[Trabeculotomy (ab externo) as primary intervention for open-angle glaucoma : 5-year results]. / Trabekulotomie (ab externo) als Ersteingriff bei Offenwinkelglaukomen : 5-Jahres-Ergebnisse.

BACKGROUND: The published results of trabeculotomy ab externo (TOT), as an outflow channel surgery in adults with open-angle glaucoma, are underrepresented in comparison with other pressure-lowering glaucoma procedures. OBJECTIVE: To determine the long-term pressure lowering effect and complications of TOT as a stand-alone procedure or in combination with phacoemulsification with intraocular lens implantation (PIT) as a primary pressure-lowering procedure in adult patients with forms of chronic open-angle glaucoma. METHOD: This was a retrospective analysis of 121 eyes of 106 patients wherby 90 eyes underwent TOT and 31 eyes underwent PIT. The follow-up period was 5 years. Follow-up was performed in the same center under standardized conditions. Preoperative as well as postoperative best-corrected distance visual acuity, intraocular pressure, pressure-lowering medication, and complications were recorded. For success criterion 1, the intraocular pressure was not allowed to exceed 17 mm Hg at any control. For success criterion 2, the intraocular pressure was allowed to be above 17 mm Hg at 1 control throughout the follow-up period. RESULTS: Preoperative intraocular pressure in the TOT group was 25.92 mm Hg (SD 6.58) and 26.32 mm Hg (SD 6.06) in the PIT group. The annual cumulative success rates with pressure-lowering medications for success criterion 1 were 92.8%, 82.5%, 70.5%, 52.7% and 26.1%. For success criterion 2 these were 97.9%; 94.9%, 93.2%, 91.3%, and 89%. We found no relevant difference in pressure reduction between TOT and PIT. Without pressure-lowering medications, success rates were significantly lower for both success criteria. No serious complications occurred. The most common postoperative complication was spontaneously resorbable hyphema. CONCLUSION: Performing TOT or PIT as a primary glaucoma procedure for chronic open-angle glaucoma in adults is reasonable, has a significant pressure-lowering effect and very low complication rate.

Decompensated cornea with epithelial and stromal edema.

A 66-year-old patient underwent surgery for congenital cataract in both eyes in her first year of life without implantation of an intraocular lens (IOL). In 1994, at the age of 39 years, both eyes received secondary Kelman multiflex-style angle-fixated anterior chamber IOLs (AC IOLs). The surgeries were followed by retinal detachments in both eyes, in the left eye in the same year and in the right eye 4 years later, which were successfully repaired. The patient presented with a decompensated cornea with epithelial and stromal edema in the left eye. The AC IOL axis was oriented from 5- to 8-o'clock position with the haptic contacting the cornea. The distal portion of the inferior-nasal haptic was deeply buried and entrapped in a broad iridocorneal synechia extending between 6- and 8-o'clock positions. The synechia also caused adjacent pupillary distortion and pigment leaf eversion (Figure 1JOURNAL/jcrs/04.03/02158034-202205000-00021/figure1/v/2022-04-22T173532Z/r/image-tiff). The AC IOL in the right eye was well positioned, and the cornea was clear with an endothelial cell count (ECC) of 2160 cells/mm2 and central corneal thickness (CCT) of 650 µm. No ECC was obtainable in the left eye, and CCT was 775 µm (Figure 2JOURNAL/jcrs/04.03/02158034-202205000-00021/figure2/v/2022-04-22T173532Z/r/image-tiff). Visual acuity was 0.8 corrected in the right eye and hand motion in the left eye. Both eyes were normotonic. On optical coherence tomography (OCT) imaging, a broad iridocorneal synechia was visible with a canal corresponding to the deeply buried haptic end of the AC IOL (Figure 3JOURNAL/jcrs/04.03/02158034-202205000-00021/figure3/v/2022-04-22T173532Z/r/image-tiff). Abundant condensed cortical material (Soemmerring's ring) was found behind the iris and above the ciliary body. What would be your surgical options to rehabilitate the patient's left eye considering corneal decompensation caused by haptic contact of an angle-fixated AC IOL and capture of 1 haptic within an iridocorneal synechia extending along 2 clock hours?

Electrical neurostimulation in glaucoma with progressive vision loss.

BACKGROUND: The retrospective study provides real-world evidence for long-term clinical efficacy of electrical optic nerve stimulation (ONS) in glaucoma with progressive vision loss. METHODS: Seventy glaucoma patients (45 to 86 y) with progressive vision loss despite therapeutic reduction of intraocular pressure (IOP) underwent electrical ONS. Closed eyes were separately stimulated by bipolar rectangular pulses with stimulus intensities up to 1.2 mA sufficient to provoke phosphenes. Ten daily stimulation sessions within 2 weeks lasted about 80 min each. Right before ONS at baseline (PRE), vision loss was documented by static threshold perimetry and compared to the same assessment approximately 1 year afterwards (POST). Mean defect (MD) was defined as primary outcome parameter. Perimetries with a reliability factor (RF) of max. 20% were considered. RESULTS: Perimetry follow-up of 101 eyes in 70 patients fulfilled the criterion of a max. 20% RF. Follow-up was performed on average 362.2 days after ONS. MD significantly decreased from PRE 14.0 dB (median) to POST 13.4 dB (p < 0.01). 64 eyes in 49 patients showed constant or reduced MD as compared to baseline (PRE 13.4 dB vs. POST 11.2 dB). In 37 eyes of 30 patients, MD increased from PRE 14.9 dB to POST 15.6 dB. CONCLUSIONS: Innovative treatments that preserve visual function through mechanisms other than lowering IOP are required for glaucoma with progressive vision loss. The present long-term data document progression halt in more than 63% of affected eyes after ONS and, thus, extend existing evidence from clinical trials.

[Age-related Cataract]. / Die senile Katarakt.

The purpose of this article is a condensed overview of contemporaneous "state of art and knowledge" of age-related cataract. As an introduction, some aspects of terminology, epidemiology, lens anatomy and pathophysiology of age-related cataract, selected for clinical interest and relevance, are outlined. Clinical aspects include signs and symptoms: Objective criteria for cortical, nuclear and posterior subcapsular cataract are described, followed by typical symptoms such as decreased visual acuity, contrast sensitivity and foggy vision, altered colour perception, decreased mesopic and scotopic vision, glare, myopization and monocular diplopia. Diagnostic evaluation consists of a general ophthalmic examination, including history, refraction and vision testing, tonometry and morphologic examination of anterior and posterior segment, and is supplemented by special tests and examinations, such as interference vision (retinometer), keratometry including corneal topo-/tomography, biometry (ultrasound and optical), specular microscopy of the corneal endothelium and OCT of the central retina. Treatment is exclusively surgical: Evaluating the indication for surgery individually, weighing chances and risks, determining individual decisions such as anesthesia, surgical technical options, target refraction and intraocular lens options is discussed in detail. Finally, some perioperative considerations for medical treatment and infection prophylaxis are outlined. The last section deals with short- and long-term complications and their management - including early pressure rises, corneal edema, inflammatory response and endophthalmitis, and, in the longer term, secondary cataract, refractive problems, cystoid macular edema and retinal detachment.

The impact of vitrectomy on outcomes achieved with 0.19 mg fluocinolone acetonide implant in patients with diabetic macular edema.

BACKGROUND: There is a lack of consensus on the use of intravitreal corticosteroid therapies in patients with diabetic macular edema (DME) and prior vitrectomized eyes in clinical practice. METHODS: Retro-IDEAL was a 3-year retrospective, multicenter study in patients with chronic DME (i.e. DME that persists or recurs despite treatment) treated with ILUVIEN® (0.2 µg daily fluocinolone acetonide intravitreal implant), who had suboptimal outcomes with first-line vascular endothelial growth-factor inhibitors and other DME therapies. RESULTS: A total of 81 eyes (63 patients) were included of which 39 eyes had undergone prior vitrectomy (PV group) while 42 eyes had not undergone prior vitrectomy (NPV). Baseline characteristics were balanced; however, more patients had proliferative diabetic retinopathy in the PV group vs. the NPV group (21.62% vs 9.38%, respectively). Over 36 months, mean visual acuity (VA) increased in both groups with a tendency for more ETDRS letters being gained in the NPV group (+5.33) vs. the PV group (+2.42). By month 36, central retinal thickness was reduced to ⩽300 µm in two-thirds of the eyes in both groups and the mean change from baseline in intraocular pressure was similar in both groups (+0.50 mmHg -0.75 mmHg; NPV and PV group). CONCLUSIONS: These long-term data suggest that the 0.2 µg/day FAc implant is effective in both vitrectomized and non-vitrectomized patients, with a manageable safety profile, and improved VA and reduced supplemental therapies for patients with a suboptimal response to first-line DME therapies. Clinicians may consider utilizing the FAc implant earlier in the DME disease process.

Three-year results from the Retro-IDEAL study: Real-world data from diabetic macular edema (DME) patients treated with ILUVIEN® (0.19 mg fluocinolone acetonide implant).

INTRODUCTION: The Retro-IDEAL (ILUVIEN Implant for chronic DiabEtic MAcuLar edema) study is a retrospective study designed to assess real-world outcomes achieved with the ILUVIEN® (0.19 mg fluocinolone acetonide (FAc)) in patients with chronic diabetic macular edema (DME) in clinical practices in Germany. METHODS: This study was conducted across 16 sites in Germany and involved 81 eyes (63 patients) with persistent or recurrent DME and a prior suboptimal response to a first-line intravitreal therapy (primarily anti-VEGF intravitreal therapies). RESULTS: Patients were followed-up for 30.8 ± 11.3 months (mean ± standard deviation) and had a mean age of 68.0 ± 10.4 years. Best-recorded visual acuity (BRVA) improved by +5.5 letters at month 9 (P ⩽ 0.005, n=56; from a baseline of 49 letters) and this was maintained through to month 30 (P ⩽ 0.05, n = 42). There was a concurrent improvement in central macular thickness with a reduction from 502 µm at baseline to 338 µm at year 1 (P ⩽ 0.0001, n = 43). This effect was sustained to year 3 (i.e. 318 µm; P ⩽ 0.0001, n = 29). Mean intraocular pressure (IOP) remained constant between baseline and year 3 with a peak change of 1.9 mm Hg occurring at year 1. Elevated IOP was observed in a similar percentage of patients prior to (22.2% of cases) and following (27.2%) treatment with the FAc implant. In the majority of cases, these elevations were managed effectively with IOP medications. CONCLUSIONS: Despite substantial amounts of prior intravitreal treatments - primarily with anti-vascular endothelial growth factor (VEGF) drugs - this real-world study showed that sustained structural and functional improvements can last for up to 3 years with a single FAc implant.

Telemetric Intraocular Pressure Monitoring after Boston Keratoprosthesis Surgery Using the Eyemate-IO Sensor: Dynamics in the First Year.

PURPOSE: To analyze the dynamics of telemetrically measured intraocular pressure (IOP) during the first year after implantation of a Boston keratoprosthesis type I (BI-KPro) cornea and to compare agreement of telemetric IOP measurements with finger palpations. DESIGN: Prospective, open-label, multicenter, single-arm clinical trial. METHODS: In the ARGOS (NCT02945176) study, 12 individuals underwent implantation of an Eyemate-IO intraocular system. Follow-up after surgery took place 12 months later with 13 visits planned per patient. During BI-KPro surgery, an electromagnetic induction sensor ring enabling telemetric IOP data transfer to a hand-held reading device outside the eye was implanted into the ciliary sulcus with or without trans-scleral suture fixation. Comprehensive ophthalmic examinations and IOP assessments through the telemetric system were compared to IOP assessed by finger palpation by 2 experts. RESULTS: Preoperative IOP measured by Goldmann tonometry was 13.4 ± 6.2 mm Hg. Telemetric IOP peaked at 23.1 ± 16.5 mm Hg at the first postoperative day. On day 5, mean IOP was 16.0 ± 5.2 mm Hg and 20.95 ± 6.5 mm Hg after 6-12 months. IOP estimation by finger palpation was grouped in 4 categories: normal, A; soft/hypotonic, B; borderline, C; and hypertonic, D. Mean telemetric IOP was 18.2 ± 6.1 mm Hg in category A, 8.9 ± 2.8 mm Hg in B, 22.4 ± 4.9 mm Hg in C, and 34.3 ± 11.0 mm Hg in D. Differences in mean telemetric IOPs per category were statistically significant (P < .001). Daily IOP fluctuations and peaks could be identified. CONCLUSIONS: Telemetric IOP assessment seems to be able to identify postoperative IOP peaks and a longitudinal increase of IOP after BI-KPro surgery. IOP measurements using the telemetric Eyemate-IO sensor showed a satisfactory agreement with those of finger palpations by 2 experts.

Refractive outcomes of femtosecond laser-assisted secondary arcuate incisions in patients with residual refractive astigmatism after trifocal intraocular lens implantations.

PURPOSE: To evaluate the refractive and visual outcomes of arcuate incisions performed with the femtosecond laser in patients with a residual refractive astigmatism after refractive lens exchange (RLE) with trifocal intraocular lenses (IOLs). SETTING: EuroEyes Clinical Group, Hamburg, Germany. DESIGN: Retrospective interventional case series. METHODS: Pseudophakic patients with remaining refractive astigmatism after RLE with a trifocal IOL were treated with femtosecond laser-assisted corneal arcuate incisions. Patients who had a previous corneal treatment were excluded. Outcome measures were uncorrected (UDVA) and corrected distance visual acuities, manifest refraction, and a power vector analysis. RESULTS: The study enrolled 95 eyes of 70 patients. The mean follow-up was 5.6 months ± 4.9 (SD). Constructing an astigmatic power vector (APV) with Jackson cross-cylinder axes at 180 degrees and 90 degrees and Jackson cross-cylinder axes at 45 degrees and 135 degrees, the mean preoperative vector length was 0.46 ± 0.16 diopter (D). The mean postoperative APV was 0.17 ± 0.16 D. This difference was statistically significant (P < .001). The difference between the UDVA preoperatively (0.17 ± 0.15) and postoperatively (0.08 ± 0.10) was statistically significant (P < .001). No intraoperative or postoperative complications were observed. CONCLUSION: Femtosecond laser-assisted corneal arcuate incisions were safe, efficient, and feasible to reduce refractive astigmatism after trifocal IOL implantation.

Keratoplasty in patients with intellectual disability.

PURPOSE: The aim was to report the outcome of keratoplasty in patients with intellectual disability (ID). METHODS: All patients with ID who had undergone keratoplasty at the Eye Department, Red Cross Hospital, Munich, between January 1, 1991, and December 31, 2010, were identified and recalled for examination. In cases of missing data, the information contained in the patient's chart was analyzed and/or his ophthalmologist was contacted. RESULTS: A total of 38 eyes (29 patients) that had undergone 53 keratoplasty procedures were included in the analysis. In 20 patients, the general diagnosis was Down syndrome, 1 patient had ID as a result of brain tumor excision, and 8 patients had ID of an unknown origin. The indication for the primary keratoplasty (n = 35) was keratoconus in 33 patients and corneal opacity because of exposure in facial nerve palsy in 2 patients. In the 3 remaining patients, the first procedure at the study institution was a repeat keratoplasty. The median follow-up was 9 years (minimum 6 months, maximum 20 years). The graft survival rate of the primary graft was 86% (n = 30/35) from 27 months to 11 years. At the last follow-up visit, a clear graft was present in 89% of all the patients (n = 34/38). One eye underwent enucleation, and 3 other eyes remained with a cloudy graft after multiple interventions for rejection/corneal ulceration. CONCLUSIONS: The majority of the patients with ID clearly benefited from keratoplasty, although a few deleterious courses occurred. Keratoplasty in these individuals can be considered whenever patients can no longer comply with the visual demands of their particular individual life.

Intraocular lens calcification after keratoplasty.

PURPOSE: To report calcification of intraocular lenses (IOLs) after various keratoplasty procedures. METHODS: Clinical data of all cases with calcified IOLs after keratoplasty procedures were analyzed. A total of 6 explanted IOLs were analyzed with light microscopy before and after staining with 1% alizarin red and the von Kossa method. RESULTS: A total of 7 cases occurred after Descemet stripping automated endothelial keratoplasty, 1 case after deep anterior lamellar keratoplasty, and 2 cases after penetrating keratoplasty. Median time interval from keratoplasty to first notice of IOL opacification was 6.5 months (minimum 3 months, maximum 51 months). A total of 3 IOLs had been placed at the time of keratoplasty and 7 IOLs before keratoplasty. All affected IOLs were hydrophilic acrylic and comprised IOLs from at least 3 different polymer sources. Common clinical aspects were some amount of inflammation in the anterior chamber during the postoperative period and use of air at the end of surgery in 8 of the 10 cases. Histochemical analysis demonstrated the presence of fine granular deposits located within the very superficial optic material in all cases. The deposits stained positive for calcium with alizarin red and the von Kossa method. CONCLUSIONS: IOL calcification associated with keratoplasty in our series does not seem to be a problem related to a specific IOL model or polymer. The process of calcification may be mediated by inflammation, which also may be related to multiple injections of air into the anterior chamber.

Determination of valid benchmarks for outcome indicators in cataract surgery: a multicenter, prospective cohort trial.

OBJECTIVE: To evaluate a systematic approach to derive valid benchmarks for 2 outcome indicators intended to ascertain quality in cataract surgery and to propose benchmark levels drawn from the study results. DESIGN: Prospective, multicenter cohort trial. PARTICIPANTS: A total of 1685 patients (206-239 eyes per trial site) were recruited consecutively at 7 study sites. The patients featured age-related cataracts and were undergoing unilateral cataract surgery in the period between January 2007 and August 2008. METHODS: Only patients with uncomplicated age-related cataracts were included. Cataract surgery was performed by phacoemulsification. The SN60AT (Alcon, Inc., Fort Worth, TX) intraocular lens (IOL) was used as a study lens. The IOL power was calculated using the SRK-T formula with a standardized A constant. Biometry was performed with the IOL Master (Carl Zeiss Meditex, Jena, Germany). Only highly experienced senior surgeons were involved. MAIN OUTCOME MEASURES: The outcome indicators 1 month and 3 months after surgery were the respective achievement of: (1) maximum absolute deviation of 0.5 diopter (D) between target refraction and postoperative spherical equivalent (primary end point, refractive accuracy); (2) best-corrected visual acuity of at least 0.8 (secondary end point, visual acuity outcome). RESULTS: In the pooled data, maximum absolute deviation of ± 0.5 D from target refraction was achieved in 80% (95% confidence interval, 78%-82%) of cases. Visual acuity of 0.8 or more was reached in 87% (95% confidence interval, 80%-93%) of cases. The results from the trial centers differed significantly in the outcomes of the primary and secondary end points (P<0.001). CONCLUSIONS: The study quantified benchmark levels for 2 outcome indicators in a standardized cataract surgery procedure. External confounding factors such as the comorbidity of patients, which cannot be influenced by the surgeon, were excluded. The derived benchmarks selectively illustrate the quality of the surgery and are superior to success rates published in the literature from unspecific data collections. This method is more suited for improving outcome quality by benchmarking. General methodologic problems are discussed, leading to recommendations for future study designs. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

A homozygous microdeletion within ADAMTSL4 in patients with isolated ectopia lentis: evidence of a founder mutation.

PURPOSE: The purpose of the study was to look for ADAMTSL4 mutations in a cohort of German patients with isolated ectopia lentis from nonconsanguineous families. METHODS: Mutation screening was performed by PCR amplification of the coding exons of ADAMTSL4 and subsequent sequencing. RESULTS: An identical homozygous deletion of 20 bp of coding sequence within exon 6 (NM_019032.4:c.759_778del20) was identified in eight individuals from seven unrelated families. In a screen of 360 ethnically matched, unaffected individuals, two heterozygous mutation carriers were found. The mutation was always accompanied by the identical haplotype, suggestive of a founder mutation. CONCLUSIONS: The results emphasize the association of ADAMTSL4 null mutations with isolated ectopia lentis and the presence of a founder mutation in the European population. Screening of ADAMTSL4 should be considered in all patients with isolated ectopia lentis, with or without family history. In patients from nonconsanguineous families, the authors propose a two-step diagnostic approach, starting with an examination of exon 6 before sequencing the entire coding region of ADAMTSL4.

Static and dynamic rotational eye tracking during LASIK treatment of myopic astigmatism with the Zyoptix laser platform and Advanced Control Eye Tracker.

PURPOSE: To evaluate the amount of cyclotorsion and the effect of static and dynamic rotational eye tracking with the Advanced Control Eye Tracker (Bausch & Lomb) based on iris recognition in the treatment of myopic astigmatism with LASIK. METHODS: All patients with myopic LASIK and attempted cylinder correction >0.75 diopters (D) on the Zyoptix 217z100 excimer laser platform between May 2005 and May 2007 were identified retrospectively through the existing databank. Pre- and postoperative refraction and the amount of cyclotorsion during treatment were extracted and analyzed in 828 eyes with >3-month follow-up. RESULTS: Preoperative mean manifest refraction spherical equivalent (MRSE) was -4.31+/-1.84 D (range: -0.37 to -9.50 D), and mean cylinder was -1.27+/-0.87 D (range: -0.75 to -6.75 D). Mean static rotation was 3.96+/-2.96 degrees (maximum 14.8 degrees ). Median dynamic rotation was 1.32+/-1.85 degrees (maximum 24 degrees). At 3 months postoperatively, MRSE was -0.10+/-0.36 D (range: -2.25 to +1.25 D), and mean cylinder was -0.33+/-0.35 D (range: -2.00 to 0 D). Predictability was 90.2% within +/-0.50 D and 98.2% within +/-1.00 D (MRSE), and 82.5% within +/-0.50 D and 96.9% within +/-1.00 D (cylinder). The efficacy ratio was 0.99. Safety was 99.4% (5 dry eyes), reaching 100% at 12 months. Stability from 3 to 12 months (n=275) was 98.2% for sphere, 95.3% for cylinder, and 96.0% for MRSE. CONCLUSIONS: Our study demonstrates that significant cyclotorsion occurs before and during treatment. By using the dynamic rotational eye tracker presented, the efficacy of cylinder correction can be improved compared to those studies not performing cyclotorsional correction.