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Intraoperative optical coherence tomography (OCT) was so far only available as a microscope-integrated or handheld device. Recently, this technology has been integrated into a femtosecond (FS) laser. This pilot study analyzed the potential of intraoperative imaging using OCT during FS-assisted procedures of the anterior eye segment. Therefore, intraoperatively acquired videos using FS-integrated intraoperative OCT (laser-integrated [LI] OCT) in 14 patients (Victus, Bausch & Lomb) were analyzed in different surgical procedures. The results showed that all surgical steps could be successfully visualized by LI-OCT. LI-OCT added important information regarding the depth and location of the incisions and dissection planes. Moreover, dynamic processes could be observed in real-time. LI-OCT represents a new imaging technology that makes it possible to visualize intraoperative steps during FS-assisted surgery. In the future, automatic image analysis based on artificial intelligence could be helpful to detect complications at an early stage and to automatically stop the laser process in relevant constellations.

To evaluate a novel hydrophobic, non-diffractive, extended depth of focus (EDOF) intraocular lens (IOL) design in comparison to two monofocal aspheric lenses. Inclusion criteria for this prospective, monocentric cohort study were opacification of the crystalline lens and patients’ wishes for surgery. In the case of the EDOF IOL, patients asked for a presbyopia correction. All patients received surgery on both eyes. Corrected and uncorrected distance visual acuity (CDVA, UCDVA), uncorrected and distance corrected intermediate visual acuity (UIVA, DCIVA) and defocus curves (all monocular and binocular) were compared three months postoperatively. Fifty-six eyes were implanted with an EDOF IOL (LuxSmartTM, Bausch & Lomb GmbH, Berlin, Germany), 50 eyes with a monofocal aspheric IOL: 32 eyes with a clear IOL (Polylens® AS 61, Polytech Domilens, Roßdorf, Germany), 16 eyes with a yellow IOL (iSert® 251, Hoya Surgical Optics GmbH, Frankfurt, Germany). Three months postoperatively, UCDVA was comparable with the EDOF IOL, versus the monofocal IOL (P > 0.9). Binocular DCIVA in the EDOF IOL was significantly higher than in the monofocal IOL (P = 0.001). Monocular DCIVA better than 20/23 Snellen was achieved in 10% with the monofocal IOL and in 68% (P < 0.0001) with the EDOF IOL. Defocus curves showed a depth of focus at 20/23 Snellen of 1.6 vs. 0.83 diopters (D) in the EDOF IOL, vs. the monofocal IOL. No patient reported halos or starbursts in non-standardized questioning. This non-diffractive EDOF IOL provided comparably high UCDVA and significantly higher DCIVA than the mono-focal lenses, causing only mild optical phenomena.

Central subendothelial geographic deposits are formed as a fibrillar layer (FL) in advanced Fuchs endothelial corneal dystrophy (FECD). Previous studies demonstrated a significant decrease in corneal endothelial cell (CEC) density and an increase in focal corneal backscatter in the FL area. The present study investigated the association of the FL with edema formation and its localization. Patients (n = 96) presenting for Descemet membrane endothelial keratoplasty (DMEK) for advanced FECD were included. Slit-lamp biomicroscopy with FECD grading was followed by Scheimpflug imaging with en face backscatter analysis and pachymetric analysis. FL dimensions were measured, and correlation with pachymetric values was performed. An FL was detected in 74% of all eyes (n = 71). Pachymetric values in FL-positive versus FL-negative eyes were for corneal thickness at the apex (ACT) 614 ± 52 µm and 575 ± 46 µm (p = 0.001), for peripheral corneal thickness at 1 mm (PCT1mm) 616 ± 50 µm and 580 ± 44 µm (p = 0.002), for PCT2mm 625 ± 48 µm and 599 ± 41 µm (p = 0.017), for PCT3mm 651 ± 46 µm and 635 ± 40 µm (p = 0.128) and for PCT4mm 695 ± 52 µm and 686 ± 43 µm (p = 0.435), respectively. Correlation analysis indicated a weak correlation for the FL maximum vertical caliper diameter with ACT and PCT1mm values but no further relevant correlations. In FL-positive eyes, increased focal corneal backscatter and increased corneal thickness showed primarily central and inferotemporal localization. In conclusion, Scheimpflug imaging shows an association of the FL with increased corneal thickness in advanced FECD and shows localization of the FL and increased corneal thickness in the central and inferotemporal region. This may provide important information for progression assessment and therapeutic decision making in FECD patients in the future.

Purpose Deep anterior lamellar keratoplasty (DALK) has become a safe and standardized technique for the treatment of corneal diseases. The use of femtosecond lasers for corneal trephination in DALK allows for a precise and controlled corneal trephination very close to Descemet’s membrane (DM) which is important for a successful pneumatic dissection and results in separation of Pre-Descemet’s layer (Dua’s layer, PDL) and/or DM from the stroma. However, even with newer curved contact interfaces the cornea becomes massively warped during trephination causing irregular trephination patterns which results in high postoperative astigmatism. Here we present a novel technique of Femto-DALK using a non-contact liquid interface where the cornea keeps its natural curvature during the complete laser process. Methods Case series of two patients, which underwent femtosecondlaser-assistant deep anterior lamellar keratoplasty by using a non-contact liquid interface. The laser device (Ziemer LDV Z8, Ziemer Ophthalmic Systems AG, Port, Switzerland) was used for trephination of the donor and recipient cornea. In one patient Femto-DALK was combined with femtolaser-assisted cataract surgery (Femto-Phaco). Read-out parameters were the feasibility of the technique and postoperative outcome. Results Trephination was successful in both cases leading to a circular trephination very close to the recipients’ Descemet’s membrane. In both patients a big bubble type 1 was induced successfully. Conclusions Femtosecondlaser-assisted DALK using a liquid interface is a novel procedure representing an alternative to manual DALK or Femto-DALK with a contact interface. Future studies need to evaluate outcomes and complication rates in comparison to manual DALK and microscope-integrated Optical Coherence Tomography-aided DALK.

Zusammenfassung Hintergrund Die okuläre Beteiligung bei vernarbendem Schleimhautpemphigoid (SHP) ist mit einer Prävalenz von 25 Fällen je 1 Mio. Einwohner und damit ca. 2100 Patienten in ganz Deutschland selten. Die Diagnosestellung kann – besonders in Abwesenheit anderer Beteiligungen – schwierig und die Therapie komplex und langwierig sein. Nicht selten kommen Immunsuppressiva zum Einsatz. Aufgrund der Komplexität von Diagnose und Therapie sind SHP-Patienten meist an entsprechend spezialisierte Zentren angebunden. Ziel dieses Projektes war die Erfassung der aktuellen augenärztlichen Versorgungssituation von Patienten mit SHP in Deutschland. Methoden Eine papierbasierte Umfrage wurde konzipiert und im April 2020 an alle Universitätsaugenkliniken und weitere potenzielle Zentren versandt. Gefragt wurde nach dem Bestehen einer spezialisierten Sprechstunde, der jährlichen Gesamtzahl der betreuten Patienten, der jährlichen Anzahl von neu diagnostizierten Patienten, den klinischen Kooperationspartnern in Diagnostik und Therapie sowie nach der angewendeten lokalen und systemischen Therapie. Ergebnisse Von insgesamt 44 angeschrieben Kliniken erfolgten 28 (64%) vollständige Rückmeldungen. Im Mittel werden in den Kliniken 27 ± 42 (0 – 200) Patienten betreut und jährlich pro Zentrum 3,6 ± 2,2 (0 – 10) neue Fälle diagnostiziert. Dies entspricht einer Gesamtpatientenzahl von 741 Patienten. Lediglich 9 (32%) der antwortenden Kliniken bieten eine spezialisierte SHP-Sprechstunde an. 93% der Zentren kooperieren mit der lokalen Klinik für Dermatologie. 79% führen die serologische und histologische Diagnostik intern durch. Etwa die Hälfte der Zentren (n = 16) wendet ein standardisiertes Therapieschema an. Systemisch werden Glukokortikoide (66,7%) am häufigsten verwendet, gefolgt von Mycophenolatmofetil und Dapson (57,1%), Rituximab (33,3%), Azathioprin und Cyclophosphamid (28,6%) sowie Methotrexat (19,0%). Am seltensten werden i. v. Immunoglobuline eingesetzt (14,3%). Schlussfolgerung Mit dieser Umfrage unter deutschen augenärztlichen Zentren wurden Daten von etwa einem Drittel der geschätzten Gesamtzahl aller in Deutschland an einem SHP erkrankten Menschen erhoben. Dabei handelt es sich vermutlich ausschließlich um Patienten mit mindestens einer okulären Beteiligung. Aktuell wird eine augenärztliche SHP-Registerstudie etabliert, um die Epidemiologie und Versorgungssituation besser zu erfassen und langfristig zu verbessern.

Objective: To evaluate changes over 3 years in the thickness of inner retinal layers including the peripapillary retinal nerve fiber layer (pRNFL), and combined macular ganglion cell and inner plexiform layers (mGCIPL), in individuals with relapsing-remitting multiple sclerosis (RRMS) versus healthy controls; to determine whether optical coherence tomography (OCT) is sufficiently sensitive and reproducible to detect small degrees of neuroaxonal loss over time that correlate with changes in brain volume and disability progression as measured by the Expanded Disability Status Scale (EDSS). Methods: Individuals with RRMS from 28 centers (n = 333) were matched with 64 healthy participants. OCT scans were performed on Heidelberg Spectralis machines (at baseline; 1 month; 6 months; 6-monthly thereafter). Results: OCT measurements were highly reproducible between baseline and 1 month (intraclass correlation coefficient >0.98). Significant inner retinal layer thinning was observed in individuals with multiple sclerosis (MS) compared with controls regardless of previous MS-associated optic neuritis–group differences (95% CI) over 3 years: pRNFL: -1.86 (-2.54, -1.17) µm; mGCIPL: -2.03 (-2.78, -1.28) µm (both p < 0.0001; effect sizes 0.39 and 0.34). Greater inner retinal layer atrophy was observed in individuals diagnosed with RRMS 5 years (pRNFL: p < 0.05; mGCIPL: p < 0.01). Brain volume decreased by 1.3% in individuals with MS over 3 years compared to 0.5% in control subjects (effect size 0.76). mGCIPL atrophy correlated with brain atrophy (p < 0.0001). There was no correlation of OCT data with disability progression. Interpretation: OCT has potential to estimate rates of neurodegeneration in the retina and brain. The effect size for OCT, smaller than for magnetic resonance imaging based on Heidelberg Spectralis data acquired in this study, was increased in early disease.

Purpose To compare two surgical treatment options for acute corneal hydrops in keratoconus: Mini-DMEK versus predescemetal sutures. Methods Sixteen patients were treated by either Mini-Descemet membrane endothelial keratoplasty (Mini-DMEK) (n = 7, group 1) or predescemetal sutures (n = 9, group 2) early after onset of acute hydrops. Visual acuity, maximum corneal thickness (SD-OCT) in the affected oedematous area, complications and recurrence rates were retrospectively compared between both groups. Measurements were taken immediately preoperatively as well as 1 day, 1 week and 1 month postoperatively (Table 1). Results Both groups showed reductions in corneal thickness and increased visual acuity shortly after surgery. In group 1 (average age 33 years ± 7 years), the best corrected visual acuity (BCVA) increased from logMAR 1.65 ± 0.7 before Mini-DMEK to logMAR 0.93 ± 0.6 30 days after Mini-DMEK (p = 0.046). During that period, maximum corneal thickness decreased from 1159 ± 338 µm before surgery to 531 ± 75 µm after Mini-DMEK (p = 0.046). Patients from group 2 (average age 34 ± 10 years) had a BCVA of logMAR 1.59 ± 0.8 which increased to logMAR 0.97 ± 0.5 (p = 0.014) 30 days after surgery. At the same time, the preoperative maximum corneal thickness decreased from 1439 ± 272 µm to 476 ± 162 µm (p = 0.014). There was no difference in corneal thickness or BCVA one month after the surgical intervention between both groups (p = 0.394 and p = 0.871). Conclusions Both techniques, Mini-DMEK and predescemetal sutures, are effective in the treatment of an acute hydrops in keratoconus. Mini-DMEK appears to be beneficial in large DM tears.

Purpose To identify mechanical factors, as well as patients’ biometric and surgeons’ experience factors that correlate with the FF incidence in microkeratome (MK)-assisted LASIK and to construct a predictive model based on these parameters. Methods 55,700 consecutive LASIK treatments of 28,506 patients between January 2017 and April 2020 done by 50 surgeons in 10 centers, all with Sub Bowman Keratome (SBK) and 90μ head (OUP) were analyzed retrospectively for the incidence of FF and their correlation to mean keratometry, central corneal thickness, MK ring height and stop, as well as surgeons’ experience. A prediction model was built and tested for sensitivity and specificity. Results The incidence of FF using the SBK MK was 0.276%. Risk factors were low central corneal thickness, very flat (-1) or very thick (+2) ring height, and higher stop values (p Conclusions Free flaps are rarely seen in modern MK LASIK. However, the incidence of this complication using the SBK MK increases using higher stop values, very thick and very thin MK rings, and in eyes with thin corneas.

This study aimed to identify the risk factors for endothelial cell density (ECD) loss after Descemet membrane endothelial keratoplasty (DMEK) and analyse whether donor tissues from cold versus organ culture differ in terms of ECD loss after DMEK. Consecutive DMEK cases from a prospective database for Fuchs’ endothelial corneal dystrophy were retrospectively analysed between 2011 and 2016 at the University of Cologne, and the possible risk factors for ECD loss, including patient-related factors, type of tamponade (air or 20% sulphur hexafluoride gas), type of surgery (triple DMEK or DMEK alone), re-bubbling, immune rejection, and donor-related factors were determined. Eight hundred and forty-one eyes were selected. There was no significant difference in the best-corrected visual acuity (logarithm of the minimal angle of resolution) and corneal thickness (P = 0.540 and P = 0.667) between groups. Immune reactions were more common in cold cultures (P = 0.019), but ECD loss (1 year after DMEK) was greater in organ cultures (38.3 ± 0.8%) than in cold cultures (34.7 ± 1.4%) (P = 0.022). Only re-bubbling was significantly associated with ECD loss (P

Purpose To assess the long-term outcome of Descemet membrane endothelial keratoplasty (DMEK) following failed penetrating keratoplasty (PK). Methods Retrospective review of 1840 consecutive DMEK surgeries from the prospective Cologne DMEK database performed between 07/2011 and 08/2017 at the Department of Ophthalmology, University of Cologne. Results Fifty-two eyes received a DMEK surgery after failed PK. Main indications for initial PK were Fuchs endothelial corneal dystrophy (23.1%), keratoconus and herpetic keratitis (each 15.4%). Best-corrected visual acuity (BCVA) at 3, 6 and 12 months was 0.72 ± 0.39 (n = 33), 0.56 ± 0.36 (n = 32) and 0.38 ± 0.28 (n = 23), respectively. Two- and 3-year BCVA was 0.37 ± 0.21 (n = 21) and 0.32 ± 0.18 (n = 10). Mean improvement in visual outcome in logMAR lines was +4.3 ± 3.4 at 6 months, +5.0 ± 3.6 at 12 months, +6.0 ± 2.3 at 24 months and +5.4 ± 2.7 at 36 months, respectively. 59.6% received at least one rebubbling and 40.4% did not necessitate a rebubbling. Endothelial cell density (ECD)-decrease at 6 months was 36% (n = 17), 37% at 12 months (n = 17), 40% at 2 years (n = 8) and 32% at 3 years (n = 2). 34.6% of transplants needed a regraft. Conclusion Descemet membrane endothelial keratoplasty (DMEK) is a feasible treatment option after failed PK having a relatively good long-term outcome.

Spaceflight-associated neuro-ocular syndrome (SANS) involves unilateral or bilateral optic disc edema, widening of the optic nerve sheath, and posterior globe flattening. Owing to posterior globe flattening, it is hypothesized that microgravity causes a disproportionate change in intracranial pressure (ICP) relative to intraocular pressure. Countermeasures capable of reducing ICP include thigh cuffs and breathing against inspiratory resistance. Owing to the coupling of central venous pressure (CVP) and intracranial pressure, we hypothesized that both ICP and CVP will be reduced during both countermeasures. In four male participants (32 ± 13 yr) who were previously implanted with Ommaya reservoirs for treatment of unrelated clinical conditions, ICP was measured invasively through these ports. Subjects were healthy at the time of testing. CVP was measured invasively by a peripherally inserted central catheter. Participants breathed through an impedance threshold device (ITD, −7 cmH2O) to generate negative intrathoracic pressure for 5 min, and subsequently, wore bilateral thigh cuffs inflated to 30 mmHg for 2 min. Breathing through an ITD reduced both CVP (6 ± 2 vs. 3 ± 1 mmHg; P = 0.02) and ICP (16 ± 3 vs. 12 ± 1 mmHg; P = 0.04) compared to baseline, a result that was not observed during the free breathing condition (CVP, 6 ± 2 vs. 6 ± 2 mmHg, P = 0.87; ICP, 15 ± 3 vs. 15 ± 4 mmHg, P = 0.68). Inflation of the thigh cuffs to 30 mmHg caused no meaningful reduction in CVP in all four individuals (5 ± 4 vs. 5 ± 4 mmHg; P = 0.1), coincident with minimal reduction in ICP (15 ± 3 vs. 14 ± 4 mmHg; P =0.13). The application of inspiratory resistance breathing resulted in reductions in both ICP and CVP, likely due to intrathoracic unloading.

Lymphangiogenesis is essential for fluid homeostasis in vascularized tissues. In the normally avascular cornea, however, pathological lymphangiogenesis mediates diseases like corneal transplant rejection, dry eye disease, and allergy. So far, a physiological role for lymphangiogenesis in a primarily avascular site such as the cornea has not been described. Using a mouse model of perforating corneal injury that causes acute and severe fluid accumulation in the cornea, we show that lymphatics transiently and selectively invade the cornea and regulate the resolution of corneal edema. Pharmacological blockade of lymphangiogenesis via VEGFR-3 inhibition results in increased corneal thickness due to delayed drainage of corneal edema and a trend towards prolonged corneal opacification. Notably, lymphatics are also detectable in the cornea of a patient with acute edema due to spontaneous Descemet´s (basement) membrane rupture in keratoconus, mimicking this animal model and highlighting the clinical relevance of lymphangiogenesis in corneal fluid homeostasis. Together, our findings provide evidence that lymphangiogenesis plays an unexpectedly beneficial role in the regulation of corneal edema and transparency. This might open new treatment options in blinding diseases associated with corneal edema and transparency loss. Furthermore, we demonstrate for the first time that physiological lymphangiogenesis also occurs in primarily avascular sites.

Ziel der Studie war es, mithilfe der Smartphone-App DryEyeRhythm Charakteristika und Risikofaktoren bei diagnostiziertem und nicht diagnostiziertem Trockenen Auge zu identifizieren. Dazu wurden die Daten der App-User gesammelt und analysiert (vorliegende Informationen schlossen ein: Demografie, medizinische Vorgeschichte, Informationen zur Lebenweise der Nutzer, subjektive und krankheitsspezifische Symptome erhoben mithilfe des Ocular Surface Disease Index und der Zung Self-Rating Depression Scale). Insgesamt wurden die Daten von 4454 Nutzern (899 mit diagnostiziertem und 2395 mit nicht diagnostiziertem Trockenen Auge) anaysiert und folgende Risikofaktoren für ein symptomatisches Trockenes Auge identifiziert: junges Alter, weibliches Geschlecht, Heuschnupfen, Depression, psychische Erkrankungen außer Depression oder Schizophrenie, momentanes Tragen von Kontaktlinsen, lange Bildschirmarbeit und Rauchen. Risikofaktoren für ein nicht diagnostiziertes symptomatisches Trockenes Auge umfassten: junges Alter, männliches Geschlecht, kein Vorliegen einer Kollagenose, psychische Erkrankungen außer Depression oder Schizophrenie, ophthalmologische chirurgische Eingriffe außer LASIK oder Kataraktoperation und Kontaktlinsennutzung (momentan oder in der Vergangenheit). Risikofaktoren für ein nicht diagnostiziertes, nicht symptomatisches Trockenes Auge konnten nicht identifiziert werden.

Purpose: Manual measurements of strabismus are subjective, time consuming, difficult to perform in babies, toddlers, and young children, and rely on the examiner’s skill and experience. An automated system, based on eye tracking and dedicated full occlusion glasses, was developed to provide a fast, objective, and easy-to-use alternative to the manual measurements of strabismus. This study tested the efficacy of the system in determining the presence of strabismus in children, as well as its type and the amount of deviation, in addition to differentiating between phorias and tropias. Design: A prospective, masked, inter-rater reliability study. Methods: A prospective, masked, cross-sectional study included 69 children, 3–15 years of age. A cover-uncover test and a prism alternating cover test (PACT) for the primary gaze, at a distance of 50 cm, were performed by 2 independent, masked examiners and by the automated system. Results: A high correlation was found between the automated and the manual test results (R = 0.9 and P < 0.001 for the horizontal deviation, and R = 0.91 and P < 0.001 for the vertical deviations, with 100% correct identification of the type of deviation). The average automated test duration was 46 seconds. The Bland-Altman plot, used to compare the 2 measurement methods, showed a mean value of −2.9 prism diopters (PD) and a half-width of the 95% limit of agreement of ± 11.4 PD. Conclusion: The automated system provides precise detection and measurements of ocular misalignment and differentiated between phorias and tropias. It can be used in participants from the ages of 3 years old and up.

Introduction: Anti-inflammatory, topical therapy of severe keratitis in dry eye disease (DED) and ocular graft-versus-host disease (oGvHD) includes steroids, cyclosporine (Cs), and others. In Germany, a commercial product containing 0.1% Cs in a cationic formulation is available since 2015. Objective: The aim of this study was to present real-life data using cationic 0.1% Cs in oGvHD patients. Methods: This was a retrospective study of 26 oGvHD and 41 DED patients with corneal staining of at least Oxford grade III. Parameters analyzed were Ocular Surface Disease Index, corneal staining, intraocular pressure, tear film break-up time, Schirmer, and visual acuity. In addition, it was evaluated how different Cs formulations were tolerated. Results: Corneal staining improved significantly in 1 eye in DED but not in oGvHD. In DED, cationic 0.1% Cs was not tolerated by 32% of the patients, in contrast to 0.05% Cs in castor oil not tolerated by 47% and liposomal 0.05% Cs by 63%. In oGvHD patients, cationic 0.1% Cs was not tolerated by 62%, 0.05% Cs in castor oil by 33%, and liposomal 0.05% Cs by 39% of the patients. Conclusions: This study demonstrates differences between the tolerance of different Cs formulations depending on the underlying cause of severe keratitis. Cationic 0.1% Cs is considerably less tolerated in oGvHD, and its use should be considered with care.

In vielen laufenden Studien zu Gentherapien in der Augenheilkunde werden Adeno-assoziierte Viren oder Lentiviren als Vektoren benutzt. Allerdings können diese Vektoren die Retina aufgrund der relativ impermeablen epiretinalen Membran schlecht durchdringen, weswegen das Gen-Therapeutikum vorzugsweise subretinal injiziert wird. Ziel der vorliegenden Studie war es, die subretinale Applikation des AAV-REP1-Gentherapeutikums, bestehend aus einem genetischen Vektor, der auf das Rab-Escort-Protein-1 (REP-1) codierende Gen abzielt (AAV-REP1), mithilfe der Mikroskop-intregrierten Optischen Kohärenztomographie (MI-OCT) durchzuführen.

Purpose Corneal neovascularization, in particular lymphangiogenesis, is a limiting factor in corneal transplant survival. Novel treatment approaches focus on (selective) inhibition and regression of lymphatic vessels. Imaging clinically invisible corneal lymphatic vessels is a prerequisite for these strategies. Using a murine model, this study investigates whether corneal lymphatic vessels can be imaged using microscopic optical coherence tomography (mOCT). Methods Corneal neovascularization was induced by intrastromal placement of 11.0 nylon sutures in one eye of BALB/c mice. After 2 weeks, cross-sectional images and volumes of the corneas with a 0.5 mm lateral and axial field of view were acquired using a custom-built mOCT system enabling a resolution of 1 μm at a B-scan rate of 165/s. Three of the six animals received an additional intrastromal injection of India ink 24 hours before the measurement to stain the corneal lymphatic system in vivo. Immunohistochemistry using CD31 and LYVE-1 was used to validate the mOCT findings. Results Using mOCT, lymphatic vessels were visible as dark vessel-like structures with the lumen lacking a hyperreflective wall and mostly lacking cells. However, individual, slowly moving particles, which most likely are immune cells, occasionally could be observed inside the lumen. In lymphatic vessels of ink-stained corneas, hyperreflection and shadowing underneath was observed. Ink-filled lymphatic vessels were colocalized in consecutive corneal flat mounts of the same specimen. Conclusions Corneal lymphatic vessels can be imaged using mOCT. This novel approach opens new options for noninvasive clinical imaging of corneal lymphatic vessels for diagnostic and therapeutic indications.

A 3-year-old boy presented with acute corneal hydrops on the left eye and spontaneous corneal rupture on the right eye. A diagnosis of brittle cornea syndrome was confirmed by molecular analysis. A novel mutation, the homozygous variant c.17T>G, p.V6G, was found in the gene for PR-domain-containing protein 5 (PRDM5) in exon 1. Brittle cornea syndrome is a rare connective tissue disease with typical ocular, auditory, musculoskeletal, and cutaneous disorders. Almost all patients suffer from declined vision due to corneal scarring, thinning, and rupture. The most common ophthalmologic findings include keratoconus, progressive central corneal thinning, high myopia, irregular astigmatism, retinal detachment, and high risk for spontaneous corneal or scleral rupture. In addition to describing the case with a novel mutation here we review the current literature on brittle cornea syndrome pathogenesis, clinical findings, and therapy.

Background Corneal neovascularization is considered an important risk factor for allograft rejection after corneal transplantation (keratoplasty). Therefore, the aim of this study was to determine whether preoperative reduction of corneal neovascularization by fine-needle thermal cauterization combined with bevacizumab reduces the incidence of allograft rejection after subsequent high-risk keratoplasty. Methods In this interventional uncontrolled clinical pilot study, 31 eyes of 31 patients with corneal neovascularization in at least one corneal quadrant were included. All eyes were treated by fine-needle thermal cauterization of corneal vessels and subconjunctival injection of bevacizumab. Both treatments were repeated in the cases of visible reperfusion of occluded vessels. Afterward, penetrating keratoplasty was performed. When corneal neovascularization was present on the day of keratoplasty, additional vessel cauterization and injection of bevacizumab was performed. Patients were then followed to determine the incidence of allograft rejection. Results In 18 eyes, vessel cauterization with bevacizumab injection was performed once before keratoplasty, whereas 13 eyes required retreatment before keratoplasty. No complications were observed. In 23 eyes, corneal neovascularization was present on the day of keratoplasty due to reperfusion of previously occluded vessels and simultaneous vessel cauterization with bevacizumab injection was performed. During follow-up (mean: 560 days; range: 59-1095 days), 4 graft rejection episodes in 4 eyes were observed. Estimated probabilities of corneal graft survival were 92.9% after 1 year (number at risk: 23), 78.4% after 2 years (number at risk: 9), and 78.4% after 3 years (number at risk: 3). Conclusions Our initial results indicate that angioregressive treatment of pathological corneal vessels by fine-needle thermal cauterization combined with subconjunctival injection of bevacizumab before high-risk keratoplasty seems to result in graft survival rates comparable to survival rates seen in normal-risk keratoplasty. The findings of our pilot study warrant further controlled clinical trials with longer follow-up in a larger patient cohort.

Boston keratoprosthesis (KPro) type I is a technique to treat patients with corneal diseases that are not amenable to conventional keratoplasty. Correct assembly and central implantation of the prosthesis are crucial for postoperative visual recovery. This study investigates the potential benefit of intraoperative optical coherence tomography (OCT) to monitor KPro surgery. Retrospective case series are presented for two patients who underwent Boston KPro type I implantation. The surgery in both patients was monitored intraoperatively using a commercially available intraoperative OCT (iOCT) device mounted on a surgical microscope. Microscope-integrated intraoperative OCT was able to evaluate the correct assembly and implantation of the KPro. All parts of the prosthesis were visible, and interfaces between the corneal graft and titanium backplate or anterior optics were clearly depictable. Moreover, iOCT visualized a gap between the backplate and graft in one case, and in the other case, a gap between the anterior optic and graft. Neither gap was visible with a conventional surgical microscope. The gap between the anterior optic and the graft could easily be corrected. Microscope-integrated iOCT delivers enhanced information, adding to the normal surgical microscope view during KPro surgery. Correct assembly can be controlled as well as the correct placement of the Boston KPro into the anterior chamber.

Purpose Conjunctiva-associated lymphoid tissue (CALT) is thought to play a key role in initiating ocular surface related immune responses. This study was planned to get first profound insights into the function of CALT related to development, cellular dynamics and morphological alteration using a novel mouse model. Methods Expression and morphology of CALT were investigated using BALB/c mice kept under different housing conditions, after topical antigen-stimulation and following lymphadenectomy and splenectomy. Particles and bacteria were applied topically to study antigen-transport. Intravital visualization was performed using two-photon microscopy. Results Postnatal development and ultrastructure of CALT in the mouse is similar to humans. Topical antigen-challenge significantly alters CALT expression. Bacterial translocation is demonstrated via lymphoepithelium whereas cellular velocities within follicles were approximately 8 µm/min. Conclusions CALT in the mouse is an immunological interface of the ocular surface, featuring dynamic processes such as morphological plasticity, particle/bacteria transport and cellular migration.

Immunologic graft rejection is the main complication after corneal transplant into pathologically prevascularized so‐called high‐risk eyes. The aim of this study was to evaluate whether ultraviolet (UV) light crosslinking can regress pathologic corneal blood and lymphatic vessels and thereby improve subsequent graft survival. Using the murine model of suture‐induced corneal neovascularization, we found that corneal crosslinking with UVA light and riboflavin regressed both preexisting blood and lymphatic vessels significantly via induction of apoptosis in vascular endothelial cells. In addition, macrophages and CD45+ cell counts were significantly reduced. Consistently, corneal crosslinking reduced keratocyte density and corneal thickness without affecting corneal nonvascular endothelial cells, iris, and lens depending on the crosslinking duration. Furthermore, using the murine model of corneal transplant, long‐term graft survival was significantly promoted (P, Corneal crosslinking with ultraviolet‐A light and riboflavin can regress mature pathological corneal blood and lymphatic vessels, thereby promoting graft survival of a prevascularized high‐risk corneal transplantation.