XEN® implantation: an effective strategy to stop glaucoma progression despite prior minimally invasive glaucoma surgery.

PURPOSE: The aim of this study was to evaluate whether XEN® implantation is a reasonable and safe method to lower the intraocular pressure (IOP) and amount of medication for adult primary open-angle glaucoma (POAG) over a 3-year period. The influence of the type of anesthesia, previous glaucoma surgery, and postoperative interventions on the outcome were examined. METHODS: In this retrospective study, 96 eyes were included. XEN® implantation was performed as sole procedure under general (n = 86) or local anesthesia (n = 10). IOP and number of glaucoma medication were assessed preoperatively: day 1, week 6, month 3, 6, 12, 24, and 36. Further outcome parameters were Kaplan-Meier success rates, secondary intervention, and complication rates. RESULTS: IOP decreased from 20.7 ± 5.1 to 12.8 ± 2.5 mmHg at the 36-month follow-up (p < 0.001) and glaucoma therapy was reduced from 3.3 ± 0.8 to 1.2 ± 1.6 (36 months, p < 0.001). Transient postoperative hypotony was documented in 26 eyes (27.1%). General anesthesia resulted in a significant improvement of the survival rate compared to local anesthesia (77% vs. 50%, p = 0.044). Prior iStent inject®, Trabectome®, or SLT laser had no significant impact, such as filter bleb revision. The number of postoperative needlings had a significantly negative influence (p = 0.012). CONCLUSION: XEN® implantation effectively and significantly lowers the IOP and number of glaucoma therapy in POAG in the 36-month follow-up with a favorable profile of side effects and few complications. In case of IOP, general anesthesia has a significant positive influence on the survival rate, whereas prior SLT or MIGS does not have significant impact.

Cytomegalovirus-positive Posner-Schlossman syndrome: to compare differences in retinal vessel area density between the affected and non-affected eye using optical coherence tomography angiography.

PURPOSE: To analyse differences in the retinal microvasculature in eyes with cytomegalovirus (CMV)-positive Posner-Schlossman syndrome (PSS) compared to the non-affected eyes using optical coherence tomography angiography (OCTA). METHODS: In this monocentric, observational prospective case series, 25 patients with unilateral CMV-positive PSS were included. We compared the vessel area densities (VAD) in the macula, optic disc, and peripapillary region in PSS-affected and non-affected eyes using OCTA. We compared the visual fields (VF) of the affected and healthy eyes of each patient. The mean deviation (MD) of the VF was analysed together with the retinal nerve fibre layer (RNFL) thickness to evaluate the strength of correlation with the VAD parameters. RESULTS: The VAD of the peripapillary superficial vascular complex (SVC) is significantly reduced in CMV-positive PSS-affected eyes (46.1 ± 9.3% versus 50.1 ± 6.3%, p = 0.008, adjusted p = 0.048). The VAD of the deeper macular, papillary, and peripapillary layers showed no differences between the affected and non-affected eyes. The mean deviation and the retinal nerve fibre layer thickness had correlations with the VAD of the macula (r = 0.451, p = 0.001, r = 0.553, p < 0.001), the peripapillary SCV (r = 0.430, p = 0.002, r = 0.723, p < 0.001), and the papillary region (r = 0.512, p < 0.001, r = 0.292, p = 0.039). Patients receiving systemic antiviral therapy (SAT) showed better VAD of the peripapillary choriocapillary layer (p = 0.001, no therapy: 31.4 ± 1.9%, SAT: 35.0 ± 1.6%), and choroidal layer (p = 0.009, no therapy: 34.2 ± 0.3%, SAT: 36.3 ± 1.8%) compared to those with no SAT. CONCLUSION: A lower peripapillary VAD in the SVC might indicate vascular dysfunction as a sign of glaucomatous damage. SAT might have positive effects on the microcirculation in the deep retinal and choroidal layers. TRIAL REGISTRATION: TRN: DRKS00028266, https://www.drks.de/drks_web/ .

Graft failure rate and complications after Descemet membrane endothelial keratoplasty in eyes with pre-existing glaucoma.

PURPOSE: To evaluate the outcome of Descemet Membrane Endothelial Keratoplasty (DMEK) in eyes with pre-existing glaucoma. DESIGN: In this retrospective, observational case series we included data of 150 consecutive DMEKs in eyes with pre-existing glaucoma of 150 patients after excluding data of the second treated eye of each patient and of re-DMEKs during follow-up. Cumulative incidences of IOP elevation (IOP > 21 mmHg or ≥ 10 mmHg increase in IOP from preoperative value), post-DMEK glaucoma (need of an additional intervention due to worsening of the IOP), graft rejection, and graft failure rate were analyzed using Kaplan-Meier survival analysis. COX regression analysis was used to evaluate independent risk factors. RESULTS: The 36-month cumulative incidence of IOP elevation was 53.5% [95 CI 43.5-63.5%] and of post-DMEK glaucoma 36.3% [95 CI 26.3-46.3%]. Graft rejection occurred with a 36-month cumulative incidence of 9.2% [CI 95% 2.3-16.1]. None of the analyzed risk factors increased the risk for the development of graft rejection. The 36-month cumulative incidence of graft failure was 16.6% [CI 95% 8.4-24.8]. Independent risk factors for graft failure were the indication for DMEK "status after graft failure" (n = 16) compared to Fuchs' dystrophy (n = 74) (p = 0.045, HR 8.511 [CI 95% 1.054-68.756]) and pre-existing filtrating surgery via glaucoma drainage device (GDD) (n = 10) compared to no surgery/iridectomy (n = 109) (p = 0.014, HR 6.273 [CI 95% 1.456-27.031]). CONCLUSION: The risks of postoperative complications (IOP elevation, post-DMEK glaucoma, graft rejection, and graft failure) in patients with pre-existing glaucoma are high. In particular, pre-existing filtrating surgery via GDD implantation-but not trabeculectomy-and DMEK after graft failure increase the risk of graft failure.

Macular, papillary and peripapillary perfusion densities measured with optical coherence tomography angiography in primary open angle glaucoma and pseudoexfoliation glaucoma.

PURPOSE: To compare the blood flow situation in primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG) using optical coherence tomography angiography (OCTA). METHODS: In this prospective study a total of 26 POAG and 23 PXG eyes were included. All patients underwent a complete ophthalmological examination including standard automated perimetry, stereoscopic photographs of the optic disc, peripapillary retinal nerve fibre layer analysis and examination of vascular parameters of the optic nerve head (ONH), the peripapillary region and macula using OCTA. In addition to the vascular parameters recorded by the device, the vascular images were graphically evaluated using Image J. All recorded vascular parameters were compared between both groups and correlated to structural and functional parameters. RESULTS: The mean superficial perifoveal plexus perfusion density (PD) was significantly lower in PXG eyes than compared to POAG eyes using OCTA (32.57% ± 3.57% vs. 34.92% ± 2.11%, p = 0.007). The mean PD parameters for the superficial peripapillary plexus (40.98% ± 3.04% vs. 42.09% ± 2.29%, p = 0.152) as well as the size of the foveal avascular zone (FAZ) (0.23 mm2 ± 0.1 mm2 vs. 0.23 mm2 ± 0.09 mm2) did not differ between both groups. Additional graphic evaluation using Image J showed no significant difference for superficial perifoveal plexus PD (32.97% ± 1.11% vs. 33.35% ± 0.95%, p = 0.194) and peripapillary plexus PD (46.65% ± 0.83% vs. 46.95% ± 0.5%, p = 0.127) between the groups. Retinal nerve fibre layer (RNFL) thickness correlated significantly with peripapillary plexus PD for both OCTA data and Image J data (p < 0.001, p = 0.032). CONCLUSION: The severity of the glaucoma seems to be crucial for peripapillary and macular perfusion densities, and not the form of glaucoma. An additional graphic evaluation is a possible step that could be implemented to improve the comparability of OCTA scans and to optimize the possibility of quantitative perfusion analysis in the case of deviating quality criteria.

Survey of Rejection Prophylaxis Following Suture Removal in Penetrating Keratoplasty in Germany. / Umfrage zur Abstoßungsprophylaxe bei Fadenentfernung nach perforierender Keratoplastik in Deutschland.

BACKGROUND: Penetrating keratoplasty (PK) gets more and more reserved to cases of increasing complexity. In such cases, ocular comorbidities may limit graft survival following PK. A major cause for graft failure is endothelial graft rejection. Suture removal is a known risk factor for graft rejection. Nevertheless, there is no evidence-based regimen for rejection prophylaxis following suture removal. Therefore, a survey of rejection prophylaxis was conducted at 7 German keratoplasty centres. OBJECTIVE: The aim of the study was documentation of the variability of medicinal aftercare following suture removal in Germany. METHODS: Seven German keratoplasty centres with the highest numbers for PK were selected. The centres were sent a survey consisting of half-open questions. The centres performed a mean of 140 PK in 2018. The return rate was 100%. The findings were tabulated. RESULTS: All centres perform a double-running cross-stitch suture for standard PK, as well as a treatment for rejection prophylaxis with topical steroids after suture removal. There are differences in intensity (1 - 5 times daily) and tapering (2 - 20 weeks) of the topical steroids following suture removal. Two centres additionally use systemic steroids for a few days. DISCUSSION: Rejection prophylaxis following PK is currently poorly standardised and not evidence-based. All included centres perform medical aftercare following suture removal. It is assumed that different treatment strategies show different cost-benefit ratios. In the face of the diversity, a systematic analysis is required to develop an optimised regimen for all patients.

Impact of difficult unfolding and attachment of the graft lamella on the long-term outcome after Descemet membrane endothelial keratoplasty.

PURPOSE: Unfolding and attachment of the posterior donor lamella may be the most challenging part in Descemet membrane endothelial keratoplasty (DMEK) procedure. We investigated the correlation of the difficulty degrees of this step to the postoperative clinical outcome 6 years after surgery. METHODS: One hundred sixty-nine consecutive DMEKs between September 2012 and August 2013 at the Charité-University Medicine Berlin were graded prospectively into 4 groups according to their grade of difficulty in unfolding and attachment of the graft lamella. Postoperative visual acuity, endothelial cell density, and rate of graft failure were measured after 1 year, after 2 years, and after 6 years and analyzed according to their grading group. RESULTS: Visual acuity improved significantly in all groups and did not differ significantly between the grading groups at any time point postoperatively. There was a significant decrease of endothelial cell density in all groups with a significantly higher endothelial cell loss in group IV compared with the other groups within the first 24 months after surgery. The graft failure rate was significantly higher in eyes graded III and IV than in groups I and II (p = 0.012). CONCLUSION: Although the endothelial cell loss and the graft failure rate increase significantly with a more difficult graft unfolding and attachment, DMEK surgery is a promising procedure with a good long-term postoperative outcome. A direct manipulation of the graft lamella for unfolding and centering by cannula or forceps should be avoided if possible to reduce the risk of an increased endothelial cell loss and a higher graft failure rate. TRIAL REGISTRATION: NCT02020044.

Influence of Selective Laser Trabeculoplasty (SLT) on the iStent inject® outcomes.

BACKGROUND: To evaluate the influence of Selective Laser Trabeculoplasty (SLT) on iStent inject® outcomes in open-angle glaucoma (OAG). METHODS: In this retrospective comparative cohort outcome study, 66 patients who were treated with two iStent inject® devices were included. Patients were divided into two subgroups consisting of patients without SLT treatment prior to surgery and patients who had been treated previously with 360° SLT but without sufficient response. Outcome measures included intraocular pressure (IOP) and number of antiglaucoma medications after 6 weeks with three, six, 12, and 24 month follow-ups. RESULTS: Mean preoperative IOP decreased from 20.4 ± 5.3 mmHg to 14.8 ± 3.0 mmHg for patients without SLT treatment prior to surgery (p = 0.001) and from 19.2 ± 4.5 mmHg to 14.0 ± 1.6 mmHg for patients with insufficient response to 360° SLT treatment (p = 0.027) at 12 months after iStent inject® implantation. No significant difference was found between the two groups (p >  0.05). The number of antiglaucoma medications did not change in both groups (p >  0.05) and showed no significant difference between the two groups (p >  0.05). CONCLUSION: Prior SLT treatment seems to have no negative influence on the IOP lowering-effect of iStent inject® implantation in patients with OAG. It is therefore an appropriate incremental procedure with no exclusion criterion for an iStent inject® implantation.

Three-year results of ab interno trabeculectomy (Trabectome): Berlin study group.

PURPOSE: To assess the long-term outcome of Trabectome surgery in the treatment of primary open angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEX): 3-year results. METHODS: Trabectome surgery (NeoMedix, Tustin, CA, USA) was performed in 268 POAG patients (women 57.46%, men 42.54%, age 72.35 ± 9.63 years) and 98 PEX glaucoma patients (women 58.16%, men 41.84%, age 73.42 ± 8.54 years), and uncontrolled intraocular pressure (IOP). Parameters were examined preoperatively, 1 day, 6 weeks, 3, 6, 12, 24 and 36 months post surgery. Kaplan-Meier analysis was performed using Criteria A (IOP ≤ 21 mmHg or ≥20% reduction from preoperative IOP), Criteria B (IOP ≤ 18 mmHg or ≥20% IOP reduction), Criteria C (IOP ≤ 21 mmHg, with or without medication) and D (IOP ≤ 18 mmHg, with or without medication). Complete success was defined as IOP ≤ 21 mmHg (Criteria E) and IOP ≤ 18 mmHg without medication (Criteria F). RESULTS: IOP was reduced from 19.10 ± 4.11 mmHg to 14.27 ± 2.93 mmHg (p < 0.001) and glaucoma medication was decreased from 2.40±0.92 to 1.77±1.00 (p < 0.001) in POAG after 36 months. In PEX, IOP decreased from 22.49±9.40 mmHg to 14.57±5.05 mmHg after 36 months (p < 0.001). Medications dropped from 2.31±1.02 to 1.75±0.91 (p = 0.006). Kaplan-Meier analysis showed a success rate of 80.5% for POAG and 80.8% for PEX using criteria A (p = 0.933) and 62.4% for POAG and 73.7% for PEX using criteria B (p = 0.147) at 36 months postoperatively. Complete success showed a low survival rate (criteria E-13.5% in POAG and 7.9% in PEX, p = 0.070 and criteria F-12.8% in POAG and 5.9% in PEX, p = 0.083). CONCLUSIONS: Trabectome is a safe method to lower IOP in patients with POAG and PEX glaucoma in the long-term period. It is beneficial to inform patients prior to surgery about adjuvant glaucoma medication after the surgery.

DMEK in phakic eyes: targeted therapy or highway to cataract surgery?

PURPOSE: To investigate outcome and postoperative complications in patients undergoing isolated DMEK in phakic eyes compared to patients undergoing DMEK combined with cataract surgery (triple procedure). METHODS: A retrospective analysis of 13 eyes undergoing DMEK in phakic eyes and 54 eyes undergoing triple procedure. Intraoperative and postoperative complications were recorded, visual acuity, refraction outcome, central corneal thickness, endothelial cell count and optical coherence tomography (OCT) of the anterior eye segment were evaluated 6 months postoperatively. RESULTS: Graft detachment occurred in two eyes (18 %) undergoing phakic DMEK surgery and 23 eyes (50 %) undergoing triple procedure. Two eyes of the phakic group needed subsequent cataract surgery. In all cases, visual acuity significantly increased with a medium visual acuity of 0.13 ± 0.12 (phakic group, p = 0.005) and 0.15 ± 0.11 (triple group, p < 0.001) logMAR. Visual acuity of at least 0.1 logMAR was found in 55 % (phakic group) and 52 % (triple procedure group) of eyes. In the group after triple procedure, there were 62.8 % of eyes within 1 D of emmetropia. Corneal thickness was reduced to 515.3 ± 36.9 µm (phakic group, p = 0.012) and 516.5 ± 40.4 µm (triple group, p < 0.001). Endothelial cell count was reduced to 1529.7 ± 695.6/mm(2) (phakic group, p = 0.008) and 1,676.8 ± 355.2/mm(2) (triple group, p < 0.001). CONCLUSIONS: DMEK in phakic eyes provides very good visual acuity with lower postoperative complications compared to eyes undergoing triple procedure. As the accommodative power can be preserved, this method is especially interesting for young patients.

Influence of the difficulty of graft unfolding and attachment on the outcome in Descemet membrane endothelial keratoplasty.

PURPOSE: Descemet membrane endothelial keratoplasty (DMEK) is a standard procedure in patients with endothelial corneal disorders. We investigated the difficulty of unfolding and attaching the graft lamella and its correlation to characteristics of the graft lamella donor, preoperative patient characteristics, and the postoperative outcome. METHODS: After preparation of the graft lamella, we prospectively graded the unfolding of the graft lamella in 169 consecutive DMEK procedures between September 2012 and August 2013 at the Charité-Universitätsmedizin Berlin with four different grades. Various donor characteristics and preoperative patient characteristics were analyzed and correlated to the grading. Additionally, visual acuity, corneal thickness and endothelial cell density were measured and correlated. RESULTS: Donor characteristics (age [range, 49 - 79 years], gender, endothelial cell density, total storage time, storage de-swelling time, postmortem time) did not correlate to the grading. Preoperative visual acuity significantly influenced the grade of unfolding and attaching of the graft lamella (p = 0.023), while all other preoperative parameters (age, gender, indication for DMEK, preoperative endothelial cell density and preoperative central corneal thickness) showed no correlation. Visual acuity improved significantly after surgery (p < 0.001, preoperative 0.73 ± 0.43 LogMAR versus 0.31 ±0.28 LogMAR after one month, 0.25 ± 0.29 LogMAR after three months, and 0.21 ± 0.25 LogMAR after six months). Visual acuity did not differ significantly between the grading groups at any time point postoperatively. After 6 months, the mean loss rate of endothelial cell density was 24.7 %. Grading group IV developed significantly higher endothelial loss after one month, after three months and after six months compared to the other groups (p = 0.039, p = 0.008, p = 0.048). Graft detachment requiring an additional intracameral air injection to fix the graft detachment (re-bubbling) occurred in 61 eyes (38.1 %). In eyes graded IV, more re-bubblings were necessary than in all other groups (grade I: 37.0 %; grade II: 44.7 %; grade III: 43.8 %; grade IV: 50.0 %; p = 0.128; df = 3; χ (2) = 5.676). CONCLUSION: There is no correlation between corneal donor tissue characteristics and the degree of difficulty of unfolding using graft lamella older than 49 years. Therefore, it is not possible to select grafts best suited for DMEK surgery on the basis of donor characteristics when the donor age is above 50 years. Preoperative visual acuity influences the grade of difficulty. The rate of graft detachments and endothelial cell loss increases significantly with a more difficult graft unfolding. The proposed grading system may therefore be relevant for postoperative management.

iStent inject in phakic open angle glaucoma.

BACKGROUND: The effectiveness and complication profile of the iStent inject implantation among different open angle glaucoma subgroups were analyzed. METHODS: In this retrospective cohort outcome study, 35 consecutive patients suffering from glaucoma (primary open angle glaucoma (POAG) N = 17, pseudoexfoliation glaucoma (PEX) N = 15, and pigmentary glaucoma (PG) N = 3) were treated with the iStent inject. The intraocular pressure (IOP) and the number of antiglaucoma medications before and after surgery were evaluated. RESULTS: In POAG, the mean IOP at 6 months measured 14.19 ± 1.38 mmHg with an average decrease of 33 % from preoperative IOP (p < 0.001), and 15.33 ± 1.07 mmHg with an average decrease of 35 % in PEX (p < 0.001), respectively. The number of antiglaucoma medications significantly decreased from 2.19 ± 0.91 to 0.88 ± 0.62 in POAG (p < 0.001) and from 2.33 ± 1.23 to 1.04 ± 0.30 in PEX (p < 0.001) after 6 months. In PG, IOP before surgery was 28.31 ± 3.21 mmHg and the number of antiglaucoma medications was 3.66 ± 0.57. One day after surgery, IOP decreased significantly to 12.33 mmHg ± 4.93 (p < 0.001). Within four weeks after surgery, IOP was raised above 30 mmHg in every patient. To exclude a steroid response, topical steroids were stopped, but IOP did not decrease. To exclude blockage, Nd:YAG - laser treatment of the visible opening of the iStents was performed. Since the IOP stayed high and escalation of antiglaucoma medication was insufficient to control IOP, trabeculectomy was performed. CONCLUSIONS: In conclusion, implantation of the iStent inject has the ability to lower the postoperative IOP significantly in POAG and PEX after a short follow-up of 6 months with a favorable risk profile. However, limitation of this surgical procedure in phakic PG may exist and need to be investigated in further studies.

Anterior segment analysis and intraocular pressure elevation after penetrating keratoplasty and posterior lamellar endothelial keratoplasty.

BACKGROUND: Peripheral anterior synechiae (PAS) is a common problem after penetrating keratoplasty (PK) and leads to intraocular pressure (IOP) elevation. This study examines the risk factors for IOP elevation and post-keratoplasty glaucoma. METHODS: A retrospective analysis was performed of 47 eyes following PK and of 65 eyes following Descemet's stripping endothelial keratoplasty (DSEK) between 2009 and 2011. The assessment included preoperative history of corneal disease and glaucoma, response to treatment, IOP, and visual acuity. Irido-trabecular contacts (ITC), the angle opening distance (AOD 500) and the anterior chamber angle (ACA 500) were calculated. RESULTS: The incidences of IOP elevation and post-keratoplasty glaucoma were 27-36% and 10-29%, respectively. The incidence did not differ significantly between both procedures. Pre-existing glaucoma increased the risk for developing IOP elevation and post-DSEK glaucoma. Eyes with bullous keratopathy (BK) developed significantly more IOP elevation (p = 0.01, d.f. = 1, χ(2) = 6.11) and post-keratoplasty glaucoma (p = 0.01, d.f. = 1, χ(2) = 6.22) than eyes with Fuchs' endothelial dystrophy. Eyes with ITC developed post-keratoplasty glaucoma significantly more often than eyes without ITC (p = 0.01, d.f. = 1, χ(2) = 6.63). CONCLUSION: IOP elevation and post-keratoplasty glaucoma showed a high incidence. Risk factors like pre-existing glaucoma, BK and PAS elevated the rate of IOP elevation and post-keratoplasty glaucoma for both procedures.

Influence of Selective Laser Trabeculoplasty (SLT) on combined clear cornea phacoemulsification and Trabectome outcomes.

BACKGROUND: In this retrospective comparative cohort outcome study, the influence of Selective Laser Trabeculoplasty (SLT) on combined clear cornea phacoemulsification and ab interno trabeculectomy (Trabectome) outcomes in Primary Open Angle Glaucoma (POAG), Pseudoexfoliation Glaucoma (PEX), and Pigmentary Glaucoma (PG) was examined. METHODS: Combined clear cornea phacoemulsification and Trabectome were performed in 27 consecutive patients with POAG, in 27 patients with PEX, and in 20 patients with PG. Each group was divided into two subgroups including patients without SLT treatment prior to surgery and patients who had insufficient response to 360° SLT treatment three months prior to surgery. RESULTS: In the SLT group, mean IOP at six months measured 13.33 ± 2.08 mmHg with an average decrease of 30 % from preoperative IOP in the POAG group, 12.10 ± 1.40 mmHg with an average decrease of 46 % in the PEX group, and 11.83 ± 2.21 mmHg with an average decrease of 38 % in the PG group. In eyes without previous SLT, mean IOP sixt 6 months measured 11.00 ± 1.73 mmHg with an average decrease of 38 % from preoperative IOP in the POAG group, 15.50 ± 1.41 mmHg with an average decrease of 35 % in the PEX group, and 15.67 ± 2.91 mmHg with an average decrease of 36 % in the PG group, respectively. CONCLUSIONS: Prior SLT treatment seems not to negatively influence combined clear cornea phacoemulsification and Trabectome outcomes in glaucoma patients. However, SLT treatment may even have an additive effect on following combined Trabectome outcomes in patients with PEX and PG.

Intraocular pressure elevation and post-DMEK glaucoma following Descemet membrane endothelial keratoplasty.

PURPOSE: Intraocular pressure (IOP) elevation and post-keratoplasty glaucoma occur commonly after penetrating keratoplasty (PK), but also after Descemet stripping endothelial keratoplasty (DSEK). In this study, we evaluated the risk after Descemet membrane endothelial keratoplasty (DMEK) to develop IOP elevation and post-DMEK glaucoma. METHODS: The 12-month incidence of IOP elevation and post-DMEK glaucoma was analyzed retrospectively in the first 117 consecutive eyes that underwent DMEK between September 2011 and December 2012 at the Universitätsmedizin-Charité, Berlin. IOP elevation was defined as IOP ≥ 22 mmHg, or ≥10 mmHg from preoperative baseline. The assessment included the pre-operative history of corneal disease and glaucoma. Furthermore, the response to anti-glaucoma treatment, the graft failure, the IOP, the visual acuity, and the endothelial cell count were evaluated. RESULTS: The 12-month incidence of IOP elevation was 12.10 % [95 % confidence interval (CI): 0.94 %, 18.37 %], post-DMEK glaucoma 2.7 % (95 % CI: -0.44 %, 5.84 %). The most frequent cause remained steroid-induced IOP elevation, with an 12-month incidence of 8.0 % (95 % CI: 7.95 %, 8.05 %). In all cases, IOP elevation was treated effectively by tapering down steroid medication and initiating or increasing anti-glaucoma medication. The incidence of postoperative postoperative pupillary block IOP elevation was 15.40 % (95 % CI: 8.93 %, 21.87 %). The number of eyes with iridocorneal contacts after surgery was low (4.2 %). Only the preoperative increased IOP is a significant risk factor for IOP elevation (p = 0.005). Visual acuity improved significantly after surgery (p < 0.001), and clear grafts were achieved in all eyes. Mean endothelial cell count did not differ between patients with and without IOP elevation. CONCLUSION: Incidence of IOP elevation and post-keratoplasty glaucoma after DMEK were low, but regular IOP measurements, especially in eyes with pre-existing glaucoma and bullous keratopathy, are necessary. Steroid-induced IOP elevation was the most frequent reason, and could be treated effectively by tapering down steroid medication or changing the steroid drug. Development of peripheral anterior synechiae after DMEK occured rarely. Therefore, the risk for IOP elevation and especially post-DMEK keratoplasty was reduced compared to PK and DSEK. In all cases, successful management by medical treatment was possible, and resulted in good visual acuity.

Viral Anterior Uveitis: Differences in Retinal Vessel Area Density between the Affected and Non-Affected Eye Using Optical Coherence Tomography Angiography.

PURPOSE: To investigate differences in the retinal vessel area density (VAD) on optical coherence tomography angiography (OCTA) between eyes with unilateral herpetic viral anterior uveitis (VAU) (herpes-simplex virus (HSV) and varicella-zoster virus (VZV)) and the non-affected fellow eye. METHODS: In this monocentric, observational, prospective case series we analyzed the VAD of the macula, optic disc, and peripapillary region in affected and non-affected eyes of 22 patients with HSV-positive and 22 patients with VZV-positive VAU using OCTA. We analyzed also the visual field mean deviation (MD), the retinal nerve fiber layer (RNFL) thickness, Bruch's Membrane Opening-Minimum Rim Width (BMO-MRW), and ganglion cell layer (GCL) thickness on OCT and correlated the results with the different VADs. RESULTS: The macular VAD in the superficial vascular plexus (SVC) was significant lower in the affected compared to the non-affected eye for both viruses (HSV: 33.0% ± 3.3% vs. 34.7% ± 2.6%, p = 0.011; adjusted p = 0.040; VZV: 33.1% ± 3.2% vs. 34.3% ± 2.8%, p = 0.012; adjusted p = 0.050). Additionally, the VAD of the peripapillary SVC differed between the affected and non-affected eye for VZV-positive VAU (47.1% ± 6.2% vs. 50.5% ± 6.3%, p = 0.048, adjusted p = 0.100). For both HSV-positive and VZV-positive VAU, there were correlations between macular or peripapillary SVC VAD and BMO-MRW, GCL thickness, RNFL thickness or MD of the affected eye. CONCLUSION: We observed vascular dysfunction characterized by decreased macular and peripapillary VAD in the superficial plexus on OCTA in eyes with HSV- and VZV-positive VAU compared to non-affected fellow eyes. These changes might be an early sign of glaucomatous damage or may be a direct consequence of the herpes viruses themselves.

Glaucoma in penetrating keratoplasty: risk factors, management and outcome.

INTRODUCTION: Glaucoma is a leading cause for graft failure. This retrospective study analyzes the risk factors, graft status, and treatment modalities in patients with post-penetrating keratoplasty glaucoma. METHODS: A retrospective analysis of case records of 1,848 penetrating keratoplasties carried out between 2000 and 2005 was performed. A total of 160 patients (160 eyes) with post-penetrating keratoplasty glaucoma were included; 112 cases were primary grafts, 48 repeated grafts. The assessment included the pre-operative history of corneal disease and glaucoma, the lens status, and the anesthesiological techniques. Furthermore, the response to anti-glaucoma treatment, graft failure, and endothelial cell loss was evaluated. RESULTS: The incidence of post-penetrating keratoplasty glaucoma was 8.7 % (160/1,848). Preoperative glaucoma was the most important risk factor (62/160). Half of the patients (81 patients) responded to medical therapy (51 %) and the other half of patients (79 patients) to surgical therapy (49 %); of the latter, filtering surgery were performed in 16 %, cyclodestructive procedures in 66 % and both in 16 %. One patient received a glaucoma implant and cyclodestructive procedures (1 %). After 24 months, clear grafts were achieved in 94 eyes (59 %). Visual acuity after 24 months of 20/200 (logMAR 1.0) or better was achieved in 77 eyes (46 %) and of 20/50 (logMAR 0.4) in 33 eyes (21 %). CONCLUSIONS: Careful and ongoing observation of IOP, especially in the first year after PK, is recommended for patients after penetrating keratoplasty and prompt treatment of IOP elevation when indicated. Early filtering surgery with a better outcome than other surgery procedures should be preferred if medical treatment is not sufficient. Despite anti-glaucoma therapy, good visual outcome can remain beyond expectations despite a clear graft. While there is a potential option for graft exchange, damage to the optic nerve from end-stage glaucoma leads immutably to visual loss.

Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty.

BACKGROUND: To evaluate the indication, visual outcome, and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL) during penetrating keratoplasty. METHODS: This retrospective study comprised 23 eyes (23 patients) without adequate capsule support undergoing posterior iris-claw aphakic IOL implantation (Verisyse/Artisan) during penetrating keratoplasty between 2005 and 2010. Mean follow-up was 18 months (range from 12 to 37 months). RESULTS: The IOLs were inserted during an IOL exchange in 17 eyes and as a secondary procedure in six aphakic eyes. Pseudophakic bullous keratopathy with corneal scar after anterior chamber intraocular lens (ACIOL) was the main indication for penetrating keratoplasty in 16 eyes (69.6 %). The final corrected distance visual acuity (CDVA) in logMAR (mean 1.0 ± 0.46) improved significantly (p < 0.05) compared to the preoperative CDVA (mean 1.8 ± 0.73). Twenty eyes (86.9 %) had a final visual acuity in logMAR better than the pre-operative CDVA. The mean postoperative IOP 16.3 mmHg ± 4.0 was not significantly (p > 0.05) higher compared to the preoperative IOP 15.6 mmHg ± 5.1. Complications included slight temporary pupil ovalization in three eyes (13.0 %) and iris-claw IOL sublocation in three eyes (13.0 %); all IOLs could be easily repositioned. Cystoid macular edema occured in one eye (4.3 %) 8 weeks after primary surgery. All grafts remained clear without any sign of graft rejection. CONCLUSIONS: Retropupillar iris-claw IOL during penetrating keratoplasty provides good visual outcomes with a favorable complication rate, and can be used for a wide range of indications in eyes without adequate capsule support.

Intraocular pressure elevation and post-DSEK glaucoma after Descemet`s stripping endothelial keratoplasty.

BACKGROUND: Intraocular pressure (IOP) elevation is a common problem in penetrating keratoplasty (PK), and possibly leads to graft failure. IOP elevation and secondary glaucoma may also be present after Descemet`s stripping endothelial keratoplasty (DSEK). This retrospective study analyzes the risk factors for IOP elevation and the functional outcome in those patients with post-DSEK glaucoma. METHODS: A retrospective analysis of case records of 72 DSEKs between 2007 and 2010 was performed. A total of 59 operated eyes were included. The assessment included the pre-operative history of corneal disease and glaucoma. Furthermore, the response to antiglaucoma treatment, the graft failure, the IOP, and visual acuity development were evaluated. RESULTS: The incidence of IOP elevation was 28.8 % and of post-DSEK glaucoma 11.9 %. Steroid-induced IOP elevation was the most frequent cause, with an incidence of 18.6 %. Patients with pre-existing glaucoma showed a significantly higher risk of developing IOP elevation, steroid-induced glaucoma and post-DSEK glaucoma (p = 0.006, p = 0.023, p = 0.009). In all cases, IOP elevation was treated effectively by tapering down steroid medication and initiating or increasing antiglaucoma medication. Visual acuity after 6 and 12 months improved significantly in cases with and without pre-existing glaucoma (p < 0.0001). After 24 months, clear grafts were achieved in 53 eyes (89.9 %). There was no significant difference in graft failure rates between cases with or without pre-existing glaucoma (p = 0.581) and with or without post-DSEK glaucoma (p = 0.306). CONCLUSIONS: IOP elevation after DSEK shows a high incidence. Pre-existing glaucoma increased the risk of developing IOP elevation and post-DSEK glaucoma. Although steroid-induced IOP elevation was the most frequent cause and could be treated effectively by tapering down steroid medication; there are other reasons why post-DSEK glaucoma developed. Management by medical treatment results in good visual acuity and graft survival.

Combined clear cornea phacoemulsification in the treatment of pseudoexfoliative glaucoma associated with cataract: significance of trabecular aspiration and ab interno trabeculectomy.

BACKGROUND: In the present study, the effectiveness of combined cataract surgery and ab interno trabeculectomy (Trabectome) in exfoliation glaucoma (PEX) was compared with combined cataract surgery and trabecular aspiration. METHODS: In this retrospective comparative cohort outcome study, 27 consecutive patients (mean age 73.41 years ± 10.78) in group 1 suffering from visually significant cataract and PEX glaucoma (mean preoperative IOP 23.41 mmHg ± 5.86) were treated with phacoemulsification combined with Trabectome; and 28 consecutive patients (73.83 years ± 8.94) were treated with phacoemulsification combined with trabecular aspiration (mean preoperative IOP 22.22 mmHg ± 6.33). The intraocular pressure (IOP) and the number of antiglaucoma eyedrops before and after surgery were evaluated. RESULTS: Examinations were performed prior to surgery, 1 day, 6 weeks, 3 months, 6 months, and 1 year after surgery. In both groups there was a statistically significant decrease in postoperative IOP during the whole follow-up period. Comparing the two groups, there was a statistically significant lower IOP in the Trabectome group 1 day (p = 0.019), 6 months (p = 0.025), and 1 year (p = 0.019) after surgery. Between the two groups, there was no statistically significant difference in the number of antiglaucoma eyedrops at any time. CONCLUSIONS: Both procedures have the ability to significantly lower the postoperative IOP during the first year. However, clear cornea phacoemulsification combined with Trabectome seems to be more effective in IOP reduction in cases of PEX glaucoma associated with cataract.

Ocular surface temperature gradient is increased in eyes with bacterial corneal ulcers.

AIMS: To investigate the ocular surface temperature gradient in eyes with bacterial corneal ulcers. METHODS: Prospective examination of 12 eyes with bacterial corneal ulcers (group 1) and 12 control eyes (group 2). Infrared thermal imaging (Tomey TG 1000) was used to study the temperature of the ocular surface. The mean, minimum and maximum temperature of the ocular surface and temperature course over a time period of 10 s of sustained eye opening were evaluated. Furthermore, a correlation between the overall corneal temperature and the temperature at the base of the corneal ulcers was determined. RESULTS: A significant difference between both groups was present. Mean corneal temperature was 35.6°C ± 0.9 in group 1 and 34.8°C ± 0.8 in group 2 (p = 0.033). The temperature course over 10 s of sustained eye opening was -0.6°C ± 0.4 in group 1 and -0.3°C ± 0.2 in group 2 (p = 0.045). There was a close correlation between the mean temperature at the base of the corneal ulcer and the overall corneal temperature (r = 0.92, p < 0.001). CONCLUSION: Infrared thermal imaging can be used to objectively determine the increased ocular surface temperature in patients with bacterial corneal ulcers. The use of dynamic thermography may offer new options to monitor ocular surface alterations.