A long-term therapy of nAMD in the clinical routine can be achieved by a close relationship with the ophthalmologist, continuous follow-up controls and therapy cycles. A close telemedical networking between the ophthalmologist and the treatment center can lead to better patient compliance. Furthermore, the construction of such platforms represents a challenge not only for the treatment of nAMD but also for other diseases.

Zusammenfassung Hintergrund Bei der geografischen Atrophie (GA) im Rahmen einer altersabhängigen Makuladegeneration (AMD) entwickelt sich ein Verlust an Photorezeptoren (PR), retinalem Pigmentepithel (RPE) und Choriokapillaris (CC). Für therapeutische Ansätze ist es entscheidend, welche morphologische Struktur bei einem individuellen Patienten primär geschädigt ist und dann sekundäre Schädigungsprozesse initiiert. Wurde bisher das RPE mit seiner Lipofuszinakkumulation als primär geschädigte und zum Untergang „verdammte“ Struktur bei der Entwicklung einer GA angesehen, so zeigte sich in histologischen Studien, dass bei einigen Patienten primär die Photorezeptoren untergehen mit sekundärem Verlust an RPE und CC oder aber auch primär eine CC-Regression vorliegen kann. Ziel der vorliegenden Studie war es, mittels multimodaler Bildgebung das Ausmaß der Schädigung auf der Ebene der PR, des RPE und der CC zu bestimmen, individuelle phänotypische Variationen der GA zu charakterisieren und die korrespondierenden funktionellen Veränderungen zu untersuchen. Patienten und Methode Bei 20 Augen von 20 Patienten (mittleres Alter 78 Jahre; 14 weiblich, 6 männlich) mit der klinischen Diagnose einer GA wurden Fundusautofluoreszenzaufnahmen (FAF-Aufnahmen) zur Beurteilung des RPE-Schadens, SD-OCT-En-face-Aufnahmen auf der Ebene der PR zur Charakterisierung des PR-Schadens und eine OCT-Angiografie (OCT-A) AngioVue, Optovue, 50 µm CC-Segmentierung mit Lokalisation unterhalb des RPE zur Beurteilung einer Regression der Choriokapillaris vorgenommen. Die entsprechenden Flächen des veränderten Areals wurden in den entsprechenden Schichten vermessen. Bei allen Patienten wurde zudem der Visus bestimmt und eine automatische standardisierte 10°-Mikroperimetrie (MAIA-Mikroperimeter, CENTERVUE; 4-2-Strategie, 68 Untersuchungspunkte) durchgeführt. Die Ergebnisse dieser Untersuchungen wurden evaluiert und miteinander korreliert. Ergebnisse Alle Augen zeigten eine unterschiedliche Ausdehnung der jeweils atrophen Areale im Bereich der PR, des RPE und der CC. Bei einer Differenzierung der Gesamtgruppe in Bezug auf das jeweils größte atrophe Areal war bei 13 Augen (65%) das größte atrophe Areal auf Ebene des RPE zu beobachten. Bei 3 Augen (15%) war das größte atrophe Areal in der PR-Schicht und bei 4 Augen (20%) auf Ebene der CC zu finden. Während die Visusminderung allein vom Vorhandensein einer fovealen Restinsel abhing, wiesen die mikroperimetrischen Ergebnisse eine Korrelation zwischen dem Ausmaß des nachweisbaren funktionellen Defizits und dem jeweils größten atrophen Areal auf. Schlussfolgerungen Die multimodale Bildgebung mittels FAF, En-face-OCT, OCT-A und die Korrelation mit der Mikroperimetrie als funktioneller Parameter ermöglichen klinisch eine phänotypische Differenzierung der GA sowie eine präzisere Charakterisierung der funktionellen Auswirkungen. Sie bestätigt klinisch die histologisch aufgezeigten Unterschiede der am „intensivsten“ geschädigten Struktur (PR, RPE oder CC) bei der klinischen Diagnose GA. Die in dieser Pilotstudie aufgezeigten Unterschiede müssen allerdings in Reading-Center-basierten größeren Kohorten bestätigt werden. Sie hätten allerdings zentrale Auswirkungen für die Ansatzpunkte, Patientenselektion und klinische Outcome Measures für zukünftige Behandlungsstudien bei der GA.

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Objectives: Cryoballoon pulmonary vein isolation (cPVI) in patients with atrial fibrillation requires fluoroscopic guidance, causing a relevant amount of radiation exposure. Strategies to reduce radiation exposure in electrophysiologic procedures and specifically cPVI are of great importance. The aim of this study was to evaluate a possible reduction of radiation dose using the novel Azurion 7 F12 x-ray system compared with its predecessor Allura FD10. Methods: In February 2017, the Philips Azurion angiography system was introduced, combining the Allura Clarity radiation dose reduction technology with a more powerful generator, improved image resolution, and a large screen display. In 173 patients undergoing cPVI by a single experienced operator in our institution between December 2016 and April 2018, dose area products (cGy×cm2) and image quality were compared using Azurion 7 F12 or Allura FD10 angiography system. Results: A significant reduction in total radiation dose expressed as a dose area products of 524 (332; 821) cGy×cm2 on the Allura system compared with 309 (224; 432) cGy×cm2 on the Azurion system was observed (P<0.001). The number of imaging scenes recorded were 14.7 versus 13.9, and mean overall imaging quality scores (grading 4.85±0.4 with Azurion vs. 4.80±0.4 with Allura, P=0.38) and scores based on specific quality parameters were similar in both groups. Conclusion: Use of the new Azurion 7 F12 angiography system substantially reduced radiation doses compared with the previous generation reference system, Allura Clarity, without compromising imaging quality in patients undergoing cryoballoon pulmonary vein isolation.

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Background: The clinical appearance of macular neovascularization (MNV) in age-related macular degeneration (nAMD) varies widely, but so far, this has had no relevance in terms of therapeutic approaches or prognosis. Therefore, our purpose was to investigate if and which differences exist in the vascular architecture of MNV and to quantify them. Methods: In 90 patients with newly diagnosed nAMD, MNV was identified by means of optical coherence tomography angiography (OCTA), and automated quantitative vascular analysis was carried out. The analyzed vascular parameters were area, flow, fractal dimension (FD), total vascular length (sumL), number of vascular nodes (numN), flow, and average vessel caliber (avgW). The current classification of MNVs divides them according to their localization into type 1 (grown from the choroid below the RPE), type 2 (grown from the choroid through RPE), and type 3 (grown from the retina toward the RPE). We compared the analyzed vascular parameters of each of the three MNV types. Kruskal–Wallis test was applied, Dunn test was performed for post hoc analysis, and for pairwise comparison, p-values were adjusted using Bonferroni comparison. Results: Regarding the MNV area, there was no significant difference between types 1 and 2, but type 3 was significantly smaller than types 1 and 2 (p < 0.00001). For FD, types 1 and 2 did not differ significantly, but again, type 3 was lower than type 1 and 2 (p < 0.00001). The numN were significantly higher in types 1 and 3 than in 2 (p < 0.005), but not between types 1 and 3. No significant differences were found between MNV types for flow. As for sumL, types 1 and 2 did not differ significantly, but type 3 was significantly lower than types 1 and 2 (p < 0.00001). For avgW, there was no significant difference between types 1 and 2 or between types 2 and 3, but type 3 was significantly larger than type 1 (p < 0.05). Conclusions OCTA yields detailed information on the vascular morphology of MNV in patients with nAMD and is able to show differences among types 1, 2, and 3. Especially comparing types 1 and 2 with type 3 reveals significant differences in area, FD, sumL, and numN. One explanation could be the similar pathogenesis of types 1 and 2 with their origin in the choroid and their growth towards the retinal pigment epithelium (RPE), whereas type 3 originates in the deep capillary plexus. Between types 1 and 2, however, only the numN differ significantly, which could be due to the fact that type 1 spreads horizontally below the RPE and, thus, display more vascular branching, while type 2 grows more vertically through the RPE and under the neurosensory retina. Detailed information about the pathologic vasculature is important for proper monitoring of the disease and to assess the efficacy of medication, especially with regard to new substances. This should be taken into consideration in future studies.

Retinal pigment epithelium (RPE) tears are a typical complication of vascular pigment epithelium detachment in age-related macular degeneration (AMD). During proactive intense anti-VEGF therapy, stabilisation or improvement of function may occur. With the new method of OCT angiography (OCT-A), retinal vessels and flow density can be quantified. This pilot study investigates changes in the choriocapillars (CC) in areas with increasing FAF in OCT following an RPE-tear. In six eyes with an RPE-tear, prospectively initially and every three months thereafter, multimodal imaging was performed, including fundus autofluorescence (FAF) (HRA2, Heidelberg Engineering, Heidelberg, Deutschland) and OCT-A (RTVue XR Avanti, SSDA-Modus, Angiovue, Optovue, Freemont, CA, USA). With interactive MATLAB-software (MATLAB, MathWorks, Natick, MA, USA), FAF and OCT were geometrically superimposed. With the help of the Fiji software (National Institutes of Health, Bethesda, MD, USA), areas with increasing FAF flow intensity in OCT-A with CC-segmentation were measured during an average follow-up period of 12 months. We measured a reduction in the RPE-free area - due to an increase in autofluorescence tissue - of an average of 2.94 mm (SD 2.1 mm; 42.1% of initial RPE-free area) in the boundary area of RPE-tears. At the end of the different follow-ups, some patients exhibited lower flow density in areas of regenerated autofluorescence than the initial findings. On the other hand, in some follow-ups, the same or increased flow density was seen. In this pilot study, OCT-A was tested to analyse the structure of CC in areas of regenerated FAF after RPE-tears. Using external image editing software, FAF and OCT-A were compared during the follow-up. Thus apparent initial regression of the CC in the area mentioned above could be observed. During the follow-up and development of autofluorescent SHT, CC also regenerates up to the level of the initial findings of CC.

Background: Invasive coronary angiography (ICA) still causes a significant amount of radiation exposure for patients and operators. In February 2017, the Azurion system was introduced, a new-generation fluoroscopy image acquisition and processing system. Radiation exposure in patients undergoing ICA was assessed comparing the novel Azurion 7 F12 angiography system to its predecessor Allura Xper in a randomized manner. Methods: Radiation exposure was prospectively analyzed in 238 patients undergoing diagnostic ICA. Patients were randomly assigned to the novel Azurion system (119 patients) or its predecessor Allura Xper system (119 patients). In each patient, 8 predefined standard projections (5 left coronary artery, 3 right coronary artery) were performed. Image quality was quantified by grading of the images on the basis of a 5-point grading system. Results: Radiation dose area product was significantly lower in the Azurion group 109 (interquartile range [IQR 75-176] cGy cm2) compared with the Allura Xper group 208 [IQR 134-301] cGy cm2 (P<0.001). Body mass index (26.6 [IQR 23.9-29.7] kg/m2 vs. 26.2 [IQR 24.2-29.4] kg/m2; P=0.607), body surface area (1.96 [IQR 1.81-2.11] m2 vs. 1.90 [IQR 1.77-20.4] m2; P=0.092), and procedure duration (1.5 [IQR 1.2-2.3] min vs. 1.6 [IQR 1.2-2.5] min; P=0.419) were similar in both groups. Images from the Azurion system were at least of equal quality compared with Allura Xper (image quality grade 4.82±0.45 vs. 4.75±0.52, P=0.43). Conclusion: Use of the novel Azurion 7 F12 angiography system resulted in a significant reduction of dose area product in patients undergoing diagnostic ICA by 56%.