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To compare the efficacy and safety of ultrathin Descemet stripping (automated) endothelial keratoplasty (UT-DS(A)EK) versus Descemet membrane endothelial keratoplasty (DMEK) for the treatment of Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK).Systematic review and meta-analysis.Literature containing DMEK and UT-DSAEK were searched in the Cochrane Database of Systematic Reviews, PubMed, EMBASE, LILACS, and through manual reference searching. Studies were included that measured the outcome of interventions-including best corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications, especially graft detachment with the need of re-bubbling, graft rejection, graft failure, and postoperative elevated intraocular pressure (IOP)-in patients with FED and BK. Included outcomes were pooled as standardized mean differences (SMD) or risk ratios (RR) using random effects models. Inter-study heterogeneity was assessed using the Q-test and ISeven (of 163) studies met all the inclusion and exclusion criteria. Meta-analysis showed a significantly better BCVA 12 months postoperatively, but an increased re-bubbling rate in eyes after DMEK compared with eyes after UT-DS(A)EK (BCVA: SMD = 0.50 [95% CI 0.27-0.74] and re-bubbling rate: RR = 0.33 [95% CI 0.16-0.67]). All other parameters did not differ significantly between both interventions, although estimates were imprecise (graft failure: RR = 0.65 [95% CI 0.18-2.30], graft rejection: RR = 1.40 [95% CI 0.27-7.30], and postoperative intraocular pressure elevation: RR = 1.14 [95% CI 0.60-2.18]). Postoperative SMDs of ECD could not be evaluated due to significant heterogeneity between studies.Although the improvement in BCVA was higher after UT-DS(A)EK than after conventional DS(A)EK, the BCVA after DMEK was still superior. The complication rates were comparable for both procedures, except for the higher rate of re-bubbling after DMEK.

Purpose To evaluate the outcome of Descemet Membrane Endothelial Keratoplasty (DMEK) in eyes with pre-existing glaucoma. Design In this retrospective, observational case series we included data of 150 consecutive DMEKs in eyes with pre-existing glaucoma of 150 patients after excluding data of the second treated eye of each patient and of re-DMEKs during follow-up. Cumulative incidences of IOP elevation (IOP > 21 mmHg or ≥ 10 mmHg increase in IOP from preoperative value), post-DMEK glaucoma (need of an additional intervention due to worsening of the IOP), graft rejection, and graft failure rate were analyzed using Kaplan–Meier survival analysis. COX regression analysis was used to evaluate independent risk factors. Results The 36-month cumulative incidence of IOP elevation was 53.5% [95 CI 43.5–63.5%] and of post-DMEK glaucoma 36.3% [95 CI 26.3–46.3%]. Graft rejection occurred with a 36-month cumulative incidence of 9.2% [CI 95% 2.3–16.1]. None of the analyzed risk factors increased the risk for the development of graft rejection. The 36-month cumulative incidence of graft failure was 16.6% [CI 95% 8.4–24.8]. Independent risk factors for graft failure were the indication for DMEK “status after graft failure” (n = 16) compared to Fuchs’ dystrophy (n = 74) (p = 0.045, HR 8.511 [CI 95% 1.054–68.756]) and pre-existing filtrating surgery via glaucoma drainage device (GDD) (n = 10) compared to no surgery/iridectomy (n = 109) (p = 0.014, HR 6.273 [CI 95% 1.456–27.031]). Conclusion The risks of postoperative complications (IOP elevation, post-DMEK glaucoma, graft rejection, and graft failure) in patients with pre-existing glaucoma are high. In particular, pre-existing filtrating surgery via GDD implantation—but not trabeculectomy—and DMEK after graft failure increase the risk of graft failure.

Introduction To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice. Methods A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95–105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome®, NeoMedix, Tustin, USA), and 130 patients received iStent inject® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan–Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy). Results In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p

PURPOSE To study the change in contrast sensitivities in eyes with Fuchs endothelial dystrophy and bullous keratopathy after Descemet membrane endothelial keratoplasty (DMEK). METHODS In this prospective study, 50 pseudophakic eyes of 50 patients who received DMEK surgery at the Charite-Universitatsmedizin Berlin were included. Visual acuity; contrast sensitivity using OPTEC 6500 at spatial frequencies of 1.5, 3, 6, 12, and 18 cycles/degree in photopic and mesopic light with and without glare; central corneal thickness (CCT); and anterior and posterior corneal aberrations were measured preoperatively and at 3 and 12 months postoperatively. RESULTS Best-corrected visual acuity (preoperative 0.67 ± 0.46 and after 12 months 0.19 ± 0.16 LogMAR, P < 0.001) and photopic and mesopic contrast sensitivities with and without glare improved significantly, whereas CCT decreased significantly (preoperative 677 ± 114 μm, after 12 months 527 ± 29 μm, P < 0.001). Preoperative CCT correlates significantly with preoperative photopic contrast sensitivity (correlation coefficient -0.462, P = 0.002), and postoperative total anterior aberrations correlates with postoperative photopic contrast sensitivity (correlation coefficient -0.361, P = 0.006). CONCLUSIONS Photopic and mesopic contrast sensitivities, especially with glare, are impaired in patients with Fuchs endothelial dystrophy and bullous keratopathy. The extent of the corneal thickening seems to mainly influence the contrast sensitivity preoperatively. DMEK surgery improves the contrast sensitivity significantly. However, higher postoperative anterior corneal aberrations limit the postoperative contrast sensitivities.

Purpose/Aim of the study: Graft detachment after DMEK can be treated easily with an additional air injection – re-bubbling. The aim of our study was to investigate the effect of a re-bubbling on th...

Unfolding and attachment of the posterior donor lamella may be the most challenging part in Descemet membrane endothelial keratoplasty (DMEK) procedure. We investigated the correlation of the difficulty degrees of this step to the postoperative clinical outcome 6 years after surgery. One hundred sixty-nine consecutive DMEKs between September 2012 and August 2013 at the Charite–University Medicine Berlin were graded prospectively into 4 groups according to their grade of difficulty in unfolding and attachment of the graft lamella. Postoperative visual acuity, endothelial cell density, and rate of graft failure were measured after 1 year, after 2 years, and after 6 years and analyzed according to their grading group. Visual acuity improved significantly in all groups and did not differ significantly between the grading groups at any time point postoperatively. There was a significant decrease of endothelial cell density in all groups with a significantly higher endothelial cell loss in group IV compared with the other groups within the first 24 months after surgery. The graft failure rate was significantly higher in eyes graded III and IV than in groups I and II (p = 0.012). Although the endothelial cell loss and the graft failure rate increase significantly with a more difficult graft unfolding and attachment, DMEK surgery is a promising procedure with a good long-term postoperative outcome. A direct manipulation of the graft lamella for unfolding and centering by cannula or forceps should be avoided if possible to reduce the risk of an increased endothelial cell loss and a higher graft failure rate. NCT02020044

Carbohydrate-specific antibodies can serve as valuable tools to monitor alterations in the extracellular matrix resulting from pathologies. Here, the keratan sulfate-specific monoclonal antibody MZ15 was characterized in more detail by immunofluorescence microscopy as well as laser ablation ICP-MS using tissue cryosections and paraffin-embedded samples. Pretreatment with keratanase II prevented staining of samples and therefore demonstrated efficient enzymatic keratan sulfate degradation. Random fluorescent labeling and site-directed introduction of a metal cage into MZ15 were successful and allowed for a highly sensitive detection of the keratan sulfate landscape in the corneal stroma from rats and human tissue.

Purpose To compare the blood flow situation in primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG) using optical coherence tomography angiography (OCTA). Methods In this prospective study a total of 26 POAG and 23 PXG eyes were included. All patients underwent a complete ophthalmological examination including standard automated perimetry, stereoscopic photographs of the optic disc, peripapillary retinal nerve fibre layer analysis and examination of vascular parameters of the optic nerve head (ONH), the peripapillary region and macula using OCTA. In addition to the vascular parameters recorded by the device, the vascular images were graphically evaluated using Image J. All recorded vascular parameters were compared between both groups and correlated to structural and functional parameters. Results The mean superficial perifoveal plexus perfusion density (PD) was significantly lower in PXG eyes than compared to POAG eyes using OCTA (32.57% ± 3.57% vs. 34.92% ± 2.11%, p = 0.007). The mean PD parameters for the superficial peripapillary plexus (40.98% ± 3.04% vs. 42.09% ± 2.29%, p = 0.152) as well as the size of the foveal avascular zone (FAZ) (0.23 mm2 ± 0.1 mm2 vs. 0.23 mm2 ± 0.09 mm2) did not differ between both groups. Additional graphic evaluation using Image J showed no significant difference for superficial perifoveal plexus PD (32.97% ± 1.11% vs. 33.35% ± 0.95%, p = 0.194) and peripapillary plexus PD (46.65% ± 0.83% vs. 46.95% ± 0.5%, p = 0.127) between the groups. Retinal nerve fibre layer (RNFL) thickness correlated significantly with peripapillary plexus PD for both OCTA data and Image J data (p p = 0.032). Conclusion The severity of the glaucoma seems to be crucial for peripapillary and macular perfusion densities, and not the form of glaucoma. An additional graphic evaluation is a possible step that could be implemented to improve the comparability of OCTA scans and to optimize the possibility of quantitative perfusion analysis in the case of deviating quality criteria.

Penetrating keratoplasty (PK) gets more and more reserved to cases of increasing complexity. In such cases, ocular comorbidities may limit graft survival following PK. A major cause for graft failure is endothelial graft rejection. Suture removal is a known risk factor for graft rejection. Nevertheless, there is no evidence-based regimen for rejection prophylaxis following suture removal. Therefore, a survey of rejection prophylaxis was conducted at 7 German keratoplasty centres.The aim of the study was documentation of the variability of medicinal aftercare following suture removal in Germany.Seven German keratoplasty centres with the highest numbers for PK were selected. The centres were sent a survey consisting of half-open questions. The centres performed a mean of 140 PK in 2018. The return rate was 100%. The findings were tabulated.All centres perform a double-running cross-stitch suture for standard PK, as well as a treatment for rejection prophylaxis with topical steroids after suture removal. There are differences in intensity (1 - 5 times daily) and tapering (2 - 20 weeks) of the topical steroids following suture removal. Two centres additionally use systemic steroids for a few days.Rejection prophylaxis following PK is currently poorly standardised and not evidence-based. All included centres perform medical aftercare following suture removal. It is assumed that different treatment strategies show different cost-benefit ratios. In the face of the diversity, a systematic analysis is required to develop an optimised regimen for all patients.Heutzutage bleibt die perforierende Keratoplastik (pKP) immer komplizierteren Ausgangssituationen vorbehalten. Die Komorbiditäten bergen oft Risiken, welche die Überlebensrate der perforierend operierten Transplantate limitieren. Die häufigste Ursache für das Versagen eines Hornhauttransplantates ist die endotheliale Immunreaktion. Die Fadenentfernung nach pKP ist als Risikofaktor für eine Abstoßung bekannt. Dennoch existiert keine evidenzbasierte Empfehlung zur Prophylaxe der Abstoßung im Rahmen der Fadenentfernung. Daher wurde eine Umfrage an 7 deutschen Keratoplastikzentren zu diesem Thema durchgeführt.Ziel der Studie ist die Dokumentation der Variabilität der medikamentösen Nachsorge nach Fadenentfernung in Deutschland.Aus dem Deutschen Keratoplastikregister wurden die 7 Zentren mit den größten Operationszahlen für perforierende Eingriffe ausgewählt und mit einem halboffenen Fragebogen angeschrieben. Die Zentren hatten in 2018 durchschnittlich jeweils 140 pKP durchgeführt. Der Rücklauf betrug 100%. Zur deskriptiven Auswertung wurde eine Tabelle erstellt.Alle Zentren wenden im Standardfall die doppelt fortlaufende Kreuzstichnaht nach Hoffmann an und führen eine Abstoßungsprophylaxe mit topischen Steroiden nach Fadenentfernung durch. Unterschiede zeigen sich hinsichtlich der Intensität (1 – 5 × tgl.) und Ausschleichdauer (2 – 20 Wochen) der topischen Steroidtherapie nach Fadenentfernung. Zwei Zentren wenden zusätzlich kurzfristig systemisches Steroid an.Die Nachbehandlung der Fadenentfernung nach pKP ist aktuell wenig standardisiert und nicht evidenzbasiert. Alle befragten Zentren indizieren eine medikamentöse Nachbehandlung nach Fadenentfernung. Es ist davon auszugehen, dass die jeweiligen Regimes unterschiedlich günstige Kosten-Nutzen-Eigenschaften aufweisen. Angesichts der Diversität ist eine systematische Untersuchung der Ergebnisse angezeigt, um ein optimiertes Schema für alle Patienten zu entwickeln.

Introduction: In instances where peribulbar anaesthesia (PBA) cannot be used, Descemet membrane endothelial keratoplasty (DMEK) surgery can be performed under topical anaesthesia (TA). We evaluated subjective pain and post-operative outcomes of DMEK surgeries performed under PBA and TA. Methods: Sixty pseudophakic patients without history of ocular comorbidities underwent DMEK surgery under either PBA or TA. PBA was performed with a single injection of 6 mL Prilocaine Hydrochloride 2% in combination with 1500 I.U. hyaluronidase. For TA, patients were given 0.4% Oxybuprocaine eye drops followed by a 2% Lidocain Hydrochloride-Gel and an intraoperative injection of a 2% Lidocaine Hydrochloride solution into the anterior chamber. All surgeries were performed by the same surgeon. Subjective pain was measured using a visual analog scale (VAS). Secondary outcomes (BCVA, duration of surgery, endothelial density, rebubbling rate) were recorded during a follow-up period of 3 months. Results: The mean subjective pain of patients in the PBA group was 1.27 (95% CI 0.87–1.68) and 1.64 (95% CI 1.15–2.21) in the TA group. The mean duration of surgery was 402 s (95% CI 356–448) in the PBA group and 427 s (95% CI 371–483) in the TA group, p = 0.477. No major differences were observed in BCVA, endothelium density and rebubbling rate between the two groups. Anaesthesia-related side effects were more frequent in the PAB group than in the TA group. Conclusion: Although levels of subjective pain are lower under PBA than under TA, in selected patients without ocular comorbidities TA can achieve levels of pain acceptable for DMEK surgery.

PURPOSE Intraocular pressure (IOP) elevation occurs regularly after Descemet membrane endothelial keratoplasty (DMEK). This study evaluated the long-term incidence of IOP elevation and post-DMEK glaucoma after DMEK. METHODS A total of 463 consecutive DMEKs in 352 patients performed between September 2011 and September 2014 at the Universitatsmedizin-Charite Berlin were reviewed. Data of the second treated eye of each patient and of re-DMEKs during the follow-up were excluded. The 12- and 36-month incidence of IOP elevation and post-DMEK glaucoma was analyzed using the Kaplan-Meier survival analysis. IOP elevation was defined as IOP ≥22 mm Hg or ≥10 mm Hg from preoperative baseline. COX regression analysis was used to evaluate the risk factors for IOP elevation and the development of a post-DMEK glaucoma. RESULTS The 12-month incidence of IOP elevation was 15.9% [95 confidence interval (CI), 12.0%-19.8%] and that of post-DMEK glaucoma was 3.9% (95 CI, 1.7%-6.1%); the 36-month incidence was 18.8% (95 CI, 14.5%-23.1%) and that of post-DMEK glaucoma was 6.6% (95 CI, 3.7%-9.5%). The most frequent cause was steroid-induced IOP elevation with a 12-month incidence of 11.7% (95 CI, 8.2%-15.2%) and a 36-month incidence of 12.9% (95 CI, 9.2%-16.6%), respectively. The incidence of postoperative pupillary block IOP elevation was 7.5% (95 CI, 4.8%-10.2%). A preexisting glaucoma increased the risk of IOP elevation [P < 0.001, hazard ratio (HR) 3.331; 95% CI, 1.919-5.782] and the development of a post-DMEK glaucoma (P < 0.001, HR 6.633; 95% CI, 2.556-17.215). The preoperative diagnosis also influenced the risk of IOP elevation [Fuchs corneal dystrophy (FED) vs. bullous keratopathy; P = 0.012, HR 2.354; 95% CI, 1.203-4.608] and post-DMEK glaucoma (FED vs. graft failure; P = 0.01, HR 4.412; 95% CI, 1.419-13.723, FED vs. bullous keratopathy; P = 0.09, HR 2.679; 95% CI, 0.858-8.358). CONCLUSIONS Incidence of IOP elevation is high in the first 12 months after DMEK, especially steroid-induced IOP elevation. Steroid-induced IOP elevation could be treated effectively by tapering down the steroid medication or changing the steroid drug. A preexisting glaucoma and the preoperative diagnosis increase the risk for an IOP elevation and a post-DMEK glaucoma.

To investigate functional and anatomical results up to 12 months after Descemet's membrane endothelial keratoplasty (DMEK) for Fuchs' endothelial dystrophy (FED) versus bullous keratopathy (BK) in consideration of morphologic characteristics on host's endothelium-Descemet's membranes (EDM).In a prospective consecutive case series, 119 eyes underwent a primary DMEK for FED or BK. Intraoperatively obtained EDM were investigated immunohistologically. Clinical and morphological parameters were compared between FED and BK.Overall, the 12-months best-corrected visual acuity (BCVA) was 0.14 logMAR, and 0.10 logMAR in eyes without vision-limiting comorbidities; thereby no differences were revealed between eyes with FED and BK up to 12 months postoperative (p = 0.186 and p = 0.095, respectively). Correspondingly, the mean central corneal thickness (CCT) measured 520 vs. 529 µm and the mean endothelial cell density (ECD) was 1743 vs. 1457 cells/mmDMEK produces similar results for FED and BK. However, the postoperative course may differ with regard to the recurrence of secondary graft detachments that may be associated by histopathologic particularities.

To assess the long-term outcome of Trabectome surgery in the treatment of primary open angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEX): 3-year results. Trabectome surgery (NeoMedix, Tustin, CA, USA) was performed in 268 POAG patients (women 57.46%, men 42.54%, age 72.35 ± 9.63 years) and 98 PEX glaucoma patients (women 58.16%, men 41.84%, age 73.42 ± 8.54 years), and uncontrolled intraocular pressure (IOP). Parameters were examined preoperatively, 1 day, 6 weeks, 3, 6, 12, 24 and 36 months post surgery. Kaplan-Meier analysis was performed using Criteria A (IOP ≤ 21 mmHg or ≥20% reduction from preoperative IOP), Criteria B (IOP ≤ 18 mmHg or ≥20% IOP reduction), Criteria C (IOP ≤ 21 mmHg, with or without medication) and D (IOP ≤ 18 mmHg, with or without medication). Complete success was defined as IOP ≤ 21 mmHg (Criteria E) and IOP ≤ 18 mmHg without medication (Criteria F). IOP was reduced from 19.10 ± 4.11 mmHg to 14.27 ± 2.93 mmHg (p

AIM: To compare IOPen and ICare rebound tonometry to Goldmann applanation tonometry (GAT) according to International Standards Organization (ISO) 8612 criteria. METHODS: Totally 191 eyes (n=107 individuals) were included. Criteria of ISO 8612 were fulfilled: 3 clusters of IOP, measured by GAT, were formed. The GAT results were given as mean±standard deviation. RESULTS: GAT (19.7±0.5 mm Hg) showed a significant correlation to ICare (19.8±0.5 mm Hg) (r=0.547, P

PURPOSE To investigate the rate and localization of graft detachment after Descemet membrane endothelial keratoplasty. METHODS Sixty-six consecutive cases operated between June and August 2014 at the Charite-Universitatsmedizin Berlin were examined prospectively 1 week postoperatively. A single masked observer analyzed the rate and localization of graft detachment using optical coherence tomography (OCT), and the rebubbling rate was measured. Localization of graft detachment was correlated to the incision approach. Preoperative data were correlated to the rate of graft detachment and rebubbling. RESULTS Graft detachment occurred in more than 2 clock hours and with postoperative corneal edema in 33.3% and required rebubbling. In 33.3%, graft detachment occurred in more than 2 clock hours and with postoperative corneal edema and required rebubbling. The mean graft detachment rate was 8.3% per clock hour. A significantly higher graft detachment rate was noted in the inferior clock hours (21.1%, P < 0.0001, 16.7%, P = 0.003). Only higher age of the patient correlated to a higher rate of graft detachment (P = 0.022). No correlation was found between localization of graft detachment and the incision approach (P = 0.615). CONCLUSIONS The graft detachment rate is high after Descemet membrane endothelial keratoplasty, but detachment is usually peripheral, partial and mainly inferior and involves only a few clock hours. Only higher age of the patient is strongly associated with a higher rate of graft detachment. The incision approach is not significantly correlated with the localization of graft detachment. Therefore, the postoperative supine position of the patient seems to be of major importance.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02020044.

Fragestellung: Die Langzeitergebnisse und Komplikationen nach chirurgischer Nachstarabsaugung wurden untersucht. Patienten und Methoden: Diese retrospektive Studie umfasst 265 Augen von 234 Patienten (134 Frauen, mittleres Alter: 61 Jahre) bei denen im Zeitraum von 1997 bis 2010 eine chirurgische Nachstarabsaugung durchgefuhrt wurde. Es wurden ausschlieslich Augen mit einem minimalen Nachbeobachtungszeitraum > 12 Monate eingeschlossen. Ergebnisse: Die Nachstarabsaugung erfolgte bei 220 myopen Augen (Achsenlange ≥ 25 mm), bei 28 Augen mit Z. n. Ablatio retinae sowie bei 17 Augen mit Z. n. traumatischer Katarakt. Der mittlere Nachbeobachtungszeitraum lag bei 73 Monaten (Spannbreite: 12–202 Monate). Bei 206 Augen (77,8 %) betrug die Nachbeobachtungszeit mehr als 3 Jahre. Der mittlere bestkorrigierte Fernvisus verbesserte sich signifikant von praoperativ 0,93 ± 0,72 logMar auf postoperativ 0,56 ± 0,63 logMar bei der letzten Nachuntersuchung (p

Milena Pahlitzsch,1 Necip Torun,1 Carl Erb,2 Jeanette Bruenner,1 Anna Karina B Maier,1 Johannes Gonnermann,1 Eckart Bertelmann,1 Matthias K J Klamann1 1Department of Ophthalmology, University Medicine Charité, Campus Virchow Clinic, Berlin, 2Augenklinik am Wittenbergplatz, Berlin, Germany Purpose: To assess the correlation between the disc damage likelihood scale (DDLS) objectively measured by a non-mydriatic fundus camera, Heidelberg Retina Tomograph 3, and optic coherence tomography in preperimetric glaucoma. Methods: One-hundred-twenty-five patients with preperimetric primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (n=30) were included (mean age 58.9±15.9 years). All three devices graded the optic disc topography: Diagnosis 1 was defined as “outside normal limits”, while Diagnosis 2 as “borderline or outside normal limits”. Results: For Diagnosis 1, a significant correlation was shown between DDLS and Moorfields regression analysis (P=0.022), and for Diagnosis 2 with glaucoma probability score analysis (P=0.024), in POAG. In pseudoexfoliation glaucoma, DDLS did not correlate significantly with Heidelberg Retina Tomograph 3 and optic coherence tomography. Regarding the area under the curve the highest predictive power was demonstrated by the objective DDLS (0.513–0.824) compared to Burk (0.239–0.343) and Mikelberg (0.093–0.270) coefficients. Conclusions: The DDLS showed a significant correlation to the Moorfields regression analysis in preperimetric POAG. The objective DDLS showed the highest predictive power and thus is an additive tool in diagnosing preperimetric glaucoma. Keywords: DDLS, preperimetric glaucoma, optic coherence tomography, stereophotography, Heidelberg Retina Tomograph

Hintergrund: Das Ziel der Studie war es, den drucksenkenden Effekt und die Reduktion der antiglaukomatosen Therapie durch die Trabekulotomie ab interno (Trabectome) zu evaluieren und die Einsatzmoglichkeit im klinischen Alltag zu bewerten. Patienten und Methoden: 296 Augen (n = 296 Patienten) mit diagnostiziertem primarem Offenwinkelglaukom (PCOWG) und Pseudoexfoliationsglaukom (PEX) wurden in die Studie von 06/2012 bis 06/2014 eingeschlossen. Bei zeitgleichem Vorliegen einer Katarakt wurde die Trabectomeoperation mit einer Phakoemulsifikation (Phako) und IOL-Implantation kombiniert. Zur statistischen Auswertung wurden 4 Gruppen gebildet (Gruppe 1 = Trabectome bei PCOWG, Gruppe 2 = Trabectome bei PEX, Gruppe 3 = Trabectome + Phako bei PCOWG, Gruppe 4 = Trabectome + Phako bei PEX). IOD-Messungen und die Zahl der antiglaukomatosen Medikation wurde bei jedem Follow-up uber 1 Jahr erhoben. Ergebnisse: In Gruppe 1 und 2 betrug der mittlere IOD praoperativ 19,8 ± 5,9 mmHg und 23,7 ± 9,5 mmHg. Es zeigte sich eine signifikante IOD-Reduktion auf 14,8 ± 3,2 mmHg (p = 0,001) und 14,0 ± 3,3 mmHg (p = 0,046) 1 Jahr postoperativ. Die Anzahl der topischen Glaukommedikamente sank auf 2,1 ± 1,2 (p = 0,004) und 2,4 ± 1,2 (p = 0,593) nach 1 Jahr Follow-up in Gruppe 1 und 2. Der mittlere IOD praoperativ betrug 19,2 ± 4,0 mmHg und 23,2 ± 9,2 mmHg in der Gruppe 3 und 4. Eine signifikante IOD-Reduktion auf 11,8 ± 3,1 mmHg (p

Purpose: To analyze the preferred practice respective diagnosis, treatment, and complications in patients with acute retinal necrosis in Germany.Methods: The uveitis-section of the German Ophthalmologic Society developed a questionnaire with 12 questions concerning patients with acute retinal necrosis seen in the 5 years up to August 2009.Results: In total, 35 eye hospitals answered the questionnaire and reported 213 patients with acute retinal necrosis. Diagnosis was made clinically in 86%. Anterior chamber tap, vitreous biopsy, diagnostic vitrectomy, and serology were performed for confirmation. Therapy was started with acyclovir in all institutions, and continued with ganciclovir, foscarnet and brivudine in some cases. Intravitreal injections were performed in 46%. Additional oral steroids were given in 80%. A following oral antiviral treatment was performed in 94%.Conclusions: Relevant variations were seen in diagnosis and treatment practices. The survey outlines the need for a unique diagnost...

To assess the outcome of trabectome surgery in the treatment of glaucomatocyclitic crisis (Posner–Schlossman syndrome) in patients with uncontrolled intraocular pressure (IOP). Trabectome surgery was performed in seven patients with diagnosed glaucomatocyclitic crisis and uncontrolled IOP where cytomegalovirus DNA was verified by polymerase chain reaction in aqueous humour samples. All patients were treated with oral valganciclovir. After surgery the patients were followed-up for 12 months. Mean IOP before trabectome surgery was 40±10 mm Hg (range 33–58 mm Hg). The mean number of antiglaucoma medication prior to surgery was 3.1±0.4. By the end of the 12 months, IOP in all patients was reduced to normal level (13±1 mm Hg) and their antiglaucoma medication was decreased to 0.8±1.1. No recurring attack of glaucomatocyclitic crisis occurred. In addition to oral valganciclovir therapy, trabectome surgery seems to be a reliable and effective tool for the management of glaucomatocyclitic crisis with uncontrolled IOP.

The effectiveness and complication profile of the iStent inject implantation among different open angle glaucoma subgroups were analyzed. In this retrospective cohort outcome study, 35 consecutive patients suffering from glaucoma (primary open angle glaucoma (POAG) N = 17, pseudoexfoliation glaucoma (PEX) N = 15, and pigmentary glaucoma (PG) N = 3) were treated with the iStent inject. The intraocular pressure (IOP) and the number of antiglaucoma medications before and after surgery were evaluated. In POAG, the mean IOP at 6 months measured 14.19 ± 1.38 mmHg with an average decrease of 33 % from preoperative IOP (p

Purpose: To assess the correlation between the disc damage likelihood scale (DDLS) objectively measured by a nonmydriatic fundus camera, confocal laser scanning ophthalmoscopy (HRT3), and spectral-domain optical coherence tomography (SD-OCT) in uveitic glaucoma. Methods: A total of 59 patients with uveitic glaucoma (21 female, 38 male; mean age 56.8 ± 18.7 years) were included in this prospective cross-sectional study. All patients were measured by the Kowa Nonmyd WX 3D camera (2D/3D nonmydriatic retinal camera, Kowa Company), the HRT3 (Heidelberg Engineering), and SD-OCT (Carl Zeiss Meditec) by one examiner on the same day. All 3 devices graded the optic disc topography. Statistical data were calculated using SPSS (v 20.0, SPSS). Results: In patients showing borderline results in one of the modalities (n = 45), the DDLS showed a significant correlation with the retinal nerve fiber layer (p = 0.016), while Moorfields regression analysis (p = 0.550) and glaucoma probability score (p = 0.629) did not correlate significantly. The highest predictive power was demonstrated by the objectively measured DDLS (area under the receiver operating characteristic curve 0.445-0.588), compared to R. Burk (0.149-0.375) and F.S. Mikelberg (0.033-0.450) coefficients considering HRT and optical coherence tomography. Conclusions: In this study cohort, the objective DDLS showed the highest predictive power and thus is a reliable tool in diagnosing uveitic glaucoma. These 3 devices cannot be used interchangeably. As diagnosis and follow-ups are challenging in uveitis patients, the stereophotography is additionally a valuable tool.

PURPOSE Intraocular pressure (IOP) elevation occurs regularly after Descemet membrane endothelial keratoplasty (DMEK). This study evaluated the effect of central corneal thickness (CCT) on the IOP after DMEK. PATIENTS AND METHODS This prospective study recorded the IOP of 46 eyes from 46 patients preoperatively, and then 1 and 3 months after DMEK. IOP measurement was performed by noncontact pneumatic tonometry (NCT), iCare, Goldmann applanation tonometry (GAT), and dynamic contour tonometry (DCT). CCT was analyzed by anterior-segment optical coherence tomography. RESULTS Mean IOPs as measured by NCT, iCare, GAT, and DCT, respectively, were 14.3, 11.6, 12.7, and 16.0 mm Hg preoperatively; 13.1, 12.6, 12.7, and 16.0 mm Hg after 1 month; and 14.7, 14.5, 12.9, and 17.7 mm Hg after 3 months. There was a correlation of IOP measurements between GAT and NCT (P=0.119), GAT and iCare (P=0.892), and iCare and NCT (P=0.081) after 1 month and between iCare and NCT (P=0.702) after 3 months. Although GAT recorded approximately stable IOP values, NCT, iCare, and DCT tended to measure a higher IOP postoperatively than preoperatively. Preoperatively, correlations between IOP and CCT were not statistically significant for any measurement technique. After 3 months, the IOP measured by NCT and iCare correlated significantly with CCT (P=0.003, 0.041). CONCLUSIONS Correlation between the different measurement techniques was poor and showed a broad distribution of limits of agreement. Therefore, a change between the 4 techniques during follow-up is not recommended. Nevertheless, all techniques detected the IOP elevation during follow-up, requiring therapy.

Purpose To explore the impact of intracameral air tamponade pressure and duration on graft attachment and rebubbling rates. Design A prospective, interventional, nonrandomized study. Methods setting: Department of Ophthalmology, Charite – Universitatsmedizin Berlin. study population: One hundred seventeen patients who underwent Descemet membrane endothelial keratoplasty (DMEK). observation: Intraocular pressure (IOP) at the end of the surgery, immediately after filling the anterior chamber with air, categorized into low ( 20 mm Hg), and the time until partial removal of the air. main outcome measures: Rebubbling rates and endothelial cell density over a 3-month follow-up period analyzed by a multivariable Cox regression model and an analysis of covariance model. Results Thirty-two patients required a rebubbling (27% [95% CI 19%–35%]). Nine patients required more than 1 rebubbling (7% [95% CI 3%–12%]). Compared with normal IOP, lower (HR 8.98 [95% CI 1.07–75.41]) and higher IOP (HR 10.63 [95% CI 1.44–78.27]) increased the risk of requiring a rebubbling ( P = .006). Independent of the IOP, an air tamponade duration beyond 2 hours reduced the risk of rebubbling (HR 0.36 [95% CI 0.18–0.71, P = .003]). One month after surgery, the mean endothelial cell loss was 13% (95% CI 2%–25%) and 23% (95% CI 17%–29%) in the group with air tamponade duration of below and above 2 hours, respectively ( P = .126). At 3 months after surgery, it was 31% (95% CI 17%–42%) and 42% (95% CI 32%–52%) in the respective groups ( P = .229). Conclusions A postsurgical air tamponade of at least 2 hours with an IOP within the physiological range could help to reduce rebubbling rates.

To assess the outcome of modified goniotomy and trabeculotomy ab interno (Trabectome) surgery in adult primary open-angle glaucoma (POAG) and pseudoexfoliation (PEX) glaucoma.Retrospective cohort outcome study.Two hundred and thirty-six eyes of 236 patients.This cohort outcome study included 68 POAG (mean age: 65.7 ± 16.0 years) and 22 PEX glaucoma patients (mean age: 78.3 ± 7.9 years) in the modified goniotomy cohort and 119 POAG (mean age: 73.9 ± 9.6 years) and 27 PEX glaucoma patients (mean age: 75.2 ± 8.0 years) in the Trabectome cohort. Modified goniotomy is defined as combined ab interno cyclodialysis and goniotomy. The patients were followed up for 12 months, and we analysed the data using SPSS v19.0.In POAG, the intraocular pressure (IOP) was significantly reduced by 4.6 mm Hg in the Trabectome cohort (p0.001) and by 5.8 mm Hg (p0.001) in the goniotomy group at 1-year follow-up. In PEX glaucoma, the mean IOP was reduced by 9.7 mm Hg (p = 0.002) in the Trabectome surgery and by 6.7 mm Hg (p = 0.004) in the goniotomy cohort 1 year later. Comparing both surgery techniques in POAG, no significant correlation was found in terms of IOP at any of the follow-up visits (IOP at 1 year, p = 0.553). In PEX glaucoma, the IOP, visual acuity, and number of glaucoma medications did not differ significantly between the 2 surgery techniques 1 year later (IOP: p = 0.300; VA: p = 0.391; therapy: p = 0.908).Modified goniotomy and Trabectome surgery are reliable and effective tools for the management of moderate POAG and PEX glaucoma. There was no significant difference in IOP between the 2 procedures over a follow-up period of 1 year.

To investigate visual outcome and postoperative complications in patients undergoing Descemet membrane endothelial keratoplasty with graft failure after penetrating keratoplasty.A retrospective analysis was performed with 5 patients who underwent Descemet membrane endothelial keratoplasty after failed penetrating keratoplasty. Intraoperative and postoperative complications were recorded. Visual acuity, rehabilitation phase, refraction stability, central corneal thickness, endothelial cell count, possible immunologic reactions, and optical coherence tomography of the anterior eye segment were evaluated. A subjective questionnaire was used to evaluate patient satisfaction.There were no intraoperative complications. All patients had graft detachment, which made air injection necessary. In all cases, visual acuity significantly increased (medium visual acuity [logarithm of the minimum angle of resolution]: 0.68 ± 0.31 logarithm of the minimum angle of resolution after 4 weeks and 0.35 ± 0.37 after 6 months; P = .043), refraction was stable, corneal thickness was reduced (average, 514 ± 11 μm), and endothelial cell count was reduced (average, 1398 ± 510 cells/mm(2)) after 6 months, which corresponds with a medium loss 40%. In the questionnaire, visual outcome, estimated time for recovery, and rehabilitation and patient satisfaction were better after Descemet membrane endothelial keratoplasty than penetrating keratoplasty. No postoperative elevation of pressure, development of pupillary block, or graft rejection, and no peripheral anterior synechiae or other abnormalities were observed with optical coherence tomography during the first 6 postoperative months.Descemet membrane endothelial keratoplasty is a suitable technique for the treatment of graft failure after penetrating keratoplasty and helped our patients rapidly achieve good visual acuity, with reduction of postoperative complications, but the visual outcome might be limited.

Importance The management of graft failure is increasingly relevant with the spread and growing acceptance of endothelial keratoplasty. Objectives To investigate the functional and anatomical results of secondary Descemet membrane endothelial keratoplasty (DMEK) for graft failure after Descemet stripping endothelial keratoplasty (DSEK) and to histologically analyze the stroma-to-stroma interface with respect to clinical implications. Design, Setting, and Participants In a single-surgeon prospective comparative case series at the Department of Ophthalmology, Charite-University Medicine Berlin, Berlin, Germany, 8 eyes (3.8%) of 210 consecutively performed DMEK procedures underwent a secondary DMEK for graft failure after DSEK from March 1, 2012, through February 28, 2013. Those cases were compared with the eyes of a reference collective (n = 30) and matched-pairs group (n = 8) after primary DMEK for Fuchs endothelial dystrophy. Intervention Descemet membrane endothelial keratoplasty. Main Outcomes and Measures Postoperative best-corrected visual acuity (BCVA) and central corneal thickness at 1, 3, 6, and 12 months. Intraoperatively obtained DSEK graft lenticels were investigated immunohistochemically. Results Patients with graft failure after DSEK had a mean (SD) age of 79.4 (7.2) years (range, 70-90 years). Preoperatively, the mean (SD) BCVA was 1.13 (0.50) logMAR (20/250 Snellen equivalents), and the mean (SD) central corneal thickness measured 704 (161) µm. Twelve months postoperatively, the mean (SD) corneal thickness decreased to 524 (27) µm after secondary and 516 (27) µm after primary DMEK ( P = .57). A mean (SD) BCVA of 0.38 (0.36) logMAR (20/50 Snellen equivalents) was achieved after secondary DMEK compared with 0.15 (0.15) logMAR (20/28 Snellen equivalents) after primary DMEK. Histologically, failed DSEK graft lenticels presented condensations of collagen layers. Fibronectin and cytokeratin were accumulated along the stroma-to-stroma interface; vimentin was found in loosened graft stroma. Conclusions and Relevance These data suggest that DMEK might be considered a feasible choice in patients with graft failure after DSEK. However, the visual restitution might be impeded because of preceded depositions of matrix proteins within the corneal stroma and the stroma-to-stroma interface, which are associated with corneal fibrosis. Thereby, fibrotic processes might be avoided by performing a secondary DMEK in an early phase of graft failure.

Purpose Netrin-4, a secreted protein, is found in the basement membrane of blood vessels and acts as a key regulator of angiogenesis. Here we investigated the role of Netrin-4 in the mouse-model of suture-induced corneal hem- and lymphangiogenesis. Methods Corneal hem- and lymphangiogenesis were induced in Netrin-4-deficient (Ntn4-/-) and wild-type (WT) mice by placing three 11-0 nylon sutures intrastromally. Fourteen days after suturing, the vascularized area was analyzed via corneal flat mount immunohistochemistry. Messenger RNA levels for VEGF-A, VEGF-C, Lyve-1, Netrin-4, Unc5H2, "deleted in colon cancer" receptor, and Neogenin in treated and nontreated mouse corneas, cultured human corneal keratocytes (HCK) and epithelial cells (HCEC+HCET) were analyzed by quantitative PCR. Results In wild-type mice, Netrin-4 mRNA expression in the cornea decreased in growing corneal neovascularization after suturing. Correspondingly, Ntn4-/- mice showed an increased vascularized area compared to that in WT mice. Expression of VEGF-A mRNA was higher in Ntn4-/- versus WT mice. There was no Netrin-4 expression in lymphatic vessels and the area of lymphatic vascularization did not differ between Ntn4-/- and WT mice, nor did expression of VEGF-C and Lyve-1 mRNA. Human corneal epithelial cells showed mainly Netrin-4 mRNA expression, which increased after stimulation, while HCK demonstrated Unc5H2 mRNA expression. Expression of VEGF-A, Netrin-4, Unc5H2, and Neogenin mRNA in HCEC and HCK did not differ significantly between the serum-free condition and VEGF-A or Netrin-4 stimulation. Conclusions Absence of Netrin-4 increased corneal hemangiogenesis but not lymphangiogenesis in the mouse-model of suture-induced neovascularization. Netrin-4 acted as an antiangiogenic factor in the cornea, with which the healthy cornea is enriched via its expression by corneal epithelial cells.