Treatment exit options for non-infectious uveitis registry: participant characteristics at 3 years.

PURPOSE: The Treatment exit Options For non-infectious Uveitis (TOFU) registry documents disease courses for non-anterior non-infectious uveitis entities with and without treatment to generate more evidence for clinical management recommendations including treatment exit strategies. In this article, we present the participants' baseline characteristics after the first 3 years. METHODS: TOFU is an observational, prospective registry and recruits patients ≥18 years of age with non-anterior non-infectious uveitis with or without a history of previous disease-modifying antirheumatic drugs (DMARDs) treatment. The data are collected in the electronic data capture software REDCap and include ophthalmological and general medical history as well as clinical findings. RESULTS: Between 24.10.2019 and 27.12.2022, 628 patients were enrolled at 25 clinical sites in Germany and Austria. Patients with intermediate uveitis were most frequently included (n=252; 40.1%) followed by posterior uveitis (181; 28.8%), panuveitis (n=154; 24.5%) and retinal vasculitis (n=41, 6.5%). At baseline, 39.6% were treated with systemic corticosteroids, 22.3% with conventional synthetic (cs) DMARDs, 20.5% with biological (b) DMARDs and 3.6% with other systemic treatments. Average best corrected visual acuity (BCVA) was 0.69 decimal. Patients with panuveitis had the worst BCVA with 0.63 decimal. Overall, only 8 patients (1.3%) suffered from severe visual impairment. CONCLUSIONS: Less than half of participants required DMARD treatment at baseline, with csDMARDs used more frequently than bDMARDs. The presence of severe visual impairment was low, mostly affecting patients with panuveitis. These findings are in line with comparable monocentric cross-sectional studies of tertiary uveitis centres in Germany and will allow us to generate generalisable evidence in TOFU.

Efficacy of a new fragmentation pattern in femtosecond laser-assisted cataract surgery with the Ziemer FEMTO LDV Z8.

PURPOSE: To determine the efficacy of different fragmentation patterns in femtosecond laser-assisted cataract surgery (FLACS) using Ziemer FEMTO LDV Z8. METHODS: We compared three different types of surgery: conventional cataract surgery (CCS), FLACS with conventional radial slices (named No-Spiderweb), and FLACS with a novel fragmentation pattern (radial slices combined with one or two rings) called "Spiderweb." Visual acuity (VA), nuclear opacity (NO) according to the Lens Opacities Classification System (LOCS lll), effective phacoemulsification time (EPT) and vacuum time were obtained for 845 eyes. RESULTS: Using FLACS (Spiderweb + No-Spiderweb), EPT was significantly reduced by 26% compared to CCS (FLACS: 2.46 ± 2.60 s; CCS: 3.34 ± 2.89 s; ΔM = - 0.88 s, p < .001). Furthermore, EPT as a function of progression of lens opacity was found to be not only lower in Spiderweb compared to CCS, but also in comparison with No-Spiderweb. At NO3, a significant reduction of 65% in EPT was observed by using Spiderweb compared to CCS (Spiderweb: 0.68 ± 1.23 s; CCS: 1.96 ± 1.53 s; ΔM = - 1.28 s, p <.001). Interestingly, EPT at NO3 was also significantly reduced by 57% in Spiderweb compared to No-Spiderweb (Spiderweb: 0.68 ± 1.23 s; No-Spiderweb: 1.57 ± 1 .59 s; ΔM = - 0.90 s, p <.001). The use of Spiderweb only marginally extends the vacuum time compared to No-Spiderweb by 11 s (Spiderweb: 209.13 ± 35.83 s; No-Spiderweb: 198.35 ± 36.84 s; p = .003) and the postoperative improved VA showed no significant difference among the different types of surgery (all ps ≥ .05). CONCLUSION: FLACS significantly reduces EPT compared to CCS. Furthermore, the novel Spiderweb pattern significantly reduces EPT in patients with a cataract of NO3 compared to CCS, but also to FLACS with the existing radial pattern (No-Spiderweb).

New optical coherence tomography grading system for macula-off rhegmatogenous retinal detachment: how off is off?

BACKGROUND/AIMS: The classification of retinal detachment is currently still based on many objective criteria such as duration of symptoms and funduscopic macular status, which leaves some important questions unanswered. The most important factor is the macular status, which is determined using direct or indirect ophthalmoscopy. Optical coherence tomography (OCT) has become a standard tool in clinical practice and enables detecting the exact extent of subretinal fluid in macula-off/on retinal detachment. We introduce a new and simple OCT-based grading system for macular detachment to provide a basis for further investigations to determine the optimal timing for surgery. METHODS: We retrospectively included 155 patients who were treated for retinal detachment. We defined the extent of the macular detachment in six stages based on the Early Treatment Diabetic Retinopathy Study (ETDRS) grid of the OCT scan.The outermost ring of the ETDRS grid was defined as zone 1, the middle ring as zone 2 and the inner ring as zone 3. Only zone 3 differed in the retinal detachment height grades (grade a <250 µm vs grade b >250 µm). Retinal detachment heights that could not be measured were considered grade 4 (ungradable) detachments. RESULTS: Forty-seven patients had no macular involvement (grade 0). Regarding macular detachment, 14 patients had grade 1, 20 had grade 2, 9 had grade 3a, 29 had grade 3b and 36 had grade 4. CONCLUSION: The newly developed OCT grading system for macular involvement following retinal detachment is a crucial tool to objectively classify a retinal detachment in order to be able to make better statements in the future, like for defining the optimal time for surgical intervention. A secondary benefit of this grading system would be that it improves predicting postoperative visual acuity.

Effectiveness of immediate vitrectomy and intravitreal antibiotics for post-injection endophthalmitis.

PURPOSE: To show that an immediate vitrectomy with an intravitreal injection of antibiotics can be an effective approach for the treatment of acute endophthalmitis following intravitreal injections. METHODS: We reviewed all cases of clinical endophthalmitis caused by an intravitreal injection that were treated in our department between March 2012 and November 2019. Only patients that underwent a vitrectomy within 6 h after presentation to the clinic and with a documented visual acuity shortly before the causative event were included. Baseline best-corrected visual acuity (BCVA) before the causative event was compared to BCVA measured within a follow-up period of 8 months (up to 14 months). RESULTS: In total, 30 eyes of 30 patients were included. The BCVA before the intraocular infection was a mean value of 0.55 logMAR, and the BCVA on the day of the endophthalmitis decreased significantly to 1.66 logMAR. Within 2 months following the pars plana vitrectomy (PPV), the mean BCVA improved to 0.83 logMAR. Eight months following PPV (mean value, 8.20 months; SD, 3.59 months), the mean BCVA was 0.63 logMAR. In the last follow-up interval most of the eyes recovered, and the BCVA did not differ significantly from baseline. Two eyes underwent further pars plana surgery during the follow-up period. No enucleation was required. CONCLUSION: In this study, we have shown that an immediate vitrectomy with subsequent intravitreal injection of antibiotics is an effective option for treating post-injection endophthalmitis and frequently results in recovery of vision; thus, it should be performed as early as possible, where available.

The impact of limbus detection, arcus lipoides and limbal vessels on the primary patency of clear cornea incisions in femtosecond laser-assisted cataract surgery.

PURPOSE: To analyse the factors influencing the primary patency of clear corneal incisions in femtosecond laser-assisted cataract surgery (FLACS). METHODS: In this prospective single-centre study, the graphical user interfaces of 159 patients undergoing femtosecond laser-assisted cataract surgery were documented by video. Subsequently, the quality of limbus detection along with the incidence of vessels and an arcus lipoides were assessed by a grading system and analysed in relation to the primary patency of the incisions. In particular, the differences between a superior and a temporal main incision were analysed. RESULTS: The designed grading system could be applied in all cases without any problems. Limbus detection was highly inhomogeneous but had no influence on the patency of the incisions (46.3% poor, 18.4% moderate, 35.1% good). The characteristics of the arcus lipoides had little influence on the patency of the main incisions. Pronounced vascular ingrowth caused more tissue bridges but did not reduce the patency of the incisions. Temporal access was generally easier to open than a superior one (97.1% versus 88.9%). CONCLUSION: We showed a patency rate of superior FLACS incisions of over 97% with the Femto LDV Z8 in our study. Temporal main incision is preferable to superior main incision in more difficult situations. The new grading system is suitable for further studies to provide information on the quality of the incision.

Stability of a non-applanating handheld liquid patient interface for femtosecond laser-assisted cataract surgery.

PURPOSE: A stable and reliable vacuum is crucial for the correct planning and performance of femtosecond laser-assisted cataract surgery (FLACS) in order to avoid complications such as suction loss and cyclorotation. This study investigates, for the first time, the impact of different vacuum levels on the stability of the application of a liquid patient interface for FLACS in view of break-away forces. METHODS: Break-away forces were measured using a multifunctional material testing machine with a mounted digital manometer. Sixteen porcine eyes were docked to the patient interface of a femtosecond laser platform (FEMTO LDV Z8), and the impact of different vacuum levels between 300 and 500 mbar investigated. RESULTS: Mean break-away forces for each vacuum level were as follows: 1.78 N (± 0.58 N) for 300 mbar; 2.24 N (± 0.68 N) for 350 mbar; 2.66 N (± 0.68 N) for 400 mbar; 2.86 N (± 0.77 N) for 420 mbar; and 3.49 N (± 0.86 N) for 500 mbar. CONCLUSION: The stability increases with the vacuum in a nearly linear manner. Vacuum levels higher than 500 mmHg and lower than 350 mmHg are not recommended for FLACS.

[Current value of femtosecond laser-assisted cataract surgery]. / Aktueller Stellenwert der Femtosekundenlaser-assistierten Kataraktchirurgie.

After more than 10 years of experience with the femtosecond laser in cataract surgery, it can be concluded that the safety profile of femtosecond laser-assisted cataract surgery (FLACS) is comparable to that of conventional cataract surgery. This technique offers the possibility to perform incisions with a precision superior to that of any surgeon in the world, based on the connection of preoperative and intraoperative diagnostics. This results in new possibilities to revolutionize the surgical procedure of cataract surgery and to generate new therapeutic approaches for the treatment of cataracts. The combination of keratotomy for correcting astigmatism, intraocular lenses supported by capsulotomy and individually adapted fragmentation patterns is already a component of a personalized cataract surgery.

Novel Liquid Interface for Femtosecond Laser-Assisted Penetrating Keratoplasty.

PURPOSE: To introduce a methodical description and to investigate first clinical safety of a novel liquid interface technology for femtosecond laser-assisted perforating keratoplasty, maintaining the corneal curvature without applanation of the cornea. METHODS: In this pilot study six patients received a femtosecond laser keratoplasty using a new liquid interface providing a non-applanating trephination. Clinical outcomes were evaluated 1, 3 and 6 months after surgery. RESULTS: All procedures were performed without complications and donor and recipient corneas could be aligned without problems, even in cases of advanced keratoconus. Although this initial pilot study investigated clinical safety, a positive effect on postoperative astigmatism was observed. CONCLUSION: We could show in this first pilot study that a hand-held liquid patient interface in combination with a femtosecond laser has a preliminary safety and reliability in penetrating keratoplasty.

Impact of Patient Interface Diameter and Vacuum Level on Suction Stability Using a Flat Applanating Interface for Femtosecond Laser-Assisted LASIK.

PURPOSE: To investigate the impact of different patient interface (PI) diameters and different vacuum levels on the suction stability during vacuum application for femtosecond laser-assisted LASIK. METHODS: Break-away forces as a marker for suction stability were measured by an automated test bench set-up. The test bench was based on a customized stamp connected to a digital load cell. Three flat applanating PI with different diameters (8.5, 9.5 and 10.0 mm) and four different vacuum levels (500, 600, 700 and 800 mbar) were investigated using the FEMTO LDV Z8 (Ziemer Ophthalmic Systems AG, Switzerland). RESULTS: Mean break-away force was 5.23N (±0.99N) using the 8.5 mm PI and 500 mbar vacuum, 8.18N (±1.39N) using the 8.5 mm PI and 800 mbar, 3.37N (±0.56N) using the 10.0 mm PI and 500 mbar, and 6.14N (±0.68N) using the 10.0 mm PI and 800 mbar vacuum (p < .001; CI95%). Increasing the PI diameter from 8.5 to 10.0 mm resulted in a 28.89% (+1.97 ± 1.02N) lower break-away force (p < .001) when using default vacuum settings (700 mbar) compared to increasing vacuum from 500 to 800 mbar, which resulted in a 60.37% (+1.95 ± 1.40N) higher mean break away force (p < .001). CONCLUSION: The vacuum level and the diameter of the PI showed significant impact on suction stability measured as break-away force during flat applanating docking for corneal and refractive surgery. Break-away forces were inversely related to the PI diameter and directly to the vacuum level. Increasing the PI diameter by one step or reducing vacuum by 100 mbar resulted in a comparable decrease of break-away forces. Therefore, the surgeon could potentially maintain stabile suction by increasing vacuum when choosing a larger PI diameter to obtain a larger treatment zone. Furthermore, reduction of the PI diameter and/or increasing vacuum could help improving suction stability in situations of poor suction and in situations with increased risk of suction loss during LASIK.

Favourable outcome after late reorientation of an upside-down Descemet Membrane Endothelial Keratoplasty (DMEK) graft: a case report.

BACKGROUND: Clinical outcome after successful reorientation of an upside-down implanted DMEK (Descemet Membrane Endothelial Keratoplasty) graft 4 weeks after initial transplantation. CASE PRESENTATION: A 71-year-old woman presented with Fuchs' endothelial corneal dystrophy for DMEK. After initial DMEK the donor graft was fully attached and well centred during intracameral gas filling. When the gas bubble was fully resorbed the graft started to detach. Therefore, two intracameral gas injections were consecutively performed. During the second re-bubbling, an upside-down orientation was observed and so the graft was flipped, centred, re-attached and finally stabilized by an intracameral gas bubble. Three weeks after reorientation slit lamp examinations showed a well centred and attached graft, endothelial cells that started functioning and a patient's visual acuity of 20/40. Visual acuity increased to a 20/32 vision in the observed eye three months later and further improved to 20/20 6 months after reorientation and stayed stable between 20/32 and 20/20 during the remaining 15 months of follow-up, with a clear and well-attached graft. CONCLUSION: Reorientation of an upside down DMEK graft was successful even 4 weeks after initial DMEK. Visual recovery and endothelial cell count increase were stepwise noticed during the first 6 months and 15 months after reorientation, respectively. Finally a favourable outcome with 20/32 to 20/20 vision at least 6 months after graft reorientation was achieved. Therefore, restoring full graft function could last several weeks or even months following (late) reorientation of an upside-down DMEK graft.

Impact of 10% SF6 Gas Compared to 100% Air Tamponade in Descemet's Membrane Endothelial Keratoplasty.

PURPOSE: To compare the clinical outcomes following Descemet's membrane endothelial keratoplasty (DMEK) with 100% air tamponade versus 10% sulfur hexafluoride (SF6) tamponade. METHODS: Retrospective analysis of 108 consecutive DMEK cases subdivided by anterior chamber tamponade with 54 eyes receiving 10% SF6 and 54 eyes receiving 100% air injection. A post-hoc matched analysis revealed no statistically significant differences between the groups. The main outcome measurements were the complication rate, including intra- and postoperative complications and graft detachment rate requiring re-bubbling. Clinical outcome included best-corrected visual acuity (BCVA), endothelial cell count (ECC), and central corneal thickness (CCT) measured 1, 3, and 6 months after DMEK surgery. RESULTS: The graft detachment rate with consecutive re-bubbling was 18.5% in the air group and 22.2% in the SF6 group (p = 0.2). Remaining small peripheral graft detachments with a clear cornea occurred more often in the 100% air group (air: 22.2%; 12/54, 6/12 inferior compared to SF6: 7.4%; 4/54, 2/4 inferior; p = 0.06). The primary graft failure rate was comparable between the two groups. No complete graft detachment occurred. Outcome results for BCVA, ECC, and CCT at all follow-up time points were comparable between the two groups. CONCLUSION: The clinical outcomes (including re-bubbling rate, primary graft failure rate, and endothelial cell loss) were comparable with 100% air versus 10% SF6 tamponade, whereas other studies suggest that a higher SF6 concentration (20%) may result in a lower re-bubbling rate.

Clinical Comparison of Two Methods of Graft Preparation in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: Descemet membrane endothelial keratoplasty (DMEK) has been improved over the last decade. The aim of this study was to compare the clinical outcome of the recently introduced liquid bubble method compared to the standard manual preparation. METHODS: This retrospective study evaluated the outcome of 200 patients after DMEK surgery using two different graft preparation techniques. Ninety-six DMEK were prepared by manual dissection and 104 by the novel liquid bubble technique. The mean follow-up time was 13.7 months (SD ± 8, range 6-36 months). RESULTS: Best corrected mean visual acuity (BCVA) increased for all patients statistically significant from baseline 0.85 logMAR (SD ± 0.5) to 0.26 logMAR (SD ± 0.27) at the final follow-up (Wilcoxon, p = 0.001). Subgroup analyses of BCVA at the final follow-up between manual dissection and liquid bubble preparation showed no statistically significant difference (Mann-Whitney U Test, p = 0.64). The mean central corneal thickness was not statistically different (manual dissection: 539 µm, SD ± 68 µm and liquid bubble technique: 534 µm, SD ± 52 µm,) between the two groups (Mann-Whitney U Test, p = 0.64). At the final follow-up, mean endothelial cell count of donor grafts was statistically not significant different at the final follow-up with 1761 cells/mm2 (-30.7%, SD ± 352) for manual dissection compared to liquid bubble technique with 1749 cells/mm2 (-29.9%, SD ± 501) (Mann-Whitney U-Test, p = 0.73). The re-DMEK rate was comparable for manual dissection with 8 cases (8.3%) and 7 cases (6.7%) for liquid bubble dissection (p = 0.69, Chi-Square Test). CONCLUSION: Regarding the clinical outcome, we did not find a statistical significant difference between manual dissection and liquid bubble graft preparation. Both preparation techniques lead to an equivalent clinical outcome after DMEK surgery.

Suprachoroidal drainage with collagen sheet implant- a novel technique for non-penetrating glaucoma surgery.

PURPOSE: Our purpose was both to introduce the new technique of suprachoroidal drainage with collagen sheet implantation as a novel technique of non-penetrating glaucoma surgery and to present first results of a prospective pilot study. METHODS: A superficial rectangular sclera flap of half-scleral thickness sized 4 × 4.5 mm is dissected anteriorly until clear cornea. Then, a second scleral flap is created underneath the first one sized 3.5x4mm and is cut down full-thickness to the choroid exposing the suprachoroidal space. The flap is then bluntly prepared until the scleral spur is reached. Sharp dissection above the sclera spur exposes Schlemm's canal, which is located directly anteriorly. Schlemm's canal is unroofed, juxtacanalicular meshwork is peeled and the deep flap is cut off at its base. An absorbable collagen sheet (Ologen®, Dahlhausen, Cologne, Germany) is placed into the suprachoroidal space at the level of the ciliary body, and the superficial sclera flap is sutured tightly to prevent leakage. RESULTS: We prospectively analyzed 65 eyes that underwent suprachoroidal drainage with collagen sheet implantation. Mean reduction of intraocular pressure after 3 months was 35.1% (from 21.0 ± 4.3 mmHg to 13.5 ± 3.4 mmHg)(p < 0.01) and after 12 months 35.6% (from 21.0 ± 4.3 mmHg to 13.5 ± 3.0  mmHg)(p < 0.01). The number of topical IOP-reducing medication decreased significantly from 3.5 ± 0.7 to 0.6 ± 0.9 and to 0.9 ± 1.1 after 3 and 12 months, respectively (p < 0.01). No serious complications occurred. CONCLUSION: Suprachoroidal drainage with collagen sheet implantation seems to be a safe and effective surgical technique for non-penetrating glaucoma surgery that yields the opportunity of a sufficient IOP reduction for eyes unsuitable for canaloplasty.

Comparison of intraocular pressure during the application of a liquid patient interface (FEMTO LDV Z8) for femtosecond laser-assisted cataract surgery using two different vacuum levels.

BACKGROUND: To evaluate intraocular pressure (IOP) using the application of a novel liquid patient interface for femtosecond laser-assisted cataract surgery with the FEMTO LDV Z8. METHODS: IOP was evaluated in enucleated porcine eyes prior, during and after the application of the Femto LDV Z8 liquid patient interface (Ziemer Ophthalmic Systems, Switzerland) using intracameral cannulation (n=20), intravitreal cannulation (n=20), rebound tonometry (n=20) and indentation tonometry (n=20). Pressure was assessed prior vacuum, during vacuum (30 s, 1 min, 2 min, 3 min) and after releasing the vacuum (1 min and 2 min). Two groups with different predefined vacuum levels (350 mbar, 420 mbar) were investigated. RESULTS: Mean intracameral pressure (±SD) increased during vacuum application from 20 mm Hg to 52.00 mm Hg (±6.35mm Hg; p=0.005) and 45.18 mmHg (±4.34 mm Hg; p=0.005) for the 420 mbar and the 350 mbar vacuum levels, respectively. Mean intravitreal pressure increased from 20 mm Hg to 25.60 mm Hg (±9.85 mm Hg; p=0.058) and 28.10 mm Hg (±2.54 mm Hg; p=0.059) for the 420 mbar and the 350 mbar vacuum levels, respectively. Pressure values from indentation and rebound tonometry were in between intracameral and intravitreal values. Mean intracameral IOP was 18.1% higher (p=0.019) in the 420 mbar group compared with the 350 mbar group. CONCLUSION: During vacuum application of the liquid patient interface of the Femto LDV Z8 for femtosecond laser-assisted cataract surgery, IOP values were higher in the anterior chamber compared with the intravitreal pressure measurements. The higher predefined vacuum level (350 mbar vs 420 mbar) resulted in significant higher intracameral IOP.

Femtosecond laser-assisted cataract surgery: First clinical results with special regard to central corneal thickness, endothelial cell count, and aqueous flare levels.

PURPOSE: To evaluate clinical data and outcomes after femtosecond laser-assisted cataract surgery with the recently introduced low-energy Femto LDV Z8 laser during a 3-month follow-up. SETTING: Knappschaft Eye Clinic Sulzbach, Knappschaft Hospital Saar GmbH, Sulzbach, Germany. DESIGN: Consecutive case series. METHODS: Femtosecond laser-assisted cataract surgery was performed using the low-energy femtosecond laser. Clinical data including objective refraction, corrected distance visual acuity, central corneal thickness (CCT), endothelial cell count (ECC), and aqueous flare were evaluated 1 day, 1 week, 4 weeks, and 3 months postoperatively. RESULTS: The median CCT and aqueous flare were statistically significantly elevated during the first day and 4 weeks after surgery, respectively (P < .001). There were no significant differences between CCT preoperatively and 1 week postoperatively (P = .079) and aqueous flare preoperatively and 3 months postoperatively (P = .082). No statistically significant difference was found in the median ECC and spherical equivalent refraction between preoperatively and postoperatively (P > .05). CONCLUSION: Visual outcomes and investigated parameters reflecting corneal integrity indicated safe and atraumatic surgery using a new low-energy femtosecond laser for laser-assisted cataract surgery (including capsulotomy and lens fragmentation). FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Novel liquid bubble dissection technique for DMEK lenticule preparation.

PURPOSE: Descemet endothelial keratoplasty (DMEK) has replaced penetrating keratoplasty in many cases of endothelial cell disorders. While DMEK has been greatly improved by the introduction of no-touch injection cartridges, the tear-free preparation of the delicate Descemet's membrane (DM) remains a critical step. We present a novel liquid bubble dissection technique for DM preparation that could offer several advantages. METHODS: After identification of the iris base, a sharp dissection until Schwalbe's line was performed. Then, a narrow tunnel was created with a blunt spatula using a tangential dissection technique. After the tunnel was created, the liquid bubble dissection was performed. The complete detachment process took only a few seconds after a successful preparation of the tunnel in the correct plane between the DM and corneal stroma. RESULTS: Between February and September 2015, we consecutively performed 86 DMEK lenticule preparations using the liquid bubble technique. The preparation time until complete detachment was about 3 min (mean 194 ± 20 s). Ninety-two percent of preparations were completely uncomplicated; the total success rate was 99 %. One graft could not be used for transplantation because of a central tear. The graft failure rate was 1.16 %, similar to other authors. CONCLUSIONS: The presented novel liquid bubble technique is easy, can be learned and performed rapidly, is highly reproducible in a standardized fashion with minor tissue manipulation (no touch) and, with a low rate of graft preparation failure, necessitates no special equipment and allows for a simultaneous and selective staining of the stromal side of DM, thus avoiding direct contact.