperopic regression were included. Three treatment groups were defined based on the magnitude of preoperative angle κ defined as low (<0.25 mm), moderate (0.25 to 0.50 mm), or high (>0.50 mm).

Results: The study analyzed 170 hyperopic eyes of 112 patients (mean age 29.8 years ± 10.04 [SD], range 21 to 62 years). The preoperative angle κ was low, moderate, or high in 23, 49, and 98 cases, respectively. In eyes with a preoperative angle κ of 0.25 mm or more, changes in the x-axes and y-axes of angle κ and its magnitude were statistically significant (P < .05) between preoperative and intraoperative measurements. In these eyes, intraoperative angle κ (offset) was statistically significantly smaller (P < .05), and Purkinje images were statistically significantly more caudal (P < .001). Treatment predictability was independent from using preoperative or intraoperative angle κ, and there were no statistically significant differences in efficacy or safety.

Conclusions: A preoperative magnitude of angle κ as high as 0.50 mm or higher was present in more than 50% of regressed hyperopic eyes. Measuring angle κ preoperatively did not reflect its real-time intraoperative magnitude. Using the preoperatively larger angle κ as an intraoperative offset might result in a too nasally centered ablation that causes topographic and optical drawbacks; therefore, centering the ablation based on the intraoperative measured offset is recommended.
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http://dx.doi.org/10.1016/j.jcrs.2019.01.030DOI Listing
July 2019

[Praktische Tipps für ein Fellowship in London].

Authors:
Andreas Frings

Ophthalmologe 2019 Mar;116(3):291-292

Moorfields Eye Hospital, London, UCL Institute of Ophthalmology, London, Univ.-Augenklinik Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland.

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http://dx.doi.org/10.1007/s00347-018-0842-6DOI Listing
March 2019

Tomographic and Biomechanical Scheimpflug Imaging for Keratoconus Characterization: A Validation of Current Indices.

J Refract Surg 2018 Dec;34(12):840-847

Purpose: To analyze the potential benefit of the newly developed Tomography and Biomechanical Index (TBI) for early keratoconus screening.

Methods: In this retrospective study, the discriminatory power of the corneal tomography Belin/Ambrósio Enhanced Ectasia Display (BAD-D) index and the newly developed Corvis Biomechanical Index (CBI) and TBI to differentiate between normal eyes, manifest keratoconus eyes (KCE), very asymmetric keratoconus eyes with ectasia (VAE-E), and their fellow eyes with either regular topography (VAE-NT) or regular topography and tomography (VAE-NTT) were analyzed by applying the t test (for normal distribution), Wilcoxon matched-pairs test (if not normally distributed), and receiver operating characteristic curve (ROC). The DeLong test was used to compare the area under the ROC (AUROC). Further, the cut-offs of the analyzed indices presented in a study by Ambrósio et al. from 2017 were applied in the study population to enable a cross-validation in an independent study population.

Results: All indices demonstrated a high discriminative power when comparing normal and advanced keratoconus, which decreased when comparing normal and VAE-NT eyes and further when analyzing normal versus VAE-NTT eyes. The difference between the AUROCs reached a statistically significant level when comparing TBI versus BAD-D analyzing normal versus all included keratoconic eyes (P = .02). The TBI presented with the highest AUROCs throughout all conducted analyses when comparing different keratoconus stages, although not reaching a statistically significant level. Applying the cut-offs presented by Ambrósio et al. to differentiate between normal and VAE-NT in the study population, the accuracy was reproducible (accuracy in our study population with an optimized TBI cut-off: 0.72, with the cut-off defined by Ambrósio et al. 0.67).

Conclusions: The TBI enables karatoconus screening in topographical and tomographical regular keratoconic eyes. To further improve the screening accuray, prospective studies should be conducted. [J Refract Surg. 2018;34(12):840-847.].
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http://dx.doi.org/10.3928/1081597X-20181012-01DOI Listing
December 2018

Ocular manifestation in Marfan syndrome: corneal biomechanical properties relate to increased systemic score points.

Graefes Arch Clin Exp Ophthalmol 2018 Jun 10;256(6):1159-1163. Epub 2018 Mar 10.

Department of Ophthalmology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Purpose: To evaluate corneal deformation to an air puff as a new noninvasive tool to document disease status in Marfan syndrome (MFS) METHODS: Prospective observational cohort study. We included patients diagnosed with MFS who had their routine cardiovascular follow-up and applied the revised Ghent nosology to define two subgroups according to a high (≥ 7) and a low (< 7 points) systemic score. Dynamic Scheimpflug-based biomechanical analyses (CorvisST® [CST; Oculus GmbH]) were performed. The main outcome measure was the displacement of the corneal apex as given by the parameters highest concavity (HC; in ms), peak distance (PD; in mm), and highest concavity deformation amplitude (DA; mm).

Results: Forty-three eyes of 43 individuals (19 female, 24 male; mean age 42.0 ± 12.0 years, range 18-67 years) diagnosed with MFS were included. Applying the Ghent criteria, 21 patients had an advanced systemic score of ≥ 7, and 22 had score points < 7. There were no differences in age or sex between both groups. In contrast, HC was faster (P = 0.004), and PD (P < 0.001) was longer in those individuals with systemic score ≥ 7; maximum DA did not result in a statistically significant difference between the groups (P = 0.250).

Conclusions: In vivo noninvasive biomechanical analyses with CST offer a new, non-invasive method to identify pathologic corneal deformation responses in adults with MFS. In the future, corneal deformation to an air puff could thus assist early identification of patients with high Ghent score as an adjunct to existing diagnostic tests.
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http://dx.doi.org/10.1007/s00417-018-3946-4DOI Listing
June 2018

The Top 100 Papers of 25 Years of Macular Imaging Using Optical Coherence Tomography.

Semin Ophthalmol 2018 26;33(6):772-781. Epub 2018 Feb 26.

c Eye Clinic Schweinfurt-Gerolzhofen , Gerolzhofen , Germany.

We analyzed and quantified the 100 most frequently cited papers in macular imaging using optical coherence tomography (OCT). The databases of the Institute for Scientific Information databases utilized for identification of articles in macular imaging using OCT over the last 25 years since the introduction of OCT in ophthalmology. All articles containing "optical coherence tomography" and "retina" without "glaucoma". The publication dates of the 100 most-cited articles ranged from 1991 to 2015, with the greatest number of articles published in the 2000s, while the total number of citations per article was greatest for articles published in the 1990s. Most studies were conducted in the U.S. and represented Level-IV clinical outcome studies indicating that also small case series or cohort studies could gain attention. The top 5 senior authors contributed to 39 of the 100 selected publications and accrued a total of 66.0% of all citations of those articles.
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http://dx.doi.org/10.1080/08820538.2018.1443219DOI Listing
September 2018

Outcomes of retreatment after hyperopic laser in situ keratomileusis.

J Cataract Refract Surg 2017 11;43(11):1436-1442

From the Department of Ophthalmology (Frings), Heinrich-Heine-University Düsseldorf, Düsseldorf, the Department of Ophthalmology (Intert, Steinberg, Druchkiv, Linke, Katz), University Medical Centre Hamburg-Eppendorf, zentrumsehstärke (Steinberg, Linke) Hamburg, and Care Vision (Steinberg, Druchkiv, Linke, Katz), Hamburg, Germany.

Purpose: To evaluate the efficacy, predictability, and safety of laser in situ keratomileusis (LASIK) retreatment in eyes with hyperopia.

Setting: Multicenter refractive surgery centers and University Hospital, Germany.

Design: Retrospective case series.

Methods: This multicenter study included hyperopic patients with a preoperative difference between cycloplegic and manifest refraction of 1.00 diopter (D) or less who had LASIK retreatment based on manifest refraction. The refractive outcome was analyzed according to standard graphs for reporting the efficacy, predictability, and safety of refractive surgery.

Results: One hundred thirteen eyes of 113 consecutive hyperopic patients were enrolled. Efficacy (P < .001) and safety (P = .004) were statistically significantly improved by retreatment without being negatively influenced by preoperative manifest spherical equivalent (SE), manifest cylinder, or keratometry. In cases still showing a trend toward undercorrection, retreatment resulted in 88 eyes (78.0%) being within ±0.50 D of the attempted correction. The optical zone (OZ) diameter of the retreatment did not correlate with efficacy, predictability, or safety.

Conclusions: Retreatment after hyperopic LASIK resulted in high efficacy, predictability, and safety outcomes. The efficacy and safety of the retreatment were not affected by preoperative manifest SE, manifest cylinder, keratometry, or OZ diameter.
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http://dx.doi.org/10.1016/j.jcrs.2017.08.014DOI Listing
November 2017

Keratoconus Screening With Dynamic Biomechanical In Vivo Scheimpflug Analyses: A Proof-of-Concept Study.

J Refract Surg 2017 Nov;33(11):773-778

Purpose: This proof-of-concept study was designed to analyze the ability of in vivo biomechanical corneal analyses with the corneal visualization Scheimpflug technology (CorvisST; Oculus Optikgeräte, Wetzlar, Germany) to differentiate between normal eyes and eyes with manifest keratoconus after strictly eliminating the potential confounding factors intraocular pressure (IOP) and central corneal thickness (CCT).

Methods: In this retrospective, cross-sectional study, after pairwise matching for CCT and IOP, 29 normal eyes and 29 keratoconic eyes (one eye from each patient) were selected as study population. Older CorvisST parameters and the new Corvis Biomechanical Index (CBI), including several biomechanical and one tomographic parameter, as well as an adjusted CBI (aCBI) (including only biomechanical parameters), were compared regarding their discriminative ability between both groups.

Results: None of the CorvisST parameters of the former software version demonstrated statistically significant differences between normal and keratoconic eyes. On the other hand, the CBI and aCBI reached accuracies of 0.91 and 0.93, respectively, to discriminate between CCT- and IOP-matched normal and keratoconic eyes (CBI: [AUC/sensitivity/specificity]: 0.961/0.90/0.93; aCBI: [AUC/sensitivity/specificity]: 0.986/0.93/0.93).

Conclusions: This study demonstrated that the concept of keratoconus screening with the CorvisST is effective in differentiating keratoconic from non-keratoconic eyes. The next steps will be testing the indices in subclinical keratoconus cases and hopefully combining biomechanical analyses with already established topography and tomography indices to further improve current keratoconus screening. [J Refract Surg. 2017;33(11):773-778.].
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http://dx.doi.org/10.3928/1081597X-20170807-02DOI Listing
November 2017

[The 100 Most Often Articles on Glaucoma Research: a Bibliometric Analysis].

Klin Monbl Augenheilkd 2019 Jul 25;236(7):858-870. Epub 2017 Oct 25.

Augenklinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf.

Background: Bibliometric science employs statistical and quantitative analyses to analyse the scholarly impact and characteristics of publications within a research field. The present study was initiated to analyse and quantify the 100 most often cited papers in glaucoma research.

Materials And Methods: The databases of the Institute for Scientific Information were utilised for the identification of articles published from 1900 to December 2016. All glaucoma articles were identified that had been published in 109 relevant journals and which had been cited at least 200 times. The top 100 articles were selected for further analysis of authorship, source journal, number of citations, citation rate, geographic origin, article type, and level of evidence.

Results: The publication dates of the 100 most often cited articles ranged from 1966 to 2011, with the greatest number of articles published in the 1990s. Citations per article ranged from 258 to 1908. All articles were published in 18 of the 109 journals. The leading countries of origin were the U. S. A., followed by the U. K. The study focussed on two main clinical articles (diagnostics; epidemiology) and basic research articles. The number of citations per article was greatest for articles published in the 2000s. Most articles provided level III evidence, followed by levels I and II.

Conclusion: The majority of the most cited articles were published in three of the top-ranked journals. Most clinical articles dealt with epidemiology and diagnostics. Individuals who authored multiple articles in the list often focussed on one of these two areas. Most studies were conducted in the U. S. A. and presented level III clinical outcomes. This indicates that even studies with small case series or cohort studies can attract attention.
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http://dx.doi.org/10.1055/s-0043-118177DOI Listing
July 2019

In Reply.

Authors:
Andreas Frings
September 2017

The top 100 papers in dry eye - A bibliometric analysis.

Ocul Surf 2018 01 18;16(1):180-190. Epub 2017 Sep 18.

Department of Ophthalmology, Heinrich-Heine-University Düsseldorf, Germany.

Purpose: Citation analysis represents one of the best currently available methods for quantifying the impact of articles. Bibliometric studies list the ''best sellers'' in a single field of interest. The purpose of the present study was to identify and analyze the most frequently cited papers in dry eye research that may be of high interest for researchers and clinicians.

Methods: We reviewed the database of the Institute for Scientific Information to identify articles published from 1900 to September 2016. All dry eye articles published in 59 ophthalmology journals were identified. The top 100 articles were selected for further analysis of authorship, source journal, number of citations, citation rate, geographic origin, article type, and level of evidence.

Results: The 100 most-cited articles were published between 1983 and 2011, with most of them in the 2000s. The number of citations per article ranged from 96 to 610, and was greatest for articles published in the 2000s. Each of these articles was published in one of 15 journals. Most articles represented Level-III evidence, followed by Levels II and I.

Conclusions: The present study focusing on dry eye research revealed that 55% of the most-cited articles came from the U.S. and 18% from Japan. Diagnostics and therapy were the areas of focus of most of the clinical articles; 13% of the most cited papers were review articles. This analysis provides researchers and clinicians with a detailed overview on the most cited dry eye papers over the past decades.
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http://dx.doi.org/10.1016/j.jtos.2017.09.006DOI Listing
January 2018

Recovery From Amiodarone-Induced Cornea Verticillata by Application of Topical Heparin.

Cornea 2017 Nov;36(11):1419-1422

*Department of Ophthalmology, University Hospital Düsseldorf, Heinrich-Heine University, Düsseldorf, Germany; and †Eye Clinic Gerolzhofen, Gerolzhofen, Germany.

Purpose: To report a case of amiodarone-induced vortex keratopathy-associated anatomical findings and subjective visual perception before and after treatment with topical heparin eye drops.

Methods: Case report.

Results: A 76-year-old man complained of halos in his vision in both his eyes due to prominent bilateral cornea verticillata. For treatment of cornea verticillata, we prescribed unpreserved eye drops of a sterile, phosphate-free solution of 0.1% sodium hyaluronate with 1300 IU/mL heparin sodium 3 times daily to the left eye, whereas the other side served as the control. The area of corneal deposits was measured by 2 examiners before and at the 1- and 3-month examination. At last follow-up, cornea verticillata had been reduced from 6 to 2 mm in area by approximately 66% from grade-III to grade-II amiodarone keratopathy.

Conclusions: In patients using amiodarone, clearing of cornea verticillata may be achieved by topical use of unpreserved eye drops of a sterile, phosphate-free solution of 0.1% sodium hyaluronate with 1300 IU/mL heparin sodium.
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http://dx.doi.org/10.1097/ICO.0000000000001306DOI Listing
November 2017

Hyperopia shows the strongest association with LASIK retreatment.

Acta Ophthalmol 2018 05 3;96(3):e404. Epub 2017 Aug 3.

Department of Ophthalmology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany.

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http://dx.doi.org/10.1111/aos.13486DOI Listing
May 2018

Retinal degeneration in progressive supranuclear palsy measured by optical coherence tomography and scanning laser polarimetry.

Sci Rep 2017 07 13;7(1):5357. Epub 2017 Jul 13.

Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

This cross-sectional study compared the retinal morphology between patients with progressive supranuclear palsy (PSP) and healthy controls. (The retinal nerve fiber layer (RNFL) around the optic disc and the retina in the macular area of 22 PSP patients and 151 controls were investigated by spectral domain optical coherence tomography (SD-OCT). Additionally, the RNFL and the nerve fiber index (NFI) were measured by scanning laser polarimetry (SLP). Results of RNFL measurements with SD-OCT and SLP were compared to assess diagnostic discriminatory power. Applying OCT, PSP patients showed a smaller RNFL thickness in the inferior nasal and inferior temporal areas. The macular volume and the thickness of the majority of macular sectors were reduced compared to controls. SLP data showed a thinner RNFL thickness and an increase in the NFI in PSP patients. Sensitivity and specificity to discriminate PSP patients from controls were higher applying SLP than SD-OCT. Retinal changes did not correlate with disease duration or severity in any OCT or SLP measurement. PSP seems to be associated with reduced thickness and volume of the macula and reduction of the RNFL, independent of disease duration or severity. Retinal imaging with SD-OCT and SLP might become an additional tool in PSP diagnosis.
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http://dx.doi.org/10.1038/s41598-017-05575-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509679PMC
July 2017

Refractive predictability in eyes with intraocular gas tamponade - results of a prospective controlled clinical trial.

Clin Ophthalmol 2017 23;11:993-998. Epub 2017 May 23.

Department of Ophthalmology, University Hospital Düsseldorf, Heinrich-Heine University, Düsseldorf, Germany.

Purpose: To determine the postoperative refractive error in eyes with intraocular gas tamponade in combined phacovitrectomy using a Z-haptic intraocular lens (IOL).

Methods: This prospective non-randomized case-control study compared patients with combined phacovitrectomy with or without intraocular gas tamponade to cataract surgery-only. The main outcome measure was the IOL power prediction error (PE). Secondary outcome measures were spherical equivalent, anterior chamber depth (ACD), and axial length.

Results: Thirty-four patients with epiretinal membranes and 18 patients with cataract only were enrolled. There were no statistically significant (>0.05) differences of IOL power PE or postoperative ACDs (=0.952-1.00). Nevertheless, IOL power PE indicated a myopic shift in cases with phacovitrectomy independent of gas tamponade (=1.00). No statistically significant between-group differences between secondary outcome measures were observed.

Conclusion: A myopic shift after phacovitrectomy seems to be independent of the use of intraocular gas tamponade. When using a Z-haptic IOL, aiming for slight residual hyperopia (+0.50 D) is suggested in patients having phacovitrectomy.
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http://dx.doi.org/10.2147/OPTH.S132644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5449115PMC
May 2017

Red Eye: A Guide for Non-specialists.

Dtsch Arztebl Int 2017 Apr;114(17):302-312

Department of Ophthalmology, Düsseldorf University Hospital; Ophthalmological Medical Center Schweinfurt, Eye Hospital Schweinfurt Gerolzhofen.

Background: Red eye can arise as a manifestation of many different systemic and ophthalmological diseases. The physician whom the patient first consults for this problem is often not an ophthalmologist. A correct assessment of the urgency of the situation is vitally important for the planning of further diagnostic evaluation and treatment.

Methods: This review is based on pertinent publications retrieved by a selective literature search in PubMed in August 2016 as well as on the authors' own clinical and scientific experience.

Results: Primary care physicians typically see 4-10 patients per week who complain of ocular symptoms. Most of them have red eye as the major clinical finding. A detailed history, baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (uni- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for by a general practitioner from diseases calling for elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.

Conclusion: The differential diagnosis of red eye can be narrowed down rapidly with simple baseline tests and targeted questioning. Patients with ocular emergencies should be referred to an ophthalmologist at once, as should all patients whose diagnosis is in doubt.
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http://dx.doi.org/10.3238/arztebl.2017.0302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443986PMC
April 2017

Role of Initial Intraocular Pressure in Graft Adhesion After Descemet Membrane Endothelial Keratoplasty.

Cornea 2017 Jan;36(1):7-10

Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany; and Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen-Nürnberg, Germany.

Purpose: To analyze the role of initial intraoperative intraocular pressure (IOP) in graft adhesion in Descemet membrane endothelial keratoplasty (DMEK) during early follow-up.

Methods: This retrospective, observational, single-center case series included 118 eyes from 118 consecutive patients treated between May and July 2015 for DMEK or combined DMEK and phacoemulsification (triple-DMEK). Exclusion criteria were previous eye surgery other than cataract surgery, loss of follow-up, any application of IOP-lowering medication before and after surgery, and low intraindividual repeatability of IOP measurements. The main outcome measure was graft adhesion that was correlated to the magnitude of IOP measured by Schiötz tonometry intraoperatively.

Results: Fifty-four eyes of 118 (45.8%) patients undergoing DMEK met the above-mentioned inclusion and exclusion criteria. In 43 (79.6%) eyes, complete graft adhesion was achieved at 1-week follow-up examination. Differences of the initial IOP in the presence of the air bubble were not statistically significant between eyes with complete and incomplete graft adhesion.

Conclusions: Incomplete graft adhesion during early follow-up could not be associated with the magnitude of the initial IOP in DMEK. We found no evidence that higher IOP values enhance graft adhesion resulting in lower rebubbling rates after DMEK.
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http://dx.doi.org/10.1097/ICO.0000000000001055DOI Listing
January 2017
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