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Das Risiko der Abstosung und des Transplantatversagens nach Hochrisikokeratoplastik steigt mit Zunahme der kornealen Neovaskularisation. Die medikamentose und physikalische Regression der kornealen Neovaskularisation vor Keratoplastik bietet moglicherweise das Potenzial, das Risiko einer Abstosung nach anschliesender Hochrisikokeratoplastik zu reduzieren. Die vorliegende Arbeit gibt eine Literaturubersicht hinsichtlich der Prakonditionierung von vaskularisierten Hochrisikoaugen mittels Feinnadeldiathermie und kornealem Crosslinking vor Hochrisikokeratoplastik („lymphangioregressive Prakonditionierung“). Es erfolgen eine Literaturrecherche via PubMed sowie eine Zusammenfassung eigener Daten. Tierexperimentelle Studien zeigen, dass sowohl die Feinnadeldiathermie als auch das korneale Crosslinking zu einer Regression der kornealen Neovaskularisation fuhren und das Transplantatuberleben nach anschliesender Hochrisikokeratoplastik verlangern. Untersuchungen aus unserem Institut geben daruber hinaus erste Hinweise, dass beide Verfahren auch in der klinischen Praxis zur Reduktion der kornealen Neovaskularisation fuhren und damit potenziell das Abstosungsrisiko reduzieren. Die Feinnadeldiathermie und das korneale Crosslinking bieten effektive Therapieansatze zur angioregressiven Behandlung und scheinen das Transplantatuberleben nach Hochrisikokeratoplastik zu verlangern. Groser angelegte prospektive und kontrollierte klinische Studien sind notwendig, um diese vielversprechenden Therapieansatze weitergehend zu untersuchen.

Bei schwerstbeeintrachtigten und vaskularisierten Hochrisikoaugen stellt die Versorgung mittels Boston-Keratoprothese die oftmals letzte Therapieoption dar. Die Transparenz der Optik wird hier nicht durch endotheliale Abstosungsreaktionen beeintrachtigt. In diesem Ubersichtsbeitrag werden relevante Literatur sowie eigene Daten und Erfahrungen zur Versorgung von Hochrisikoaugen mit der Boston-Keratoprothese diskutiert. Die relevanten Komplikationen sowie das postoperative Management werden erortert. In mehr als 60 % der Hochrisikoaugen kann durch eine Keratoprothesenversorgung langfristig ein Visusanstieg erreicht werden. Keratoprothesenretentionswerte schwanken stark, nach 5 Jahren liegen diese im Mittel bei 75 %. Die haufigsten postoperativen Komplikationen umfassen die Ausbildung einer retroprothetischen Membran und das Auftreten von Keratolysen in jeweils bis zu 50 %. Bereits praoperativ leiden mehr als 70 % der Augen an einem (Sekundar‑)Glaukom, sodass ein glaukomchirurgischer Eingriff simultan in mindestens 20 % der Falle erfolgt und im postoperativen Verlauf in bis zu 31 % ein weiterer Eingriff erforderlich wird. Vitreoretinale Komplikationen umfassen insbesondere die sterile Vitritis und die infektiose Endophthalmitis, aber auch die persistierende Bulbushypotonie ist bei einem Drittel der Patienten beschrieben. Die Boston-Keratoprothese kommt bei sehr schlechter Prognose fur einen konventionellen Hornhautersatz infrage. Postoperative Komplikationen sind haufig, sodass dem postoperativen Management eine wichtige Rolle zukommt. Fur vaskularisierte Hochrisikoaugen ist sie jedoch oftmals die einzige verbliebene Option zur Visusrehabilitation.

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 Knappheit an Hornhautspendergewebe in der Ukraine erfordert eine möglichst effiziente Nutzung der vorhandenen Transplantate. In diesem Kontext wird in der vorliegenden Arbeit eine Methode beschrieben, bei der mehrere Hornhauttransplantate mit geringerem Durchmesser aus einer einzelnen Spenderhornhaut gewonnen werden, um der Knappheit an Hornhauttransplantaten entgegenzuwirken („multimodales Spendergewebesplitting“). Material und Methoden Die hier beschriebene Studie ist eine retrospektive Kohortenstudie aller durchgeführten Hornhauttransplantationen in der Abteilung für Hornhauterkrankungen des Staatsinstituts „Filatov Institut für Augenkrankheiten und Gewebetherapie der Nationalen Akademie der medizinischen Wissenschaften der Ukraine“, Odessa, Ukraine aus den Jahren 2016 und 2017. Bei dieser Methode der Transplantatpräparation wird das Spendertransplantat entweder über die gesamte Fläche oder lediglich partiell lamelliert, um 1 oder 2 lamelläre bzw. durchgreifende Transplantate zu erhalten. Diese Methode ermöglicht es, nicht nur runde Transplantate auszuschneiden, sondern auch Transplantate, die durch die Form des Hornhautdefekts vorgegeben werden. Ergebnisse Von Januar 2016 bis Dezember 2017 wurden 324 Keratoplastiken unter Verwendung von 270 Transplantaten im o. g. Institut durchgeführt. In 54 Fällen (von denen 34 Notfallsituationen waren) wurde 1 Transplantat für 2 Patienten verwendet. Davon wurden 43 therapeutische Keratoplastiken und 11 periphere lamelläre Keratoplastiken aufgrund rezidivierender Pterygien Grad III – IV durchgeführt. In 2 Fällen wurden 2 Transplantate für einen Patienten aus einer Spenderhornhaut ausgeschnitten. Von 43 Patienten, die eine Keratoplastik mit kurativer Absicht erhielten, verbesserte sich die Sehschärfe in 28 Augen (65,1%) oder blieb in 15 Augen unverändert (34,9%). Die Sehschärfe nach der Operation hing vom Anfangszustand des Auges, der Lokalisation, der Tiefe und der Fläche des Hornhautdefektes ab. Bei peripherer Lokalisation von kornealen Ulzera, selbst beim Vorhandensein einer Perforation der Hornhaut, wurden gute funktionelle Ergebnisse erzielt. Schlussfolgerung Die Gewinnung von 2 oder mehr Transplantaten aus einer einzelnen Spenderhornhaut für verschiedene Keratoplastiktypen verringert den Bedarf an Hornhauttransplantaten und folglich die Kosten für deren Konservierung. Insbesondere in Regionen mit starkem Spendermangel kann dadurch auch mehr Gewebe für Hornhauttransplantationen in Notfallsituationen vorgehalten werden.

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.

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.

Die „Descemet membrane endothelial keratoplasty“ (DMEK) hat sich in Deutschland zur operativen Standardtherapie der Fuchs-Endotheldystrophie entwickelt. Sie kann aber auch bei Endothelerkrankungen in Verbindung mit „komplexen“ Veranderungen des vorderen Augenabschnitts angewendet werden, wie z. B. bei anterioren Synechien oder groseren Irisdefekten, nach Glaukomoperationen, nach Vitrektomie oder nach Trauma. Die Arbeit gibt einen Uberblick uber die Moglichkeiten zur Versorgung mit einer DMEK bei Endotheldekompensation bei komplexer Ausgangssituation. Es erfolgt die Beschreibung von Problemen bei komplexen Ausgangssituationen sowie aktueller Techniken zur Versorgung mit einer DMEK. Fur die Versorgung von Patienten mit komplexer Situation des vorderen Augenabschnitts mit einer DMEK mussen haufig Rekonstruktionen des Iris‑/Linsen-Diaphragmas durchgefuhrt werden. Ein groses Problem stellen sowohl sehr flache als auch sehr tiefe Vorderkammern dar. DMEK-Transplantate von alteren Spendern (>70 Jahre) neigen zu weniger Transplantatrollung und sollten entsprechend bei Patienten mit tiefer Vorderkammer (z. B. nach Vitrektomie) bevorzugt werden. Auch sollte die Transplantatgrose dem Platzangebot angepasst werden, also bei z. B. anterioren Synechien ein kleinerer Transplantatdurchmesser gewahlt werden. Es liegen nur wenige Auswertungen zur DMEK unter komplexen Bedingungen vor. Es zeichnet sich aber ab, dass die Rate an sekundaren Transplantatversagern, der Endothelzellverlust und die Rebubblingrate in dieser sehr heterogenen Gruppe erhoht sind. Weitere Studien sind notwendig, um Risikofaktoren fur einen negativen Verlauf nach DMEK in „komplexen“ Augen zu identifizieren.

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.

Vorgestellt wird das therapeutische Prinzip der Narkoseuntersuchungen von Kindern in Vollnarkose mithilfe der mikroskopintegrierten optischen Koharenztomographie (MI-OCT). Ziel ist die Evaluierung neuartiger Indikationen und Limitationen der MI-OCT mit dem Ziel, die ophthalmologischen Untersuchungen unter Vollnarkose bei Neugeborenen und Kleinkindern zu verbessern. Grundlage war eine Literaturubersicht aus google.scholar.com und PubMed. Wir erganzten eigene Daten einer prospektiven Studie am Zentrum fur Augenheilkunde der Uniklinik Koln. Es wurden 14 Kinder mit Anomalien des vorderen und hinteren Augenabschnittes eingeschlossen, bei denen eine Narkoseuntersuchung unter Zuhilfenahme eines kommerziell erhaltlichen MI-OCT-Gerates durchgefuhrt wurde. Analysiert wurden die generelle Durchfuhrbarkeit der MI-OCT bei der ophthalmologischen Untersuchung von Kindern unter Vollnarkose fur den vorderen und hinteren Augenabschnitt und der Benefit fur die jeweilige Indikationsstellung sowie die intraoperativen Befunde. Die MI-OCT bereicherte signifikant die Narkoseuntersuchungen von Kindern und lieferte zusatzliche Informationen, die mit dem alleinigen Operationsmikroskop nicht zuganglich waren. Gerade in Situationen, bei denen der Einblick in die Vorderkammer limitiert war, ermoglichte die MI-OCT die Schatzung von Distanzen wie der Hornhautdicke. Daruber hinaus wurden 12/14 therapeutische Entscheidungen intraoperativ beeinflusst. Zudem ermoglichte die MI-OCT die Untersuchung der Nervenfaserschichtdicke der Sehnervenpapille und der Retina. Die hier prasentierten Daten verdeutlichen den Benefit der mikroskopintegrierten intraoperativen OCT bei ophthalmologischen Untersuchungen von Kindern unter Vollnarkose, insbesondere auch bei Kindern mit Hornhauttrubungen, falls eine Untersuchung unter Vollnarkose notwendig wird.

Bei der „Descemet membrane endothelial keratoplasty“ (DMEK) werden selektiv erkranktes Hornhautendothel und Descemet-Membran entfernt und durch gesundes Spendergewebe ersetzt. Die DMEK stellt heute den Goldstandard zur Therapie der kornealen endothelialen Dysfunktion dar. Im vorliegenden Beitrag wird die Operationstechnik der DMEK anhand eines Videos dargestellt, und daruber hinaus werden Operationsindikationen, Patientenaufklarung, Anasthesie und Lagerung, postoperative Behandlung sowie mogliche Komplikationen und deren Management erlautert. Die DMEK kann im breiten Spektrum zur Therapie der kornealen endothelialen Dysfunktion angewendet werden. Die Grundlage fur die hervorragenden Ergebnisse des Operationsverfahrens sind neben der operativen Umsetzung auch sorgfaltige Spender-Patienten-Allokation, grundliche Voruntersuchung und Nachsorge der Patienten und Erfahrung des Operateurs. Die DMEK ist ein sicheres und effektives Verfahren zur Therapie der kornealen endothelialen Dysfunktion. Ein standardisiertes und individualisiertes Vorgehen ermoglicht im Vergleich mit allen bisherigen Transplantationsverfahren optimalste Ergebnisse.

Purpose To assess the evolution of clinical outcomes of more than 1300 Descemet membrane endothelial keratoplasties (DMEKs) alone or in combination with cataract surgery (triple DMEK) throughout a 5-year period at a single center, performed by 2 already experienced DMEK surgeons. Design Retrospective trend study. Methods Review of charts between July 2011 and July 2016 at the Department of Ophthalmology, University of Cologne, Germany. Results A total of 1340 out of 1340 eyes with sufficient information were included. Six-month and 12-month best spectacle-corrected visual acuity (logMAR) had already reached high levels for the surgeries performed in 2011 (0.10 ± 0.06 and 0.09 ± 0.07, respectively) and did not further improve in later years ( P = .272). Likewise, endothelial cell loss (ECL) and central corneal thickness (CCT) reached comparable levels independently of the year of surgery (average 12-month ECL was 38% ± 15% and average 6-month CCT decrease was 19% ± 11%). However, there was a decrease in the rebubbling rate, from 68% in 2011, 67% in 2012, and 70% in 2013 to 53% in 2014, 29% in 2015, and 16% in 2016, which was associated with the introduction of 20% sulfur hexafluoride (SF 6 ) instead of room air for anterior chamber tamponade in 2015 (n = 986; P P Conclusions After an initial learning curve in DMEK surgery, results of visual acuity and ECL do not seem to further improve. However, the complication rate continuously declines, at least over the subsequent 5-year period analyzed herein.

Zusammenfassung Hintergrund 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). Methoden Literaturübersicht aus PubMed und Google.scholar.de ergänzt mit eigenen Bildgebungsdaten. Ergebnisse 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. Schlussfolgerung 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.

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.

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.

ZusammenfassungSeit 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 SF6-Gas zur Transplantatanlage vermindert die Transplantatablösungsrate und damit die Notwendigkeit erneuter Vorderkammertamponaden (Rebubblings), und die richtige postoperative Behandlung mit topischen Steroiden hat maßgeblichen Einfluss auf die Entwicklung von zystoidem Makulaödem und Abstoßungsreaktionen. Durch die weitere Standardisierung, aber auch Individualisierung der DMEK kann sie mittlerweile auch bei Patienten mit schwierigen anatomischen Voraussetzungen des vorderen Augenabschnitts (anteriore Synechien, größere Irisdefekte, Glaukomdrainageimplantate) regelmäßig durchgeführt werden, wodurch gerade solche Patienten mit tendenziell erhöhtem Risiko von Wundheilungsstörungen und Abstoßungsreaktionen im Übermaß profitieren.

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 1-year clinical outcome and complication rates following Descemet membrane endothelial keratoplasty (DMEK) with sulfur hexafluoride 20% (SF 6 20%) anterior chamber tamponade compared with conventionally used 100% air for primary graft attachment during DMEK surgery. Methods Records of 1112 consecutive DMEKs were reviewed retrospectively and grouped by anterior chamber tamponade used during DMEK surgery (SF 6 20% vs 100% air). Outcome measures included intraocular pressure (IOP), best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD) and central corneal thickness (CCT) at 1, 3, 6 and 12 months after DMEK surgery. Complication rates were assessed, including intraoperative and postoperative complications, and graft detachment rate requiring rebubbling. Results A total of 854 cases were included in this study. In 105 cases (12.3%), DMEK was performed with SF 6 20%, and in 749 cases (87.7%) 100% air was used for anterior chamber tamponade. Outcome results for IOP, BSCVA, ECD and CCT at all follow-up time points were comparable for both anterior chamber tamponade groups without statistical significant differences (p≥0.05), but graft detachment rate requiring rebubbling was significantly lower in the SF 6 20% group (p Conclusion Whereas SF 6 20% anterior chamber tamponade does not seem to negatively affect the clinical outcome of DMEK surgery within the first postoperative year, use of SF 6 20% significantly reduces the rate of rebubblings.

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.

Lamellar keratoplasties are evolving techniques to selectively replace diseased or opacified layers of the cornea. In recent years, the popularity of lamellar keratoplasties, especially Descemet membrane endothelial keratoplasty, Descemet stripping-automated endothelial keratoplasty and deep anterior lamellar keratoplasty, increased dramatically, since lamellar surgeries reduce intra- and postoperative complications and achieve faster visual recovery. Nonetheless, the surgical procedures are delicate. Novel imaging techniques, as intraoperative optical coherence tomography (OCT), may substantially help standardize these procedures to even further reduce intra- and postoperative complications and potentially improve outcome. The present review summarizes the current literature regarding the use of intraoperative OCT during lamellar keratoplasties and its effect on postoperative outcome.

Narkoseuntersuchungen von Kindern sind notwendig, um die Entwicklung einer Amblyopie zu vermeiden. Ihre Aussagekraft ist allerdings oftmals durch den Mangel an State-of-the-Art-Diagnostik, wie z. B. der optischen Koharenztomographie (OCT), eingeschrankt. Seitdem neuerdings die OCT-Technik in Operationsmikroskope integriert wurde, steht diese Technik auch im Operationssaal bei Untersuchungen in Vollnarkose zur Verfugung. Die vorliegende Arbeit gibt einen Uberblick uber die Moglichkeiten der intraoperativen OCT-Technik bei der Narkoseuntersuchung von Kindern. Zugrunde gelegt wurden eine Literaturubersicht (PUBMED) und eigene klinische Erfahrungen am Zentrum fur Augenheilkunde der Uniklinik Koln. Die intraoperative OCT-Technik ermoglicht eine Echtzeitbildgebung wahrend der Narkoseuntersuchung von Sauglingen und Kindern. Sie ist in der Lage, alle Strukturen des vorderen Augenabschnittes darzustellen (Hornhaut, Linse, Kammerwinkel, Iris). Zudem liefert sie, insbesondere bei reduziertem Einblick in die Augenvorderkammer, wichtige strukturelle Informationen, die uber den Erkenntnisgewinn des Mikroskops hinausgehen. Die dabei gewonnenen Informationen sind ausschlaggebend fur die Diagnostik und die weitere Therapie der Patienten. Die intraoperative OCT stellt eine sinnvolle Erganzung zum normalen Operationsmikroskop dar, insbesondere bei Sauglingen und Kindern mit Anomalien des vorderen Augenabschnittes und reduziertem Einblick in die Vorderkammer. Unseren Erfahrungen nach ist auch eine Ausweitung der Technik auf Anomalien des hinteren Augenabschnitts sinnvoll, da eine Bildgebung von Papille und Makula moglich ist.

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.

Deep anterior lamellar keratoplasty (DALK) offers tremendous advantages over penetrating keratoplasty (PK). Intraoperative safety is increased due to reduced opening of the eye interoperatively and the fact that no endothelial graft rejection can take place as the patient's own corneal endothelium is retained. Despite these advantages the number of DALK procedures performed each year in Germany remains constant at a low level. One reason could be that the DALK technique offers some complexity and at the same time intraoperative conversion to PK has to be performed in some cases due to rupture of Descemet's membrane. Moreover, interface-related and DALK-specific complications exist which can contribute to an unfavorable visual outcome. Most of these complications, such as incomplete attachment of Descemet's membrane or opacification within the interface between Descemet's membrane and the posterior corneal stoma can be resolved by adequate measures making PK for revision barely necessary. As visual acuity does not differ between PK and DALK, the benefits of DALK - lack of endothelial immune reaction and increased ocular stability during surgery - outweigh the risk of additional complications and DALK should therefore be performed whenever appropriate.

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.

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.

Therapy for ocular graft-vs-host disease (ocular GvHD) is challenging for ophthalmologists as progress of the disease often occurs rapidly and is unforeseeable. Primary goal is the preservation or restoration of visual acuity, however, studies on ocular GvHD that have investigated therapeutic concepts are limited. In contrast, most therapeutic recommendations from consensus conferences derive from studies on dry eye diseases other than ocular GvHD. This review demonstrates the available therapies in the following categories: local, systemic, surgical and prophylactic. Primary targets are anti-inflammation, anti-fibrosis and lubrification of the ocular surface. In conclusion, studies strictly on ocular GvHD are needed to enable better evidence-based therapeutic decision-making in the future.

Die okulare GvHD (Graft-versus-Host Disease) stellt eine haufige Komplikation nach allogener Blutstammzelltransplantation dar. Dabei fuhren verschiedene Faktoren zu einer milden bis starken Storung der Integritat der Augenoberflache. Leitsymptom ist dabei das Trockene Auge, welches eine starke inflammatorische Komponente aufweist und in vielen Fallen einen schweren Verlauf, bis hin zu kornealen Ulzerationen, zeigt. Diagnosestellung und Behandlung einer okularen GvHD stellen eine Herausforderung an den Augenarzt dar und erfordern eine intensive Zusammenarbeit mit den hamatoonkologischen Kollegen. Sowohl bei der Erstvorstellung als auch in der Verlaufskontrolle setzt sich die Diagnostik aus einer Vielzahl von Untersuchungen zusammen. Diese beurteilen einerseits sowohl qualitativ als auch quantitativ die Zusammensetzung des Tranenfilms, andererseits werden aber auch subjektive Beschwerden des Patienten mit berucksichtigt. Die zur Verfugung stehenden Tests sind dabei zwar sensitiv fur das Vorliegen eines Trockenen Auges, aber relativ unspezifisch fur das Vorliegen einer okularen GvHD. Daher lasst nur eine umfassende Zusammenschau der erhobenen Befunde eine endgultige Aussage hinsichtlich des okularen Status zu. Die folgende Ubersicht fasst sowohl etablierte als auch innovative, nicht invasive diagnostische Tests zusammen und bewertet diese hinsichtlich einer moglichen Anwendung in der Zukunft.

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.

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.

Posterior lamellar keratoplasty has been demonstrated to be a successful, increasingly applied surgical method to replace diseased endothelial cells of the human cornea. Potential immune reactions may occur following DMEK or DSAEK with different clinical phenotypes, reasons, and risk factors that accompany graft failure. In addition in this chapter the clinically relevant yet only rudimentarily investigated development of dry eye disease following posterior lamellar keratoplasty is outlined.

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.

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.

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.

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.