"Dirty Dry Eye"- A waste volume analysis from topical therapy in keratoconjunctivitis sicca.

PURPOSE: The healthcare system is responsible for around 5% of CO2 emissions globally and in Germany. So far, there are no data on the amount of waste from dry eye disease (DED) therapy in ophthalmology. The aim of this project was to evaluate the amount and type of waste from single- and multi-dose units (SDU/MDU) generated by eyedrops used to treat DED in Germany. METHODS: The net waste weight (outer/inner packaging, instruction leaflet, empty container) from factory-sealed products was determined using a precision scale. Based on prescription data from PharMaAnalyst, a database of medical prescriptions from over 70 million patients in Germany, the total annual waste volume for 2016-2021 and the net weight of a 30-day treatment were calculated. RESULTS: The total annual waste volume increased significantly (p < 0.0001) from 7.13 tons in 2016 to 20.64 tons in 2021. A 30-day treatment with MDUs (without/with filter) results in a significantly lower mean waste volume (paper: SDU 24.3 ± 18.7 g; MDU 4.8 ± 1.7 g/8.8 g ± 1.7 g; SDU/MDU p = 0.0003, with filter p = 0.0034; plastic: SDU 35.0 ± 4.0, MDU 6.6 ± 0.7 g/ 15.1 g ± 5.8 g, SDU/MDU p < 0.0001, with filter p < 0.0001). CONCLUSION: Prescription-based treatment of DED in Germany causes an increasing and substantial waste volume. The use of SDUs is considerably more resource-intensive than MDUs. Due to the large and rising number of patients suffering from DED improvements in packaging could considerably reduce the CO2 footprint of DED treatment.

Real-world insights and outcomes related to ciclosporin A 0.1% cationic emulsion for the long-term treatment of dry eye disease in Germany: Country-level sub-analysis of the PERSPECTIVE study.

PURPOSE: The PERSPECTIVE study was a real-world European, non-interventional, multicenter, observational study that evaluated the effectiveness, tolerability, and safety of ciclosporin A (CsA) 0.1% cationic emulsion (CE) in routine clinical practice as a treatment for adults with severe keratitis and dry eye disease (DED) that remained insufficiently controlled with artificial tears. This sub-analysis examined data from ophthalmology clinics in Germany to provide more precise insights into treatment patterns, outcomes, and clinical decision-making related to CsA 0.1% CE. METHODS: Study data were collected from adults starting CsA 0.1% CE (one drop in both eyes at bedtime) and followed up at Week 4, 12, and 24, and Month 12. The primary endpoint was mean change from baseline in corneal fluorescein staining (CFS) score (Oxford Grade Scale) at Month 12. Secondary endpoints examined the severity of ocular signs and symptoms, and adverse events (AEs). RESULTS: A total of 236 patients from 20 ophthalmology clinics in Germany participated in the PERSPECTIVE study (69.9% female; mean age 60.8 years). Following treatment with CsA 0.1% CE, patients experienced significant reductions in CFS score from Week 4, which were maintained through to Month 12 (P < 0.0001). From baseline, 81.6% of patients experienced an improvement in CFS score at Month 12. CsA 0.1% CE provided significant reductions in the severity of eyelid and conjunctival erythema at Month 12 compared with baseline (P < 0.001), as well as significant reductions in the severity of subjective ocular symptoms (all P ≤ 0.015). Safety data were consistent with the known safety profile of CsA 0.1% CE. Tolerability was rated as "satisfactory," "good," or "very good" by 97.2% of physicians and 95.7% of patients. CONCLUSION: Outcomes in Germany were similar to those reported for the overall European study population and are indicative of the treatment results that ophthalmologists may expect to see with CsA 0.1% CE treatment in real-life clinical practice. Treatment with CsA 0.1% CE provided long-term improvements over 12 months and was generally well tolerated.

Intravitreal Injections: Improving Sustainability by Reducing Clinical Waste. / Intravitreale Injektionen: Nachhaltigkeit durch Reduktion von Klinikabfall.

BACKGROUND: Intravitreal injections are one of the most commonly performed ophthalmic procedures. It is estimated that over 1 million intravitreal injections are performed in Germany annually. The aim of this study was to quantify the waste and carbon footprint associated with single-use injection sets, and to establish a waste reduction strategy. MATERIAL AND METHODS: The clinical waste and associated carbon footprint from standard disposable injection sets used by tertiary referral centres in Germany (n = 6) and the United Kingdom (n = 2) were assessed. The safety of performing intravitreal injections with a minimalistic material-sparing approach was evaluated. RESULTS: The average weight of an injection set (and hence the waste generated from each injection) was 165 g. On average, each injection set comprised 145 g (88%) of plastic, 2.1 g (1.3%) of metal, 4.3 g (2.6%) of paper, and 12.9 g (7.8%) of gauze/swabs. The production of such injection sets was extrapolated to a CO2 equivalent of 752.6 tonnes (t), and the incineration of the resulting waste to a CO2 equivalent of 301.7 t. For 1 million injections, this equates to 145.2 t of plastic, 2.1 t of metal, 4.3 t of paper, and 12.9 t of gauze/swabs. A material-sparing approach can reduce injection set-associated waste by 99% without necessarily compromising patient safety. CONCLUSION: A resource-saving approach to intravitreal injections can minimise the generation of clinical waste and its associated carbon footprint, thereby supporting sustainability.

Microvascular anastomosis of the human lacrimal gland: a concept study towards transplantation of the human lacrimal gland.

INTRODUCTION: Severe aqueous tear deficiency is caused by primary or secondary main lacrimal gland insufficiency. The transplantation of a human lacrimal gland could become a potential treatment option to provide physiological tears with optimal properties. To this end, we performed an ex vivo study to develop a surgical strategy that would ensure a vascular supply for a lacrimal gland transplant using microvascular techniques. MATERIAL AND METHODS: Five cadaver heads were used to perform a lateral orbitotomy in order to identify the vascular pedicle and the lacrimal gland itself. The principal feasibility and the time of the required surgical steps for an intraorbital microvascular re-anastomosis of the human lacrimal gland were documented. Patency and potential leakage of the anastomosis were tested with hematoxylin intraoperatively. Postoperatively, routine histological, as well as scanning electron microscopy (SEM) of the gland and vascular anastomosis, were performed. RESULTS: The vascular pedicle of all five glands could be isolated over a minimum stretch of at least 1 cm, severed, and successfully reanastmosed microsurgically. Time for arterial anatomization (n = 4) was 23 ± 7 min and 22 ± 3 min for the vein (p = 0.62). The total time for the entire microvascular anastomosis was 46 ± 9 min. All anastomosis were patent upon testing. SEM revealed well-aligned edges of the anastomosis with tight sutures in place. CONCLUSION: Our study demonstrates as proof of principle the feasibility of intraorbital microvascular re-anastomosis of a human lacrimal gland within the presumed window of ischemia of this tissue. This should encourage orbital surgeons to attempt lacrimal gland transplantation in humans in vivo.

Impact of implementation of polymerase chain reaction on diagnosis, treatment, and clinical course of Acanthamoeba keratitis.

PURPOSE: Acanthamoeba keratitis (AK) is a painful and possibly sight-threatening ocular infection. While the correct diagnosis and specific treatment in the early stages significantly improve the prognosis, the disease is often misdiagnosed and in clinical examination confused with other forms of keratitis. Polymerase chain reaction (PCR) for the detection of AK was first introduced in our institution in December 2013 to improve the timely diagnosis of AK. The aim of this study was to assess the impact of implementation of Acanthamoeba PCR on the diagnosis and treatment of the disease in a German tertiary referral center. PATIENTS AND METHODS: Patients treated for Acanthamoeba keratitis between 1st of January 1993 and 31st of December 2021 in the Department of Ophthalmology of the University Hospital Duesseldorf were identified retrospectively via in-house registries. Evaluated parameters include age, sex, initial diagnosis, method of correct diagnosis, duration of symptoms until correct diagnosis, contact lens use, visual acuity, and clinical findings as well as medical and surgical therapy by keratoplasty (pKP). In order to assess the impact of implementation of Acanthamoeba PCR, the cases were divided into two groups (before (pre-PCR group) and after PCR implementation (PCR group). RESULTS: Seventy-five patients with Acanthamoeba keratitis were included (69.3% female, median age 37 years). Eighty-four percent (63/75) of all patients were contact lens wearers. Until PCR was available, 58 patients with Acanthamoeba keratitis were diagnosed either clinically (n = 28), by histology (n = 21), culture (n = 6), or confocal microscopy (n = 2) with a median duration until diagnosis of 68 (18; 109) days. After PCR implementation, in 17 patients, the diagnosis was established with PCR in 94% (n = 16) and median duration until diagnosis was significantly shorter with 15 (10; 30.5) days. A longer duration until correct diagnosis correlated with a worse initial visual acuity (p = 0.0019, r = 0.363). The number of pKP performed was significantly lower in the PCR group (5/17; 29.4%) than in the pre-PCR group (35/58; 60.3%) (p = 0.025). CONCLUSIONS: The choice of diagnostic method and especially the application of PCR have a significant impact on the time to diagnosis and on the clinical findings at the time of confirmation of diagnosis and the need for penetrating keratoplasty. In contact lens-associated keratitis, the first crucial step is to take AK into consideration and perform a PCR test as timely confirmation of diagnosis of AK is imperative to prevent long-term ocular morbidity.

Indications and outcomes of keratoplasty ≤ 5.5 mm diameter ("mini-keratoplasty").

PURPOSE: To report indications and clinical outcomes of corneal grafts ≤ 5.5 mm in diameter ("mini-KP") in a German tertiary referral center. METHODS: Patients who had undergone mini-KP to treat corneal ulcers with or without perforation between 2011 and 2018 at the Department of Ophthalmology, University of Düsseldorf, Germany, were identified from the local keratoplasty registry. All patient records were reviewed for age, gender, laterality, systemic and ophthalmological diseases, etiology of the corneal ulcerative disease, pre- and postoperative visual acuity over a follow-up time of up to 12 months, graft size, postoperative complications and the need for and timing of further corneal interventions. RESULTS: 37 eyes of 37 patients (male: n = 20; female: n = 17) with a mean age (± standard deviation) at presentation of 70 ± 18.8 years (range: 22-92 years) were identified. Most common etiologies were neurotrophic keratopathy (n = 15), dysfunctional tear syndrome (n = 9) and atopic keratoconjunctivitis (9). Mean graft diameter was 4.51 ± 0.63 mm (range: 3-5.5 mm). 23/37 eyes (62%) required no further intervention in the acute phase. 14/37 patients (38%) required secondary corneal intervention, due to complications. One-year graft survival was 78.4%. One eye had to be eviscerated due to recurrent corneal ulceration and endophthalmitis. 36 of 37 eyes were preserved. We found a highly significant correlation between type 2 diabetes and the development of postoperative complications (r = .46; p = .005). Corrected distance visual acuity (CDVA) improved from 1.42 ± 0.75 logMAR to 0.9 ± 0.65 logMAR postoperatively (t (23) = 5.76; p < .001). CONCLUSION: Mini-KP can be used successfully in eyes with advanced corneal ulcers due to various infectious and noninfectious etiologies to restore tectonic stability in the long-term and with moderate visual gains.

High-Impact Actions to Reduce the Carbon Dioxide Footprint in an Ophthalmic Operation Room: A Narrative Review.

Germany's health care footprint accounts for 5.2% of the national emissions footprint which results in 0.71 tons of CO2 emission per capita. Thus, the health sector has a responsibility to take climate action. Surgery is a resource-intensive health care activity, requiring expensive equipment, sterilization procedures, advanced operative technologies, and obligatory life support systems. We spotlight the situation in a department of ophthalmology with frequent anesthesia services and highly standardized procedures. This narrative review discusses high-impact actions which result in a major reduction of the CO2 footprint according to the global road map for health care decarbonization, considering both the ophthalmic and anesthesiologic point of view.

Assessment of Laser Parameters to Improve Lid Tension-A Proof of Concept towards Lasercanthoplasty.

BACKGROUND: Preliminary clinical work indicates that increasing eyelid tension improves the function of the meibomian glands. The aim of this study was to optimize laser parameters for a minimally invasive laser treatment to increase eyelid tension by coagulation of the lateral tarsal plate and canthus. METHODS: Experiments were performed on a total of 24 porcine lower lids post mortem, with six lids in each group. Three groups were irradiated with an infrared B radiation laser. Laser-induced lower eyelid shortening was measured and the increase in eyelid tension was assessed with a force sensor. A histology was performed to evaluate coagulation size and laser-induced tissue damage. RESULTS: In all three groups, a significant shortening of the eyelids after irradiation was noticed (p < 0.0001). The strongest effect was seen with 1940 nm/1 W/5 s, showing -15.1 ± 3.7% and -2.5 ± 0.6 mm lid shortening. The largest significant increase in eyelid tension was seen after placing the third coagulation. CONCLUSION: Laser coagulation leads to lower eyelid shortening and an increase in lower eyelid tension. The strongest effect with the least tissue damage was shown for laser parameters of 1470 nm/2.5 W/2 s. In vivo studies of this effect have to confirm the efficacy of this concept prior to clinical application.

[Tonometry: Review and Perspectives]. / Tonometrie: Rückblick und Ausblick (Teil 2).

Reliable and repeated IOP measurement are essential in the diagnosis and treatment of glaucoma. In this second part, the other contact tonometry and non-contact tonometry are presented. The clinical value of the different methods and the value of multimodality in tonometry will be discussed based on a review of the literature, and the latest innovations with telemetric IOP sensors will be introduced.

Descemet Membrane Endothelial Keratoplasty in Combination with Pars Plana Vitrectomy in Complex Eyes for Enhanced Gas Tamponades. / Descemet-Membran-Endothel-Keratoplastik in Kombination mit Pars-plana-Vitrektomie in komplexen Augen zur extensiven Gastamponade.

BACKGROUND: DMEK is well-established to treat endothelial corneal diseases. The procedure involves the use of an anterior chamber gastamponade to attach the graft. In eyes after lense extraction, fistulating glaucoma surgery or with large iris defects the gas tamponade is often lost postoperatively in the vitreous cavity or subconjunctival. We are reporting on three cases below, in which simultaneous anterior and posterior chamber gas tamponade were inserted with a combination of DMEK and 23-G pars plana vitrectomy (ppV). CASE DESCRIPTIONS: In the first case, a 70-year-old man experienced complete gas dislocation into the vitreous cavity early on after DMEK, resulting in re-bubbling being carried out in combination with 23-G ppV. In the second case, DMEK was immediately combined with ppV for an 80-year-old man who had an Ahmed glaucoma implant, and for a 61-year-old woman, our third case, who had traumatic aphakia. In all three cases, the vitreous cavity and anterior chamber were filled with 20% SF 6 as much as possible. In the second case, it was necessary to perform a re-bubbling due to partial graft dehiscence that occurred on the fifth day post-DMEK. The intraocular pressure in all three cases remained compensated postoperatively, and visual acuity increased despite the complex pre-existing conditions that had limited vision prior. DISCUSSION: The combined endotamponade of the anterior and posterior chambers while performing DMEK with 23-G ppV can extend the gas endotamponade in patients whose eyes have a complex medical history, and can thus ensure successful graft adherence.

Brillouin Spectroscopy in Ophthalmology. / Gegenwärtiger Stand der Brillouin-Spektroskopie in der Ophthalmologie.

BACKGROUND: Information about corneal biomechanics is crucial for achieving satisfactory outcomes after surgical corneal interventions, e.g., for astigmatic keratotomies, but also to identify corneas that are at risk for postoperative complications such as corneal ectasia. Hitherto, approaches to characterize corneal biomechanics in an in vivo setting have yielded only minor success, demonstrating the unmet medical need for a diagnostic technique to measure ocular biomechanics. OBJECTIVE: This review shall explain the mechanism of Brillouin spectroscopy and summarize the current scientific knowledge for ocular tissue. METHODS: PubMed research of relevant experimental and clinical publications, as well as reporting of own experience using Brillouin spectroscopy. RESULTS: Brillouin spectroscopy can measure different biomechanical moduli with a high spatial resolution. Currently, available devices are able to detect focal corneal weakening, e.g., in keratoconus, as well as stiffening after corneal cross-linking. Also, the mechanical properties of the crystalline can be measured. Corneal anisotropy and hydration, together with the dependence on the angle of the incident laser beam in Brillouin spectroscopy, are challenges in the precise interpretation of measured data. A clear advantage in the detection of subclinical keratoconus compared to corneal tomography, however, has not been shown yet. CONCLUSION: Brillouin spectroscopy is a technique to characterize biomechanical properties of ocular tissue in vivo. Published results confirm ex vivo data of ocular biomechanics; however, further improvements in the acquisition and interpretation of measured data are required until this technique can be used in a clinically viable setting.

Use of Endoscopy in Keratoprostheses with Biological Haptics. / Endoskopieeinsatz bei Keratoprothesen mit biologischer Haptik.

INTRODUCTION: In severe ocular surface disease where penetrating keratoplasty cannot be successfully performed, implantation of a keratoprosthesis can achieve visual rehabilitation. Osteo-odonto-keratoprosthesis offers good tissue integration due to its biological haptics, resulting in a better survival rate and lower extrusion rate. Due to corneal opacity, which is often complete, assessing the potential visual acuity is challenging. Also, during implantation of a keratoprosthesis or during later intraocular revision surgery, there is a limited field of view of the peripheral retina or ciliary body region. This is due to the small size and central location of the prosthesis optics and the geometric conditions of the prosthetic haptics. These factors can complicate surgery. METHODS: Endoscopic video assistance was used in 7 eyes of 6 different patients (6 male, 2 female, mean age 66 ± 9 years). In 3 eyes the indication was for preoperative estimation of potential visual acuity during a 23 G vitrectomy. In 2 eyes it was used during implantation surgery itself, and in 2 eyes it was used during revision surgery and vitrectomy. An endoscope with semirigid optics and an image guidance system with 3,000 pixels and 70°field of view from PolyDiagnost was used, with a 23 G trocar system. RESULTS: Endoscopy was successfully applied in all eyes examined. In 1 of 3 eyes where endoscopy was performed to estimate the visual acuity potential, a keratoprosthesis was subsequently planned. In the other two eyes, the visual acuity potential was rated insufficient for future keratoprosthesis surgery. Detailed assessment of the retina and optic disc was limited to gross pathologies because of low image resolution. During implantation, it was possible to visualize correct positioning of the posterior haptic behind the host cornea. Retroprosthetic membranes could successfully be removed by endoscopy-assisted vitrectomy. CONCLUSION: Endoscopy assistance offers advantages in visualization both for determining the indication for KPro surgery, during implantation, and in the management of complications after implantation of a keratoprosthesis. Low resolution of the imaging system places limits on assessment capabilities. Although technical improvements and miniaturization may enhance its future capabilities, endoscopy in its current form is already a valuable addition in the context of keratoprosthesis surgery.

Total Full-Thickness Upper Eyelid Reconstruction: Combination of Mustardé Eyelid Switch Flap with a Bipedicled Periosteal and Tenzel Flap Technique.

INTRODUCTION: In recent decades, two techniques for large full-thickness upper eyelid reconstruction have been described, the Cutler-Beard lid sharing flap and the Mustardé eyelid switch flap. In the literature, modifications are being introduced to improve those techniques. Here, we present our approach for the reconstruction of total full-thickness upper eyelid defects and compare it with these established upper lid reconstruction techniques. METHODS: Three patients presented with upper eyelid tumors and required extensive excision resulting in total full-thickness upper eyelid defects. Reconstruction consisted of a two-stage procedure: a Mustardé eyelid switch flap was performed followed by division of the rotation flap and lateral canthoplasty using a periosteal bipedicled flap and Tenzel flap. Patients were followed-up every 3 months for at least 1 year. During every preoperative and postoperative check-up, palpebral fissure height, levator function, margin reflex distance, and presence of lagophthalmos were measured. RESULTS: Histopathological examination revealed a Merkel cell carcinoma in two cases and a Basal cell carcinoma in one case. Postoperatively, all patients showed a stable reconstructed upper eyelid with preserved motility and satisfying aesthetic results when compared to the fellow eye. In one case, a lagophthalmos of 1.5 mm was observed, which was treated conservatively to prevent exposure keratopathy. CONCLUSION: The eyelid switch flap combined with a bipedicled periosteal and a Tenzel flap is a good alternative for the reconstruction of total upper eyelid defects with the advantage of leaving the contralateral eye untouched. It achieves satisfying anatomical results, including an upper eyelid margin with eyelashes and well-matched skin color.

Evaluation of the Use of Intraoperative OCT in Routine Surgery: A Two-year Comparison. / Evaluation der Nutzung von intraoperativer OCT im operativen Alltag: ein 2-Jahres-Vergleich.

BACKGROUND: In recent years, an increasing number of surgical microscopes fitted with an OCT module (intraoperative OCT, iOCT) have become available, providing high-resolution images of the surgical site in real time. While a 2018 survey at our hospital showed that iOCT delivered an additional intraoperative benefit in only 2.4% of all operations, considering that the manufacturer had since revised the hardware and software, we conducted a second user evaluation of this technology. MATERIAL AND METHODS: Prospective monocentric analysis of the application and user-friendliness of an EnFocus Ultra-Deep OCT (Leica Microsystems) over a period of 25 (2018) and 20 working days (2021). A standardized questionnaire was used to assess the surgeons' use of iOCT and its influence on the surgical course. RESULTS: 118 operations were performed over a 25-day period in 2018 and 92 operations were performed over a 20-day period in 2021. In 2018, iOCT was used in 24.6% and in 2021 in 48.9% of all surgeries, with iOCT proving to be "critical" to the surgical course in 2.4% and 3.3% of cases, respectively, as assessed by the surgeons in both years. These were operations in which the intraocular view was limited, e.g., with decompensated cornea, vitreous hemorrhage, or after previous surgery, e.g., after penetrating keratoplasty. CONCLUSION: Further development of the user interface led to an improvement in usability, and the iOCT was used significantly more often. In both years, the iOCT proved to be critical for the course of the surgery in a comparably small number of operations, especially those involving complex situations.

Current Practice in the Treatment of Epithelial and Melanocytic Tumours with Interferon-α2b: A Survey of Tertiary Eye Centres in Germany.

PURPOSE: To evaluate the standard of care, in particular the use of topical or subconjunctival interferon-α2b, in treating ocular surface squamous neoplasia or melanocytic tumours in tertiary eye centres in Germany. METHODS: A survey containing 14 questions was sent to 43 tertiary eye centres in Germany. The questions addressed the surgical and medical management of ocular surface squamous neoplasia and melanocytic tumours (primary acquired melanosis and malignant melanoma), as well as the clinical experiences and difficulties in prescribing off-label interferon-α2b eye drops and subconjunctival injections. RESULTS: Twenty-four tertiary eye centres responded to the survey. Eighty-three percent of centres had used interferon-α2b in their clinical practice and 25% prescribed it as the first-line cytostatic agent following surgical excision of ocular surface squamous neoplasia, while 10% would do so for melanocytic tumours. Correspondingly, the majority of respondents selected mitomycin C as their first-line agent. Side effects were uncommon with topical interferon-α2b eye drops but were more frequently reported after subconjunctival interferon-α2b injections. In total, eight centres had experience with interferon-α2b injections. The most significant obstacles perceived by ophthalmologists when prescribing interferon-α2b were its high cost and the reimbursement thereof. CONCLUSION: Off-label mitomycin C was the preferred adjuvant therapy for epithelial and melanocytic tumours, with interferon-α2b being the standard second-line option. Interferon-α2b has predominantly been used to treat ocular surface squamous neoplasia and, to a lesser extent, melanocytic tumours at German tertiary eye centres. Following its market withdrawal, supply shortages of interferon-α2b are likely to have a profound impact on patient care and their quality of life.

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.

Lagophthalmos-induced corneal perforation in a patient with congenital erythropoietic porphyria.

Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disorder in which the activity of uroporphyrinogen III synthase (UROS) is decreased. This results in the accumulation of photoreactive porphyrinogens, primarily in the skin and bone marrow. We describe a case of a patient with CEP who initially presented with scarring and shortening of the anterior and posterior lid lamella, which led to the development of lagophthalmos. Vascularized hyperkeratotic plaques in both corneas were also present. Despite treatment with topical ocular surface lubricants, corneal perforation with iris and uvea prolapse developed and evisceration of the right eye under local anesthesia was performed. The presented case suggests that despite topical therapy, ocular complications may exacerbate requiring surgical intervention, especially in the presence of lagophthalmos.

Spectrum and resistance in bacterial infections of the ocular surface in a German tertiary referral center 2009-2019.

PURPOSE: Aim of this study was to evaluate the frequencies, trends, and antibiotic resistance of bacteria collected from ocular surface or contact lens material in a German tertiary referral center from 2009 to 2019. METHODS: Microbiological data from 2009 to 2019 was analyzed. Culture-dependent microbial identification and analysis of antibiotic sensitivity was completed by the Institute of Microbiology. Statistical analysis of age- and sex-specific differences as well as changes in the microbial spectrum and resistance over the study period was performed with GraphPad Prism 9.0 applying nonparametric tests (level of significance: p ≦ 0.05). RESULTS: A total of 6361 specimens were analyzed. Positivity rate was 18.6%. Sixty-three percent (n = 680) of the bacterial isolates were derived from ocular surface and 37% (n = 399) from contact lens material. The ratio of gram-negative bacteria was significantly higher in contact lens material. Multiresistant bacteria showed a significant increase with patient age (p < 0.0001). An overall increase in resistance to levofloxacin (p = 0.0239) was detected. Only 2.4% and 3.1% isolates were resistant to a combination of moxifloxacin and gentamicin, respectively, levofloxacin and gentamicin. CONCLUSIONS: The reported bacterial spectrum is similar to comparable centers. Our data show that it should not be assumed that the newest classes of antibiotics have the best efficacy or lowest resistance levels. In suspected bacterial conjunctivitis, we propose using gentamicin as first-line therapy. In therapy refractive cases and in involvement of the cornea, we recommend a combination of gentamicin and ofloxacin or moxifloxacin. Overall, the evaluated organisms showed good sensitivity to the regularly used antibiotics.

Incidence, prevalence, and outcome of moderate to severe neurotrophic keratopathy in a German tertiary referral center from 2013 to 2017.

BACKGROUND: Neurotrophic keratopathy (NK) is an orphan disease, with an estimated prevalence of 1-5/10,000. No data regarding the incidence exists. The primary aim was to evaluate incidence and prevalence of NK at a tertiary referral center in Germany, and the secondary aim was to analyze demographic parameters, etiology, and clinical features and therapeutic outcomes. METHODS AND MATERIAL: All patients treated for NK with serum eye drops (SED), amnionic membrane transplantation (AMT), or penetrating keratoplasty (PK) in 2013-2017 were identified. Age, sex, etiology of NK, visual acuity, disease stage, treatment, and visual acuity were analyzed. Incidence and prevalence of NK in our hospital and the overall population of the city were calculated. RESULTS: In 63 eyes of 60 patients (56.7% male; 68 ± 16 years), the most common underlying diseases were herpetic infections (23.8%), neurological causes (19%), and diabetes mellitus (14.3%). The annual incidence of NK in our tertiary referral center ranges between 5/10,000 and 3/10,000, the prevalence between 9/10,00 and 22/10,000. In all patients treated with corneal ulcers, the prevalence was up to 27% (2706/10,000). The incidence in the overall population is estimated at 0.1-0.3/10,000, the prevalence at 0.2-0.5/10,000 to 0.5/10,000. CONCLUSION: Based on our assessment, the prevalence of NK in the overall population is lower than estimated before. However, in patients with corneal ulcers, the percentage of NK is comparably high. The disease may still be underdiagnosed due to the variety of underlying disorders and unknown comorbidities. Thus, in cases of therapy-refractive superficial keratopathy or ulcerations, NK should be considered more frequently.

S2k Guideline for the diagnosis and treatment of mucous membrane pemphigoid.

Mucous membrane pemphigoid (MMP) is a pemphigoid disease with predominant mucous membrane involvement. It mainly affects the mucous membranes of the mouth, eyes, nose and pharynx, but also the larynx, trachea, esophagus, genital and perianal regions. The manifestation of the disease covers a wide spectrum from gingival erythema and single oral lesions to severe tracheal strictures that obstruct breathing and conjunctival scarring with marked visual impairment and, not infrequently, blindness. In addition to a clinical picture of predominant mucosal involvement, diagnosis is based on direct immunofluorescence of a peri-lesional biopsy and serology. The main target antigen is BP180 (collagen XVII), and reactivity with laminin 332 is associated with malignancy in approximately 25 % of MMP patients. The treatment of MMP is challenging. On the one hand, due to the involvement of different mucous membranes, good interdisciplinary cooperation is required; on the other hand, due to the rarity of the disease, no randomized controlled clinical trials are available. The aim of this guideline is to present the clinical picture, including severity and scoring systems, and to give guidance for diagnosing and treating this complex disease. In MMP, interdisciplinary cooperation plays an essential role as well as the prompt diagnosis and initiation of adequate therapy in order to avoid irreversible damage to the mucous membranes with serious complications.