Selective Laser Trabeculoplasty Versus MIGS: Forgotten Art or First-Step Procedure in Selected Patients with Open-Angle Glaucoma.

INTRODUCTION: To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice. METHODS: A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95-105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome®, NeoMedix, Tustin, USA), and 130 patients received iStent inject® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan-Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy). RESULTS: In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p < 0.001) 3 years postoperatively; in Trabectome® IOP decreased by 31.4% from 20.5 ± 1.3 to 13.8 ± 2.0 mmHg (p < 0.001) and in iStent inject® by 29.9% from 19.5 ± 2.0 to 13.8 ± 2.7 mmHg (p < 0.001). Trabectome® and iStent inject® could not demonstrate a significant reduction in glaucoma therapy (Trabectome® p = 0.138, iStent inject® p = 0.612); a significant drop was noted in SLT (2.2 ± 1.2 to 1.7 ± 1.2, p = 0.046). SLT and MIGS achieved good to moderate survival rates using criterion A (93.3% SLT, 79.7% Trabectome®, 77.6% iStent inject®) and criterion B (74.5% SLT, 48.0% Trabectome®, 56.2% iStent inject®). As expected, low survival rates were obtained with non-filtering procedures: criterion C 11.1% in SLT, 6.5% in Trabectome®, 7.0% in iStent inject® and criterion D 3.0% in SLT, 4.3% in Trabectome®, 3.7% in iStent inject® in 3-year follow-up. CONCLUSION: The SLT is a low-complication and effective method for reducing pressure in mild to moderate POAG. SLT is suitable as an initial procedure when setting up a step scheme; MIGS is the treatment of choice as a follow-up for mild to moderate forms of glaucoma and accepted topical therapy. Ethic approval had been given by the Ethikkommission Charité - Universitätsmedizin Berlin, EA4/047/20-retrospectively registered.

Influence of Selective Laser Trabeculoplasty (SLT) on the iStent inject® outcomes.

BACKGROUND: To evaluate the influence of Selective Laser Trabeculoplasty (SLT) on iStent inject® outcomes in open-angle glaucoma (OAG). METHODS: In this retrospective comparative cohort outcome study, 66 patients who were treated with two iStent inject® devices were included. Patients were divided into two subgroups consisting of patients without SLT treatment prior to surgery and patients who had been treated previously with 360° SLT but without sufficient response. Outcome measures included intraocular pressure (IOP) and number of antiglaucoma medications after 6 weeks with three, six, 12, and 24 month follow-ups. RESULTS: Mean preoperative IOP decreased from 20.4 ± 5.3 mmHg to 14.8 ± 3.0 mmHg for patients without SLT treatment prior to surgery (p = 0.001) and from 19.2 ± 4.5 mmHg to 14.0 ± 1.6 mmHg for patients with insufficient response to 360° SLT treatment (p = 0.027) at 12 months after iStent inject® implantation. No significant difference was found between the two groups (p >  0.05). The number of antiglaucoma medications did not change in both groups (p >  0.05) and showed no significant difference between the two groups (p >  0.05). CONCLUSION: Prior SLT treatment seems to have no negative influence on the IOP lowering-effect of iStent inject® implantation in patients with OAG. It is therefore an appropriate incremental procedure with no exclusion criterion for an iStent inject® implantation.

Secondary glaucoma in uveitis: comparison of the optic nerve head morphology among a nonmydriatic fundus camera, HRT, and SD-OCT.

PURPOSE: To assess the correlation between the disc damage likelihood scale (DDLS) objectively measured by a nonmydriatic fundus camera, confocal laser scanning ophthalmoscopy (HRT3), and spectral-domain optical coherence tomography (SD-OCT) in uveitic glaucoma. METHODS: A total of 59 patients with uveitic glaucoma (21 female, 38 male; mean age 56.8 ± 18.7 years) were included in this prospective cross-sectional study. All patients were measured by the Kowa Nonmyd WX 3D camera (2D/3D nonmydriatic retinal camera, Kowa Company), the HRT3 (Heidelberg Engineering), and SD-OCT (Carl Zeiss Meditec) by one examiner on the same day. All 3 devices graded the optic disc topography. Statistical data were calculated using SPSS (v 20.0, SPSS). RESULTS: In patients showing borderline results in one of the modalities (n = 45), the DDLS showed a significant correlation with the retinal nerve fiber layer (p = 0.016), while Moorfields regression analysis (p = 0.550) and glaucoma probability score (p = 0.629) did not correlate significantly. The highest predictive power was demonstrated by the objectively measured DDLS (area under the receiver operating characteristic curve 0.445-0.588), compared to R. Burk (0.149-0.375) and F.S. Mikelberg (0.033-0.450) coefficients considering HRT and optical coherence tomography. CONCLUSIONS: In this study cohort, the objective DDLS showed the highest predictive power and thus is a reliable tool in diagnosing uveitic glaucoma. These 3 devices cannot be used interchangeably. As diagnosis and follow-ups are challenging in uveitis patients, the stereophotography is additionally a valuable tool.

Modified goniotomy as an alternative to trabectome in primary open angle glaucoma and pseudoexfoliation glaucoma: 1 year results.

OBJECTIVE: To assess the outcome of modified goniotomy and trabeculotomy ab interno (Trabectome) surgery in adult primary open-angle glaucoma (POAG) and pseudoexfoliation (PEX) glaucoma. DESIGN: Retrospective cohort outcome study. PARTICIPANTS: Two hundred and thirty-six eyes of 236 patients. METHODS: This cohort outcome study included 68 POAG (mean age: 65.7 ± 16.0 years) and 22 PEX glaucoma patients (mean age: 78.3 ± 7.9 years) in the modified goniotomy cohort and 119 POAG (mean age: 73.9 ± 9.6 years) and 27 PEX glaucoma patients (mean age: 75.2 ± 8.0 years) in the Trabectome cohort. Modified goniotomy is defined as combined ab interno cyclodialysis and goniotomy. The patients were followed up for 12 months, and we analysed the data using SPSS v19.0. RESULTS: In POAG, the intraocular pressure (IOP) was significantly reduced by 4.6 mm Hg in the Trabectome cohort (p < 0.001) and by 5.8 mm Hg (p < 0.001) in the goniotomy group at 1-year follow-up. In PEX glaucoma, the mean IOP was reduced by 9.7 mm Hg (p = 0.002) in the Trabectome surgery and by 6.7 mm Hg (p = 0.004) in the goniotomy cohort 1 year later. Comparing both surgery techniques in POAG, no significant correlation was found in terms of IOP at any of the follow-up visits (IOP at 1 year, p = 0.553). In PEX glaucoma, the IOP, visual acuity, and number of glaucoma medications did not differ significantly between the 2 surgery techniques 1 year later (IOP: p = 0.300; VA: p = 0.391; therapy: p = 0.908). CONCLUSION: Modified goniotomy and Trabectome surgery are reliable and effective tools for the management of moderate POAG and PEX glaucoma. There was no significant difference in IOP between the 2 procedures over a follow-up period of 1 year.

Impact of the Femtosecond Laser in Line with the Femtosecond Laser-Assisted Cataract Surgery (FLACS) on the Anterior Chamber Characteristics in Comparison to the Manual Phacoemulsification.

PURPOSE: To assess the alterations of the anterior chamber conditions including laser flare photometry after femtosecond laser-assisted cataract surgery (FLACS) compared to the manual phacoemulsification. METHODS: Data of n=70 FLACS (mean age 67.2 ± 8.9 years) and n=40 manual phacoemulsification (mean age 69.5 ± 9.6 years) were analyzed. The procedures were performed by LenSx Alcon, USA, and Alcon Infiniti Vision System, USA. The following parameters were recorded: laser flare photometry (Kowa FM 700, Japan), anterior chamber (AC) depth, AC volume, AC angle (Pentacam, Oculus Inc., Germany), lens density, pupil diameter, endothelial cell count and pachymetry. The analysis was performed preoperatively, immediately after femtosecond laser procedure and one day postoperatively. RESULTS: Between FLACS and the phaco control group, there was a significant difference in the AC depth (p=0.023, 3.77 mm vs. 4.05 mm) one day postoperatively. The AC angle (p=0.016) showed a significant difference immediately after the femto laser treatment. The central and thinnest pachymetry and endothelial cell count did not show a significant difference between the two study cohorts (p=0.165, p=0.291, p=0.979). The phaco cohort (n=40) demonstrated a non-statistically significant difference in the flare photometry of 15.80 photons/ms one postoperative day compared to the FLACS group 26.62 photons/ms (p=0.322). CONCLUSION: In this study population, no evidence for an additive damage caused by the use of the femtosecond laser was demonstrated. Furthermore, no increase in the central and thinnest corneal thickness and no increased endothelial cell loss was demonstrated by the laser energy.

Is there a change in the quality of life comparing the micro-invasive glaucoma surgery (MIGS) and the filtration technique trabeculectomy in glaucoma patients?

PURPOSE: This study was conducted to assess the impact on the Quality of Life (QOL) of micro-invasive glaucoma surgery (MIGS: iStent, Trabectome) and a penetrating technique such as Trabeculectomy (TE). METHODS: This study evaluated 88 eyes of 88 open angle glaucoma patients undergoing glaucoma surgery: 43 (mean age 72.8 ± 8.8y, female 59.5 %, male 40.5 %) Trabectome (NeoMedix, Inc., Tustin, CA, USA), 20 (mean age 68.6 ± 16.4y, female 60 %, male 40 %) iStent (Glaucos Corporation, Laguna Hills, CA, USA), and 25 TE patients (mean age 74.2 ± 9.1y female 58.3 %, male 41.7 %). The National Eye Institute-Visual Functioning Questionnaire (VFQ-25) survey was used to assess the QOL at 6 months post surgery. The following 12 QOL parameters were evaluated: general health, ocular pain, general vision, near and distance activities, mental health, social functioning, role difficulties, dependency, driving, color vision, and peripheral vision. Intraocular pressure (IOP), number of topical medications, and visual acuity (VA) were examined preoperatively, 1 day, 6 weeks, 3 months, and 6 months post surgery. Statistical data were calculated using SPSS (v20.0, SPSS, Inc.). RESULTS: There was no significant difference between TE and MIGS in the quality of life 6 months postoperatively. IOP was significantly lower in TE compared to MIGS at 6 weeks and 3 months postoperatively (p = 0.046 and p = 0.046). Number of medications was significantly decreased in TE compared to MIGS (p < 0.001). A significant difference in VA between TE and MIGS could be assessed at day 1 post-op (p = 0.011). CONCLUSION: In this study cohort, the QOL can be maintained by all three surgical techniques. Patients, however, need lower numbers of topical medication in TE, which would impact QOL even though it is not included in the NEI-VFQ-25. The decision of the most appropriate surgical technique should be made by including single QOL categories, IOP and glaucoma medication outcome.

Intraocular Pressure Measurements After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: Intraocular pressure (IOP) elevation occurs regularly after Descemet membrane endothelial keratoplasty (DMEK). This study evaluated the effect of central corneal thickness (CCT) on the IOP after DMEK. PATIENTS AND METHODS: This prospective study recorded the IOP of 46 eyes from 46 patients preoperatively, and then 1 and 3 months after DMEK. IOP measurement was performed by noncontact pneumatic tonometry (NCT), iCare, Goldmann applanation tonometry (GAT), and dynamic contour tonometry (DCT). CCT was analyzed by anterior-segment optical coherence tomography. RESULTS: Mean IOPs as measured by NCT, iCare, GAT, and DCT, respectively, were 14.3, 11.6, 12.7, and 16.0 mm Hg preoperatively; 13.1, 12.6, 12.7, and 16.0 mm Hg after 1 month; and 14.7, 14.5, 12.9, and 17.7 mm Hg after 3 months. There was a correlation of IOP measurements between GAT and NCT (P=0.119), GAT and iCare (P=0.892), and iCare and NCT (P=0.081) after 1 month and between iCare and NCT (P=0.702) after 3 months. Although GAT recorded approximately stable IOP values, NCT, iCare, and DCT tended to measure a higher IOP postoperatively than preoperatively. Preoperatively, correlations between IOP and CCT were not statistically significant for any measurement technique. After 3 months, the IOP measured by NCT and iCare correlated significantly with CCT (P=0.003, 0.041). CONCLUSIONS: Correlation between the different measurement techniques was poor and showed a broad distribution of limits of agreement. Therefore, a change between the 4 techniques during follow-up is not recommended. Nevertheless, all techniques detected the IOP elevation during follow-up, requiring therapy.

Contralateral eye comparison study in MICS & MIGS: Trabectome® vs. iStent inject®.

PURPOSE: To compare the safety and efficacy profile after combined micro-incision cataract surgery (MICS) and micro-invasive glaucoma surgery (MIGS) with the ab interno trabeculectomy (Trabectome®) in one eye versus two iStent® inject devices in the contralateral eye in patients with open-angle glaucoma (OAG) and cataract. METHODS: This retrospective, intraindividual eye comparison study included 27 patients (54 eyes) who were treated with combined MICS and ab interno trabeculectomy (group I, Trabectome®) in one eye and two iStent® inject devices (group II, GTS 400) in the fellow eye. Primary outcome measures included intraocular pressure (IOP) and glaucoma medication after 6 weeks, 3, 6, and 12 months follow-up. Secondary outcome measures were number of postoperative interventions, complications, and best-corrected visual acuity (BCVA). RESULTS: Mean preoperative IOP decreased from 22.3 ± 3.7 mmHg in group I and 21.3 ± 4.1 mmHg in group II to 15.6 ± 3.6 mmHg for Trabectome (p < 0.001) and 14.0 ± 2.3 mmHg for iStent inject (p < 0.001) at 12 months after surgery without a significant difference between the two groups (p > 0.05). No vision-threatening complications such as choroidal effusion, choroidal hemorrhage, or infection occurred. In each group trabeculectomy had to be performed in two eyes due to insufficient IOP lowering effect. CONCLUSIONS: Ab interno trabeculectomy and iStent® inject were both effective in lowering IOP with a favourable and comparable safety profile in an intraindividual comparative study over a 12-months follow-up in OAG. However, longer follow-up of these patients will be necessary to determine long-term outcomes and to evaluate significant differences.

Rate and Localization of Graft Detachment in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To investigate the rate and localization of graft detachment after Descemet membrane endothelial keratoplasty. METHODS: Sixty-six consecutive cases operated between June and August 2014 at the Charité-Universitätsmedizin Berlin were examined prospectively 1 week postoperatively. A single masked observer analyzed the rate and localization of graft detachment using optical coherence tomography (OCT), and the rebubbling rate was measured. Localization of graft detachment was correlated to the incision approach. Preoperative data were correlated to the rate of graft detachment and rebubbling. RESULTS: Graft detachment occurred in more than 2 clock hours and with postoperative corneal edema in 33.3% and required rebubbling. In 33.3%, graft detachment occurred in more than 2 clock hours and with postoperative corneal edema and required rebubbling. The mean graft detachment rate was 8.3% per clock hour. A significantly higher graft detachment rate was noted in the inferior clock hours (21.1%, P < 0.0001, 16.7%, P = 0.003). Only higher age of the patient correlated to a higher rate of graft detachment (P = 0.022). No correlation was found between localization of graft detachment and the incision approach (P = 0.615). CONCLUSIONS: The graft detachment rate is high after Descemet membrane endothelial keratoplasty, but detachment is usually peripheral, partial and mainly inferior and involves only a few clock hours. Only higher age of the patient is strongly associated with a higher rate of graft detachment. The incision approach is not significantly correlated with the localization of graft detachment. Therefore, the postoperative supine position of the patient seems to be of major importance.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02020044.

Significance of the disc damage likelihood scale objectively measured by a non-mydriatic fundus camera in preperimetric glaucoma.

PURPOSE: To assess the correlation between the disc damage likelihood scale (DDLS) objectively measured by a non-mydriatic fundus camera, Heidelberg Retina Tomograph 3, and optic coherence tomography in preperimetric glaucoma. METHODS: One-hundred-twenty-five patients with preperimetric primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (n=30) were included (mean age 58.9±15.9 years). All three devices graded the optic disc topography: Diagnosis 1 was defined as "outside normal limits", while Diagnosis 2 as "borderline or outside normal limits". RESULTS: For Diagnosis 1, a significant correlation was shown between DDLS and Moorfields regression analysis (P=0.022), and for Diagnosis 2 with glaucoma probability score analysis (P=0.024), in POAG. In pseudoexfoliation glaucoma, DDLS did not correlate significantly with Heidelberg Retina Tomograph 3 and optic coherence tomography. Regarding the area under the curve the highest predictive power was demonstrated by the objective DDLS (0.513-0.824) compared to Burk (0.239-0.343) and Mikelberg (0.093-0.270) coefficients. CONCLUSIONS: The DDLS showed a significant correlation to the Moorfields regression analysis in preperimetric POAG. The objective DDLS showed the highest predictive power and thus is an additive tool in diagnosing preperimetric glaucoma.

iStent inject in phakic open angle glaucoma.

BACKGROUND: The effectiveness and complication profile of the iStent inject implantation among different open angle glaucoma subgroups were analyzed. METHODS: In this retrospective cohort outcome study, 35 consecutive patients suffering from glaucoma (primary open angle glaucoma (POAG) N = 17, pseudoexfoliation glaucoma (PEX) N = 15, and pigmentary glaucoma (PG) N = 3) were treated with the iStent inject. The intraocular pressure (IOP) and the number of antiglaucoma medications before and after surgery were evaluated. RESULTS: In POAG, the mean IOP at 6 months measured 14.19 ± 1.38 mmHg with an average decrease of 33 % from preoperative IOP (p < 0.001), and 15.33 ± 1.07 mmHg with an average decrease of 35 % in PEX (p < 0.001), respectively. The number of antiglaucoma medications significantly decreased from 2.19 ± 0.91 to 0.88 ± 0.62 in POAG (p < 0.001) and from 2.33 ± 1.23 to 1.04 ± 0.30 in PEX (p < 0.001) after 6 months. In PG, IOP before surgery was 28.31 ± 3.21 mmHg and the number of antiglaucoma medications was 3.66 ± 0.57. One day after surgery, IOP decreased significantly to 12.33 mmHg ± 4.93 (p < 0.001). Within four weeks after surgery, IOP was raised above 30 mmHg in every patient. To exclude a steroid response, topical steroids were stopped, but IOP did not decrease. To exclude blockage, Nd:YAG - laser treatment of the visible opening of the iStents was performed. Since the IOP stayed high and escalation of antiglaucoma medication was insufficient to control IOP, trabeculectomy was performed. CONCLUSIONS: In conclusion, implantation of the iStent inject has the ability to lower the postoperative IOP significantly in POAG and PEX after a short follow-up of 6 months with a favorable risk profile. However, limitation of this surgical procedure in phakic PG may exist and need to be investigated in further studies.

Influence of the difficulty of graft unfolding and attachment on the outcome in Descemet membrane endothelial keratoplasty.

PURPOSE: Descemet membrane endothelial keratoplasty (DMEK) is a standard procedure in patients with endothelial corneal disorders. We investigated the difficulty of unfolding and attaching the graft lamella and its correlation to characteristics of the graft lamella donor, preoperative patient characteristics, and the postoperative outcome. METHODS: After preparation of the graft lamella, we prospectively graded the unfolding of the graft lamella in 169 consecutive DMEK procedures between September 2012 and August 2013 at the Charité-Universitätsmedizin Berlin with four different grades. Various donor characteristics and preoperative patient characteristics were analyzed and correlated to the grading. Additionally, visual acuity, corneal thickness and endothelial cell density were measured and correlated. RESULTS: Donor characteristics (age [range, 49 - 79 years], gender, endothelial cell density, total storage time, storage de-swelling time, postmortem time) did not correlate to the grading. Preoperative visual acuity significantly influenced the grade of unfolding and attaching of the graft lamella (p = 0.023), while all other preoperative parameters (age, gender, indication for DMEK, preoperative endothelial cell density and preoperative central corneal thickness) showed no correlation. Visual acuity improved significantly after surgery (p < 0.001, preoperative 0.73 ± 0.43 LogMAR versus 0.31 ±0.28 LogMAR after one month, 0.25 ± 0.29 LogMAR after three months, and 0.21 ± 0.25 LogMAR after six months). Visual acuity did not differ significantly between the grading groups at any time point postoperatively. After 6 months, the mean loss rate of endothelial cell density was 24.7 %. Grading group IV developed significantly higher endothelial loss after one month, after three months and after six months compared to the other groups (p = 0.039, p = 0.008, p = 0.048). Graft detachment requiring an additional intracameral air injection to fix the graft detachment (re-bubbling) occurred in 61 eyes (38.1 %). In eyes graded IV, more re-bubblings were necessary than in all other groups (grade I: 37.0 %; grade II: 44.7 %; grade III: 43.8 %; grade IV: 50.0 %; p = 0.128; df = 3; χ (2) = 5.676). CONCLUSION: There is no correlation between corneal donor tissue characteristics and the degree of difficulty of unfolding using graft lamella older than 49 years. Therefore, it is not possible to select grafts best suited for DMEK surgery on the basis of donor characteristics when the donor age is above 50 years. Preoperative visual acuity influences the grade of difficulty. The rate of graft detachments and endothelial cell loss increases significantly with a more difficult graft unfolding. The proposed grading system may therefore be relevant for postoperative management.

Anterior segment analysis and intraocular pressure elevation after penetrating keratoplasty and posterior lamellar endothelial keratoplasty.

BACKGROUND: Peripheral anterior synechiae (PAS) is a common problem after penetrating keratoplasty (PK) and leads to intraocular pressure (IOP) elevation. This study examines the risk factors for IOP elevation and post-keratoplasty glaucoma. METHODS: A retrospective analysis was performed of 47 eyes following PK and of 65 eyes following Descemet's stripping endothelial keratoplasty (DSEK) between 2009 and 2011. The assessment included preoperative history of corneal disease and glaucoma, response to treatment, IOP, and visual acuity. Irido-trabecular contacts (ITC), the angle opening distance (AOD 500) and the anterior chamber angle (ACA 500) were calculated. RESULTS: The incidences of IOP elevation and post-keratoplasty glaucoma were 27-36% and 10-29%, respectively. The incidence did not differ significantly between both procedures. Pre-existing glaucoma increased the risk for developing IOP elevation and post-DSEK glaucoma. Eyes with bullous keratopathy (BK) developed significantly more IOP elevation (p = 0.01, d.f. = 1, χ(2) = 6.11) and post-keratoplasty glaucoma (p = 0.01, d.f. = 1, χ(2) = 6.22) than eyes with Fuchs' endothelial dystrophy. Eyes with ITC developed post-keratoplasty glaucoma significantly more often than eyes without ITC (p = 0.01, d.f. = 1, χ(2) = 6.63). CONCLUSION: IOP elevation and post-keratoplasty glaucoma showed a high incidence. Risk factors like pre-existing glaucoma, BK and PAS elevated the rate of IOP elevation and post-keratoplasty glaucoma for both procedures.

Thermography: a new option to monitor filtering bleb function?

PURPOSE: To evaluate the filtering bleb function after trabeculectomy using a new ocular surface thermography device. METHODS: Thirty-five eyes of 35 patients after trabeculectomy were included in this prospective study. The filtering bleb function was tested with a new ocular surface-oriented, infrared radiation thermographic device in a noncontact manner (TG 1000). The eyes were classified into poorly controlled and well-controlled intraocular pressure (IOP) groups according to the patients' postoperative IOP. According to Kawasaki and colleagues, the mean temperature decrease in the filtering bleb (TDB) for evaluating bleb function was used, where TDB=(mean temperature of the temporal and nasal bulbar conjunctiva)-(mean temperature of the filtering bleb). Furthermore, the filtering bleb was evaluated during 10 seconds of eye opening and a new parameter was introduced, the TB10sec. TDB and TB10sec were analyzed statistically. RESULTS: The TDB was 0.911°C (±0.467) and the TB10sec was -1.027°C (±0.312) in the well-controlled IOP group. The TDB was 0.599°C (±0.499), and the TB10sec was -0.623°C (±0.265) in the poorly controlled IOP group, respectively. The difference in TDB (P=0.045), as well as that of TB10sec (P<0.001), between the well-controlled and poorly controlled IOP groups was significant. CONCLUSIONS: Temperature decrease in the filtering bleb provides information about its function. Because of the easy handling and reproducible measurements, thermography using Tomey TG 1000 may be a useful tool in the evaluation of filtering bleb function.

Superior versus temporal approach in descemet membrane endothelial keratoplasty.

PURPOSE: To compare superior vs temporal approach in patients who underwent Descemet membrane endothelial keratoplasty (DMEK). DESIGN: Monocentric, prospective nonmasked study. METHODS: A prospective analysis of 53 DMEKs between January and September 2013 was performed at the Charité-Universitätsmedizin Berlin. Only DMEK cases with an incision size of 2.3 mm and with at least 1 month of follow-up were included. The surgically induced astigmatism (SIA), changes in corneal aberrations and in spherical equivalent, visual acuity, endothelial cell density, and complications were evaluated. RESULTS: Visual acuity improved significantly (0.70 ± 0.39 logMAR vs 0.32 ± 0.31 logMAR after 1 month (n = 48), 0.19 ± 0.15 logMAR after 3 months (n = 46), and 0.16 ± 0.17 logMAR after 6 months (n = 47) (P < .001)) regardless of the approach. SIA was significantly lower after temporal than after superior approach (1.42 ± 0.91 diopters [D] [n = 13] vs 0.81 ± 0.68 D [n = 13], P = .038). Change in total root mean square of all aberrations (RMS) (P = .046) at 6 mm pupil diameter, and change in total RMS (P = .019), third-order aberrations (P = .007), and fourth-order aberrations (P = .041) at 4 mm pupil diameter, demonstrated significantly lower results after temporal compared to superior approach. A higher rate of eyes after temporal approach underwent at least 1 rebubbling (39.1% vs 26.7%, P = .252). The endothelial cell density (P = .053) and the change in spherical equivalent (P = .145) did not differ significantly. CONCLUSIONS: The temporal approach induces significantly less SIA and corneal aberration. There are no significant differences between superior and temporal approach according to the change in spherical equivalent, visual acuity, and endothelial cell density. The need for rebubbling is higher using the temporal approach.

Descemet membrane endothelial keratoplasty in a child with corneal endothelial dysfunction in Kearns-Sayre syndrome.

PURPOSE: To evaluate clinical outcomes and complications after Descemet membrane endothelial keratoplasty (DMEK) in a child. METHODS: A 12-year-old boy with Kearns-Sayre syndrome (chronic progressive external ophthalmoplegia, cardiac conduction block, and pigmentary retinal degeneration) and corneal endothelial dysfunction was successfully treated with DMEK. Corneal transparency, central corneal thickness (CCT), endothelial cell density (ECD), visual outcomes, and complication rates were measured during the follow-up of 6 months. RESULTS: Best spectacle-corrected visual acuity (BSCVA) improved from counting fingers at 4 feet preoperatively to 20/100, 1 week after surgery. The ECD of the graft was 2595 cells per square millimeter. The CCT diminished from 837 µm preoperatively to 735 µm 1 week after surgery. Six months postoperatively, the BSCVA was still 20/100, and the cornea remained clear and compact. The ECD was 2341 cells per square millimeter and CCT was almost normal with 583 µm. No postoperative complications were observed. Fundus examination showed atypical pigmentary retinal degeneration with arterial narrowing. Electroretinography with full-field flash stimulation showed bilaterally severe retinal dysfunction with absent photopic and scotopic amplitudes explaining the reduced BSCVA. CONCLUSIONS: Although DMEK has been used in adult populations, we are unaware of previous reports of DMEK in a child. DMEK should be considered as a feasible technique in pediatric patients with endothelial dysfunction.

Intraocular pressure elevation and post-DMEK glaucoma following Descemet membrane endothelial keratoplasty.

PURPOSE: Intraocular pressure (IOP) elevation and post-keratoplasty glaucoma occur commonly after penetrating keratoplasty (PK), but also after Descemet stripping endothelial keratoplasty (DSEK). In this study, we evaluated the risk after Descemet membrane endothelial keratoplasty (DMEK) to develop IOP elevation and post-DMEK glaucoma. METHODS: The 12-month incidence of IOP elevation and post-DMEK glaucoma was analyzed retrospectively in the first 117 consecutive eyes that underwent DMEK between September 2011 and December 2012 at the Universitätsmedizin-Charité, Berlin. IOP elevation was defined as IOP ≥ 22 mmHg, or ≥10 mmHg from preoperative baseline. The assessment included the pre-operative history of corneal disease and glaucoma. Furthermore, the response to anti-glaucoma treatment, the graft failure, the IOP, the visual acuity, and the endothelial cell count were evaluated. RESULTS: The 12-month incidence of IOP elevation was 12.10 % [95 % confidence interval (CI): 0.94 %, 18.37 %], post-DMEK glaucoma 2.7 % (95 % CI: -0.44 %, 5.84 %). The most frequent cause remained steroid-induced IOP elevation, with an 12-month incidence of 8.0 % (95 % CI: 7.95 %, 8.05 %). In all cases, IOP elevation was treated effectively by tapering down steroid medication and initiating or increasing anti-glaucoma medication. The incidence of postoperative postoperative pupillary block IOP elevation was 15.40 % (95 % CI: 8.93 %, 21.87 %). The number of eyes with iridocorneal contacts after surgery was low (4.2 %). Only the preoperative increased IOP is a significant risk factor for IOP elevation (p = 0.005). Visual acuity improved significantly after surgery (p < 0.001), and clear grafts were achieved in all eyes. Mean endothelial cell count did not differ between patients with and without IOP elevation. CONCLUSION: Incidence of IOP elevation and post-keratoplasty glaucoma after DMEK were low, but regular IOP measurements, especially in eyes with pre-existing glaucoma and bullous keratopathy, are necessary. Steroid-induced IOP elevation was the most frequent reason, and could be treated effectively by tapering down steroid medication or changing the steroid drug. Development of peripheral anterior synechiae after DMEK occured rarely. Therefore, the risk for IOP elevation and especially post-DMEK keratoplasty was reduced compared to PK and DSEK. In all cases, successful management by medical treatment was possible, and resulted in good visual acuity.

Posterior iris-claw aphakic intraocular lens implantation and Descemet membrane endothelial keratoplasty.

PURPOSE: To evaluate clinical outcomes and complications after Descemet membrane endothelial keratoplasty (DMEK) and posterior iris-claw aphakic intraocular lens (IOL) implantation. METHODS: This prospective cohort study comprised seven consecutive eyes (seven patients) without adequate capsular support and bullous keratopathy undergoing posterior iris-claw aphakic IOL implantation and DMEK. Corneal transparency, central corneal thickness, endothelial cell density, visual outcomes and complication rates were measured during the follow-up. RESULTS: The iris-claw IOLs were inserted during an IOL exchange in three eyes, and as a secondary IOL implantation in one aphakic eye during DMEK procedure. Three eyes had IOL exchange prior to secondary DMEK. Mean follow-up was 7 months (range 3-14 months). The final best spectacle-corrected visual acuity improved significantly (0.33±0.31 logMAR) compared with the preoperative best spectacle-corrected visual acuity (1.84±0.90 logMAR). The mean endothelial cell loss was 24.8% over the follow-up. Complications included graft dislocation in four eyes; which could be easily reattached with a rebubbling procedure. No graft failures, no cases of pupillary block glaucoma and no IOL dislocations were encountered. CONCLUSIONS: DMEK and retropupillar iris-claw IOL implantation provide good visual outcomes with a fast visual recovery and appear to be a feasible method for the management of bullous keratopathy but with higher graft detachment rates. TRIAL REGISTRATION NUMBER: NCT02020044.

Influence of Selective Laser Trabeculoplasty (SLT) on combined clear cornea phacoemulsification and Trabectome outcomes.

BACKGROUND: In this retrospective comparative cohort outcome study, the influence of Selective Laser Trabeculoplasty (SLT) on combined clear cornea phacoemulsification and ab interno trabeculectomy (Trabectome) outcomes in Primary Open Angle Glaucoma (POAG), Pseudoexfoliation Glaucoma (PEX), and Pigmentary Glaucoma (PG) was examined. METHODS: Combined clear cornea phacoemulsification and Trabectome were performed in 27 consecutive patients with POAG, in 27 patients with PEX, and in 20 patients with PG. Each group was divided into two subgroups including patients without SLT treatment prior to surgery and patients who had insufficient response to 360° SLT treatment three months prior to surgery. RESULTS: In the SLT group, mean IOP at six months measured 13.33 ± 2.08 mmHg with an average decrease of 30 % from preoperative IOP in the POAG group, 12.10 ± 1.40 mmHg with an average decrease of 46 % in the PEX group, and 11.83 ± 2.21 mmHg with an average decrease of 38 % in the PG group. In eyes without previous SLT, mean IOP sixt 6 months measured 11.00 ± 1.73 mmHg with an average decrease of 38 % from preoperative IOP in the POAG group, 15.50 ± 1.41 mmHg with an average decrease of 35 % in the PEX group, and 15.67 ± 2.91 mmHg with an average decrease of 36 % in the PG group, respectively. CONCLUSIONS: Prior SLT treatment seems not to negatively influence combined clear cornea phacoemulsification and Trabectome outcomes in glaucoma patients. However, SLT treatment may even have an additive effect on following combined Trabectome outcomes in patients with PEX and PG.

Posterior iris-claw aphakic intraocular lens implantation in subluxated lenses due to Marfan syndrome.

PURPOSE: To evaluate the indications, visual outcomes, and complication rate after posterior implantation of an iris-claw aphakic intraocular lens (IOL) in subluxated lenses due to Marfan syndrome. METHODS: Eyes without adequate capsular support had posterior chamber iris-claw aphakic IOL implantation between 2006 and 2012. RESULTS: This retrospective cohort study comprised 13 eyes of 10 patients (7 female, 3 male; mean age ± standard deviation, 34.7 ± 19.6; range 9-61 years). The mean follow-up was 37 months (range 6-74 months). The mean final postoperative best-corrected visual acuity was significantly (0.24 ± 0.36 logMAR) better at the last follow-up than 1 day preoperatively (0.72 ± 0.46 logMAR) (p<0.05). There was no significant change in intraocular pressure before and after surgery. The mean endothelial cell density decreased from 2793 ± 478 cells/mm2 preoperatively to 2637 ± 612 cells/mm2 at last follow-up, representing a mean endothelial cell loss of 5.6%. Complications included early transient postoperative hypotony in 2 eyes (15.4%), slight persistent pupil ovalization in 1 eye (7.7%), and retinal detachment in 1 eye (7.7%). CONCLUSIONS: The posterior implantation technique of aphakic iris-claw IOL provided good visual outcomes with a favorable complication rate and can be used as a reasonable alternative in subluxated lenses due to Marfan syndrome without adequate capsular support.