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Introduction: To evaluate the anterior chamber (AC) inflammation in the early postoperative period after cataract surgery and before Descemet membrane endothelial keratoplasty (DMEK) by quantifying oxidative stress and inflammatory mediators in aqueous humor of patients with Fuchs' endothelial corneal dystrophy (FECD)., Methods: In this prospective single-center study, 15 patients with FECD underwent cataract surgery and DMEK in a two-stage procedure. Aqueous humor was collected from the AC at the beginning of cataract surgery and 3 months later at the beginning of DMEK. In the control group, which consisted of 15 age-matched phakic patients without FECD, aqueous humor was only collected at the beginning of cataract surgery. Mediators of postoperative inflammation including TNF-α, VEGF, IL-2, IL-1 β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, GM-CSF, IFN-γ, CXCL5/ENA-78, FGF-basic, G-CSF, IL-1-α, IL-1-ra, IL-17, CCL2/MCP-1, CCL3/MIP-1a, CCL4/MIP-1b, TPO, TGF-β-1, TGF-β-2, and TGF-β-3 concentrations were measured using a Multiplex-Array-System., Results: The concentration of TNF-α (p = 0.021), IL-6 (p = 0.005), IL-8 (p = 0.001), CXCL5/ENA78 (p = 0.002), CCL2/MCP-1 (p = 0.001) and CCL4/MIP-1b (p = 0.037) were significantly higher 3 months after cataract surgery at the beginning of DMEK compared to control group at beginning of cataract surgery. The levels of IL-2, IL-5, IL-8, IL-10, and IL-1-α were significantly higher in phakic eyes in the control group (p < 0.05) before cataract surgery., Conclusions: The present study indicates significantly increased proinflammatory cytokines 3 months after cataract surgery in eyes with FECD. Our findings suggest postoperative inflammation in the AC up to 3 months after cataract surgery. Therefore, it may be reasonable to combine cataract surgery with DMEK in cataract patients with FECD., Competing Interests: Declarations. Conflict of Interest: Lizaveta Chychko, Hyeck-Soo Son, Maximilian Friedrich, Ramin Khoramnia, and Victor A. Augustin have nothing to disclose. Gerd. U. Auffarth receives funding from the Klaus Tschira Stiftung, Heidelberg, Germany. Funding organizations had no role in the design or conduct of this research. Ethical Approval: Written informed consent was obtained from all patients prior to the surgical procedure. This study was approved by the local Ethics Committee of the University of Heidelberg and was performed in accordance with the Helsinki Declaration of 1964, and its later amendments., (© 2024. The Author(s).)

Background: Homogeneous intraocular lens (IOL) calcification deteriorates patient's visual quality. There is a lack of functional and patient-reported data on patients with this material change undergoing IOL exchange surgery. The aim of this study was to evaluate subjective and objective outcomes following IOL exchange due to homogeneous IOL calcification to improve evidence-based patient counseling., Methods: In this prospective, non-interventional, clinical study, 53 eyes of 42 patients with homogeneous IOL calcification were included. IOL exchange was performed in 30 out of 53 eyes. Subjective symptoms using a quality-of-life questionnaire (Catquest-9SF), photic phenomena, corrected distance visual acuity (CDVA), straylight (C-Quant, Oculus, Wezlar, Germany) and contrast sensitivity with and without glare (CSV-1000, VectorVision, Houston, USA) were assessed before (T0) and at 3 to 12 months after IOL exchange (T1)., Results: Preoperative CDVA and straylight did not correlate. Average halo and glare size and intensity decreased and Catquest-9SF items improved. The CDVA rose significantly from 0.16 ± 0.13 to 0.05 ± 0.10 logMAR, and contrast sensitivity increased with and without glare. The straylight value decreased statistically and clinically significant from 2.32 ± 0.34 to 1.23 ± 0.33 log(s)., Conclusion: Homogeneous IOL calcification is not always associated with a pronounced reduction in visual acuity. In most cases, IOL exchange still reduces subjective complaints and improves quality of vision of affected patients. Visual acuity should not be the sole functional parameter in assessing patients with homogeneous IOL calcification as intraocular straylight and contrast sensitivity can better objectify patients' visual impairment. We recommend a straylight value above 1.56 log(s) as a cut-off when deciding on an IOL exchange surgery., Competing Interests: Declarations. Ethics approval and consent to participate: The study was performed in accordance with the principles of the Declaration of Helsinki. Before commencing the study, approval was obtained from the local Ethics Committee (S-193/2022) and the collection of this patient data was registered in the Clinical Trials Register (DRKS00007837). All patients provided written informed consent to participate in this study prior to any study-related examinations. Consent for publication: Not applicable. Competing interests: Timur M. Yildirim receives personal fees from Alcon and Hoya, and non-financial support from Johnson & Johnson, outside the submitted work. Victor A. Augustin reports grants from Kowa and Eyeyon. Ramin Khoramnia reports grants, personal fees, and non-financial support from Alcon, Johnson & Johnson, Hoya, Physiol, Rayner, personal fees, and non-financial support from Kowa, Ophtec, Oculentis/Teleon, Santen, and Acufocus, outside the submitted work. Gerd U. Auffarth reports grants, personal fees, non-financial support and consulting fees from Johnson & Johnson and Alcon, grants, personal fees, and non-financial support from Carl Zeiss Meditec, Hoya, Kowa, Oculentis/Teleon, Rayner, Santen, Sifi, Ursapharm, grants, and personal fees from Biotech, Oculus, EyeYon grants from Acufocus, Anew, Contamac, Glaukos, Physiol, Rheacell, outside the submitted work. Grzegorz Łabuz, Hyeck-Soo Son, Nikola Henningsen, Leoni Britz and Lizaveta Chychko have nothing to disclose., (© 2024. The Author(s).)

Purpose: To evaluate the biomechanical and tomographic outcomes of keratoconus patients up to four years after corneal crosslinking (CXL)., Methods: In this longitudinal retrospective-prospective single-center case series, the preoperative tomographic and biomechanical results from 200 keratoconus eyes of 161 patients undergoing CXL were compared to follow-up examinations at three-months, six-months, one-year, two-years, three-years, and four-years after CXL. Primary outcomes included the Corvis Biomechanical Factor (CBiF) and five biomechanical response parameters obtained from the Corvis ST. Tomographically, the Belin-Ambrósio deviation index (BAD-D) and the maximal keratometry (K max ) measured by the Pentacam were analyzed. Additionally, Corvis E-staging, the thinnest corneal thickness (TCT), and the best-corrected visual acuity (BCVA) were obtained. Primary outcomes were compared using a paired t-test., Results: The CBiF decreased significantly at the six-month (p < 0.001) and one-year (p < 0.001) follow-ups when compared to preoperative values. E-staging behaved accordingly to the CBiF. Within the two- to four-year follow-ups, the biomechanical outcomes showed no significant differences when compared to preoperative. Tomographically, the BAD-D increased significantly during the first year after CXL with a maximum at six-months (p < 0.001), while K max decreased significantly (p < 0.001) and continuously up to four years after CXL. The TCT was lower at all postoperative follow-up visits compared to preoperative, and the BCVA improved., Conclusion: In the first year after CXL, there was a temporary progression in both the biomechanical CBiF and E-staging, as well as in the tomographic analysis. CXL contributes to the stabilization of both the tomographic and biomechanical properties of the cornea up to four years postoperatively., Competing Interests: Declarations. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Ethics Committee from Ruprecht-Karls University of Heidelberg (trial registration number: S-621/2021) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study. Conflict of interest: R. Khoramnia reports grants, personal fees, and nonfinancial support from Johnson & Johnson Vision, Alcon Laboratories, Hoya Corp., Kowa Co., Ltd., Oculentis GmbH/Teleon, Physiol S.A., Sifi Medtech Srl, and Rayner Intraocular Lenses Ltd.; grants and personal fees from Oculus Optikgeräte GmbH, Carl Zeiss Meditec AG, and Ophtec BV; and grants from Acufocus Inc. outside the submitted work. G.U. Auffarth reports lecture fees and research grants from Johnson & Johnson Vision, Alcon Laboratories, Carl Zeiss Meditec AG, Hoya Corp., Kowa Co., Ltd., Oculentis GmbH/Teleon, Physiol S.A., Rayner Intraocular Lenses Ltd., Oculus Optikgeräte GmbH, Ophthec BV, Santen, Sifi Medtech Srl, Acufocus Inc., Novartis, Ursapharm and Biotech; nonfinancial support from Rheacell, Contamac, Cristalens, Croma, EyeYon, Hanita, and VSY outside the submitted work. V. A. Augustin reports research grants from Eye Yon and Kowa Co. outside the submitted work. The remaining authors have no relevant financial or non-financial interests to disclose., (© 2024. The Author(s).)

Purpose: To develop and test a parameter for early keratoconus screening by quantifying the localized epithelial thickness differences in keratoconic eyes., Methods: The cross-sectional study included 189 eyes of 116 subjects in total: 86 eyes of 54 keratoconus patients with bilateral ectasia and 40 eyes of 20 healthy subjects in the parameter-development dataset and 42 eyes of 21 keratoconus patients with asymmetric ectasia and 21 eyes of 21 healthy subjects in the parameter-validation dataset. Epithelial thickness maps were obtained using anterior segment optical coherence tomography and the inter-zonal epithelial thickness differences were calculated. The developed parameter was tested in keratoconus patients with asymmetric ectasia., Results: Compared to healthy controls, the inferior-temporal and global inter-zonal epithelial thickness differences were higher not only in eyes with tomographically significant keratoconus (median [interquartile range] of 4.42 [3.13] µm vs. 0.78 [0.42] µm, p < 0.001, and 3.05 [1.51] µm vs. 1.07 [0.26] µm, p < 0.001, respectively), but also in tomographically normal keratoconus fellow eyes (1.36 [0.85] µm vs. 0.78 [0.42] µm, p = 0.005, and 1.31 [0.32] µm vs. 1.07 [0.26] µm, p = 0.01, respectively). The inferior-temporal inter-zonal epithelial thickness differences had an area under the receiver operating characteristic curve (95% confidence interval) of 0.991 (0.972-1) for detecting tomographically significant keratoconus and 0.749 (0.598-0.901) for differentiating between tomographically normal keratoconus fellow eyes and healthy controls., Conclusions: The inter-zonal epithelial thickness differences are increased in keratoconus fellow eyes which still have a normal Scheimpflug corneal tomography, and therefore may serve as a useful parameter to detect early ectatic changes., (© 2024. The Author(s).)

Background: Small Descemet membrane detachments after cataract surgery are relatively common and most cases do not require any secondary surgical intervention and can be treated conservatively. However, in case of advanced Descemet membrane detachment (DMD), it needs to be recognized and treated appropriately. The advent of anterior segment imaging using optical coherence tomography (OCT) technology has made diagnosing pathologies of the anterior segment accurate and time efficient and has proven as an invaluable tool to guide decision making., Case Presentation: A 71-year-old patient presented after complicated cataract surgery with decreased visual acuity and cloudy vision. On examination, best corrected visual acuity was 1.5 logMAR. A high-resolution swept-source OCT (Anterion, Heidelberg Engineering, Heidelberg, Germany) was used to better evaluate and visualize the extent of DMD. An anterior chamber gas bubble was injected to reattach the Descemet membrane (DM) to the corneal stroma. The success of the surgery was visualized using the high-resolution swept-source OCT. This revealed a completely attached Descemet membrane., Conclusions: Clinically, it can be difficult to distinguish the etiology of epithelial and stromal edema post cataract surgery. This case demonstrated the clinical usefulness using high resolution swept source imaging to guide clinical decision making in evaluating timing and treatment success of pneumodescemetopexy after complicated cataract surgery., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2024 Köppe et al.)

Purpose: The aim of this study was to compare visual function, with a focus on contrast sensitivity, between patients with Fuchs endothelial corneal dystrophy (FECD) with and without subclinical corneal edema., Methods: In this cross-sectional, observational, single-center study, 46 pseudophakic eyes of 31 patients with FECD were divided into 2 groups depending on the presence of subclinical corneal edema. All eyes presented with a Krachmer grade of 5 and no clinical corneal edema. The criteria for subclinical corneal edema were loss of regular isopachs, displacement of the thinnest point, and focal posterior surface depression in Scheimpflug tomography. If more than 1 criterion was present, subclinical corneal edema was diagnosed. The corrected distance visual acuity, contrast sensitivity (Pelli-Robson chart and CSV-1000 test with optional glare), and straylight were measured. The differences between both groups were analyzed using clustered Wilcoxon rank-sum tests., Results: The corrected distance visual acuity and the contrast sensitivity, measured with a Pelli-Robson chart, were significantly inferior in eyes with subclinical corneal edema compared with eyes without subclinical edema ( P < 0.05). At all spatial frequencies, eyes with subclinical edema demonstrated lower contrast sensitivity with a statistically significantly reduction in total contrast sensitivity when tested with ( P = 0.005) and without ( P = 0.002) glare. The straylight did not significantly differ between both groups ( P > 0.05)., Conclusions: The corrected distance visual acuity and contrast sensitivity were significantly reduced in FECD eyes with subclinical corneal edema compared with those with no subclinical edema. This decrease in visual quality may be considered when evaluating the need for surgical intervention at earlier stages of FECD., Competing Interests: R. Khoramnia reports grants, personal fees, and nonfinancial support from Johnson & Johnson Vision, Alcon Laboratories, Hoya Corp, Kowa Co, Ltd, Oculentis GmbH/Teleon, Physiol S.A., Sifi Medtech Srl, and Rayner Intraocular Lenses Ltd; grants and personal fees from Oculus Optikgeräte GmbH, Carl Zeiss Meditec AG, and Ophtec BV; and grants from Acu Focus Inc., outside the submitted work. G. U. Auffarth reports lecture fees and research grants from Johnson & Johnson Vision, Alcon Laboratories, Carl Zeiss Meditec AG, Hoya Corp, Kowa Co, Ltd, Oculentis GmbH/Teleon, Physiol S.A., Rayner Intraocular Lenses Ltd, Oculus Optikgeräte GmbH, Ophtec BV, Santen, Sifi Medtech Srl, Acu Focus Inc, Novartis, Ursapharm, and Biotech; nonfinancial support from Rheacell, Contamac, Cristalens, Croma, EyeYon, Hanita, and VSY, outside the submitted work. V. A. Augustin reports research grants from Kowa Co., outside the submitted work. The remaining authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: In Descemet Membrane Endothelial Keratoplasty (DMEK) a gas bubble is usually used to attach the graft to the host cornea. In this study, we observed the bubble size and bubble-graft coverage at different gaze angles following DMEK., Methods: This observational prospective study analyzed 465 images of patients who underwent an uneventful DMEK. Intraoperatively, the anterior chamber was filled up to 90% of its volume with a 20% Sulfur Hexafluoride (SF 6 ) gas-air mixture. Postoperatively, the bubble was photographed daily in different gaze angles ranging from a supine position (0°) to an upright position (90°) and a slightly inclined position (105°). The primary outcomes were bubble-graft coverage and bubble diameters depending on the gaze angle and time after DMEK., Results: The highest bubble-graft coverage was achieved at a 0° gaze angle at all times of measurement. In the first 48 h after DMEK, the mean bubble-graft coverage was over 85% at a gaze angle between 0° and 45°. Starting 72 h after DMEK, the graft coverage declined at all gaze angles. The graft coverage at a 0° gaze angle was 88.61 ± 10.90% after 96 postoperative hours, while the graft coverage was below 85% at all other gaze angles., Conclusion: Our clinical results provide novel insight into variation in bubble-graft coverage as a function of gaze angle and may be used to aid in patient counselling for appropriate body positioning following DMEK to prevent early graft detachment. Maintaining supine positioning seems to be most advantageous starting 48 h after DMEK., Competing Interests: Declaration of conflicting interestsT. M. Yildirim reports lecture fees from Alcon Laboratories and Hoya Corp. and nonfinancial support from Johnson & Johnson Vision.R. Khoramnia report grants, personal fees, and nonfinancial support from Johnson & Johnson Vision, Alcon Laboratories, Hoya Corp., Kowa Co., Ltd., Teleon, Physiol S.A., Sifi Medtech Srl, and Rayner Intraocular Lenses Ltd.; grants and personal fees from Oculus Optikgeräte GmbH, Carl Zeiss Meditec AG, Heidelberg Engineering and Ophtec BV; and grants from Acufocus, Inc., outside the submitted work.G.U. Auffarth reports lecture fees and research grants from Johnson & Johnson Vision, Alcon Laboratories, Carl Zeiss Meditec AG, Hoya Corp., Kowa Co., Ltd., Oculentis GmbH/Teleon, Rayner Intraocular Lenses Ltd., Santen, Sifi Medtech Srl, and Biotech.V.A. Augustin reports research grant from Kowa Co., Ltd.For the remaining authors, no financial disclosures were declared.

Fungal keratitis due to Fusarium species is a rare but serious ocular disease. Due to its rapid progression, often late diagnostic confirmation as well as limited topical treatment options, this is potentially sight threatening. Increasing contact lens use and global climate change have been suggested to be factors leading to an increase in cases of fusarium keratitis, even in regions with moderate climate. Early recognition and initiation of antimycotic treatment, as well as early surgical treatment by penetrating keratoplasty are decisive for the outcome., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht./The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: High-order aberrations (HOAs) are known to be increased in corneas with Fuchs endothelial dystrophy (FECD) and are associated with visual impairment. This case series aimed to analyze whether tomographic changes in FECD affect the HOA in the early period of the disease., Methods: In this retrospective single-center case series, 144 eyes of 85 patients were included, of which 78 eyes of 47 patients with FECD with slit-lamp biomicroscopically visible guttae but no visible corneal edema served as the study-cohort. According to Sun et al, included eyes were divided into 2 groups: group 0 (n = 28; no subclinical corneal edema) and group 1 (n = 50; subclinical corneal edema). A total of 66 healthy eyes of 38 patients served as control group. Mean values and standard deviations were calculated for the root mean square (RMS), coma, trefoil and spherical aberrations (SA) of the cornea (C), the anterior surface (CF), and the posterior surface (CB)., Results: Statistically significant differences (P < 0.001) in the RMS HOA (group 0: 0.209 ± 0.044 μm, group 1: 0.372 ± 0.122 μm) and in coma (group 0: 0.082 ± 0.054 μm, group 1: 0.214 ± 0.101 μm) and SA (group 0: -0.130 ± 0.038 μm, group 1: -0.176 ± 0.074 μm) of the CB were found in eyes in group 1 versus those in group 0. There were no statistically significant differences in HOA between the control group and eyes in group 0., Conclusions: FECD eyes with subclinical corneal edema demonstrated significant increase in RMS, coma, and SA of the CB. Tomographic analysis, therefore, helps in visual impairment assessment, disease progression, and decision-making for early endothelial keratoplasty in patients with FECD., Competing Interests: L. Blöck reports reimbursement of travel expenses from Oculus Optikgeräte, Wetzlar, Germany. H.-S. Son, M. Friedrich, and M. K. Köppe declare that they have no conflict of interest. V. A. Augustin reports research grant from Kowa Co., Ltd. G. Auffarth reports grants, personal fees, nonfinancial support, and consulting fees from Johnson&Johnson and Alcon, grants, personal fees, and nonfinancial support from Carl Zeiss Meditec, Hoya, Kowa, Oculentis/Teleon, Rayner, Sifi, Ursapharm, grants and personal fees from Biotech, Oculus, EyeYon grants from, Contamac outside the submitted work., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The aim of this study was to analyze the causes and characteristics of IOL explantation within the first year after primary implantation., Methods: In this retrospective, cross sectional database study, a database consisting of over 2500 IOL explants sent from 199 national and international doctors over the past 10 years was analyzed. All IOLs explanted within the first year after implantation were included in this analysis. Explants with insufficient information as well as phakic and Add-on IOLs were excluded. Main outcome measures were the reason for explantation, the time between implantation and explantation, as well as IOLs' and patients' characteristics. Additionally, the explanted IOLs were microscopically and histologically analyzed, as required., Results: Of all explanted IOLs from the database, 1.9% (n = 50) were explanted within the first year after implantation. The most frequent reasons for early IOL explantation were IOL dislocation (32%), visual intolerance (26%), opacification (20%), and intraoperative complications (16%). The time between implantation and explantation was the shortest in cases with intraoperative complications (1.5 ± 3.1 days), followed by IOL dislocation (90.9 ± 103.9 days), visual intolerance (98.3 ± 86.5 days), opacifications (253.5 ± 124.0 days) and other indications (249.7 ± 124.0 days). Calcification of hydrophilic IOLs was the main type of opacification (80%). Notably, seven IOLs required immediate intraoperative exchange due to an intraoperative crack in the optic or a torn off haptic., Conclusion: Indications for early IOL explantation were IOL dislocation, visual intolerance, opacification, and intraoperative complications. Especially intraoperative damages to the IOL and early calcification show a potential for improvement of affected IOLs and implantation systems., (© 2024. The Author(s).)

Purpose: The purpose of this study was to determine whether the Scheimpflug tomographically normal fellow eyes of keratoconus patients are also classified as normal using an ectasia screening algorithm based on anterior segment optical coherence tomography (AS-OCT)., Methods: This monocentric cross-sectional study included 22 very asymmetric ectasia patients with tomographically significant keratoconus in 1 eye and normal Scheimpflug tomography in the fellow eye. Twenty-two eyes of 22 healthy subjects served as a control group. We performed corneal tomography using Pentacam AXL (Oculus, Wetzlar, Germany) and used Belin/Ambrósio Enhanced Ectasia total deviation index as well as Belin ABCD keratoconus classification to identify Scheimpflug tomographically normal eyes. We also performed AS-OCT using Anterion (Heidelberg Engineering, Heidelberg, Germany) and analyzed for the presence of ectasia using the Screening Corneal Objective Risk of Ectasia (SCORE) algorithm, with positive values indicating ectasia suspect tomography., Results: The SCORE value was positive in 9.1% (n = 2) of the healthy eyes, in 45.5% (n = 10) of the Scheimpflug tomographically normal eyes of keratoconus patients and in all eyes (n = 22) with tomographically significant keratoconus. The Scheimpflug tomographically normal eyes of keratoconus patients had higher SCORE values compared with healthy controls ( P < 0.001). The median (interquartile range) SCORE value was -1.7 (1.3) in healthy controls, -0.5 (2.2) in Scheimpflug tomographically normal eyes of keratoconus patients, and 11.1 (11.0) in tomographically significant keratoconus eyes., Conclusions: The Scheimpflug tomographically normal fellow eyes of keratoconus patients had higher AS-OCT-based SCORE values than healthy controls, with positive SCORE values found in 46% of the eyes, indicating early tomographic ectatic changes., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the biomechanical longitudinal variability and progression of tomographically normal fellow eyes of patients with keratoconus., Methods: Of 513 patients with keratoconus, 30 patients with tomographically normal fellow eyes were included in this study. Tomographic and biomechanical parameters of the Pentacam and Corvis ST (Oculus Optikgeräte GmbH) were analyzed in multiple follow-up examinations, including the ABCD grading, Belin/Ambrósio Enhanced Ectasia total deviation index (BAD-D), Corvis Biomechanical Index (CBI), Corvis Biomechanical Factor (CBiF), and Tomographic and Biomechanical Index (TBI). A mixed regression model was applied. The results were compared to a healthy control group (n = 17) and a keratoconus group (n = 20)., Results: Within a maximum observation period of 3.3 years, no fellow eye (0%) showed a progression to tomographically evident keratoconus. No significant change in tomographic or biomechanical parameters was detected over the study period. The indices BAD-D, CBI, CbiF, and TBI exhibited a certain variability over time, whereas the tomographic ABC parameters and maximum keratometry barely changed. This was also shown in the control group and for all parameters in the keratoconus group, except the TBI., Conclusions: During the observation period none of the normal fellow eyes progressed to tomographically detectable keratoconus. However, biomechanical parameters CBI, CbiF, and TBI showed pathological values in 43.3% of eyes and certain variability. Subsequent studies with a longer observation period are warranted to confirm the biomechanical trends seen in this study and to rate the ability of single measurements to diagnose early keratoconus. [ J Refract Surg . 2024;40(1):e48-e56.] .

In this meta-analysis and systematic literature review of refractive outcomes after Descemet membrane endothelial keratoplasty (DMEK), the extent of the refractive shift and an overview of reasons for refractive shift after DMEK are provided. The PubMed library was screened for articles containing the terms "Descemet membrane endothelial keratoplasty," "DMEK," "Descemet membrane endothelial keratoplasty combined with cataract surgery," "triple-DMEK" combined with "refractive outcomes," "refractive shift," and "hyperopic shift." The refractive outcomes after DMEK were analyzed and compared using a fixed and random effects model. The overall mean change of the spherical equivalent outcome when compared with the preoperative value in cases of DMEK or when compared with the preoperative target refraction in cases of DMEK combined with cataract surgery was +0.43 diopters (D) (95% CI, 0.31-0.55). When DMEK is combined with cataract surgery, a target refraction of -0.5 D is recommended to achieve emmetropia. Changes in the posterior corneal curvature are identified as the main cause of the refractive hyperopic shift., (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Background: Keratoconus is a bilateral, yet asymmetric disease. In rare cases, the second eye may show no signs of tomographic changes. The purpose of this study was to analyze the biomechanical characteristics in tomographically regular keratoconus fellow eyes., Materials and Methods: This retrospective, consecutive case series analyzed 916 eyes of 458 patients who presented to our keratoconus clinic between November 2020 and October 2022. Primary outcome measures included best-corrected visual acuity (BCVA), tomographic Scheimpflug analysis using Pentacam AXL (Oculus, Wetzlar, Germany), and biomechanical assessment using Corvis ST (Oculus, Wetzlar, Germany). Tomographic changes were assessed via analysis of the anterior and posterior curvature, K-max, thinnest corneal thickness (TCT), the Belin/Ambrosio Deviation Display (BAD-D), and the ABCD-Grading. Biomechanical changes were analyzed using Corvis Biomechanical Index (CBI) and Tomographic Biomechanical Index (TBI)., Results: Of 916 eyes, 34 tomographically regular fellow eyes (7.4%) were identified and included in the analysis. Overall, the mean BCVA was - 0.02 ± 0.13 logMAR. Tomographic analysis showed mean K-max of 43.87 ± 1.21 D, mean TCT of 532 ± 23 µm, and mean BAD-D of 1.02 ± 0.43. Biomechanical analysis demonstrated mean CBI of 0.28 ± 0.26 and mean TBI of 0.34 ± 0.30. While normal CBI-values were observed in 16 (47%) of 34 eyes, only 13 eyes (38%) showed a regular TBI and only 7 eyes (21%) showed regular TBI and CBI. The sensitivity of CBI and TBI to detect a tomographically normal keratoconus fellow eye was 53% and 62%, respectively., Conclusion: A highly asymmetric corneal ectasia with regular tomographic finding in a fellow eye is rare among keratoconus patients. In such cases, a biomechanical analysis may be useful in detecting early signs of corneal ectasia. In our analysis, the TBI showed high sensitivity for detecting a biomechanical abnormality in tomographically regular fellow eyes., Competing Interests: R. K. berichtet über Forschungszuschüsse und Vortragshonorare von Alcon, Hoya, PhysIOL, Rayner, 1stQ und Johnson & Johnson, Vortragshonorare von Kowa, Ophtec, Teleon, Santen, Acufocus, Bauch & Lomb und Reisestipendien von Alcon, Teleon, Johnson & Johnson, Rayner und 1stQ. G. U. A. berichtet über Forschungsstipendien, Reisestipendien und Vortragshonorare von Alcon, Hoya, Kowa, SIFI, Forschungsstipendien und Vortragshonorare von Johnson & Johnson und Santen sowie Forschungsstipendien von Zeiss, PhysIOL und Acufocus. T. M. Y. erhält Vortragshonorare von Alcon. Alle anderen Autoren geben keine Interessenkonflikte an./R. K. reports research grants and lecture fees from Alcon, Hoya, PhysIOL, Rayner, 1stQ and Johnson & Johnson, lecture fees from Kowa, Ophtec, Teleon, Santen, Acufocus, Bauch & Lomb and travel grants from Alcon, Teleon, Johnson & Johnson, Rayner and 1stQ. G. U. A. reports research grants, travel grants and lecture fees from Alcon, Hoya, Kowa, SIFI, research grants and lecture fees from Johnson & Johnson and Santen and research grants from Zeiss, PhysIOL and Acufocus. T. M. Y. receives lecture fees from Alcon. All other authors indicate no conflicts of interest., (Thieme. All rights reserved.)

Differentiating between various intraocular lens (IOL) changes can be a challenge. In particular, certain IOL models carry the risk of late postoperative calcification. A major cause of IOL exchange surgery could be avoided if appropriate modifications were made during the IOL manufacturing process. The use of a hydrophilic acrylate carries the risk of IOL calcification, especially when a secondary procedure, such as a pars plana vitrectomy or other procedures using gas or air, is performed. In secondary IOL calcification, there is a wide range of opacification patterns, which are usually located in the centre on the anterior surface of the IOL or sometimes elsewhere. Often, granular deposits accumulate just below or on the surface of the IOL, leading to significant deterioration in visual quality and eventually requiring IOL exchange surgery. Therefore, in the case of eyes requiring secondary surgical intraocular intervention in the future, the use of hydrophilic IOLs should be critically evaluated. With regard to hydrophobic IOL materials, there are clear differences in the susceptibility to the formation of glistenings. Over time, there has been a significant decrease in glistening formation over the past 30 years due to optimisation of the material. With hydrophobic IOLs, special care should also be taken to avoid mechanical damage. In general, the only treatment option for functionally-impairing IOL opacification is surgical lens exchange, which carries potential risks of complications. In cases with a low degree of functional impairment, and especially in eyes with additional ocular diseases, it may be difficult to weigh the risk of additional surgery against the potential benefit. In some cases, it may be more appropriate not to perform an IOL exchange despite the IOL opacification. Recent visualisation methods that allow high-resolution analysis of the opacities in vivo and in vitro may be used in the future to estimate the functional effects of various IOL material changes on the optical quality., Competing Interests: TY berichtet von persönlichen Honoraren von Alcon und nicht finanzieller Unterstützung von Johnson & Johnson, die nicht in Zusammenhang mit der eingereichten Arbeit stehen. GA berichtet von Zuschüssen, persönlichen Honoraren, nicht finanzieller Unterstützung und Beratungshonoraren von Johnson & Johnson und Alcon, Zuschüssen, persönlichen Honoraren, nicht finanzieller Unterstützung von Carl Zeiss Meditec, Hoya, Kowa, Oculentis/Teleon, Rayner, Santen, Sifi, Ursapharm, Zuschüssen und persönlicher Unterstützung von Biotech, Oculus, EyeYon, Zuschüssen von Acufocus, Anew, Contamac, Glaukos, Physiol, Rheacell, die alle nicht in Zusammenhang mit der eingereichten Arbeit stehen. RK berichtet von Zuschüssen, persönlicher Unterstützung, nicht finanzieller Unterstützung von Alimera, Alcon, Bayer, Johnson & Johnson, Hoya, Novartis, Physiol, Rayner und Roche, von Zuschüssen von Chengdu Kanghong, von persönlichen Zuschüssen und nicht finanzieller Unterstützung von Allergan, Carl Zeiss, Kowa, Heidelberg Engineering, Oculentis/Teleon, Oculus, Santen, Sifi and Acufocus, die nicht in Zusammenhang mit der eingereichten Arbeit stehen. NH, GŁ, VA, HS und LM geben an, keine Interessenkonflikte zu haben. Bei dieser Arbeit gab es keinerlei finanzielle Unterstützung./TY reports personal fees from Alcon and non-financial support from Johnson & Johnson that are unrelated to the submitted work. GA reports grants, personal fees, non-financial support, and consulting fees from Johnson & Johnson and Alcon, grants, personal fees, non-financial support from Carl Zeiss Meditec, Hoya, Kowa, Oculentis/Teleon, Rayner, Santen, Sifi, Ursapharm, grants and personal support from Biotech, Oculus, EyeYon, grants from Acufocus, Anew, Contamac, Glaucoma, Physiol, and Rheacell, all of which are unrelated to the submitted work. RK reports grants, personal support, non-financial support from Alimera, Alcon, Bayer, Johnson & Johnson, Hoya, Novartis, Physiol, Rayner, and Roche, grants from Chengdu Kanghong, personal grants and non-financial support from Allergan, Carl Zeiss, Kowa, Heidelberg Engineering, Oculentis/Teleon, Oculus, Santen, Sifi, and Acufocus that are not related to the submitted work. NH, GŁ, VA, HS, and LM report that they have no conflicts of interest. This study received no financial support whatsoever., (Thieme. All rights reserved.)

Purpose: In intraocular lens (IOL) implantation, insertion of the IOL injector enlarges the clear corneal incision. A larger incision size (IS) is associated with a higher risk for surgically induced astigmatism and endophthalmitis. The goal of this study was to determine which parameters most influence the final IS., Design: Experimental study., Subjects: A total of 126 cadaver porcine eyes were included in this study., Methods: We analyzed 409 clear corneal incisions made with 126 injectors from 13 injector models. We noted the vertical diameter and the tip angulation for every model. The corneal thickness of each incision location was measured using Scheimpflug tomography. The IS was measured before and after injector insertion and described as preoperative and final ISs, respectively. During surgery, the insertion depth and incision length were documented. A mixed effects model was applied to analyze the influence of the parameters on the final IS., Main Outcome Measures: Influence on the final IS., Results: Increases in the vertical diameter of the injector tip, the preoperative IS and the insertion depth, and a reduction of incision length were all significantly associated with increased final IS ( P  < 0.05). The conditional Pseudo-R 2 -Measure was 0.92. The preoperative IS had the largest standardized estimated effect on the final IS, followed by the vertical diameter of the injector tip, insertion depth, and lastly, incision length. Neither corneal thickness nor the tip angle of the injector had a significant effect on the final IS ( P  > 0.05)., Conclusions: The IOL injector's vertical diameter should be as small as possible to ensure a minimal final IS. The injector's insertion depth may be minimized, and the incision length should be long enough to reduce the final IS. Further studies are needed to confirm the findings in human autopsy eyes and in clinical practice., Financial Disclosures: Proprietary or commercial disclosure may be found after the references in the Footnotes and Disclosures at the end of this article.., (© 2023 by the American Academy of Ophthalmology.)

Purpose: The purpose of this research was to compare the ability of Scheimpflug and anterior segment optical coherence tomography (OCT) in detecting subclinical corneal edema in patients with Fuchs endothelial corneal dystrophy (FECD) without clinical corneal edema., Methods: In this single-center, consecutive case series, 47 eyes of 29 patients with FECD were analyzed. The main outcome measures were anterior/posterior keratometry and central/thinnest corneal thickness. The criteria for subclinical corneal edema were loss of regular isopachs, displacement of the thinnest point of the cornea, and presence of posterior surface depression. Tomographic analyses were performed using Scheimpflug imaging (Pentacam HR) and OCT (anterior segment swept-source optical coherence tomography)., Results: The measurement of the continuous variables revealed a significant difference between the 2 devices. The anterior curvature was steeper and the posterior curvature was flatter when measured with OCT ( P < 0.001). The OCT showed a lower central corneal thickness and thinnest corneal thickness ( P < 0.001). The agreement between both devices to detect subclinical corneal edema was high. The interdevice reliability for loss of parallel isopachs as measured by Cohen kappa coefficient was 0.84; for the displacement of the thinnest point of the cornea, it was 0.6, and for the focal posterior corneal surface depression, it was 0.62. Subclinical corneal edema was detected in 72.3% of the patients with both devices. In only 2 cases (4.3%), subclinical corneal edema was detected by one of the devices., Conclusions: Scheimpflug and OCT imaging were both able to detect tomographic patterns of subclinical corneal edema. Therefore, both devices can help decision-making, favoring early endothelial keratoplasty in symptomatic patients with FECD without clinical corneal edema., Competing Interests: G. U. Auffarth reports grants, personal fees, nonfinancial support, and consulting fees from Johnson & Johnson and Alcon; grants, personal fees, and nonfinancial support from Carl Zeiss Meditec, Hoya, Kowa, Oculentis/Teleon, Rayner, Santen, Sifi, and Ursapharm; grants and personal fees from Biotech, Oculus, and EyeYon; grants from Acufocus, Anew, Contamac, Glaukos, PhysIOL, and Rheacell, outside the submitted work. R. Khoramnia report grants, personal fees, and nonfinancial support from Alimera, Alcon, Bayer, Johnson & Johnson, Hoya, Novartis, PhysIOL, Rayner, and Roche, outside the submitted work. R. Khoramnia reports grants from Chengdu Kanghong, outside the submitted work. R. Khoramnia reports personal fees and nonfinancial support from Allergan, Kowa, Oculentis/Teleon, Oculus, Santen, Sifi, and Acufocus, outside the submitted work. The remaining authors have no conflict of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Fungal keratitis due to Fusarium species is known to be typical of developing countries; however, with the increasing use of contact lenses a rise of Fusarium keratitis has been observed in Germany., Methods: In a monocentric retrospective study, we analyzed all patients who presented to our university eye hospital with infectious keratitis between January 2011 and December 2021 and had a proof of Fusarium species in either microscopy, culture or PCR., Results: We could identify 13 patients with a proof of Fusarium species. A significant increase of cases in 2021 was observed. In 76.9% of our cases the patients were female and in 76.9% the patients had a history of prior contact lens use. In only 4 cases the initial corneal sample gave a positive result for Fusarium. On average the suspicion of fungal keratitis arose 13.1 days after onset of symptoms, correct diagnosis was achieved after 14.6 days. All isolated specimens showed resistance against at least one of the common fungicides. In 70% of our cases treatment with penetrating keratoplasty was necessary. The patients showed a 57.1% recurrence rate after penetrating keratoplasty. In 80% of our cases best documented visual acuity after Fusarium keratitis was ≤ 0.4., Conclusion: Due to difficult detection and a high resistance rate to common antifungals, Fusarium keratitis is prone to delayed diagnosis and limited treatment outcomes. Whenever risk factors are present and infectious keratitis does not respond to antibiotics, antimycotic treatment must be initiated. Early keratoplasty may be necessary., (© 2022. The Author(s).)

The aim of this prospective clinical study was to establish and verify an adaptation for axial length (AL) measurement in silicone oil (SO)-filled pseudophakic eyes with a Scheimpflug and partial coherence interferometry (PCI)-based biometer. The AL was measured with a Pentacam AXL (OCULUS Optikgeräte GmbH, Wetzler, Germany) and IOLMaster 700 (Carl Zeiss Meditec, Jena, Germany). The coefficients of variation (CoV) and the mean systematic difference (95% confidence interval (CI)) between the devices were calculated. After implementing a setting for measuring AL in tamponaded eyes with a Pentacam based on data of 29 eyes, another 12 eyes were examined for verification. The mean AL obtained with the Pentacam was 25.53 ± 1.94 mm (range: 21.70 to 30.76 mm), and with IOLMaster, 24.73 ± 1.97 mm (ranged 20.84 to 29.92 mm), resulting in a mean offset of 0.80 ± 0.08 mm (95% CI: 0.77, 0.83 mm), p < 0.001. The AL values of both devices showed a strong linear correlation (r = 0.999). Verification data confirmed good agreement, with a statistically and clinically non-significant mean difference of 0.02 ± 0.04 (95% CI: -0.01, 0.05) mm, p = 0.134. We implemented a specific adaptation for obtaining reliable AL values in SO-filled eyes with the Pentacam AXL.

Purpose: The purpose of this study was to describe a novel device that may serve as an alternative to Descemet membrane endothelial keratoplasty (DMEK) for the treatment of chronic corneal edema., Methods: The EndoArt (EyeYon Medical, Israel) is a flexible, 50-μm thin artificial endothelial layer that matches the cornea's posterior curvature and functions as a fluid barrier at the posterior stroma, replacing the diseased endothelium. Similar to a DMEK approach, it is implanted into the anterior chamber, carefully positioned on the posterior stroma, and secured using an air-gas mixture. Two patients with chronic corneal edema resulting from endothelial decompensation underwent implantation of the new artificial lamella., Results: In patient 1, the central corneal thickness (CCT) decreased from 730 μm preoperatively to 593 μm at 1 day postoperatively. In patient 2, the CCT decreased from 761 μm preoperatively to 487 μm at 1 day postoperatively. Both patients reported high satisfaction and an overall brighter visual quality. Although dislocation of the lamella occurred in both cases, the CCT was promptly restored after a repositioning procedure and remained stable at the 17-month follow-up (CCT of 526 and 457 μm for patients 1 and 2, respectively). In contrast to DMEK donor tissue, the artificial lamella is sufficiently robust to allow easy intraocular manipulation without the risk of damaging the implant. It is easily removable and does not require any immunosuppressive treatment because of its nonbiological nature., Conclusions: Implantation of the EndoArt led to rapid corneal deturgescence and CCT restoration, presenting a possible option for patients with chronic corneal edema., Competing Interests: G. U. Auffarth received research grants and lecture fees by EyeYon Medical. O. Daphna and A. L. Marcovich are consultants at EyeYon Medical. The remaining authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To analyze the tomographically non-affected second eyes of keratoconus patients using the Corvis ST to detect any biomechanical abnormalities or subclinical keratoconus., Methods: In this retrospective, single-center, consecutive case series 244 eyes of 122 keratoconus patients were analyzed between November 2020 and February 2021. Fourteen fellow eyes fulfilled the inclusion criteria and showed no clinical or tomographic signs of keratoconus. Main outcome measures included best-corrected visual acuity, tomographic and biomechanical analyses using Scheimpflug imaging: Pentacam and Corvis ST (Oculus, Wetzlar, Germany). Tomographic analyses included anterior and posterior simulated keratometry, K-Max, central corneal thickness, thinnest corneal thickness, Belin/Ambrosio Ectasia Display, and the ABCD grading system. For biomechanical analyses, the corneal biomechanical index (CBI) and tomographic biomechanical index were used., Results: The mean best-corrected visual acuity was 0.01 ± 0.10 logMAR. Mean K-Max was 43.79 ± 1.12 D, mean central corneal thickness 529 ± 25 µm, mean thinnest corneal thickness 524 ± 23 µm, and mean Belin/Ambrosio Ectasia Display 1.0 ± 0.32. The mean CBI was 0.30 ± 0.21. Regular CBI values were found in six of 14 patients. The mean tomographic biomechanical index was 0.47 ± 0.22 with regular values observed in only two of 14 patients. No signs of tomographic or biomechanical abnormalities were shown in only one of 14 keratoconus fellow eyes, with regular ABCD, Belin/Ambrosio Ectasia Display, CBI and tomographic biomechanical index values., Conclusions: Tomographically normal fellow eyes of keratoconus patients are rare. In these cases, a biomechanical analysis of the cornea may help detect a subclinical keratoconus. The tomographic biomechanical index was the most sensitive index to verify a mild ectasia.

Aims: To evaluate the contrast sensitivity in patients with nuclear cataract and corneal guttae compared to patients with nuclear cataract without guttae., Methods: In this retrospective, single-centre case series, 50 eyes of 50 patients fulfilling the inclusion criteria were enrolled. Patients with corneal guttae and nuclear cataract (n=25, study group) underwent triple Descemet membrane endothelial keratoplasty (DMEK). Patients with nuclear cataract and healthy corneas underwent cataract surgery (n=25, control group). Inclusion criteria were preoperative best-corrected visual acuity ≥20/40, no corneal oedema and similar lens opacity (nuclear opalescence 2.0-2.9). Outcome measures included MARS letter and OPTEC 6500P contrast sensitivity test, corneal volume, central corneal thickness and anterior and posterior corneal densitometry., Results: Preoperative MARS letter and OPTEC 6500P contrast sensitivity was significantly worse in the study group (MARS: p<0.001; OPTEC 6500P: p<0.007 at low spatial frequencies in daylight with and without glare and nightlight without glare). After surgery, there was no significant difference in MARS letter contrast sensitivity between groups (p=0.225). OPTEC 6500P contrast sensitivity remained significantly lower in the study group in daylight and nightlight with and without glare at most spatial frequencies (p<0.01) postoperatively. Preoperative and postoperative corneal volume, central corneal thickness and anterior corneal densitometry were equal in both groups (p>0.05). Posterior densitometry was significantly higher in the study group than in the control group preoperatively (p<0.001) but turned into equal values postoperatively (p=0.07)., Conclusions: Corneal guttae cause an additional significant decrease in contrast sensitivity in eyes with nuclear cataract. This is in favour of performing a triple DMEK even in eyes with a visual acuity of ≥20/40., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)