[Boston keratoprosthesis: 73 eyes from Germany : An overview of experiences from two centers]. / Boston-Keratoprothese: 73 Augen aus Deutschland : Übersicht der Erfahrungen aus zwei Zentren.

BACKGROUND: The Boston Keratoprosthesis (B-KPro) is a therapeutic option for corneal replacement for visual rehabilitation in eyes with poor a prognosis for penetrating keratoplasty (high-risk eyes). Since 2009, this approach has been used in the MVZ Prof. Neuhann, Munich, and since 2013 also at the Department of Ophthalmology, University of Cologne. An overview of results from the first 73 eyes in these departments is presented. METHODS: All recipient eyes of both centers which received a B-KPro type I (BI-KPro) between November 2009 and March 2017 were included. Indications, preoperative findings, intraoperative procedures, and clinical results, as well as postoperative complication and retention rates were documented and analyzed. RESULTS: A total of 73 eyes from 68 patients (mean age 55 ± 21.1 years, range 7 months-93 years; 26 women, 42 men) were treated with a BI-KPro. In 53 eyes (72.6%) the BI-KPro was implanted due to corneal graft failure, whereas BI-KPro was used as the primary corneal replacement in 20 eyes (27.4%). In 46 eyes (63.0%) a long-term increase in visual acuity was achieved and in 21.9% visual acuity was stabilized, while a decrease in preoperative visual acuity occurred in 15.1% of cases. During an average follow-up of 24.7 ± 23.0 months (range 1-78 months), 1.7 ± 2.4 re-interventions (range 0-9) were required. Only 4 keratoprostheses (5.5%) could not be retained. In 3 eyes (4.2%), a change of the BI-KPro device was necessary. CONCLUSION: There is a wide range of indications for BI-KPro in eyes with a poor prognosis for conventional keratoplasty. The surgical technique is safe but with a notable postoperative complication rate, which does not seem to decrease in the medium or long term. The retention rate is excellent for eyes without stem cell deficiency. Nevertheless, the BI-KPro is the only therapeutic option for high-risk eyes and leads to a gain in visual acuity in most cases.

[Case numbers and revenues of main and affiliated ophthalmological departments: Developments since 2005]. / Fallzahlen und Erlöse in ophthalmologischen Haupt- und Belegabteilungen : Entwicklungen seit 2005.

BACKGROUND: Currently, very little data exist on the development of healthcare-related and financial parameters of both types of inpatient treatment: clinical units run by affiliated physicians and those run by hospital physicians. AIM: This study used a methodology based on published secondary data to estimate the annual number of cases and revenues for in inpatient ophthalmological treatment differentiated into clinical units run by affiliated physicians and those run by hospital physicians. MATERIAL AND METHODS: The case-based flat-rate catalogs and accompanying research data published annually by the Institute for the Hospital Remuneration System (Institut für Entgeltsysteme im Krankenhaus, InEK) served as a data source. The numbers of annual cases according to major diagnostic categories (MDC) and diagnosis-related groups (DRG), stratified by the unit type are reported for the period 2005-2012. The cumulative total revenues were calculated based on the number of ophthalmological cases, the effective DRG cost weighting, the length of stay and the national basic case values. RESULTS: Between 2005 and 2012 the units run by affiliated physicians showed a contrasting trend to those run by hospital physicians: the number of cases in units run by hospital physicians increased by 14 %, while those in units run by affiliated physicians decreased by 6 %. Up to 2012 the effective cost weighting for cases in units run by hospital physicians decreased to 0.60 (- 3 %) and increased to 0.43 (+ 5 %) for units run by affiliated physicians. In 2012 the corresponding effective case revenue accounted for 1767 euros and 1271 euros, respectively. Total revenue estimates for all inpatient ophthalmological treatment increased from 549 million euros in 2005 to 630 million euros in 2012, while the share of units run by affiliated physicians amounted to 10.6 % and 9.7 %, respectively. CONCLUSION: According to the indicators "number of cases" and "total revenue", the affiliated ophthalmologists lost ground compared with inpatient units run by hospital physicians over the period from 2005-2012.

[Primary vitrectomy for rhegmatogenous retinal detachment without use of heavy liquids]. / Primäre Vitrektomie bei rhegmatogener Ablatio ohne Verwendung von schweren Flüssigkeiten.

PURPOSE: The purpose of this study was to analyse the outcome of vitrectomy for rhegmatogenous retinal detachment without intraoperative use of heavy perfluorocarbon liquids (PFCL). MATERIAL AND METHODS: All patients who had undergone vitrectomy with a PFCL-free approach during 4/2001-3/2008 by one single surgeon were recruited retrospectively from the electronic database and their data analysed. RESULTS: A total of 79 patients (42 pseudophakic, 37 phakic) with unilateral surgery were included in the study. The median follow-up was 20.5 months (minimum 3, maximum 133). Median preoperative best-corrected visual acuity was 0.5 logMAR (minimum 0, maximum 2.5) as compared to a postoperative median of 0.45 logMAR (minimum - 0.2, maximum 1.3). The primary anatomic success rate (portion of patients not requiring further retinal surgery, including macular pucker or macular hole surgery) was 70 % for the phakic group, 71 % for the pseudophakic group, and 71 % for all cases. The redetachment rate was 19 % for all cases. The final reattachment rate was 100 %. Complications requiring a repeat surgical intervention occurred in 23 cases, including 7 patients (9 %) with proliferative vitreoretinopathy, and 4 patients (5 %) with macular pucker and macular hole each. CONCLUSION: Even though this surgical procedure avoids possible disadvantages of retained intraocular PFCL and may be more cost-effective, the potential benefits do not outweigh the reduced primary anatomic success rate. The authors therefore recommend this approach in selected cases only.

[Potentials and limitations of the planned compulsory quality assurance program for cataract surgery (Qesü)]. / Potenziale und Grenzen der geplanten obligatorischen Qualitätssicherung für Kataraktoperation (Qesü).

Cataract surgery is scheduled for a federal program for quality improvement across the different sectors of care (outpatient care and hospitals). In case of implementation not only ophthalmic surgeons but all ophthalmologists would have to contribute to the documentation. Urgency, potential benefits and limitations of a compulsory compared to a voluntary quality assessment system are analyzed.

[Conspicuous crystalline lens foreign body after intravitreal injection]. / Auffälliger Linsenfremdkörper nach intravitrealer Injektion.

In January 2011 a 63-year-old woman with retinal branch vein occlusion and a macular edema first presented with a conspicuous foreign body of the crystalline lens. The rare event of an inadvertently into the lens placed Ozurdex® was diagnosed. Due to recurrent macular edema several reinjections of Ozurdex® were necessary. Phacoemulsification was performed 11 months later for advanced cataract formation. An uncomplicated fixation of the intraocular lens (IOL) into the capsular bag was enabled due to fibrosis of the capsular defect.

[Reasons for exchange and explantation of intraocular lenses]. / Ursache von Austausch und Explantation von Intraokularlinsen.

BACKGROUND: This study was performed to analyse the reasons for explantation/exchange of intraocular lenses (IOL), which had originally been implanted for the correction of aphakia during cataract extraction. MATERIAL AND METHODS: All cases with IOL explantation, which had been performed at one institution between 1/2008 and 12/2009 were analysed retrospectively. RESULTS: A total of 105 eyes of 100 patients were analysed. The median time interval between implantation and explantation of the IOL was 5.9 years (min. 0, max. 29.6). The most frequent cause for the intervention was subluxation/dislocation of the implant in 55.2% of cases. This group comprised 21% of cases with subluxation within the capsular bag in pseudoexfoliation syndrome. Other reasons were optical problems/incorrect IOL power (21%), calcification of hydrophilic acrylic IOL (7.6%), corneal decompensation associated with an anterior chamber lens (4.8%), and single cases with varying problems. CONCLUSION: The reasons for IOL exchange presented in this study are comparable to those of other series in the literature. Explantations due to optical problems may gain weight in the future due to a rise in refractive procedures and demands.

[Results with the Boston keratoprosthesis]. / Ergebnisse nach Boston-Keratoprothese.

BACKGROUND: The Boston keratoprosthesis (BKP) is a surgical therapeutic option in patients with corneal disease and poor prognosis for penetrating keratoplasty. The purpose of this study was to summarize our results with this surgical technique which we have employed at our institution since November 2009. METHODS: All patients who underwent the BKP procedure at our institution between November 2009 and August 2011 were identified retrospectively and the data were analyzed. The surgical procedure and postoperative treatment were performed following the recommendations of the developers of the BKP. RESULTS: A total of 14 patients were included in the study and the patient age ranged from 36 to 78 years. All patients had superficial and stromal corneal opacification with loss of the normal corneal surface (conjunctivalization). In 13 patients the BKP was implanted after at least 1 penetrating keratoplasty (including 3 matched grafts) and in 1 patient it was performed as a primary procedure. The underlying diseases were Stevens-Johnson syndrome, chemical injury, chronic atopic dermatitis in neurodermitis, keratoconus, granulomatous uveitis, congenital glaucoma and eyeball injury/burn. The follow-up ranged from 1 to 21 months. Postoperative complications consisted of prolonged inflammatory anterior chamber reaction with synechia, deposits on the intraocular lens, posterior capsule opacification, secondary glaucoma, hypotension, conjunctival growth over the keratoprosthesis and cystoid macular edema. All cases had overall improvement of visual acuity at the last follow-up visit. The maximum improvement was from counting fingers to 0.7. CONCLUSION: Until now all BKPs have been preserved. At our institution the BKP is becoming increasingly more important even in such cases with a (very) poor prognosis for matched limbal and/or corneal grafts. Reimbursement for the BKP must, however be organized on a case by case basis.

[Result-related success rates of cataract operations. Results of a systematic literature review]. / Ergebnisbezogene Erfolgsraten der Kataraktoperation. Ergebnisse einer systematischen Literaturübersicht.

This systematic literature review, including 7 publications released since 2000, provides references for outcome indicators of cataract surgery for quality management initiatives. The reported relative numbers of cases achieving visual rehabilitation and refractive accuracy were determined and compared. With one exception the success rates did not represent benchmarks defined as best possible outcome but describe the results of data collected in a population during routine clinical practice. A best corrected visual acuity (BCVA) of ≥ 0.5 was achieved in 84-93% of all patients and in 95-99% of patients without preoperative visually impairing comorbidities. A refractive accuracy (absolute deviation of target refraction from spherical equivalent) of ≤ 1 D was reported in 72-97% of the patients. The success rates of these well established outcome indicator levels were high. Differences between operators were more distinguishable and the clinical relevance higher with less liberal indicator levels. A BCVA ≥ 1 was realized in 30-47% of all patients and in 52-62% of patients without visually impairing comorbidities. A total of 45-80% of the patients showed a refractive accuracy of ≤ 0.5 D. Exogenous factors not influencable by the surgeon have a relevant impact on the success rates. The literature review confirms the strong association of visually impairing comorbidities and BCVA outcome. Based on literature methodological problems of quality management systems for cataract surgery are discussed. While voluntary initiatives have the ability to solve these difficulties appropriate concepts for mandatory procedures are currently lacking.

[Aspheric profiles for refractive laser ablation of the cornea]. / Asphärische profile für refraktiven laserabtrag an der hornhaut.

Conventional ablation profiles for excimer lasers for myopic refractive correction of the cornea are of spheric geometry. Therefore, they induce additional imaging aberrations into the optical system of the eye, most notably spherical aberration. This is a major cause of the observed deterioration of visual quality after such corrections, especially under low illumination and ensuing larger pupil diameter. Therefore, aspheric ablation profiles compromizing the preexisting imaging/visual quality of the eye as little as possible are currently being developed and optimized for all laser platforms. Employed methods include customized correction profiles on the basis of individual wavefront data of the anterior corneal topography on the one hand, and correction profiles that minimize the induced spherical aberration in a "standardized" way on the other hand. We demonstrate for a particular laser platform how such profiles must be developed and optimized. Mathematical theoretical calculations appear to be an indispensable but insufficient prerequisite. The biological reaction of the corneal stroma and epithelium ("biodynamic response") can only be determined experimentally and must lead to adjustment of the calculated ablation algorithm. The results show that aspheric profiles developed on this basis can lead to significant reduction of induced spherical aberration. The obtainable effect is, however, limited by the biological response and the ensuing peripheral ablation depth and volume.

[Resistance of limbo-keratoplasty to blunt trauma]. / Stabilität der Limbo-Keratoplastik bei stumpfem Bulbustrauma.

BACKGROUND: Traumatic wound dehiscence is a rare complication after penetrating keratoplasty. Limbo-keratoplasty seems to alter the pattern of rupture after blunt trauma. CASE REPORT: We report on one patient with dehiscence of a penetrating limbo-keratoplasty after blunt trauma. RESULTS: The dehiscence occurred over the entire extent of the clear corneal scar, whereas the sclero-corneal interface remained adapted. CONCLUSIONS: This case suggests a different tensile strength of these two scar types, possibly associated with their different grades of vascularization or epithelialization.