97 example, it is known that patients with diabetes exhibit a more length-dependent variant of SFN, while SFN in patients with immune-mediated disease tends to present in a more patchy, non-length dependent pattern.24 The prevalence of ocular involvement in sarcoidosis ranges between 10-50%, with a higher prevalence reported in African-Americans and women.25 Ocular sarcoidosis could cause keratoconjunctivitis sicca which then results in superficial punctate keratitis or band keratopathy, which in turn can affect the Bowman’s epithelial layer.26 In addition, uveitis can result in glaucoma, which can also contribute to decreased CNFD.27 The aim of the current study is threefold: First, to investigate whether CCM results differ between sarcoidosis patients with and without SFN. Secondly, to determine the correlation of CNFL calculated with manual analysis (CCMetrics18), semi-automatic analysis (NeuronJ19) and fully automatic analysis (ACCMetrics20), and the correlation of NFA calculated with NFA FIJI21 and ACCMetrics in patients with sarcoidosis. Finally, the potential value of automatic NFA analysis in diagnosing SFN will be evaluated. Methods Design This was a prospective, cross-sectional observational study. Sarcoidosis patients with and without clinical symptoms of SFN between 18-75 years were included between January 2021 and September 2022. In addition, colleagues and partners of sarcoidosis patients were included as healthy controls. The diagnosis of sarcoidosis was made based on the official American Thoracic Society clinical practice guideline.1 Exclusion criteria were: established polyneuropathy, diseases associated with (poly)neuropathy, other diseases with a risk of developing (poly)neuropathy, neurologic diseases affecting sensory nerve function, language difficulties, cognitive failure, glaucoma, corneal dystrophy, cornea infection, previous corneal surgery, contact lenses use, pregnancy and excessive alcohol consumption. Blood was tested for serum levels of glucose, Creatine Kinase (muscle damage) and vitamin B12 in addition to all known parameters used to diagnose sarcoidosis. The study was conducted according to the Declaration of Helsinki and GCP guidelines. All participants provided informed consent for study number R19.080 prior to the start of the analysis. Ophthalmologic assessment The eye condition of participants was assessed by the ophthalmologist. General eye condition, glaucoma, keratoconus and uveitis were evaluated based on visual acuity, best corrected visual acuity, slit lamp examination, and funduscopy. The grade of the anterior chamber angle of the eye was determined using the Van Herrick technique. Assessment of neuropathy A diagnosis of SFN was based on the Besta criteria5 except of skin biopsy. All participants underwent a detailed assessment of neuropathy by a neurologist. Participants were asked to report any type of annoying spontaneous or evoked pain sensations. Extensive neurological physical examination was used to test for clinical signs of SFN. Participants completed the small fiber neuropathy screening list (SFNSL)28 to quantify somatic and autonomic symptoms. The SFNSL can be divided in 2 parts: part I (8 questions) assesses the frequency of complaints and part II (13 questions) assesses the severity of the complaints. The response scale ranged from 0-4 per item and a total number of 84 points was the maximum. SFNSL < 11 was defined as “no SFN”, SFNSL 11-48 was defined as “possible SFN” and SFNSL > 48 was defined as “definite SFN”.28 6 102 6
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