Successful Regression in Patients with Progressive Keratoconus by Corneal Crosslinking. / Erfolgreiche Regression durch Crosslinking bei Patienten mit fortschreitendem Keratokonus.

BACKGROUND: Since 2019, corneal collagen crosslinking (CXL) is included in the catalog of procedures covered by statutory health insurance in Germany. CXL is an established ophthalmological procedure for the last 20 years. The aim of this investigation was the measurement of progression before and after CXL. MATERIAL UND METHODS: 65 consecutive eyes with progressive keratoconus from 53 patients were included in the retrospective study, which were observed at the University Eye Hospital Tübingen at least two years before and at least two years after CXL. The time of observation took place from October 2009 until March 2018. Parameters of interest had been the best corrected visual acuity (BCVA) and the keratometric values from the elevation maps measured by a Scheimpflug camera. RESULTS: 65 eyes of 53 patients had been documented. The study population included 46 (86.8%) male and 7 (13.2%) female subjects. The mean age was 24 ± 8 years. The averaged observation time between the primary consultation and CXL showed 25 ± 15 months. Preoperatively the mean BCVA pointed out in a significant increase (0.13 ± 0.17 [first visit] vs. 0.23 ± 0.22 [preOP], p < 0.0001) while the mean Kmax resulted in a statistically significant increase (46.34 ± 3.33 dpt [first visit] vs. 48.78 ± 4.17 dpt [preOP], p < 0.0001). The mean thinnest point of the cornea showed a significant decrease (490.48 ± 34.23 µm [first visit] vs. 468.62 ± 29.84 µm [preop], p < 0.0001). Postoperatively the mean BCVA resulted in a significant improvement at the 12th postoperative month in comparison to the preoperative measurement (0.23 ± 0.22 [preOP] vs. 0.16 ± 0.14 [12 months], p = 0.04 respectively 0.17 ± 0.17 [24 months], p = 0.0006). The mean Kmax demonstrated in the 12th postoperative month a significant reduction (48.78 ± 4.17 dpt [preOP] vs. 47.91 ± 3.41 dpt [12 months], p = 0.0009 respectively 48 ± 4.56 dpt [24 months], p = 0.0051). The mean thinnest point of the cornea indicated a decrease at the 12th postoperative month (468.62 ± 29.84 µm [preOP] vs. 459.82 ± 35.88 µm [12 months], p = 0.0078 respectively 453.47 ± 43.39 µm [24 months], p = 0.0227). CONCLUSION: CXL is a successful procedure for the therapy of progressive keratoconus.

Clinical Management of Squamous Cell Carcinoma of the Conjunctiva.

BACKGROUND Conjunctival squamous cell carcinoma is the most common non-pigmented malignancy of the ocular surface. This report illustrates the clinical management of squamous cell carcinoma of the conjunctiva. CASE REPORT A 33-year-old female was referred to our eye hospital with a tumorous lesion on the nasal bulbar conjunctiva of the right eye. A topical therapy with antibiotic and corticosteroid eye drops did not change the lesion. The conjunctival tumor was widely resected. The histopathological diagnosis suggested a squamous cell carcinoma. After resection, a treatment with topical mitomycin C (MMC) 0.02% eye drops were started 4 times daily for 14 days. Two cycles of treatment were done with a 2-week interval during which only artificial tears eye drops were administered. At the 12-month follow-up, there was no sign of recurrence. CONCLUSIONS This case illustrates the effective and successful clinical management of squamous cell carcinoma of the conjunctiva with excision and postoperative treatment with MMC 0.02% eye drops.

A Retrospective Study to Compare the Recurrence Rate After Treatment of Pterygium by Conjunctival Autograft, Primary Closure, and Amniotic Membrane Transplantation.

BACKGROUND This study aimed to investigate the effectiveness of conjunctival autograft compared with primary closure and amniotic membrane transplantation for primary pterygium excision. MATERIAL AND METHODS Data were retrospectively studied from all primary pterygium excisions from January 2002 to December 2017 from the electronic database at the University Eye Hospital, Tübingen. RESULTS From 521 primary pterygium excisions, 284 (54.5%) were primary closures, 203 (39.0%) were conjunctival autografts, and 34 (6.5%) were amniotic membrane transplants. The mean number of primary pterygium excisions was 33 per year (range, 14-56 per year). The mean patient age was 58±15 years. Younger age was associated with a significantly increased recurrence rate (P=0.002). The mean pterygium recurrence rate in the three study groups at 12 months after surgery was 11.3% (range, 6.4-14.7%). Recurrence occurred 13 patients (6.4%) in the conjunctival autograft group, 41 patients (14.4%) in the primary closure group, and five patients (14.7%) in the amniotic membrane transplantation group. Conjunctival autograft was associated with a significantly lower recurrence rate (P=0.005). CONCLUSIONS A retrospective study at a single center to compare conjunctival autograft with primary closure and amniotic membrane transplantation for primary pterygium excision showed a significantly lower recurrence rate after surgery using a conjunctival autograft.

Donor-Dependent Factors Influencing Contamination Rates of Conjunctival Swabs of Human Donor Eyes.

BACKGROUND This study investigated the effect of donor-dependent factors on contamination rates of conjunctival swabs of human donor eyes. MATERIAL AND METHODS From July 2015 to September 2017 a total of 1008 conjunctival swabs from 504 consecutive human donor eyes were analyzed. Cross-tabulation, chi-squared tests, and Fisher's exact tests were used to evaluate the effect of donor-dependent factors on contamination rates of conjunctival swabs. RESULTS The mean conjunctival swabs contamination rate was 28.4%. Donors with the diagnosis of carcinoma or metastases were associated with an increased conjunctival swab contamination rate [odds ratio (OR)=1.8, 95% confidence interval (CI)=1.2-2.6, p=0.007; OR=1.7, 95% CI=1.1-2.6, p=0.016; respectively]. However, the age, sex, diagnosis of diabetes mellitus, and donors who received chemotherapy did not significantly increase the conjunctival swab contamination risk. CONCLUSIONS Donors with the diagnosis of a carcinoma or metastases seemed to be predisposed to increased conjunctival swab contamination risk.

Factors influencing the contamination rates of the conjunctival swabs and organ culture media of human donor eyes.

This study assessed the influence of donor, environmental, and logistical factors on the contamination rates of the conjunctival swabs and organ culture media of human donor eyes.In total, 1008 conjunctival swabs and 418 organ culture media samples from 504 consecutive human donor eyes were analyzed. Cross-tabulation, chi-squared tests, and Fisher's exact tests were used to assess the influence of the different factors on the contamination rates of the conjunctival swabs and organ culture media.The overall contamination rates were 28.4% for the conjunctival swabs and 1.0% for the organ culture media. A prolonged time between death and the conjunctival swab collection was associated with an increased conjunctival swab contamination rate [odds ratio (OR) = 1.9, 95% confidence interval (CI) = 1.2-3.0, P = .007]. The highest conjunctival swab contamination rate was found in the corneas procured in external institutions (outside the university hospital) (44.1%, OR = 3.6, 95%CI = 1.5-8.4, P = .003). Hospitalization times of 2 to 7 days prior to death were associated with an increased conjunctival swab contamination risk (OR = 2.6, 95%CI = 1.1-5.8, P = .021). However, the sex, age, cause of donor death, differentiation between septic and aseptic donors, differentiation between heart-beating brain-dead multiorgan donors and cadaveric donors, a warmer mean monthly temperature, and death to corneoscleral disc excision time did not significantly increase the conjunctival swab contamination risk. In addition, none of these factors affected the organ culture media contamination risk. Moreover, a positive conjunctival swab did not significantly increase the media contamination risk (P = .08). Surprisingly, the microorganisms causing media contamination were present at 50% of the amount detected on the conjunctival surface of the respective donor eye.A prolonged time between death and the conjunctival swab collection, a hospitalization time of 2 to 7 days prior to death, and corneal collection outside the university hospital seemed to be the main factors responsible for an increased conjunctival swab contamination risk. In addition, our investigation illustrated that a positive conjunctival swab is not a strong indicator for organ culture media contamination. Critical discussion is necessary regarding the validity of conjunctival swabs as prognostic parameters for organ culture media contamination.

Amniotic Membrane Transplantation in Reconstructive and Regenerative Ophthalmology.

BACKGROUND The goal of this study was to investigate numbers, indications, surgical techniques, and experiences of amniotic membrane transplantation at the University Eye Hospital Tübingen over the last 16 years. MATERIAL AND METHODS Data from all amniotic membrane transplantations from January 2001 to December 2016 were retrospectively analyzed. Data was accessed from the electronic database and the annual reports of the Eye Bank at the University Eye Hospital Tübingen. RESULTS A total of 771 amniotic membrane transplantations were performed between 2001 and 2016 at the University Eye Hospital Tübingen. The mean number of amniotic membrane transplantations was 48 per year (range: 7-81). Overall, the mean number of amniotic membrane transplantations more than doubled, from 31 amniotic membrane transplantations per year during the first 8-year period to 66 amniotic membrane transplantations per year during the second 8-year period (p<0.0001). The most common surgical indications for amniotic membrane transplantation were corneal ulcers and persistent corneal epithelial defects. The inlay, overlay, and sandwich technique became the favored surgical methods for various disorders of the ocular surface. CONCLUSIONS Our study showed a significant increase of amniotic membrane transplantations from 2001 to 2016. This increase is likely influenced by the introduction of different surgical amniotic membrane transplantation techniques, the rising knowledge about containing growth factors, neurotrophins and cytokines, and the demographic change with aging of the population.

The Evolution of Corneal Transplantation.

BACKGROUND The aim of this study was to investigate the evolution of surgical methods in and leading indications for corneal transplantation from 2005 to 2016. MATERIAL AND METHODS Data from the corneal graft waiting list and from all keratoplasties carried out between 2005 and 2016 at the University Eye Hospital Tübingen were retrospectively evaluated. RESULTS A total of 1259 keratoplasties were performed between 2005 and 2016 at the University Eye Hospital Tübingen. The most common surgical indications for corneal transplantation were Fuchs endothelial corneal dystrophy (45.5%) and keratoconus (14.2%). The mean rate of corneal transplantations almost doubled from 71 keratoplasties per year in the first 6-year period to 139 keratoplasties per year in the second 6-year period (P=0.005). The number of penetrating keratoplasties remained similar. The number of Descemet membrane endothelial keratoplasties (DMEK) increased significantly from 2008 to 2016 (P<0.0001). One DMEK procedure was performed in 2008 (representing 1.4% of all transplantations), while 75 DMEK procedures were performed in 2016 (representing 60.5% of all transplantations) (P<0.0001). DMEK became the favored surgical method for endothelial disorders, exceeding penetrating keratoplasty in 2013. CONCLUSIONS Our study shows evolutionary changes in preferred corneal transplantation techniques and leading indications for keratoplasty from 2005 to 2016. Since its introduction a decade ago, DMEK is currently the golden standard in the management of corneal endothelial dysfunction.

Organ transplantation scandal influencing corneal donation rate.

In the majority of countries, there is a shortage of donor corneas for corneal transplantations. This study investigated the impact of organ transplantation scandals on corneal donation rate at the University Hospital Tübingen. Each deceased patient was considered as a potential corneal donor. An ophthalmic resident handled with stable methods of procedures the corneal donor procurement from 2009 to 2015. The rates of corneal donation were examined and analyzed. Among the 5712 hospital deaths, consent for corneal donation was obtained in 711 cases. The mean annual corneal donation rate was 12.4%. Since 2009, the donation rate per year could be increased with exception of 2013 and 2015. In the end of 2012 and 2014 two huge organ donation scandals were known in Germany. In the following years 2013 and 2015 corneal donation rate decreased significantly (P=0.0181 and P=0.0006). We concluded that transplantation scandals have a significant impact on corneal donation rate. Improving professional's performance through full transparency and honesty is very important to earn trust of potential donors and their families.

Factors influencing the virological testing of cornea donors.

To assess the influence of donor, environment, and logistical factors on the results of virological testing of blood samples from cornea donors.Data from 670 consecutive cornea donors were analyzed retrospectively. Logistic regression analysis was used to assess the influence of different factors on the results of virological testing of blood samples from cornea donors.The mean annual rate of donors with serology-reactive or not evaluable result was 14.8% (99 of 670) (range 11.9%-16.9%). The cause of donor death by cancer increased the risk of serology-reactive or not evaluable result (P = .0300). Prolonged time between death and post mortem blood removal was associated with a higher rate of serology-reactive or not evaluable result (P < .0001). Mean monthly temperature including warmer months, differentiating between septic and aseptic donors, sex, and donor age had no significant impact on the results of virological testing of blood samples from cornea donors.The cause of donor death by cancer and a prolonged time between death and post mortem blood removal seem to be mainly responsible for serology-reactive or not evaluable result of blood samples from cornea donors. The percentage of discarded corneas caused by serology-reactive or not evaluable result may be reduced by shortening the period of time between death and post mortem blood removal.

Influence of axial length on thickness measurements using spectral-domain optical coherence tomography.

PURPOSE: The purpose of this study was to assess the influence of axial length on spectral-domain optical coherence tomography (SD-OCT) thickness measurements in patients with subretinal visual implants. METHODS: Data from eight emmetropic pseudophakic eyes of eight patients with subretinal visual implants were analyzed retrospectively. These patients participated in the monocentric part of a multicenter trial. The axial length was measured in three short (<22.5 mm), three medium (22.51-25.50 mm), and two long (>25.52 mm) eyes. Using Heidelberg Spectralis, the known thickness of a subretinal implant microchip (70 µm) was measured on 15 images per eye with SD-OCT, using the software calipers. RESULTS: The mean axial length was 20.8 ± 0.8 mm in short eyes, 23.3 ± 0.4 mm in medium eyes, and 26.3 ± 0.5 mm in long eyes. We found in short eyes, in medium eyes, and in long eyes a mean value of microchip thickness measurements from SD-OCT of 82.9 ± 1.4 µm, 70.5 ± 1.3 µm, and 64.2 ± 1.3 µm, respectively. The thickness measurements decreased in SD-OCT measurements with longer axial lengths significantly (P < 0.0001). CONCLUSIONS: Axial length influences SD-OCT thickness measurements. Our findings demonstrate accuracy of the scaling in SD-OCT thickness measurements in emmetropic medium eyes. Caution is recommended when comparing the measured values of short and long eyes with the normative database of the instrument. There is a need for larger sample-size studies to confirm our results. (ClinicalTrials.gov number, NCT01024803.).

Modern wound care for the poor: a randomized clinical trial comparing the vacuum system with conventional saline-soaked gauze dressings.

BACKGROUND: A clinical randomized trial was performed to determine whether a simple homemade wound vacuum-dressing system (HM-VAC) is a feasible alternative to the use of conventional saline-soaked gauze dressings (WET) for the treatment of complex wounds in a resource-poor hospital. METHODS: Forty patients were analyzed to compare the HM-VAC and the WET dressings. The HM-VAC was assembled with tools available in most operating room worldwide. The primary outcome measure was the time of complete wound healing. Additionally, the costs of both methods were calculated. RESULTS: The time required to achieve complete healing was 16 days in the HM-VAC group compared with 25 days in the WET group (P = .013). The HM-VAC costs US $360 per case, and the WET technique costs US $271 per case (P = .008). CONCLUSIONS: The HM-VAC should be considered in underdeveloped countries to provide modern management for complex wounds because healing is significantly faster compared with conventional wound care. Although the HM-VAC is more costly than the conventional approach, it is probably affordable for most resource-poor hospitals.

[Pharmacoeconomic evaluation of clopidogrel in acute coronary syndromes. Long-term treatment, secondary prophylaxis, and percutaneous coronary intervention]. / Kosten-Nutzen-Effektivität von Clopidogrel bei akutem Koronarsyndrom : Langzeitbehandlung, sekundäre Prophylaxe, Koronarintervention.

Clopidogrel, a thienopyridine antiplatelet agent, is an adenosine diphosphate (ADP) receptor antagonist. Clopidogrel inhibits ADP binding to its platelet receptor and subsequent ADP-mediated activation of the glycoprotein IIb/IIIa complex, thus inhibiting platelet aggregation. Clopidogrel irreversibly modifies the ADP receptor so platelets are affected for the remainder of their life span. The treatment of acute coronary syndromes consists of an inpatient diagnosis and inpatient treatment usually done in an emergency room and intensive care unit and a long-term secondary prophylaxis of the underlying condition, coronary artery disease. Therefore, efficacy of different treatments and their implication on costs have to be examined over a long time period. The cost perspective (hospital, society, country) is another important point. In each country different charges for drugs, medical procedures and hospitalization are existing; varying drug costs may result in a more or less cost-effective ratio of a treatment. Furthermore, not only direct medical costs, but also implications on indirect costs should be taken into account when measuring cost-effectiveness of treatments.Worldwide, cardiovascular diseases account for a significant burden of hospital and societal costs. In particular for colleagues running their own private practice, cost-consciousness has become important in recent times. On the other hand, there has to be carried the duty to accord patients the best possible treatment. This - against the background of ethical responsibility, physicians can come into a conflict - continues to require cost-effectiveness studies in the future. By means of the set-forth results configurations can be seen in which clopidogrel has both, a benefit on the medical and on the economic side of view. From most of the quoted analyses application of clopidogrel was warrantable and the scope of costs within the amount of established cardiovascular therapies.

Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis.

BACKGROUND: Open abdomen treatment because of severe abdominal sepsis and abdominal compartment syndrome remains a difficult task. Different surgical techniques are available and are often used according to the surgeon's personal experience. Recently, the abdominal vacuum-assisted closure (VAC) system has been introduced, providing a new possibility to treat an open abdomen. In this study, we evaluate the role of this treatment option. STUDY DESIGN: This prospective observational cohort study includes 37 consecutive patients who were temporarily treated with VAC for severe abdominal sepsis or abdominal compartment syndrome, or both. Patients with abdominal trauma were excluded from the study. Thirty-seven patients undergoing major elective laparotomy and primary abdominal closure served as control group. Primary end points were fascial closure rate, physicoemotional recovery, and appearance outcomes 1 year after closure. Secondary end points included mortality, duration of open abdomen, length of ICU stay, and hospitalization time. RESULTS: Abdomens were left open for 23 days (range 3 to 122 days) with 3.8 dressing changes (range 1 to 22) per patient. Abdominal closure was achieved in 70% (n = 26), with no marked relation to duration of open abdomen treatment (p > 0.05). After 3 months, patients with VAC treatment recovered to a physical and mental health status similar to patients in the control group (p > 0.05). This status remained stable until the end of the study. Aesthetic outcomes (according to the Vancouver Scar Scale) were considerably poorer in the VAC group compared with controls (p < 0.01). CONCLUSIONS: Treatment of laparostomy with VAC for abdominal sepsis and abdominal compartment syndrome results in a high rate of successful abdominal closure. In addition, patients recover more rapidly, although hypertrophic scars might interfere with body perception. We recommend abdominal VAC system as first option if open abdomen treatment is indicated.

Determinants of costs and the length of stay in acute coronary syndromes: a real life analysis of more than 10,000 patients.

AIMS: The aim of this study was to investigate inpatient costs of acute coronary syndromes (ACS) in Switzerland and to assess the main cost drivers associated with this disease. METHODS AND RESULTS: We used the national multicenter registry AMIS (acute myocardial infarction in Switzerland) which includes a representative number of 65 hospitals and a total of 11.623 patient records. The following cost modules were analyzed: hospital stay, percutaneous coronary interventions (PCI) and thrombolysis. Expenses were assessed using data from official Swiss national statistical sources. Mean total costs per patient were 12.101 Euro (median 10.929 Euro; 95% CI: 1.161-27.722 Euro). The length of stay ranged from one to 129 days with a mean of 9.5 days (median 8.0 days; 95% CI: 1-23). Overall costs were independently influenced by age, gender and existent co-morbidities, e.g. cerebrovascular disease and diabetes (p < 0.0001). CONCLUSION: Our study determined specific causes for the high costs associated with hospital treatment on a large representative sample. The results should highlight unnecessary expenses and help policy makers to evaluate the base case for a DRG (Diagnosis Related Groups) scenario in Switzerland. Cost weighting of the identified secondary diagnosis should be considered in the calculation and coding of a primary diagnosis for ACS.

Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass.

A 44-year-old woman was admitted from the emergency department with severe acute upper abdominal pain. The patient had undergone a laparoscopic Roux-en-Y gastric bypass (RYGBP) operation 16 months previously. CT scan showed intraabdominal free air. At emergency laparoscopic reoperation, a perforated ulcer at the gastrojejunostomy was found. This late complication of RYGBP can be a rapidly progressing life-threatening situation, and requires prompt treatment. Closure and omental patch were successful laparoscopically.

Synchronous laparoscopic sigmoid resection and hysterectomy with transvaginal specimen removal.

INTRODUCTION: Laparoscopic sigmoid resection for recurrent or complicated diverticulitis and laparoscopically assisted hysterectomy for leiomyomas of the uterus are common procedures. A synchronous combination of these two interventions with the advantage of using the vaginal stump as a route for removal of the specimen has not previously been described. MATERIALS AND METHODS: We used a transvaginal extraction of the uterus and the colorectal segment, followed by a totally intra-abdominal circular stapler anastomosis. The procedure is performed via four trocar incisions, obviating the need for a laparotomy. RESULTS: Two women suffering from diverticulitis and symptomatic uterus myomatomas were treated by combined laparoscopic sigmoid resection and laparoscopically assisted transvaginal hysterectomy. Both patients had an uneventful intraoperative course. DISCUSSION: This new approach, combining two operations, is feasible and leads to almost perfect cosmetic results, cumulatively shorter hospitalization, and good patient satisfaction. Cooperation with a gynecologist as well as experience in advanced laparoscopic surgery is essential.