Prevalence of TERT Promoter Mutations in Orbital Solitary Fibrous Tumors

The orbital manifestation of a solitary fibrous tumor (SFT) is exceptionally rare and poses specific challenges in diagnosis and treatment. Its rather exceptional behavior among all SFTs comprises a high tendency towards local recurrence, but it rarely culminates in metastatic disease. This raises the question of prognostic factors in orbital SFTs (oSFTs). Telomerase reverse transcriptase (TERT)-promoter mutations have previously been linked to an unfavorable prognosis in SFTs of other locations. We analyzed the prevalence of TERT promoter mutations of SFTs in the orbital compartment. We performed a retrospective, descriptive clinico-histopathological analysis of nine cases of oSFTs between the years of 2017 and 2021. A TERT promoter mutation was present in one case, which was classified with intermediate metastatic risk. Local recurrence or progress occurred in six cases after primary resection; no distant metastases were reported. Multimodal imaging repeatedly showed particular morphologic patterns, including tubular vascular structures and ADC reduction. The prevalence of the TERT promoter mutation in oSFT was 11%, which is similar to the prevalence of extra-meningeal SFTs of the head and neck and lower than that in other extra-meningeal compartments. In the present study, the TERT promoter mutation in oSFT manifested in a case with an unfavorable prognosis, comprising aggressive local tumor growth, local recurrence, and eye loss.

Ophthalmological and Interdisciplinary Surgical Approaches to the Orbit

The treatment of orbital masses often requires an interdisciplinary approach. Ophthalmological surgical approaches include the anterior transcutaneous approach for removal of dermoids or taking biopsies. Anterior transconjunctival orbitotomy is suitable for masses of the inferior orbit or the intraconal compartment, but is inappropriate for masses of the orbital apex. The lateral transosseous orbitotomy often fits for masses of the lateral or intraconal compartment, especially for neoplasms of the lacrimal gland e.g. pleomorphic adenoma. Cryoextraction is often the technique of first choice for cavernous haemangiomas of all localisations. Transfrontal approaches are suitable for the resection of tumours of the optic nerve and of the orbital apex.

Analysis of higher-order aberrations in relation to the clinical outcome of an enhanced monofocal IOL

PURPOSE

To analyse higher-order aberrations of an enhanced monofocal aspheric intraocular lens (IOL) in relation to the clinical outcome compared to a monofocal aspheric IOL.

SETTING

Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Germany.

DESIGN

Prospective, monocentric, controlled, non-randomized, two-armed study.

METHODS

After phacoemulsification, a total of 30 patients (60 eyes) were bilaterally implanted with either TECNIS Eyhance IOL model ICB00 (Johnson & Johnson Surgical Vision, Inc.) or TECNIS Monofocal 1-Piece IOL model ZCB00 (Johnson & Johnson Surgical Vision, Inc.) in 30 eyes each. Assessments were performed 1 and 3 months after surgery including refraction, uncorrected and best-corrected distance, intermediate and near visual acuity, defocus curves, contrast sensitivities under photopic, mesopic and mesopic conditions with glare, higher-order aberrations (HOAs) at pupil sizes of 5, 4, 3 and 2 mm and patient satisfaction.

RESULTS

At 3-month follow-up, measurements of HOAs revealed significant higher negative internal and ocular primary spherical aberrations in the ICB00 group at pupil sizes of 5, 4, 3 and 2 mm. The ICB00 showed significant better results in intermediate and near visual acuity, but no difference in distance visual acuity. No significant difference was found in contrast sensitivities at any condition or spatial frequency. Spectacle independence was significant better without significant higher rates of dysphotopsia in the ICB00 group.

CONCLUSIONS

Higher negative spherical aberrations in the ICB00 group at all measured pupil sizes appear to lead to a superior clinical outcome in intermediate and near vision compared to the ZCB00 group without compromising contrast sensitivity or distance visual acuity.

Maligne Neoplasien der Orbita

Malignant masses of the orbit include a large variety of neoplasms of epithelial or mesenchymal origin. The treatment of orbital malignancies is an essential interdisciplinary field of medicine that integrates ENT medicine, facial surgery, plastic surgery, neurosurgery, oncology and radiology.The main symptom of malignant orbital masses is the exophthalmos. A symptom that can help to differentiate a benign from a malignant orbital mass can be the pain. The main diagnostic tool is the MRI including new sequences like DWI and DCE.After presenting symptoms and diagnostic strategies of malignant orbital masses, this article starts with the description of malignant epithelial neoplasms of the lacrimal gland. Furthermore, it describes new insights in orbital lymphomas, followed by the discussion of semimalignant orbital masses. Last but not least the text deals with malignant neoplasms of the skin that can grow secondarily in the orbit. Finally, the manuscript discusses orbital metastases.

The Supraorbital Eyebrow Approach in Pediatric Neurosurgery: Perspectives and Challenges of Frontal Keyhole Surgery

OBJECT

Supraorbital craniotomy via an eyebrow incision provides minimally invasive cosmetically favorable access to both orbital and intracranial pathologies. We describe the indication, surgical technique, and clinical course using this surgical approach in a cohort of patients from a single pediatric neurosurgery unit.

METHODS

In a retrospective analysis, we identified all surgical cases between January 2013 and April 2022 who underwent the supraorbital craniotomy via an eyebrow incision. Craniotomy was performed using piezosurgery ultrasonic bone incision. An interdisciplinary team of an orbital surgeon and a neurosurgeon performed the orbital surgeries. Clinical and surgical characteristics, perioperative data, possible complications, or redo surgeries as well as ophthalmologic status were assessed.

RESULTS

Clinical data of 37 interventions (cases) in 30 patients (age: 8 ± 6.5 years) were analyzed. The supraorbital craniotomy established access to the cranial, lateral, and central portions of the orbit (n = 11) and ipsilateral fronto-medial portions of the skull base (n = 26). Thirty cases suffered from tumor disease with heterogeneous histopathologic diagnoses, and in 13 cases, adjuvant therapy was required. The mean duration of surgery was 163 ± 95 min, and the mean time of hospital stay was 6.0 ± 2.8 days. In two cases (5.4%), the following complications were observed. One infection treated by puncture and antibiotics and one revision surgery was necessary due to loosening of osteosynthesis material. Postoperative visual function was stable compared to preoperative status after all interventions. After a mean follow-up time of 26 ± 25.9 months for oncologic cases the long term outcome was complete remission in 13, stable disease in 14, progressive disease in 1 and death in 2 patients.

CONCLUSION

The supraorbital eyebrow approach is feasible and safe in pediatric neurosurgical cases as a minimally invasive and cosmetic favorable technique and should be considered for intraorbital as well as ipsilateral intracranial lesions adjacent to the skull base. Interdisciplinary cooperation enables a broader spectrum of surgical options in orbital and complex, fronto-basal, skull base pathologies.

LGG-56. Surgical management of pre-chiasmatic intraorbital optic nerve gliomas in children after loss of visual function – Resection from bulbus to chiasm

INTRODUCTION: Optic pathway gliomas (OPG) in children carry significant morbidity and therapeutic challenges. The subgroup of pre-chiasmatic gliomas manifest with exopthalmus are a subgroup where, after blindness has occurred, an intraorbital and intradural resection is a curative option. We present a two-center cohort using two different surgical approaches and describe indication, technique, and long term surgical outcome. METHODS: A retrospective analysis in both centers was performed to included patients < 18 years at diagnosis with a pre-chiasmatic intra-orbital glioma, in whom a resection from the bulb to the chiasm was performed. RESULTS: 11 patients were included. 4 had NF1. Mean age at surgery was 7.0 years. Interval between diagnosis and surgery was 1-74 (median 10) months. Two had prior chemotherapy, one radiation, one both, one prior intraorbital surgery. In all 5 progression occurred. Indications for surgery were exophthalmos, pain, tumor progression or a combination. 8 patients (Group A) underwent an extradural trans-orbital-roof approach to resect intra-orbital tumour including the optic canal part plus intradural pre-chiasmatic resection. In 3 patients (Group B) a combined supra-orbital mini-craniotomy plus orbital frame osteotomy was used for intraorbital tumour-resection, excluding the optic canal part, plus intradural pre-chiasmatic resection. GTR was achieved in 7/8 of Group A and none had a recurrence (mean-FU 42 month). One residual behind the bulbus showed progression, treated by chemotherapy. All residuals in Group B were remnants of the optic nerve within optic canal remained stable (mean FU 11.8 months). No patient had a chiasmatic functional affection or permanent oculomotor deficits. Two after prior radiotherapy developed slight enophthalmos. CONCLUSION: In these selected patients surgical resection from bulb to chiasm (± removal of optic canal tumor) is safe without long-term sequela and with excellent cosmetic result. Surgery removes immediately exophthalmos and provides an effective long-term tumor control. It should be considered therapy of choice.

Visual outcome and optical quality of a wavefront-engineered extended depth-of-focus intraocular lens

PURPOSE

To evaluate visual performance and optical quality of an extended depth-of-focus intraocular lens (EDoF IOL) compared with a monofocal aspheric IOL.

SETTING

Department of Ophthalmology, Charité-Medical University Berlin, Germany.

DESIGN

Prospective case series.

METHODS

After phacoemulsification, a total of 28 patients (56 eyes) underwent bilateral implantation of either the Mini Well (EDoF IOL) or the Mini 4 (monofocal IOL). Assessments including refraction, distance, intermediate and near visual acuity, defocus curves, contrast sensitivity, glare disability, higher-order aberrations (HOAs), and patient satisfaction were performed at 1 month and 3 months postoperatively.

RESULTS

Both study groups comprised 14 patients (28 eyes) each. At 3-month follow-up, the EDoF IOL showed better results in monocular uncorrected intermediate visual acuity (-0.04 vs 0.10 logMAR, P = .000) and in uncorrected near visual acuity (0.13 vs 0.36 logMAR, P = .000), whereas no statistically significant difference was found between groups in monocular uncorrected distance visual acuity (0.04 vs 0.00 logMAR, P = .110). The monocular depth of focus was 0.8 D greater in the Mini Well IOL group. Measurements of internal HOAs revealed a greater negative primary spherical aberration in the EDoF group at pupil sizes of 2.0 to 5.0 mm. At 5.0 mm, total internal HOAs did not differ statistically significantly (0.376 vs 0.340 μm root mean square, P = .068).

CONCLUSIONS

The Mini Well IOL provided greater depth of focus with superior outcomes at intermediate and near distances and comparable outcomes at far distance. Although inducing higher amounts of spherical aberration, it showed good results under low lighting conditions with little subjective dysphotopsia.

Selective Laser Trabeculoplasty Versus MIGS: Forgotten Art or First-Step Procedure in Selected Patients with Open-Angle Glaucoma

Introduction

To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice.

Methods

A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95–105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome^®, NeoMedix, Tustin, USA), and 130 patients received iStent inject^® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan–Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy).

Results

In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p < 0.001) 3 years postoperatively; in Trabectome^® IOP decreased by 31.4% from 20.5 ± 1.3 to 13.8 ± 2.0 mmHg (p < 0.001) and in iStent inject^® by 29.9% from 19.5 ± 2.0 to 13.8 ± 2.7 mmHg (p < 0.001). Trabectome^® and iStent inject^® could not demonstrate a significant reduction in glaucoma therapy (Trabectome^®p = 0.138, iStent inject^®p = 0.612); a significant drop was noted in SLT (2.2 ± 1.2 to 1.7 ± 1.2, p = 0.046). SLT and MIGS achieved good to moderate survival rates using criterion A (93.3% SLT, 79.7% Trabectome^®, 77.6% iStent inject^®) and criterion B (74.5% SLT, 48.0% Trabectome^®, 56.2% iStent inject^®). As expected, low survival rates were obtained with non-filtering procedures: criterion C 11.1% in SLT, 6.5% in Trabectome^®, 7.0% in iStent inject^® and criterion D 3.0% in SLT, 4.3% in Trabectome^®, 3.7% in iStent inject^® in 3-year follow-up.

Conclusion

The SLT is a low-complication and effective method for reducing pressure in mild to moderate POAG. SLT is suitable as an initial procedure when setting up a step scheme; MIGS is the treatment of choice as a follow-up for mild to moderate forms of glaucoma and accepted topical therapy. Ethic approval had been given by the Ethikkommission Charité – Universitätsmedizin Berlin, EA4/047/20—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00347-0.

Corneal higher-order aberrations after cataract surgery: Manual phacoemulsification versus femtosecond-laser assisted technique

Purpose:

To compare and evaluate corneal higher-order aberrations (c-HOA) between conventional manual phacoemulsification (Phaco), femtosecond laser-assisted cataract surgery (FLACS), and femtosecond laser-assisted cataract surgery with astigmatic keratotomy (FSAK).

Methods:

In this retrospective single center study, 53 healthy individuals with cataract (73 eyes) underwent phacoemulsification with implantation of an intraocular lens. Three groups were formed: group A, Phaco (n = 27 eyes of 21 patients); group B, FLACS (n = 25 eyes of 15 patients); group C, FSAK (n = 21 eyes of 17 patients). An iTrace aberrometer (Tracey Technologies, Houston, TX, USA) was used to perform aberrometry with a pupil scan size of 5.0 mm. We used ANOVA analysis and the paired sample t-test for statistical analysis.

Results:

There was no difference in total c-HOA between the groups prior to surgery (F(2,66) = 2.2, p = 0.128), but some evidence for a difference between the groups after surgery (F(2,65) = 3.87, p = 0.025). After surgery, total c-HOA increased in all groups, but the greatest increase occurred FSAK.

Conclusion:

Manual phacoemulsification and femtosecond laser-assisted cataract surgery seem to have less impact on corneal higher-order aberrations than the combination of femtosecond laser-assisted cataract surgery with astigmatic keratotomy.

[IgG4-Related Orbitopathy as an Important Differential Diagnosis of Advanced Silent Sinus Syndrome. German version]

Hintergrund

Mit Immunglobulin (Ig)G4 assoziierte Erkrankungen werden als immunvermittelte Erkrankungen klassifiziert. Die Ätiologie dieser Krankheiten ist bisher noch nicht geklärt. Sie manifestieren sich auf verschiedene Weise, und die gleichzeitige Beteiligung mehrerer Organe ist nicht ungewöhnlich.

Kasuistik

Es wird der Fall eines Patienten vorgestellt, der in die Klinik der Autoren überwiesen wurde, nachdem mehrere erfolglose Nasennebenhöhlenoperationen bei ihm durchgeführt worden waren; bei Vorliegen eines Enophthalmus und einer resultierenden Durchwanderungskeratitis bestand die Verdachtsdiagnose eines Silent-Sinus-Syndroms. Der Erhalt der Orbita war nicht mehr möglich. Nach 5 Jahren ohne definitive Diagnose wurde nun die Diagnose einer IgG4-assoziierten Erkrankung gesichert.

Diskussion

IgG4-assoziierte Erkrankungen stellen einen wichtigen Baustein bei der Differenzialdiagnose chronischer fortgeschrittener Erkrankungen der Orbita und der Nasennebenhöhlen dar. Bei unklaren Krankheitszeichen sollte diese Diagnose in Erwägung gezogen werden. Zu den typischen histologischen Befunden gehören ein storiformes Muster der Fibrose, Vaskulopathie und Gewebeinfiltration durch IgG4-Plasmazellen.

Iris and Lens Trauma - Iris Reconstruction

Iris and lens injuries entail a large spectrum and occur in closed and open globe injuries. Depending on accompanying ocular trauma (e.g. corneal involvement) as well as on the extend of the injuries several different surgical options are available ranging from suturing techniques to special individualized implants. The aim of this article is to present and discuss current treatment options for lens and iris trauma in regards to typical cases.

Use of topical anaesthesia and peribulbar anaesthesia in Descemets membrane endothelial keratoplasty

INTRODUCTION

In instances where peribulbar anaesthesia (PBA) cannot be used, Descemet membrane endothelial keratoplasty (DMEK) surgery can be performed under topical anaesthesia (TA). We evaluated subjective pain and post-operative outcomes of DMEK surgeries performed under PBA and TA.

METHODS

Sixty pseudophakic patients without history of ocular comorbidities underwent DMEK surgery under either PBA or TA. PBA was performed with a single injection of 6 mL Prilocaine Hydrochloride 2% in combination with 1500 I.U. hyaluronidase. For TA, patients were given 0.4% Oxybuprocaine eye drops followed by a 2% Lidocain Hydrochloride-Gel and an intraoperative injection of a 2% Lidocaine Hydrochloride solution into the anterior chamber. All surgeries were performed by the same surgeon. Subjective pain was measured using a visual analog scale (VAS). Secondary outcomes (BCVA, duration of surgery, endothelial density, rebubbling rate) were recorded during a follow-up period of 3 months.

RESULTS

The mean subjective pain of patients in the PBA group was 1.27 (95% CI 0.87-1.68) and 1.64 (95% CI 1.15-2.21) in the TA group. The mean duration of surgery was 402 s (95% CI 356-448) in the PBA group and 427 s (95% CI 371-483) in the TA group, p = 0.477. No major differences were observed in BCVA, endothelium density and rebubbling rate between the two groups. Anaesthesia-related side effects were more frequent in the PAB group than in the TA group.

CONCLUSION

Although levels of subjective pain are lower under PBA than under TA, in selected patients without ocular comorbidities TA can achieve levels of pain acceptable for DMEK surgery.

Outcome of a penetrating keratoplasty in a 3-month-old child with sclerocornea

Sclerocornea is a rare congenital anomaly with clouding of the peripheral cornea that possibly extends up to the center of the cornea. Characteristically, a clear distinction (limbus) between sclera and cornea is lacking. Early surgical treatment is essential for preventing amblyopia, but penetrating keratoplasty in children carries a relatively high risk of complications. Especially for sclerocornea, penetrating keratoplasty has generally been reported to have a poor surgical outcome and a high risk of complications, including corneoscleral adhesions. Here, we report the 4-year follow-up on a child with sclerocornea, who was successfully operated on at the age of 3 months and had a favorable outcome. Our findings suggest that in some cases, penetrating keratoplasty may be an option to treat sclerocornea in young children.

IgG4-related orbitopathy as an important differential diagnosis of advanced silent sinus syndrome

BACKGROUND

Immunoglobulin (Ig)G4-related disease is classified as an immune-mediated disease. The etiology of this condition has not been explained to date. Manifestations of the disease are diverse, and simultaneous involvement of multiple organs is not unusual.

CASE REPORT

We report the case of a patient referred to us after multiple unsuccessful paranasal sinus operations who presented with enophthalmos and a resultant migratory keratitis with a suspected diagnosis of silent sinus syndrome. Preservation of the orbit was no longer feasible. After five years without a definitive diagnosis, we ascertained that this was a case of IgG4-related disease.

DISCUSSION

IgG4-related disease represents an important element in the differential diagnosis of chronic advanced diseases of the orbit and paranasal sinuses. The diagnosis should be considered in the case of unclear disease presentations. Typical histological findings include a storiform pattern of fibrosis, vasculopathy, and tissue infiltration by IgG4 plasma cells.

Virus-associated anterior uveitis and secondary glaucoma: Diagnostics, clinical characteristics, and surgical options

In this retrospective, single-center, observational study, we compared the clinical characteristics, analyzed the glaucoma development, and the glaucoma surgery requirement mediators in patients with different virus-associated anterior uveitis (VAU). In total, 270 patients (= eyes) with VAU confirmed by positive Goldmann-Witmer coefficients (GWC) for cytomegalovirus (CMV), herpes simplex virus (HSV), varicella-zoster virus (VZV), rubella virus (RV), and multiple virus (MV) were included. Clinical records of these patients were analyzed. Demographic constitution, clinical findings, glaucoma development, and surgeries were recorded. The concentrations of 27 immune mediators were measured in 150 samples of aqueous humor. The GWC analysis demonstrated positive results for CMV in 57 (21%), HSV in 77 (29%), VZV in 45 (17%), RV in 77 (29%), and MV in 14 (5%) patients. CMV and RV AU occurred predominantly in younger and male patients, while VZV and HSV AU appeared mainly with the elderly and females (P<0.0001). The clinical features of all viruses revealed many similarities. In total, 52 patients (19%) showed glaucomatous damage and of these, 27 patients (10%) needed a glaucoma surgery. Minimal-invasive glaucoma surgery (MIGS) showed a reliable IOP reduction in the short-term period. In 10 patients (37%), the first surgical intervention failed and a follow-up surgery was required. We conclude that different virus entities in anterior uveitis present specific risks for the development of glaucoma as well as necessary surgery. MIGS can be suggested as first-line-treatment in individual cases, however, the device needs to be carefully chosen by experienced specialists based on the individual needs of the patient. Filtrating glaucoma surgery can be recommended in VAU as an effective therapy to reduce the IOP over a longer period of time.

Assessing full thickness oral mucosal grafting: complications and postoperative outcomes in a broad collective of patients

Background

Conjunctival defects can be repaired with several mucosal tissues. The simplicity of harvesting oral mucosa and its wide availability makes it the preferred graft tissue for all indications requiring mucosal grafting. Through analysing the postsurgical outcomes and rate of revisions, this study explores the suitability of oral mucosa grafts, depending on the initial diagnosis.

Methods

We reviewed all the files of patients with a history of oral mucosal graft surgery, performed at our clinic between 2012 and 2018, focusing on complications and revision rates.

Results

In total, we analysed 173 oral mucosa grafts in 131 patients. The most common initial diagnosis was tumour resection, followed by surgical complications, postenucleation socket syndrome, trauma and ocular surface disorders. Complication and revision rates depended highly on the initial diagnosis. Revision rates were highest if the initial diagnosis included ocular surface disorders or chemical trauma.

Conclusions

Oral mucosa grafting (OMG) is the most effective treatment for a wide range of ocular conditions involving conjunctival defects. Conjunctival defects that result from trauma or cicatricial surface diseases seem less suitable for OMG and may benefit from alternative graft tissue or treatment options.

Firework-inflicted ocular trauma in children and adults in an urban German setting

PURPOSE

To assess firework-inflicted ocular trauma in the German capital during the week around New Year's Eve with regards to patient characteristics and age, severity of injuries, and their management and outcome.

METHODS

A retrospective chart review of all patients presenting to the department of ophthalmology of Charité-University Medicine Berlin during a 7-day period around New Year's Eve in the years 2014-2017 was performed. Patients with ocular complaints and injuries caused by fireworks were included. We recorded demographic data, active role, visual acuity at presentation and at last follow-up, the most pertinent clinical findings, management and outcome with regards to visual acuity, and integrity of the eye.

RESULTS

A total of 146 patients with 165 injured eyes were included. Median age at presentation was 23 (4-58) years, and 71.2% were male. Fifty-one patients (34.9%) were less than 18 years old. Ninty-seven patients (66.4%) sustained minor, 34 (23.3%) sustained moderate, and 15 (10.3%) sustained severe injuries. Severe trauma was seen in younger patients (median age: 12, range: 4-58 years) than mild and moderate trauma (median age: 23, range: 4-45 years) and resulted in loss of light perception in two eyes and in a visual acuity of only light perception in three eyes. One eye was enucleated.

CONCLUSION

Ocular trauma inflicted by fireworks can have serious consequences for ocular morbidity and visual acuity, especially in severe trauma which affected younger patients. To significantly reduce firework-inflicted trauma, a ban of private fireworks in densely populated areas and in the vicinity of children should be considered.

DCE-MR imaging of orbital lesions: diagnostic performance of the tumor flow residence time τ calculated by a multi-compartmental pharmacokinetic tumor model based on individual factors

BACKGROUND

Differentiating benign from malignant orbital lesions by imaging and clinical presentation can be challenging.

PURPOSE

To differentiate benign from malignant orbital masses using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) based on tumor flow residence time τ calculated with the aid of a pharmacokinetic tumor model.

MATERIAL AND METHODS

Sixty patients with orbital masses were investigated by 3-T MRI including dynamic sequences. The signal intensity-time curve after i.v. contrast medium administration within lesions was approximated by Gd-concentration profiles on the basis of model calculations where the tumor is embedded in a whole-body kinetic model. One output of the model was tumor flow residence time τ, defined as the ratio of the tumor volume and the tumor blood flow rate. Receiver operating characteristic (ROC) curves were used to analyze the diagnostic performance of τ. The results were compared with those of K^trans, k_ep, v_e, iAUC, and ADC.

RESULTS

Thirty-one benign and 29 malignant orbital masses were identified (reference standard: histopathology, clinical characteristics). Mean τ was significantly longer for benign masses (94 ± 48 s) than for malignant masses (21 ± 19 s, P < 0.001). ROC analysis revealed the highest area under the curve (AUC = 0.94) for τ in orbital masses compared to standard methods.

CONCLUSION

Tumor flow residence times τ of benign and malignant orbital masses are valuable in the diagnostic work-up of orbital tumors. Measures of diagnostic accuracy were superior for τ compared to ADC, K^trans, v_e, and iAUC.

[Benign Neoplasms of the Orbit]

Benign orbital neoplasms comprise a wide spectrum of different entities. The origin of the tumours can be epithelial or mesenchymal. Epithelial neoplasms of the orbit originate from the lacrimal gland. The most important tumour is the pleomorphic adenoma, which should not be biopsied but resected in toto. The most common intraconal neoplasm in adults is the cavernous hemangioma. Symptomatic cavernous hemangiomas should be treated. The treatment of choice for most symptomatic benign neoplasms of the orbit is surgical resection. Suitable surgical approaches are anterior transconjunctival and lateral orbitotomy. Cryoextraction is a minimally invasive technique that is particularly suitable for cavernous hemangiomas.

Benigne Neoplasien der Orbita

Die Vielfalt orbitaler Raumforderungen ist außerordentlich groß. Manche Entitäten sind sehr selten. Das häufigste Symptom ist der Exophthalmus, daneben können Bulbusdislokation, Strabismus, Schmerzen, Sehverschlechterung und Gesichtsfeldausfälle auftreten. Die Therapie der Wahl bei den meisten symptomatischen benignen Neoplasien der Orbita ist die chirurgische Resektion.

Exploring the precision of femtosecond laser-assisted descemetorhexis in Descemet membrane endothelial keratoplasty

Objective

Descemet membrane endothelial keratoplasty (DMEK) remains a challenging technique. We compare the precision of femtosecond laser-assisted DMEK to manual DMEK.

Methods and Analysis

A manual descemetorhexis (DR) of 8 mm diameter was compared with a femtosecond laser-assisted DR of the same diameter (femto-DR) in 22 pseudophakic patients requiring DMEK. We used OCT images with a centred xy-diagram to measure the postoperative precision of the DR and the amount of endothelial denuded area. Endothelial cell loss (ECL) and best corrected visual acuity were measured 3 months after surgery.

Results

In the manual group, the median error of the DR was 7% (range 3%–16%) in the x-diameter and 8% (range 2%–17%) in the y-diameter. In the femto group, the median error in the respective x and y-diameters was 1% (range 0.4%–3%) and 1% (range 0.006%–2.5%), smaller than in the manual group (p=0.001). Endothelial denuded areas were larger in the manual group (11.6 mm², range 7.6–18 mm²) than in the femto group (2.5 mm², range 1.2–5.9 mm²) (p<0.001). The ECL was 21% (range 5%–78%) in the manual DR and 17% (range 6%–38%) in the femto-DR group (p=0.351). The median visual acuity increased from 0.4 logMAR (range 0.6–0.4 logMAR) in both groups to 0.1 logMAR (range 0.4–0 logMAR) in the manual group and to 0.1 logMAR (range 0.3–0 logMAR) in the femto group (p=0.461). Three rebubblings were required in the manual group, whereas the femto group required only one.

Conclusion

The higher precision of the femto-DR bears the potential to improve DMEK surgery.

Predictive Factors for Clinical Outcomes after Primary Descemet's Membrane Endothelial Keratoplasty for Fuchs' Endothelial Dystrophy

PURPOSE

The purpose of this study is to identify predictors for the best-corrected visual acuity (BCVA), central corneal thickness (CCT), and the endothelial cell density (ECD) after primary Descemet's membrane endothelial keratoplasty (DMEK).

METHODS

In a prospective observational study, 108 eyes with Fuchs' endothelial dystrophy underwent a primary DMEK. Preoperative data, histologic parameters from host's Descemet's membrane, and follow-up data of the first eye were analyzed in regard to BCVA, CCT, and ECD, 12 months after surgery.

RESULTS

Overall, 12 months postoperative, the BCVA improved to 0.11 ± 0.11 logMAR, the CCT declined to 529 ± 42 µm, and the ECD measured 1675 ± 418 cells/mm². A significant influence of the preoperative CCT on postoperative BCVAs and CCTs was observed (r = 0.299, p = 0.014 and r = 0.507, p < 0.001, respectively). Especially eyes with a CCT <625 µm demonstrated a better BCVA (0.05 ± 0.07 logMAR) than eyes with a CCT ≥625 µm (0.13 ± 0.11 logMAR, p = 0.002). Furthermore, the identification of eyes with an early visual restitution was possible by considering follow-up data of the first eye. A preoperative CCT ≥625 µm was also sensitive to identify eyes with a persistent corneal swelling. The anterior banded layer thickness, which was obtained histologically, correlated to the preoperative CCT and the frequency of graft detachments (r = 0.601, p = 0.023 and r = 0.652, p = 0.041, respectively). Furthermore, a graft's baseline ECD ≤2100 cells/mm² was found to be a risk factor for an ECD deterioration under 1000 cells/mm² (1.8% vs. 15.8%, p = 0.020).

CONCLUSIONS

Simple clinical parameters, such as the preoperative CCT, the course of visual restitution of the first eye, and the graft's baseline ECD, are efficient predictors for relevant outcome parameters after DMEK and therefore may be used for stratification. Furthermore, our findings indicate that a DMEK should be performed in eyes with Fuchs' endothelial corneal dystrophy, if possible, before the CCT exceeds 625 µm to maintain good clinical results.

Clinical outcome and higher order aberrations after bilateral implantation of an extended depth of focus intraocular lens

Purpose:

The purpose of this study was to assess the clinical outcome after a bilateral implantation of an extended depth of focus intraocular lens in comparison to a monofocal intraocular lens.

Setting:

Department of Ophthalmology, Charité—Medical University Berlin, Germany.

Patients and Methods:

A total of 60 eyes of 30 patients were enrolled in this prospective, single-center study. The cataract patients underwent phacoemulsification with bilateral implantation of a TECNIS® Symfony (Abbott Medical Optics, Santa Ana, CA, USA, 15 patients) or a TECNIS Monofocal ZCB00 (Abbott Medical Optics, Santa Ana, CA, USA, 15 patients). Postoperative evaluations were performed after 1 and 3 months, including visual acuities at far, intermediate, and near distance. Mesopic, scotopic vision, and contrast sensitivity were investigated. Aberrometry was performed using an iTrace aberrometer with a pupil scan size of 5.0 mm.

Results:

After 3 months, the TECNIS Symfony group reached an uncorrected visual acuity at far distance of −0.02 logMAR compared to −0.06 logMAR in the TECNIS Monofocal group ( p = 0.03). Regarding the uncorrected vision at intermediate and near distance the following values were obtained: intermediate visual acuity −0.13 versus 0.0 logMAR (TECNIS Symfony vs TECNIS Monofocal, p = 0.001) and near visual acuity 0.11 versus 0.26 logMAR (TECNIS Symfony vs TECNIS Monofocal, p = 0.001). Low-contrast visual acuities were 0.27 versus 0.20 logMar (TECNIS Symfony vs TECNIS Monofocal, p = 0.023).

Conclusion:

The TECNIS Symfony intraocular lens can be considered an appropriate alternative to multifocal intraocular lenses because of good visual results at far, intermediate, and near distance as well as in low-contrast vision.

iStent inject as a reasonable alternative procedure following failed trabeculectomy?

PURPOSE:

The aim of this study is to assess the intraocular pressure lowering effect and the performance of the glaucoma therapy of the iStent inject in glaucoma patients with uncontrolled intraocular pressure after failed trabeculectomy.

METHODS:

In this retrospective study, iStent inject implantation (Glaukos Corporation, Laguna Hills, CA, USA) was performed in 22 eyes of 21 subjects suffering from glaucoma (n = 18 primary open angle glaucoma, n = 3 pseudoexfoliation glaucoma, and n = 1 for secondary glaucoma) with an intraocular pressure above target pressure after failed trabeculectomy (mean = 9.6 ± 8.1 years; range: 1-35 years). The intraocular pressure and the number of antiglaucomatous medication were assessed preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1 year after surgery and compared to preoperative findings (SPSS v23.0; Shapiro-Wilk test, Wilcoxon test, Friedman test).

RESULTS:

The results showed a significant intraocular pressure decrease from 22.5 ± 4.6 to 15.5 ± 3.4 mmHg after 1 year follow-up (p = 0.012). The glaucoma therapy was 2.6 ± 1.2 preoperatively and reduced to 2.25 ± 1.5 number of medications after 1 year (p > 0.05). There was no significant difference in the number of medication during the whole follow-up period (1 year, p = 0.012). No significant intra- or postoperative complications were reported.

CONCLUSION:

Minimal invasive glaucoma surgery (iStent inject) can offer an effective intraocular pressure reduction in advanced adult primary and secondary open angle glaucoma after failed trabeculectomy in a follow-up period of 1 year. Glaucoma therapy, however, needs to be maintained to achieve an individual target pressure and to prevent glaucoma progression. In addition, a failure rate of 27.3% makes it necessary to select carefully patients for this treatment option.

Modified goniotomy as an alternative to trabectome in primary open angle glaucoma and pseudoexfoliation glaucoma: 1 year results

OBJECTIVE

To assess the outcome of modified goniotomy and trabeculotomy ab interno (Trabectome) surgery in adult primary open-angle glaucoma (POAG) and pseudoexfoliation (PEX) glaucoma.

DESIGN

Retrospective cohort outcome study.

PARTICIPANTS

Two hundred and thirty-six eyes of 236 patients.

METHODS

This cohort outcome study included 68 POAG (mean age: 65.7 ± 16.0 years) and 22 PEX glaucoma patients (mean age: 78.3 ± 7.9 years) in the modified goniotomy cohort and 119 POAG (mean age: 73.9 ± 9.6 years) and 27 PEX glaucoma patients (mean age: 75.2 ± 8.0 years) in the Trabectome cohort. Modified goniotomy is defined as combined ab interno cyclodialysis and goniotomy. The patients were followed up for 12 months, and we analysed the data using SPSS v19.0.

RESULTS

In POAG, the intraocular pressure (IOP) was significantly reduced by 4.6 mm Hg in the Trabectome cohort (p < 0.001) and by 5.8 mm Hg (p < 0.001) in the goniotomy group at 1-year follow-up. In PEX glaucoma, the mean IOP was reduced by 9.7 mm Hg (p = 0.002) in the Trabectome surgery and by 6.7 mm Hg (p = 0.004) in the goniotomy cohort 1 year later. Comparing both surgery techniques in POAG, no significant correlation was found in terms of IOP at any of the follow-up visits (IOP at 1 year, p = 0.553). In PEX glaucoma, the IOP, visual acuity, and number of glaucoma medications did not differ significantly between the 2 surgery techniques 1 year later (IOP: p = 0.300; VA: p = 0.391; therapy: p = 0.908).

CONCLUSION

Modified goniotomy and Trabectome surgery are reliable and effective tools for the management of moderate POAG and PEX glaucoma. There was no significant difference in IOP between the 2 procedures over a follow-up period of 1 year.

Comparison of ICare and IOPen vs Goldmann applanation tonometry according to international standards 8612 in glaucoma patients

AIM

To compare IOPen and ICare rebound tonometry to Goldmann applanation tonometry (GAT) according to International Standards Organization (ISO) 8612 criteria.

METHODS

Totally 191 eyes (n=107 individuals) were included. Criteria of ISO 8612 were fulfilled: 3 clusters of IOP, measured by GAT, were formed. The GAT results were given as mean±standard deviation.

RESULTS

GAT (19.7±0.5 mm Hg) showed a significant correlation to ICare (19.8±0.5 mm Hg) (r=0.547, P<0.001) and IOPen (19.5±0.5 mm Hg) (r=0.526, P<0.001). According to ISO 8612 criteria in all 3 IOP groups the number of outliers (of the 95% limits of agreement) exceeded 5% for ICare and IOPen vs GAT: No.1 (n=68) 29.4% and 22.1%, No.2 (n=62) 35.5% and 37.1%, No.3 (n=61) 26.2% and 42.6%, respectively.

CONCLUSION

The strict requirements of the ISO 8612 are not fulfilled in a glaucoma collective by ICare and IOPen at present. As long as the Goldmann tonometry is applicable it should be used first of all for reproducible IOP readings. ICare and IOPen tonometry should be considered as an alternative tool, if application of Goldmann tonometry is not possible.

Contralateral eye comparison study in MICS & MIGS: Trabectome® vs. iStent inject®

PURPOSE

To compare the safety and efficacy profile after combined micro-incision cataract surgery (MICS) and micro-invasive glaucoma surgery (MIGS) with the ab interno trabeculectomy (Trabectome®) in one eye versus two iStent® inject devices in the contralateral eye in patients with open-angle glaucoma (OAG) and cataract.

METHODS

This retrospective, intraindividual eye comparison study included 27 patients (54 eyes) who were treated with combined MICS and ab interno trabeculectomy (group I, Trabectome®) in one eye and two iStent® inject devices (group II, GTS 400) in the fellow eye. Primary outcome measures included intraocular pressure (IOP) and glaucoma medication after 6 weeks, 3, 6, and 12 months follow-up. Secondary outcome measures were number of postoperative interventions, complications, and best-corrected visual acuity (BCVA).

RESULTS

Mean preoperative IOP decreased from 22.3 ± 3.7 mmHg in group I and 21.3 ± 4.1 mmHg in group II to 15.6 ± 3.6 mmHg for Trabectome (p < 0.001) and 14.0 ± 2.3 mmHg for iStent inject (p < 0.001) at 12 months after surgery without a significant difference between the two groups (p > 0.05). No vision-threatening complications such as choroidal effusion, choroidal hemorrhage, or infection occurred. In each group trabeculectomy had to be performed in two eyes due to insufficient IOP lowering effect.

CONCLUSIONS

Ab interno trabeculectomy and iStent® inject were both effective in lowering IOP with a favourable and comparable safety profile in an intraindividual comparative study over a 12-months follow-up in OAG. However, longer follow-up of these patients will be necessary to determine long-term outcomes and to evaluate significant differences.

Fulminant Endophthalmitis in a Child Caused by Neisseria meningitidis Serogroup C Detected by Specific DNA

This case report describes a local Neisseria meningitidis eye infection with a long protracted course in a seemingly healthy previously vaccinated child. Bacterial infection was detected by polymerase chain reaction techniques.

Correlation between anterior chamber characteristics and laser flare photometry immediately after femtosecond laser treatment before phacoemulsification

PurposeTo assess the anterior chamber (AC) characteristics and its correlation to laser flare photometry immediately after femtosecond laser-assisted capsulotomy and photodisruption.Patients and methodsThe study included 97 cataract eyes (n=97, mean age 68.6 years) undergoing femtosecond laser-assisted cataract surgery (FLACS). Three cohorts were analysed relating to the flare photometry directly post femtosecond laser treatment (flare <100 n=28, 69.6±7 years; flare 100-249 n=47, 67.7±8 years; flare >249 photon counts per ms cohort n=22, 68.5±10 years). Flare photometry (KOWA FM-700), corneal topography (Oculus Pentacam, Germany: AC depth, volume, angle, pachymetry), axial length, pupil diameter, and endothelial cells were assessed before FLACS, immediately after femtosecond laser treatment and 1 day postoperative (LenSx Alcon, USA). Statistical data were analysed by SPSS v19.0, Inc.ResultsThe AC depth, AC volume, AC angle, central and thinnest corneal thickness showed a significant difference between flare <100 vs flare 100-249 10 min post femtosecond laser procedure (P=0.002, P=0.023, P=0.007, P=0.003, P=0.011, respectively). The AC depth, AC volume, and AC angle were significantly larger (P=0.001, P=0.007, P=0.003, respectively) in the flare <100 vs flare >249 cohort 10 min post femtosecond laser treatment.ConclusionsA flat AC, low AC volume, and a narrow AC angle were parameters associated with higher intraocular inflammation. These criteria could be used for patient selection in FLACS to reduce postoperative intraocular inflammation.

[Long-term Outcomes and Complications after Surgical Posterior Capsule Polishing Due to Secondary Cataract]

BACKGROUND

To evaluate the long-term outcome and complication rate after surgical posterior capsule polishing as an alternative to Nd : YAG-Laser posterior capsulotomy in the treatment of posterior capsule opacity after cataract extraction in eyes with high risk of developing pseudophakic retinal detachment.

PATIENTS AND METHODS

This retrospective study comprised 265 eyes in 234 patients (134 women, 100 men, mean age: 61 years) with posterior capsule opacity who underwent surgical posterior capsule polishing between 1997 and 2010, with a follow-up of at least 12 months.

RESULTS

Surgical posterior capsule polishing was performed in 220 myopic eyes (axial length > 25 mm), in 28 eyes after retinal detachment surgery and in 17 eyes with traumatic cataract. The mean follow-up was 73 months (range: 12 to 202 months); in 206 eyes (77.8 %), follow-up was more than 3 years. The final best-corrected visual acuity (BCVA) in logMAR (mean 0.56 ± 0.63) improved significantly (p < 0.001) compared to the preoperative BCVA (mean 0.93 ± 0.72). Recurrent posterior capsule opacity occurred in 74 eyes (27.9 %) and was treated by one or more surgical posterior capsule polishing procedures. Nd : YAG-Laser posterior capsulotomy was performed in 28 eyes (10.6 %) and surgical capsulectomy in 8 eyes (3.0 %). Complications after surgical posterior capsule polishing included intraoperative capsule rupture in 9 eyes (3.5 %). No postoperative endophthalmitis was observed. However, retinal detachment occurred in 6 eyes (2.3 %) 62 months after surgical posterior capsule polishing. All eyes were myopic (axial length > 25 mm) and initially vitrectomised during first retinal detachment surgery.

CONCLUSIONS

Long-term outcome and complication rate indicate that surgical posterior capsule polishing is not only a more complex procedure but is also associated with a higher relapse risk than Nd : YAG-Laser posterior capsulotomy in the treatment of regenerative secondary cataract. Furthermore, conserving the posterior lens capsule does not always seem to minimise the cumulative risk of developing pseudophakic retinal detachment in high risk patients.

Significance of the disc damage likelihood scale objectively measured by a non-mydriatic fundus camera in preperimetric glaucoma

Purpose

To assess the correlation between the disc damage likelihood scale (DDLS) objectively measured by a non-mydriatic fundus camera, Heidelberg Retina Tomograph 3, and optic coherence tomography in preperimetric glaucoma.

Methods

One-hundred-twenty-five patients with preperimetric primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (n=30) were included (mean age 58.9±15.9 years). All three devices graded the optic disc topography: Diagnosis 1 was defined as “outside normal limits”, while Diagnosis 2 as “borderline or outside normal limits”.

Results

For Diagnosis 1, a significant correlation was shown between DDLS and Moorfields regression analysis (P=0.022), and for Diagnosis 2 with glaucoma probability score analysis (P=0.024), in POAG. In pseudoexfoliation glaucoma, DDLS did not correlate significantly with Heidelberg Retina Tomograph 3 and optic coherence tomography. Regarding the area under the curve the highest predictive power was demonstrated by the objective DDLS (0.513–0.824) compared to Burk (0.239–0.343) and Mikelberg (0.093–0.270) coefficients.

Conclusions

The DDLS showed a significant correlation to the Moorfields regression analysis in preperimetric POAG. The objective DDLS showed the highest predictive power and thus is an additive tool in diagnosing preperimetric glaucoma.

[Trabeculectomy Ab Interno in Primary Open Angle Glaucoma and Exfoliative Glaucoma]

BACKGROUND

To assess the outcome of routine trabectomy surgery in the treatment of primary (POAG) and secondary open angle glaucoma.

PATIENTS/METHODS

296 eyes of 296 patients with diagnosed open angle glaucoma and exfoliative glaucoma were analysed from June 2012 until June 2014. IOP readings (intraocular pressure) and the number of antiglaucoma medications was evaluated at every follow-up visit. For statistical analysis, 4 study cohorts were built (cohort 1 = trabectomy in POAG, cohort 2 = trabectomy in exfoliative glaucoma (PEX), cohort 3 = trabectomy + IOL in POAG, cohort 4 = trabectomy + IOL in PEX glaucoma).

RESULTS

Mean IOP before trabectomy surgery was 19.8 ± 5.9 mmHg and 23.7 ± 9.5 mmHg in cohorts 1 and 2, respectively. At 1 year follow-up, IOP was reduced to normal level for cohorts 1 and 2 (14.8 ± 3.2 mmHg (p = 0.001) and 14.0 ± 3.3 mmHg (p = 0.046), respectively). The number of topical antiglaucoma medications changed to 2.1 ± 1.2 (p = 0.004) and 2.4 ± 1.2, respectively (p = 0.593) at one year follow-up, respectively, for POAG and exfoliative glaucoma. In study cohort 3 and 4, mean IOP before trabectomy surgery was 19.2 ± 4.0 mmHg and 23.2 ± 9.2 mmHg, respectively. At 1 year follow-up, IOP was reduced to normal levels in cohorts 3 and 4 (11.8 ± 3.1 mmHg (p < 0.01) and 12.6 ± 1.1 mmHg, respectively (p = 0.043)); the number of topical antiglaucoma medications changed to 2.3 ± 1.4 (p = 0.469) and 1.4 ± 0.8, respectively, (p = 0.102) at 1 year follow-up. A significant difference in IOP reduction could be demonstrated in POAG between the trabectomy + IOL group and the trabectomy cohort 1 year postoperative (p = 0.017); in the PEX trabectomy + IOL versus PEX trabectomy cohort no statistically significant difference (p = 0.678) could be demonstrated. No serious postoperative complications were recorded.

CONCLUSION

Trabectomy surgery seemed to be a reliable and effective tool for the management of mild and moderate primary and secondary open angle glaucoma with uncontrolled IOP in daily routine. One year follow-up showed a significant reduction in intraocular pressure in all cohorts.

Descemet Membrane Endothelial Keratoplasty for Graft Failure After Descemet Stripping Endothelial Keratoplasty: Clinical Results and Histopathologic Findings

IMPORTANCE

The management of graft failure is increasingly relevant with the spread and growing acceptance of endothelial keratoplasty.

OBJECTIVES

To investigate the functional and anatomical results of secondary Descemet membrane endothelial keratoplasty (DMEK) for graft failure after Descemet stripping endothelial keratoplasty (DSEK) and to histologically analyze the stroma-to-stroma interface with respect to clinical implications.

DESIGN, SETTING, AND PARTICIPANTS

In a single-surgeon prospective comparative case series at the Department of Ophthalmology, Charité-University Medicine Berlin, Berlin, Germany, 8 eyes (3.8%) of 210 consecutively performed DMEK procedures underwent a secondary DMEK for graft failure after DSEK from March 1, 2012, through February 28, 2013. Those cases were compared with the eyes of a reference collective (n = 30) and matched-pairs group (n = 8) after primary DMEK for Fuchs endothelial dystrophy.

INTERVENTION

Descemet membrane endothelial keratoplasty.

MAIN OUTCOMES AND MEASURES

Postoperative best-corrected visual acuity (BCVA) and central corneal thickness at 1, 3, 6, and 12 months. Intraoperatively obtained DSEK graft lenticels were investigated immunohistochemically.

RESULTS

Patients with graft failure after DSEK had a mean (SD) age of 79.4 (7.2) years (range, 70-90 years). Preoperatively, the mean (SD) BCVA was 1.13 (0.50) logMAR (20/250 Snellen equivalents), and the mean (SD) central corneal thickness measured 704 (161) µm. Twelve months postoperatively, the mean (SD) corneal thickness decreased to 524 (27) µm after secondary and 516 (27) µm after primary DMEK (P = .57). A mean (SD) BCVA of 0.38 (0.36) logMAR (20/50 Snellen equivalents) was achieved after secondary DMEK compared with 0.15 (0.15) logMAR (20/28 Snellen equivalents) after primary DMEK. Histologically, failed DSEK graft lenticels presented condensations of collagen layers. Fibronectin and cytokeratin were accumulated along the stroma-to-stroma interface; vimentin was found in loosened graft stroma.

CONCLUSIONS AND RELEVANCE

These data suggest that DMEK might be considered a feasible choice in patients with graft failure after DSEK. However, the visual restitution might be impeded because of preceded depositions of matrix proteins within the corneal stroma and the stroma-to-stroma interface, which are associated with corneal fibrosis. Thereby, fibrotic processes might be avoided by performing a secondary DMEK in an early phase of graft failure.

Descemet Membrane Endothelial Keratoplasty as a Secondary Approach After Failure of Penetrating Keratoplasty

OBJECTIVES

To investigate visual outcome and postoperative complications in patients undergoing Descemet membrane endothelial keratoplasty with graft failure after penetrating keratoplasty.

MATERIALS AND METHODS

A retrospective analysis was performed with 5 patients who underwent Descemet membrane endothelial keratoplasty after failed penetrating keratoplasty. Intraoperative and postoperative complications were recorded. Visual acuity, rehabilitation phase, refraction stability, central corneal thickness, endothelial cell count, possible immunologic reactions, and optical coherence tomography of the anterior eye segment were evaluated. A subjective questionnaire was used to evaluate patient satisfaction.

RESULTS

There were no intraoperative complications. All patients had graft detachment, which made air injection necessary. In all cases, visual acuity significantly increased (medium visual acuity [logarithm of the minimum angle of resolution]: 0.68 ± 0.31 logarithm of the minimum angle of resolution after 4 weeks and 0.35 ± 0.37 after 6 months; P = .043), refraction was stable, corneal thickness was reduced (average, 514 ± 11 μm), and endothelial cell count was reduced (average, 1398 ± 510 cells/mm(2)) after 6 months, which corresponds with a medium loss 40%. In the questionnaire, visual outcome, estimated time for recovery, and rehabilitation and patient satisfaction were better after Descemet membrane endothelial keratoplasty than penetrating keratoplasty. No postoperative elevation of pressure, development of pupillary block, or graft rejection, and no peripheral anterior synechiae or other abnormalities were observed with optical coherence tomography during the first 6 postoperative months.

CONCLUSIONS

Descemet membrane endothelial keratoplasty is a suitable technique for the treatment of graft failure after penetrating keratoplasty and helped our patients rapidly achieve good visual acuity, with reduction of postoperative complications, but the visual outcome might be limited.

Superior versus temporal approach in descemet membrane endothelial keratoplasty

PURPOSE

To compare superior vs temporal approach in patients who underwent Descemet membrane endothelial keratoplasty (DMEK).

DESIGN

Monocentric, prospective nonmasked study.

METHODS

A prospective analysis of 53 DMEKs between January and September 2013 was performed at the Charité-Universitätsmedizin Berlin. Only DMEK cases with an incision size of 2.3 mm and with at least 1 month of follow-up were included. The surgically induced astigmatism (SIA), changes in corneal aberrations and in spherical equivalent, visual acuity, endothelial cell density, and complications were evaluated.

RESULTS

Visual acuity improved significantly (0.70 ± 0.39 logMAR vs 0.32 ± 0.31 logMAR after 1 month (n = 48), 0.19 ± 0.15 logMAR after 3 months (n = 46), and 0.16 ± 0.17 logMAR after 6 months (n = 47) (P < .001)) regardless of the approach. SIA was significantly lower after temporal than after superior approach (1.42 ± 0.91 diopters [D] [n = 13] vs 0.81 ± 0.68 D [n = 13], P = .038). Change in total root mean square of all aberrations (RMS) (P = .046) at 6 mm pupil diameter, and change in total RMS (P = .019), third-order aberrations (P = .007), and fourth-order aberrations (P = .041) at 4 mm pupil diameter, demonstrated significantly lower results after temporal compared to superior approach. A higher rate of eyes after temporal approach underwent at least 1 rebubbling (39.1% vs 26.7%, P = .252). The endothelial cell density (P = .053) and the change in spherical equivalent (P = .145) did not differ significantly.

CONCLUSIONS

The temporal approach induces significantly less SIA and corneal aberration. There are no significant differences between superior and temporal approach according to the change in spherical equivalent, visual acuity, and endothelial cell density. The need for rebubbling is higher using the temporal approach.