[Career prospects for ophthalmologists under 49 years old : A survey in Germany from 2022]. / Berufliche Zukunftsperspektive von Augenärzten unter 49 Jahren : Eine Umfrage in Deutschland aus dem Jahr 2022.

OBJECTIVE: The need for care in ophthalmology is constantly increasing due to demographic changes. The study analyzed the current professional situation and future prospects of ophthalmologists under 49 years old. METHODS: The survey of members of the German Association of Ophthalmologists (Berufsverband der Augenärzte Deutschlands) and the German Ophthalmologic Society (Deutsche Ophthalmologische Gesellschaft) was conducted in 2022. All members under the age of 49 years received an online questionnaire on the current professional situation as well as future perspectives (desired working hours, form of organization). The results of the survey were additionally compared with the 2016 survey of the German Association of Ophthalmologists. A similar questionnaire was used at that time. RESULTS: A total of 1014 people participated in the survey (62.7% women, mean age 39.3 ± 8 years, 75.6% specialists). The response rate to the survey was 25%. Specialist practice from 0 to 5 years showed a higher number of employed ophthalmologists (21% self-employed vs. 32% employed); over time the number of self-employed ophthalmologists increased (6-10 years: 40%, > 10 years: 59.3%). Overall, 46% of women were employed in a practice compared with 33% of men. Of the self-employed specialists, 95.9% said they planned to work in the same type of employment in 10 years as currently. Regarding ophthalmologists' career future, the other employment types showed a desire to move to independent practice. Compared to the 2016 survey, gender differences related to the current type of employment were evident. The number of self-employed women decreased from 43% to 26% and self-employed men decreased from 63% to 39%. The number of ophthalmologists in ambulatory healthcare centers was doubled compared to 2016. Ophthalmologists reported similar future perspectives at both survey times. CONCLUSION: The results of the survey of ophthalmologists under 49 years in Germany showed similar perceptions as in 2016. It became clear that the desire to be self-employed in 10 years is very high; however, ophthalmologists expected large practices or medical care centers to prevail in the market. The number of self-employed doctors is decreasing and the desire for self-employment is difficult to realize.

[Diagnostics, clinical aspects and genetics of congenital corneal opacities]. / Diagnostik, Klinik und Genetik kongenitaler Hornhauttrübungen.

BACKGROUND: Congenital corneal opacities are comparatively rare diseases with high amblyogenic potential. PURPOSE: The present work provides an overview of the diagnostics, clinical aspects and genetics of congenital corneal opacities. METHODS: A literature search was carried out to compile an overview and illustration with own clinical case examples. RESULTS: Differentiated diagnostics are of high importance in the treatment of patients with congenital corneal opacities. A close cooperation between the medical departments involved and also the parents is absolutely essential. The structured classification of congenital corneal opacities provides the basis for a targeted treatment. DISCUSSION: The causes and the clinical symptoms of congenital corneal opacities are manifold. The correct diagnosis should be made early and in an interdisciplinary manner. Based on this, conservative and surgical treatment measures can be planned and an impending development of amblyopia can be specifically counteracted.

[Preconditioning of vascularized high-risk eyes using fine-needle diathermy and cross-linking]. / Präkonditionierung von vaskularisierten Hochrisikoaugen mittels Feinnadeldiathermie und Crosslinking.

BACKGROUND: The risk of allograft rejection following high-risk keratoplasty increases with the area of corneal neovascularization. Pharmaceutical and physical regression of corneal neovascularization before keratoplasty may offer the potential to reduce the risk of graft rejection after high-risk keratoplasty. OBJECTIVE: This article provides a review of the literature on the preconditioning of vascularized high-risk eyes using fine-needle diathermy and corneal cross-linking (preoperative preconditioning by lymphangioregression). METHODS: A literature search was carried out in PubMed and a summary of own data is presented. RESULTS: Animal experimental studies showed that both fine-needle diathermy and corneal cross-linking lead to a regression of corneal neovascularization and prolong graft survival after high-risk keratoplasty. Furthermore, studies from our institute provide first evidence that both procedures also lead to a reduction of corneal neovascularization in the clinical practice and thus potentially reduce the risk of allograft rejection after subsequent high-risk keratoplasty. DISCUSSION: Fine-needle diathermy and corneal cross-linking provide effective therapeutic approaches for angioregressive treatment and seem to prolong graft survival following high-risk keratoplasty. Larger prospective and controlled clinical trials are needed to further investigate these promising therapeutic approaches.

[Treatment of vascularized high-risk eyes with a Boston keratoprosthesis]. / Versorgung von vaskularisierten Hochrisikoaugen mittels Boston-Keratoprothese.

BACKGROUND: In severely compromised and vascularized high-risk eyes, the Boston keratoprosthesis procedure is often the last treatment option. The transparency of the optics is not impaired by endothelial immune reactions. METHODS: This review article discusses relevant literature as well as our own data and experiences with the Boston keratoprosthesis in high-risk eyes. The relevant complications as well as the postoperative management are discussed. RESULTS: In more than 60% of the high-risk eyes a long-term increase in visual acuity can be achieved. Keratoprosthesis retention rates show a variable span with reported mean 5­year retention rates of 75%. The most common postoperative complications include the formation of a retroprosthetic membrane and keratolysis in up to 50% each. More than 70% of the eyes already suffer from (secondary) glaucoma preoperatively, so that glaucoma surgery is performed simultaneously in at least 20% of cases and in the postoperative course further antiglaucomatous surgery is necessary in up to 31%. Vitreoretinal complications include, in particular, sterile vitritis and infectious endophthalmitis but persistent hypotonia is also described in one third of patients. CONCLUSION: The Boston keratoprosthesis is an alternative to conventional corneal replacement if the prognosis for allogeneic transplants is poor. Postoperative complications are common; therefore, postoperative management plays an important role. For vascularized high-risk eyes, however, it is often the only remaining option for visual rehabilitation.

[Descemet membrane endothelial keratoplasty in complex eyes]. / "Descemet membrane endothelial keratoplasty" in komplexen Augen.

BACKGROUND: Descemet membrane endothelial keratoplasty (DMEK) has become the standard surgical treatment for Fuchs' endothelial corneal dystrophy (FECD) in Germany. In addition to classical FECD, there are endothelial disorders amenable to DMEK associated with complex changes in the anterior segment of the eye, such as anterior synechia of the iris, larger iris defects, after glaucoma surgery, after vitrectomy and after trauma. OBJECTIVE: This article provides an overview of the possibilities to treat patients with complex anterior segment situations in the presence of corneal endothelial decompensation with DMEK. MATERIAL AND METHODS: Description of problems and current surgical techniques when performing DMEK in complex situations. RESULTS: Reconstruction of the iris or the iris/lens diaphragm often needs to be performed either simultaneously or in a previous operation to treat patients with complex anterior segment alterations with DMEK. Both very shallow and very deep anterior chambers pose a major problem. A DMEK graft from older donors (above 70 years) is prone to less rolling and should be preferred in patients with a deep anterior chamber (e.g. after vitrectomy). The graft size should also be adapted to the available space, e. g. a smaller graft diameter should be selected for eyes with anterior synechia. CONCLUSION: There are only a few evaluations of DMEK under complex conditions; however, it appears that the rate of secondary graft failure, endothelial cell loss and the rebubbling rate are increased in this very heterogeneous group of diseases. Further studies are needed to identify risk factors for a negative progression after DMEK in "complex" eyes.

[10 years of Descemet membrane endothelial keratoplasty in Fuchs endothelial corneal dystrophy : What have we learned?] / Zehn Jahre "Descemet membrane endothelial keratoplasty" bei Fuchs-Dystrophie : Was haben wir gelernt?

BACKGROUND AND OBJECTIVE: Descemet membrane endothelial keratoplasty (DMEK) has increased in popularity since its introduction over 10 years ago. This article presents a summary of the experiences of the past years collected at the Department of Ophthalmology at the University of Cologne. METHODS: A literature review of DMEK studies primarily from the Department of Ophthalmology at the University of Cologne, Germany was carried out. Own experiences in the fields of donor selection and graft preparation, DMEK surgery, complication management and postoperative treatment are summarized. RESULTS: Since the introduction of DMEK experience has been gained and ongoing improvements have occurred ranging from donor-recipient allocation to postoperative follow-up. These led to a better reproducibility of the intervention for the surgeon, to a better postoperative result and to a reduction of the complication rate. DISCUSSION: The DMEK represents a safe and individualized procedure for endothelial transplantation for corneal endothelial dysfunction. Continuing development of the method leads to optimization and safer results.

[Boston type I keratoprosthesis implantation technique : Video article]. / Technik der Boston-Typ-I-Keratoprothesen-Implantation : Videobeitrag.

BACKGROUND: Keratoprosthetics refer to the replacement of human corneal tissue with an artificially produced exchange product. The most widely implanted keratoprosthesis worldwide is the Boston Type I Keratoprosthesis (BI-KPro, Massachusetts Eye and Ear Infirmary, Boston, MA, USA). METHODS: This video article demonstrates the surgical technique of BI-KPro implantation as routinely performed at this institution. In addition, an overview of the surgical indications, patient consent, anesthesia and positioning, postoperative treatment and complications as well as the evidence of the technique is provided in the article based on experience with 31 BI-KPro implantations. RESULTS: The indications for BI-KPro primarily include patients in a high-risk keratoplasty setting particularly after repeatedly failed keratoplasty. A thorough patient examination and assessment of the indications as well as detailed disclosure of information to the patient about the individual prognosis, the risk profile, the postoperative therapy and follow-up enable a positive postoperative result. CONCLUSION: The BI-KPro provides an established and relatively standardized option for surgical treatment of eyes in a high-risk keratoplasty setting. Patients should be preoperatively informed with respect to the individual prognosis, complication profile and life-long follow-up.

[Microscope-integrated intraoperative optical coherence tomography in examination of pediatric patients under anesthesia]. / Mikroskopintegrierte intraoperative optische Kohärenztomographie bei der Narkoseuntersuchung von pädiatrischen Patienten.

BACKGROUND: The therapeutic principle of examinations of children under general anaesthesia using microscope-integrated optical coherence tomography (MI-OCT) is presented. The aim was to assess novel indications as well as limitations for MI-OCT to enhance ophthalmological examinations of neonates and children under general anesthesia. METHODS: The study was based on a review of the literature from google.scholar.com and PubMed and our own data from a prospective study (Department for Ophthalmology, University of Cologne) of 14 children with anterior and posterior segment anomalies undergoing examinations under anesthesia. Patients were examined using a commercially available MI-OCT device. The study analyzed the general feasibility of MI-OCT for ophthalmological examination of children under general anesthesia for the anterior and posterior eye segments and the benefits of indications and intraoperative findings. RESULTS: The MI-OCT significantly enriched the examinations of children under general anesthesia and delivered additional information not visible with the surgical microscope. Even in situations with a limited anterior chamber view MI-OCT enabled estimation of distances, such as corneal thickness. In addition to influencing therapeutic decisions, in 12/14 children MI-OCT also enabled examination of the thickness of the nerve fibre layer of the optic nerve disc and the retina. CONCLUSION: The data presented here underline the benefit of the intraoperative MI-OCT in ophthalmological examinations of children under general anesthesia. In particular MI-OCT enables examinations of children with corneal opacification, if an ophthalmological examination under general anesthesia becomes necessary.

[Technique of Descemet membrane endothelial keratoplasty (DMEK) : Video article]. / Technik der "Descemet membrane endothelial keratoplasty" (DMEK) : Videobeitrag.

BACKGROUND: Descemet membrane endothelial keratoplasty (DMEK) selectively removes diseased corneal endothelium and Descemet membrane and replaces them with healthy donor tissue. The DMEK technique represents the current gold standard for the treatment of corneal endothelial dysfunction. METHODS: In this article the surgical technique for DMEK is presented by means of a video. The indications for surgery, patient education, anesthesia and patient positioning, postoperative treatment as well as possible complications and their management are described. RESULTS: The DMEK can be applied for the treatment of a wide range of corneal endothelial disorders. In addition to the operative implementation, the basis for the outstanding results of the surgical procedure are careful donor-patient allocation, thorough examination and follow-up of all patients and experience of the surgeon. CONCLUSION: The use of DMEK is a safe and effective procedure for the treatment of corneal endothelial dysfunction. A standardized and individualized procedure provides the basis for optimal results compared to all previous transplantation procedures.

Epidemiology of dry eye disease in Africa: The sparse information, gaps and opportunities.

Dry eye disease (DED) is an increasingly significant clinical problem in developing countries and/or emerging economies. Existing studies on DED conducted in these areas have largely reported on associations between DED and infectious disease (trachoma) and malnutrition (hypovitaminosis A), but current trends of industrialization, urbanization, and modernization in these areas could result in a shift to other forms of DED. Herein, we review the epidemiology of DED in these geographic areas, highlighting potential causes and risk factors of DED while presenting information on diagnostic tools and algorithms and insight into some treatment modalities of DED that could prove useful to clinicians and investigators in these regions.

[Intraoperative optical coherence tomography in corneal and glaucoma surgical procedures]. / Intraoperative optische Kohärenztomographie bei hornhaut- und glaukomchirurgischen Eingriffen.

BACKGROUND: Optical coherence tomography (OCT) is the clinical gold standard for anterior and posterior segment imaging. Since OCT devices have been integrated into surgical microscopes, this technique is also available intraoperatively in anterior segment surgery. OCT is well established in imaging very thin or transparent structures as they appear in corneal or glaucoma surgery. Therefore, intraoperative OCT can deliver important information for the surgeon which is superior to the normal surgical microscope. OBJECTIVES: In the present work, an overview about the opportunities of intraoperative OCT in cornea and glaucoma surgery are presented. MATERIAL AND METHODS: The recent literature (PubMed) and our own experience at the Center for Ophthalmology, University Hospital of Cologne are analysed. RESULTS: Intraoperative OCT enables real-time imaging during corneal and glaucoma surgery. Several clinical studies exist, indicating its benefit, e. g. in DMEK, DALK, DSAEK, Boston Keratoprosthesis, canaloplasty or trabectome surgery. Several structures, not visible in the surgical microscope, can be visualized using intraoperative OCT. CONCLUSIONS: As a real-time and high-resolution imaging device, intraoperative online OCT delivers additional information in glaucoma and corneal surgery, compared to the normal operating microscope. Nonetheless one of the main problems is the shadowing produced by surgical instruments. Today the main limitation is the lack of randomized-controlled clinical trials, evaluating the benefit of microscope-integrated intraoperative OCT, compared to the microscope.

[Intraoperative Optical Coherence Tomography In Deep Anterior Lamellar Keratoplasty]. / Intraoperative optische Kohärenztomografie bei der tiefen anterioren lamellären Keratoplastik.

BACKGROUND: Like penetrating keratoplasty (pKPL), deep anterior lamellar keratoplasty (DALK) is a standard treatment for keratoconus and stromal corneal dystrophies. Intraoperative optical coherence tomography permits live or real-time monitoring during surgery, especially if it is necessary to estimate distances or if the anterior chamber view is limited. METHODS: Review of literature from PUBMED and our own clinical and experimental data. Key words were "intraoperative Optical Coherence Tomograph", "DALK", "Deep anterior lamellar keratoplasty" and "iOCT". The time frame was set from 2005 to 2016. RESULTS: All surgical steps were visualisable by intraoperative OCT during DALK surgery. Intraoperative OCT permits depth estimation during deep needle insertion and allows the visualisation of intraoperative interface fluid. CONCLUSION: Intraoperative OCT facilitates standardisation during several steps of DALK. Future prospective studies should concentrate on the safety profile of intraoperative OCT-guided DALK compared to DALK without intraoperative monitoring.

[Intraoperative optical coherence tomography for examination of newborns and infants under general anesthesia]. / Intraoperative optische Kohärenztomographie bei Narkoseuntersuchungen von Säuglingen und Kleinkindern.

BACKGROUND: Examination of newborn and children under general anesthesia is essential to prevent amblyopia and blindness; however, the validity was often limited due to a lack of state of the art diagnostic tools in the intraoperative set-up, e. g. optical coherence tomography (OCT). Since OCT devices have been integrated into surgical microscopes, this technique is also available for examination with patients under general anesthesia. OBJECTIVE: To give an overview about the possibilities of intraoperative OCT (iOCT) during examination of newborn and infant children under general anesthesia. MATERIAL AND METHODS: Analysis of recent literature (PubMed) and initial experiences at the Center for Ophthalmology of the University Hospital of Cologne. RESULTS: The use of iOCT enables real-time high-resolution imaging during examinations of children under general anesthesia. All relevant structures of the anterior eye segment (including cornea, lens, chamber angle and iris) can be visualized. Especially when the anterior chamber view is limited due to corneal opacifications, iOCT can deliver important information in addition to that obtained using a surgical microscope. This information is important for the further therapy of the patients. CONCLUSION: Online iOCT is a useful extension of the normal surgical microscope, especially for examination of children under general anesthesia and limited view into the anterior chamber. In our experience it also makes sense to transfer this technique to anomalies of the posterior pole because high-resolution imaging of the macula and optic nerve head is possible.

[Boston-keratoprosthesis : Preliminary experiences in 13 high-risk eyes from the Department of Ophthalmology of the University of Cologne]. / Boston-Keratoprothese : Erste Erfahrungen bei 13 Hochrisikoaugen aus der Kölner Universitätsaugenklinik.

BACKGROUND: Corneal transplantation in high-risk eyes remains a challenge. The Boston keratoprosthesis (B-KPro) is a final option for patients with end-stage corneal disease and a poor prognosis with conventional penetrating keratoplasty. In this article the results of the first 13 eyes that received a B-KPro type I at the Department of Ophthalmology, University of Cologne, Germany are reported and the usefulness of postoperative slit-lamp optical coherence tomography (SL-OCT) for control purposes is evaluated. MATERIAL AND METHODS: All recipients of a B-KPro type I between September 2013 and May 2015 were included in the study. The feasibility of the operation, clinical outcomes, complications and revision surgery were investigated. The visualization of wound healing by SL-OCT was analyzed. RESULTS: The age of the patients ranged from 26 to 92 years (mean 57.3 ± 20.9 years). In all 13 eyes from 12 patients (6 males and 6 females) dense corneal opacification with vascularization and sometimes also conjunctivalization was present. Preoperative visual acuity was reduced and ranged from mere light perception up to a maximum of 1/35 eye chart. All 13 eyes could be supplied with a B-KPro type I without any intraoperative complications, in 6 eyes no significant postoperative complications occurred, whereas in 7 eyes various additional surgical interventions were required and 1 B-KPro could not be preserved. Postoperative visual acuity ranged from light perception to 20/32 and was significantly improved in 85 % of the treated eyes. The use of SL-OCT reproducibly allowed the postoperative assessment of stromal thinning. CONCLUSION: The B-KPro provides the possibility of visual rehabilitation in high-risk eyes that could never be achieved without artificial cornea replacement. Despite higher complication rates this technique represents a significant progress in the surgical treatment of complex corneal pathologies. Regular and intensive postoperative controls are necessary to achieve good long-term results.

[Complications of deep anterior lamellar keratoplasty. Avoid, recognize and treat]. / Komplikationen der tiefen anterioren Keratoplastik. Vermeiden, Erkennen und Behandeln.

Deep anterior lamellar keratoplasty (DALK) offers tremendous advantages over penetrating keratoplasty (PK). Intraoperative safety is increased due to reduced opening of the eye interoperatively and the fact that no endothelial graft rejection can take place as the patient's own corneal endothelium is retained. Despite these advantages the number of DALK procedures performed each year in Germany remains constant at a low level. One reason could be that the DALK technique offers some complexity and at the same time intraoperative conversion to PK has to be performed in some cases due to rupture of Descemet's membrane. Moreover, interface-related and DALK-specific complications exist which can contribute to an unfavorable visual outcome. Most of these complications, such as incomplete attachment of Descemet's membrane or opacification within the interface between Descemet's membrane and the posterior corneal stoma can be resolved by adequate measures making PK for revision barely necessary. As visual acuity does not differ between PK and DALK, the benefits of DALK - lack of endothelial immune reaction and increased ocular stability during surgery - outweigh the risk of additional complications and DALK should therefore be performed whenever appropriate.

[Non-Invasive Diagnosis of Ocular Graft-versus-Host Disease]. / Nicht invasive Diagnostik der okulären Graft-versus-Host-Erkrankung.

Ocular graft-vs-host disease (GvHD) is a major complication following allogenic blood stem cell transplantation (aBSCT) leading to a disturbance of the ocular surface integrity with a broad range of severity. Leading symptom is a pronounced autoinflammatory reaction in particular at the ocular surface with typical features of dry eye disease. Potential complications include visual loss, pain and damage to the ocular structures with, e. g. corneal ulcerations. Diagnosis and treatment of ocular GvHD are a challenge for attending ophthalmologists and require intensive interdisciplinary patient care in particular with haemato-oncologists. First and follow-up examinations consist of several diagnostic steps that include quantitative and qualitative analysis of tearfilm, visual acuity, ocular surface and retinal integrity, cataract development and subjective symptoms. Available tests are mostly evaluated for usage in dry eye diagnosis but are, however, mostly unspecific for diagnosing ocular GvHD reliably. Only combinations of several clinical tests together with the experience of specialised ophthalmologists may lead to the certain diagnosis and treatment decisions at state. This review illustrates the available established and innovative non-invasive diagnostic tests and evaluates their potential use for diagnosing ocular GvHD.

[Therapy for Ocular Graft-vs-Host Disease]. / Therapie der okulären Graft-versus-Host-Erkrankung.

Therapy for ocular graft-vs-host disease (ocular GvHD) is challenging for ophthalmologists as progress of the disease often occurs rapidly and is unforeseeable. Primary goal is the preservation or restoration of visual acuity, however, studies on ocular GvHD that have investigated therapeutic concepts are limited. In contrast, most therapeutic recommendations from consensus conferences derive from studies on dry eye diseases other than ocular GvHD. This review demonstrates the available therapies in the following categories: local, systemic, surgical and prophylactic. Primary targets are anti-inflammation, anti-fibrosis and lubrification of the ocular surface. In conclusion, studies strictly on ocular GvHD are needed to enable better evidence-based therapeutic decision-making in the future.