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Background Congenital corneal opacities are comparatively rare diseases with high amblyogenic potential. Purpose The present work provides an overview of the diagnostics, clinical aspects and genetics of congenital corneal opacities. Methods A literature search was carried out to compile an overview and illustration with own clinical case examples. Results Differentiated diagnostics are of high importance in the treatment of patients with congenital corneal opacities. A close cooperation between the medical departments involved and also the parents is absolutely essential. The structured classification of congenital corneal opacities provides the basis for a targeted treatment. Discussion The causes and the clinical symptoms of congenital corneal opacities are manifold. The correct diagnosis should be made early and in an interdisciplinary manner. Based on this, conservative and surgical treatment measures can be planned and an impending development of amblyopia can be specifically counteracted.

Background The risk of allograft rejection following high-risk keratoplasty increases with the area of corneal neovascularization. Pharmaceutical and physical regression of corneal neovascularization before keratoplasty may offer the potential to reduce the risk of graft rejection after high-risk keratoplasty. Objective This article provides a review of the literature on the preconditioning of vascularized high-risk eyes using fine-needle diathermy and corneal cross-linking (preoperative preconditioning by lymphangioregression). Methods A literature search was carried out in PubMed and a summary of own data is presented. Results Animal experimental studies showed that both fine-needle diathermy and corneal cross-linking lead to a regression of corneal neovascularization and prolong graft survival after high-risk keratoplasty. Furthermore, studies from our institute provide first evidence that both procedures also lead to a reduction of corneal neovascularization in the clinical practice and thus potentially reduce the risk of allograft rejection after subsequent high-risk keratoplasty. Discussion Fine-needle diathermy and corneal cross-linking provide effective therapeutic approaches for angioregressive treatment and seem to prolong graft survival following high-risk keratoplasty. Larger prospective and controlled clinical trials are needed to further investigate these promising therapeutic approaches.

Background In severely compromised and vascularized high-risk eyes, the Boston keratoprosthesis procedure is often the last treatment option. The transparency of the optics is not impaired by endothelial immune reactions. Methods This review article discusses relevant literature as well as our own data and experiences with the Boston keratoprosthesis in high-risk eyes. The relevant complications as well as the postoperative management are discussed. Results In more than 60% of the high-risk eyes a long-term increase in visual acuity can be achieved. Keratoprosthesis retention rates show a variable span with reported mean 5-year retention rates of 75%. The most common postoperative complications include the formation of a retroprosthetic membrane and keratolysis in up to 50% each. More than 70% of the eyes already suffer from (secondary) glaucoma preoperatively, so that glaucoma surgery is performed simultaneously in at least 20% of cases and in the postoperative course further antiglaucomatous surgery is necessary in up to 31%. Vitreoretinal complications include, in particular, sterile vitritis and infectious endophthalmitis but persistent hypotonia is also described in one third of patients. Conclusion The Boston keratoprosthesis is an alternative to conventional corneal replacement if the prognosis for allogeneic transplants is poor. Postoperative complications are common; therefore, postoperative management plays an important role. For vascularized high-risk eyes, however, it is often the only remaining option for visual rehabilitation.

BackgroundDescemet membrane endothelial keratoplasty (DMEK) has become the standard surgical treatment for Fuchs' endothelial corneal dystrophy (FECD) in Germany. In addition to classical FECD, there are endothelial disorders amenable to DMEK associated with complex changes in the anterior segment of the eye, such as anterior synechia of the iris, larger iris defects, after glaucoma surgery, after vitrectomy and after trauma.ObjectiveThis article provides an overview of the possibilities to treat patients with complex anterior segment situations in the presence of corneal endothelial decompensation with DMEK.Material and methodsDescription of problems and current surgical techniques when performing DMEK in complex situations.ResultsReconstruction of the iris or the iris/lens diaphragm often needs to be performed either simultaneously or in aprevious operation to treat patients with complex anterior segment alterations with DMEK. Both very shallow and very deep anterior chambers pose amajor problem. A DMEK graft from older donors (above 70years) is prone to less rolling and should be preferred in patients with adeep anterior chamber (e.g. after vitrectomy). The graft size should also be adapted to the available space, e.g. asmaller graft diameter should be selected for eyes with anterior synechia.ConclusionThere are only afew evaluations of DMEK under complex conditions; however, it appears that the rate of secondary graft failure, endothelial cell loss and the rebubbling rate are increased in this very heterogeneous group of diseases. Further studies are needed to identify risk factors for anegative progression after DMEK in complex eyes.

Background and objectiveDescemet membrane endothelial keratoplasty (DMEK) has increased in popularity since its introduction over 10years ago. This article presents asummary of the experiences of the past years collected at the Department of Ophthalmology at the University of Cologne.MethodsA literature review of DMEK studies primarily from the Department of Ophthalmology at the University of Cologne, Germany was carried out. Own experiences in the fields of donor selection and graft preparation, DMEK surgery, complication management and postoperative treatment are summarized.ResultsSince the introduction of DMEK experience has been gained and ongoing improvements have occurred ranging from donor-recipient allocation to postoperative follow-up. These led to abetter reproducibility of the intervention for the surgeon, to abetter postoperative result and to a reduction of the complication rate.DiscussionThe DMEK represents asafe and individualized procedure for endothelial transplantation for corneal endothelial dysfunction. Continuing development of the method leads to optimization and safer results.

BackgroundKeratoprosthetics refer to the replacement of human corneal tissue with an artificially produced exchange product. The most widely implanted keratoprosthesis worldwide is the Boston TypeI Keratoprosthesis (BI-KPro, Massachusetts Eye and Ear Infirmary, Boston, MA, USA).MethodsThis video article demonstrates the surgical technique of BI-KPro implantation as routinely performed at this institution. In addition, an overview of the surgical indications, patient consent, anesthesia and positioning, postoperative treatment and complications as well as the evidence of the technique is provided in the article based on experience with 31 BI-KPro implantations.ResultsThe indications for BI-KPro primarily include patients in ahigh-risk keratoplasty setting particularly after repeatedly failed keratoplasty. A thorough patient examination and assessment of the indications as well as detailed disclosure of information to the patient about the individual prognosis, the risk profile, the postoperative therapy and follow-up enable apositive postoperative result.ConclusionThe BI-KPro provides an established and relatively standardized option for surgical treatment of eyes in ahigh-risk keratoplasty setting. Patients should be preoperatively informed with respect to the individual prognosis, complication profile and life-long follow-up.

BackgroundDescemet membrane endothelial keratoplasty (DMEK) selectively removes diseased corneal endothelium and Descemet membrane and replaces them with healthy donor tissue. The DMEK technique represents the current gold standard for the treatment of corneal endothelial dysfunction.MethodsIn this article the surgical technique for DMEK is presented by means of avideo. The indications for surgery, patient education, anesthesia and patient positioning, postoperative treatment as well as possible complications and their management are described.ResultsThe DMEK can be applied for the treatment of awide range of corneal endothelial disorders. In addition to the operative implementation, the basis for the outstanding results of the surgical procedure are careful donor-patient allocation, thorough examination and follow-up of all patients and experience of the surgeon.ConclusionThe use of DMEK is asafe and effective procedure for the treatment of corneal endothelial dysfunction. Astandardized and individualized procedure provides the basis for optimal results compared to all previous transplantation procedures.

BackgroundThe therapeutic principle of examinations of children under general anaesthesia using microscope-integrated optical coherence tomography (MI-OCT) is presented. The aim was to assess novel indications as well as limitations for MI-OCT to enhance ophthalmological examinations of neonates and children under general anesthesia.MethodsThe study was based on a review of the literature from google.scholar.com and PubMed and our own data from aprospective study (Department for Ophthalmology, University of Cologne) of 14children with anterior and posterior segment anomalies undergoing examinations under anesthesia. Patients were examined using acommercially available MI-OCT device. The study analyzed the general feasibility of MI-OCT for ophthalmological examination of children under general anesthesia for the anterior and posterior eye segments and the benefits of indications and intraoperative findings.ResultsThe MI-OCT significantly enriched the examinations of children under general anesthesia and delivered additional information not visible with the surgical microscope. Even in situations with alimited anterior chamber view MI-OCT enabled estimation of distances, such as corneal thickness. In addition to influencing therapeutic decisions, in 12/14children MI-OCT also enabled examination of the thickness of the nerve fibre layer of the optic nerve disc and the retina.ConclusionThe data presented here underline the benefit of the intraoperative MI-OCT in ophthalmological examinations of children under general anesthesia. In particular MI-OCT enables examinations of children with corneal opacification, if an ophthalmological examination under general anesthesia becomes necessary.

Dry eye disease (DED) is an increasingly significant clinical problem in developing countries and/or emerging economies. Existing studies on DED conducted in these areas have largely reported on associations between DED and infectious disease (trachoma) and malnutrition (hypovitaminosis A), but current trends of industrialization, urbanization, and modernization in these areas could result in a shift to other forms of DED. Herein, we review the epidemiology of DED in these geographic areas, highlighting potential causes and risk factors of DED while presenting information on diagnostic tools and algorithms and insight into some treatment modalities of DED that could prove useful to clinicians and investigators in these regions. (C) 2017 Elsevier Inc. All rights reserved.

Background. Corneal transplantation in high-risk eyes remains a challenge. The Boston keratoprosthesis (B-KPro) is a final option for patients with end-stage corneal disease and a poor prognosis with conventional penetrating keratoplasty. In this article the results of the first 13 eyes that received a B-KPro type I at the Department of Ophthalmology, University of Cologne, Germany are reported and the usefulness of postoperative slit-lamp optical coherence tomography (SL-OCT) for control purposes is evaluated. Material and methods. All recipients of a B-KPro type I between September 2013 and May 2015 were included in the study. The feasibility of the operation, clinical outcomes, complications and revision surgery were investigated. The visualization of wound healing by SL-OCT was analyzed. Results. The age of the patients ranged from 26 to 92 years (mean 57.3 +/- 20.9 years). In all 13 eyes from 12 patients (6 males and 6 females) dense corneal opacification with vascularization and sometimes also conjunctivalization was present. Preoperative visual acuity was reduced and ranged from mere light perception up to a maximum of 1/35 eye chart. All 13 eyes could be supplied with a B-KPro type I without any intraoperative complications, in 6 eyes no significant postoperative complications occurred, whereas in 7 eyes various additional surgical interventions were required and 1 B-KPro could not be preserved. Postoperative visual acuity ranged from light perception to 20/32 and was significantly improved in 85 % of the treated eyes. The use of SL-OCT reproducibly allowed the postoperative assessment of stromal thinning. Conclusion. The B-KPro provides the possibility of visual rehabilitation in high-risk eyes that could never be achieved without artificial cornea replacement. Despite higher complication rates this technique represents a significant progress in the surgical treatment of complex corneal pathologies. Regular and intensive postoperative controls are necessary

Background: Like penetrating keratoplasty (pKPL), deep anterior lamellar keratoplasty (DALK) is a standard treatment for keratoconus and stromal corneal dystrophies. Intraoperative optical coherence tomography permits live or real-time monitoring during surgery, especially if it is necessary to estimate distances or if the anterior chamber view is limited. Methods: Review of literature from PUBMED and our own clinical and experimental data. Key words were intraoperative Optical Coherence Tomograph, DALK, Deep anterior lamellar keratoplasty and iOCT. The time frame was set from 2005 to 2016. Results: All surgical steps were visualisable by intraoperative OCT during DALK surgery. Intraoperative OCT permits depth estimation during deep needle insertion and allows the visualisation of intraoperative interface fluid. Conclusion: Intraoperative OCT facilitates standardisation during several steps of DALK. Future prospective studies should concentrate on the safety profile of intraoperative OCT-guided DALK compared to DALK without intraoperative monitoring.

Optical coherence tomography (OCT) is the clinical gold standard for anterior and posterior segment imaging. Since OCT devices have been integrated into surgical microscopes, this technique is also available intraoperatively in anterior segment surgery. OCT is well established in imaging very thin or transparent structures as they appear in corneal or glaucoma surgery. Therefore, intraoperative OCT can deliver important information for the surgeon which is superior to the normal surgical microscope. In the present work, an overview about the opportunities of intraoperative OCT in cornea and glaucoma surgery are presented. The recent literature (PubMed) and our own experience at the Center for Ophthalmology, University Hospital of Cologne are analysed. Intraoperative OCT enables real-time imaging during corneal and glaucoma surgery. Several clinical studies exist, indicating its benefit, e. g. in DMEK, DALK, DSAEK, Boston Keratoprosthesis, canaloplasty or trabectome surgery. Several structures, not visible in the surgical microscope, can be visualized using intraoperative OCT. As a real-time and high-resolution imaging device, intraoperative online OCT delivers additional information in glaucoma and corneal surgery, compared to the normal operating microscope. Nonetheless one of the main problems is the shadowing produced by surgical instruments. Today the main limitation is the lack of randomized-controlled clinical trials, evaluating the benefit of microscope-integrated intraoperative OCT, compared to the microscope.

Examination of newborn and children under general anesthesia is essential to prevent amblyopia and blindness; however, the validity was often limited due to a lack of state of the art diagnostic tools in the intraoperative set-up, e. g. optical coherence tomography (OCT). Since OCT devices have been integrated into surgical microscopes, this technique is also available for examination with patients under general anesthesia. To give an overview about the possibilities of intraoperative OCT (iOCT) during examination of newborn and infant children under general anesthesia. Analysis of recent literature (PubMed) and initial experiences at the Center for Ophthalmology of the University Hospital of Cologne. The use of iOCT enables real-time high-resolution imaging during examinations of children under general anesthesia. All relevant structures of the anterior eye segment (including cornea, lens, chamber angle and iris) can be visualized. Especially when the anterior chamber view is limited due to corneal opacifications, iOCT can deliver important information in addition to that obtained using a surgical microscope. This information is important for the further therapy of the patients. Online iOCT is a useful extension of the normal surgical microscope, especially for examination of children under general anesthesia and limited view into the anterior chamber. In our experience it also makes sense to transfer this technique to anomalies of the posterior pole because high-resolution imaging of the macula and optic nerve head is possible.