Mini-DMEK for the Treatment of Chronic Focal Corneal Endothelial Decompensation.

PURPOSE: The purpose of the study was to evaluate the feasibility of mini-descemet membrane endothelial keratoplasty ("Mini-DMEK," graft diameter <5 mm) for the treatment of chronic focal corneal endothelial decompensation for reasons other than acute hydrops in patients with keratoconus. METHODS: Of the 3010 patients registered in the prospective Cologne DMEK database, 16 patients with focal corneal endothelial decompensation treated with Mini-DMEK were identified. After exclusion of patients with acute hydrops in keratoconus (n = 9), indications for focal corneal endothelial decompensation were either defects in Descemet membrane after intraocular surgeries (n = 5) or corneal edema in the area of Haab striae in buphthalmus (n = 2). Best spectacle-corrected visual acuity, corneal thickness in the affected area, and rebubbling rates served as main outcome measures. RESULTS: All patients showed a postoperative increase in the best spectacle-corrected visual acuity from preoperative logarithm of the minimum angle of resolution (logMAR) 1.1 (±0.7) to logMAR 0.3 (±0.2) after the first month (P = 0.046) and to logMAR 0.3 (±0.2) after half a year (5-7 months) (P = 0.025). The corneal thickness decreased from preoperative 757 µm (±125) to 603 µm (±121) after the first month (P = 0.031) and to 593 µm (±131) after half a year (5-7 months) (P = 0.031). Rebubbling was necessary in 43% of patients (3 of 7 eyes). In 2 patients, Mini-DMEK was performed as triple Mini-DMEK including cataract surgery. CONCLUSIONS: Mini-DMEK is an effective treatment option for focal chronic corneal endothelial decompensation caused by tears in Descemet membrane or other defects such as Haab striae. Mini-DMEK can also be performed as a triple procedure including cataract surgery (triple Mini-DMEK).

Influence of Body Position on Intraocular Pressure After Descemet Membrane Endothelial Keratoplasty: A Prospective Randomized Trial.

PURPOSE: The purpose of this study was to analyze the influence of patient positioning on intraocular pressure (IOP) after Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic patients treated for Fuchs endothelial corneal dystrophy. METHODS: Forty patients were included in this prospective, single-blinded, randomized controlled clinical trial. Patients received a YAG iridotomy 1 day before surgery and an 80% anterior chamber tamponade [20% concentration of sulfur hexafluoride (SF6)]. Postoperative positioning was either supine (group 1) or seated (group 2, at least 30 degrees upper-body high position). IOP was measured with iCare. RESULTS: There was no statistically significant difference in IOP postoperatively [group 1 vs. group 2-after 1h: 13.9 mm Hg (±4.2 mm Hg) versus 13.6 mm Hg (±4.1 mm Hg) ( P = 1.00); after 2h: 13.9 mm Hg (±5.4 mm Hg) versus 15.3 mm Hg (±4.6 mm Hg) ( P = 0.370); after 4h: 13.8 mm Hg (±4.2 mm Hg) versus 15.2 mm Hg (±4.2 mm Hg) ( P = 0.401]. In group 1, 10% of patients showed IOP decompensations well above 30 mm Hg, and in group 2, there were no IOP decompensations. Seated position led to relative risk reduction of 100% and absolute risk reduction of 10% regarding IOP decompensations. The number of patients needed to position seated to prevent 1 additional IOP decompensation was 10. Rebubbling rates, best spectacle-corrected visual acuity, and reduction of corneal thickness were comparable between the 2 groups in the follow-up period up to 1 month. CONCLUSIONS: After DMEK in pseudophakic eyes with 80% anterior chamber tamponade, positioning patients with at least 30 degrees elevation of the upper body up immediately after surgery until bedtime prevents IOP decompensations.

On the Current Care Situation and Treatment of Ocular Mucous Membrane Pemphigoid in Germany. / Zur Versorgungssituation und konservativen Therapie des okulären vernarbenden Schleimhautpemphigoids in Deutschland.

BACKGROUND: Ocular involvement in mucous membrane pemphigoid (MMP) is relatively rare, with a prevalence of 25 cases per million population, equating to approx. 2,100 patients throughout Germany. Diagnosis can be difficult - especially in cases of isolated ocular involvement - and treatment can be complex and lengthy. Immunosuppressants or immunomodulatory drugs are often used. Due to the complexity of diagnosis and treatment, MMP patients are usually referred to specialized centers. The aim of this project was to evaluate the current care situation of patients with ocular MMP in Germany. METHODS: A paper-based survey was designed and sent to all university eye clinics and other specialized centers in Germany in April 2020. The survey asked about the existence of a specialized outpatient service, the total annual number of patients with MMP, the annual number of newly diagnosed patients, any interdisciplinary collaboration for diagnostic or therapeutic purposes, as well as the local and systemic therapy used. RESULTS: Of a total of 44 clinics, 28 (64%) responded, reporting a total average of 27 ± 42 (0 - 200) patients and 3.6 ± 2.2 (0 - 10) new cases per year. This corresponds to a total of 741 patients. Only nine (32%) of the responding clinics offer specialized MMP clinics. 93% of the centers collaborate with the local dermatology department. 79% perform serological and histological diagnostics in-house. About half of the centers (n = 16) apply a standardized treatment regime. Systemic glucocorticoids (66.7%) are most commonly used, followed by mycophenolate mofetil and dapsone (57.1%), rituximab (33.3%), azathioprine and cyclophosphamide (28.6%), as well as methotrexate (19.0%). The least frequently used treatment is intravenous immunoglobulin (14.3%). CONCLUSION: This survey of German ophthalmology departments obtained data from about one third of the estimated total cohort of all patients with MMP in Germany. These are presumed to be exclusively patients with at least one ocular involvement. The complex care of these patients is usually provided in collaboration with a dermatologist and with the use of systemic anti-inflammatory medication. Currently, an ophthalmological MMP register is being established to better record the epidemiology and care situation of this rare disease in Germany and to improve it in the long term.

Transferability of an Artificial Intelligence Algorithm Predicting Rebubblings After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To develop an artificial intelligence (AI) algorithm enabling corneal surgeons to predict the probability of rebubbling after Descemet membrane endothelial keratoplasty (DMEK) from images obtained using optical coherence tomography (OCT). METHODS: Anterior segment OCT data of patients undergoing DMEK by 2 different DMEK surgeons (C.C. and B.B.; University of Cologne, Cologne, Germany) were extracted from the prospective Cologne DMEK database. An AI algorithm was trained by using a data set of C.C. to detect graft detachments and predict the probability of a rebubbling. The architecture of the AI model used in this study was called EfficientNet. This algorithm was applied to OCT scans of patients, which were operated by B.B. The transferability of this algorithm was analyzed to predict a rebubbling after DMEK. RESULTS: The algorithm reached an area under the curve of 0.875 (95% confidence interval: 0.880-0.929). The cutoff value based on the Youden index was 0.214, and the sensitivity and specificity for this value were 78.9% (67.6%-87.7%) and 78.6% (69.5%-86.1%). CONCLUSIONS: The development of AI algorithms allows good transferability to other surgeons reaching a high accuracy in predicting rebubbling after DMEK based on OCT image data.

Correlation of internet search enquiries, incidence of ophthalmological diseases and corneal, cataract and refractive surgical procedures.

Analysis of internet search queries (ISQ) could be useful to study public interest and medical need for corneal, cataract, and refractive surgery. To date, there are preliminary data on seasonal trends in ophthalmic conditions, but only few studies correlate these data with real data from healthcare systems. The aim of this study is to analyze ISQ and correlate it with real healthcare system data. Data were retrieved from the KBV registry of patients who underwent outpatient ophthalmic surgery in Germany from 2017 to 2019 and from Statista GmbH from 2010 to 2020 for corneal refractive surgery. Time Series analysis of ISQ was analyzed from 2004 to 2020 and correlated with healthcare system data using bivariate correlation analysis. ISQ correlated significantly with the incidence of ophthalmic procedures such as corneal transplantations (r = 0.69, p < 0.05), cataract- (r = 0.59, p < 0.05) and refractive laser surgery (r = 0.83, p < 0.05) in Germany. In addition, specific trends were observed with respect to individual surgical procedures. The correlation between search intensities and surgical procedures varied significantly. Thus, interests in surgical procedures can be tracked by observing changes in ISQ over time. These data correlate with real healthcare data and could be used in the future for now-casting or even forecasting.

Evaluation of a Novel Non-Diffractive Extended Depth of Focus Intraocular Lens - First Results from a Prospective Study.

PURPOSE: To evaluate a novel hydrophobic, non-diffractive, extended depth of focus (EDOF) intraocular lens (IOL) design in comparison to two monofocal aspheric lenses. METHODS: Inclusion criteria for this prospective, monocentric cohort study were opacification of the crystalline lens and patients' wishes for surgery. In the case of the EDOF IOL, patients asked for a presbyopia correction. All patients received surgery on both eyes. Corrected and uncorrected distance visual acuity (CDVA, UCDVA), uncorrected and distance corrected intermediate visual acuity (UIVA, DCIVA) and defocus curves (all monocular and binocular) were compared three months postoperatively. RESULTS: Fifty-six eyes were implanted with an EDOF IOL (LuxSmartTM, Bausch & Lomb GmbH, Berlin, Germany), 50 eyes with a monofocal aspheric IOL: 32 eyes with a clear IOL (Polylens® AS 61, Polytech Domilens, Roßdorf, Germany), 16 eyes with a yellow IOL (iSert® 251, Hoya Surgical Optics GmbH, Frankfurt, Germany). Three months postoperatively, UCDVA was comparable with the EDOF IOL, versus the monofocal IOL (P > 0.9). Binocular DCIVA in the EDOF IOL was significantly higher than in the monofocal IOL (P = 0.001). Monocular DCIVA better than 20/23 Snellen was achieved in 10% with the monofocal IOL and in 68% (P < 0.0001) with the EDOF IOL. Defocus curves showed a depth of focus at 20/23 Snellen of 1.6 vs. 0.83 diopters (D) in the EDOF IOL, vs. the monofocal IOL. No patient reported halos or starbursts in non-standardized questioning. CONCLUSION: This non-diffractive EDOF IOL provided comparably high UCDVA and significantly higher DCIVA than the mono-focal lenses, causing only mild optical phenomena.

Correlation of Clinical Fibrillar Layer Detection and Corneal Thickness in Advanced Fuchs Endothelial Corneal Dystrophy.

Central subendothelial geographic deposits are formed as a fibrillar layer (FL) in advanced Fuchs endothelial corneal dystrophy (FECD). Previous studies demonstrated a significant decrease in corneal endothelial cell (CEC) density and an increase in focal corneal backscatter in the FL area. The present study investigated the association of the FL with edema formation and its localization. Patients (n = 96) presenting for Descemet membrane endothelial keratoplasty (DMEK) for advanced FECD were included. Slit-lamp biomicroscopy with FECD grading was followed by Scheimpflug imaging with en face backscatter analysis and pachymetric analysis. FL dimensions were measured, and correlation with pachymetric values was performed. An FL was detected in 74% of all eyes (n = 71). Pachymetric values in FL-positive versus FL-negative eyes were for corneal thickness at the apex (ACT) 614 ± 52 µm and 575 ± 46 µm (p = 0.001), for peripheral corneal thickness at 1 mm (PCT1mm) 616 ± 50 µm and 580 ± 44 µm (p = 0.002), for PCT2mm 625 ± 48 µm and 599 ± 41 µm (p = 0.017), for PCT3mm 651 ± 46 µm and 635 ± 40 µm (p = 0.128) and for PCT4mm 695 ± 52 µm and 686 ± 43 µm (p = 0.435), respectively. Correlation analysis indicated a weak correlation for the FL maximum vertical caliper diameter with ACT and PCT1mm values but no further relevant correlations. In FL-positive eyes, increased focal corneal backscatter and increased corneal thickness showed primarily central and inferotemporal localization. In conclusion, Scheimpflug imaging shows an association of the FL with increased corneal thickness in advanced FECD and shows localization of the FL and increased corneal thickness in the central and inferotemporal region. This may provide important information for progression assessment and therapeutic decision making in FECD patients in the future.

Outcomes of deep anterior lamellar keratoplasty and penetrating keratoplasty in keratoconic eyes with and without previous hydrops.

PURPOSE: The study aims to compare outcomes after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) in keratoconic eyes with or without previous hydrops. METHODS: Retrospective analysis of 211 eyes who received PK (group 1, n = 74 [history of hydrops: n = 33]) or DALK (group 2, n = 137 [history of hydrops: n = 9]) from 2012 to 2019 at the Department of Ophthalmology, University of Cologne, Germany. Analysis included best spectacle-corrected visual acuity (BSCVA), complications, immune reactions, graft survival and keratometry, and subgroup analyses for subjects with or without previous hydrops. RESULTS: Follow-up was 34.0 ± 23.6 months in group 1 and 30.7 ± 22.5 months in group 2. No significant difference was found in the course of BSCVA between groups 1 and 2 (p = 0.182) and in postoperative BSCVA between eyes with and without previous hydrops, regardless of the surgical method (p = 0.768). Endothelial immune reactions occurred exclusively in group 1 and did not occur more frequently in eyes with previous hydrops (p = 0.377). A higher risk of complications for eyes with previous hydrops was observed (p = 0.022). There was no difference in astigmatism and maximum keratometry (Kmax) preoperatively and postoperatively between eyes with and without history of hydrops. CONCLUSION: The prognosis for visual outcome after keratoplasty including visual acuity, astigmatism, and Kmax for keratoconic eyes with previous hydrops is as good as for keratoconic eyes without previous hydrops, irrespective of the surgical method. However, eyes after hydrops seem to have an increased risk of complications.

Impact of Early Intraocular Pressure Elevation on Postoperative Outcomes After Descemet Membrane Endothelial Keratoplasty in Non-glaucoma Patients.

PURPOSE: The purpose of this study was to investigate the impact of transient elevations in postoperative intraocular pressure (IOP) on the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) surgery in non-glaucoma patients. METHODS: Retrospective analysis from a prospective database of eyes without preexisting glaucoma that underwent DMEK with 90% anterior chamber and 20% sulfur hexafluoride endotamponade. Group A included eyes without postoperative IOP increase (IOP <30 mm Hg and a relative increase from preoperative value <10 mm Hg). Group B included eyes with IOP elevation (postoperative IOP ≥30 mm Hg or a relative increase from preoperative value ≥10 mm Hg) handled according to a standardized protocol. The impact of elevated IOP within 3 days after DMEK surgery was evaluated regarding best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell count (ECC) at 1, 3, and 6 months. RESULTS: One hundred seventy-six eyes from 164 patients were included. An IOP increase after DMEK occurred in 20 eyes (11.3%; 19 patients, group B), and the mean peak IOP was 48 ± 12 mm Hg (range 32-69 mm Hg). There were no significant postoperative differences in BCVA, CCT, and ECC on comparing both groups. The BCVA increased significantly (P < 0.001, respectively), whereas CCT (P < 0.001, respectively) and ECC (P < 0.001, respectively) decreased significantly from preoperative values. The rebubbling rate tended to be higher in group B without statistical significance (6.4% vs. 10%, P = 0.648). CONCLUSIONS: Temporary IOP elevation after DMEK may not affect functional and morphological outcomes in non-glaucoma patients. However, careful postoperative IOP monitoring and appropriate management are crucial to avoid irreversible ocular damage.

Rescue Technique to Solve Postoperative Refractory Double Anterior Chamber in Deep Anterior Lamellar Keratoplasty.

PURPOSE: The purpose of this study was to describe a simple rescue technique to solve postoperative double anterior chamber refractory to rebubbling in deep anterior lamellar keratoplasty (DALK). METHODS: This study analyzed consecutive patients who underwent DALK between June 2014 and March 2018 and required a postoperative reattachment of Descemet membrane because of macroperforation-led persistent double chambers. The technique entails placing anchoring sutures to attach Descemet membrane to the donor's posterior stroma. Anchoring sutures were removed within 1 month of surgery. The postoperative best spectacle-corrected visual acuity (BSCVA) [converted to logarithm of the minimum angle of resolution (logMAR) units], endothelial cell density (cells/mm2), graft survival, postoperative complications, and corneal astigmatism (diopters) were evaluated. RESULTS: Five eyes from 5 patients were included in this study [5 women, 63.6 ± 6.0 yrs (32-80 yrs); mean follow-up duration, 72.0 ± 23.3 mo (30-100 mo)] (mean ± SD). The grafts survived successfully in all patients without primary or secondary graft failure. The best spectacle-corrected visual acuity improved from 1.26 ± 0.66 logMAR preoperatively to 0.25 ± 0.15 logMAR postoperatively (n = 5, P = 0.042). The endothelial cell density was 1468 ± 810 cells/mm2 at the last visit. CONCLUSIONS: Macroperforation of Descemet membrane during DALK with incomplete removal of the stroma can lead to persistent double anterior chamber. This complication could be solved by the technique devised by this study.

Scheimpflug Backscatter Imaging of the Fibrillar Layer in Fuchs Endothelial Corneal Dystrophy.

A central collagen-rich subendothelial fibrillar layer (FL) correlates with areas of accentuated loss of corneal endothelial cells in advanced Fuchs endothelial corneal dystrophy (FECD). The present study sought to investigate whether the FL may be visualized by en face Scheimpflug backscatter imaging in vivo. DESIGN: Retrospective analysis of a prospective observational case series. METHODS: A total of 34 eyes (34 subjects) undergoing Descemet membrane endothelial keratoplasty (DMEK) surgery with preoperative high-quality Scheimpflug backscatter imaging data were included. The Descemet endothelium complex (DEC) was retrieved during DMEK surgery, and immunofluorescence staining was performed for collagens I, III, and IV. The FL morphology in en face Scheimpflug backscatter and immunofluorescence imaging was compared and agreement of FL parameters was analyzed using intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS: Scheimpflug backscatter imaging delineated the FL in 26 eyes and was FL negative in 8 eyes with deviation compared to immunofluorescence in 1 case and good agreement of morphology characteristics. Horizontal caliper diameter ± SD was 4.84 ± 0.85 mm, vertical caliper diameter was 3.92 ± 0.78 mm, maximum caliper diameter was 5.12 ± 0.82 mm, and surface area was 12.43 ± 4.74 mm2. Compared to immunofluorescence imaging, mean difference (95% limits of agreement) and intraclass correlation coefficients were for horizontal caliper diameter 0.13 mm (-0.81 to 1.1 mm) and 0.88, vertical caliper diameter 0.23 mm (-0.76 to 1.2 mm) and 0.81, maximum caliper diameter 0.06 mm (-1.1 to 1.2 mm) and 0.86, and surface area 1.4 mm2 (-3.9 to 6.7 mm2) and 0.85. CONCLUSIONS: Scheimpflug backscatter imaging facilitates visualization of the FL in advanced FECD eyes, offering the potential to identify particularly diseased areas of the FECD endothelium in vivo.

A deep learning approach for successful big-bubble formation prediction in deep anterior lamellar keratoplasty.

The efficacy of deep learning in predicting successful big-bubble (SBB) formation during deep anterior lamellar keratoplasty (DALK) was evaluated. Medical records of patients undergoing DALK at the University of Cologne, Germany between March 2013 and July 2019 were retrospectively analyzed. Patients were divided into two groups: (1) SBB or (2) failed big-bubble (FBB). Preoperative images of anterior segment optical coherence tomography and corneal biometric values (corneal thickness, corneal curvature, and densitometry) were evaluated. A deep neural network model, Visual Geometry Group-16, was selected to test the validation data, evaluate the model, create a heat map image, and calculate the area under the curve (AUC). This pilot study included 46 patients overall (11 women, 35 men). SBBs were more common in keratoconus eyes (KC eyes) than in corneal opacifications of other etiologies (non KC eyes) (p = 0.006). The AUC was 0.746 (95% confidence interval [CI] 0.603-0.889). The determination success rate was 78.3% (18/23 eyes) (95% CI 56.3-92.5%) for SBB and 69.6% (16/23 eyes) (95% CI 47.1-86.8%) for FBB. This automated system demonstrates the potential of SBB prediction in DALK. Although KC eyes had a higher SBB rate, no other specific findings were found in the corneal biometric data.

Prediction model of free flaps in microkeratome-assisted LASIK.

PURPOSE: To identify mechanical factors, as well as patients' biometric and surgeons' experience factors that correlate with the FF incidence in microkeratome (MK)-assisted LASIK and to construct a predictive model based on these parameters. METHODS: 55,700 consecutive LASIK treatments of 28,506 patients between January 2017 and April 2020 done by 50 surgeons in 10 centers, all with Sub Bowman Keratome (SBK) and 90µ head (OUP) were analyzed retrospectively for the incidence of FF and their correlation to mean keratometry, central corneal thickness, MK ring height and stop, as well as surgeons' experience. A prediction model was built and tested for sensitivity and specificity. RESULTS: The incidence of FF using the SBK MK was 0.276%. Risk factors were low central corneal thickness, very flat (-1) or very thick (+2) ring height, and higher stop values (p<0.001). Mean keratometry and low surgeon experience were not correlated to FF incidence. A prediction model with a cut-off FF risk of 0.274%, a 76% specificity, and a 73% sensitivity was applied. CONCLUSIONS: Free flaps are rarely seen in modern MK LASIK. However, the incidence of this complication using the SBK MK increases using higher stop values, very thick and very thin MK rings, and in eyes with thin corneas.

Laser-integrated real-time OCT in anterior segment procedures.

Intraoperative optical coherence tomography (OCT) was so far only available as a microscope-integrated or handheld device. Recently, this technology has been integrated into a femtosecond (FS) laser. This pilot study analyzed the potential of intraoperative imaging using OCT during FS-assisted procedures of the anterior eye segment. Therefore, intraoperatively acquired videos using FS-integrated intraoperative OCT (laser-integrated [LI] OCT) in 14 patients (Victus, Bausch & Lomb) were analyzed in different surgical procedures. The results showed that all surgical steps could be successfully visualized by LI-OCT. LI-OCT added important information regarding the depth and location of the incisions and dissection planes. Moreover, dynamic processes could be observed in real-time. LI-OCT represents a new imaging technology that makes it possible to visualize intraoperative steps during FS-assisted surgery. In the future, automatic image analysis based on artificial intelligence could be helpful to detect complications at an early stage and to automatically stop the laser process in relevant constellations.

Comparison of Mini-DMEK versus predescemetal sutures as treatment of acute hydrops in keratoconus.

PURPOSE: To compare two surgical treatment options for acute corneal hydrops in keratoconus: Mini-DMEK versus predescemetal sutures. METHODS: Sixteen patients were treated by either Mini-Descemet membrane endothelial keratoplasty (Mini-DMEK) (n = 7, group 1) or predescemetal sutures (n = 9, group 2) early after onset of acute hydrops. Visual acuity, maximum corneal thickness (SD-OCT) in the affected oedematous area, complications and recurrence rates were retrospectively compared between both groups. Measurements were taken immediately preoperatively as well as 1 day, 1 week and 1 month postoperatively (Table 1). RESULTS: Both groups showed reductions in corneal thickness and increased visual acuity shortly after surgery. In group 1 (average age 33 years ± 7 years), the best corrected visual acuity (BCVA) increased from logMAR 1.65 ± 0.7 before Mini-DMEK to logMAR 0.93 ± 0.6 30 days after Mini-DMEK (p = 0.046). During that period, maximum corneal thickness decreased from 1159 ± 338 µm before surgery to 531 ± 75 µm after Mini-DMEK (p = 0.046). Patients from group 2 (average age 34 ± 10 years) had a BCVA of logMAR 1.59 ± 0.8 which increased to logMAR 0.97 ± 0.5 (p = 0.014) 30 days after surgery. At the same time, the preoperative maximum corneal thickness decreased from 1439 ± 272 µm to 476 ± 162 µm (p = 0.014). There was no difference in corneal thickness or BCVA one month after the surgical intervention between both groups (p = 0.394 and p = 0.871). CONCLUSIONS: Both techniques, Mini-DMEK and predescemetal sutures, are effective in the treatment of an acute hydrops in keratoconus. Mini-DMEK appears to be beneficial in large DM tears.

The Cologne rebubbling study: a reappraisal of 624 rebubblings after Descemet membrane endothelial keratoplasty.

BACKGROUND/AIMS: To analyse graft detachments prior to rebubbling, the influence of rebubbling on the postoperative outcome after Descemet membrane endothelial keratoplasty (DMEK) and the need for rebubbling on the contralateral eye. METHODS: In this retrospective cohort study, out of 1541 DMEKs, optical coherence tomography scans and clinical records of 499 eyes undergoing rebubbling after DMEK at the University Hospital of Cologne, Cologne, Germany, were examined. Main Outcome measures were (a) number, localisation and size of graft detachments; (b) influence of rebubbling/s on postoperative outcome after 12 months; and (c) rebubbling risk of the contralateral eye after DMEK. RESULTS: Mean number of detachment areas was 2.02±0.9. Mean lateral diameter of all detachments was 4534.76±1920.83 µm. Mean axial diameter was 382.53±282.02 µm. Detachments were equally distributed over all regions of the cornea. Best spectacle corrected visual acuity ( BSCVA) after 12 months was 0.197±0.23 logarithm of the minimum angle of resolution, endothelial cell density (ECD) was 1575.21±397.71 cells/mm2 and mean central corneal thickness (CCT) was 566.37±68.11 µm. BSCVA, CCT, ECD or endothelial cell loss of all rebubbled patients were not influenced by the number of rebubblings or the time between DMEK and rebubbling. Of the rebubbled patients, which received a DMEK subsequently on the other eye, 193 (58.8%) also received a rebubbling, which was significantly higher, when compared to the overall rebubbling rate of 32.3% (p=0.000). CONCLUSIONS: The overall number of rebubblings has no influence on the postoperative outcome after DMEK, if a rebubbling becomes necessary. Patients who received a rebubbling on one eye have an elevated risk for a rebubbling on the fellow eye.

Fibrillar Layer as a Marker for Areas of Pronounced Corneal Endothelial Cell Loss in Advanced Fuchs Endothelial Corneal Dystrophy.

PURPOSE: We sought to assess the correlation of corneal endothelial cell (CEC) density to alterations of collagen composition of Descemet membrane (DM) in advanced Fuchs endothelial corneal dystrophy (FECD) and to image such changes by slit-lamp biomicroscopy in vivo. DESIGN: Prospective, observational consecutive case series. METHODS: Fifty eyes (50 subjects) with advanced FECD were enrolled. After slit-lamp biomicroscopy and corneal Scheimpflug imaging, the Descemet endothelium complex (DEC) was retrieved during DM endothelial keratoplasty (DMEK) surgery. The expression of collagens I, III, and IV (COL I, COL III, and COL IV) and corresponding CEC density were analyzed by immunofluorescence flat mount-staining. Presence, diameter and surface area of collagen expression, and CEC density served as the main outcome measures. RESULTS: Immunofluorescence staining revealed central coherent collagen positive areas (mean surface area = 10 mm2 ± 6 mm2) corresponding to a fibrillar layer burying the guttae of DM in 84% (42/50) of DECs. CEC density overlying the fibrillar layer compared with the periphery was significantly reduced (-54.8%, P < .0001) with a steep decline of CEC density at its borders. Subgroup analysis revealed that the fibrillar layer may be imaged by slit-lamp biomicroscopy in vivo with significant positive correlation of mean maximum diameter detected by slit-lamp biomicroscopy (dSL max = 4.1 mm ± 0.9 mm) and by immunofluorescence staining (dIF max = 4.7 mm ± 1.1 mm; r = 0.76; P = .001). CONCLUSION: A fibrillar layer with a clear geographic pattern marks areas of pronounced loss of CEC density in advanced FECD eyes and may be imaged by slit-lamp biomicroscopy in vivo.

Tolerance and Adherence to Cationic 0.1% Cyclosporine in Ocular Graft-versus-Host Disease.

INTRODUCTION: Anti-inflammatory, topical therapy of severe keratitis in dry eye disease (DED) and ocular graft-versus-host disease (oGvHD) includes steroids, cyclosporine (Cs), and others. In Germany, a commercial product containing 0.1% Cs in a cationic formulation is available since 2015. OBJECTIVE: The aim of this study was to present real-life data using cationic 0.1% Cs in oGvHD patients. METHODS: This was a retrospective study of 26 oGvHD and 41 DED patients with corneal staining of at least Oxford grade III. Parameters analyzed were Ocular Surface Disease Index, corneal staining, intraocular pressure, tear film break-up time, Schirmer, and visual acuity. In addition, it was evaluated how different Cs formulations were tolerated. RESULTS: Corneal staining improved significantly in 1 eye in DED but not in oGvHD. In DED, cationic 0.1% Cs was not tolerated by 32% of the patients, in contrast to 0.05% Cs in castor oil not tolerated by 47% and liposomal 0.05% Cs by 63%. In oGvHD patients, cationic 0.1% Cs was not tolerated by 62%, 0.05% Cs in castor oil by 33%, and liposomal 0.05% Cs by 39% of the patients. CONCLUSIONS: This study demonstrates differences between the tolerance of different Cs formulations depending on the underlying cause of severe keratitis. Cationic 0.1% Cs is considerably less tolerated in oGvHD, and its use should be considered with care.