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Chrysovalantis Sourlis,1 Berthold Seitz,1 Mathias Roth,2 Loïc Hamon,1 Loay Daas1 1Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany; 2Department of Ophthalmology, Heinrich-Heine University Düsseldorf, Düsseldorf, GermanyCorrespondence: Loïc Hamon, Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany, Tel +49-6841-1622387, Fax +49-6841-1622400, Email loic.hamon@uks.euPurpose: The purpose of this study was to assess the impact of early diagnosis using in vivo confocal microscopy and early therapeutic penetrating keratoplasty (TPK) on the outcomes of severe cases of fungal keratitis.Methods: This retrospective single-center study included 38 patients (40 eyes) with fungal keratitis who presented between December 2013 and February 2020. Preoperative, intraoperative, and postoperative parameters were recorded to assess the role of early correct diagnosis and early surgical therapy on visual acuity outcome and enucleation rate during follow-up.Results: The mean patient age was 51 years (71% females). The initial external diagnosis was correct in 20 cases (50%). The mean time from symptom onset until admission to our department was 46.8 ± 68.0 (median 28.5) days. The mean time to correct diagnosis after admission to our department was 1 day with in vivo confocal microscopy (IVCM). IVCM was performed in 38 cases, of which 36 (sensitivity: 94.7%) were positive for fungal infection. Twenty-seven out of 40 (67.5%) eyes received a TPK 4.2 ± 3.9 days after admission, with a mean graft size of 8.9 ± 1.9 mm. Three eyes (7.5%) were enucleated. The corrected distance visual acuity of the entire study population increased from 2.0 ± 1.2 LogMAR to 0.96 ± 1.17 LogMAR.Conclusion: In vivo confocal microscopy is a powerful tool for the early detection of fungal organisms in infectious keratitis. An early TPK with a large graft helps to eradicate the infection timely and results in a favorable visual acuity outcome and lower enucleation rate, especially when treating filamentous fungi.Keywords: fungal keratitis, in vivo confocal microscopy, penetrating keratoplasty

Shady Suffo, Mohammed El Halabi, Berthold Seitz, Alaa Din Abdin, Cristian Munteanu, Loay Daas Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg, Saar, GermanyCorrespondence: Mohammed El HalabiDepartment of Ophthalmology, Saarland University Medical Center, Kirrberger Straße 100, Bldg. 22, Homburg, 66421, GermanyTel +491739920686Email mohammed.elhalabi@uks.euBackground and Objectives: The Homburg cross-stitch marker, according to Suffo, was developed in 2017 in the Department of Ophthalmology at Saarland University Medical Center. With this instrument, a surgeon can precisely define and mark the points of the first and second continuous cross-stitch sutures, according to Hoffmann. The aim of this retrospective study was to compare the functional outcomes of Hoffmann’s double continuous cross-stitch suture in penetrating keratoplasty (PKP) with vs without the Homburg cross-stitch marker in inexperienced surgeons.Methods: A total of 130 eyes from 130 patients with central corneal scars, corneal dystrophies and advanced keratoconus were included. All eyes underwent elective excimer laser-assisted penetrating keratoplasty (excimer laser PKP) with a diameter of 8.0/8.1mm. In 65 eyes each, surgery was performed without (group 1) or with (group 2) the Homburg cross-stitch marker. Corrected distance visual acuity, topographic astigmatism, and refractive cylinder were obtained 6 weeks, 10 months post-PKP as well as 6 weeks after the first and after the second suture removal, respectively. The rate of early postoperative single interrupted suture addition was compared between the two groups.Results: Visual acuity, astigmatism and refractive cylinder values were significantly more favorable in group 2 (with device) compared to group 1 (without device) before and after suture removal. Postoperative single interrupted suture addition was performed in 34.4% of patients in group 1 compared to 10.6% in group 2 (P = 0.001, Fisher’s Exact Test).Conclusion: The use of the Homburg cross-stitch marker for excimer laser PKP in young cornea specialists results in significantly better visual acuity before and after suture removal, significantly lower astigmatism and cylinder value before suture removal, as well as a reduced necessity of early postoperative single interrupted suture addition.Keywords: excimer laser-assisted penetrating keratoplasty, Hoffmann cross-stitch suture, Homburg cross-stitch marker, corrected distance visual acuity, astigmatism, refractive cylinder