[Trabeculectomy with Collagen Matrix Implant as Bevacizumab Depot: Clinical Results on Efficacy and Safety]. / Trabekulektomie mit Kollagen-Matrix-Implantat als Bevacizumabdepot: klinische Ergebnisse zur Effektivität und Sicherheit.

BACKGROUND: Trabeculectomy for the surgical reduction of internal eye pressure is an established procedure, but the principle limitations are in postoperative wound healing. Various antimetabolites are regularly used to avoid postoperative subconjunctival scarring. The present study investigates whether the combination of an Ologen implant with bevacizumab can modify the rates of success and/or complications during trabeculectomy. METHODS: Three different groups of patients were evaluated in which trabeculectomy was performed with mitomycin C, either alone (group 1) or in combination with an Ologen implant (group 2) or with an Ologen implant with bevacizumab (group 3). The success and failure rates, changes in tension, postoperative complications and postoperative revision for pressure regulation were evaluated. The follow-up was 12 months for all eyes. RESULTS: A total of 130 eyes in 130 patients (mean age 67.74 ± 12.16 years). The number of substances applied preoperatively to reduce intraocular pressure was 2.89 ± 0.98 and the internal ocular pressure was 21.74 ± 5.49 mmHg. Twelve months postoperatively; the mean pressure was 13.14 ± 3.71 mmHg. The greatest absolute success rate (= IOD ≤ 15 mmHg without antiglaucoma medication) was in the group with exclusive goniotrepanation + mitomycin C (MMC; 72.5%), followed by the groups with Ologen (67.5%) and Ologen + bevacizumab (63.6%). The greatest failure rate (= IOD > 15 mmHg) was in the Ologen bevacizumab group (17.3%), followed by the pure Ologen group with 22.5% and the pure trabeculectomy group (12.3%). There were no significant differences in the success and failure rates. There were no serious intra- or postoperative complications in any group. The number of patients for whom it was necessary to loosen the traction thread was significantly lower in the sole Ologen group (p = 0.02). There were also no significant differences between the groups with respect to revisions. CONCLUSION: Using Ologen as drug depot for bevacizumab in a trabeculectomy (TE) with MMC is a safe and active surgical method without an increased risk of complications in comparison to pure TE with MMC or TE with MMC and Ologen implant. After 12 months, this treatment exhibited no significant advantages.

Transcriptomic and proteomic analysis of iris tissue and aqueous humor in juvenile idiopathic arthritis-associated uveitis.

Gene and protein expression profiles of iris biopsies, aqueous humor (AqH), and sera in patients with juvenile idiopathic arthritis-associated uveitis (JIAU) in comparison to control patients with primary open-angle glaucoma (POAG) and HLA-B27-positive acute anterior uveitis (AAU) were investigated. Via RNA Sequencing (RNA-Seq) and mass spectrometry-based protein expression analyses 136 genes and 56 proteins could be identified as being significantly differentially expressed (DE) between the JIAU and POAG group. Gene expression of different immunoglobulin (Ig) components as well as of the B cell-associated factors ID3, ID1, and EBF1 was significantly upregulated in the JIAU group as compared to POAG patients. qRT-PCR analysis showed a significantly higher gene expression of the B cell-related genes CD19, CD20, CD27, CD138, and MZB1 in the JIAU group. At the protein level, a significantly higher expression of Ig components in JIAU than in POAG was confirmed. The B cell-associated protein MZB1 showed a higher expression in JIAU patients than in POAG which was confirmed by western blot analysis. Using bead-based immunoassay analysis we were able to detect a significantly higher concentration of the B cell-activating and survival factors BAFF, APRIL, and IL-6 in the AqH of JIAU and AAU patients than in POAG patients. The intraocularly upregulated B cell-specific genes and proteins in iris tissue suggest that B cells participate in the immunopathology of JIAU. The intracameral environment in JIAU may facilitate local effector and survival functions of B cells, leading to disease course typical for anterior uveitis.

Rotation of a toric intraocular lens with and without capsular tension ring: data from a multicenter non-inferiority randomized clinical trial (RCT).

BACKGROUND: Evaluation of clinical outcome in cohorts with versus without simultaneous implantation of a capsular tension ring (CTR) and a toric lens (Tecnis Toric). Main parameter was rotation referring - in contrast to misalignment - to the IOL axis change from immediately after implantation to the final postoperative position. METHODS: Lens position was measured at baseline with the patient still in recumbent position, postoperative rotation was calculated by software. Postoperative evaluation included measurement three months after surgery or prior to an indicated revision surgery. Explorative re-evaluation of the underlying RCT's intent-to-treat population was performed for the entire sample and stratified for cohorts by 95% confidence intervals for binary endpoints' incidences (primary endpoint: absolute postoperative rotation ≤5 degrees; secondary endpoints: absolute deviation between achieved cylinder and target cylinder ≤0.5 dpt, postoperative corrected distance visual acuity (CDVA) ≥ 0.8). Data exploration was based on medians and quartiles. SETTING: Outpatient study sites. DESIGN: Re-evaluation based on data from a multicenter non-inferiority randomized clinical trial (RCT). RESULTS: Sub cohorts (without CTR 89, with CTR 90 patients) did not present clinically relevant differences in preoperative characteristics: revision surgery was performed in 7 cases (3 without and 4 with CTR). Primary endpoint incidences for the total sample, without and with CTR were 90%/89%/90%; cylinder endpoint incidences were 46%/45%/46% and CDVA endpoint incidences 90%/92%/88%. Median absolute rotations were 1.74°/1.79°/1.72°, median absolute cylinder deviations 0.55/0.52/0.55 dpt and median visual acuity 1.0/1.0/1.0. CONCLUSION: No clinically relevant differences between CTR subgroups were found; a satisfying three months rotational stability was achieved. TRIAL REGISTRATION: The trial was registered retrospectively in the trial registry DRKS, trial registration number DRKS00015316 , date of registration 27. August 2018.

Long-term reduction of laser flare values after trabeculectomy but not after cyclodestructive procedures in uveitis patients.

The aim of this study was to examine long-term changes of laser flare (LF) after trabeculectomy (TE) and transscleral diode cyclophotocoagulation (TDCPC) in patients with uveitic secondary glaucoma. Retrospective, single-center analysis. Overall, 40 TE (mean follow-up 21.1 months) and 68 TDCPC (mean follow-up 21.8 months, P = 0.38) procedures were performed. The intraocular pressure (IOP) level was consistently lower in the TE group at the preoperative visit and at each follow-up visit, while IOP reduction was similar in both groups (P = 0.91). LF decreased from 59.4 photons/ms at baseline to 41.9 photons/ms in the TE group (P = 0.017) and remained unchanged in the TDCPC group (71.2 vs. 70.7 photons/ms, P = 0.84). No significant increase in the number of complications could be observed at the end of the postoperative follow-up, while best-corrected visual acuity drop and cataract formation was higher in the TE group. TE significantly reduced postoperative LF values. Higher LF values did not increase the development of new complications in this study, but an increased occurrence of cataract formation was seen in the TE group.

Multiplex Cytokine Analysis of Aqueous Humor in Juvenile Idiopathic Arthritis-Associated Anterior Uveitis With or Without Secondary Glaucoma.

Patients with juvenile idiopathic arthritis often develop chronic anterior uveitis (JIAU). JIAU patients possess a particularly high risk for developing secondary glaucoma when inflammatory inactivity has been achieved. By using multiplex bead assay analysis, we assessed levels of pro- and anti-inflammatory cytokines, chemokines, or metalloproteinases in the aqueous humor (AH) of patients with clinically inactive JIAU with (JIAUwG) or without secondary glaucoma (JIAUwoG), or from patients with senile cataract as controls. Laser-flare photometry analysis prior to surgery showed no significant differences between JIAUwG or JIAUwoG. Compared with the control group, levels of interleukin-8, matrix metalloproteinase-2, -3, -9, serum amyloid A (SAA), transforming growth factor beta-1, -2, -3 (TGFß-1, -2, -3), and tumor necrosis factor-alpha in the AH were significantly higher in patients with clinically inactive JIAUwG or JIAUwoG. Samples from JIAwoG patients displayed significantly higher levels of SAA (P < 0.0116) than JIAUwG patients. JIAUwG patients showed an increased level of TGFß-2 in AH samples compared with JIAUwoG (P < 0.0009). These molecules may contribute to the clinical development of glaucoma in patients with JIAU.

Mitomycin-C assisted photorefractive keratectomy in the treatment of buttonholed laser in situ keratomileusis flaps associated with epithelial ingrowth.

The prophylactic intraoperative use of mitomycin-C (MMC) to prevent haze and scarring after excimer laser surface ablation (phototherapeutic/photorefractive keratectomy [PTK/PRK]) in an eye with a previous laser in situ keratomileusis (LASIK) flap buttonhole with epithelial ingrowth is described. A well-centered buttonhole measuring 2.0 mm in diameter was cut within a thin LASIK flap in an amblyopic eye. Over the next 8 weeks, corneal haze and progressive epithelial ingrowth formed centrally. An early transepithelial PTK/PRK approach was chosen to manage the buttonhole together with the epithelial ingrowth and to treat ametropia before the onset of scarring. The approach included epithelial removal with PTK, application of MMC 0.02% for 1 minute, irrigation, a short waiting period to allow for diffusion, PRK correction of -4.0 diopters without nomogram adjustment, and bandage contact lens. A regimen of prednisolone acetate 1% and ofloxacin 0.03% 5 times a day for 1 week (steroid tapered) was prescribed. Epithelial ingrowth was removed successfully. Minimal haze formation was visible 2 weeks after the retreatment but did not reduce best spectacle-corrected visual acuity (BSCVA) and resolved within the next few weeks. After 6 weeks, uncorrected visual acuity was equal to BSCVA preoperatively (20/50). There was no evidence of recurrent epithelial ingrowth or central scarring after 24 months. Transepithelial PTK/PRK was effective in managing central epithelial ingrowth in a buttonholed LASIK flap. Prophylactic intraoperative use of MMC may reduce haze formation and corneal scarring in early treatments and may also prevent recurrent epithelial ingrowth. This approach may offer faster visual recovery and no risk for a repeated buttonhole creation compared with the widespread recutting a new flap after a couple of months. The optimal application time and concentration of MMC need to be established.

Combined phacoemulsification and pars plana vitrectomy: clear corneal versus scleral incisions: prospective randomized multicenter study.

PURPOSE: To compare the complications and outcomes of implantation of a foldable intraocular lens (IOL) through a clear corneal incision and implantation of a poly(methyl methacrylate) (PMMA) IOL through a scleral incision in combined phacoemulsification and pars plana vitrectomy. SETTING: Departments of Ophthalmology, St. Franziskus Hospital, Muenster, Eye Hospital, Muelheim, and University of Essen, Essen, Germany. METHODS: This prospective randomized study included 62 eyes having implantation of a PMMA IOL (811B, Pharmacia) through a scleral incision and 61 eyes having implantation of a polyacrylic (AcrySof, Alcon) IOL through a clear corneal incision. The preoperative visual acuity, underlying retinal disease, and vitreoretinal surgical maneuvers did not differ between groups. The surgical methods and intraoperative complications were noted. Examinations 2 days and 3 months after surgery included visual acuity, refractive error, keratometry, slitlamp evaluation, tonometry, and ophthalmoscopy. RESULTS: Intraoperatively, both incisions were stable and no serious complications occurred. Two days after surgery, the incidence and quantity of cells and fibrin in the anterior chamber were lower in the clear corneal incision group than in the scleral incision group (P<.05). Corneal endothelial dysfunction was more common in the clear corneal group than in the scleral group (P<.05). Three months after surgery, the astigmatic changes did not differ significantly between groups and the incidence of posterior capsule opacification (PCO) was lower in the clear corneal group (P<.05). Postoperative visual acuity improved significantly in 63% of eyes and 61% of eyes in the scleral group and clear corneal group, respectively. Visual acuity was limited by macular pathology. CONCLUSIONS: Both clear corneal and scleral incisions were safe in combined phacoemulsification and vitrectomy. Eyes with smaller clear corneal incisions and foldable IOLs had less postoperative inflammation and PCO.

Hypermotility of an iris-fixated anterior chamber phakic intraocular lens due to nontraumatic iris laxity.

PURPOSE: Permanent immovability of phakic intraocular lenses (pIOLs) for the correction of high myopia is crucial in avoiding injury to the corneal endothelium and maintaining visual acuity. Unstable position of iris-fixated pIOLs due to traumatic or nontraumatic disenclavation of the haptic has been described previously. METHODS AND RESULTS: We report a different mechanism of repeated excessive implant motility in both eyes of a young woman who developed late nontraumatic elongation of the iris fibers to which an iris-claw pIOL was fixated. This led to increased motility of the pIOLs with blinking causing mild iritis. Subsequent bilateral successful re-enclavation to other iris fibers ameliorated these symptoms. After 2.5 years, these iris fibers, too, were elongated, causing excessive movements of the pIOLs and consecutive endothelial cell loss necessitating removal of the pIOLs. The etiology of this iris fiber laxity remains unclear. CONCLUSIONS: Surgeons should be aware of this rare potential complication.

Trabeculectomy or modified deep sclerectomy in juvenile uveitic glaucoma.

PURPOSE: The purpose of this study is to report the effectiveness of trabeculectomies (TE) and modified deep sclerectomies (mdS) in a group of patients with juvenile uveitic secondary glaucoma. METHODS: This is a retrospective analysis of 16 TE and eight mdS. RESULTS: Postoperatively, an IOP reduction to 11.6 ± 4.7 mmHg was achieved in the TE group and to 18.5 ± 11.4 mmHg in the mdS group (p = 0.045). In the TE group, 14 patients showed postoperative success, one limited success and another was a failure compared to four successes and four failures in the mdS group (p = 0.041). The mean number of complications was 1.25 ± 1.49 in the TE group and 0.38 ± 0.74 after mdS (p = 0.11). In the mdS group, four patients (50%) needed additional glaucoma surgery compared to one TE patient (p = 0.023). CONCLUSION: Both surgical techniques showed a marked reduction of IOP. Trabeculectomy has a higher probability of achieving success and lowering IOP.

Effect of repositioning or discarding the epithelial flap in laser-assisted subepithelial keratectomy and epithelial laser in situ keratomileusis.

PURPOSE: To evaluate the influence of the epithelial flap after epithelial laser in situ keratomileusis (epi-LASIK) and laser-assisted subepithelial keratectomy (LASEK) to correct low to moderate ametropia on visual recovery, epithelial closure, pain, and haze formation. SETTING: Zentrum für Refraktive Chirurgie, Augenabteilung am St. Franziskus Hospital, Münster, Germany. DESIGN: Comparative case series. METHODS: Patients having bilateral epi-LASIK or bilateral LASEK had 1 treatment with a repositioned epithelial flap and 1 treatment with a discarded flap. Patients were masked to the epithelial replacement. Primary outcomes were visual acuity (decimal scale), diameter of epithelial defect, pain score (subjective visual analog scale 0 to 10), and haze formation (Fantes scale). Postoperative visits were at 1, 2, and 4 days and after 3 months. RESULTS: Twenty patients had epi-LASIK and 20 patients had LASEK. The mean increase in uncorrected distance visual acuity from 1 day to 3 months was 0.32 to 0.99 (epi-LASIK flap-on), from 0.41 to 0.98 (epi-LASIK flap-off), from 0.26 to 0.96 (LASEK flap-on), and from 0.37 to 0.92 (LASEK flap-off), respectively. At 4 days, epithelial closure was complete in 79 of 80 eyes. Postoperative pain levels decreased comparably in all groups. Haze levels after 3 months were 0.45, 0.43, 0.35, and 0.35 (epi-LASIK flap-on, epi-LASIK flap-off, LASEK flap-on, LASEK flap-off, respectively). Efficacy indices after 3 months were 1.07, 1.09, 1.11, 1.07, respectively. CONCLUSION: No clinically significant differences in terms of visual recovery, epithelial closure time, pain perception, and haze formation between LASEK and epi-LASIK were detected regardless of epithelial flap retention. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Prevalence of uveitic secondary glaucoma and success of nonsurgical treatment in adults and children in a tertiary referral center.

PURPOSE: The aim of this study is to compare treatment strategies, the success of topical and systemic therapy, and the need for glaucoma surgery in children and adults with secondary uveitic glaucoma. METHODS: Retrospective observational case series with 1997 consecutive new uveitis patients. RESULTS: Overall, 176 patients (8.8%) suffered from secondary glaucoma (n = 126) or ocular hypertension (n = 50). All patients received topical therapy, and 107 (62%) patients also received systemic glaucoma therapy. Topical therapy was successful (IOP

[Indication and effect of immunosuppression in patients with scleritis]. / Indikation und Wirksamkeit einer Immunsuppression bei Patienten mit Skleritis.

PURPOSE: The value of immunosuppressive drugs for the therapy of scleritis patients is unclear. The authors investigated the indications and effects of immunosuppression in a group of patients with scleral inflammation. METHOD: Retrospective study of patients treated for scleritis (n = 87) or episcleritis (n = 18). The demographic factors, clinical symptoms, visual outcome, course of inflammation, ocular complications resulting from inflammation, topical and systemic antiinflammatory medication, and associated systemic diseases were analysed. RESULTS: Only one patient with episcleritis, but 37 with scleritis presented with ocular complications (P = 0.003). The vision was impaired in 15 patients with scleritis, but not in episcleritis patients (P = 0.022). In the group of patients with episcleritis, only those with frequent relapses required more than topical antiinflammatory drugs, especially systemic non-steroidals. In contrast, systemic therapy was indicated in all of the scleritis patients. Ocular complications were found more often in patients with necrotising (n = 7/10) or posterior scleritis (n = 10/11) than in those with diffuse (9/39) or nodular (11/27) scleritis. Compared with the other patients, associated systemic autoimmune diseases were more common in patients with necrotising scleritis (P = 0.03). The need for immunosuppression was associated with vision-threatening complications (glaucoma, uveitis, peripheral ulcerative keratitis) (P < 0.01), systemic autoimmune disease, and necrotising and posterior form of scleritis (P < 0.01). Quiescence of scleritis was obtained in 59 of the scleritis patients, and improvement of inflammation was achieved in further 21. In 26 patients, scleritis did not improve with systemic steroid or non-steroidal treatment, but with immunosuppression. CONCLUSIONS: Scleritis is often associated with life-threatening systemic diseases and vision-threatening ocular complications. In patients with severe scleritis, especially with the posterior and necrotising form, improvement can often be achieved with immunosuppression.