How Implementing a Quality Management System at the LIONS Eye Bank Saar-Lor-Lux, Trier/Western Palatinate from 2006 to 2016 Impacted the Rate and Reasons for Discarding Human Organ-Cultured Corneas. / Einfluss der Einführung des Qualitätsmanagementsystems auf die Verwerfungsrate und -gründe von menschlichem organkultivierten Spendergewebe der LIONS-Hornhautbank Saar-Lor-Lux, Trier/Westpfalz von 2006 bis 2016.

BACKGROUND: The aim of this study was to explore how the implementation of the quality management system (QM; according to DIN EN ISO 9001 : 2008) at the LIONS Eye Bank impacted the rate and reasons for discarding donated corneas. The QM system was introduced in November 2010. MATERIAL AND METHODS: The rate of and reasons for discarding cornea tissues at the LIONS Eye Bank Saar-Lor-Lux,Trier/Western Palatinate from 2006 to 2016 were analysed retrospectively. 4,140 corneas from 2,084 donors were analysed. 1,640 corneas were processed before the QM system had been introduced and 2,500 corneas thereafter. Main reasons for discarding cornea tissues were endothelial quality, contamination of the medium and a positive conjunctival swab. The data was extracted from clinical files and data filing systems, entered into a Microsoft Access database and analysed statistically with SPSS. OUTCOME: Following the implementation of a QM system, the discard rate decreased significantly from 50.1% to 39.7% (p < 0.0001). Prior to the implementation of the QM system, 493 (30.1%) cornea tissues had been discarded due to endothelial quality, while this figure improved significantly to 604 (24.2%) after the QM system had been implemented (p < 0.0001). Contamination was the reason for discarding tissue in 173 (10.5%) cases before implementation of the QM system, and in 124 (5.0%) cases thereafter (p < 0.0001). Positive conjunctival swab was the reason for discarding tissue in 10 (0.6%) cases before the QM system had been implemented, and in 53 (2.1%) cases thereafter (p < 0.0001). CONCLUSION: Implementation of a QM system significantly reduced the rate of discarded donor tissue in the LIONS Eye Bank. Better management of contamination as a reason for discarding cornea tissues can be attributed to improved standards, protocols and training that are part of this QM system.

[Inverted In Vitro Confocal Microscopy in Mycotic Keratitis with Corneal Endothelial Epithelial Decompensation]. / Invertierte in vitro konfokale Mikroskopie bei mykotischer Keratitis mit Hornhaut-Endothel-Epithel-Dekompensation.

The sensitivity of confocal microscopy ranges between 80 and 90% and thus lies above the sensitivity of pathogen identification by microbiological culture. Typically, in vivo confocal microscopy enables us to diagnose mycotic keratitis non-invasively and atraumatically on the day of admission. Herein we present a patient with an ulcer on a corneal graft, pronounced corneal endothelial epithelial decompensation and a retrocorneal fungal adhesion after repeat-keratoplasty 5 years ago - due to chronic graft rejection after keratoplasty for Fuchs endothelial corneal dystrophy. Clinically there was a suspicion of fungal keratitis. Conventional en face confocal microscopy, however, did not detect hyphae. Due to the pronounced corneal endothelial epithelial decompensation, we were able to detect the fungal hyphae only after repeat penetrating keratoplasty by means of inverted in vitro confocal microscopy on the day of surgery. Histology confirmed the diagnosis of keratomycosis.

[Growth Factor Concentration in Keratocyte Supernatant after Incubation with Human Serum In Vitro]. / Wachstumsfaktorenkonzentration im Kulturüberstand von Keratozyten mit humanem Serum in vitro.

PURPOSE: Application of serum eye drops is an alternative treatment option for therapy-resistant corneal epithelial defects. In case of persisting epithelial defects, cytokines, which are secreted from stromal keratocytes, may play a role in epithelial wound healing. Our aim was to analyze fibroblast growth factor basic (FGFb), hepatocyte growth factor (HGF), keratinocyte growth factor (KGF) and transforming growth factor ß1 (TGF-ß1) concentration in the supernatant of keratocytes, after incubation with human serum (HS). MATERIALS AND METHODS: Serum eye drops of 10 patients were prepared using the standards of the LIONS Eye Bank Saar-Lor-Lux, Trier/Westpfalz, and were stored at - 80 °C. Primary human keratocytes were isolated from human corneoscleral rings using collagenase A (1 mg/ml) (n = 1) and were cultured in DMEM/Ham's culture medium with 10% fetal bovine serum (FBS). Thereafter, keratocyte cultures were incubated in 15 or 30% HS (in DMEM/F14 without FBS) and FGFb, HGF, KGF and TGF-ß1 concentration was determined with an enzyme-linked immunoabsorbent assay (ELISA) from the supernatant of the culture after 24 hours. We used 15 or 30% HS without keratocytes (under the same storage conditions) as controls. RESULTS: HGF concentration was, for both HS concentrations, significantly higher in the supernatant of keratocytes, than in HS controls (without keratocytes) following 24 hours (p < 0.01). FGFb concentration was significantly increased in 30% HS with keratocytes compared to 30% HS without keratocytes after 24 hours (p < 0.01). TGF-ß1 and KGF concentrations remained unchanged through keratocytes. CONCLUSION: HGF and FGFb concentrations increase in the supernatant of keratocytes, 24 hours after incubation with human serum. These concentration changes may play a role in wound healing of epithelial defects.

Growth Factor and Interleukin Concentrations in Amniotic Membrane-Conditioned Medium.

PURPOSE: Application of amniotic membrane-conditioned medium (AMM) eye drops is a potential treatment alternative for therapy-resistant corneal epithelial defects. Our purpose was to determine the concentration of growth factors epidermal growth factor (EGF), nerve growth factor (NGF), vascular endothelial growth factor (VEGF), transforming growth factor ß1 (TGFß1), fibroblast growth factor basic (FGFb), and interleukins, IL-1ß, IL-6, IL-8, in AMM following different preparation methods. METHODS: Amniotic membranes of 10 placentas were prepared and thereafter stored at -80°C using the standard method of our LIONS Cornea Bank. Following defreezing, amniotic membrane pieces with a standard size were inserted in a 12-well plate either complete or cut in small pieces, and 2000 µl DMEM culture medium was added. EGF, NGF, VEGF, TGFß1, FGFb, IL-1ß, IL-6, and IL-8 concentrations in the culture medium were determined following 8, 48, and 96 hours, and 1, 2, 3, and 4 weeks of incubation using enzyme-linked immunosorbent assay (ELISA). RESULTS: Concentrations of NGF, VEGF, TGFß1, and IL-1ß were beyond the detection limit at all time points. EGF concentrations were between 0.14 and 0.80 ng/g tissue, FGFb between 0.48 and 2.89 ng/g tissue, IL-6 between 0.11 and 1.41 ng/g tissue, and IL-8 between 0.32 and 6.18 ng/g tissue. A significant difference between both preparation methods was shown for the IL-6 concentration after 8 and 48 hours (p < 0.001; p = 0.01) and in IL-8 concentration after 8 and 96 hours and after 3 weeks (p = 0.02; p = 0.002; p = 0.027). CONCLUSION: AMM containing EGF and FGFb, and IL-6 and IL-8 AMM is a potential nonsurgical treatment alternative of therapy-resistant corneal epithelial defects. However, the most effective preparation method and the optimal harvesting time point are yet to be determined.

Analysis of the changes in keratoplasty indications and preferred techniques.

BACKGROUND: Recently, novel techniques introduced to the field of corneal surgery, e.g. Descemet membrane endothelial keratoplasty (DMEK) and corneal crosslinking, extended the therapeutic options. Additionally contact lens fitting has developed new alternatives. We herein investigated, whether these techniques have affected volume and spectrum of indications of keratoplasties in both a center more specialized in treating Fuchs' dystrophy (center 1) and a second center that is more specialized in treating keratoconus (center 2). METHODS: We retrospectively reviewed the waiting lists for indication, transplantation technique and the patients' travel distances to the hospital at both centers. RESULTS: We reviewed a total of 3778 procedures. Fuchs' dystrophy increased at center 1 from 17% (42) to 44% (150) and from 13% (27) to 23% (62) at center 2. In center 1, DMEK increased from zero percent in 2010 to 51% in 2013. In center 2, DMEK was not performed until 2013. The percentage of patients with keratoconus slightly decreased from 15% (36) in 2009 vs. 12% (40) in 2013 in center 1. The respective percentages in center 2 were 28% (57) and 19% (51). In both centers, the patients' travel distances increased. CONCLUSIONS: The results from center 1 suggest that DMEK might increase the total number of keratoplasties. The increase in travel distance suggests that this cannot be fully attributed to recruiting the less advanced patients from the hospital proximity. The increase is rather due to more referrals from other regions. The decrease of keratoconus patients in both centers is surprising and may be attributed to optimized contact lens fitting or even to the effect corneal crosslinking procedure.