Blood-Aqueous Barrier Disruption in Penetrating and Posterior Lamellar Keratoplasty: Implications for Clinical Outcome. / Blut-Kammerwasser-Schranken-Störungen bei perforierender und posteriorer lamellärer Keratoplastik: Implikationen für das klinische Ergebnis.

BACKGROUND: The blood-aqueous barrier (BAB) separates immunoprivileged tissue of the eye from the blood circulation. Disruption of the BAB is therefore a risk factor for rejection after keratoplasty. PURPOSE: The present work provides a review of the work of our group and others on BAB disruption in penetrating and posterior lamellar keratoplasty and its implications for clinical outcome. METHODS: A PubMed literature search was performed to generate a review paper. RESULTS: Laser flare photometry provides an objective and reproducible method to assess the integrity of the BAB. Studies of the flare after penetrating and posterior lamellar keratoplasty demonstrate a mostly regressive disruption of the BAB in the postoperative course, which is influenced in extent and duration by multiple factors. Persistently elevated flare values or an increase in flare after initial postoperative regeneration may indicate an increased risk of rejection. DISCUSSION: In case of persistent or recurrent elevated flare values after keratoplasty, intensified (local) immunosuppression may potentially be useful. This could become important in the future, especially for the monitoring of patients after high-risk keratoplasty. Whether an increase of the laser flare is a reliable early indicator of an impending immune reaction after penetrating or posterior lamellar keratoplasty has to be shown in prospective studies.

Long-Term Outcome of Descemet Membrane Endothelial Keratoplasty in Eyes With Fuchs Endothelial Corneal Dystrophy Versus Pseudophakic Bullous Keratopathy.

PURPOSE: The aim of this study was to compare the long-term outcome of Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK). METHODS: Records of consecutive DMEK surgeries performed between 2015 and 2016 at the Department of Ophthalmology, Cologne, Germany, were retrospectively reviewed from the prospective Cologne DMEK Database. Eyes with either PBK or FECD with a complete 3-year follow-up were enrolled. Main outcome parameters included central corneal thickness (CCT), peripheral corneal thickness (PCT), best spectacle-corrected visual acuity (BSCVA, logarithm of the Minimum Angle of Resolution), and endothelial cell count (ECC) before and after DMEK. RESULTS: Four hundred two eyes from 402 patients were included (FECD n = 371, PBK n = 31). Preoperatively, CCT (FECD: 681.91 ± 146.78 µm; PBK: 932.25 ± 319.84 µm) and PCT (FECD: 732.26 ± 98.22 µm; PBK: 867.54 ± 88.72 µm) were significantly higher in the PBK group (P < 0.01). Three years after DMEK, CCT (FECD: 526.56 ± 27.94 µm; PBK 663.71 ± 132.36 µm) was significantly lower in both groups compared with the preoperative values (P < 0.01), whereas PCT showed no significant difference. PCT increased during the course in the PBK group from month 12 after DMEK (12 mo: 783.73 ± 127.73 µm; 24 mo: 837.50 ± 110.19 µm; 36 mo: 857.79 ± 140.76 µm). The increase in PCT correlated with an accelerated ECC loss starting 12 months after DMEK (P = 0.036). Before DMEK, BSCVA in FECD was significantly higher (P < 0.001) compared with that in PBK. After 3 years, BSCVA improved in FECD and PBK eyes without significant difference (P = 0.239). CONCLUSIONS: Visual acuity after DMEK in PBK and FECD seems to be comparable during the long-term follow-up. Peripheral and central corneal edema seems to recur faster in eyes with PBK than in those with FECD. Therefore, using a donor graft with higher ECC or possibly a larger graft could be a promising approach for PBK patients.

Predicting outcome of epilepsy surgery in clinical practice: Prediction models vs. clinical acumen.

PURPOSE: Epilepsy surgery is an evidence-based treatment for drug-refractory focal epilepsy. We aimed to evaluate how well preoperative outcome estimates of epilepsy surgery in clinical practice correlated with postoperative outcome and to compare prediction by the clinical team with available scores (m-SFS, ESN). METHOD: Retrospective cohort study including patients with drug-refractory focal epilepsy who underwent resective epilepsy surgery at Epilepsy Center Hessen, Marburg, between 1998-2016. Patients were categorized into four groups based on their estimated chance of postoperative seizure freedom documented in preoperative medical records. Variables required for calculation of m-SFS and ESN were also extracted from presurgical medical records. Seizure outcome using Engel/ILAE classifications was extracted from postoperative medical records. RESULTS: 148 patients were included and 98 had follow-up at 5 years. 69 (70%) had Engel I and 50 (51%) ILAE 1 outcome. Observed 5-year outcome for very good candidates was 20/22 (91%) Engel I and 14/22 (64%) ILAE 1, for good candidates 29/40 (73%) Engel I and 21/40 (53%) ILAE 1, for candidates with slightly reduced chance 11/18 (61%) Engel I and 9/18 (50%) ILAE 1 and for candidates with considerably reduced chance 1/5 (20%) Engel I and 1/5 (20%) ILAE 1.There were no significant differences in discrimination or overall performance between predictions by the clinical team, ESN and m-SFS. CONCLUSIONS: Preoperative outcome estimates corresponded well with observed outcome indicating adequate patient counseling.