Exploring the precision of femtosecond laser-assisted descemetorhexis in Descemet membrane endothelial keratoplasty

Objective Descemet membrane endothelial keratoplasty (DMEK) remains a challenging technique. We compare the precision of femtosecond laser-assisted DMEK to manual DMEK. Methods and Analysis A manual descemetorhexis (DR) of 8 mm diameter was compared with a femtosecond laser-assisted DR of the same diameter (femto-DR) in 22 pseudophakic patients requiring DMEK. We used OCT images with a centred xy-diagram to measure the postoperative precision of the DR and the amount of endothelial denuded area. Endothelial cell loss (ECL) and best corrected visual acuity were measured 3 months after surgery. Results In the manual group, the median error of the DR was 7% (range 3%-16%) in the x-diameter and 8% (range 2%-17%) in the y-diameter. In the femto group, the median error in the respective x and y-diameters was 1% (range 0.4%-3%) and 1% (range 0.006%-2.5%), smaller than in the manual group (p=0.001). Endothelial denuded areas were larger in the manual group (11.6 mm(2), range 7.6-18 mm(2)) than in the femto group (2.5 mm(2), range 1.25.9 mm(2)) (p<0.001). The ECL was 21% (range 5%-78%) in the manual DR and 17% (range 6%-38%) in the femto-DR group (p=0.351). The median visual acuity increased from 0.4 logMAR (range 0.6-0.4 logMAR) in both groups to 0.1 logMAR (range 0.4-0 logMAR) in the manual group and to 0.1 logMAR (range 0.3-0 logMAR) in the femto group (p=0.461). Three rebubblings were required in the manual group, whereas the femto group required only one. Conclusion The higher precision of the femto-DR bears the potential to improve DMEK surgery

Pseudophakic corneal donor tissue in Descemet membrane endothelial keratoplasty (DMEK): implications for cornea banks and surgeons

Objective: Increasingly, cornea banks are recovering donor tissue from pseudophakic donors. Little is known about their suitability for Descemet membrane endothelial keratoplasty (DMEK) surgery in terms of endothelial cell density (ECD) and preparation failure. Methods and Analysis: We explored ECD during donor tissue preparation in 2076 grafts. Preparation failure was analysed in 1028 grafts used in DMEK surgery at our clinic. To monitor ECD and functional results, we matched 86 DMEK patients who received pseudophakic donor grafts with similar recipients of phakic donor grafts and followed them up for 36 months. Results: At recovery, mean ECD in pseudophakic donor grafts was 2193 cells/mm2 (SD 28.7) and 2364 cells/mm2 (SD 15.7) in phakic donor grafts (p<0.001). After cultivation, the difference increased as pseudophakic donor grafts lost 14% of ECD while phakic lost only 6% (p<0.001). At transplantation, mean ECD in pseudophakic donor grafts was 2272 cells/mm2 (SD 250) and 2370 cells/mm2 (SD 204) in phakic donor grafts (p<0.001). After transplantation, the difference in ECD increased as pseudophakic donor grafts lost 27.7% of ECD while phakic donor grafts lost only 13.3% (p<0.001). The risk of preparation failure in pseudophakic donor grafts was higher than in phakic donor grafts (OR 4.75, 95% CI 1.78 to 12.67, p=0.02). Visual acuity increased in both groups similarly. Conclusions: Pseudophakic donor grafts have a lower ECD, are more prone to endothelial cell loss during recovery and surgery and are associated with a higher risk of preparation failure. Cornea banks and surgeons should consider this in the planning of graft preparation and transplantation

Graft failure rate and complications after Descemet membrane endothelial keratoplasty in eyes with pre-existing glaucoma

Purpose: To evaluate the outcome of Descemet Membrane Endothelial Keratoplasty (DMEK) in eyes with pre-existing glaucoma. Design: In this retrospective, observational case series we included data of 150 consecutive DMEKs in eyes with pre-existing glaucoma of 150 patients after excluding data of the second treated eye of each patient and of re-DMEKs during follow-up. Cumulative incidences of IOP elevation (IOP > 21 mmHg or >= 10 mmHg increase in IOP from preoperative value), post-DMEK glaucoma (need of an additional intervention due to worsening of the IOP), graft rejection, and graft failure rate were analyzed using Kaplan-Meier survival analysis. COX regression analysis was used to evaluate independent risk factors. Results: The 36-month cumulative incidence of IOP elevation was 53.5% [95 CI 43.5-63.5%] and of post-DMEK glaucoma 36.3% [95 CI 26.3-46.3%]. Graft rejection occurred with a 36-month cumulative incidence of 9.2% [CI 95% 2.3-16.1]. None of the analyzed risk factors increased the risk for the development of graft rejection. The 36-month cumulative incidence of graft failure was 16.6% [CI 95% 8.4-24.8]. Independent risk factors for graft failure were the indication for DMEK "status after graft failure" (n = 16) compared to Fuchs' dystrophy (n = 74) (p = 0.045, HR 8.511 [CI 95% 1.054-68.756]) and pre-existing filtrating surgery via glaucoma drainage device (GDD) (n = 10) compared to no surgery/iridectomy (n = 109) (p = 0.014, HR 6.273 [CI 95% 1.456-27.031]). Conclusion: The risks of postoperative complications (IOP elevation, post-DMEK glaucoma, graft rejection, and graft failure) in patients with pre-existing glaucoma are high. In particular, pre-existing filtrating surgery via GDD implantation-but not trabeculectomy-and DMEK after graft failure increase the risk of graft failure

Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty

Abstract Background To evaluate the indication, visual outcome, and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL) during penetrating keratoplasty. Methods This retrospective study comprised 23 eyes (23 patients) without adequate capsule support undergoing posterior iris-claw aphakic IOL implantation (Verisyse™/ Artisan®) during penetrating keratoplasty between 2005 and 2010. Mean follow-up was 18 months (range from 12 to 37 months). Results The IOLs were inserted during an IOL exchange in 17 eyes and as a secondary procedure in six aphakic eyes. Pseudophakic bullous keratopathy with corneal scar after anterior chamber intraocular lens (ACIOL) was the main indication for penetrating keratoplasty in 16 eyes (69.6 %). The final corrected distance visual acuity (CDVA) in logMAR (mean 1.0 ± 0.46) improved significantly (p &lt; 0.05) compared to the preoperative CDVA (mean 1.8± 0.73). Twenty eyes (86.9 %) had a final visual acuity in logMAR better than the pre-operative CDVA. The mean postoperative IOP 16.3 mmHg±4.0 was not significantly (p &gt; 0.05) higher compared to the preoperative IOP 15.6 mmHg±5.1. Complications included slight temporary pupil ovalization in three eyes (13.0 %) and iris-claw IOL sublocation in three eyes (13.0 %); all IOLs could be easily repositioned. Cystoid macular edema occured in one eye (4.3 %) 8 weeks after primary surgery. All grafts remained clear without any sign of graft rejection. Conclusions Retropupillar iris-claw IOL during penetrating keratoplasty provides good visual outcomes with a favorable complication rate, and can be used for a wide range of indications in eyes without adequate capsule support

Determinants of postoperative visual rehabilitation after posterior lamellar keratoplasty

In den letzten zehn Jahren haben die posterior lamellären Transplantationsmethoden zunehmend an Bedeutung gewonnen und machen mittlerweile mehr als die Hälfte aller Transplantationen aus. Lamelläre Verfahren, die zur Behandlung von Hornhautendothelerkrankungen derzeit angewandt werden, sind die DSAEK und die DMEK. Wir konnten im intraindividuellen Vergleich für die DMEK einen signifikant besseren Visus als für die pKPL nachweisen. Zudem ermöglichte die DMEK signifikant bessere Ergebnisse hinsichtlich des induzierte Astigmatismus, des sphärischen Äquivalentes und der Aberrationen höherer Ordnung. Dies führte in unserer Patientenbefragung zu einer höheren Patientenzufriedenheit für die DMEK. Auch im Vergleich zur DSAEK konnten wir für die DMEK eine signifikant bessere unkorrigierte als auch korrigierte Sehschärfe und ein besseres Kontrastsehen nachweisen. Der eingeschränkte Visus nach einer DSAEK wird durch die Interface-Problematik und das zusätzliche Stromagewebe erklärt. Wir haben in einer Untersuchung an 53 Patienten den Einfluss der intra- und postoperativ gemessenen Transplantatdicke auf die funktionellen Ergebnisse ausgewertet. Dabei zeigte sich, dass die postoperativ gemessene Transplantatdicke signifikant mit dem resultierenden Visus korrelierte. Eine postoperative Transplantatdicke von 120 μm ermöglichte eine bessere Sehschärfe, ohne die postoperative Endothelzellzahl negativ zu beeinflussen. Bessere Resultate werden im Rahmen der DMEK mit einem noch dünneren Transplantat, welches keine Stromagewebsanteile aufweist, erzielt. In einer prospektiven Studie konnten wir zeigen, dass durch eine temporale Inzision ein signifikant geringerer Astigmatismus induziert wird und zudem weniger Aberrationen höherer Ordnung verursacht werden. Jedoch scheint ein temporaler Zugang zu einer höheren Rate an Transplantatablösungen zu führen. Trotz der funktionell besseren postoperativen Ergebnisse etabliert sich die DMEK nur langsam. Dies liegt vor allem an der anspruchsvolleren Operationstechnik, wobei wir zeigen konnten, dass Transplantat- bzw. Spendereigenschaften keinen Einfluss auf den Schwierigkeitsgrad des Eingriffes haben. Ein komplizierterer Operationsverlauf jedoch führte in unserer Studie zu einem signifikant höheren Endothelzellverlust sowie zu einer häufigeren Transplantatablösung. Diese ist die häufigste Komplikation nach einer DMEK. Wir konnten in histologischen und immunhistochemischen Untersuchungen nachweisen, dass eine unvollständige Abtrennung der Empfänger-Descemetmembran mit einer Separation des „Anterior Banded Layer“ eine Transplantatablösung begünstigt.In the last ten years, posterior lamellar keratoplasty methods have become increasingly important. Lamellar methods currently used to treat corneal endothelial diseases are DSAEK and DMEK. The aim of this work is to investigate factors that influence the results of different posterior lamellar transplantation techniques. We demonstrate a significantly better postoperative visual acuity for DMEK than for penetrating keratoplasty. In addition, DMEK was associated with less induced astigmatism and fewer higher- order aberrations. This resulted in a higher patient satisfaction after DMEK in our patient survey. Compared to DSAEK, DMEK patients had a better uncorrected and best corrected visual acuity and higher contrast vision. The limited visual acuity after DSAEK could be related to a higher refractive interface and differences in graft thickness. We evaluated the influence of intra- and postoperatively measured graft thickness on functional results. We found that the postoperatively measured graft thickness correlated significantly with the resulting visual acuity. A postoperative graft thickness of 120 μm was associated with a better visual acuity without negatively influencing the postoperative endothelial cell count. In a prospective study, we could show that a temporal incision induces significantly less astigmatism and, in addition, causes fewer higher order aberrations. However, a temporal access seems to result in a higher rate of graft detachment. Despite the better postoperative results, DMEK is establishing itself only slowly. This is mainly due to the more sophisticated surgical technique. We could show that corneal donor characteristics have no influence on the difficulty of the DMEK procedure. A more difficult surgical procedure, however, meant an increase in endothelial cell loss and a higher rate of graft detachment. Postoperative graft detachment is the most common complication after DMEK surgery. In histological and immunohistochemical investigations we found that an incomplete removal of the recipient Descemet´s membrane, with separation of the anterior banded layer, may be a risk factor for graft detachment after DMEK surgery

Demography, diagnosis and therapy of ocular toxoplasmosis - a retrospective analysis of the patient data at the ophthalmic clinic Charité from 1996 to 2002

Titelblatt und Inhaltsverzeichnis Einleitung Material und Methoden Ergebnisse Diskussion Zusammenfassung LiteraturverzeichnisEinführung und Fragestellung Die okuläre Toxoplasmose ist eine der häufigsten Ursachen einer posterioren Uveitis. Während in klinisch eindeutigen Fällen die Diagnose häufig anhand der Morphologie gestellt werden kann, stellt der Nachweis in weniger eindeutigen Fällen im Anbetracht eines potentiell visusbedrohenden Verlaufs der Erkrankung eine hohe Herausforderung dar. In Bezug auf die Therapie der Erkrankung gibt es derzeit ebenfalls noch keinen Konsens. Methoden Um die Wertigkeit der Kammerwasseranalyse innerhalb der Diagnostik zu bestimmen und die verschiedenen therapeutischen Strategien zu erfassen, haben wir eine retrospektive Auswertung eigener Daten von 104 Patienten, die sich wegen okulärer Toxoplasmose behandeln liessen, vorgenommen. Darüber hinaus haben wir eine Umfrage unter den Mitgliedern der Sektion Uveitis der Deutschen Ophthalmologischen Gesellschaft (DOG) durchgeführt und die Ergebnisse dieser Umfrage den Ergebnissen unserer eigenen Daten gegenübergestellt. Ergebnisse Es wurden 65 (64%) Patientinnen und 39 (38%) Patienten behandelt. Die Sensitivität der serologischen Diagnostik für IgM lag bei 6% (IgG: 98%), ihre Spezifität bei 100% (IgG: 16%). Dagegen lag die Sensitivität der Kammerwasseranalyse bei 93% und ihre Spezifität bei 92%. Die Standardtherapie bestand in einer oralen Gabe von Clindamycin, bei zentraler Läsion wurde diese durch eine systemische Steroidgabe ergänzt. Die Therapiedauer betrug 6,8 Wochen (4-12 Wochen). In einer Subgruppenanalyse zeigten sich keine statistisch signifikanten Unterschiede hinsichtlich der Therapiedauer, dem Alter der Patienten, der Anwendung systemischer Steroide oder dem Vorliegen einer Erstmanifestation bzw. eines Rezidivs der Erkrankung. Umfrage unter Uveitis Spezialisten: Der Fragebogen wurde von 29 (72%) der Ophthalmologen beantwortet. 6 von 29 Kollegen stellen die Diagnose ausschließlich anhand des klinischen Befundes, 72% hingegen wenden auch serologische Verfahren an, wobei der IgM-Titer (59%) am häufigsten hinzugezogen wird. 17 Kollegen (38%) wenden die Kammerwasseranalyse an. 13 von 29 Ophthalmologen behandeln alle Patienten mit okulärer Toxoplasmose unabhängig von der Schwere der Erkrankung, alle Kollegen behandeln ihre Patienten bei visusbedrohender Läsion. Die am häufigsten angewandte Therapie (48%) bestand in Pyrimethamin kombiniert mit Sulfadiazin, gefolgt von Clindamycin (34%). Diskussion Unsere Untersuchung zeigt, dass die Kammerwasseruntersuchung bei der Diagnose einer intraokulären Toxoplasmose- Infektion eine diagnostische Maßnahme mit hohem Aussagewert ist und in ihrer Sensitivität und Spezifität der Serumuntersuchung überlegen ist. Als Therapie der ersten Wahl wurde in unserer Umfrage die Kombination von Pyrimethamin und Sulfadiazin (48%).Purpose. Ocular toxoplasmosis (OT) remains the most prevalent form of posterior Uveitis. Although OT is an important clinical condition with high morbidity, there remains no consensus about its diagnosis and treatment. To gain a better understanding of these issues, we conducted a mail survey among uveitis specialists in Germany. We also analysed the use of clindamycin in ocular toxoplasmosis in a consecutive, single center study with a significant number of patients. Methods. In a consecutive series of 996 uveitis patients we identified 104 individuals with active ocular toxoplasmosis. All patients underwent a standard diagnostic protocol and if indicated, additional diagnostic tests such as aqueous humor analysis. Data were analysed regarding clinical characteristics, presentation of ocular manifestation and treatment response following a standardized therapeutic approach. In addition a questionnaire containing questions and clinical case reports including authentic photographs was distributed to physician-members of the German Uveitis Society. Results. Of the 104 patients included in our trial 39 (38%) were males and 65 (64%). Specific intraocular antibody synthesis could be confirmed in 69 of 74 patients (93%). In two patients of the control group, antibody synthesis was detected (false positive). 72 patients (98%) with diagnoses of ocular toxoplasmosis were positive for serum anti-toxplasma- gondii IgG, but only 5 patients had increased IgM levels. Our standardized initial treatment approach consisting of clindamycin was generally well tolerated but led to adverse effects in 7 patients. Within a treatment period of 6.8 weeks the visual acuity increased with an average of 2 Snellen lines. Survey: The completed questionnaire was returned by 72% (29/40) of the members. According to answers, the majority (72%) of responders base their diagnosis of ocular toxoplasmosis on clinical examination and serological findings. A positive IgM titre or increasing IgG titres are reported to support the diagnosis by 59% and 41%, respectively. Invasive procedures such as aqueous humor analysis are performed by 38% of colleagues to establish the diagnosis in selected patients. A total of 6 antimicrobial agents have been reported for treatment in different regimens for typical clinical conditions in patients with recurrent toxoplasma retinochoroiditis. The combination of pyrimethamine and sulfadiazine is the most commonly used (48%), followed by clindamycin (34%). Conclusion: Analysis of local antibody production is a reliable method for confirming or excluding a suspected clinical diagnosis of toxoplasma retinochoroiditis. The determination of toxoplasma antibodies in serum is of limited value. In our survey a total of 6 drugs were used as treatments of choice for toxoplasma retinochoroiditis, with the combination of pyrimethamine and sulfadiazine being the most commonly used regimen (48% of respondents)

Pseudophakic corneal donor tissue in Descemet membrane endothelial keratoplasty (DMEK): implications for cornea banks and surgeons

ObjectiveIncreasingly, cornea banks are recovering donor tissue from pseudophakic donors. Little is known about their suitability for Descemet membrane endothelial keratoplasty (DMEK) surgery in terms of endothelial cell density (ECD) and preparation failure.Methods and AnalysisWe explored ECD during donor tissue preparation in 2076 grafts. Preparation failure was analysed in 1028 grafts used in DMEK surgery at our clinic. To monitor ECD and functional results, we matched 86 DMEK patients who received pseudophakic donor grafts with similar recipients of phakic donor grafts and followed them up for 36 months.ResultsAt recovery, mean ECD in pseudophakic donor grafts was 2193 cells/mm2 (SD 28.7) and 2364 cells/mm2 (SD 15.7) in phakic donor grafts (p&lt;0.001). After cultivation, the difference increased as pseudophakic donor grafts lost 14% of ECD while phakic lost only 6% (p&lt;0.001). At transplantation, mean ECD in pseudophakic donor grafts was 2272 cells/mm2 (SD 250) and 2370 cells/mm2 (SD 204) in phakic donor grafts (p&lt;0.001). After transplantation, the difference in ECD increased as pseudophakic donor grafts lost 27.7% of ECD while phakic donor grafts lost only 13.3% (p&lt;0.001). The risk of preparation failure in pseudophakic donor grafts was higher than in phakic donor grafts (OR 4.75, 95% CI 1.78 to 12.67, p=0.02). Visual acuity increased in both groups similarly.ConclusionsPseudophakic donor grafts have a lower ECD, are more prone to endothelial cell loss during recovery and surgery and are associated with a higher risk of preparation failure. Cornea banks and surgeons should consider this in the planning of graft preparation and transplantation.</jats:sec

Aqualase® Revisited: Endothelial Cell Loss Strongly Depends on Lens Density

&lt;b&gt;&lt;i&gt;Purpose:&lt;/i&gt;&lt;/b&gt; To analyze the dependence between corneal endothelial cell loss by Aqualase® cataract surgery and the nuclear opalescence grade of the lens. &lt;b&gt;&lt;i&gt;Patients and Methods:&lt;/i&gt;&lt;/b&gt; A total of 100 eyes of 92 patients were enrolled in this prospective, single-center study. Patients were randomly assigned to the Aqualase (50 eyes) or the phacoemulsification group (50 eyes). The nuclear density was classified with the Lens Opacities Classification System III. All procedures were performed by the same surgeon. Preoperatively and 1 week postoperatively, endothelial cell counts were obtained using a noncontact specular microscope (Konan, Japan). &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; (1) Aqualase group: the group of patients with a nuclear density of 1-2 (17 patients) showed no significant endothelial cell loss (4.1%, p = 0.163). The endothelial cell loss in grade 3 cataracts (28 eyes) was 13.9% (p = 0.004) and in grade 4 cataracts (5 eyes) 69.1% (p = 0.043), being statistically significant in both groups. (2) Phacoemulsification group: in nuclear density groups 1 and 2, endothelial cell loss was 6.3% (p = 0.41), in group 3 it was 17.6% (p = 0.001) and in group 4 it was 14.9% (p = 0.08). Only in nuclear opalescence grade 4 there was a significant difference between the Aqualase and the phacoemulsification procedure (p = 0.008). &lt;b&gt;&lt;i&gt;Conclusion:&lt;/i&gt;&lt;/b&gt; Endothelial cell loss by Aqualase technology depends strongly on the nuclear opalescence grade. In low- and medium-density cataracts, Aqualase does not seem to provoke significant endothelial cell loss. Due to very high endothelial loss in hard nuclei, Aqualase is unsuitable for these cataracts.</jats:p

Use of topical anaesthesia and peribulbar anaesthesia in Descemets membrane endothelial keratoplasty

Introduction: In instances where peribulbar anaesthesia (PBA) cannot be used, Descemet membrane endothelial keratoplasty (DMEK) surgery can be performed under topical anaesthesia (TA). We evaluated subjective pain and post-operative outcomes of DMEK surgeries performed under PBA and TA. Methods: Sixty pseudophakic patients without history of ocular comorbidities underwent DMEK surgery under either PBA or TA. PBA was performed with a single injection of 6 mL Prilocaine Hydrochloride 2% in combination with 1500 I.U. hyaluronidase. For TA, patients were given 0.4% Oxybuprocaine eye drops followed by a 2% Lidocain Hydrochloride-Gel and an intraoperative injection of a 2% Lidocaine Hydrochloride solution into the anterior chamber. All surgeries were performed by the same surgeon. Subjective pain was measured using a visual analog scale (VAS). Secondary outcomes (BCVA, duration of surgery, endothelial density, rebubbling rate) were recorded during a follow-up period of 3 months. Results: The mean subjective pain of patients in the PBA group was 1.27 (95% CI 0.87–1.68) and 1.64 (95% CI 1.15–2.21) in the TA group. The mean duration of surgery was 402 s (95% CI 356–448) in the PBA group and 427 s (95% CI 371–483) in the TA group, p = 0.477. No major differences were observed in BCVA, endothelium density and rebubbling rate between the two groups. Anaesthesia-related side effects were more frequent in the PAB group than in the TA group. Conclusion: Although levels of subjective pain are lower under PBA than under TA, in selected patients without ocular comorbidities TA can achieve levels of pain acceptable for DMEK surgery. </jats:sec