[Global ophthalmology : Update]. / Globale Ophthalmologie : Aktueller Stand.

The aim of global ophthalmology is to maximize vision, ocular health and functional ability, thereby contributing to overall health and well-being, social inclusion and quality of life of every individual worldwide. Currently, an estimated 1.1 billion people live with visual impairment, 90% of which can be prevented or cured through largely cost-effective interventions. At the same time, 90% of people affected live in regions with insufficient eye health coverage. This challenge drove the World Health Organization (WHO) and a group of nongovernmental organizations to launch "VISION 2020: the Right to Sight", a global campaign which recently concluded after 20 years. The achievements, challenges and lessons learned were identified and incorporated into the current campaign "2030 IN SIGHT".

Supine Positioning for Graft Attachment After Descemet Membrane Endothelial Keratoplasty: A Randomized Controlled Trial.

PURPOSE: The Supine Positioning for Descemet Membrane Endothelial Keratoplasty Attachment (SUPER-DMEK) trial assessed the efficacy of prolonged supine head positioning on graft attachment. DESIGN: Randomized controlled trial. METHODS: Participants with Fuchs' dystrophy were randomized to 5 days of supine head positioning (intervention) or to 1 day (control). Participants, surgeons, and investigators were masked until the day after surgery. Adherence to the allocated intervention was monitored using a head sensor. Main outcome measures were area and volume of graft detachment (coprimary end points) 2 weeks after surgery quantified using a validated neural network for image segmentation on anterior segment optical coherence tomography images, and repeat air injection (rebubbling), subjective visual function, and adverse events (secondary end points). RESULTS: A total of 86 participants received the allocated intervention (35 eyes intervention and 51 eyes control). In the intention-to-treat analysis, the mean area of graft detachment was 28.6% in the intervention arm and 27.5% in the control arm (adjusted between-arm difference, 1.3; 95% CI, -8.7 to 11.4; P = .80). Results for volume of detachment and as-treated analyses based on head position sensor data indicated no potentially clinically relevant effect of prolonged supine positioning on graft attachment. Results were not compatible with a relevant treatment effect on rebubbling or subjective visual function. Adverse events, most commonly back pain, were more common and more severe with the intervention. CONCLUSIONS: In this randomized controlled trial, graft attachment was not improved with prolonged supine head positioning. Prolonged supine positioning frequently caused back pain. Prolonged supine positioning after Descemet membrane endothelial keratoplasty for Fuchs' dystrophy may not be needed in routine practice.

Hyperosmolar Eye Drops for Diurnal Corneal Edema in Fuchs' Endothelial Dystrophy: A Double-Masked, Randomized Controlled Trial.

PURPOSE: The Eye Drops for Early Morning-Associated Swelling (EDEMAS) trial assessed the efficacy of hyperosmolar eye drops on corneal edema resolution. DESIGN: Double-masked, randomized controlled trial of hyperosmolar eye drops. PARTICIPANTS: Participants with Fuchs' dystrophy scheduled for Descemet membrane endothelial keratoplasty. METHODS: One eye was randomized to hyperosmolar eye drops (treatment); the fellow eye was randomized to artificial tears (placebo). After baseline examination in the afternoon, corneas were examined using Scheimpflug tomography after eye opening in the morning. Participants received eye drops twice. Imaging was repeated every 30 minutes up to 4 hours. MAIN OUTCOME MEASURES: Decrease in central corneal thickness 1 hour after eye opening (primary end point), corneal thickness, subjective visual function, glare, visual acuity, and adverse events (AEs) (secondary end points). RESULTS: A total of 68 participants received the allocated intervention (59 eyes received treatment; 55 eyes received placebo). All eyes had stromal edema; none had epithelial edema. Corneal thickness was 626 µm in the treatment arm and 622 µm in the placebo arm after eye opening, indicating an early morning edema compared with baseline of +21 µm and +24 µm, respectively. Decrease in corneal thickness after 1 hour was -10.5 µm in the treatment arm (95% confidence interval [CI], -12.8 to -8.2) and -11.2 µm (95% CI, -13.6 to -8.9) in the placebo arm (between-arm difference, 0.7 µm, 95% CI, -2.0 to 3.5; P = 0.59), indicating no clinically relevant effect of hyperosmolar eye drops on early morning corneal edema. Results were not compatible with a relevant treatment effect on corneal thickness, visual acuity, and glare over the entire course of the study. Increase in subjective visual function was less rapid in the treatment arm than in the placebo arm. Adverse events, most commonly burning after eye drop application, were more common with treatment (30 eyes) than placebo (1 eye; risk difference, 49 percentage points; 95% CI, 36-62). CONCLUSIONS: In this double-masked, randomized controlled trial, resolution of early morning stromal edema was not accelerated by hyperosmolar eye drops, which more frequently caused AEs. These results are not compatible with a clinically relevant effect of hyperosmolar eye drops and do not support their routine use.

Rotational alignment of corneal endothelial grafts and risk of graft detachment after Descemet membrane endothelial keratoplasty: a double-masked pseudo-randomized study.

PURPOSE: The posterior cornea is rotationally asymmetric, and Descemet membrane endothelial keratoplasty (DMEK) grafts preferentially scroll vertically. This prospective study assessed whether graft attachment after DMEK differed depending on the rotational alignment of the donor graft in the recipient eye. METHODS: Pseudo-randomization and blinding of the graft orientation in the recipient's eye were possible by procedural separation: (1) The eye bank recorded the position of an orientation marker in the donor cornea; (2) the surgeon preparing the DMEK graft recorded an upside-down marker relative to the eye bank marker; and (3) the surgeon assessed the position of the upside-down marker in the recipient after DMEK. Surgeons were masked towards the eye bank marker. Using mixed-effects models, we assessed graft attachment relative to the rotational alignment of the donor graft. RESULTS: Postoperatively, the graft was not fully attached in 59 of 179 eyes (33%). A second air fill (rebubbling) was performed in 11%. The graft axis was in line with the recipient cornea axis in 40%, oblique in 28% and orthogonal in 32%. We did not detect an elevated risk of incomplete attachment (odds ratio [OR], 1.16; 95% CI, 0.61-2.20), risk of rebubbling (OR, 1.25; 95% CI, 0.47-3.31) or larger areas of graft detachment in non-aligned grafts compared to aligned grafts. CONCLUSION: Rotational alignment was not strongly associated with the risk of incomplete graft attachment, although modestly elevated risks cannot be ruled out. Efforts are needed to reduce the need for rebubbling after DMEK and to identify modifiable risk factors for graft detachment.

Predicting Edema Resolution After Descemet Membrane Endothelial Keratoplasty for Fuchs Dystrophy Using Scheimpflug Tomography.

IMPORTANCE: Predicting the extent of corneal edema resolution after Descemet membrane endothelial keratoplasty (DMEK) may help in preoperative decision-making by identifying patients who may benefit from restoring endothelial function. OBJECTIVE: To develop and validate a predictive model for edema resolution after DMEK using Scheimpflug tomographic imaging. DESIGN, SETTING, AND PARTICIPANTS: Two prospective studies recruited participants with advanced Fuchs dystrophy at a university-based tertiary referral center between July 1, 2017, and August 31, 2019. Analyses were designed in November 2019 and completed on June 30, 2020. Development of a predictive model using linear least absolute shrinkage and selection operator regression was conducted in a derivation cohort (100 eyes). Overall performance, discrimination, and calibration were tested in the separate validation cohort (32 eyes). EXPOSURES: Preoperative Scheimpflug parameters and patient-reported visual disability were considered as potential predictors of edema resolution: (1) tomographic features (irregularity of lines of equal corneal thickness, displacement of the thinnest point of corneal thickness from the inferior-temporal quadrant, and absolute amount of focal posterior corneal depression), (2) standardized anterior and posterior corneal backscatter, (3) preoperative central corneal thickness, and (4) Fuchs dystrophy-specific visual disability. MAIN OUTCOMES AND MEASURES: Decrease in central corneal thickness after DMEK indicative of edema resolution. RESULTS: Of the 88 patients included in the analysis, 54 were women (61%); median age was 68 years (interquartile range [IQR], 59-76 years). A median of 13 months after DMEK (IQR, 9-16 months), median corneal thickness was 77 µm lower (IQR, 51-94 µm) in the derivation cohort and 75 µm lower in the validation cohort (IQR, 54-96 µm) than before surgery. Per 10-µm edema resolution, eyes gained 0.66 Early Treatment Diabetic Retinopathy Study letters (95% CI, 0.09-1.23) in best-corrected visual acuity. Three tomographic features were present in 68 of 100 eyes (68%) in the derivation cohort and in 18 of 32 eyes (56%) in the validation cohort before DMEK and in only 1 of 132 eyes (1%) after DMEK. To predict edema resolution after DMEK based on preoperative assessment, 5 variables were selected by the statistical learning algorithm: nonparallel isopachs, focal posterior depression, anterior and posterior corneal backscatter, and central corneal thickness. In the separate validation cohort, the model showed high overall performance, discrimination, and calibration. CONCLUSIONS AND RELEVANCE: These post hoc analyses of prospective cohorts support a model for use in the prediction of edema resolution after DMEK using Scheimpflug measurement to identify patients benefitting most from DMEK.

Vertical Scrolling Axis of Corneal Endothelial Grafts for Descemet Membrane Endothelial Keratoplasty.

PURPOSE: Heterogeneity in scrolling behavior of Descemet membrane endothelial keratoplasty (DMEK) grafts complicates DMEK surgery. This prospective observational study assessed scrolling axes of DMEK grafts relative to the donor's eye. METHODS: The eye bank randomly marked the rim of corneoscleral donor buttons during trephination and recorded the position relative to the donor's axis. Surgeons were masked to the absolute position of the eye bank marking and recorded the scrolling axis relative to the eye bank marking and DMEK upside-down orientation. The scrolling axis was categorized as vertical (0 to 30 degrees and 150 to 180 degrees), oblique (>30 to 60 degrees and 120 to <150 degrees), and horizontal (>60 to <120 degrees). Scrolling patterns of corneas from the same donor were assessed. RESULTS: Scrolling patterns of 202 donor corneas from 149 donors were determined. The donor graft scrolled predominantly vertically to the donor's cornea [75%; 95% confidence interval (CI), 68%-80%]. Horizontal axes (11%) and oblique axes (14%) were less common. The median deviation in scrolling axes after unfolding the grafts was 0 degrees from the original scrolling axis (interquartile range, 0-15), indicating that scrolling axes were stable. Fellow eyes of 46 donors had 3.55 times higher odds of a nonvertical scrolling pattern if the first eye had a nonvertical scrolling pattern (95% CI, 1.37-9.20), suggesting that donor factors influencing both eyes could contribute to scrolling patterns. CONCLUSIONS: DMEK grafts have a natural and stable scrolling tendency at vertical axis of donor's cornea. Anticipating scrolling axes might help improve preparation techniques for DMEK grafts and outcomes.

Correlation between visual acuity and interface reflectivity measured by pentacam following DSAEK.

PURPOSE: Descemet-stripping automated endothelial keratoplasty (DSAEK) is an advanced method of lamellar endothelial keratoplasty. In comparison with penetrating keratoplasty, visual rehabilitation seems to be faster. Final visual outcome of DSAEK, however, seems to be limited, especially in comparison with Descemet membrane endothelial keratoplasty (DMEK). DSAEK cases without graft failure often do not show any definite correlate for the reduced optical performance. In this study, we tried to correlate visual acuity following DSAEK with interface reflectivity as measured by a rotating Scheimpflug system. METHODS: We examined 14 eyes of 13 patients with the pentacam for 2-11 months following DSAEK. Reflectivity of the interface region in the centre of the optical axis as well as central corneal thickness was determined. Statistical correlation between interface reflectivity and best spectacle-corrected visual acuity, central corneal thickness and follow-up time was drawn (multifactorial linear regression analysis). RESULTS: Statistically significant correlation between interface reflectivity and BSCVA as well as follow-up time was found. Reflectivity was highest in regions of interface (metal) particles. There was no statistically significant correlation between interface reflectivity and central corneal thickness. CONCLUSION: We present a measurable correlate for reduced visual outcome following DSAEK despite a clear graft. Inverse correlation between interface reflectivity and best spectacle-corrected visual acuity (BSCVA) indicates that irregularities or scarring in the interface region may influence the optical quality following DSAEK.

Clinical results of 123 femtosecond laser-assisted penetrating keratoplasties.

BACKGROUND: Postoperative astigmatism following penetrating keratoplasty is a major problem after corneal transplantation. The main goal of new trephination techniques such as femtosecond laser or excimer-laser trephination is to improve refractive and visual outcomes. The femtosecond laser technique makes profiled corneal trephinations such as the top hat or mushroom profile possible. We present the postoperative outcome of femtosecond laser-assisted penetrating keratoplasties. METHODS: We performed 123 femtosecond laser-assisted penetrating keratoplasties in 119 patients. The main outcome measures were intraoperative specifics, astigmatism, and irregularity in Orbscan corneal topography, as well as the occurrence of immune reactions and side-effects. RESULTS: All sutures have been removed in 49 of these 123 eyes. Their mean follow-up was 13.9 ± 4.5 months. Time to complete suture removal (n = 49) was 12.0 ± 3.7 months in the mushroom group and 9.8 ± 2.1 months in the top hat group. Mean astigmatism in Orbscan topography was 6.4 ± 3.0 diopters in the mushroom and 5.8 ± 4.6 diopters in the top hat group (all sutures out). CONCLUSIONS: Femtosecond laser-assisted penetrating keratoplasty is a safe surgical technique. Due to the steps in profiled trephinations, the wound area is larger and theoretically the wound healing is, thus, faster and more stable. Complete suture removal is possible at an earlier time point compared to conventional penetrating keratoplasty. However, refractive results are not superior to those following conventional trephination.

Treatment of ocular hypertension and open angle glaucoma: meta-analysis of randomised controlled trials.

OBJECTIVE: Open angle glaucoma is one of the most common causes of blindness in industrialised nations. Treatments to lower ocular pressure are widely used in glaucoma prevention and treatment, despite conflicting evidence. DESIGN: We performed meta-analyses to reassess the effectiveness of pressure lowering treatment to delay the development of glaucoma in ocular hypertension, as well as progression of manifest open angle glaucoma. DATA SOURCES: Medline, Embase, and the Cochrane Library. SELECTION OF STUDIES: Eligible studies were randomised controlled trials with a concurrent untreated control group and information on time to glaucomatous changes to visual field and optic disc. Trial reports were reviewed independently by two investigators in an unblinded standardised manner. RESULTS: Meta-analysis of trials in ocular hypertension showed a significant preventive effect of reducing intraocular pressure on progression to glaucoma (hazard ratio 0.56, 95% confidence interval 0.39 to 0.81, P = 0.01; number needed to treat 12). Pooled data of studies in manifest glaucoma showed a significant delay of visual field deterioration (0.65, 0.49 to 0.87, P = 0.003; NNT = 7), with subgroup analysis showing a larger effect in patients with raised pressure and a reduced effect in normal tension glaucoma (subgroup comparison: not significant). CONCLUSIONS: Lowering intraocular pressure in patients with ocular hypertension or manifest glaucoma is beneficial in reducing the risk of visual field loss in the long term.