Update Glaukom: Diagnostik und TherapieMay 30, 2022
welcome to today's webinar why diagnosis and therapy I wish you a warm welcome from me at heidelberg engineering the topic is diagnosis and therapy the diagnosis heidelberg engineering gets yes quite well for therapy we have reinforcements on board Today this is a cooperation with allergan company and I would like to give a warm welcome to Dr. Norbert Jahre, he is a senior manager of allergy medical affairs team. A warm welcome to you. Dr. I would like to briefly introduce you to an agenda. ct in the diagnostic equation this will be held by my finnish colleague and trainer andreas kasper then we will welcome professor christian martin from erlangen then he will show some case studies and then he will bring us closer to diagnosis and therapy in the diagnostic cup after which we'll look at the quiz and the questions means you'll end up with a little box of questions gen you have to complete these as a basic requirement for you to get the three points which I'm going to show you on the next slide so you're definitely sure you've completed the quiz at the end , very briefly about the virtual academy, many of you will already know and probably some will also have registered through it on the heidelberg engineering home page we have the virtual academy area and there you can see a number of webinars that have already been recorded and they can also see all the webinars that will be taking place shortly there so you can take a look at them.
Check back regularly and find out what's coming soon or watch existing webinars last but not least a little hint if there are any suggestions or further questions you would like to send us then you can do so at the email address schulungen heidelberg engineering and come yes i wish you all success he is a nice berliner and can announce the first speaker directly my dear colleague andreas kasper is in heidelberg at the company right now he usually travels in north rhine westphalia today at the company in heiligenberg hello andreas yes hello matthias hello at home everyone hannover dpa thank you very much for the introduction again, a warm welcome from me.
It's good that they're all here. We are already more than 100,142 participants. Of course, we are very happy and in the next few minutes I will only give you the theory of what people will be like. Speaking of case studies, Professor Martin explains in a relatively fundamental way what he did. Today is happening together. You have probably heard it very often. measured as the first area we take care of is basically papi ere same the head of the optic nerve in which we place an erasure scan with the premium edition of the bell module that contains 24 lines and in each of these 24 lines mesz with then automatically segmented by the software the movie or the program expects the shortest path between these two points the minimum width of the portfolio results automatically, that is, these blue arrows give a value that we can compare with normal data the second measurement and this is a measurement relatively well known because it has been done for a long time is the nerve fiber layer measurement perry daddy read that means we have a circle that measures a circular measurement in three different diameters and from these different diameters or in these different circles mesz, the Nerve fiber layers are automatically segmented by the system and can then be compared with the normal data that is stored for the two pr The first measurements are just a combined measurement that are not performed separately, but are always combined so that they are centered in the same position, and the second optional measurement, which we also consider useful by default and will always be performed, tells us that let's pick up the mail gang measurement On the one hand, the pohl measurement has a differentiated coarse map, we will see that later, but above all, as its name indicates, it has an asymmetry analysis and from these measurements we can compare the values that are they measure with normal patients or the nerve fiber layer as well as segmenting the galleon cell layer separately so these measurements show coarse maps and also compare with normal data these are just a quick overview of our positions that would be used as standard for extensive diagnostics a prerequisite for each of these measurements or for both measurements is of the so-called anatomical positioning system ico and this anatomical positioning system is ultimately an ax positioning, which means that we detect the fire brigade and the center of the professional opening during the first measurement and thus receive a very individual part for each patient, which means we can carry out each measurement you make compare as best as possible to normal data now let's go directly to the analysis window so you can also see what you can do with the measured data so when we open the measurement you can always see the spectrum in the top left city the infrared image next to it in the demo CD sectional image on the right you will always see the deposited positions light green the light green glow position is always what you see and for glaucoma diagnosis it is like this that we get a histogram of a sector analysis in the bottom left and next to it on the right we see that program That means the exact measurement is always stored in the histogram and these different areas, which are always bounded by these gray lines, are always a doddle, so to speak, in heart sector analysis.
The question is, of course, how do you parse such a histogram, and it's like the values you've measured are compared to the normal data are stored, but that also means that the normal data, i.e. this is the normal range that we have here in the lower area, it is not used in the same way for each patient but is calculated individually for each patient and it is here on the one hand, the program planning area and the age of the housing the bigger the problems with the aperture area and the bigger the patient the smaller the comparative value to analyze the histogram once it's just for you to zoom in on the wheel for a bit see the middle green line and this line of the middle is basically 50 percent that t in the normal database, we would expect a normal, healthy, fair, healthy eye to lie more or less completely or, ideally, exactly on this green line or in a parallel position, that is say, a small arc h above or below would still be a correct measurement. i would just expect this measurement the histogram to run more or less parallel it looks different if we have a complete reduction of the amplitudes then we already have a very flat histogram that means we barely have an increase in this program and we are with almost everyone we are right in the zone from the edge but above all very smart in the red which then would be a measurement that no longer seems normal it will be much clearer but especially if you have a very strong notch where the nerve fiber tissue is damaged at this point and then the decrease already it is much more present at this point than the rest of the area when we look d If you look at the measurements over time, you have the option, as you probably know from retinal diagnostics, that you can see the current measurement as a line black on the histogram and then we have the basic exam measurement on a gray background and on top of the blue line you can see what food is presented which time that means we have the left arrow here and we have the right arrow here on the third basic measurement if the patient was with you more often than of course it's also interesting to see the course of various measurements and you can always do that via the progression tab, i.e. if you click on the progression here you will get this plot as it is now and have the points connect automatically If you have three or more points and you can look at this histogram or this progression analysis separately for all measurements that were carried out in the chapel, or if you don't have time to do it yet or want to take a closer look, then I can still click on the individual sector item and an extended analysis or a separate analysis for this sector will automatically be displayed .
Now we have a dashed line in this example because statistically or mathematically there can only be a relevant or significant change if you have five or more measures and in this example we see a professional with five measures and you can tell that this has just been completely drawn and also you can see that this blue line is a bit more pronounced than the normal age-correlated decline, i.e. in this example you can see that abn happens more in this patient's eye than one would normally expect if we then go from the minimum stroke planning measurement to the nerve fiber layer measurement then is similar in principle we have the same representation we have the same reference database the histogram can also be evaluated in a similar way but this is what that probably all of you have known for a long time or more than I already know that in this histogram we have two very present hills, that is, have or an increase when we come from the Left from the temporal to the upper area where we have a lot of nerve fibers, then we go down the hill in the direction of being there, where everything ripples a bit and back towards the serial temporal as the hill is very steep up. so that the nerve fibers are more present and we have an even slope towards the temporal area decrease which would be what we would want for a normal finding au Here it is similar, a reduction in amplitude lowers the entire histogram if it has redaction in the amplitude areas both sexual as temporary or this very present notch that can also be seen very clearly here on the one hand in the histogram or on the other hand also in the sector analyzes now let's briefly move on to a very frequently asked question, of course, with all technology or so good as technology, there can always be anomalies that people say that the contradiction in the two measurements is still there, that means that I have a measurement directly an optic nerve head at the minimum edge so far in that it is discreet and the nfl measurement that is already noticeable and there are several causes with this configuration it is only so that on the one hand the oculists cannot cope with it, it may have atrophy that follows It means that I already have defective tissue outside of the papers, but the papers themselves or the minimal gain z so far little is influenced by it, we can also have an atypical position of the arcuate vessels or have been arcuate as in this example, it is That is, the upper running vessels should actually run in this area if we could wish to because the tempo as In this case the upper zone of the normal database is somewhat stony, which actually occurs more often than the upper zone lower, which means that up here we would have thinner values than what the system expects and then the third and last reason automatically appears conspicuous and that it is more or less the same in all systems if we have a micro paper where we have looked at very little space directly in the head and all the information is clumped then we automatically get comparatively higher values and if we go to 1000 then we see who sent but still already in the analysis of the nerve fiber layer if if we have exactly the opposite information then in reality there is more or less only one realistic explanation and that would be just a physiological macro which means that the minimum edge in what As regards the measurement it is conspicuous simply because the paper is very large there is a lot of space around all the nerve fibers to relocate and if you go further outwards the image actually shows more or less normal or little influenced by the paper and the size. you can always check how big the opening area is on the Brockenbahn if you look very closely and especially here at the bottom right of the picture you can now see in this example that the opening area of the program planner is 1.99 millimeters squares and the average value is quite normal the database is 1.78 square millimeters 97 I would not speak of an aperture that is too big but it is a little larger than the average value what we in this case of course we would recommend another we for Usually, other measurements have already been made to use them.
If you follow the procedure, we recommend that you analyze the gang lin cell layer, and if we want to analyze the galleon cell layer, we will move on to our next measurement in the post. postille pohl asymmetry analysis guarantees or allows you to carry out perform a discrete coarse map analysis, i.e. in this example on the left we can see how you would access the fitness tab with more than the normal offer profiles of the network measurement and you can see here that the histogram or the scale it varies from 0 to 100 micrometers which is particularly relevant when the patient has a diagnosis of the retina for the first time because there are very strong increases and very strong decreases, which means that we have to perform or map a very large area when we do want to check if there is glaucoma, the smallest areas are usually enough for us because the changes here progress very slowly and are not carried out asdramatically by the big changes and that's why there's a big card from a karner in the press that goes from 200 to 500 50 micron achieves as well as a bit of a difference picture erected which means pohl post office is in the analysis on the right hand side we can see the differences a bit more precisely here because we use a different color scale and on the other hand you can imagine if you want to approach the subject a bit visually that with a healthy eye you might see a structure that is it looks like a butterfly wing if you use a little imagination and if we mirror this card to the other side then you could imagine that you don't have a butterfly now again to assess the asymmetry it had I already promised you that on the left side we will remove the post for tickets here it is just that we are looking for a butterfly wing here as we only expected it is missing at the bottom only as information that we are very happy as donath we described precisely this area and around the lamina of the especially through the prominent ganglion cells show up early is not as round as we would like that means healthy for us would mean we have a donut in this case we have more of a snail shell or croissant per what a little bit is missing here at the back and that is possibly already an indication that something is missing here if not just or if you don't just want to speculate on this thick map then hemisphere analysis helps above all this work for that we can see the relevant fields in the lower area like this, for example, with the would compare the same sign in question in the upper area, that means that we compare these two or also the two most external ones and that is how it happens that we get gray fields dark black for the miss fair analysis at the point where the relevant sign falls, here for example the value 2 154 564 rotation compared to 315 yes It means that we have a very large di here discrepancy in the measured values and this means that this area is displayed in black, you can imagine it similar to the field of view if a measurement point is gray or black then it is significantly thinner than in the area relevant in this analysis of asymmetry we would also always recommend that the outer square be viewed with a bit of caution because in these areas it happens very often that the vessels run very symmetrically now it is natural that it be re-introduced here as well, it should not focus only on this asymmetry card or the neglect the thick card because in the analysis of the hemisphere now we could say here that it's more or less evenly distributed but if you look at the thick map we see that from our highest butterfly wing there's only very little dunk left strong with strong warm colors and strong and warm colors speak for themselves a thick fabric that means in this case defects advance two fishing over all samples of interest of course you also have the ability to run a progression analysis by posting your measurements here it's similar to how you'll compare retinal measurements we always have the reference exam indicated in the area below the current measurement and if we then go down even further we see a very prominent defect in the difference map which means we can very well compare the defect in the nerve fibers here in this image and that would be exactly the same instead they represent how the dark gray spots here have turned black, who previously made helmet purchases when you only told them everything that has several spots from neighboring fields is already an anomaly that you only observe or can see very well if a defect arises then I liked them a lot and let's say that we can not only segment the entire region but also enter individual structures, in this example we have again the defect of ha z of nerve fibers interested in the ear area of the interview the lower part is shown here as completely healthy if we look at the separated nerve fiber layer then we have the same defect in the lower area the left eye is healthy and also when we go at 16 we can check what we already suspected in the general index after that we can check this very well here this cardboard- the shaped representation is already a little different from the more or less donut-shaped united representation that we would like with healthy eyes, so we always have something new and the new thing we have now is the diversion skid for mail pickup measurement was just the question over and over again or the effort on our part that we not only have data on the pill but also for d in rear eyes you have polynormative data and then you can compare it to these current measurements or to the measurement of patients with healthy eyes and this is aviation net bw se presente It looks like this when we click on the last tab in this view after the Posse Pohl measurement is it possible with newer software to click on this deflection skid and here it is so we can select different layers in this example it's just the world of the nerve fiber layers that you can see here you can click that also you see up here once again, the name of the individual layer is legal.
You can see on the left side the thick potato sticks in which area we are moving and below we have a classic action diagram that gives us information about the individual sectors in the central area on the right side so the entire retina always remains Now that I have from 1 to the whole network you may have seen additional information if you looked closely ie thick map in definition web now they are a bit different so a third thick map is the advantage of this. The thick card is that the card has a so-called sexual uniform. That would mean that the differences in colors are perceptible to the naked eye.
The difference that I can see corresponds to a certain numerical value and here it is also the same that we only have warm colors. the warm colors will show thick areas and the calbes blue colors will only show thinner areas and you can see here how well the nerve fibers run in a healthy patient and how reduced these warm colors are to a defect in a comatose person which I have already Mentioned is the color coding on the billing card similar if it's the same as the comparative measurements in the chapel that means we have a lot of green up here in this example maybe a little blue or purple but mostly what we see here with the stained nerve fibers they send analyzes that we have an area that is very large colored in red it would mean that we already have some severely reduced findings yellow is the borderline area blue would always mean that we have a little more than normal and purple only would indicate that the area is already increasing a bit purple and learning areas will probably increase a lot, which we often see when measuring We go into areas or when you check areas where the glasses are run because these glasses are also automatically measured and then lead directly to increases that are more or less averaged over the standard value The action diagrams are similar here to the paper measure as well, just that the sector areas are almost the same size.
We also have here the color code in which zone they fit and in the middle is the total value here so that the nerve fiber layer always shows a white representation because it is the central zone nerve fiber layer but because it is for the nerve fiber layer. nerve fiber in the central area results in relatively low measured values and these are not normally distributed, ie this central area is primarily optimized for the garden. The Vincent cape in this area works perfectly because it more or less completely closes off the hallway. cell area or all direction here we see it again like what we just saw we have sent the nerve fiber against once you can see here the harvest club is selected we see the nfl here and above all it is relatively fast if the the model of classification is white, then it acts mainly also around the ehrenfeld a complete layer if it is very nice to see n that only the thick card that the ganglion cells of gang linz donate we would like to have that fits perfectly in this pattern in this example they are in the circle the upper area is very slimmed down the lower area is still relatively prominent and we see above all in the diversion skate very nice that the thick card area the cold area in the billing code is automatically displayed the same game also in the ranking is important here that the aps so that this anatomical positioning system is configured correctly, especially that the correct hitting mind I show you that a little enlarged in this example and see here because if I hit the central position where I should have hit the previous one does not exactly cross the foil, then I have problems or abnormalities in the evaluation, that is to say an area where the previous one is expected is much thicker because we are in this area h Here you are working and the left area a little bit next to the fire brigade is exactly the one that goes down earlier and of course it is thinner than the system normally expects which means which here is already up to the aps so this ax positioning is carried out very correctly the first time around that should have been my explanation for now i think we are about to see a lot of really interesting case studies of a teacher you see it if you still can't get enough after that you can visit our blog oma image atlas in business lounge or not just now you can scan in qr code otherwise rio, still in the business lounge you will find all this atlas also contains an example of a professor martin of course since the players are all over the world of their colleagues that is why this atlas is only available in english if you don't you want to read both right away here's another one to atul pid glaucoma because it was so painful before or also this how to guide ie you already have these two booklets in your docs on the right otherwise of course also those you will get from us in the business coach so i would like first of all thank you for your attention i hope you were able to learn a thing or two about everything i hope but that is a good preparation it was for what is to come with exciting case studies of the hijacker. the detailed explanations maybe a very small note on my behalf many of you may have seen the nations maps for the first time and are wondering why i don't have them in my software why am i missing them its a simple software
updatethey need to have What to do You can download the software from the home page and then you have to install it both on the device and on the i install your workstations if you have any questions you can simply write to engineering at schulungen heidelberg at any time we will be happy to help you and last but not least andreas a comment thanks great lecture i would like to say that too so a comment from a listener and there are also scales and in fact there is often the question of limit values for micro and macro poplars with ht , there were limits that you could set yourself, like this with the dm surface, yes that's very cool and that's also one of the most fre count.
Of course I would also like to ask Professor Martin right away that the difficulty is simply that we kundus would scan a different area copiously than we do in measurement or ct when checking the papillae in the premium editions of the jako module or adjusting the surfaces of aperture is not like analyzing the surface itself, we are going to go there into the depths and it shows very clearly that the Brockenbahn aperture does not exactly coincide with the optically visible area of the bottom, i.e. very often we get larger and that would mean that if you have an area where the profane opening of the bottom visible paper pool may correspond to us more or less take the batch readings but if you deviate from that and go to larger regions then it's not the same area anymore and then it gets quite difficult, which means, in short, there are some patients where you can adjust accordingly and that's for sure. a good orientation, but very often we will get larger areas that will be very difficult to compare with the previous ones.
Yeah, so another question, what do we do with a tilted view? the same goes for optic nerve damage, it's not as easy with a background that's copically visible or with a background that's comical, because we don't necessarily know how it changes down, but we have the advantage of oecd measures, and in the oecd measurements at least we can use our experience After looking very hard at where the program ends of course it can always be a bit difficult because the tissue grants so the action on the tissue is sometimes very prominent and need to look a bit closer but we have found there are also some jackpots with very stable value which is very stressful even with tilted jobs yes now it hails but eventually more questions come up in the proceedings we at ep regional membranes will interfere with the correction how much because the membranes interfere with the fire, especially if we look at the mr pohl press measurement as the entire retina. that means of course we have an extra blanket which makes aspectspositive are almost impossible for us.
Of course you can still see how the individual layers work or the nerve fiber layer or the cell layer that has disappeared I think. which might not affect it as much but of course it does with the membrane depending on how hard i pull there are the schichtun g and just too thick compared to normal patients and it doesn't really help if i laboriously operate the 61 lines because the structure just changes well thank you very much one more question i think we can deal with them limit values very briefly for the world cup area where i think mr. caspar has already done it pretty well equipped there are no hard limits for micro and macro wobble there is only a standards database average value of 1.78 so there are no hard limits for a micro and macro macro band and then i can go soon to play mr allergan company thank you very much for the great presentation and we are driving with ford in the program mr dr. years i had the ball for you thank you very much mr. befort for passing the microphone yes ladies and gentlemen of course also on behalf of allergan i would like to welcome an application as a company that the cooperation event with heidelberg in cordial difficult thanks also to the engineering colleagues from heidelberg for allow me to be there of course it was very interesting the first part so sir caspar i learned a thing or two again thank you very much the day before now you have to come to the second part and this this the course in line needs to better introduce diagnoses and
therapies and also introduce a bit of practice and since I'm very particular Martin will now take us on a journey but an interactive journey through complaint diagnoses yes how do you suggest that professor martin let's go in and go we embark on the journey so i would like to pass you the microphone and i hope i love you mad rb how dr thank you very much for handing over the microphone today's topic is leaching diagnostics and process monitoring with optical tomography of the quran and we love the colleagues because now we are all spatially separated and just having fun via live cam I still expect everything to be relatively exciting.
I tried to relax a bit and above all show case studies in which each of you will surely recognize one or more of the patients. First of all, I knelt before the lecture. so we can talk about the course of diagnosis, then the video cd talks a lot about the optical strobe, especially tips and tricks, and finally, another therapy option that he believes is common sense because as an example of minimally invasive surgery, if the optical comments demography has the great advantage that we not only have the newspapers in perspective or the regional one at a glance, but like Superman, we can practically look through the cloth and get a very high resolution of the structure of the stories of the device in a black and black color.
White and counterclockwise representation that allows us to see several changes that only a histology in the great love approaches we are interested in a balloon where the axons serve the glial cells and of course also the regional pigments due to the alpha and beta zone we can represent all of this as in the histology demo cd 11 and we have tested this historical section to be carried out in exactly the same way as the oecd section performed in vigo and you can see quite a few similarities in the structures and we also see the essential structures that are used for an evaluation of the ball ex work in histology as well as in the oecd and of course you can do it accordingly measure measure is very important because skin loss on the face in the course of the disease marks the beginning of the end, just as it once happened on the phone, we have to lose 30 percent of the gang yen cells or nerve fibers r egional tests before doing Petri or sensory tests, it would be good if patients invested before in the lemma state, that is, the losses that n a layer of nerve fiber is gone the cell layer that can represent and that is where the construction optics has become a huge help.
It's also important not just for the patient but for the entire health economy to catch the patient early in the early stages and then stabilize and treat them because of course as glaucoma progressed, it also became more financially expensive, Mr. Kasper, which was already briefly mentioned or a good feed, which is also indicated for people who were not quite there at the beginning. I will briefly repeat how it shows optics. construction mission measurement we measured the fundus of a patient look once in the pill area the rantzau minimal wanted then a circular scan to measure the papers and the final thickness of the nerve fiber layer and finally a window was place a cube in the macula area around then jens l rules in.
The eventful story will be measured accordingly in thickness. I will repeat this here again from Mr. Kasper because he himself shows what our OECD and especially the premium model of glaucoma really sucks. We have segmented the membrane into a dance and segmented the accord. Boys' membrane opening. and the shortest way to swim to the surface from the ngg book is then a measurement of the thickness of the race song, which is significantly better than how it was done before, we simply measure the rantzauer on the horizontal, which has already been shown in the work means it is very sensitive for glaucoma section these values are compared to normal population just as kaspar just showed and the second value is retinal support fibers around the papers with three different measurement circles on the modules glogow premium you normally take the diameter 3.5mm the west circle then you get e a layer thickness profile in the picture, which is then measured accordingly in thickness compared continuously and thus enormously population and the macula as shown above measured in layer thickness, so the version is the interesting stories about all the regional lining cell layer can select centralm entity stops in the thick map to see if there are already changes here or late changes we take these three variables together to assess for glaucoma or other diseases accordingly in the posterior pole that's why it's a holistic approach one measurement would never be enough for me .
I would always like to know what to say also the other measures and if we look at an old work from 2010 the photos of the papillae have been issued by experts in Europe the stereo paper photos here were normal or documents were found then you can see that there was a clear dispersion among our experts in the sensitivity to detect glaucoma and d given that the devices that were used for the comparison, then placed, as well as the nerve fibers, the correct measurement and the ht with the paper multivariate formula generally performed better than most the experts, which means the machine can be very useful if I can do it myself the current values we have from the ocean we see the nerve fiber layer measurement is also ahead in sensitivity select a glaucoma when I'm up here on the corner I recognize all the healthy as healthy and all the sick as sick they are not so far yet with the devices, but m oops close here you can see the performance going into the tent layer thickness and here the minimal rantzau performance worked on all rantzau fabric layers now we can see its optical crailsheimer many that the hood really must make changes when we see one here on the left normal patients have in the field of papers and here a patient with glaucoma there will be in any case, it can happen that the inner layer of rational nerve fibers here in the top portfolio is significantly thicker in normal patients than in patients with glaucoma and significantly lose the thickness of the layer and that also goes for the thickness of the underlying ganglion cell layer and if we look at everything again in the marrow or look and go through the cell layer of normal people and compare that to a patient, It's also noticeable here, although not as much as with this layer, that all the dilution also takes place here and we pretty much have this population of cells. those in the seller who performs the actions recently inserted in the corridor for chic and the soma represents the axons that break if the soma breaks the action must also break or vice versa the action in the public area is damaged to glaucoma it must be go down the whole turn and be able to do that in the historical metering we also show high res in the ot how auto damage to nerve fibers works increases we know we have this wonderful radius arrangement around the papers a very tight structure with a weapon the upper and lower ipad in part very rational nerve fibers lactose a colleague that you finished the structure is a support tissue where the clear if pressure is exerted on the papers you see your historical section 1 normal paper then it happens that in the large teaching area the action shuts down under pressure and all pressure atrophies so in the end it limps big damage patterns in glaucoma are relatively typical there are affected axis beams that run a temple at the top and a temple at the bottom at points that are generally relatively far from the false am and when we look at it all again here in the electron microscope image look at all the deals there are that precisely these areas that are very sensitive to loss of action bundles and we often see that in the nerve fiber layer maps that follow that the first yellow red sectors next to the temples are at the top and bottom the background is that there are two here several gang inzell systems have the subscription cell system the modular system and this gang count send me your shares back to the pink merkel in the center circle 20mm it's mostly the packages the learning room entrances say and then around of them the framework cellular structures and if we then see where the münchner action is we see that in the typical areas temple above temple below above all s framework cellular pathways are affected accordingly we can also see something similar with parkinson's disease it's different with multiple sclerosis or alzheimer's disease where mostly central cells missing underneath we'll see soon it's now i have my o.ct impression.
I have done my three measures the portfolio the moderate nerve fiber sends it measured cellular layer how I can not approach such a printing time economically and here I have to say that our experience is and also obtaining my personal opinion that I transmit here I look at my minister ready more sensitive that first the retinal nerve fibers if here one believes that the typical payment as shown here I observe that the second look is then applied to the minimum rantzau up to a measure value for the neuronal edge of a pill and look compared to the populations of rooms in the sectors there are conspicuous features in the production I look at the image and also my segmentation if my patient is in a pathological area somewhere I also look at the infrared image because of course I am here very nice horizontal rantzau like a dark circle contrasting them sun I offer myself helga is probably the neural rantzau after jonas normally can't e estimate pretty well my last look is then go down the hall tell the story here on the postcard to see if we are also anomalies in defense are everything For me, time is especially important when I'm not with a baby wmfquite agree, I am a very good referee to decide if you had a nokia report or not there would be more examples and of course asymmetry between the right and left eye is important because many studies have shown that an asymmetry is a clear indication that one side so the comparison between right and left is still corrupted from the start, so I'd also try a printout you can practice leaning your eyes at it and then relatively quickly acknowledging that it was of course not in order , of course, and I want to do it. being relatively old fashioned sooner having looked at roll calls it's important to look at the whole picture as well as optical cables are a demographic technology i have to get everyone to the patient office to speak for or against a prick about mohammed as far as morphology is concerned, that means to me that I always tried first the consideration of pills seen here in these patients 52 year old wild glaucoma temples open and a relatively wide notch with the beginning of new fossa formation and here you can see the rational loss of nerve fiber layer thickness if i continue to look at the minimal number of patients i see quite a few gas sectors are conspicuous here but keep in mind that the papers are relatively large from the opening of the cup of the world and here naturally the rantzau is a little flatter and thinner than with somewhat smaller papillae here we were also able to show in a t work of aon arias that the two great premiere directly on a nerve fiber reflects reality and here we see very clearly and its unusual sectorwhich makes this part of the hood pathological in the rnf in postille paul's analysis see how competition with the vowel faulty nerve fibers is the supply step in the akku cells four so that the thickness of the layer has changed significantly call me even more the web definition on the population deviation map all the big red field shows us that here in the shrimp cell layer is clearly attacked here again the fine sectors mentioned by Kasper where we can look the measured values again, I always look at the blank in white parameters if I also find a corresponding effect in the upper half and that is also the case with these patients, this centrally close defect in the Petri shows that the patient has now lost as much gait in a zone that already has parametric glitches when i want to cover everything a bit can fail here on shift and FOV then of course I know my face time from the number is always mirror inverted to the flash mob and that is made easier by the so called hotspot in this ten degree field of view recording where only the viewpoints overlap again with an inverted course in two image layers so that from this case it can be understood precisely that in my field of vision I have to look outside and that corresponds very well to the failure of our example so it is always important to look at holistic education for all the beauty of technology we come to believe that it is not a profession only useful to have an assistant in the diagnosis of glaucoma based on measured values, so more evidence than not eminence or suspicion, but measured values also count to possibly intensify a bit of therapy but also the progression of the curl is there these devices are of great help because I have just improved almost as well as papillae recordings it looks significant mently load tissue or time disappears with optical choreography we already learned that in healthy people we already confirmed a decrease in thickness means we have national works and if we compare this regression skate with patients that the mind names from the visual field image of ocular pressure As a result , we had to painfully learn that these patients simply also lose layers of nerve fibers and more than normal in old age, but it turns out that on average we have less than 0.6 in normals twice as much in the supposedly stable ones and of course in the patient it is the straight line significantly steeper which depends entirely on rental and opel setup here is an example of a 2008-13 patient the inclined observer immediately notices the patient had a hood bleed between 5 and 4 o'clock and then he decided to play after five years in this area also cart 2 stadium according to jonas and we can see everything in one a event analysis event analysis has the great appearance that over time I can see a red and localized change related to location and look exactly at the author something may change for this patient that's the great advantage of event analysis requires a little time because you may need to retrieve all printouts accordingly, but you can see exactly where natural vision has hidden them from the patient.
The alternative is of course the trend analysis that Mr. Caspar also showed. It is mostly an overview. A great help. You can see it as The respective sectors of the pill are also a great advantage because nothing changes in its entirety and we can judge here that the nerve fibers in our patients as a whole simply deteriorate significantly to a level of less than five percent. at a rate of about 1.4 million per year If we go back to the numbers, 0.6 was just normal, 1.2 was just below stable, so the patient is just in the range where they already cannot be considered stable. it also depends on the quality of the recordings etc. it also normalizes a bit here, as well as the degree of the recession statistically advocated on ironing and then we get a very good statement if the patient has to be quite hidden here I have to operate on him now I don't have to operate it that's the most frequently asked question here here's an example that clearly shows how all values play together in 2014 this patient with a regulator comes 2016 and 17 on the course at national borders I don't see much in a few pills photo the only thing I It catches my attention it's the small crown defect here I hope you see us on your screen it widens a bit there it must if you look closely at the palm tree buds as well as the white perimeter that we always carry with us shows a normal face in 2014 2016 then the typical cracked nose in the upper half of the field that matched our part after the father was faulty at 7 o'clock, but ro in 2017 this effect is somewhat less including fds less because due to patient cooperation there can of course be fluctuations in sensory testing.
Now look at the whole thing it affects us with the progression the pattern the retinal nerves are damaged that even the classical circle knows we've been walking on walls for a long time so this shows again here in the course that we see here in the infrared image very well the defective vocal nerve fiber layer discover in the baby as in the area in the course that the patient loses nerve fiber relatively early if you look specifically at our sector in the temple and then continue to lose the thickness of the fiber layer nervous in this area that we already suspected in the photo if we do it again with the look at the glaucoma module as the 3d scanner you can see from the falls sitting there you can also see a change not in the general view but clearly in the view sector where there is suspicion of a loss of the patient from 95 to the new jumped beyond 99% alternative here you can also do it no Watch this short film, the first and last shot we see here in the infrared image again the little flaw is getting a little bit bigger and especially in the image how i look at here the associated nerve fiber layer connects clearly on course very clear indications of progression , very clear. signal to act if we observe that with the bmw we have the same experience in general in the region analysis a trend analysis small change but the typical sector we see here a dilution of the edge songs I have not seen a photo on paper so I have to add that completely and we've been doing this for many decades here in general but one here you can see that a network is very important for diagnosis especially for progression assessment here we also look at this sector on the first and last image and see how all were moving slowly in dilute and the small cavities in the reservoir layer 19 form the fair ads that as there is no longer very healthy here we also know the same boston rpo regional nerve fiber layer phenomenon in the boundary layer representation which initially shows 14 to 19 without big memory and now we take the reaction maps and departmental maps here 2014 we jump to 2016 then We see here how an area of bile cells thins in these patients and how here in the thickness of the nerve fiber layer a decrease in striae appears exactly where we saw it in the 2017 image we see striae again in the night shift it is lengthening and counting here that the glitch is gone in the slightly compressed and enlarged area 2019 then we see that the area in the passage to exile has gotten larger and the glitch now almost extends to our transition cell layer glitched area you can see very well the pc here anatomical relationship between ganglion cells the sonata of actions and action a lost action action bündel loss and since I am going home the trophy that is very impressive and the maximum nation that has not existed for a long time i really like just showing in the first part how i can easily switch and progress using loccumer mode with my co cc c later i get tips and tricks for recording and also evaluation at a somewhat advanced stage first of all we just want to say a few things about the recording technique that jenny b's chemistry coach could explain to you better i would like to use case studies take a few things of course it's just a picture but it will be It's all about images and one image can change everything as you can see here right now and that's why it's important to take these images correctly and discuss them here for example we see a patient who is in the outer ring here it starts to become suspicious we see here on the graph that in this area even the history of the nerve fiber layers beyond 99 percent is a lot of slip look at me but a stable on the segmentation you should always do to just assess which computer has done the right job and that's what i decide it also distinguishes blueberries in jining from many others here i have of course i have control over what the device measures and i can correct it accordingly sometimes it takes time but it is less precise we see here the segmentation has not been done correctly and that is why the nerve fiber layer is too thin you have to be careful here we have a probable short term patient where in the background it goes up and down like a mountain russian and we see here that the examiner fed the tour bus too close to the cornea and we cut the passengers on the surface here and that's why my cut is definitely too short here also artifact and of course you have to take the picture we will catch up here One more change in the segmentation of the image does not contribute anything and you simply have to talk again with your technical assistant and of course let him train well.
A very interesting example of artifact suppression in image recording is this work of experiments on the magic of 2017 has shown that with keratoconus patients you can use a normal video tommy lens with accessories for the elektro m capsule obilia and sorry for the powerful props with a keratoconus patient i can achieve a significant improvement in image quality here from this work we can see the image completely distorted without optics and blurry and after exposing the fa-cup tomi glass capsule of the simons of the seed lens we see significantly better image quality and then of course the segmentation is much better.
Here is an example from my friend apostoloff from holland who always sends very good examples to use ng consideration here we see a couple of toes with very dry eyes while doing pathological training here the blisters and sharp image no good segmentation the patient gets here the segmentation even as a pathological temple up mr. borsdorf uses the lens according to the absolute - and significantly better image quality is seen in the infrared in form b, the segmentation of the nerve water layer works better here and we see the patient I don't even have a problem on the top should probably also have a temple on the top bottom and the recording is much more reliable so it's good advice for uneven surfaces 100 dry eyes for to stand on such a glass, but it takes a second man because one has to hold the glass and the other has to take the picture, so that that is not very smooth here we have a patient who apparently praises the speed of the infrared image the speed below is faulty in the regional nerve phase h here here and probably also here so clearly to see me here also my wallet oops what is passing here all sectors in green although partly not in the normal range at the lower edge of the normal range dawn all sectors are first shown in green and let's take a look at the segmentation and in and present the loss too thin too thin and on the graph compared to 9 stocks here 99% ihle and 4 exceeded 99% per note why doesn't this graph show me that the reason is that these failures are stupidly correct in the transition from one sector to another? and so statistically not noticeable in the industry average so a brief look at the color screen is disappointing if you don't look at the ebel or look at what the device actually measured there you can put that image and this patient is anything but normal Matthäus believes that he has already been damaged and this phenomenon was once referred to as greenpeace in the literature and this is my part post from 2016 describing various circumstances in his work where the device shows the sector green despite the fact that there is a pathological finding with the Heidelberg machine you have the opportunity to look at the images again and also correct them ren and that is always worth it before passing judgment on patient cases also the center of the mess is the cold from regional markets the father plays a role the old great circle we focused on the roles in the middle as best we could and here we have the same patient recorded again with the circle of mesz focused on emo, which then clearly slides towards more speed here and, consequently, our patient's maximum also changes and, consequently, the evaluation with a population, of course, can turn out differently, we see here the 3.5 mm of zeiss and here 47 mm I measure a circle with the panel model and it must be said that because this circle is centered on the membraneuniversity has straight sloping papillae that come out very slightly obliquely towards the temporal side it may happen that this circle is very abstruse from that it differs from what we would judge as a paper center and I think I have to accept that with technology because the calculation of the university it is simply the area where the nerve fibers emerge, but I have to say that it takes some getting used to even if you have looked at photos for decades, so it is important to first achieve the best possible image quality that the patient should sit correctly and comfortably.
Tracking of any kind is very useful for getting better image quality and monitoring progress. The eyepiece should be at the optimal distance optically for the best possible resolution, but avoid clipping the tear film. one hand pot contact lenses should be examined with contacts or also yak absolute lens placed according to siemens fixation should be easier just a few eyes some patients sorry they find it very difficult with fixation here, you must have tricks of the external fixation ready to get a good image lighting focus is very important to r the image quality of the scan position is of course important as you just saw with the following circle of fiber layers, fractions of astigmatism have a great influence on image quality if everything is done correctly it has to come all the way to your clinical evaluation we look at the different types of files I once classified into associated glaucoma and a time not associated with glaucoma how do we associate with the bells they asked it is an interesting finding that patients the para central line also the nerve fiber layer has e bongani cells have an expansion show an expansion cyst of the inner nuclear layer so that in full thickness the retina does not thin because the inner layer can compensate for the thinning of the gangrene cells peru when we are mentally more fun ha trac As in these In patients with the clear notch, we see a clear break in the nerve fiber.
We see here that the layer of cells has gone as it deserves, but we see a thickening. A thickening of the internal clinic due to the change of the system. Does it happen with various innovative forms of brand atrophy? It also has the goal. It's still a very interesting phenomenon, especially his multiple sclerosis, which is not uncommon to see where you can also see the biggest failures with the osce, especially on the borderline. layer, but the artificial thickening also occurs here on the entire retina or there are simply no changes that I would expect if I look at everything, but that behind it there is a pronounced loss of time and that not only listlessly in the lower half of the field but also in the upper half of the field, the patient is a clear damage when walking towards the cell identification card soon with the expansion of the layer in halo already tells a very advanced finding shows with 81 years of history from 2009 to 14 see photos on paper we do not see large changes here with the Bavarian atrophy in the course of postel no I do not see any major changes, you can also see that the patient has some difficulties with fiction and if we look at the nerve fibers that are now being damaged in the case of then we see that we have less 50 years old with night shifts and is actually stable. and is the patient really stable that's the question when we look at this in the ht what's still going on here with those who have it with them we see the rim area go down significantly more and that's in contrast to the stability in the rational nerve layer of fiber the goal is to look at the field of vision the patient has also clearly lost vs. global the patient has deteriorated significantly throughout his life right here it was through the nerve fiber layer let's look at the other variable elements paul almost no I have tissue left what I can judge on the way to the right place in the forex market I have a very large area that has been lost for a long time so we are also the next few days the thickness of the bmw layer has also become very thin and the layers are so thin that production can no longer be established here either there is no new work which gives hope that this will probably change more in an advanced stage it gives the ta, but that still has to be seen even with the work groups of the workers, we have a very clear effect here, even the floor or floor effect and you have to look at that in ford in glaucoma mid-strip structure and pay attention because otherwise you have a false sense of security here you have to, for example, make your face stop to assess your course really well and now you might get the idea there ss you can also examine a patient who is just in the stages .
You may not have to go through the whole machine every year or two years because the proportion that is considered the mini version is so effective that the visual field deteriorates to the left and regional. allied nerve fiber layer from top to bottom and that all in one if a stoll diagram was put on then I take off that I have a media defect with us is about 3.0 g for the parametric start image will have as possible flaws that is the area around 80m with a layer over the patients initial visual field that goes pretty well up to a layer thickness of 50m where the field of view has increased further but our intermediate layer is unchanged so this effect of soil and so the suggestion here would be to use different methods in different areas very early glaucoma is still the most sensitive in a All year history my eyes have progressed glaucoma the hzdr field of view can possibly half the photo and in the middle area I can really fully extend the field of view the optical zoom or a lot, for my sake b nrw all ftth maybe it will be integrated in the future, especially if you arrive early, probab lemente will return rdf actually quite good here is an example of a patient who showed an increase in layer thickness or correct increases instead of a decrease everything was fine here too that is the picture of eva roth and if we look at the patients you can see that we have a big big bleed they have the edge that we probably barely notice because the laser pretty much goes through the bleed but it makes a production of the regional nerve fiber layer and here I would not recognize the deterioration of the quality of the bleeding I would say well everything is fine although practically rare fund patient an obvious sign of deterioration and over time this can of course also be accompanied by an encounter and action through the vitreous body.
I had to trigger it automatically, but bleeding if you think it's rare is my sign of progression and that's why the fundus copy is still really here a 78 year old patient with open political glaucoma we don't see any paper here over the course of the 2009 bleeding 2017 we already see a clear vowel production of the wallet and a cup for the rational nerve fiber layer you could imagine almost all gugl starts in the field of view are still relatively good values in the way that petri knows he can see with the flickr image that the patient then deteriorates with local failure if we look at the upper sector of the temple then we can see the deterioration to be expected across the board if we look at the lower campers look at the sector series a rantzau deterioration more and plö Finally what is happening here can't really be an improvement and if we then look at the picture we see that we have a division of the nerve fiber layer of the backpack here, which are now internals and here the layer just comes apart a full day. drawing a subsequent Impairment, however, is a pseudo improvement in the measured value, which in turn auctions a deterioration.
In the event analysis, we see that the patient clearly loses nerve fiber layer thickness from 8 to 17. In the trend analysis, we see that temple on top over and over and over again the patient continually loses the right nerve fiber so it rather deteriorates how can it happen that he down here in the broad verdict of the number he explained that it is this opinion and that you have to go back to the bible, on the other hand, if we then look at the current lines here because we are worth it, then we see the whole story in the market is lost and against the note should finally say yes, the The patient is clearly deteriorating and that's why the three variables are always very helpful to really get clarity on progress. tell me a clear exit account here also a very clear sign of progress the measurement points in my eyes even better than the colored coupon elegant presentation of these failures compared to an operation there and here is a clear sector in red another example where we are also here everything is served in green and here we can clearly see that something is wrong here we have a hybrid plus all the fractions a curious one that will probably tear our retinas and look at the things that the policemen widen we see that in the food in the fiber layer regional nervous system in the area where we already have a total failure in vitro image there is the warning that it has simply become ill and it is more likely that it will give in to these mechanical forces so at some point there is a very clear sign of future deterioration that is not it must be overlooked the patient has an absolute problem with his stamp our sector in the above corresponding is the failure and again the march of the nation too it will be all day that associates never say to each other here they have significantly watered down our ref after clearly worsening this alignment you have to see it in the bebel and also as a role of the ad pictured I also perceive because I just said again for the third and fourth time that there is a deterioration in the house with the patients this work 2011 has systematically examined it again and I have only seen this for the services especially there the temple above and the Temple below where the nerve fibers are a thick layer Preferably , it goes down with the bells so it also seems to have something to do with fiber layer atrophy so the artifacts associated with deacon is a microcystic expansion of the internal clock layer which can also occur with other degeneratives recognized, one has to clarify the background of the effect look at already advanced temptations a grabbing action creates a pseudo-manufacture and on t all the on instead of in a layer of nerve fibers or space can mimic a thickening of the diseased tissue although it does represent a deterioration to which we arrive at influencing factors or artifacts not associated with glaucoma, that is, when we take a picture of mi apostolos netherlands we see very clearly the formation of gas shells in the body and a traction of the vitreous body on the regional nerve fiber that the retina is literally lifted up here very well compared to lightning and the aurora borealis in the far north because it's very similar there seem to be very clear moments where our segmentation is no longer successful where process tracking no longer works here either I can tilt this image if the result is better in a year or I just have to throw out the analysis of nerve fiber as requested before a still pohl posted in the spoils me the full analysis of course i can correct everything layer by layer which would be artificial and , above all, the next time in the observation process, the computer does not say anything about it in the same error, I leave the publication in the survey analysis and take other variants for evaluation because here the vitreous body is natural the great enemy from the ocde analysis these effects this is also shown here in 2014 work by assani and colleagues is not uncommon and these artifacts, as also shown here, occurred with the authors in 15 to 36 percent of the recordings not very rare and that's why you should always pay attention to it and then judge if the image is of good quality or if I have to use another variable even with tilted scenes.
The question probably arose here as well. one that we don't find grotesque april open in the naked world cup opening game here is of course the measurement in einigu He called Silva from the industry membrane and I can just measure the retinal tissue here and not only slowly or the nerve fiber layer and here of course I artificially like this measurement as too thick and that is also called major popular which here is measured especially in the temporal lobe. terrifying april and possibly wanting to hide something in the future in the course of a slimming, of course, her tissue is also measured, which does not change her additional biological papillae are a challenge for optical advice, especially the comparison with normal copulation that there just aren't that many high quality articles being hosted that's why there is also an initiative backed by the heidelberg engine, a consortium to create a standard database for millions of peter pilz and also to improve the logical bell tracking of the glaucoma. shaped papillae we see that through the lining of the angular body temporarily the inclined sina club meets in the high w ie open eye, the maxima have temporarily turned outward and leave a huge working area and a fee representation of artificial sectors that are archaeological, although the paper represents a normal European table tested Kartik was consumed and must be prepared forthe european here a few cents with folk locomotive i see very very large poplars 60 square millimeters at least here a vessel cover that indicates a notch to me the corresponding positive absorption in a nerve fiber layer unfortunately in these patients due to the homeopathy area where it is not must eat used and also in markkula area i have a religious app that spoils any long term analysis for me and i go back to my good old face just to observe patients in calw i show you a 50 year old patient from our registry with melanie installation version of premium service suspected of open glaucoma he s for years we have been observing the interocular pressure always between 10 16 - 18 it helps that it is the oblique loop papers of this right eye we see here in the mlb analysis the book already open the membrane had to be manually reset here this is often the case with paper logic that needs to be done but in the normal range and we can see er in the thickness of the layer of nerve fibers that the maximum speed is correct what we have here a bunch of red scrolls in the Greek representation in which not at all my referee stupidly with the patient where he would have said well that the paper actually looks normal but here a local gang inzell correct loss also regional markets the thickness of the fiber layer seems to show a thinning of the vowels here we should look at everything again carefully and i have to look at the infrared image it is on run one that doesn't overshadow it actually here a cup effects regional shot phase layer has that patients should continue to monitor themselves petri in that case it doesn't help me much because the patient is paying www connect below range but only from final values from the target forward with no complications in the course the patient does not show any deterioration in his field of vision, either to the right or on the left, and the thickness of the nerve fiber layer actually decreases over the course of, well, slowly over many years, from age 39 to 50, so sneaking up on it is the nerve fiber layer that is just wrote about minutes it's not glaucoma either so mosquitoes are extremely hard here at and that's why the rule here is if I can't keep up with you I have to go back to facial skin analysis and especially progression analysis on the field of vision, as well as with my other parameters, so the therapy must be further intensified to evaluate the patient, we had the topic before that the opening of the membrane of children is not the area of the papilla that is clinically see how union is not always the opening of the ramus membrane see here an example of the work of look here it is shown in green what you would judge clinically as papa country and in red what the device as a ruptur to ever park the Boys, it was a transparent GWB that they could not see clinically for the best of will and in this work they compared how the area of poplars really differs clinically measured in green measured since the opening of the university railway in roth which dieburg voted here on the x- axis was open in the area plotted here the difference between the area of the paper and the book the apparent open days divided by the increase in open time if it were one to one that here is a line but it is not we see that with small packages we with large packages there is a discrepancy between the two values it is probably the critical rating for small items ilung a little larger than the children's mark, judge something and in the Eurovision papillae with letters caps opening, it's more of the reverse that the children's opening is larger than what we'd see as an attractive border, so there's a clear discrepancy, not h ouch Membrane opening for children either standard rating knowledge just with us on a record it's 1.9 and I think in the big database it's stored in pagewizz 1.78 square millimeters but up, down, the two first, the standard deviation there are no values.
It's interesting that the colleges at the hospital are always like this high lights which I've always been interested in and the pigments that you pipet the one is much thicker it looks a lot smaller and looks like fertilizer this is probably because the colleges just have a different density like a plywood board because they are flat and ordered of different fabrics in electron microscopy and that is probably highly effective that only this width of structure looks like it is happy but the opening of the orbit of the breakpoints can help us to interpret the images here here you have a small university calculation of 1.4 here a size of 2.9 squares with antifa many photos here again that infrared image of the small chapel and the large one we see that we are here in the small chapel on the upper edge of the minimum backpack both measures are the new population and in the very large the papers slide to the bottom edge Above this has a very simple reason that the nerve fibers in the opening of the small pills present and accumulate a bit stuttered than in the large opening, the large fragments of the image simply offer a larger circle where the nerve fibers can spread out. better or, let's say, they can be distributed thinner and therefore of course many correspondingly thinner measured ads and which of course in a borderline situation can cause the opening of the membrane of the university, so the rantzau-breitburg spanish measure slides relatively quickly into suspect area while nerve fiber layer still shows relatively good jobs again to influence segmentation we saw segmentation had to be improved in 84 percent of bmw world, especially with us in patients with small bundles and the nerves actually need to be improved less frequently to to play with the kaizen percentage selection, especially the vitreous body, the old nerve fiber layer thickness, so always look at segmentation in the bible, we see a patient here who has a visual field but no luck we'll see we look at the measured values we see here on the bmw the patient is a bit suspiciously temporary in the sectors the other sectors you can see on the left are actually normal and we see in the rational nerve fiber ski equipment multiplies the speed of 35mm for a significant gain of almost 90% patients thats something we almost never see in loccum because its playing the temple of music up and down just tie the paper around the battery indicator a disease its not dead multiple sclerosis and if i have such a discrepancy between the gross number and the nerve fiber layer and especially with temporary emphasis, i have to think about this disease in libya march it is quite clear that t All the cape goes around in circles, it's not just in a corner up or down, so it's not just a squirrel, but it forms a pretty nationally known circle. a right one in our patients with multiple sclerosis and also shows an expansion of the history of the internal clock somewhat typical of this disease o.ct and in patients with progression it is more pronounced and this phenomenon with red with the red cross a thick card in the history as a position is also called apple ipad and then it should definitely not always be necessary to multiply a neurological cause think about fluff adenomas and other diseases that affect the seaway can trigger this phenomenon but if I have this constellation I still have to clarify the patient neurologically and especially with a skull image of this patient has a pseudo a few pills with him a small hood and a thickening witness to everything we see, but the inclined viewer immediately sees the cans in this hood in the elegant form of auto-fluorescence very beautifully presented of course also with contact in the trial case but woe is me the hsp kahles got rid of the cars, decided on the roses because these cans are also presented here at the bvb as cavities and lead to an artificial production of our bioenergy measurement in the nerve fiber layer. the patient shows a clear for the rational the very advanced ship in the area due to the complicated g Larger profiles along the descendants of the patient make the office area small 1.7 square millimeters after a relatively small pattern and this is a typical pattern for complicated cruisers a thickening of the bmw above normal but clear for the nerve fiber layer and that is a constellation where we have to think of a paper with the thickness of the nerve fiber layer thinning a large model to follow that also makes a parallelism also makes mine do too but also druse and here we see the direction maps my favorites we see the foot walked here cells have fallen according to some lower heidfeld pattern here as our time is falling too facial skin breaks are a bit chaotic with these patients even if i see something like that i have to think of something like a big hood but if tom or my hotel port then i see the facial skin glitches match nicely click the cells on the corridors cells map here just came out accordingly i patched it all again and then the corridor production on the cells is very compatible here with the field of view glitch at the top here also the dilution with the glitch at the bottom doesn't always go one to one with it you can also see here a more than normal loss of www diffuse nfl with a chaotic music tent you also have to go to the big band and know that now we have talked a lot about the diagnosis I will coincide again with the artifacts that have not been associated influencing factors we have the change once it is the green interface neuropathies enjoy in addition to glaucoma the anatomy db immo plays a role homoki with gifts entrance the attractiveness the roles area plays a role bm area around the segment action plays a role so we can divi dir these complete changes in three groups in three days pathologies other than vacuum made with the original area or from the office often in the logical area anatomical influencing factors or simply the software determines that the segment is a problem and therefore, I keep going back to the picture I get to the last 15 minutes which is therapy and we have Allergan on board who does the cement and the stent is a very good example of minimally invasive surgery that would like to correspond to a little more than the säntis if we look igs wetter.com therapy guidelines we will always start almost all patients on local therapy with monotherapy first and then see if we are successful or not because spikes are not tolerated or intraocular pressure is cut off let's try a second single second substance before it is enough for a double or triple therapy and here you can, of course, even if you do not reach the goals achieved after the double therapy already your thought if one in times stoffau exchange, but that is usually not so easy because of compatibility, especially not more patients who come to us because they are already from the midfield, then it is usually mainly about geology or laser therapy, there are many factors that influence me if you think about therapy which is of course the side effects.
Can my patient take it? He doesn't he? In Nepal, it is a big problem. they are mostly very high of course life could play a role and of course preservatives that are colored in the long term are not well tolerated in a long term therapy and that of course always makes me wonder if I would not then also be able to use a mild but surgical therapy and the relatively mild one in comparison. Economic therapy is a minimally invasive surgery. No doubt you've heard a lot from other speakers and I'd like to focus on the many possibilities out there today as I said of 10 gs because this state will be about a patient from tempo to medial through the chapter works optimally is a master amongst the t9 and this tube is pushed into the skin inside which has a lumen of 145 million this holder has a length of six millimeters and is immediately in contact with the liquid the collected set are soft and then always want these typical times in the ultrasound and then we see the outer end of the lasalle sales team up here yellowish lying down we picture your flat filter pad of you support this or pad that prix operational something like this could with 10 1 there one try here in any case do not open the conjunctiva because here the tub as the rudder should not be injured should not be too much of the cushion leaving scars the results actually we have a very good printed material this it is a very up-to-date information that has been sent by christa more time with us at home with her uppe working group examined her patients to see if melanie returned to snow version and lakomy text and in the course of booking after booking noticed quite a bit of pressure on the effect of the pressure reduction in the middle works, whether it was just a dime or a window Combined with the question of what goes very well, we see here that the effect of the scythe alone is not a little greater than in combination, but in percentage terms, both
therapies still give us pretty decent pressure drops at 170 percent were withoutantibiotics after two years of therapy and drug consumption decreased from 27 to 0.6 after two years, however, 50 percent of patients required low and intensified surgical follow-up if we compare the results of another work with migros time fits me that the postoperative eto'o co boost pressure with the window still at its lowest point and in this very nice work mainz that only compared the fans because the therapy collects how in a very large and pleasant population the authors they saw that after six months after 12 months after six and twelve months with santos in blue and ti in green a similarly large reduction in pressure was achieved has with the addition of drops here has completely no drops here we see we still achieved a slightly greater pressure reduction with the t than with the window shown here again by the authors over the course of six green months and one gray or beige year with 10 cents and ti v We em the middle of leverage a little bigger here t but the authors found in both groups that never had to go in and mentoring with sony as well as 1 end state and that takes the sensler out of the field of minimally invasive surgery a bit i hadn't than to be attended to as intensely as a phil jackson as a bystander after tea and also hypertension occurs pah we have already experienced everything full cam quote we have all experienced skin tightening up to chris collins post sandstedt things that happen a little more often , but here are not uncommon what arose between the pure mixing procedures under t that classifies the spectrum of complications but also of course in the spectrum of effects and here we see again that such a window is shown with the officiant in the longitudinal scan course of the wizard until it is useful you need a little patience you can also use a transall science pnas we see e l stent lying here and to the left and to the right the ceiling cushions again and with such a radiant scan it is easier to find your way to the equipment in everything that is presented here and here is already the resulting filter pad longitudinally a tencent effective with the filter pad similar to atheist loosening and retained is our resistance is the shadow go everything according to how with ultrasound and here we see the flowers in the optional space lie gene as an example a city of 82 with collection syndrome she got a ten when he had 45 cents he dealt with innovative myth 03 see standard and but he also traded five times with avastin like five and we see that this patient is already in an advanced stage partner with after a long history we see here the first day lying in the ral flavor and sub zonal we see the lumen and the smallest one you can see the water forming from here after three days they were still here for me now we are something ongoing in z shape in the middle subaltern poles and after 28 days it's probably a bit common says the location we want to see on the stent still lying here the pressure is however eight mm ag optimal no signs of hypotension we actually see recordings even if we don't Now we show a lot of clearly prominent pillows before, but we have a very extensive knowledge of what is very flat, but here it is clear. as you can see in a long column with the study and that is probably also the reason why the zoom left and right of the trick that is full of carlotta is also here because the pressure is so low because the aqueous humor is not only likely to leak at the same level, the eye to the left and right of the stands also pretty much passes it, so it was very important to observe more and observe on the field the progress of these small winning teams.
It has been seen that the degree of effectiveness of the equipment gives a lot of information on whether we are right or not and also the degree of satisfaction shown can give information on whether everything goes well or not, as we do in the s palt lamp, microcysts can be seen high reflected cysts were like petre kisten already shown can give info very soon before pressure rises if i need more intensive aftercare with avastin or five in the future probably can also o.ct hertake which showed a work from italy with a working Sandys because the south axis when it's not working stan gestures as you can see we have significantly less vascular networks here than with the fan called ngs similar to lte who knows we know who all the work of 40 to go to this topic and here I also need the micro cyst for the function here we see the zoom of its state and here the high affinity of the subject and the many shots that only say very clearly here it cannot function ion if we go back to ours also for an initial graph of the therapy scheme because here the question of the three-year distributor can start here with 1 mg it is an extra-clinical experience that I do not dare to do yet because the risk profile does not say that the end it is as it is but there is just something behind it and i would really use all ten it happened with patients where i don't want the c but i don't want to achieve it with the best will in the world with a laser or i don't have it or i can't achieve it with drug therapy there is a good alternative to filtering surgery, so we put the business status of the cell, as such data model has always looked pretty good and successful, and the future will show if it can really be patient profiled where you can say yes, otherwise you're your typical penny-faced patient. o and the sign are available for your questions thank you very much mr professor martin for this great lecture the many case studies and the grand finale with the therapies before moving on to the question and answer session we will continue with the quiz and after chris we will do the last questions yes everyone can see the first one now The question is already displayed on your computer and I will read the question to you once so in principle with document thick reductions in the nfl and bmw m rw shaped of regular pill, temporarily more pronounced nasally up and down more nasal and temporarily more pronounced temporarily up and down in the most pronounced ones are allowed to mark a few things that they think are correct and then in a few seconds it goes to the next question and before that to the table with us shows how they answered, how big is the percentages are there we see it more when we have them last answer option answered mr martin have you never been there live what do you say i'm there i don't feel so sleepy anymore and his colleague knows that next to the temple up and down that's the area where glaucoma strikes and they all saw that correctly very good ok ok so to the next question, rantzau's minimum width is suitable for detection. nerve fiber bundle very narrow defective differentiation of comatose blue and non-comatose blue optic atrophy for the only follow-up control with bells for the detection of paper on bleeding you can vote again yes here we also see the answer yes it meant of course the first question about the effects of narrow nerve fiber bundles which of course with the enev and in a circle like to reflect better than of course with the mrb and therefore the second answer is simply the correct answer question number three ipad purple denotes a cmv in the eta a sectorial loss of retina nerve fiber layer balconies loss of right gcl in the web division acceptance of the pavilion in see r working with volume knowing that the herbalife meters practically reached the end of their presentation such Maybe that will be a little help so we can see how you voted you are satisfied and very kind I am very happy it was a long presentation def initiatively you also had a very long day and that's why i'm glad this fair has arrived because that's really a very clear sign of a neurological akram point. only nfl's are pathologically gcl and pathologically remembered which actually has to do with körbel's syndrome and that's exactly how the show has it very well because with multiple sclerosis we see the temporal nerve fiber send sector people that initially they had no gcl and bioenergy a lot to do to report this disease and this discrepancy it can only help to think about it otherwise life is short in comment my compliment it works so well with voting i have to say respect thank you question number 5 and I also refer to the last question which statement applies to drusen papillae diagnosis with car florence they are harmless and do not impede seeing the vision maps play for diagnosis has no role visual field failures are similar to those of the comatose atrophy yes and here too the answer is very clear so it's great to hear that the audience turns 80 again tonight the res correct setting that we really want with 160 participants that is really a very good result of course as many have voted but the question is all day is from these patients an example of the car for sensix non-invasive and without kitsch to discover that cans is not harmless , especially as you get older and harmless deviation maps show that the ganglion cells are lost in a very diffuse way and how time except naturally different to atrophy glaucoma They can be very diffuse chaotic and therefore the first question is answered completely correctly.
Thank you. Ok, so we want to continue with the questions. the first question i would like to ask mr. dr. professor martin the three nfl circles often show different results on which one is the best is the most relevant that is absolutely correct especially with the bottom of the eyes what tissues don't plan on laying down but with cabinets Poplars for For example, they can give different lives due to the atrophy of the paper, there are differences, there are two cans with wide pants, and it has also been seen that the 3.5 millimeters that circulate are the most significant, but I have a strange anomaly, then small poplars, big eg ready where many have said i just have to switch to one or the other mesz circle of r gives me more information than the standard 5mm circle keeps 3.5mm means its the most sensitive of which is you are getting acquainted with the next one ok thank you very much then it goes to the subject of oceanography here is the question of what exactly is patients with angiography or ct measured in oceanography with the heidelber apparatus g you can see three layers in lick the retina in the market area this is the superficial layer the intermediate layer and the deep layer and it is precisely in the superficial intermediate layer that there is a loss of capital density that is if that almost shows this real kabila is going down was of course also the tissue is thinning and in the pub in the area you can also see a disappearance of the capella pieces in the surface layer very well along with the victims in terms of CT scans because probably here structure and care go hand in hand. then you see the consolidated and the cigarette becomes infected with glaucoma but it is also the case with all other opticians advofin which is not typical of glaucoma but the place where it happens is typical of glaucoma ok another question relates to implant therapy how does xen therapy continue in the oecd and how does this affect glaucoma o.ct that patients after a successful 10 ch lowered right now there may well be a change for the first time bmw heiress also the rational papers first layer depending on how high the intraocular pressure was we have seen patients with more than 30mm pressure first saw an increase in nerve fiber layer thickness as well as bmw among those with high pressure after the pressure reduction came back to go through this thickness for the first time, which sounds paradoxical, it is not because it is probably at a very high pressure, your sailors will change the tissue first if under intraocular pressure again everything changes again and works, first of all, the story goes back and I want to achieve in the long term, then, beyond the perioperative stage, that the patient with whom he stabilizes is important and then he only loses as much after the father as a normal ok two more questions about the end of a program in one to andreas kasper one last prose martin as it should in the minimum or maximum exam distances of the osce bells to evaluate the course that is a good question because he searches more often for my statistics are so much more stable only that is compatible with the daily life of the patient in our clinical or daily practice because there is simply not enough time, but when I see the patient for the first time, we usually ask him again after half a year and then see him every year if we treat the patient surgically, of course, then before and after the operation and at correspondingly short intervals, something like what happens with the field of view because a frequent measurement also with computed tomography gives a statistically more reliable course reliable course of course it must also make patients practicable that's our problem if everything is so far then it took half a year for the second control and then the annual checks that actually should for a stable observation are enough, okay,very good answer thank you very much for that and the last question to andreas is about the butte report is the hotspot available in current software and maybe the next question is how do i get this report yes in current software it should be available These questions always come up.
I would just ask Dr. Becker if it doesn't work to get back in touch with her but I just checked baydemir and the software is now working. so it looks like it is a car and on the other hand it has picked up the mail that means I have selected both fairs right click then print field and then I get a relatively long list of the variant of impression I have and so I want him to be able to use the money here, maybe he could also click his screen or go with the screen until just before today's show, now I have the beginning here.
Well, that's the poplar measure I mark along with the public right-click postal collection measure of the additional window via print. I come to the perspective that it is not about you and then I only have a rock report oma or also German that The The only thing in the program that is in German is the summary of the reservations and then I can take a look at the premiere and the view would finally be what we have already seen at the end, and on the one hand we have integrated the thick card and then also the shunt scart as we have it on the left side only once the minimum pension analyzes worked mr nfl and then we have here only once the thick map of the nerve fibers gender band go cell layer and only stepped on that is the visual field adapts to the nerve fiber highlights the deviations with the twelve points and the same analogous to the realistic gang if we have ten degrees for the hangover and 24 degrees tot ichtsfeld after hst degree exactly in general yes now 24 in the experienced ducks thank you super thank you andreas could you show that directly in the software i see that the 157 participate Before you really held to the end thank you very much for that I think we do it now well and we can all leave by the end of the day thank you commissioner martin and andreas willing excellent driving lectures and also for answering the questions and I wish you all a good rest of the evening and maybe we will see each other again soon for a new webinar and the last words maybe for the professor dr years one more time from you the farewell yes thank you very much before i will be happy to do this professor martin thank you very much for your lecture I I liked it very much yes also ladies and gentlemen for your participation and it is always very good when you see that everyone stayed with us until the end and that the Christian also participated, so to s Have a good night, then everyone and yes we will cook for me side until next time, thank you see you again too, you are doing well.
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