Clinical, Anatomical, and Densitometric Changes following Dresden vs. Accelerated Corneal Cross-Linking in Progressive Keratoconus.

BACKGROUND: To compare clinical, anatomical, and densitometric changes following Dresden (DCXL) vs. accelerated (ACXL) corneal UVA cross-linking (CXL; Avedro KXL, Geuder, Heidelberg, Germany) in progressive keratoconus (KC). METHODS AND MATERIAL: In this retrospective study, we analyzed 20 patients following DCXL (3 mW/cm², 30 min, 5.4 J/cm²) and 44 patients following ACXL (9 mW/cm², 10 min, 5.4 J/cm²) between January 2016 and February 2020. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), steepest keratometry (Kmax), keratoconus index (KI), thinnest pachymetry (Pthin), and corneal densitometry (CD) were measured before and 3, 6, 12, and 24 months after CXL. RESULTS: During the follow-up period, no changes in UCVA, BSCVA, Kmax, KI, or Pthin occurred. CCT significantly decreased 3 months after DCXL (p = 0.032) and ACXL (p = 0.006). At the 12- and 24-month follow-up, CCT remained decreased in the DCXL (p = 0.035, 0.036, respectively) but not in the ACXL group. At the 12-month follow-up, the reduction in CCT was significantly greater in DCXL compared to ACXL (p = 0.012). At the 3-, 6-, 12-, and 24-month follow-ups, we found a significant increase in the anterior stroma CD following DCXL (p = 0.019, 0.026, 0.049, 0.047, respectively) but not ACXL. The CD changes were localized in the central concentric zones (0.0 to 6.0 mm). No intra- or postoperative complications occurred. CONCLUSION: ACXL and DCXL effectively halted KC progression. ACXL proved to be a safe time-saving alternative to conventional DCXL. DCXL led to a reduction in CCT and an increment in the CD of the central anterior stroma during 24 months of follow-up.

Outcomes of combined single-use dual blade goniotomy and cataract surgery.

PURPOSE: Single-use dual blade goniotomy (SBG) is a novel ab interno procedure that removes three to five clock hours of trabecular meshwork (TM). We analysed the reduction of intraocular pressure (IOP) and topical glaucoma medication (Meds) in eyes following combined cataract surgery and SBG (Cat-SBG). METHODS: IOP and Meds were evaluated retrospectively in 55 eyes of 38 patients. 44 eyes had high tension glaucoma (HTG) and eleven eyes had normal tension glaucoma (NTG). Complete success (no Meds) and qualified success (with Meds) for IOP levels ≤ 21, ≤ 18 , ≤ 16 mmHg or ≥ 20% IOP reduction at the two- and six-month follow-up were evaluated. RESULTS: IOP and Meds were significantly reduced from before to two months after Cat-SBG in HTG- and NTG-patients (HTG: IOP 19.4 ± 3.3 to 15.1 ± 3.3 mmHg; p < 0.001; Meds 2.1 ± 1.3 to 0.8 ± 1.3; p < 0.001; NTG: IOP 14.0 ± 2.3 to 11.5 ± 2.3 mmHg; p = 0.004; Meds 1.6 ± 0.7 to 0.3 ± 0.7; p < 0.001). IOP and Meds did not change significantly from two to six months after Cat-SBG. In HTG, complete and qualified success rates were 43% (19/44) and 93% (41/44) for IOP ≤ 18 mmHg, 36% (16/44) and 64% (28/44) for IOP ≤ 16 mmHg and 30% (13/44) and 43% (19/44) for ≥ 20% IOP reduction six months after surgery. In NTG, complete and qualified success was 81% (9/11) and 100% (11/11) for IOP ≤ 18 and ≤ 16 mmHg, and 27% (3/11) for IOP reduction ≥ 20%. IOP and Meds reduction were comparable between HTG and NTG eyes. Only minor postoperative complications occurred. CONCLUSION: Cat-SBG is an efficient method to significantly lower IOP in patients with HTG and NTG.

Failure of XEN Gel Stent Implantation as a Stand-Alone Procedure in Congenital Glaucoma: Case Report of Secondary Congenital Glaucoma in Neurofibromatosis Type 1.

A XEN gel stent implant procedure was performed in a one-year-old child with severe unilateral congenital glaucoma. At the age of 6 weeks, an uncomplicated 360° trabeculotomy had been performed, which resulted in intraocular pressure (IOP) control for only 4 months. The gel stent implantation was performed ab interno without complications. However, 1 month later, the stent was repelled into the anterior chamber due to the elasticity of Tenon's layer. A first revision surgery was performed, with excision of Tenon's layer and implantation of a new gel stent under sight. At the age of 18 months, a second revision surgery was performed because of an encapsulated Tenon cyst with insufficient IOP control, again with the implantation of a new stent. At that time, a progressive upper eyelid swelling was apparent. Eyelid biopsy led to the diagnosis of neurofibromatosis type 1, presenting with an orbital plexiform neurofibroma. Further insufficient IOP control resulted in a cyclodestructive procedure and loss of light perception during follow-up. XEN gel stent implantation in congenital glaucoma in infants is more challenging than that in adult patients. Gel stent implantation ab interno may be difficult due to the thickness and elasticity of Tenon's layer. Gel stent dislocation may occur, even months after surgery. Trabeculectomy might be a better approach after failed trabeculotomy in congenital glaucoma. An underlying systemic disease might become apparent late during follow-up.

Intraocular lens power calculation for plus and minus lenses in high myopia using partial coherence interferometry.

PURPOSE: We assessed the accuracy of lens power calculation in highly myopic patients implanting plus and minus intraocular lenses (IOL). METHODS: We included 58 consecutive, myopic eyes with an axial length (AL) > 26.0 mm, undergoing phacoemulsification and IOL implantation following biometry using the IOLMaster 500. For lens power calculation, the Haigis formula was used in all cases. For comparison, refraction was back-calculated using the Barrett Universal II (Barrett), Holladay I, Hill-RBF (RBF) and SRK/T formulae. RESULTS: The mean axial length was 30.17 ± 2.67 mm. Barrett (80%), Haigis (87%) and RBF (82%) showed comparable numbers of IOLs within 1 diopter (D) of target refraction. Visual acuity (BSCVA) improved (p < 0.001) from 0.60 ± 0.35 to 0.29 ± 0.29 logMAR (> 28-days postsurgery). The median absolute error (MedAE) of Barrett 0.49 D, Haigis 0.38, RBF 0.44 and SRK/T 0.44 did not differ. The MedAE of Haigis was significantly smaller than Holladay (0.75 D; p = 0.01). All median postoperative refractive errors (MedRE) differed significantly with the exception of Haigis to SRK/T (p = 0.6): Barrett - 0.33 D, Haigis 0.25, Holladay 0.63, RBF 0.04 and SRK/T 0.13. Barrett, Haigis, Holladay and RBF showed a tendency for higher MedAEs in their minus compared to plus IOLs, which only reached significance for SRK/T (p = 0.001). Barrett (p < 0.001) and RBF (p = 0.04) showed myopic, SRK/T (p = 002) a hyperopic shift in their minus IOLs. CONCLUSIONS: In highly myopic patients, the accuracies of Barrett, Haigis and RBF were comparable with a tendency for higher MedAEs in minus IOLs. Barrett and RBF showed myopic, SRK/T a hyperopic shift in their minus IOLs.

[Treatment success of canaloplasty and trabeculectomy by the same surgeon with the same level of experience in the long-term course]. / Therapieerfolg von Kanaloplastik und Trabekulektomie durch denselben Operateur mit demselben Erfahrungslevel im Langzeitverlauf.

BACKGROUND: Trabeculectomy (TE) with the use of antimetabolites is the standard procedure in glaucoma surgery, whereas canaloplasty (CP) is a nonpenetrating and potentially less invasive alternative. OBJECTIVE: The aim of this retrospective case series was to compare the long-term success of CP and TE under the same conditions and with the same levels of experience of the surgeon as well as to investigate whether preoperative intraocular pressure (IOP) and postoperative IOP correlate with eachother. METHODS: The study included 57 eyes that underwent either CP or TE (CP n = 27; male = 50.0% age 60.7 ± 13.2 years; TE n = 30; male = 55.6% age 68.0 ± 9.1 years). Each of the procedures was performed by the same surgeon with comparable levels of experience. The comparison included preoperative and postoperative visual field damage, preoperative and postoperative IOP (mm Hg) after 1 and 6 weeks, 6 and 12 months as well as in the long-term course (1-3 years) and the necessary local treatment at the corresponding times. RESULTS: With both methods no worsening of the visual field could be detected and the patient groups showed comparable preoperative and postoperative mean deviations (MD). The CP showed a positive correlation between preoperative and postoperative 1­year IOP (r = 0.4; p = 0.022), whereas TE showed no significant correlation between preoperative and postoperative IOP. The count of local antiglaucoma medication in long-term comparison (1-3 years after surgery) was higher after CP than after TE (1.5 ± 1.6 vs. 0.5 ± 0.8; p = 0.003). In both groups there were no severe postoperative complications. The overall success rates (without treatment) were higher at all time points after TE. DISCUSSION: With both methods conducted by the same surgeon with the same levels of experience, an effective reduction of the IOP was achieved. It seems that the higher the preoperative IOP before CP, the higher the achievable pressure after 1 year and in the long term. In contrast, after TE the IOP was effectively reduced in the long term regardless of the initial IOP. The CP seems to be inferior to TE under the same conditions with respect to complete surgical success (without local treatment).

Outcomes of 360° suture trabeculotomy after unsuccessful canaloplasty.

BACKGROUND: Canaloplasty is a well-established non-penetrating glaucoma surgery. Unsuccessful outcomes can be enhanced by micro-invasive 360° suture trabeculotomy (360°trabeculotomy), analyzed in this study. METHODS: This retrospective study included twenty eyes of 19 patients, mean age 59.7±17.2 years, with primary open-angle glaucoma (POWG n = 14), pseudoexfoliation glaucoma (PEX n = 3), juvenile glaucoma (n = 2) and aphakic glaucoma (n = 1), who underwent micro-invasive 360° trabeculotomy after unsuccessful (intraocular pressure (IOP) >21 mmHg under maximum glaucoma eye drop therapy (Meds)) canaloplasty. IOPs, Meds, complications and failure rates (IOP >21 mmHg at two consecutive follow-ups) were evaluated. Complete success (no Meds) and qualified success (with Meds) rates for IOP levels ≤21 mmHg and ≤ 18 mmHg at the last follow-up were evaluated. RESULTS: IOPs and Meds were significantly reduced from before to 1 week (10.3±3.1 days) after 360° trabeculotomy (IOP, 28.3±6.0 mmHg to 15.8±4.5 mmHg; p < 0.001; Meds, 3.1 ± 1.2 to 1.0 ± 1.2; p < 0.001). IOPs (p = 0.37) and Meds (p = 0.33) did not decrease further from 1 week until the last follow-up (18.3 ± 8.2 months (IOP, 14.4±3.8 mmHg; Meds, 1.5±1.3)). Complete and qualified success was 25% (5/20) and 70% (14/20) for IOP ≤21 mmHg, as well as 25% (5/20) and 60% (12/20) for IOP ≤18 mmHg. Four eyes had postoperative hyphema, which resolved after a mean period of 4.0 ± 2.2 days. Five failures occurred after a mean of 40.6 ± 51.9 days after 360° trabeculotomy. All failures underwent trabeculectomy. Eyes that needed early (≤3 months post canaloplasty) 360° trabeculotomy showed higher IOPs before (p < 0.001) and lower (p = 0.03) IOPs 2 months post 360° trabeculotomy than eyes with late (>3 months) 360° trabeculotomy surgery. CONCLUSIONS: 360° trabeculotomy is a safe, micro-invasive, simple and successful method to enhance failed canaloplasty.

One-Year Safety and Performance Assessment of the Argus II Retinal Prosthesis: A Postapproval Study.

IMPORTANCE: The Argus II Retinal Prosthesis System is indicated for patients with vision loss due to severe to profound outer retinal degeneration, a group with few treatment options. OBJECTIVES: To collect postapproval safety and visual function data for the Argus II. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, postapproval clinical trial conducted at 9 sites in Germany and Italy. Data were collected from December 2, 2011, to September 30, 2017, and patients were followed-up for 12 months or longer. Patients were 25 years or older with severe to profound outer retinal degeneration, some residual light perception or the ability of the retina to respond to electrical stimulation, and a history of useful form vision and were already planning to undergo Argus II implantation. MAIN OUTCOMES AND MEASURES: The primary end point of this study was the nature and rate of adverse events. Secondary end points included 3 visual function tests: square localization (SL), direction of motion, and grating visual acuity (GVA). RESULTS: Forty-seven patients were followed for 12 months or longer after implant. Mean (SD) age was 56 (12) years, 37 (79%) had retinitis pigmentosa, and 27 (57%) were male. Through the first 12 months postimplantation, 23 patients (49%) experienced 51 nonserious adverse events and 12 (26%) experienced 13 serious adverse events (SAEs), 9 of which were judged to be related to the Argus II, and 4 of which were judged to be related to the procedure. The most common SAE was conjunctival erosion, reported in 4 patients. No significance testing was done for group analysis for the SL or direction-of-motion tests. When averaged across the group, patients' accuracy on the SL test, but not on the direction-of-motion test, appeared better when the Argus II was on than when it was switched off. For GVA, more patients at each point in time achieved the 2.9 GVA cutoff in the implanted eye when the Argus II was on compared with it switched off. CONCLUSIONS AND RELEVANCE: Safety and visual function outcomes in this clinical practice setting cohort of patients with Argus II implants were consistent with previously reported results. Longer follow-up of these patients and data from additional patients are required to better outline the risks and benefits of this approach to addressing blindness secondary to severe-to-profound outer retinal degeneration. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01490827.