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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.

PURPOSE To explore the impact of iris color on the outcome of Descemet membrane endothelial keratoplasty (DMEK). METHODS Consecutive cases of Fuchs endothelial dystrophy after DMEK were retrospectively analyzed from the prospective Cologne DMEK database between 2011 and 2017 at the University of Cologne, Germany. Iris pictures were graded by color into blue, green, or brown and compared regarding outcome parameters including best-corrected visual acuity (converted to logarithm of the minimal angle of resolution), central corneal thickness, endothelial cell density (ECD), each at preoperative (baseline) and postoperative 12 months, rebubbling rates, cystoid macular edema (CME), and immune rejections after surgery. RESULTS One thousand one hundred six eyes of 814 patients were included in this study that consisted of 354 blue eyes, 418 green eyes, and 244 brown eyes. There was no significant correlation between iris color and any parameter (best corrected visual acuity; P = 0.064 at preoperatively, P = 0.959 at 12 months) (ECD; P = 0.158 preoperatively, P = 0.859 at 12 months) (central corneal thickness; P = 0.148 preoperatively, P = 0.252 at 12 months). The loss of ECD at 12 months after surgery was 37.2% ± 1.0% in blue eyes, 37.2% ± 0.9% in green eyes, and 37.2% ± 1.2% in brown eyes (P = 0.999). Immune rejections were 1.7%, 2.9%, and 0.8% (P = 0.168) in blue, green, and brown eyes, respectively. Rebubbling rates and CME incidence were similar in each group (P = 0.129, and P = 0.552 respectively). CONCLUSIONS The iris color has no significant impact on the outcome after DMEK. Thus, DMEK can be applied effectively, regardless of the iris color.

The study aims to compare outcomes after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) in keratoconic eyes with or without previous hydrops.Retrospective analysis of 211 eyes who received PK (group 1, n = 74 [history of hydrops: n = 33]) or DALK (group 2, n = 137 [history of hydrops: n = 9]) from 2012 to 2019 at the Department of Ophthalmology, University of Cologne, Germany. Analysis included best spectacle-corrected visual acuity (BSCVA), complications, immune reactions, graft survival and keratometry, and subgroup analyses for subjects with or without previous hydrops.Follow-up was 34.0 ± 23.6 months in group 1 and 30.7 ± 22.5 months in group 2. No significant difference was found in the course of BSCVA between groups 1 and 2 (p = 0.182) and in postoperative BSCVA between eyes with and without previous hydrops, regardless of the surgical method (p = 0.768). Endothelial immune reactions occurred exclusively in group 1 and did not occur more frequently in eyes with previous hydrops (p = 0.377). A higher risk of complications for eyes with previous hydrops was observed (p = 0.022). There was no difference in astigmatism and maximum keratometry (KThe prognosis for visual outcome after keratoplasty including visual acuity, astigmatism, and K

Purpose: To evaluate the course of corneal biomechanical properties (corneal hysteresis and corneal resistance factor) after Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial dystrophy (FECD). Methods: In this prospective study, we consecutively included 49 patients with FECD with an indication for DMEK. Central corneal thickness, measured using the Oculus Pentacam, and corneal hysteresis (CH) and corneal resistance factor (CRF), both measured using the Reichert Ocular Response Analyzer, were examined preoperatively, 3 months, and 6 months after DMEK. Results: CH was significantly increased 6 months postoperatively (8.66 +/- 2.50 mm Hg) compared with preoperative baseline (7.43 +/- 1.56 mm Hg). Preoperative CRF (7.89 +/- 1.68 mm Hg) increased significantly 6 months after DMEK (8.49 +/- 1.71 mm Hg). Preoperative central corneal thickness showed a significant decrease from 629 +/- 58 mm to 550 +/- 40 mm after 3 months and 535 +/- 40 mm after 6 months postoperatively. Conclusions: DMEK affects both measured corneal biomechanical properties in patients with FECD: CH and CRF. This has to be taken into account for the accuracy of intraocular pressure measurements.

The purpose of this study was to describe a simple rescue technique to solve postoperative double anterior chamber refractory to rebubbling in deep anterior lamellar keratoplasty (DALK).This study analyzed consecutive patients who underwent DALK between June 2014 and March 2018 and required a postoperative reattachment of Descemet membrane because of macroperforation-led persistent double chambers. The technique entails placing anchoring sutures to attach Descemet membrane to the donor's posterior stroma. Anchoring sutures were removed within 1 month of surgery. The postoperative best spectacle-corrected visual acuity (BSCVA) [converted to logarithm of the minimum angle of resolution (logMAR) units], endothelial cell density (cells/mm2), graft survival, postoperative complications, and corneal astigmatism (diopters) were evaluated.Five eyes from 5 patients were included in this study [5 women, 63.6 ± 6.0 yrs (32-80 yrs); mean follow-up duration, 72.0 ± 23.3 mo (30-100 mo)] (mean ± SD). The grafts survived successfully in all patients without primary or secondary graft failure. The best spectacle-corrected visual acuity improved from 1.26 ± 0.66 logMAR preoperatively to 0.25 ± 0.15 logMAR postoperatively (n = 5, P = 0.042). The endothelial cell density was 1468 ± 810 cells/mm2 at the last visit.Macroperforation of Descemet membrane during DALK with incomplete removal of the stroma can lead to persistent double anterior chamber. This complication could be solved by the technique devised by this study.

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.

PURPOSE The purpose of this study was to investigate the impact of transient elevations in postoperative intraocular pressure (IOP) on the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) surgery in non-glaucoma patients. METHODS Retrospective analysis from a prospective database of eyes without preexisting glaucoma that underwent DMEK with 90% anterior chamber and 20% sulfur hexafluoride endotamponade. Group A included eyes without postoperative IOP increase (IOP

PURPOSE To analyze the effect of anticoagulant therapy (ACT) for systemic diseases on the outcome of Descemet membrane endothelial keratoplasty (DMEK). METHODS Consecutive eyes with Fuchs endothelial dystrophy that underwent DMEK between August 4, 2011, and July 15, 2016, were retrospectively analyzed. Data were obtained from the Cologne DMEK database at the University of Cologne, Germany. Best spectacle-corrected visual acuity (logMAR), endothelial cell density (at baseline and postoperatively up to 12 months), and rebubbling rates were compared between patients receiving ACT (ACT group) and those with no anticoagulant treatment (NCT group). RESULTS In this study, 329 eyes of 329 patients were included (ACT group n = 97, NCT group n = 232; mean age 69.9 ± 9.1 years). Bleeding was more common in the ACT group (P < 0.001). Preoperative best spectacle-corrected visual acuity was 0.59 ± 0.44 and 0.48 ± 0.35 logMAR for the ACT and NCT groups, respectively, which improved to 0.13 ± 0.08 and 0.08 ± 0.16 logMAR, respectively, at 12 months postoperatively. No significant difference in endothelial cell density loss at 12 months was found between the groups (ACT group 36.2% ± 14.7%, NCT group 38.5% ± 15.1%; P = 0.467). Rebubbling rate was 19.6% in the ACT group and 28.9% in the NCT group (P = 0.08). CONCLUSIONS Although ACT increases the risk for preoperative and intraoperative bleeding in DMEK, there seems to be no negative effect on DMEK outcome. Thus, it is not advisable to stop ACT for DMEK surgery.

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 We sought to assess the correlation of corneal endothelial cell (CEC) density to alterations of collagen composition of Descemet membrane (DM) in advanced Fuchs endothelial corneal dystrophy (FECD) and to image such changes by slit-lamp biomicroscopy in vivo. Design Prospective, observational consecutive case series. Methods Fifty eyes (50 subjects) with advanced FECD were enrolled. After slit-lamp biomicroscopy and corneal Scheimpflug imaging, the Descemet endothelium complex (DEC) was retrieved during DM endothelial keratoplasty (DMEK) surgery. The expression of collagens I, III, and IV (COL I, COL III, and COL IV) and corresponding CEC density were analyzed by immunofluorescence flat mount-staining. Presence, diameter and surface area of collagen expression, and CEC density served as the main outcome measures. Results Immunofluorescence staining revealed central coherent collagen positive areas (mean surface area = 10 mm2 ± 6 mm2) corresponding to a fibrillar layer burying the guttae of DM in 84% (42/50) of DECs. CEC density overlying the fibrillar layer compared with the periphery was significantly reduced (−54.8%, P Conclusion A fibrillar layer with a clear geographic pattern marks areas of pronounced loss of CEC density in advanced FECD eyes and may be imaged by slit-lamp biomicroscopy in vivo.

Background/AimsTo analyse graft detachments prior to rebubbling, the influence of rebubbling on the postoperative outcome after Descemet membrane endothelial keratoplasty (DMEK) and the need for rebubbling on the contralateral eye.MethodsIn this retrospective cohort study, out of 1541 DMEKs, optical coherence tomography scans and clinical records of 499 eyes undergoing rebubbling after DMEK at the University Hospital of Cologne, Cologne, Germany, were examined. Main Outcome measures were (a) number, localisation and size of graft detachments; (b) influence of rebubbling/s on postoperative outcome after 12 months; and (c) rebubbling risk of the contralateral eye after DMEK.ResultsMean number of detachment areas was 2.02±0.9. Mean lateral diameter of all detachments was 4534.76±1920.83 μm. Mean axial diameter was 382.53±282.02 μm. Detachments were equally distributed over all regions of the cornea. Best spectacle corrected visual acuity ( BSCVA) after 12 months was 0.197±0.23 logarithm of the minimum angle of resolution, endothelial cell density (ECD) was 1575.21±397.71 cells/mm2 and mean central corneal thickness (CCT) was 566.37±68.11 μm. BSCVA, CCT, ECD or endothelial cell loss of all rebubbled patients were not influenced by the number of rebubblings or the time between DMEK and rebubbling. Of the rebubbled patients, which received a DMEK subsequently on the other eye, 193 (58.8%) also received a rebubbling, which was significantly higher, when compared to the overall rebubbling rate of 32.3% (p=0.000).ConclusionsThe overall number of rebubblings has no influence on the postoperative outcome after DMEK, if a rebubbling becomes necessary. Patients who received a rebubbling on one eye have an elevated risk for a rebubbling on the fellow eye.

PURPOSE Descemet membrane endothelial keratoplasty (DMEK) has developed into a safe procedure for the replacement of diseased corneal endothelium. However, DMEK still results in a significant donor endothelial cell loss. Here, we compare 2 different graft implantation techniques. METHODS Twenty patients undergoing DMEK, where a DMEK injection cartridge was used to flush the graft into the anterior chamber (G-38635 single-use DMEK-Cartridge; Geuder AG, Heidelberg, Germany; group A), were retrospectively compared with 20 patients, where a standard lens injection cartridge (AT.Smart Cartridge; Carl Zeiss Meditec AG, Jena, Germany; group B) was used to push the graft with a plunger. Outcome parameters were intraoperative orientation of the graft, insertion-to-attachment time, rebubbling rates, and postoperative best spectacle-corrected visual acuity, endothelial cell count, and central corneal thickness after 12 months. The surfaces of both cartridges were evaluated by scanning electron microscopy. RESULTS In group A, the insertion-to-attachment time was significantly higher (P = 0.003). Initially, the graft was oriented correctly in 40% of the patients in group A compared with 90% in group B (P = 0.001). No differences were obtained between both groups regarding central corneal thickness, endothelial cell count or best spectacle-corrected visual acuity, and rebubbling rates after 12 months. Scanning electron microscopy analysis demonstrated a rougher and sharper surface of the shooter of group B. CONCLUSIONS This study shows significant differences between both insertion techniques regarding correct graft orientation directly after graft implantation leading to prolonged insertion-to-attachment time when the graft is flushed instead of pushed into the anterior chamber.

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.

Purpose The change from air to 20% sulfur hexafluoride (SF6) as anterior chamber tamponade for Descemet membrane endothelial keratoplasty (DMEK) significantly reduced the rebubbling rate. Nonetheless, underlying mechanisms are not completely understood. In this study, we investigate the morphology of graft detachments after DMEK depending on the tamponade and its influence on postoperative rebubbling. Methods In this retrospective analysis of prospective data of 204 consecutive patients who underwent DMEK with 100% air, or 20% SF6, we compared the SF6 group with the air group regarding the number, lateral and axial diameter and localization of detachments, visual acuity (BSCVA), and incidence of rebubbling after 1 week (T1), after 1 (T2), 3 (T3), 6 (T4), and 12 (T5) months postoperatively. Results The air group showed more detachments at all time points. Detachments in this group were of a larger axial diameter at T1, T4, and T5 and of a larger lateral diameter at T1, T3, T4, and T5 compared with the SF6 group. Patients receiving SF6 needed fewer rebubblings at T1 compared with patients receiving air (12.1% vs. 29.1%, P = 0.003), but not at T2 (15.1% vs. 19.1%, P = 0.56). There was no difference in postoperative BSCVA between the groups. Conclusions Early graft attachment after DMEK, which is improved by the use of SF6 as anterior chamber tamponade, is important for the overall rebubbling rate and improves wound-healing mechanisms between the graft and recipient cornea. Faster resolving air tamponade is associated with extended detachments especially inferiorly and mid-peripherally, but has no negative effect on the long-term BSCVA.

Excimer laser phototherapeutic keratectomy (PTK) is a safe treatment for superficial corneal opacities, e.g., in corneal dystrophies or degenerations. Nevertheless, no standardized treatment protocols are available and intraoperative monitoring was not possible, so far. Here we evaluate the potential benefits of the intraoperative assessment by microscope-integrated intraoperative optical coherence tomography (MI-OCT) of corneal optical properties during PTK. Retrospective study of eight patients (one male, seven females; age range, 43–80 years, mean = 66.1 years) using an 840-nm microscope-integrated spectral-domain OCT (iOCT; OptoMedical Technologies, Luebeck, Germany adapted to HS Hi-R Neo 900A, Haag Streit Surgical, Wedel, Germany). Images were acquired before and after corneal abrasion and after PTK. For PTK, a SCHWIND Amaris 750S excimer laser (SCHWIND eye-tech-solutions GmbH und KO. KG) was used. Parameters assessed were the central corneal thickness (CCT), changes in central depth-dependent corneal tissue intensity (TI), and corneal surface roughness (SR) in cross-sectional images of the cornea. Intraoperative monitoring using microscope-integrated OCT was possible in all patients at all time points. TI of the anterior corneal stroma decreased significantly (p = 0.037) after PTK (T1 = 15.1 ± 3.6, T2 = 15.0 ± 3.84, T3 = 13.7 ± 3.38), but not after corneal abrasion alone, indicating increased transparency caused by excimer laser PTK. CCT was significantly lower after corneal abrasion (p = 0.017), but not after PTK (T1 = 630.4 ± 70 μm, T2 = 544.1 ± 59.4 μm, T3 = 558.3 ± 52.5 μm. SR significantly decreased (p = 0.043) after PTK (T1 = 614.4 ± 37.5 pixels, T2 = 634.4 ± 35.6 pixels, T3 = 611.0 ± 40.3 pixels). Intraoperative OCT allows real-time imaging during PTK and the assessment of corneal optical transparency and its surface roughness. It has to be clarified in larger studies if these parameters correlate with later postoperative visual outcomes.

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.

Trypan blue (TB) is used for visualization of the endothelium-Descemet membrane graft during Descemet membrane endothelial keratoplasty (DMEK). However, TB is assumed to have a dose-dependent toxic effect on the corneal endothelium. We retrospectively compared a lutein/zeaxanthin and Brilliant Blue (LZ/BB)-based dye for preparation and transplantation of the graft in DMEK to TB.In 20 patients, a dye composed of 1% LZ /0.025% BB was used, and in 22 patients, 0.06% TB was used for graft visualization in DMEK. We evaluated the rebubbling rate, best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), and endothelial cell density (ECD) before and 3 and 6 months after transplantation.Staining of endothelium-Descemet membrane with LZ/BB was faint but sufficient. There was no significant difference between both groups, except in CCT after 3 months, which was lower in the LZ/BB group (P = 0.02). In the LZ/BB group, BSCVA improved from 0.48 ± 0.39 before DMEK to 0.19 ± 0.09 after 6 months (P0.05) (20% rebubbling rate). Donor ECD decreased from 2735 ± 259 cells/m preoperatively to 1876 ± 316 cells/mm (P0.0001) at 6 months (31.4%). CCT decreased from 642 ± 130 μm preoperatively to 519.8 ± 38 μm (P0.0001) at 6 months. In the TB group, BSCVA improved from 0.43 ± 0.27 to 0.17 ± 0.14 (P = 0.0003) at 6 months (30% rebubbling rate). ECD decreased from 2825 ± 263 to 1777 ± 302 cells/mm (P0.0001) after 6 months (36.3%), CCT from 638 ± 48 μm preoperatively to 531 ± 48 μm (P0.0001) at 6 months.LZ/BB-based dyes are suitable for DMEK with outcomes comparable to TB. However, available formulas result in faint staining, discouraging their routine use in donors with assumed difficult preparation.

PURPOSE To investigate the effect of intensified postoperative topical steroid therapy after Descemet membrane endothelial keratoplasty combined with cataract surgery (Triple-DMEK) on postoperative endothelial cell density (ECD). METHODS This comparative clinical study with historical controls was conducted at a tertiary hospital, specialized in corneal surgery. Patients undergoing DMEK or Triple-DMEK are included prospectively in the Cologne DMEK Database. Until April 2014, first week's postoperative standard therapy for lamellar keratoplasties was prednisolone acetate eye drops 1% applied 5× daily. After April 2014, first week's postoperative standard therapy changed to prednisolone acetate eye drops 1% applied hourly. We compared 75 consecutive eyes before (group 1) with 75 consecutive eyes after the change of therapy regimen (group 2). Patients received ECD analysis 3 and 6 months after surgery. RESULTS ECD of grafts in group 1 before transplantation, and 3 months and 6 months after surgery was 2697 ± 218, 1765 ± 349, and 1703 ± 432 cells/mm, respectively. ECD of grafts in group 2 was 2696 ± 267, 1737 ± 450, and 1694 ± 482 cells/mm, respectively. Over 3 and 6 months, ECD in group 1 decreased by 35% ± 13% and 38% ± 18%, respectively. In group 2, ECD decreased by 36% ± 16% and 38% ± 16%, respectively. Neither absolute numbers nor decrease in ECD differed significantly between groups 1 and 2 at any time point (all P > 0.60). CONCLUSIONS Intensified early postoperative topical steroid therapy during the first postoperative week does not stabilize ECD, nor does it have a toxic effect on endothelial cells during a follow-up of 6 months.

Impaired subjective morning visual acuity with improvement of symptoms during the day is pathognomonic for corneal endothelial dysfunction in advanced Fuchs endothelial corneal dystrophy (FECD). This study aimed to analyze the daily fluctuations of corneal thickness, refraction, and (glare) visual acuity in advanced FECD.Prospective cohort study.Patients with advanced FECD (FECD group) and patients with normal cornea (control group) were enrolled. Routine clinical examination was performed using slit-lamp biomicroscopy, funduscopy, and macular optical coherence tomography. In addition, assessment using corneal Scheimpflug tomography (Pentacam), refraction, corrected distance visual acuity (CDVA), and glare CDVA was performed at 4 PM (afternoon) and the following day at 8 AM (morning).A total of 29 FECD eyes and 22 control eyes were included. Diurnal variations from afternoon to morning were Δ corneal thickness (apex) ± standard deviation (SD) 41.45 ± 34.1 μm (P.001, FECD group) and 5.5 ± 6.72 μm (P = .001, control group); Δ spherical equivalent ± SD -0.64 ± 0.6 diopters (D) (P.001, FECD group) and -0.01 ± 0.50 D (P = .461, control group); Δ total corneal refractive power ± SD 0.60 ± 0.83 D (P = .001, FECD group) and -0.01 ± 0.49 D (P = .602, control group), Δ CDVA ± SD 0.15 ± 0.18 logarithm of minimal angle of resolution (logMAR) (P.001, FECD group) and 0.02 ± 0.04 logMAR (P = .174, control group), Δ CDVA glare ± SD 0.34 ± 0.25 logMAR (P.001, FECD group) and 0.05 ± 0.11 logMAR (P = .106, control group).A morning myopic shift and increased glare paralleling increased corneal thickness may particularly contribute to subjective visual impairment in advanced FECD in the first hours after awaking. This should be taken into account during assessment and surgical decision-making in patients with FECD.

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.

Purpose To describe a new surgical option for the treatment of acute corneal hydrops in keratoconus and to present the first results. Methods This is a retrospective analysis of 3 patients who presented to our clinic with a massive corneal hydrops in acute keratoconus and were treated by mini-Descemet membrane endothelial keratoplasty (DMEK). According to the size and the shape of the gap in the patient's Descemet membrane (DM), 1 DMEK graft was trephined with a round 5-mm punch. The other grafts were trimmed with a razor blade to a width of about 3 mm and a length adjusted to the length of the defect of the recipients' DM. The graft was inserted with a regular intraocular lens shooter. Correct unfolding of the graft was controlled by using intraoperative optical coherence tomography. At the end of the surgery, the graft was attached to the posterior corneal surface by a small air bubble. Thereafter, the complete anterior chamber was filled with 20% SF6 gas. Results All 3 patients (age 32 ± 3 years on average) showed a rapid increase in uncorrected visual acuity from the logarithm of the minimum angle of resolution (LogMAR) 1.66 (±0.46) before mini-DMEK to the LogMAR 1.2 (±0.3) within 6 to 8 weeks after mini-DMEK. The thickest corneal point within the edematous cornea decreased in all 3 patients (1088 ± 280 μm before surgery vs. 630 ± 38 μm 1 week after surgery). One mini-DMEK failed in a first attempt. In this patient, the recipient DM was under strong tension and showed a pronounced dehiscence. Therefore, a small part of the recipient's DM around the preexisting gap in DM was removed before a second mini-DMEK graft was placed successfully. The other 2 patients developed partial graft detachment within 1 to 2 weeks after surgery. However, the corneas of these patients were dehydrated to physiological levels after mini-DMEK, and despite partial detachment, there was no relapse of the hydrops. Conclusions Mini-DMEK could be helpful in patients with larger defects and detachments of DM in very ectatic corneas in the acute phase of corneal hydrops in acute keratoconus. These patients may not be successfully treated by intracameral gas application alone or in combination with pre-Descemetal sutures. Further investigations are needed to identify factors helping to decide on the best surgical approach in hydrops in acute keratoconus.

The treatment of acute corneal hydrops due to keratoconus has so far been limited to awaiting the spontaneous resorption of corneal edema, supportive care, and finally keratoplasty. A recent publication describes the surgical reattachment of Descemet Membrane (DM) facilitated by pre-Descemetic sutures and anterior chamber air/gas filling. Here, we present a novel microscope-integrated intraoperative optical coherence tomography (MI-OCT)-guided technique for the immediate reattachment of DM in corneal hydrops due to keratoconus in 2 male patients with small central DM defects.Case series of 2 consecutive patients with acute corneal hydrops due to keratoconus. The novel technique consists of the MI-OCT-guided puncture and drainage of intrastromal fluid pockets combined with anterior chamber sulfur hexafluoride-fill and pre-descemetic sutures using a commercially available MI-OCT (iOCT; Haag Streit Surgical, Wedel, Germany).After uneventful surgery, corneal edema showed fast resolution and DM was reattached to the corneal stroma. In both patient's central corneal thickness decreased after surgery and visual acuity improved.MI-OCT guided micropuncture of stromal edema combined with compression sutures and SF6 tamponade is a new therapeutic option in acute corneal hydrops with small Descemet membrane defects.

The surgical treatment of corneal dystrophies develops rapidly as the use of lamellar corneal grafting techniques continue. While penetrating keratoplasty was the gold standard for treating a variety of dystrophies a few years ago, the affected layers of the cornea can, nowadays, be selectively replaced or ablated using laser technology. Of particular importance for these methods is optical coherence tomography, which has recently been integrated into surgical microscopes (MI-OCT).Literature overview from PubMed and Google.scholar.de supplemented with own imaging data.The MI-OCT enables the intraoperative real-time monitoring of different ophthalmic surgical procedures, such as deep anterior lamellar keratoplasty, Descemet's membrane endothelial keratoplasty, as well as minimally-invasive procedures, such as phototherapeutic keratectomy. In addition, it enables an evaluation of the cornea, but also of structures of the anterior chamber, in situations in which the cornea, for example, is clouded by an edema.Microscope-integrated, intraoperative optical coherence tomography (MI-OCT) represents a useful supplement to the normal surgical microscope. It is superior to the sole surgical microscope, especially in already severely clouded corneas, and represents a sensible supplement, especially for novel lamellar transplantation procedures. Prospective randomized trials are necessary to increase safety and efficacy when using MI-OCT for different indications.Die chirurgische Behandlung von Hornhautdystrophien entwickelt sich mit zunehmender Anwendung von lamellären Techniken der Hornhauttransplantation rasant weiter. War vor einigen Jahren noch die penetrierende Keratoplastik der Goldstandard zur Therapie einer Vielzahl von Dystrophien, so können heutzutage selektiv die betroffenen Schichten der Hornhaut ersetzt oder mittels Lasertechnik abladiert werden. Einen besonderen Stellenwert nimmt für diese Verfahren die optische Kohärenztomografie ein, die neuerdings auch in Operationsmikroskope integriert sein kann (MI-OCT).Literaturübersicht aus PubMed und Google.scholar.de ergänzt mit eigenen Bildgebungsdaten.Die MI-OCT ermöglicht das intraoperative Echtzeit-Monitoring unterschiedlicher ophthalmochirurgischer Prozeduren wie der tiefen, anterioren lamellären Keratoplastik, der Descemet-Membran-Endothel-Keratoplastik (DMEK), aber auch minimalinvasiver Verfahren wie der phototherapeutischen Keratektomie (PTK). Darüber hinaus ermöglicht sie eine Evaluation der Hornhaut wie auch der Vorderkammer, insbesondere in Situationen einer getrübten Hornhaut.Die mikroskopintegrierte intraoperative optische Kohärenztomografie (MI-OCT) stellt eine sinnvolle Ergänzung zum normalen Operationsmikroskop dar. Sie ist insbesondere bei bereits stark getrübten Hornhäuten dem alleinigen Operationsmikroskop überlegen und stellt gerade bei neuartigen lamellären Transplantationsverfahren eine sinnvolle Ergänzung dar. Randomisierte prospektive Studien sind nötig, um die erhöhte Sicherheit und gesteigerte Effektivität durch den Einsatz der MI-OCT bei verschiedenen Indikationen zu belegen.

Corneal dystrophies are categorized according to the International Committee for Classification of Corneal Dystrophies (IC3D) classification, and their treatment depends on the affected structures and layer of the cornea. Therefore, estimating the depth and extent of the morphological changes due to the specific dystrophy is crucial when deciding between different treatment options. Besides superficial laser treatments and penetrating keratoplasty, minimal invasive lamellar keratoplasties such as Descemet membrane endothelial keratoplasty, deep anterior lamellar keratoplasty, or Descemet stripping automated keratoplasty have become increasingly popular to exchange the specific opaque layers in dystrophic eyes. To determine the morphological changes of the cornea in the different dystrophies, in addition to slit-lamp examination, anterior segment optical coherence tomography has become an important tool with nearly histological resolution. Nonetheless, only a few case series describe the characteristics of changes seen on anterior segment optical coherence tomography. Therefore, we summarize anterior segment optical coherence tomography signs and correlate with slit-lamp examination, as well as the histopathological findings, of corneal dystrophies according to the IC3D classification.

Ab interno glaucoma surgery, such as trabecular aspiration or ab interno trabeculotomy, has been introduced as an alternative, non-filtering procedure to lower intraocular pressure in glaucoma patients. The purpose of the present study was to assess the feasibility of intraoperative spectral domain optical coherence tomography (iOCT) for improving ab interno glaucoma surgery.Intraoperative optical coherence tomography was performed to visualize the anterior chamber angle, the aspiration canula during trabecular aspiration, and the trabectome device during ab interno trabeculotomy. A commercially available 840-nm iOCT was used in a clinical setting, a 1310-nm spectral-domain OCT in an experimental setting.In the clinical setting using the 840-nm iOCT, visualization of the aspiration canula and the trabectome device was possible, however, with rather limited visibility of the chamber angle and the trabecular meshwork. In the experimental setting, the 1310-nm OCT enabled excellent visualization of the chamber angle and detailed evaluation of the instrument-trabecular meshwork relation.Intraoperative use of optical coherence tomography may be helpful for ab interno glaucoma surgery. Adjustments of the commercially available iOCT, including longer wavelengths and oblique scanning options, are necessary for the clinical use.

Descemet membrane endothelial keratoplasty (DMEK) has evolved into a routine surgical procedure for posterior lamellar keratoplasty. After its introduction more than 10 years ago, several modifications in grafting technique and postoperative treatment regimen helped to improve its safety and reproducibility. Although DMEK offers faster and better improvements in visual acuity, as well as less graft rejections when compared to Descemet's stripping (automated) endothelial keratoplasty (DS[A]EK), difficulties when implementing this technique hamper the widespread use in many areas. However, different strategies help to reduce the rate of intra- and postoperative complications, making DMEK the method of choice for most patients with corneal endothelial diseases. Certain techniques help to reduce the endothelial damage during graft preparation; correct matching of donor age and recipient's anterior chamber depth eases intracameral unfolding of the DMEK graft, the use of SFSeit der ersten erfolgreichen Descemet Membrane endothelial Keratoplasty (DMEK) vor über 10 Jahren hat sich diese Technik in vielen Regionen zu einem Routineeingriff entwickelt, der mittlerweile einen festen Platz im ophthalmochirurgischen Armamentarium bei der Behandlung von Hornhautendothelerkrankungen einnimmt. Im Vergleich mit der etwas älteren Methode der Descemetʼs Stripping (automated) endothelial Keratoplasty (DS[A]EK), bei der das Transplantat im Gegensatz zur DMEK noch eine Stromalamelle besitzt, wird bei der DMEK eine schnellere und bessere Visuserholung erzielt und gleichzeitig ist das Risiko der Abstoßungsreaktion deutlich reduziert. Dennoch birgt die Technik einige Schwierigkeiten, die ein besonderes Vorgehen zur Vermeidung intra- und postoperativer Komplikationen notwendig machen. Hierzu zählen Strategien zur Vermeidung von Endothelschädigungen während der Präparation, die richtige Spender-Patienten-Allokation ist wichtig für eine schonende Entfaltung der Transplantatrolle in der Vorderkammer, die Verwendung von SF

To investigate 1-year clinical outcome and complication rates following Descemet membrane endothelial keratoplasty (DMEK) with sulfur hexafluoride 20% (SFRecords of 1112 consecutive DMEKs were reviewed retrospectively and grouped by anterior chamber tamponade used during DMEK surgery (SFA total of 854 cases were included in this study. In 105 cases (12.3%), DMEK was performed with SFWhereas SF

Correct early graft attachment is believed to be crucial for final visual outcome after Descemet membrane endothelial keratoplasty (DMEK). Nonetheless, it is not yet known which imaging technique gives superior results for examining early postoperative graft adherence status. We compared imaging data taken with two different OCT devices to examine the development of graft adherence immediately after DMEK and to determine the superior device in terms of visualization of graft adherence. Ten consecutive patients (1 man/9 women) were examined three times postoperatively within the first 7 h after DMEK surgery using spectral domain OCT (SD-OCT) and time domain OCT (TD-OCT), as prospective case series and retrospective image data analyses. The parameters analyzed were localization and number, visibility and size of graft detachments. TD-OCT was able to detect a greater number of graft detachments after DMEK; however, SD-OCT provided better resolution of minor detachments. Graft detachments varied in position and degree at different time points immediately after surgery. All patients had some graft detachment within the first 7 h after DMEK surgery. TD-OCT enabled better overall analysis of graft detachments, even in the periphery, whereas SD-OCT allowed for the detection of even minor detachments, which suggests that a combination of the two techniques is optimal. Our results indicate that dynamic processes affecting the DMEK graft immediately after transplantation are responsible for changes in the attachment of donor tissue at an early postoperative stage. Modulation of early graft attachment may improve the final graft attachment.

To present a new treatment modality for recurrent corneal melting in a patient with a Boston type I keratoprosthesis (B-KPro) including in situ corneal cross-linking (CXL) and lamellar keratoplasty (LKP) as combined treatment.Case report.Our report concerns a 27-year-old man whose case history involved a severe chemical burn of his left eye. After failed penetrating keratoplasty and limbal stem cell transplantation, the patient underwent B-KPro implantation. Starting 1 month after surgery, recurrent corneal melting around the B-KPro developed, which was eventually treated by combining LKP, amniotic membrane transplantation, and in situ CXL. Optical coherence tomography imaging and follow-up for 12 months showed stable corneal healing without new melting or erosion. The ultraviolet A treatment did not seem to damage the material of the B-KPro.In situ CXL using riboflavin and ultraviolet A light combined with LKP and amniotic membrane transplantation can be an effective management option to treat recurrent corneal melting after B-KPro implantation.

Inflammatorische Prozesse des Auges gehören zu den häufigsten Entitäten in der Augenheilkunde. Die Anwendung antientzündlicher Substanzen ist daher für den Behandler eine zentrale therapeutische Option. Hierbei kommen zumeist aufgrund der guten Zugänglichkeit des Auges topische Applikationen zur Anwendung. Substanzgruppen wie Antiallergika, nichtsteroidale Antirheumatika, Glukokortikoide, Calcineurininhibitoren, Serumaugentropfen sowie neuere, noch in der Entwicklung befindliche Substanzen werden spezifisch sowohl in schmalen als auch in breiten Indikationsspektren eingesetzt, weshalb die Kenntnis der Wirkmechanismen und der potenziellen Nebenwirkungen von großer Bedeutung ist. Dieser Artikel soll einen Überblick über die derzeitig verfügbaren antiinflammatorisch wirksamen Substanzen geben, die topisch verabreicht werden können. Hierbei wird auf eine detaillierte Anwendungsbeschreibung (Dosis, Applikationshäufigkeit, Dauer usw.) in Bezug auf die einzelnen Krankheitsbilder bewusst verzichtet. Ziel ist es, dem Leser pharmakologisches Basiswissen mit direktem ophthalmologischen Bezug zu vermitteln.

PURPOSE Here we describe intraoperative optical coherence tomography (iOCT) as a novel noncontact imaging tool for intraoperative monitoring and procedure evaluation during canaloplasty, as a nonpenetrating surgical technique to treat primary open angle glaucoma. MATERIALS AND METHODS Retrospective case report of a patient (63 y, female), who underwent traditional canaloplasty, using a commercially available 840 nm OCT device, mounted to an operating microscope (Rescan 700). Main outcome measures were the intraoperative visibility of chamber angle structures and the ability to conduct surveillance of the surgical procedure through the prepared Descemet window, especially correct suture positioning and visible changes of the Schlemm canal after suture tensioning. RESULTS iOCT delivered high-resolution images during canaloplasty after deep sclerectomy through the prepared Descemet window. All structures of the chamber angle, including the Schlemm canal were visible. Moreover iOCT enabled intraoperative noncontact procedure monitoring and a direct control of the correct localization and changes of the Schlemm canal after suture positioning and tensioning. CONCLUSIONS iOCT seems to be a helpful intraoperative imaging tool during canaloplasty. iOCT allows for noncontact online evaluation of Schlemm canal localization and noncontact evaluation of suture tension. Shadowing of scleral tissue can be avoided by imaging through the routinely prepared Descemet window to visualize chamber angle structures including the implanted suture.

Purpose To analyze the effect of intensified topical steroid therapy after Descemet membrane endothelial keratoplasty combined with cataract surgery (triple-DMEK) on the incidence of postoperative cystoid macular edema (CME). Design Single-center comparative clinical study with historical controls. Methods Setting: Department of Ophthalmology, University of Cologne, Germany, tertiary hospital, performing 500 corneal transplant surgeries per year. Patients: Total of 131 patients (150 eyes) undergoing triple-DMEK surgery. Inclusion Criterion: Triple-DMEK surgery. Exclusion Criteria: Prior retinal surgery, history of prior CME. Interventions: Prednisolone acetate eye drops 1% 5 times daily for the first week after surgery. After an internal change of therapy regimen: Prednisolone acetate eye drops 1% hourly for the first postoperative week. We compared 75 consecutive eyes before with 75 consecutive eyes after the change of therapy regimen. Patients received macular spectral-domain optical coherence tomography (SD OCT) preoperatively, as well as 6 weeks and 3 and 6 months post surgery. Main Outcome Measure: Development of CME detected by macular SD OCT during 6 months postoperatively. Results Both groups were comparable regarding baseline age, sex, central corneal thickness, rebubbling rate, and visual acuity. With topical steroid therapy 5 times per day during the first postoperative week, we observed 9 cases of subsequent CME (12%). With hourly topical steroid therapy none of the patients developed CME subsequently ( P = .003). Apart from the topical steroids during the first week, medical treatment was identical in both groups. Conclusions Early intensified postoperative topical steroid therapy constitutes an effective prophylactic treatment to reduce incidence of CME after triple-DMEK surgery.

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.