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Lamellar macular holes (LMHs) are an entity of a progressive disease in which the efficacy of the therapy of choice, vitrectomy, seems to be reduced. It is unknown whether highly concentrated autologous platelet-rich plasma (PRP) is of value in the therapy of LMHs. The purpose of this study was to gauge the potential of highly concentrated PRP to restore foveal anatomy in LMH surgery.In this interventional case series, eight eyes of eight patients with progressive LMH were included. All patients underwent a 23-gauge pars plana vitrectomy with induction of a posterior vitreous detachment and peeling of tractive epiretinal membranes whenever present. Under air tamponade, 0.1 mL of highly concentrated autologous PRP was applied. Subsequently, a gas or air tamponade was performed. All patients were instructed to rest in the supine position for the first 1 to 2 postoperative hours. Best-corrected visual acuity (BCVA) testing, microperimetry, spectral-domain optical coherence tomography (SD-OCT) and fundus photography were performed prior to and 3 months after surgery.SD-OCT showed closure of the macular defect with restoration of a normal foveal configuration in all (8 of 8) patients 3 months postoperatively. BCVA improved significantly, from 0.28 ± 0.08 to 0.12 ± 0.14 logMAR (Wilcoxon: p = 0.03). Microperimetry remained unchanged (24.13 ± 1.96 vs. 23.7 ± 1.54 dB; p = 0.46). No clinically significant intra- or postoperative complications were observed.The use of highly concentrated PRP enables excellent anatomical and functional outcomes in the surgical therapy of LMH. Further prospective comparative trials are warranted to compare this promising technique with existing surgical strategies.Makulaschichtforamina sind eine progrediente Erkrankung, bei der die Wirksamkeit der Therapie der Wahl, der Vitrektomie, reduziert zu sein scheint. Das Potenzial von hochkonzentriertem autologem Thrombozytenkonzentrat (Platelet-rich Plasma, PRP) in der Therapie von Makulaschichtforamina ist unbekannt. Ziel dieser Studie ist die Beurteilung des Potenzials von hochkonzentriertem autologem Thrombozytenkonzentrat in der chirurgischen Therapie von Makulaschichtforamina.In diese interventionelle Fallserie wurden 8 Augen von 8 Patienten mit progressivem LMH eingeschlossen. Alle Patienten erhielten eine 23-Gauge-Pars-plana-Vitrektomie mit Induktion einer hinteren Glaskörperabhebung und Peeling traktiver epiretinaler Membranen, sofern vorhanden. Unter Lufttamponade wurde 0,1 ml hochkonzentriertes autologes Thrombozytenkonzentrat appliziert. Anschließend wurde eine Gas- oder Lufttamponade eingegeben. Alle Patienten wurden angewiesen, in den ersten 1 – 2 postoperativen Stunden in Rückenlage zu ruhen. Der bestkorrigierte Visus (BCVA), Mikroperimetrie, optische Kohärenztomografie (SD-OCT) und die Fundusfotografie erfolgten präoperativ sowie 3 Monate postoperativ.In der SD-OCT zeigte sich einen Verschluss des Makuladefekts mit Wiederherstellung der normalen fovealen Konfiguration bei allen (8 von 8) Patienten 3 Monate postoperativ. Die bestkorrigierte Sehschärfe verbesserte sich signifikant von 0,28 ± 0,08 auf 0,12 ± 0,14 logMAR (Wilcoxon: p = 0,03). Die Mikroperimetrie blieb stabil (24,13 ± 1,96 vs. 23,7 ± 1,54 dB; p = 0,46). Es wurden keine klinisch signifikanten intra- oder postoperativen Komplikationen beobachtet.Die Verwendung von hochkonzentriertem autologem Thrombozytenkonzentrat ermöglicht hervorragende anatomische und funktionelle Ergebnisse in der chirurgischen Therapie der Makulaschichtforamina. Weitere prospektive Vergleichsstudien sind notwendig, um diese vielversprechende Technik mit bestehenden chirurgischen Strategien zu vergleichen.

Evaluation of the three currently most common techniques for intraocular lens (IOL) sclera fixation: (1) Prolene suture with Hoffman sclera pocket (2) four-point GoreTex suture technique (3) sutureless flanged intrascleral IOL fixation with double-needle ("Yamane") technique.Retrospective, clinical case series (chart review) at the Department of Ophthalmology, Ludwig-Maximilians-University (LMU), Munich, Germany. Enrolled in the study were 51 patients with 55 eyes. Best-corrected visual acuity (BCVA); manifest refraction (OR); corneal tomography (central corneal thickness, CCT); biometry; central macular thickness (CMT) by optical coherence tomography (OCT); intraocular pressure (IOP); and IOL type and IOL power were recorded and compared prior to and 3 - 12 months post IOL sclera fixation surgery. Pre- and postsurgery difference analysis was performed by Wilcoxon rank sum testing (z).Intrascleral fixation by GoreTex suture was performed in 14 (25.5%) eyes, by Prolene suture in 19 (34.5%,) and by Yamane technique in 22 (40.0%) eyes. Within the 3 - 12 months follow-up post scleral fixation, a total of 2 (14.3%) eyes from the GoreTex, 3 (15.8%) from the Prolene and 1 (4.5%) eye from the Yamane group required refixation. Pre- and post-surgery analysis revealed a statistically significant difference in the total patient population BCVA (exact Wilcoxon test: z = - 3.202; p = 0.001; n = 55) and the Yamane subgroup (exact Wilcoxon test: z = - 2.068; p = 0.001; n = 22). The GoreTex (n = 14) and Prolene (n = 19) subgroups revealed no statistically significant differences versus preoperative baseline. Across groups, there was no statistically significant difference in IOP, CMT, and CCT. No retinal complications were observed, neither intraoperatively nor during follow-up.The volume of IOL revision surgery is increasing. Often, the only option left for visual rehabilitation is scleral IOL fixation. All three scleral fixation techniques studied demonstrated a good safety profile with no statistically significant impact on IOP, CMT, CCT, but with a notable revision rate. Visual rehabilitation to preoperative baseline levels (GoreTex [n = 14] and Prolene [n = 19]) and a statistically significant increase in visual acuity (total cohort [n = 55] and Yamane [n = 22]) seems possible. Unlike iris fixation, scleral fixation is surgically more complex and the surgeon must master a steeper learning curve.Evaluation der 3 aktuell meistverwendeten Sklerafixationstechniken für Intraokularlinsen (IOL) (1) Prolene-Naht mit Hoffman-Skleratasche, (2) GoreTex-Naht mit 4-Punkt-Aufhängung, (3) nahtlose intrasklerale Fixation mit gekauterten IOL-Haptikenden und Doppelnadeltechnik („Yamane-Technik“).IRB-genehmigte retrospektive klinische Studie an der Augenklinik der Ludwig-Maximilians-Universität (LMU) München. 55 Augen (n = 55) von 51 Patienten wurden eingeschlossen. Bestkorrigierter Fernvisus (BCVA), objektive Refraktion (OR), Hornhauttopografie (CCT), Biometrie, zentrale Makuladicke (CMT) mittels optischer Kohärenztomografie (OCT), Augeninnendruck (IOD), IOL-Typ und IOL-Stärke wurden vor und 3 – 12 Monate nach IOL-Sklerafixation untersucht. Eine statistische Auswertung über Unterschiede präoperativ zu postoperativ wurde mittels eines Wilcoxon-Rangsummentests (z) durchgeführt.Eine Sklerafixation mittels GoreTex-Naht wurde in 14 (25,5%) Augen, mittels Prolene-Naht in 19 (34,5%,) und mittels Yamane-Technik in 22 (40,0%) Augen durchgeführt. Innerhalb der 3 – 12 Monate Beobachtungszeitraum nach Sklerafixation mussten insgesamt 2 × (14,3%) GoreTex-, 3 × (15,8%) Prolene-, 1 × (4,5%) Yamane-Augen refixiert werden. Die Analyse zeigte einen statistisch signifikanten Unterschied bei der BCVA in der gesamten Kohorte (exakter Wilcoxon-Test: z = − 3,202; p = 0,001; n = 55) und in der Yamane-Subgruppe (exakter Wilcoxon-Test: z = − 2,068; p = 0,001; n = 22) im Vergleich zu prä-OP. Die GoreTex- (n = 14) und die Prolene-Subgruppe (n = 19) zeigten keine statistisch signifikanten Unterschiede zu prä-OP. Gruppenübergreifend war kein statistisch signifikanter Unterschied bei IOD, CMT und CCT festzustellen. Es traten keine retinalen Komplikationen auf, weder während der OP noch im Beobachtungszeitraum.Die Anzahl der IOL-Revisionen nimmt zu. Oft bleibt als einzige Option nur eine IOL-Sklerafixation zur visuellen Rehabilitation. Alle 3 untersuchten Sklerafixationsmethoden zeigten ein gutes Sicherheitsprofil ohne statistisch signifikanten Einfluss auf IOD, CMT, CCT, aber eine nennenswerte Revisionsrate. Eine visuelle Rehabilitation des BCVA auf den präoperativen Status (GoreTex [n = 14] und Prolene [n = 19]) bzw. ein statistisch signifikanter Visusanstieg (Gesamtkohorte [n = 55] und Yamane [n = 22]) scheint möglich. Verglichen mit der Irisfixation ist die Sklerafixation chirurgisch komplexer und hat eine steilere Lernkurve für den Chirurgen.

PURPOSE The study was performed to evaluate the refractive and visual outcome of patients with misaligned toric intraocular lenses (IOLs) after operative realignment, with and without back-calculation of the toric axis after implantation of the IOL. DESIGN Institutional, retrospective case-control study. METHODS This is a retrospective case series of 39 patients who underwent a second operation to realign a misaligned toric IOL from August 2013 to December 2019 at the Department of Ophthalmology, Goethe University, Frankfurt, Germany. Ideal toric axis was calculated using the back-calculator astigmatismfix.com. RESULTS The study consists of 39 treated eyes (20 [51%] right eyes). The toric IOLs showed a postoperative misalignment of 25.69 ± 26.06°. Postrotational, uncorrected distance visual acuity (UDVA) improved from 0.39 ± 0.29 logMAR to 0.27 ± 0.18 logMAR. Refractive outcome showed a reduction of residual sphere and cylinder. The postoperative UDVA when performing alignment to the preoperative calculated axis (51%) was 0.24 ± 0.16 logMAR with a cylinder of 0.90 ± 0.90 diopter (D). In the group with alignment to a back-calculated axis (49%), the UDVA was 0.32 ± 0.20 logMAR with a cylinder of 0.76 ± 0.72 D. High cylinder power IOLs (≥2 D) showed a higher decrease in residual cylinder when back-calculation was performed than low cylinder power IOLs (

PURPOSE To evaluate the repeatability and validity of total corneal power measurements (total keratometry [TK]) obtained with a recently introduced optical biometer (IOLMaster 700, Carl Zeiss Meditec AG) to a Scheimpflug device (Pentacam, Oculus). SETTING Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany. DESIGN Prospective randomized controlled trial. METHODS The inclusion criteria were a corneal astigmatism of 3.00 diopters (D) or less, no previous ocular surgery, no known corneal irregularities, and no known dry eyes. All eyes were measured 3 times using the optical biometer and the Scheimpflug device. The results were statistically compared using Bland-Altman, within-subject SD, and astigmatism vector analysis. RESULTS Ninety-three eyes of 93 subjects were included. Overall, the repeatability of all eyes measured was 0.42 for standard K, 0.40 for TK, 0.45 for total corneal refractive power (TCRP), 0.43 for true net power (TNP), and 0.39 for simulated K. Bland-Altman analysis showed no significant difference between the optical biometer's TK compared with standard K and the Scheimpflug device's simulated K, TNP, and TCRP, the P value exceeding .05 in each case. A difference of >0.50 diopters between astigmatism measurements between TK and TCRP was found in 10 cases compared with standard K and TNP with 0 and 2 cases. CONCLUSIONS Repeatability of both devices was high, although measurements of meridian showed a great variability, suggesting that numerous measurements are needed to enhance accuracy. TCRP measurements between recently introduced TK and TCRP cannot be used interchangeably. Future studies are necessary to evaluate which measurement will result in a better outcome when respective measurements are used for toric intraocular lens calculations.

Purpose To evaluate the use of highly concentrated autologous platelet-rich plasma (PRP) in lamellar macular hole (LMH) surgery with regard to function and morphology. Methods We included 12 eyes of 12 patients with progressive LMH in this interventional case series. After 23/25-gauge pars plana vitrectomy, 0.1ml highly concentrated autologous platelet-rich plasma was applied under air tamponade. Induction of posterior vitreous detachment and peeling of tractive epiretinal membranes were performed whenever present. Phacovitrectomy was undertaken in cases of phakic lens status. Postoperatively, all patients were instructed to rest in a supine position for the first two postoperative hours. Best-corrected visual acuity (BCVA) testing, microperimetry, spectral-domain optical coherence tomography (SD-OCT), and fundus photography were carried out preoperatively and 6 months postoperatively. Results Foveal configuration was restored in 10 of 12 patients (83.3%) at 6 months postoperatively. Two patients who had not undergone ILM peeling showed a recurring defect at 6-month follow-up. Best-corrected visual acuity improved significantly from 0.29 ± 0.08 to 0.14 ± 0.13 logMAR (Wilcoxon: p=0.028). Microperimetry remained unchanged (23.38 ± 2.53 preoperatively; 23.0 ± 2.49 dB postoperatively; p=0.67). No patient experienced vision loss after surgery, and no significant intra- or postoperative complications occurred. Conclusion The application of PRP in the surgical therapy of LMH results in good morphological and functional outcomes. Additional peeling of the ILM seems to be mandatory when using PRP to prevent the recurrence of LMH. Strict postoperative supine positioning for 2 h avoids PRP dislocation. Larger sample sizes are needed to confirm the results.

PURPOSE: To compare different new-generation biometric formulas and ray-tracing for small-aperture intraocular lens (IOL) (IC-8; Acufocus, Inc) implantation in patients undergoing cataract and refractive lens exchange surgery with highly irregular corneas. METHODS: This monocenter study included 17 eyes of 17 patients with highly irregular corneas of different genesis. Biometric and topographic corneal data were assessed using the IOLMaster 700 (Carl Zeiss Meditec) and Pentacam (Oculus Optkigeräte GmbH). Prediction and absolute error were compared after 3 months based on manifest refraction. Furthermore, change of total corneal refractive power in different corneal pathologies was also evaluated. For IOL power calculation, three fourth-generation IOL formulas were compared (Haigis, SRK-T, and Barrett Universal II). The dataset was then checked against ray-tracing and analyzed to improve prediction error in these highly irregular corneas. RESULTS: All patients showed an improvement in visual acuity postoperatively with a mean spherical equivalent of −1.22 ± 0.49 diopters (D). Overall comparison of the three formulas showed the Haigis formula to be superior in terms of the smallest deviation of predictive and absolute error. IOL calculations with ray-tracing were possible in all eyes, but showed inaccurate results with keratometric values of 48.00 D and greater. CONCLUSIONS: The IC-8 IOL is well suited for patients with lens exchange in highly irregular corneas. The Haigis formula seemed to be the most accurate in the patient group. Ray-tracing confirmed the results of biometric formulas up to a keratometric value of 48.00 D and should be compared with standard biometric formulas to address corneal irregularities and to minimize refractive surprises after surgery. A comparison with ray-tracing in eyes with a keratometric value of greater than 48.00 D should not be considered due to the inaccurate results. [ J Refract Surg . 2021;37(5):312–317.]

PURPOSE To evaluate functional outcome after retinal detachment (RD) repair surgery in eyes with a multifocal intraocular lens (mIOL). SETTING Ludwig-Maximilians-University, Munich, Germany. DESIGN Single-center case control study. METHODS 52 pseudophakic eyes with successful anatomical outcome after surgical RD repair were included. Retrospectively, 21 mIOL eyes were compared with a matched group of 21 monofocal eyes over 6 weeks. Prospectively, corrected distance visual acuity (CDVA) was evaluated over 12 months in these eyes. Furthermore, uncorrected distance, intermediate, and near visual acuity (UDVA, UIVA, and UNVA, respectively), defocus curves, and patient-reported outcomes were evaluated at 1 year in 24 mIOL eyes. RESULTS 52 eyes of 48 patients comprised the study. The mean CDVA (logMAR) improved significantly from 1.35 ± 1.38 to 0.29 ± 0.37 at 6 weeks and remained stable at 12 months postoperatively in monofocal eyes (P = .001) and from 1.16 ± 1.2 to 0.37 ± 0.29 (6 weeks) and 0.20 ± 0.36 (12 months) in mIOL eyes (P = .001). Univariate factorial analysis of variance showed no statistically significant differences in CDVA at 6 weeks or 12 months postoperatively for IOL type or for preoperative macular status (P > .05). In the prospective cohort of 24 mIOL eyes, a mean CDVA of 0.13 ± 0.33 logMAR, UDVA of 0.21 ± 0.34 logMAR, UIVA of 0.17 ± 0.28 logMAR, and UNVA of 0.23 ± 0.32 logMAR was achieved. Macular status did not affect final outcome significantly (P > .05). Most patients stated they usually did not need spectacles; no patient wanted mIOL replacement. CONCLUSIONS 1 year after successful anatomical repair after 23-gauge vitrectomy with gas tamponade, functionality of mIOL was restored, and CDVA was comparable with that of patients with monofocal IOL.

Purpose: To assess the efficacy and outcomes of 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment using a three-dimensional heads-up display (3D HUD) surgical platform as compared to a standard operating microscope (SOM) setting.Design: Retrospective cohort study.Participants: One hundred and forty consecutive eyes of 140 patients with primary retinal detachment.Methods: All eyes underwent 23-gauge pars plana vitrectomy for primary retinal detachment using either a 3D HUD (NGENUITY; Alcon Inc., Fort Worth, Texas, USA; n = 70 eyes) or a SOM setting (n = 70 eyes); in cases of significant cataract, additional phacoemulsification with intraocular lens (IOL) implantation was performed. Minimum follow-up was 2 months.Main Outcome Measures: Primary retinal reattachment rate, rate of proliferative vitreoretinopathy (PVR), best-corrected visual acuity (BCVA), and duration of surgery.Results: There were 70 eyes each in the 3D HUD and the SOM group. Both groups did not differ concerning age (p = 0.70), extent of retinal detachment (p = 0.07), number of retinal tears (p = 0.40), macular involvement (p = 0.99), and preoperative BCVA (p = 0.99). Postoperatively, 3D HUD and SOM were comparable concerning the primary retinal reattachment rate (88.6 vs. 94.3%; p = 0.37), the development of postoperative PVR (12.9% vs. 7.1%; p = 0.40) and final BCVA (0.26 ± 0.40 vs. 0.21 ± 0.38 logMAR; p = 0.99). Duration of surgery was significantly longer in the 3D HUD group (66.2 ± 16.5 vs. 61.2 ± 17.1 min; p = 0.04), an effect which however vanished after a “learning curve” of the first 35 eyes (p = 0.49).Conclusions: On par results to a conventional operating microscope can be achieved with a 3D HUD setting when performing 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment, including the primary retinal reattachment rate, the incidence of postoperative PVR and final BCVA. However, duration of surgery might initially be slightly longer with 3D HUD, suggesting the effect of a learning curve.

Purpose: To assess the efficacy and outcomes of 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment using a three-dimensional heads-up display (3D HUD) surgical platform as compared to a standard operating microscope (SOM) setting. Design: Retrospective cohort study. Participants: One hundred and forty consecutive eyes of 140 patients with primary retinal detachment. Methods: All eyes underwent 23-gauge pars plana vitrectomy for primary retinal detachment using either a 3D HUD (NGENUITY; Alcon Inc., Fort Worth, Texas, USA; n = 70 eyes) or a SOM setting (n = 70 eyes); in cases of significant cataract, additional phacoemulsification with intraocular lens (IOL) implantation was performed. Minimum follow-up was 2 months. Main Outcome Measures: Primary retinal reattachment rate, rate of proliferative vitreoretinopathy (PVR), best-corrected visual acuity (BCVA), and duration of surgery. Results: There were 70 eyes each in the 3D HUD and the SOM group. Both groups did not differ concerning age (p = 0.70), extent of retinal detachment (p = 0.07), number of retinal tears (p = 0.40), macular involvement (p = 0.99), and preoperative BCVA (p = 0.99). Postoperatively, 3D HUD and SOM were comparable concerning the primary retinal reattachment rate (88.6 vs. 94.3%; p = 0.37), the development of postoperative PVR (12.9% vs. 7.1%; p = 0.40) and final BCVA (0.26 ± 0.40 vs. 0.21 ± 0.38 logMAR; p = 0.99). Duration of surgery was significantly longer in the 3D HUD group (66.2 ± 16.5 vs. 61.2 ± 17.1 min; p = 0.04), an effect which however vanished after a “learning curve” of the first 35 eyes (p = 0.49). Conclusions: On par results to a conventional operating microscope can be achieved with a 3D HUD setting when performing 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment, including the primary retinal reattachment rate, the incidence of postoperative PVR and final BCVA. However, duration of surgery might initially be slightly longer with 3D HUD, suggesting the effect of a learning curve.

Myopia is the most common refractive error. Surgical correction with laser is possible. LASIK and SMILE are the techniques currently most used. Aim of the study was to compare changes in corneal volume and thickness after the respective laser treatment. 104 eyes of 52 patients were matched based on refractive error into two equally sized groups, either treated with LASIK or SMILE. Measurements were obtained from the Scheimpflug camera (Pentacam) preoperatively and at 3 and 12 months postoperatively. 3 months postoperatively, the flapless SMILE procedure resulted in a significant overall greater loss of corneal volume (P < 0.01) and corneal thickness (P < 0.01) compared to LASIK. No significant difference was found when comparing the 3 to 12-months values in each group. Within the currently used ranges of refractive error correction, loss in central corneal thickness and corneal volume with SMILE is higher in comparison to LASIK. As greater loss in corneal volume and thickness might contribute to higher level of corneal instability maximum ranges of refractive error correction with SMILE should not supersede those set currently for LASIK until more long-term results on corneal ectasia are available for SMILE.

Sub-retinal fluid (SRF) has been discussed as a protective factor against macular atrophy in eyes with neovascular age-related macular degeneration (nAMD).To gauge the impact of SRF on macular atrophy, a database of 310 nAMD eyes was screened for eyes manifesting an SRF-only phenotype under treat & extend anti-VEGF treatment, defined as nAMD expressing CNV exudation beyond the three monthly anti-VEGF loading doses by SRF only without any signs of exudative intra-retinal fluid (IRF) for ≥3 years. Incidence of macular atrophy and treatment responses were evaluated on multimodal imaging, including optical coherence tomography (OCT), blue autofluorescence (BAF) and near-infrared (NIR) confocal scanning laser ophthalmoscopy and fluorescence and indocyanine green angiography (FAG/ICGA). In total, 27 eyes (8.7%) of 26 patients with a mean follow-up of 4.2 ± 0.9 (3–5) years met the inclusion criteria. Mean age was 72 ± 6 (range: 61–86) years. The SRF only phenotype was seen from baseline in 14 eyes (52%), and in 13 eyes (48%) after a mean 1.0 ± 1.3 (1–3) injections. In years 1 to 5, mean 7.5, 5.9, 6.1, 6.1 and 7.0 anti-VEGF injections were given (p = 0.33). Cumulative macular atrophy incidence was 11.5% at year 1, 15.4% throughout years 2 to 4, and 22.4% at year 5. In conclusion, eyes manifesting activity by SRF only in treat & extend anti-VEGF regimen for nAMD seem to exhibit rather low rates of macular atrophy during long-term follow-up. SRF might be an indicator of a more benign form of nAMD.

PURPOSE To implant a small-aperture intraocular lens (IOL) (IC-8) in eyes with severe corneal irregularities to reduce higher-order aberrations and provide better central visual acuity. SETTING University Hospital, LMU Munich, Germany. DESIGN Prospective nonrandomized interventional case series. METHODS Eyes with severe corneal irregularities due to keratoconus, previous penetrating keratoplasty, status postradial keratotomy, or scarring after ocular trauma were enrolled. Exclusion criteria were progressive keratoconus, pseudoexfoliation, glaucoma, maculopathy, reduced endothelial cells (

PURPOSE We assessed differences in compliance and adherence (lateness of patients, visual acuity, reasons for abstaining) between patients with diabetic macular edema (DME) and patients with age-related macular degeneration (AMD), both under anti-vascular endothelial growth factor therapy. METHODS We included 136 patients with DME (36% women, 65 years, 22 visits, 13.9 injections, and 29.9 months of follow-up) and 109 patients with AMD (59% women, 76 years, 20 visits, 14.7 injections, and 22.3 months of follow-up) (minimum follow-up of 12 months and at least 5 injections). We assessed missed appointments (lateness >14 days) and therapy break-offs (lateness >100 days). All delayed patients were called and interviewed for abstaining reasons. RESULTS Forty-six percent of patients with DME and 22% of patients with AMD had at least one break-off. Thirty-five percent of patients with DME and 50% of patients with AMD were always on schedule. In patients with DME, there was significant correlation (P = 0.017) between the number of break-offs and change of visual acuity. In 60% DME and 38% AMD of break-off cases, visual acuity was worse than the before break-off. The most common reason for abstaining was comorbidities (33% AMD and 20% DME). CONCLUSION There are significant differences between patients with AMD and DME regarding compliance and adherence, which also affects outcome. Strategies to tie patients with DME to costly intravitreal therapy need to be developed to improve outcomes and efficacy.

PURPOSE: To report the impact of increasing minimum lenticule thickness on the safety and efficacy of small incision lenticule extraction (SMILE) in low myopia up to −3.50 diopters (D). METHODS: SMILE was performed in 76 eyes of 76 patients. Thirty-eight eyes of 38 patients with low myopia were prospectively operated on with a programmed minimum lenticule thickness of 15 to 30 μ m (thicker lenticule group). Thirty-five eyes suitable for analysis were then retrospectively matched by spherical equivalent to 35 eyes operated on with a minimum standard setting of 10 μ m (standard thickness group), as provided in the database of the SMILE Eyes Clinic Linz, Linz, Austria. Comparison of outcomes was performed with the Standard Graphs for Reporting Refractive Surgery and by analysis of higher order aberrations as provided by Scheimpflug imaging. RESULTS: Apart from lenticule thickness, there was no significant difference in preoperative baseline or treatment parameters between both groups. Mean minimum lenticule thickness differed significantly (standard thickness = 10 ± 0 μ m; thicker lenticule = 20 ± 5 μ m; P < .0001). This also translated into a significant difference in maximum lenticule thickness (standard thickness: 54 ± 11 μ m; thicker lenticule: 62 ± 8 μ m; P = .0002). Mean SEQ preoperatively was −2.25 ± 0.51 (standard thickness) and −2.24 ± 0.46 (thicker lenticule) D, respectively, and changed to −0.11 ± 0.50 (standard thickness) and +0.01 ± 0.36 (thicker lenticule) D postoperatively ( P < .0001 for both comparisons). Uncorrected postoperative visual acuity was −0.08 ± 0.35 (standard thickness) versus −0.10 ± 0.09 (thicker lenticule) logMAR ( P = .706). After SMILE, the thicker lenticule group showed better safety (1.20 vs 1.08; P = .025) and efficacy (1.14 vs 0.96; P = .011) indices, translating into more eyes within ±0.50 D from target (91% vs 77%) and with at least 0.0 logMAR visual acuity (97% vs 86%), and fewer eyes losing one (3% vs 17%) and two (0% vs 3%) lines. CONCLUSIONS: Increasing minimum lenticule border thickness seems to improve the safety and efficacy of SMILE in low myopia. [ J Refract Surg. 2018;34(7):453–459.]

To determine functional and anatomical outcomes of pars plana vitrectomy for persistent full-thickness macular hole (MH) after intravitreal injection of ocriplasmin.This is a multicenter retrospective interventional study of 37 eyes of 37 patients who underwent pars plana vitrectomy with internal limiting membrane peeling for persistent MH after ocriplasmin treatment between December 2013 and December 2015 and comparison with 35 eyes of 35 patients who were offered ocriplasmin injection but underwent pars plana vitrectomy alone without pharmacologic vitreolysis before surgery. In addition, 24 matched pairs (MH diameter at baseline ±5 µm) were analyzed. Clinical data such as visual acuity, intraoperative characteristics, and spectral domain optical coherence tomography images were reviewed. Main outcome measures were visual acuity and MH closure rate.After a mean follow-up period of 9 months, postoperative mean visual acuity showed no significant differences between ocriplasmin-treated eyes (logarithm of minimum angle of resolution 0.37 ± 0.26, Snellen 20/47) and eyes without ocriplasmin treatment (logarithm of minimum angle of resolution 0.39 ± 0.25; Snellen 20/49) (P0.9). After ocriplasmin injection, mean MH diameter enlarged from 217 ± 102 µm to 384 ± 239 µm (P0.001). Matched-pair analysis revealed no difference in gain of visual acuity between the first visit and the last follow-up (P = 0.29). Macular hole closure was observed in similar proportion in ocriplasmin-treated eyes (97%) and vitrectomy-only eyes (94%) (P0.5).Eyes with persistent MH after ocriplasmin injection showed significant visual improvement after pars plana vitrectomy. Matched-pair analysis revealed no statistical differences in functional and anatomical postoperative results comparing with eyes of similar MH diameter that proceeded directly to surgery without ocriplasmin pretreatment.

Purpose To characterize patient-reported long-term quality of vision (QoV) after small-incision lenticule extraction (SMILE), and to identify potential clinical parameters that might predispose to experiencing deteriorated visual quality. Setting University Eye Hospital, Ludwig-Maximilians-University, Munich, Germany. Design Prospective cross-sectional study. Methods For the assessment and scoring of visual symptoms, the Quality of Vision questionnaire was employed, which constitutes a clinically validated, linear-scaled 30-item instrument providing a QoV score on three scales (symptom frequency, severity, and bothersome). Subgroup analyses were performed for patient subgroups stratified by baseline characteristics (eg, age) and treatment parameters (eg, surgical refractive correction) as well as refractive outcomes (eg, residual refraction) and visual outcomes (eg, uncorrected distance visual acuity [UDVA]). Results The study comprised 394 eyes of 197 patients (117 women [59.4%], 80 men [40.6%]) were included with a mean postoperative follow-up of 24.4 months ± 14.1 (SD). The QoV scores for symptom frequency, severity, and bothersome were 34.63 ± 13.69, 29.60 ± 12.38, and 24.56 ± 16.00, respectively. Patients with a preoperative binocular corrected distance visual acuity (CDVA) of 20/12.5 or better, patients who lost 1 or more lines of UDVA as compared with preoperative CDVA, patients older than the age of 40, and patients with inadvertent anisometropia more than 0.375 diopters reported worse QoV scores. Conclusion The relationship between objective clinical parameters and patient-reported subjective QoV after SMILE seems complex. Defined prognostic factors that convey a higher risk for experiencing visual disturbances were identifiable and should be discussed with patients seeking SMILE treatment during preoperative counseling.

Background. The association between cardiovascular events, such as acute coronary syndrome and emotional triggers, such as football world cups is well-known. Significant differences could sometimes be identified depending on the country of origin and design of the study. From an ophthalmological perspective the correlation between preexisting cardiovascular diseases and retinal angiopathy is well-known. This study investigated whether the incidence of retinal vein occlusion (RVO) at a German university eye clinic increased during and 4 weeks after the 2014 football World Cup. Methods. From the electronic files of almost 290,000 patients contained in the Smart Eye database, those with RVO during and 4 weeks after the 2014 football World Cup (from 12 June to 13 August 2014) and during the same time period in 2013 could be identified. Demographic data, visual acuity, intraocular pressure (IOP) and laboratory parameters were extracted and compared, when available. Results. From 10 male (average age 68 years) and 8 female (average age 62 years) a total of 9 central RVO (CRVO), 8 branch RVO (BRVO) and 1 hemi-CRVO were identified in 2013 with a visual acuity ranging from 0.05 to 0.9 (average 0.39) and an IOP from 12 mmHg to 25 mmHg (average 16 mmHg). In 2014 a total of 26 patients (11 male average age 67 years and 15 female average age 76 years) were identified, an increase of 69% (15 CRVO, 6 BRVO and 5 hemi-CRVO). The visual acuity ranged from 0.05 to 1.0 (average 0.63) and the IOP from 8 mmHg to 24 mmHg (average 15 mmHg). Conclusion. Due to the high comparability of the patient collectives an increase of RVO during and 4 weeks after the 2014 football World Cup could be identified, compared to the same period in 2013. It can be assumed that emotional strain caused by a World Cup is a risk factor. Data from other centers have to be assessed in order to be able to make a more general statement.

To investigate the effectiveness and safety of a dexamethasone implant (Ozurdex) to treat pseudophakic macular edema (Irvine-Gass syndrome).Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany.Prospective nonrandomized study.Preoperatively and in 12 monthly postoperative intervals, a complete ophthalmic examination was performed in study patients, including measurement of corrected distance visual acuity (CDVA) using the standard Early Treatment Diabetic Retinopathy Study chart, intraocular pressure, foveal thickness using spectral-domain optical coherence tomography (SD-OCT), and retinal sensitivity (mean defect depth) using microperimetry. Morphological aspects of the inner segment-outer segment junction and visual function were correlated.Twenty-three eyes (23 patients) with pseudophakic macular edema after uneventful cataract surgery were included. The mean duration of macular edema before treatment with a dexamethasone implant was 5.4 months (range 2 to 8 months). The CDVA increased in all patients from 30.2 letters ± 4.3 (SD) at baseline to 50.4 ± 4.9 letters at 12 months (P = .0016), regardless of the time of macular edema duration. Foveal thickness decreased from 520.8 ± 71.4 μm to 232.7 ± 26.6 μm (P.002). Retinal sensitivity (mean defect depth) increased significantly over a 12-month follow-up, correlating positively with a restored inner segment-outer segment junction on SD-OCT analyses. No relevant adverse events were reported, and 9 recurrences occurred with a peak after 3 months and required a second dexamethasone implant injection.The dexamethasone implant was safe and effective in treating pseudophakic macular edema regardless of the duration of the edema.Drs. Mayer and Haritoglou are consultants to Allergan, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Purpose:To evaluate the outcomes of myopic small incision lenticule extraction (SMILE) monovision in presbyopic patients.Methods:This study included 49 presbyopic patients older than 45 years seeking surgical correction of myopia or myopic astigmatism who underwent bilateral SMILE with planned monovision in the SMILE Eyes Clinic Linz, Austria. Target refraction was plano for dominant (distance) eyes and ranged between -1.25 and -0.50 D for nondominant (near) eyes. Best-corrected distance visual acuity, uncorrected distance visual acuity (UDVA), uncorrected near visual acuity, as well as spectacle dependence were assessed after a mean postoperative period of 7.2 ± 4.8 months.Results:Mean age was 49 ± 3 years and female to male ratio was 30:19. Distance eyes achieved a spherical equivalent correction of ±0.50 D from target refraction in 80% of patients and 96% were within ±1.0 D. Binocular UDVA of 20/20 or better was achieved by 90% of patients and all patients achieved 20/25 or better. The proportion of patients with a binocular UDVA of 20/20 or better who could read J2 or better amounted to 84%. Complete spectacle independence was achieved by 84% of patients and independence from reading glasses was achieved in 92% of cases. No patient requested refractive enhancement or monovision reversal.Conclusions:This first evaluation of SMILE monovision endorses the approach as a safe and effective option for the correction of presbyopia in myopic patients seeking refractive surgery.

Purpose: To compare the efficacy of a computer-assisted marker system for toric intraocular lenses (IOLs) (Callisto Eye System) with manual marking techniques. Setting: University Eye Hospital Munich, Ludwig-Maximilians-University, Munich, Germany. Design: Prospective case series. Methods: This study included patients having cataract surgery with implantation of a toric IOL (Torbi 709 M). They were randomly assigned to 1 of 2 groups based on the marking system used, manual or digital. Patients were included if they had age-related cataract and a regular comeal astigmatism of 1.25 diopters (D) or higher. Visual and refractive outcomes as well as rotational stability were evaluated. Vector analysis was performed to evaluate total astigmatic changes. Results: The study comprised 57 eyes of 29 patients;there were 28 eyes in the manual group and 29 eyes in the digital group. The mean toric IOL misalignment was significantly lower in the digital group than in the manual group (2.0 degrees +/- 1.86 [SD] versus 3.4 +/- 2.37 degrees;P = .026). The mean deviation from the target induced astigmatism was significantly lower in the digital group (0.10 +/- 0.08 D versus 0.22 +/- 0.14 D;P = .008). During surgery, the mean toric IOL alignment time was significantly shorter in the digital group (37.2 +/- 11.9 seconds versus 59.4 +/- 15.3 seconds;P = .003). The mean overall time required to perform the surgery was significantly shorter in the digital group (727.2 +/- 198.4 seconds versus 1110.0 +/- 382.2 seconds;P < .001). Conclusions: A digital tracking approach for toric IOL alignment was efficient and safe to improve refractive outcomes. Furthermore, image-guided surgery helped streamline the workflow in refractive cataract surgery. (C) 2017 ASCRS and ESCRS

To assess treatment effects following intravitreal injection of ocriplasmin for vitreomacular traction (VMT), with or without full-thickness macular hole (FTMH), in real-life setting. This is a monocentric, retrospective, consecutive series of 82 eyes from 82 patients who underwent ocriplasmin treatment between July 2013 and December 2016. We included 57 eyes with pure VMT, 17 eyes with small FTMHs, and eight eyes with medium FTMHs. Primary outcome measures were VMT release and MH closure rates. Secondary outcomes were visual acuity (VA), morphological changes, and subjective visual impairment after 1, 3, and 6 months and at last follow-up. After a median follow-up of 10 months, VMT release was achieved by pharmacologic vitreolysis in 57% of all eyes, whereas the macular hole closure rate was 32%. In those presenting with five or more positive prognostic factors (PPF), eyes with pure VMT showed nonsurgical traction release in 88%, and FTMHs were released in 93%, with a closure rate of 20%. Small FTMHs closed in 41% and medium FTMHs in 13%. The mean change in VA (LogMAR) was −0.07 ± 0.24 (median − 0.10) in all eyes. Subretinal fluid accumulation and ellipsoid zone changes were seen in 31% and 37% of all eyes, respectively. They were more frequent in eyes with traction release, but were self-limited. In a real-life setting, release of VMT by ocriplasmin injection can be achieved in the majority of eyes, relying on a strict patient selection. Closure of FTMHs rather correlates with hole diameter than with presence of PPF, and remains a rare finding in medium FTMHs.

Purpose: This is a prospective, randomized, multicenter, investigator-initiated trial to evaluate the 12-month effectiveness of isovolemic hemodilution (IH) with prompt versus deferred intravitreal injections (IVI) of ranibizumab 0.5 mg for the treatment of macular edema secondary to early central retinal vein occlusion (CRVO). Methods: Eyes with macular edema due to CRVO having occurred not more than 8 weeks previously received either monthly ranibizumab IVI in combination with IH (group I, n = 28) or IH alone (group II, n = 30). From month 2 to 12, the patients in both groups could be treated with monthly intravitreal ranibizumab. The main outcome variables were gain of visual acuity and the course of central retinal thickness as measured with optical coherence tomography. Results: At 12 months, eyes in group I on average gained +28.1 (±19.3) letters compared to +25.2 (±20.9) letters in group II (p = 0.326). This result was achieved with significantly fewer injections in group II. Additionally, 30% of the eyes in group II did not need ranibizumab IVI during the 12 months of the trial. Conclusion: Ranibizumab IVI in addition to IH proved to be highly effective in increasing visual acuity and reducing macular edema secondary to CRVO. Initial IH in early CRVO may be a first treatment option in patients anxious about IVI.

Purpose To assess the clinical outcomes and patient satisfaction after bilateral cataract surgery with implantation of a bifocal refractive enhanced depth of focus intraocular lens (IOL) with a low near addition (add). Setting Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany. Design Prospective longitudinal case series. Methods Eyes with bilateral age-related cataract and corneal astigmatism of less than 1.0 diopter (D) had standard microincision cataract surgery with implantation of a bifocal nondiffractive shape-segmented enhanced depth of focus IOL (Lentis Comfort, LS-313 MF15). The corrected and uncorrected (UDVA) distance visual acuities, uncorrected intermediate (UIVA) and near (UNVA) visual acuities, defocus, corneal astigmatism, spectacle independence, contrast sensitivity, rotational stability, photic phenomena, and patient satisfaction were evaluated over a 3-month follow-up. Results The study comprised 22 patients (44 eyes). The mean postoperative manifest spherical equivalent was −0.10 D ± 0.58 (SD), resulting in a mean UDVA of 0.07 ± 0.10 logMAR, mean UIVA of 0.21 ± 0.15 logarithm of minimum angle of resolution (logMAR), and mean UNVA of 0.53 ± 0.15 logMAR. Binocular UDVA was 0.01 ± 0.08 logMAR. The best reading distance was 0.46 ± 0.09 m. More than 95% of patients were satisfied with their visual acuity, and less than 10% reported photic phenomena. The IOL showed an excellent rotational stability. Conclusions The enhanced depth of focus IOL with 1.5 D of near add showed excellent intermediate and far visual performance and acceptable near visual restoration. Patient satisfaction was very high, and few patients reported disturbing photic phenomena.

To prospectively characterize the stromal thickness changes during the first year after myopic small-incision lenticule extraction using spectral-domain optical coherence tomography (SD-OCT).Department of Ophthalmology, Kepler University Hospital, Linz, Austria.Prospective case series.This study evaluated eyes that had small-incision lenticule extraction to treat myopia or myopic astigmatism. A high-resolution SD-OCT system (RS 3000 Advance) in conjunction with a custom image-segmentation algorithm was applied to directly measure stromal thickness within the central 5.0 mm corneal zone. Measurements were obtained preoperatively and postoperatively at 1 day, 1 week, 6 weeks, 3 months, 6 months, and 1 year.The study enrolled 42 eyes of 21 patients. The mean surgical refractive correction was -4.94 diopters ± 1.75 (SD). Postoperatively, the stromal thickness showed a significant decrease during the first 6 weeks, which amounted to a mean of 10.4 ± 6.3 μm at the apex (P .001). Subsequently, the central stroma thickened by a mean of 8.8 ± 5.9 μm up until the 1-year follow-up (P .001). One year postoperatively, the mean observed central stromal thickness reduction was 18.7 ± 5.7 μm smaller than the planned lenticule thickness. This difference was smallest 6 weeks postoperatively (mean 9.8 ± 7.8 μm).Significant anatomic changes in the corneal stroma were detected during the first year after small-incision lenticule extraction. The achieved lenticule thickness was systematically lower than planned, and the mismatch was more pronounced with higher lenticule thickness. Refractive outcomes did not appear to be influenced by lenticule thickness accuracy.

Purpose To compare the safety and efficacy between femtosecond laser–assisted cataract surgery using the Victus laser system and conventional cataract surgery. Setting Department of Ophthalmology, Kepler University Hospital, Linz, Austria. Design Prospective randomized case series. Methods Both eyes of patients with age-related cataract were randomized to conventional cataract surgery or femtosecond laser–assisted cataract surgery, both with intraocular lens (IOL) implantation. Postoperative follow-up was at 1 day, 1 week, 1 month, 3 months, and 6 months and comprised corrected distance visual acuity, endothelial cell density (ECD), central corneal thickness (CCT), and central retinal thickness. The main outcomes were intraoperative and postoperative complications and the effective phacoemulsification time (EPT). Intraocular lens and capsulotomy centration were evaluated using retroillumination slitlamp photography. Results The study enrolled 50 patients. No intraoperative complications occurred in either group. The ECD, CCT, and central retinal thickness were similar between the groups at all follow-up examinations (P > .05). The EPT was not statistically significantly different between the groups (P = .22). The IOL centration was similar between the groups (P = .93). Conclusion Femtosecond laser–assisted and conventional cataract surgery using the mentioned system were equally safe and effective.

To evaluate intraocular pressure (IOP) in the vitreous cavity during various stages of cataract surgery.University Eye Hospital, Ludwig-Maximilians University, Munich, Germany.In consecutive eyes having combined phacoemulsification, intraocular lens implantation, and pars plana vitrectomy, IOP was monitored in real time through a 25-gauge pars plana cannula connected to an external pressure transducer. Surgery was performed by standard clear corneal phacoemulsification with a 2.5 mm incision and a Mega-Tip (1.26 mm aperture) (Group 1) or by microcoaxial phacoemulsification with a CMP-Tip (0.80 mm aperture) (Group 2).The 2 groups had 5 eyes each. The mean IOP in Group 1 and in Group 2, respectively, was 15.9 mm Hg +/- 9.5 (SD) and 17.0 +/- 13.5 mm Hg preoperatively (P = .442), 40.1 +/- 12.7 mm Hg and 36.5 +/- 17.2 mm Hg during lens removal (P.001), 17.6 +/- 14.2 mm Hg and 22.6 +/- 8.6 mm Hg during irrigation/aspiration (P.001), 13.3 +/- 13.2 mm Hg and 16.3 +/- 13.1 mm Hg during IOL implantation (P = .005), and 22.9 +/- 7.0 mm Hg and 21.5 +/- 10.0 mm Hg after IOL implantation through the end of surgery (P = .329).Although the IOP levels were significantly lower than those in previous studies, both phacoemulsification techniques had safe IOP profiles during various steps of surgery. Real-time IOP monitoring may prevent the surgeon from inducing excessive IOP elevation during intraocular manipulation.No author has a financial or proprietary interest in any material or method mentioned.

To evaluate the effect of intravitreal bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) injections on visual acuity and foveal retinal thickness in patients with central retinal vein occlusion (CRVO).In this prospective, noncomparative, consecutive, interventional case series, 46 patients received repeated intravitreal injections (1.25 mg) of bevacizumab. Main outcome measures were visual acuity (Snellen and ETDRS charts) and optical coherence tomography measurements in a 6-month follow-up period.Mean visual acuity improved from 20/250 at baseline to 20/80 at the 6-month follow-up (P0.001). ETDRS chart findings revealed a mean letter gain +/-SD from baseline to 6 months of 13.9 +/- 14.4 letters. Mean central retinal thickness +/-SD decreased from 535 +/- 148 microm at baseline to 323 +/- 116 microm at the 6-month follow-up. Ischemic CRVO was associated with significantly lower visual acuity than nonischemic CRVO (P0.001). However, visual acuity gain was similar in both groups. Independent of duration of symptoms, CRVO was associated with a similar gain in visual acuity.Intravitreal injection of bevacizumab appears to be a new treatment option for patients with macular edema secondary to CRVO.

Purpose: To compare posterior capsule opacification (PCO) by observing lens epithelial cell growth in the human capsular bag in vitro between conventional lens surgery using phacoemulsification (Phaco) technique and femtosecond laser-assisted lens surgery (FLACS). Methods: For the in vitro human capsular bag model, 18 cadaver eyes from nine human donors underwent three types of lens surgery. Three groups consisting of six capsular bags were established, that is FLACS, Phaco and extracapsular lens extraction (ECCE). The capsular bag was transferred into equal cell culture conditions after using one of the defined surgical approaches. Cellular growth of lens epithelial cells was observed and photo-documented. The time until full cell-coverage of the capsular bag was measured. Results: The human capsular bag model can be successfully prepared using FLACS. There was no statistically significant difference in time until cell-coverage of the human donor capsular bag in vitro in all three surgical settings (ECCE versus Phaco p = 0.6;ECCE versus FLACS p = 1.0;Phaco versus FLACS p = 1.0). Conclusions: In our in vitro human capsular bag model, we could not observe a statistically significant difference in PCO formation using different surgical approaches of lens extraction. Therefore, PCO formation might not be attributed to the type of surgery. Furthermore, this study shows that FLACS can be used for the human capsular bag model preparation and validates the human capsular bag model for future research.

Purpose: To evaluate the efficacy of a computerized color vision testing (Arden color contrast test) as a screening test for detection of diabetic macular edema (DME). Materials and Methods: A consecutive, prospective case series of 83 eyes of 42 diabetic patients with and without macular edema was enrolled. Macular edema was assessed clinically by stereoscopic grading and by central retinal thickness measurement with optical coherence tomography (OCT). Additionally, a computerized chromatest for the protan- and tritan-axis was performed. Analysis of test characteristics included receiver operating characteristic (ROC) curves and calculated sensitivity and specificity. Results: Sixty-one eyes had clinically significant macular edema (CSME). OCT yielded an area under the ROC curve (AUC) of 0.92. Color vision testing yielded an AUC of 0.82 for the tritan- and 0.80 for the protan-axis. Using a cut off of 199 microns OCT resulted in a 100% sensitivity at 39% specificity. With a cut-off of 4.85, color testing yielded a sensitivity of 100% at a specificity of 8% on the tritan-axis, respectively. Considering OCT instead of clinical examination as a reference standard resulted in a comparable high sensitivity, but low specificity for color vision testing. Disturbance of the tritan axis was more pronounced than for the protan axis in present macular edema and also better correlated (r = 0.46) with retinal thickness measured with OCT. Conclusions: Computerized, quantitative color testing using the chromatest allows detection of diabetic maculopathy with high sensitivity. However, only a low specificity exists for retinal macular edema, as in diabetic retinopathy (DR) frequently abnormalities of the tritan axis exist before any retinal thickening occurs.

ArisN Kollias, Markus M Schaumberger, Thomas C Kreutzer, Michael W Ulbig, Carlo A LackerbauerUniversity Eye Hospital,Ludwig-Maximilians University, Munich, GermanyPurpose: The point of interest of this retrospective case review is to study refractive changes caused by the hinged lamellar keratotomy and the refractive outcome after laser ablation in a second step within the scope of laser in situ keratomileusis (LASIK) in patients with penetrating keratoplasty.Methods: Data from eight patients obtained before lamellar keratotomy, before laser ablation, and three months later were evaluated. Keratotomies were performed with the Moria® LSK one and the Amadeus® 2 microkeratome, laser ablation was performed with the Schwind® Keratome I and the Wavelight® Allegretto WaveEyeQ. Results: Uncorrected visual acuity (UCVA) improved significantly from 1 [logMar] to 0.4 [logMar] at the last visit. Median gain of UCVA was 7.38 ± 2.96 Snellen lines. Best spectacle-corrected visual acuity did not change significantly. Preoperative manifest refraction spherical equivalent decreased from -4.02 ± 4.77 diopters (D) to -1.11 ± 2.45 D after laser ablation. Mean preoperative manifest astigmatism was -7.27 ± 3.65 D, after lamellar keratotomy -6.72 ± 3.68 D, and after laser ablation -2.08 ± 1.80 D. Manifest astigmatism did not change significantly after the keratotomy.Conclusions: Lamellar keratotomy causes biomechanical changes to the cornea. We favor a two-step LASIK in penetrating keratoplasty patients in order to improve precision and predictability of the refractive outcome.Keywords: two-step, cornea, LASIK, keratoplasty, astigmatism

Background: Our purpose was to compare the effect of triamcinolone and bevacizumab (Avastin) on the retinal thickness and functional outcome in patients with diabetic macular edema. Methods and Materials: A collective of 32 patients, who had been treated by a single 4.0-mg intravitreal triamcinolone injection (group 1), was matched to 32 patients (‘matched pairs’), who had received 3 injections of 1.25 mg of bevacizumab within 3 months in 4-week intervals (group 2). The outcome variables were changes in best corrected visual acuity (VA) and central retinal thickness 3 months after therapy. Results: Both groups did not differ regarding preoperative VA and central retinal thickness measured by optical coherence tomography. The baseline mean VA was 0.72 ± 0.39 logMAR in group 1 and 0.73 ± 0.39 logMAR in group 2 (p = 0.709). The mean central retinal thickness measured by optical coherence tomography was 548 ± 185 µm in group 1 and 507 ± 192 µm in group 2. While the patients in group 1 experienced a slight increase in VA of on average 0.7 lines following a single triamcinolone injection to a mean of 0.64 ± 0.40 logMAR (p = 0.066) after 3 months, the patients in group 2 showed almost no effect on VA with an average increase of 0.2 lines to a mean VA of 0.72 ± 0.30 logMAR (p = 0.948) following 3 intravitreal injections of bevacizumab. Comparing the effect on VA between both groups no statistically significant difference (p = 0.115) was noted. Concerning decrease in central retinal thickness both therapies were highly effective (p < 0.001 each), again, without statistically significant difference between the groups (p < 0.128). Conclusion: Our data suggest that a single triamcinolone injection may be as effective as a 3 times repeated intravitreal administration of bevacizumab for the treatment of diabetic macular edema. Further prospective trials should be performed.

PURPOSE To evaluate the long-term efficacy of bevacizumab for the treatment of chronic diffuse diabetic macular edema after various previous treatments. METHODS A total of 126 patients (mean age: 66 years) with chronic diffuse diabetic macular edema were consecutively incorporated in this prospective, noncomparative case series. Inclusion was performed independently from the size of edema, retinal thickness, visual acuity (VA), age, metabolic control, type of diabetes, or type of previous treatments. The patients underwent a complete eye examination including best-corrected VA with ETDRS charts, slit lamp examination, intraocular pressure measurement, stereoscopic biomicroscopy of the macula, retinal thickness measurement using optical coherence tomography (OCT), fluorescein angiography, and fundus photography. All patients were treated with repeated intravitreal injections of bevacizumab (1.25 mg). Patients were observed in intervals of 4-12 weeks for a period of up to 6-12 months. RESULTS All patients had received various previous treatments such as laser treatment (62% focal laser treatment, 38% panretinal laser treatment), vitrectomy (11%), or intravitreal injection of triamcinolone (41%). All patients completed 6 months and 59 patients (47%) completed 12 months of follow-up; within this period 48% had received at least three intravitreal injections of bevacizumab. Mean diameter of foveal avascular zone was 858 +/- 341 microm. At baseline mean VA was 40.3 ETDRS letters (0.82 logMAR Snellen VA) and mean central retinal thickness on OCT was 463 microm. Throughout follow-up VA changes were not significant with a mean change of -1.6 ETDRS letters after 6 months, but significant with +5.1 ETDRS letters after 12 months. Mean central retinal thickness (OCT) decreased to 374 microm after 6 months (P < 0.001) and to 357 microm after 12 months (P < 0.001). Changes of retinal thickness and visual acuity did not correlate. No other factors investigated, such as age, central retinal thickness, or previous treatments, were predictive for a change of VA. Macular ischemia was not exacerbated as a result of the treatment. CONCLUSION Even in cases with chronic diffuse ischemic diabetic macular edema, a long-term decrease of central retinal thickness can be observed following repeated intravitreal injections of bevacizumab. In these patients, mean decrease in retinal thickness is aligned with a gain in mean VA. Treatment with bevacizumab at an earlier stage of diabetic macular edema without ischemia may be associated with an even better functional outcome.

Aim: To assess whether low concentrations of a fluorescent dye such as Rhodamine 6G would help the unaided human eye visualise the vitreous and the internal limiting membrane (ILM) under standard halogen illumination. Material/methods: The UV/Vis absorption (E) and fluorescence (I) spectra of Rhodamine 6G in water were measured and compared with Indocyanine Green (ICG). Surgery was performed in two rhesus monkeys and consisted of standard pars plana vitrectomy with halogen light source used for illumination. Rhodamine 6G was diluted in balanced salt solution (BSS). A few drops of the dye in a concentration of 0.1% (307 mOsm) were applied over the posterior pole in the air-filled globe and washed out by irrigation after 1 min. Immediately after surgery, the globes were enucleated, fixated and prepared for histological evaluation. Results: In contrast to ICG, both the maximum of the absorption and emission of Rhodamin 6G are very much within the spectral sensitivity of the human eye. The Rhodamine 6G–BSS itself appears red in colour. Using a dye concentration of 0.1%, there was no visible red-staining of the ILM as such. As the dye was irrigated out with BSS, a marked green fluorescence of the fluid within the vitreous cavity was noted. With halogen illumination through a standard 20-gauge light pipe, the dye provided a sufficient green fluorescence to identify and safely remove the ILM and to clearly differentiate areas of peeled from non-peeled ILM. During light microscopy, eyes revealed a peeled ILM demarcation with no signs of acute retinal toxicity. Conclusion: The findings indicate that a fluorescent dye can be used for ILM peeling. Assuming that the fluorophore provides a high enough fluorescence quantum yield after adsorption to the ILM, much lower dye concentrations could be used compared with absorbent dyes, thereby minimising toxic effects.

PURPOSE To describe visualization of the vitreous and the posterior hyaloid membrane using bromophenol blue during vitrectomy for macular hole and retinal detachment. PATIENTS AND METHODS Six patients with macular holes and four with retinal detachments were included in the study. Before and after surgery, complete clinical examination, including funduscopy and measurements of best-corrected visual acuity and intraocular pressure, was performed. Additional functional tests, such as fluorescein angiography, optical coherence tomography (Stratus OCT; Carl Zeiss Meditec, Jena, Germany, Germany), Goldmann perimetry, and multifocal electroretinography as well as photography of the posterior pole, were performed for macular hole patients. Bromophenol blue was used in concentrations of 0.2%. During macular hole surgery, the dye was injected into the air-filled globe, while during surgery for retinal detachment, the globe was partially filled with perfluorocarbon before dye injection after induction of a posterior vitreous detachment to stain the vitreous peripherally. RESULTS Bromophenol blue provided sufficient staining of the attached posterior hyaloid membrane and vitreous remnants in the periphery. This was especially helpful for patients in whom a posterior vitreous detachment could not be induced mechanically by suction using the vitrectomy probe alone, as seen in three of six interventions for a macular hole in this series. In addition, staining of the vitreous or vitreous remnants in the periphery and at the vitreous base was seen in all patients and helped to completely remove the vitreous in a controlled fashion. After macular hole surgery, increase of visual acuity from 20/100 (mean) to 20/40 was seen during follow-up up to 6 months. In one case, the hole persisted and required a second operation. Finally, closure of the hole was achieved in all patients. After retinal detachment surgery, reattachment was achieved in all cases. No dye-related adverse events were seen during follow-up as shown by the functional tests (visual acuity measurement, electroretinography, and perimetry) applied. CONCLUSION Delineation of the vitreous and the posterior hyaloid using bromophenol blue staining greatly facilitates vitreoretinal procedures. Bromophenol blue appeared to be a very helpful and safe tool to visualize the posterior hyaloid membrane in macular hole surgery and assured its complete separation from the retinal surface. The dye also helped to remove vitreous at the vitreous base during retinal detachment surgery. Therefore, bromophenol blue appears as a very good alternative to triamcinolone, which has been used for this purpose, because the dye has no pharmacological properties and no side effects are likely to occur such as cataract formation and increase in intraocular pressure. Further studies including larger numbers of patients are mandatory.

Purpose: To evaluate the effect of intravitreal bevacizumab (Avastin) injections on visual acuity (VA) and foveal retinal thickness in patients with macular oedema secondary to branch retinal vein occlusion. Methods: A prospective, non-comparative, consecutive, interventional case series of 34 patients. Patients received repeated intravitreal injections of 1.25 mg bevacizumab. Main outcome measures were VA (Snellen charts and ETDRS) and retinal thickness (optical coherence tomography measurements) in a follow-up period of 6 months. Results: Patients presented at a mean age of 69 years (range 44–86). Mean duration of symptoms was 40 weeks (range 1–300). Mean (SD) VA at baseline was 0.79 (0.39) logMAR, improving to 0.51 (0.34) logMAR at 6 months (p = 0.009). Mean number of letters on the ETDRS chart at baseline was 45.3 (19.0), improving to 60.6 (19.9) at 6 months (p = 0.003). Mean (SD) retinal thickness at baseline was 474 (120) μm, declining to 316 (41) μm at 6 months. Conclusion: Intravitreal injection of 1.25 mg bevacizumb appears to be an effective treatment option for branch retinal vein occlusion.

Background: The pulsed electron avalanche knife (PEAK-fc) is a new pulsed electrosurgical device that allows for precise, “cold” and traction-free tissue dissection. Aim: To evaluate the surgical applicability, safety and potential complications of PEAK-fc in complicated cataract surgery. Methods: The study included five children with congenital cataracts, two patients with advanced senile cataracts, six adults with mature cataracts, three of them with posterior iris synechia, three patients with post-traumatic cataracts with zonulolysis, one patient with intumescent traumatic cataract and three patients with massive anterior capsule opacification. Anterior and posterior capsulotomies, iris synechiolysis, dissection of anterior capsule opacification and fibrotic scar tissue were performed. PEAK-fc was set at voltages of 500–700 V, pulse duration of 0.1 m and repetition rate of 40–100 Hz. Results: Anterior and posterior capsulotomies were successfully and safely performed in all eyes. The edges of capsulotomies appeared sharp, showing only limited collateral damage. PEAK-fc worked best by just gently touching the capsule, thereby avoiding tractional forces or pressure on the lens capsule. Posterior iris synechiae could be released and anterior capsule opacification was dissected without complications. Conclusions: PEAK-fc is a very helpful cutting device for complicated cases of cataract surgery, especially for mature and congenital cataracts, traumatic zonulolysis or anterior segment complications after intraocular inflammation.

Purpose To compare the efficacy of topical levofloxacin in combination with povidone–iodine irrigation vs povidone–iodine (PVI) alone in reducing conjunctival bacteria. Design Prospective, randomized, controlled trial. Methods One hundred and forty eyes of 140 patients scheduled to undergo intraocular surgery eyes were randomized to either group 1 or 2 (70 each). Whereas group 1 eyes had no prophylactic antibiotic, eyes in group 2 received topical treatment with one drop of 0.5% levofloxacin four times on the day before surgery. Both groups underwent irrigation of the fornices with 1% PVI. Conjunctival swabs were inoculated on solid and broth culture media to determine bacterial growth. Results Of 132 eyes evaluated, baseline culture analysis in thioglycolate demonstrated positive culture results in 55 (84.6%) of 65 eyes from group 1, similar to 55 (82.1%) of 67 eyes in group 2 ( P = .697). Before surgery, 57 (87.7%) of 65 eyes in group 1 had positive culture results, compared with 50 (74.6%) of 67 eyes in group 2 ( P = .055). After irrigation with PVI, 20 (30.8 %) of 65 eyes in group 1 had positive culture results, compared with only eight (11.9%) of 67 eyes in group 2 ( P = .008). After surgery, 15 (23.1%) of 65 eyes in group 1 and six (9.0%) of 67 eyes in group 2 had positive culture results ( P = .027). Conclusions Our study shows an enhanced effect of using topical levofloxacin in combination with PVI irrigation to reduce conjunctival bacteria in patients undergoing intraocular surgery.