LASER FLARE PHOTOMETRY IN PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT: An Evaluation of 2,487 Cases.

PURPOSE: Exploratory analysis associated with the prospective, multicenter, randomized PRIVENT trial. To characterize the associations between laser flare photometry and anatomical and epidemiological features of rhegmatogenous retinal detachment (RRD). METHODS: The authors measured laser flare values of all 3,048 prescreened patients excluding those with comorbidities. A mixed regression analysis evaluated the strength of the influencing factors like age, sex, lens status, and presence and extent of RRD on laser flare. RESULTS: Rhegmatogenous retinal detachment was more frequent in men (65.8%) than in women (34.2%, P < 0.001) and in right (52%) than in left eyes (48%, P = 0.045). Phakic RRD affected less quadrants and was less likely to be associated with macula-off status than pseudophakic RRD (48.4% vs. 58.0% macula off, 23% vs. 31% ≥3 quadrants, P < 0.001). Laser flare of affected eyes was significantly higher compared with fellow eyes (12.6 ± 15.2 vs. 8.3 ± 7.4 pc/ms, P < 0.001). The factors age, sex, lens status, presence of RRD, and the number of quadrants affected were independent influencing factors on laser flare. R 2 was 0.145 for phakic and 0.094 for pseudophakic eyes. CONCLUSION: The results indicate that there may be more factors affecting laser flare than previously assumed. This might limit flare as predictive value for PVR and retinal redetachment.

Clinical Experience of Two Sutureless Intrascleral Fixation Techniques for Secondary Intraocular Lens Implantation.

INTRODUCTION: The aim of this study was to evaluate the outcome of the modified Carlevale intraocular lens (IOL) fixation technique, using two different vitrectomy ports (23- vs. 27-gauge) as anchor fixation. METHODS: Retrospective, consecutive study of 282 eyes (282 patients) who underwent a secondary IOL implantation using the Carlevale IOL (Soleko IOL Division, Italy) with two anchor haptics for intrascleral implantation with either 23- or 27-gauge (G) port. RESULTS: Transient post-operative ocular hypotonia (intraocular pressure ≤5 mm Hg) was observed less in the 27-G group (13 vs. 4 patients, p = 0.057) three requiring additional tunnel sutures (2 cases for 23-G; 1 case 27-G). Post-operative vitreous haemorrhage was recorded more often in the 23-G group (8 vs. 1 patient, p = 0.034), but all cases in both groups resolved without intervention. Visual acuity did improve post-operatively in the two groups. No post-operative complications such as retinal detachment, endophthalmitis, and IOL-dislocation tilt were observed in the follow-up. CONCLUSION: The 27-G modified technique for sutureless intrascleral implantation is simple and effective and causes less post-operative hypotony.

MODIFIED SUTURELESS INTRASCLERAL FIXATION TECHNIQUE FOR SECONDARY INTRAOCULAR LENS IMPLANTATION: A Pilot Study.

BACKGROUND/PURPOSE: To demonstrate possible complications of a new intraocular lens for sutureless secondary scleral implantation and modifications of the surgical technique to optimize outcomes. METHODS: A retrospective study of 16 eyes (16 patients) who underwent a secondary intraocular lens implantation using the Carlevale intraocular lens (Soleko, Italy) with two anchor haptics for intrascleral implantation (mean follow-up 2.2 months). RESULTS: The visual acuity did not improve statistically significantly postoperatively ( P = 0.601). Seven (44%) patients suffered from postoperative hypotonia (intraocular pressure <5 mmHg) during the first three postoperative days. CONCLUSION: Owing to the early postoperative hypotony, we decided to modify the surgical technique. We present several suggestions to optimize the technique and outcome such as positioning the sclerotomies at the 2 and 8 o'clock positions, using 27 G trocars alone and suturing the frown incisions using self-resorbing sutures.

Intravitreal 5-Fluorouracil and Heparin to Prevent Proliferative Vitreoretinopathy: Results from a Randomized Clinical Trial.

PURPOSE: Proliferative vitreoretinopathy (PVR) is the major cause for surgical failure after primary rhegmatogenous retinal detachment (RRD). So far, no therapy has been proven to prevent PVR. Promising results for 5-fluorouracil (5-FU) and low-molecular weight heparin (LMWH) in high-risk eyes have been reported previously. The objective of this trial was to examine the effect of adjuvant intravitreal therapy with 5-FU and LMWH compared with placebo on incidence of PVR in high-risk patients with primary RRD. DESIGN: Randomized, double-blind, controlled, multicenter, interventional trial with 1 interim analysis. PARTICIPANTS: Patients with RRD who were considered to be at high risk for PVR were included. Risk of PVR was assessed by noninvasive aqueous flare measurement using laser flare photometry. METHODS: Patients were randomized 1:1 to verum (200 mg/ml 5-FU and 5 IU/ml dalteparin) and placebo (balanced salt solution) intravitreally applied during routine pars plana vitrectomy. MAIN OUTCOME MEASURES: Primary end point was the development of PVR grade CP (full-thickness retinal folds or subretinal strands in clock hours located posterior to equator) 1 or higher within 12 weeks after surgery. For grading, an end point committee assessed fundus photographs. Secondary end points included best-corrected visual acuity and redetachment rate. A group sequential design with 1 interim analysis was applied using the O'Brien and Fleming boundaries. Proliferative vitreoretinopathy grade CP incidence was compared using a Mantel-Haenszel test stratified by surgeon. RESULTS: A total of 325 patients in 13 German trial sites had been randomized (verum, n = 163; placebo, n = 162). In study eyes, mean laser flare was 31 ± 26 pc/ms. No significant difference was found in PVR rate. Primary analysis in the modified intention-to-treat population results were: verum 28% vs. placebo 23% (including not assessable cases as failures); odds ratio [OR], 1.25; 95% confidence interval [CI], 0.76-2.08; P = 0.77. Those in the per-protocol population were: 12% vs. 12%; OR, 1.05; 95% CI, 0.47-2.34; P = 0.47. None of the secondary end points showed any significant difference between treatment groups. During the study period, no relevant safety risks were identified. CONCLUSIONS: Rate of PVR did not differ between adjuvant therapy with 5-FU and LMWH and placebo treatment in eyes with RRD.

Persistent macular holes - what is the best strategy for revision?

PURPOSE: This study aims to analyze the success rate and functional outcome after revision surgery of persistent idiopathic full-thickness macular holes in a large patient cohort and to identify the optimal tamponade strategy and the value of new adjunctive manipulation techniques for persistent macular hole (pMH) closure. METHODS: Retrospective, comparative, non-consecutive case series of all revisional surgeries for idiopathic pMH between 2011 and 2019 at the Eye Clinic Sulzbach were identified. Of 1163 idiopathic MH surgeries, 74 eyes of 74 patients had pMH. Of those, group 1 (n = 38) had vitrectomy with tamponade alone (20% sulfur hexafluoride gas, 15% hexafluoroethane gas, silicone oil 5000, Densiron®), while group 2 (n = 36) included tamponade with adjuvant manipulation (internal limiting membrane (ILM) translocation, subretinal fluid injection, epiretinal amniotic membrane, free retina graft, or autologous blood). Main statistical outcomes were anatomic closure rate, visual acuity (VA), minimum linear diameter (MLD), and base diameter (BD). RESULTS: Overall total anatomical success rate was 81.1% and mean VA improved 3.5 lines from LogMAR 1.03 ± 0.30 to 0.68 ± 0.38 (p < .001). Preoperative MLD or BD had no effect on total anatomic success (p = 0.074, p = 0.134, respectively). When comparing the two groups, slightly better anatomic success rates were achieved in group 1 (84.2%) compared to that in group 2 (77.8%) (p = 0.68). Final VA in group 1 (LogMAR 0.67 ± 0.39) outperformed group 2 (LogMAR 0.86 ± 0.38) (p = 0.03). CONCLUSIONS: Revisional surgery for persistent idiopathic MH with tamponade alone had comparable anatomical closure but better VA outcomes, compared to tamponade with adjuvant manipulation.

NEGATIVE EFFECTS OF VITAL DYES AFTER UNEVENTFUL VITREOMACULAR SURGERY.

PURPOSE: Vital dyes have become a clinical standard during chromovitrectomy but toxicity remains an issue. We compared the clinical outcome of one supposedly toxic vital dye (AV 17 with 5% mannitol) with a standard vital dye (MBB Dual) and performed a power analysis for future comparative studies. METHODS: Retrospective analysis of 270 eyes after chromovitrectomy with internal limiting membrane peeling because of macular holes. Primary endpoint was loss in BCVA >2 lines and photoreceptor atrophy as seen on optical coherence tomography examination. RESULTS: In 173 eyes, staining of the epiretinal membrane and extracellular matrix was performed using MBB (Group A), and in 97 using AV 17-M (Group B). The mean BCVA was not significantly different after more than 3 months and also not in the early postoperative period after surgery between Group A and Group B. The number of patients suffering from a decline in BCVA of two lines and more was not significantly higher in patients of Group B. There was not a significantly higher percentage of patients with an inner segment/outer segment defect. CONCLUSION: Our rather homogeneous study showed no significant difference between both dyes. Thousand five hundred patients would need to be examined to find a significant difference in future studies.

Digital Pupillometry in Normal Subjects.

The aim of this study was to evaluate the pupil size of normal subjects at different illumination levels with a novel pupillometer. The pupil size of healthy study participants was measured with an infrared-video PupilX pupillometer (MEye Tech GmbH, Alsdorf, Germany) at five different illumination levels (0, 0.5, 4, 32, and 250 lux). Measurements were performed by the same investigator. Ninety images were executed during a measurement period of 3 seconds. The absolute linear camera resolution was approximately 20 pixels per mm. This cross-sectional study analysed 490 eyes of 245 subjects (mean age: 51.9 ± 18.3 years, range: 6-87 years). On average, pupil diameter decreased with increasing light intensities for both eyes, with a mean pupil diameter of 5.39 ± 1.04 mm at 0 lux, 5.20 ± 1.00 mm at 0.5 lux, 4.70 ± 0.97 mm at 4 lux, 3.74 ± 0.78 mm at 32 lux, and 2.84 ± 0.50 mm at 250 lux illumination. Furthermore, it was found that anisocoria increased by 0.03 mm per life decade for all illumination levels (R2 = 0.43). Anisocoria was higher under scotopic and mesopic conditions. This study provides additional information to the current knowledge concerning age- and light-related pupil size and anisocoria as a baseline for future patient studies.

Long-term results after artificial iris implantation in patients with aniridia.

BACKGROUND: The custom-made, flexible artificial iris developed by HumanOptics and Koch can reconstruct the anterior segment of patients with aniridia. The aim of this study was to evaluate the long-term clinical outcome and complication spectrum after artificial iris implantation and the role of the embedded fiber mesh in view of specific complications. METHODS: In this retrospective interventional case series, patients received an artificial iris between 2004 and 2013. Only eyes with a minimum follow-up period of 2 years were included. Indications were congenital, traumatic, or iatrogenic aniridia. The artificial iris was used either with or without embedded fiber mesh for partial or full prostheses. RESULTS: We included 34 patients (mean age 48.8 years; SD ±17.2) with a mean follow-up of 50.0 months (SD ±18.9 months). No repositioning of prostheses was necessary. In cases of keratopathy (17.6 %) visual function increased from baseline mean 1.6 logMAR (SD ±0.7) to 1.2 logMAR (SD ±0.7) after artificial iris implantation. The remaining iris tissue darkened during the follow-up in 23.5 % (83.3 % with and 10.7 % without mesh), 8.8 % developed glaucoma (50 % with and 0 % without mesh) and 14.7 % needed consecutive surgery after prostheses implantation (50 % with and 7.1 % without mesh). In three out of seven trauma cases (42.9 %) silicone oil was spilled into the anterior chamber after 2.5 years on average. CONCLUSION: The artificial iris prosthesis revealed a good clinical outcome in terms of long-term stability, cosmetic appearance, visual function, and represents a good functional iris diaphragm for compartmentalisation. Complications such as glaucoma, darkening of iris tissue, and need for consecutive anterior segment surgery are clearly associated with implants with integrated fiber mesh, but not to those without. Hence, the use of full iris prostheses without embedded fiber mesh, even in cases with remnant iris, and the use of slightly smaller implants than officially recommended may be beneficial.

Long-Term Astigmatism after Intraocular Pressure Sensor Implantation and Nonpenetrating Glaucoma Surgery - EYEMATE-SC Trial.

PURPOSE: To investigate the long-term astigmatism after combined non-penetrating glaucoma surgery (NPGS) and implantation of the first miniaturized suprachoroidal intraocular pressure (IOP) sensor EYEMATE-SC. SETTING: The study was conducted in five medical centers in two different countries. DESIGN: Retrospective multicenter clinical study. METHODS: Astigmatism of patients instrumented with the EYEMATE-SC IOP sensor was assessed over a follow-up period of three years. Refraction and corrected distance visual acuity (CDVA) were obtained preoperatively, after 6 months, 1, 2, and 3 years. A canaloplasty-operated patient cohort served as control. Astigmatism was evaluated using 3-dimensional power vector analysis involving the spherical equivalent M, and the Jackson crossed cylinder projections J0 and J45. Exclusion criteria included neovascular and angle-closure glaucoma, myopia, axial length outside 22 to 26 mm, other ocular diseases, prior glaucoma surgery, other ocular surgery within 6 months (cataract surgery within 3 months) prior to NPGS, serious generalized conditions, and other active medical head/neck implants. RESULTS: Multivariate analysis indicated no changes in astigmatism along the observation period in both the EYEMATE-SC (n = 24) and the canaloplasty (n = 24) group (P > 0.05 or nonsignificant after Bonferroni correction). Astigmatism was unchanged between the EYEMATE-SC and the canaloplasty group at all time points (P > 0.05). CDVA didn't change along the observation period of three years in each of both groups (P > 0.05). CONCLUSIONS: Despite its suprachoroidal localization, the present study indicates that the miniaturized EYEMATE-SC IOP sensor doesn't negatively affect the long-term astigmatism after combined implantation with NPGS.

Temporary iris-lens diaphragm to assist descemet membrane endothelial keratoplasty in aphakic patients.

Purpose: Presenting a simple technique using an inversely implanted contact lens to create a temporary diaphragm to assist DMEK surgery in aphakic, partially aniridic and vitrectomized eyes. Observations: The postoperative course was without pressure abnormalities and the anterior chamber remained deep. The cornea completely cleared within 3 weeks and remained clear after removal of the contact lens showing a corneal thickness of 544 µm and an intact endothelial cell pattern on endothelial cell microscopy after 3 months. Conclusion and Importance: The inversely implanted contact lens provides an easily accessible temporary diaphragm, making DMEK surgery a safer procedure even in complex eyes without an adequate posterior barrier.

Influence of the scleral indentation technique on the re-detachment rate following retinal detachment surgery.

PURPOSE: The aim of this study was to determine whether the choice of scleral indentation technique during primary rhegmatogenous retinal detachment surgery has an influence on the risk of re-detachment. METHODS: We included retrospectively 154 eyes with a primary rhegmatogenous retinal detachment treated in the Eye Clinic Sulzbach/Saar Germany, who were operated on by two experienced surgeons using the same basic surgical setup. Surgeon A performed an external 360° indentation, shaved the vitreous base using the light pipe cap, and used the operating microscope (opm) for direct visualization. Surgeon B performed an external 360° indentation, shaved the vitreous base using a simple indentor, and used an endoillumination (light pipe) with the opm and a handheld widefield lens for direct visualization. RESULTS: Comparing both indentation procedures, 15.66% (13/83) of patients operated on by surgeon A and 9.86% (7/71) of patients operated on by surgeon B had a retinal re-detachment within a follow-up period of 6 months (adj. p = 0.64, two-proportion Z-test). CONCLUSION: The rate of retinal re-detachment could be influenced by the indentation technique at the end of surgery favoring external indentation and internal visualization with an endoilluminator (chandelier light). We attribute this to the better visualization of the vitreous base facilitated by endoillumination. However, many variables play a role in the development of retinal re-detachment, requiring further studies with a larger number of patients.

[Microbiological and infectious disease aspects of postoperative endophthalmitis]. / Mikrobiologische und infektiologische Aspekte der postoperativen Endophthalmitis.

Infectious postoperative or postinjection endophthalmitis is a medical emergency. Gram-positive bacteria, such as staphylococci, streptococci and enterococci are the predominant causative agents, whereas Gram-negative pathogens (e.g. Klebsiella pneumoniae, Pseudomonas aeruginosa) and fungi account for a minority of cases. Using modern diagnostic tools, which include polymerase chain reaction-based assays in addition to Gram staining and agar culturing, a causal agent can be detected in the majority of cases, which enables a targeted treatment and estimation of the prognosis. Endophthalmitis is treated with intravitreal and often also intravenous administration of antibiotics, with the combination of vancomycin and ceftazidime being most commonly used. This article presents and summarizes recent developments in the microbiological etiology and diagnostics of endophthalmitis as well as treatment options and perioperative antibiotic prophylaxis in the light of emerging resistance patterns.

Significant differences between specular microscopy and corneal bank endothelial cell counts - a pilot study.

BACKGROUND: It was shown recently that endothelial cell count performed by cornea banks overestimates the real number of endothelial cells. The aim of this study was to investigate the internal quality of preclinical ECD in human donor corneas using two widely used methods for endothelial cell counting, transmitted light microscopy used in organ culture tissue bank and clinically used specular microscopy. METHODS: Twenty human donor corneas that could not be transplanted were included in this analysis. Differences in evaluating endothelial cell density (ECD) and hexagonal endothelial cell ratio (HEX) between clinical specular microscopy (CSM) and corneal bank transmitted light microscope (CBLM) were evaluated as well as differences between automated and manual cell counts. RESULTS: Automated CBLM showed a higher ECD of 31.85% compared to automated CSM, while manual CBLM counting is 10.51% higher compared to manual CSM (p < 0.01). Further, higher average ECD values result in a higher difference between CSM and CBLM measurements. The manual CBLM ECDs were significantly higher compared to automated derived ECD from CSM (p < 0.01). However, no systematic bias can be detected when comparing the differences of the measurements with the average ECD measurements of both methods. CONCLUSION: This preclinical pilot study confirmed a significant higher ECD using transmitted light microscopy in organ culture compared to clinical specular microscopy. This indicates that the early rapid decrease of EC universally observed after surgery might be partly artefactual.

An Unusual Case of DMEK Graft Loss into the Vitreous and Its Successful Retrieval and Survival.

PURPOSE: The aim of this article is to report an unusual case of postoperative graft loss into the vitreous cavity after Descemet membrane endothelial keratoplasty (DMEK) in a patient with an unstable iris-lens diaphragm (scleral-fixated intraocular lens [sf-IOL]) and its successful retrieval with a favourable outcome. METHODS: This is a retrospective case report. RESULTS: DMEK procedure was performed in a vitrectomized eye of an 80-year-old woman with pre-existing sf-IOL due to pseudophakic bullous keratopathy. In the setting of an inadvertently created oversized Ando iridectomy and unstable iris-lens diaphragm due to sf-IOL, repeated loss of an anterior chamber gas tamponade occurred. At the 3rd postoperative day, the patient noticed a change in visual perception, and we could detect a loss of the graft into the vitreous via B-scan ultrasound. A 23-G vitrectomy was performed promptly to recover the graft using a bimanual hand-over-hand technique. Six months after DMEK, the patient had a clear cornea without dehiscences with a central corneal thickness of 533 µm and endothelial cell count of 1,219 cells/mm2. CONCLUSIONS: This case demonstrates the possibility of graft recovery from the vitreous after DMEK and subsequent corneal clearing despite unstable iris-lens diaphragm and vitrectomized eye.