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Verfahren der kunstlichen Intelligenz (KI) wie kunstliche neuronale Netzwerke zeigen vielversprechende Ergebnisse im Bereich der automatisierten Analyse ophthalmologischer Bilddaten. Der vorliegende Beitrag diskutiert, inwiefern die Diskussion und Anwendung von KI-Algorithmen auch zur Qualitatssicherung im Bereich der Augenheilkunde beitragen kann. Relevante Literaturbeitrage werden zusammenfassend diskutiert. Systeme, basierend auf kunstlichen neuronalen Netzen, erzielen sehr gute Ergebnisse in der Diagnostik von Augenerkrankungen, indem beispielsweise OCT(optische Koharenztomographie)-Bilder sehr gut segmentiert und Lasionsbestandteile detektiert werden konnen. Zum Trainieren dieser Netzwerke werden grose Datensatze genutzt. Qualitat und Verfugbarkeit dieser Datensatze bestimmen die kontinuierliche Verbesserung der Algorithmen. Der Vergleich zwischen KI-Algorithmen und der arztlichen Bildinterpretation hat auch Einblicke in die diagnostische Ubereinstimmung zwischen ArztInnen erlaubt. Aktuelle Herausforderungen liegen in der Entwicklung von Verfahren zur Modellierung der Unsicherheit und besseren Nachvollziehbarkeit automatisierter diagnostischer Entscheidungen. KI-Systeme konnten zeitnah als Systeme zur Entscheidungsunterstutzung zum Einsatz kommen. Dadurch konnen sie zur effizienteren Qualitatssicherung beitragen.

Retinal swelling due to the accumulation of fluid is associated with the most vision-threatening retinal diseases. Optical coherence tomography (OCT) is the current standard of care in assessing the presence and quantity of retinal fluid and image-guided treatment management. Deep learning methods have made their impact across medical imaging, and many retinal OCT analysis methods have been proposed. However, it is currently not clear how successful they are in interpreting the retinal fluid on OCT, which is due to the lack of standardized benchmarks. To address this, we organized a challenge RETOUCH in conjunction with MICCAI 2017, with eight teams participating. The challenge consisted of two tasks: fluid detection and fluid segmentation. It featured for the first time: all three retinal fluid types, with annotated images provided by two clinical centers, which were acquired with the three most common OCT device vendors from patients with two different retinal diseases. The analysis revealed that in the detection task, the performance on the automated fluid detection was within the inter-grader variability. However, in the segmentation task, fusing the automated methods produced segmentations that were superior to all individual methods, indicating the need for further improvements in the segmentation performance.

Die moderne retinale Bildgebung liefert grose Mengen („big data“) an anatomischer Information. Gleichzeitig steigen die Patientenzahlen und Interventionen exponentiell an. Betrachtet wird die Einfuhrung von artifizieller Intelligenz (AI) zur gezielten Optimierung von Diagnose und Therapie. „Deep learning“ wurde verwendet zur automatischen Segmentierung und Erkennung von Risikofaktoren und Aktivitatsstadien retinaler Erkrankungen. Automatisierte Algorithmen erlauben die prazise Identifikation und Quantifizierung von retinaler Flussigkeit in allen Netzhautkompartimenten. Eine individuelle Fruherkennung von Retinopathien bei Diabetes oder Glaukom sowie die Risikobestimmung fur die Entwicklung einer altersbezogenen Makuladegeneration (AMD) ist ebenso moglich wie die individuelle Bestimmung der Visusprognose und des Wiederbehandlungsbedarfs bei intravitrealer Therapie. Methoden der AI stellen eine bahnbrechende Perspektive fur die Einfuhrung der personalisierten Medizin und der Optimierung von Diagnose und Therapie, Screening und Prognosestellung dar.

Prediction of treatment responses from available data is key to optimizing personalized treatment. Retinal diseases are treated over long periods and patients' response patterns differ substantially, ranging from a complete response to a recurrence of the disease and need for re-treatment at different intervals. Linking observable variables in high-dimensional observations to outcome is challenging. In this paper, we present and evaluate two different data-driven machine learning approaches operating in a high-dimensional feature space: sparse logistic regression and random forests-based extra trees (ET). Both identify spatio-temporal signatures based on retinal thickness features measured in longitudinal spectral-domain optical coherence tomography (OCT) imaging data and predict individual patient outcome using these quantitative characteristics. We demonstrate on a data set of monthly SD-OCT scans of 155 patients with central retinal vein occlusion (CRVO) and 92 patients with branch retinal vein occlusion (BRVO) followed over one year that we can predict from initial three observations if the treated disease will recur within the covered interval. ET predicts the outcome on fivefold cross-validation with an area under the receiver operating characteristic curve (AuC) of 0.83 for BRVO and 0.76 for CRVO. Logistic regression achieved an AuC of 0.78 and 0.79, respectively. At the same time, the methods identified stable predictive signatures in the longitudinal imaging data that are the basis for accurate prediction. Furthermore, our results show that taking spatio-temporal features into account improves accuracy compared with features extracted at a single time-point. Our results demonstrate the feasibility of mining longitudinal data for predictive signatures, and building predictive models based on observed data.

To evaluate multimodal imaging findings of solitary idiopathic choroiditis (SIC; also known as unifocal helioid choroiditis) to clarify its origin, anatomic location, and natural course.Multicenter retrospective observational case series.Sixty-three patients with SIC in 1 eye.Demographic and clinical data were collected. Multimodal imaging included color fundus photography, OCT (including swept-source OCT), OCT angiography (OCTA), fundus autofluorescence, fluorescein and indocyanine green angiography, and B-scan ultrasonography.Standardized grading of imaging features.Mean age at presentation was 56 ± 15 years (range, 12-83 years). Mean follow-up duration in 39 patients was 39 ± 55 months (range, 1 month-25 years). The lesions measured a mean of 2.4 × 2.1 mm in basal diameter, were located inferior (64%) or nasal to the optic disc, and appeared yellow (53%). No systemic associations were found. The lesions all appeared as an elevated subretinal mass, with OCT demonstrating all lesions to be confined to the sclera, not the choroid. On OCT, the deep lesion margin was visible in 12 eyes with a mean lesion thickness of 0.6 mm. Overlying choroidal thinning or absence was seen in 95% (mean choroidal thickness, 28 ± 35 μm). Mild subretinal fluid was observed overlying the lesions in 9 patients (14%). Retinal pigment epithelial disruption and overlying retinal thinning was observed in 56% and 57%, respectively. OCT angiography was performed in 13 eyes and demonstrated associated choroidal and lesional flow voids. Four lesions (6%) were identified at the macula, leading to visual loss in 1 patient. One lesion demonstrated growth and another lesion showed spontaneous resolution.In this largest series to date, multimodal imaging of SIC demonstrated a scleral location in all patients. The yellow and white clinical appearance may be related to scleral unmasking resulting from atrophy of overlying tissues. Additional associated features included documentation of deep margin on swept-source OCT, trace subretinal fluid in a few patients, and OCTA evidence of lesional flow voids. Because of the scleral location of this lesion in every patient, a new name, focal scleral nodule, is proposed.

Purpose To compare the 6-month efficacy and safety profile of an individualized stabilization criteria–driven pro re nata (PRN) regimen of ranibizumab 0.5 mg with or without laser versus laser alone in patients with visual impairment due to macular edema secondary to branch retinal vein occlusion (BRVO). Design A 24-month, prospective, open-label, randomized, active-controlled, multicenter, phase IIIb study. Participants A total of 455 patients. Methods Eligible patients were randomized 2:2:1 to receive ranibizumab (n = 183), ranibizumab with laser (n = 180), or laser only (n = 92). Patients treated with ranibizumab with or without laser received a minimum of 3 initial monthly ranibizumab injections until visual acuity (VA) stabilization, and VA-based PRN dosing thereafter. In the ranibizumab with laser and laser-only groups, laser was given at the investigator's discretion at a minimum interval of 4 months and if VA was Main Outcome Measures Mean change from baseline at month 6 in best-corrected visual acuity (BCVA) (primary end point) and central subfield thickness, and safety over 6 months. Exploratory objectives were to evaluate the influence of baseline BCVA, disease duration, and ischemia on BCVA outcomes at month 6. Results Baseline mean BCVA was 57.7 letters, and mean BRVO duration was 9.9 months. Ranibizumab with or without laser was superior to laser only in improving mean BCVA from baseline at month 6 (14.8 and 14.8 vs. 6.0 letters; both P Conclusions Ranibizumab with an individualized VA-based regimen, with or without laser, showed statistically significant superior improvement in BCVA compared with laser alone in patients with BRVO. Overall, there were no new safety events other than those reported in previous studies.

The purpose of the study was to create a standardised protocol for choroidal thickness measurements and to determine whether choroidal thickness measurements made on images obtained by spectral domain optical coherence tomography (SD-OCT) and swept source (SS-) OCT from patients with healthy retina are interchangeable when performed manually or with an automatic algorithm.36 grid cell measurements for choroidal thickness for each volumetric scan were obtained, which were measured for SD-OCT and SS-OCT with two methods on 18 eyes of healthy volunteers. Manual segmentation by experienced retinal graders from the Vienna Reading Center and automated segmentation on6300 images of the choroid from both devices were statistically compared.Model-based comparison between SD-OCT/SS-OCT showed a systematic difference in choroidal thickness of 16.26±0.725 μm (p0.001) for manual segmentation and 21.55±0.725 μm (p0.001) for automated segmentation. Comparison of automated with manual segmentations revealed small differences in thickness of -0.68±0.513 μm (p=0.1833). The correlation coefficients for SD-OCT and SS-OCT measures within eyes were 0.975 for manual segmentation and 0.955 for automatic segmentation.Choroidal thickness measurements of SD-OCT and SS-OCT indicate that these two devices are interchangeable with a trend of choroidal thickness measurements being slightly thicker on SD-OCT with limited clinical relevance. Use of an automated algorithm to segment choroidal thickness was validated in healthy volunteers.

The eye is unique in providing opportunities in medical diagnostics because direct visualization of the anatomy and pathology of nervous tissue is possible in vivo. Since the introduction of the ophthalmoscope in 1851, noninvasive retinal imaging has been exploited and continuously improved. Imaging of the ocular fundus has been revolutionized over the last decades by novel technologies such as optical coherence tomography, its extensions and adaptive optics imaging. In vivo noninvasive imaging in microscopical resolution has greatly facilitated patient care and has provided a profound understanding of pathomechanisms in retinal diseases.

Purpose Intravitreal antiangiogenic therapy is the major therapeutic breakthrough in neovascular age-related macular degeneration (AMD). Optical coherence tomography (OCT) is the leading diagnostic tool, but solid criteria for optimal therapeutic outcomes are lacking. A comprehensive analysis of structure/function correlations using Food and Drug Administration- and European Medicines Agency–approved substances and fixed and flexible regimens was performed. Design Post hoc analysis of a prospective, randomized multicenter clinical trial including 189 study sites. Participants A total of 1240 patients with active neovascular AMD. Methods Participants received intravitreal ranibizumab or aflibercept. A fixed regimen was used for 48 weeks followed by a flexible regimen until week 96. At monthly intervals, best-corrected visual acuity (BCVA) was measured and retinal morphology was assessed by standardized OCT, including intraretinal cysts (IRCs), subretinal fluid (SRF), and pigment epithelial detachment (PED), presenting with a width ≥400 μm or a height of ≥200 μm. Results were correlated for each regimen, feature, and time. Main Outcome Measures The BCVA outcomes in relation to retinal pathomorphology based on noninferiority for all treatment arms. Results In neovascular AMD, only IRC at baseline and persistent through week 12 had a negative impact on BCVA. With therapeutic intervention, exudative features such as IRC and SRF resolved rapidly in 74% of eyes, whereas PED responded only slowly with 38%. Independent of the type of regimen, fixed or flexible, retinal morphology correlated tightly with visual function. Intraretinal cysts consistently showed the lowest BCVA gains with either regimen or substance. With the switch from a fixed to a flexible pro re nata (PRN) regimen, progressive visual loss occurred exclusively in the group with primary PED presenting as the hallmark of neovascular activity and was induced by secondary formation of IRC in the neurosensory retina. Conclusions The efficacy of antiangiogenic therapy in neovascular AMD is strongly determined by morphologic features. The subretinal pigment epithelium lesion underlying PED appears to be the primary indicator for progressive disease activity, whereas secondary cystoid degeneration is the most relevant imaging marker for visual function. Clinically, PED emerged as trigger for consecutive vision loss in PRN treatment.

To compare signal penetration depth and deep structure-visualization of swept source (SS) and spectral domain (SD)-optical coherence tomography (OCT) with and without enhanced depth imaging (EDI) and B-scan averaging modes.Volume scans were obtained from 20 eyes of healthy volunteers by DRI OCT-1, Spectralis using EDI and B-scan averaging, and Cirrus HD-OCT. The signal penetration depth was measured as the distance between the retinal pigment epithelium and the deepest visible anatomical structure at the foveal center. Visibility and contrast of the choroidoscleral junction and of vascular details within the choroid were assessed across the entire volume using an ordinal scoring scale. Outcome measures were compared using paired t-test and rank-sum test.The mean signal penetration depth was 498±114 μm for Spectralis, 491±85 μm for DRI OCT-1, and 123±65 μm for Cirrus; P=0.9708 Spectralis vs DRI OCT-1, P0.0001 Spectralis vs Cirrus, and P0.0001 DRI OCT-1 vs Cirrus. Mean ranks for visibility and contrast of the choroidoscleral junction were 3.83 for Spectralis, 3.98 for DRI OCT-1, and 2.00 for Cirrus; and 3.45 for Spectralis, 2.93 for DRI OCT-1, and 1.58 for Cirrus. Mean ranks for visibility and contrast of vascular details were 3.73 (Spectralis), 3.70 (DRI OCT-1), and 2.23 (Cirrus); and 3.53 (Spectralis), 2.05 (DRI OCT-1), and 1.98 (Cirrus).Signal penetration depths are similar for SS-OCT and SD-OCT using EDI and frame averaging, and statistically significantly lower without EDI/averaging. Both SD-OCT using EDI/frame averaging and SS-OCT offer excellent visualization capabilities for volumetric imaging of the choroidoscleral interface.

Comparison of optical coherence tomography (OCT) segmentation performance regarding technical accuracy and clinical relevance.29 eyes were imaged prospectively with Spectralis (Sp), Cirrus (Ci), 3D-OCT 2000 (3D) and RS-3000 (RS) OCTs. Raw data were evaluated in validated custom software. A 1 mm diameter subfield, centred on the fovea, was investigated to compare identical regions for each case. Segmentation errors were corrected on each B-scan enclosed in this subfield. Proportions of wrongly segmented A-scans were noted for inner and outer retinal boundaries. Centre point thickness (CPT) and central macular thickness (CMT) were compared before and after correction.Segmentation errors occurred in 77% and affected on average 29% of A-scans, resulting in mean differences of 24/13 µm (CPT/CMT). The incidence of segmentation errors was 48% (Sp), 79% (Ci), 86% (3D) and 93% (RS), p0.001. Mean proportions of A-scans with wrong outer retinal boundary were 30% (Sp), 9% (Ci), 23% (3D) and 10% (RS), p=0.006; proportions for the inner retinal boundary were 11% (Sp), 12% (Ci), 6% (3D) and 21% (RS), p=0.034. Mean deviations in CPT/CMT were 41/28 µm (Sp), 17/11 µm (Ci), 30/13 µm (3D) and 18/8 µm (RS), p=0.409/0.477.By comparison of identical regions, substantial differences were detected between the tested OCT devices regarding technical accuracy and clinical impact. Spectralis showed lowest error incidence but highest error impact.

Purpose To investigate the influence of the vitreomacular interface (VMI) on the functional and anatomic efficacy of ranibizumab therapy in patients with neovascular age-related macular degeneration (AMD). Design Subanalysis of a prospective, 12-month, multicenter, phase IIIb trial. Participants A total of 353 treatment-naive patients with subfoveal choroidal neovascularization (CNV) receiving quarterly or monthly ranibizumab therapy. Methods On monthly optical coherence tomography (OCT) scan sets, the VMI configuration was graded by a certified reading center into one of the following conditions: continuous posterior vitreoretinal attachment (PVA), vitreomacular adhesion (VMA), partial vitreous detachment without vitreomacular contact, or complete posterior vitreous detachment (PVD). Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measurements were performed at monthly intervals. Analysis included patients with a minimum of 10 OCT examinations, including baseline and month 12 (n = 251). After integration of the VMI configuration over 12 months, patients were divided into one of the following categories: PVD (n = 162), release of vitreomacular contact (RELEASE; n = 48), VMA (n = 37), or PVA (n = 4). General estimation equation analyses were applied to test for noninferiority of quarterly versus monthly treatment. Main Outcome Measures The BCVA and CRT changes at month 12. Results Mean BCVA changes in letters were +4.7 (PVD), +3.2 (RELEASE), and −0.2 (VMA) in the quarterly regimen and +4.9 (PVD), +12.7 (RELEASE), and +7.5 (VMA) in the monthly regimen. No difference in therapeutic efficiency between monthly and quarterly intervention was found in eyes with PVD, and quarterly treatment was noninferior to monthly treatment ( P = 0.001). However, monthly treatment was superior to quarterly treatment in the RELEASE ( P = 0.008) and VMA ( P = 0.043) groups. Mean CRT changes were −98 and −96 μm (PVD), −117 and −136 μm (RELEASE), and −93 and −87 μm (VMA) in the monthly and quarterly regimens, respectively, without statistically significant differences. Conclusions The configuration of the VMI seems to have an important effect on visual outcomes and need for retreatment. In patients with PVD, a lower treatment frequency may be feasible, whereas patients with RELEASE or VMA may benefit from intensive retreatment. These findings may serve as a basis for individualized treatment decisions in anti-angiogenic therapy of neovascular AMD and perhaps other indications. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

To evaluate the long-term (24-month) efficacy and safety of ranibizumab 0.5 mg administered pro re nata (PRN) with or without laser using an individualized visual acuity (VA) stabilization criteria in patients with visual impairment due to macular edema secondary to branch retinal vein occlusion (BRVO).Phase IIIb, open-label, randomized, active-controlled, 3-arm, multicenter study.A total of 455 patients.Patients were randomized (2:2:1) to ranibizumab 0.5 mg (n = 183), ranibizumab 0.5 mg with laser (n = 180), or laser (with optional ranibizumab 0.5 mg after month 6; n = 92). After initial 3 monthly injections, patients in the ranibizumab with or without laser arms received VA stabilization criteria-driven PRN treatment. Patients assigned to the laser arm received laser at the investigator's discretion.Mean (and mean average) change in best-corrected visual acuity (BCVA) and central subfield thickness (CSFT) from baseline to month 24, and safety over 24 months.A total of 380 patients (83.5%) completed the study. Ranibizumab with or without laser led to superior BCVA outcomes versus laser (monotherapy and combined with ranibizumab from month 6; 17.3/15.5 vs. 11.6 letters; P0.0001). Ranibizumab with laser was noninferior to ranibizumab monotherapy (mean average BCVA change: 15.4 vs. 15.0 letters; P0.0001). However, addition of laser did not reduce the number of ranibizumab injections (mean injections: 11.4 vs. 11.3; P = 0.4259). A greater reduction in CSFT was seen with ranibizumab with or without laser versus laser monotherapy over 24 months from baseline (ranibizumab monotherapy -224.7 μm, ranibizumab with laser -248.9 μm, laser [monotherapy and combined with ranibizumab from month 6] -197.5 μm). Presence of macular ischemia did not affect BCVA outcome or treatment frequency. There were no reports of neovascular glaucoma or iris neovascularization. No new safety signals were identified.The BRIGHTER study results confirmed the long-term efficacy and safety profile of PRN dosing driven by individualized VA stabilization criteria using ranibizumab 0.5 mg in patients with BRVO. Addition of laser did not lead to better functional outcomes or lower treatment need. The safety results were consistent with the well-established safety profile of ranibizumab.

Purpose To investigate the influence of vitreomacular adhesion (VMA) on development of choroidal neovascularization (CNV) in eyes with age-related macular degeneration. Methods In a prospective study, patients with Age-Related Eye Disease Study Category IV age-related macular degeneration underwent standardized examinations, including optical coherence tomography and fluorescein angiography every 3 months for 4 years. Vitreomacular adhesion was evaluated using time- and spectral-domain optical coherence tomography. Development of CNV was detected using fluorescein angiography and optical coherence tomography. Incidences of CNV were compared concerning the presence or absence of VMA. Results Forty-nine patients were available for follow-up according to protocol. Vitreomacular adhesion was present at baseline in 18% (9 of 49) and absent in 82% (40 of 49) of patients. Thirty-seven percent of patients (18 of 49) developed exudative changes during the observation period. In patients with preexisting VMA, de novo development of CNV occurred in 33% (3 of 9). In patients without VMA, 38% developed CNV (15 of 40). Mean interval from baseline to disease progression was 20 ± 19 months in patients with VMA and 22 ± 13 months in patients without VMA. There was no significant difference between the groups regarding rate of CNV development or time to disease progression (P = 0.64). Conclusion No significant influence of VMA on the development of exudative age-related macular degeneration could be found during a 4-year prospective observation of a high-risk cohort.