New suture probe canaloplasty combined with suprachoroidal collagen implantation

PURPOSE

To present the modified surgery technique of new suture probe canaloplasty with a specially prepared monofilament 4.0 polypropylene suture combined with suprachoroidal drainage (ScD) and collagen sheet implantation for non-penetrating glaucoma surgery.

METHODS

Prospective study with a twelve months follow-up. A standard 4/0 polypropylene suture (ProleneTM by Ethicon; thickness: approximately 250 m) is cut and shaped with an ophthalmic knife (MANI® Crescent Knife, Mani Inc 8-3 Kiyohara Industrial Park, Utsunomiya, Tochigi 321-3231, Japan) to create a blunt end without sharp or compressed edges. This improves suture probe canaloplasty by providing a more stable and smoother probing device. Schlemm's canal is prepared using the standard technique of canaloplasty with suprachoroidal drainage. Then, instead of using the canaloplasty microcatheter or the previously published 6/0 double-helix suture, Schlemm's canal is probed with the blunt ending of the 4/0 Prolene suture. After successful 360-degree probing, a doubled 10/0 polypropylene tension suture is threaded through the tip of the 4/0 suture. The 4/0 suture is then pulled back and the 10/0 tension sutures are tied at both ends to tension Schlemm's canal. A special collagen sheet (Ologen®) is placed in suprachoroidal space, and the scleral flap is firmly sewed.

RESULTS

115 eyes were included in this prospective study. In 113 cases the Schlemm's canal could completely be probed with the suture probe and canaloplasty with ScD and collagen sheet implantation succeeded. In two cases the intervention was transformed to 360-degree suture trabeculotomy due to an intraoperative cheese-wiring. Twelve months after successful new suture probe canaloplasty with ScD and Collagen Implantation the IOP had decreased by 37.1% (from 21.6 ± 6.0 mmHg with 3.3 different IOP lowering eye drops to 13.5 ± 3.5 mmHg with 1.0 eye drops). 16 Patients did not achieve sufficient IOP levels and underwent 360-degree suture trabeculotomy during the follow-up. One patient had to be treated with further glaucoma surgery to achieve a sufficient IOP level. Complications were hyphema, postoperative IOP elevation and transient hypotony. No serious or sight-threatening complications occurred.

CONCLUSION

New suture probe canaloplasty with ScD and collagen sheet implantation yields the opportunity to conduct a cost-effective canaloplasty easier and less complicated than with the previously described method with the twisted 6/0 suture. The safety profile and IOP lowering effect is comparable. In cases where complete probing fails, there is still the opportunity to switch to suture trabeculotomy over the majorly probed part of Schlemm's canal. The pressure lowering effect of the deep sclerectomy with ScD and suprachoroidal collagen sheet implant seems to have an additional impact on the sufficient pressure lowering procedure.

Descemet Membrane Endothelial Keratoplasty (DMEK) Anesthesia Analysis

PURPOSE

Comparison of safety and clinical results of Descemet membrane endothelial keratoplasty (DMEK) in topical, peribulbar, or general anesthesia.

METHODS

Retrospective, post hoc matched study of 346 patients who received DMEK surgery with different types of anesthesia (n = 54 topical, n = 137 peribulbar, n = 155 general anesthesia). Outcome criteria were intraoperative complications, endothelial cell count (ECC), central corneal thickness (CCT) and graft rejection rate, rebubbling rate, and visual acuity (VA). Mean follow-up time was 9.4 ± 2.8 months.

RESULTS

The group with topical anesthesia showed intraoperative difficulties such as vitreous pressure (p = 0.01) and difficult graft unfolding (p = 0.4), possibly leading to a higher rebubbling rate (p = 0.03) and therefore graft failure (p = 0.39). However, rebubbling and graft failure occurred more often when the graft preparation was more difficult (p = 0.2, p = 0.13, respectively), which was independent of anesthesia. All three groups achieved comparable functional results regarding VA, ECC, and CCT after 6 months.

CONCLUSION

DMEK under topical anesthesia is feasible and shows comparable final visual outcomes but should be limited to selected cooperative patients and performed by experienced surgeons due to the potential for increased intraoperative challenges.

[Molecular diagnostics for vitreoretinal lymphoma]

Primary vitreoretinal lymphoma (PVRL) represents a subtype of intraocular lymphomas, which are a subgroup of malignant lymphomas of the eye. PVRL is considered a special form of primary diffuse large cell lymphoma (DLBCL) of the CNS (central nervous system) (PCNSL) and arises primary or secondary to PCNSL. According to the cell of origin (COO) classification of DLBCL, PVRL largely belongs to the activated B‑cell (ABC) type of DLBCL. Based on a recently established genetic-biological classification of DLBCL, PCNSL and thus also PVRL belong to a group of DLBCL of the MYD88/CD79B-mutated (MCD) or cluster 5 subtype, which often shows extranodal manifestations and MYD88 and CD79A mutations as well as CDKN2A deletions.PVRL diagnostics is often complicated as it represents a classic masquerade syndrome. Due to the usually limited material with often large numbers of reactive lymphocytes and/or degenerative changes in the cells, the results of diagnostic tests are difficult to interpret. Classic diagnostic tests include cytology on vitreous aspirates, immunocytochemistry, and clonality analysis.New insights into the spectrum of genetic alterations of vitreoretinal lymphomas (VRL) confirm the close relationship to PCNSL and could significantly improve pathological diagnosis. Next-generation sequencing panel-based diagnostics allow VRL diagnosis confirmation with little DNA in almost 100% of patients in cases with insufficient cytological evidence or lack of clonality detection. PVRL, as well as secondary vitreoretinal lymphomas after PCNSL or extracerebral DLBCL, have high mutation frequencies in characteristically mutated genes in PCNSL or MCD/cluster 5 type DLBCL. Supporting diagnostics, mutation detection can also be performed on cell-free DNA from the vitreous supernatant.

MODIFIED SUTURELESS INTRASCLERAL FIXATION TECHNIQUE FOR SECONDARY INTRAOCULAR LENS IMPLANTATION: A Pilot Study

BACKGROUND/PURPOSE

To demonstrate possible complications of a new intraocular lens for sutureless secondary scleral implantation and modifications of the surgical technique to optimize outcomes.

METHODS

A retrospective study of 16 eyes (16 patients) who underwent a secondary intraocular lens implantation using the Carlevale intraocular lens (Soleko, Italy) with two anchor haptics for intrascleral implantation (mean follow-up 2.2 months).

RESULTS

The visual acuity did not improve statistically significantly postoperatively ( P = 0.601). Seven (44%) patients suffered from postoperative hypotonia (intraocular pressure <5 mmHg) during the first three postoperative days.

CONCLUSION

Owing to the early postoperative hypotony, we decided to modify the surgical technique. We present several suggestions to optimize the technique and outcome such as positioning the sclerotomies at the 2 and 8 o'clock positions, using 27 G trocars alone and suturing the frown incisions using self-resorbing sutures.

A rabbit model for outer retinal atrophy caused by surgical RPE removal

PURPOSE

We aimed to establish a rabbit model with retinal atrophy induced by an iatrogenic retinal pigment epithelium (RPE) removal, for future testing of the efficacy and safety of cell therapy strategies.

METHODS

A localized detachment of the retina from the RPE/choroid layer was created in 18 pigmented rabbits. The RPE was removed by scraping with a custom-made extendable loop instrument. The resulting RPE wound was observed over a time course of 12 weeks with optical coherence tomography and angiography. After 4 days (group 1) and 12 weeks (group 2), histology was done and staining with hematoxylin and eosin, as well as immunofluorescence performed to further investigate the effects of debridement on the RPE and the overlying retina.

RESULTS

Already after 4 days, we observed a closure of the RPE wound by proliferating RPE and microglia/macrophage cells forming a multilayered clump. This pattern continued over the observation time course of 12 weeks, whereby the inner and outer nuclear layer of the retina became atrophic. No neovascularization was observed in the angiograms or histology. The observed changes were limited to the site of the former RPE wound.

CONCLUSIONS

Localized surgical RPE removal induced an adjacent progressive retinal atrophy. Altering the natural course of this model may serve as a basis to test RPE cell therapeutics.

Safety and effectiveness of pre-emptive diabetic vitrectomy in patients with severe, non-fibrotic retinal neovascularisation despite panretinal photocoagulation

OBJECTIVES

To investigate the safety and effectiveness of pre-emptive vitrectomy in eyes with severe non-fibrotic proliferative diabetic retinopathy.

METHODS

A multi-centre, retrospective, observational study. Pre-emptive vitrectomy was performed in non-fibrotic diabetic eyes with a visual acuity (VA) of 20/50 or better, where there was extensive persistent neovascularisation despite prior panretinal photocoagulation, and where the fellow eye had established sight loss despite vitrectomy for tractional complications. The primary outcome measure was the VA at last visit.

RESULTS

Twenty patients were included. The mean age was 39 ± 14 years. Fifteen patients were Type 1 diabetic. The median baseline VA was 20/30 and remained stable at 20/28 at last visit (median follow-up period: 24 months). Eight eyes (40.0%) developed post-operative vitreous cavity haemorrhage; 4 of which required a vitreous cavity washout procedure. There were no post-operative retinal detachments. The index eye remained the significantly better eye at all time points bar one month post-surgery. Regression of retinopathy grading was observed in all eyes.

CONCLUSION

In this pilot study, we found no sight loss with pre-emptive diabetic vitrectomy. Better eye status was maintained in this high-risk group. Further study with larger number of patients and longer-term follow-up is indicated.

Advances in Canaloplasty-Modified Techniques Yield Strong Pressure Reduction with Low Risk Profile

For decades, trabeculectomy (TE) was considered the gold standard for surgical treatment of open-angle glaucoma owing to its powerful intraocular pressure (IOP)-lowering potency. However, owing to the invasive nature and high-risk profile of TE, this standard is changing, and minimally invasive procedures are becoming more preferable. In particular, canaloplasty (CP) has been established as a much gentler alternative in everyday life and is under development as a full-fledged replacement. This technique involves probing Schlemm's canal with a microcatheter and inserting a pouch suture that places the trabecular meshwork under permanent tension. It aims to restore the natural outflow pathways of the aqueous humor and is independent of external wound healing. This physiological approach results in a significantly lower complication rate and allows considerably simplified perioperative management. There is now extensive evidence that canaloplasty achieves sufficient pressure reduction as well as a significant reduction in postoperative glaucoma medications. Unlike MIGS procedures, the indication is not only mild to moderate glaucoma; today, even advanced glaucoma benefits from the very low hypotony rate, which largely avoids a wipeout phenomenon. However, approximately half of patients are not completely medication-free after canaloplasty. As a consequence, a number of canaloplasty modifications have been developed with the goal of further enhancing the IOP-lowering effect while avoiding the risk of serious complications. By combining canaloplasty with the newly developed suprachoroidal drainage procedure, the individual improvements in trabecular facility and uveoscleral outflow facility appear to have an additive effect. Thus, for the first time, an IOP-lowering effect comparable to a successful trabeculectomy can be achieved. Other implant modifications also enhance the potential of canaloplasty or offer additional benefits such as the possibility of telemetric IOP self-measurement by the patient. This article reviews the modifications of canaloplasty, which has the potential to become a new gold standard in glaucoma surgery via stepwise refinement.

Safety and performance of a suprachoroidal sensor for telemetric measurement of intraocular pressure in the EYEMATE-SC trial

AIM

To investigate the safety and performance of a telemetric suprachoroidal intraocular pressure (IOP) sensor (EYEMATE-SC) and the accuracy of its IOP measurements in open angle glaucoma (OAG) patients undergoing simultaneous non-penetrating glaucoma surgery (NPGS).

METHODS

Prospective, multicentre, open-label, single-arm, interventional clinical trial. Twenty-four eyes of 24 patients with OAG regularly scheduled for NPGS (canaloplasty or deep sclerectomy) were simultaneously implanted with an EYEMATE-SC sensor. Six-month follow-up on the sensor's safety and performance as well as on the level of agreement between the EYEMATE-SC measurements and IOP measurements with Goldmann applanation tonometry (GAT).

RESULTS

The eyes underwent canaloplasty (n=15) or deep sclerectomy (n=9) and achieved successful implantation of the sensor. No device migration, dislocation or serious device-related complications occurred. A total of 367 comparisons were included in the IOP agreement analysis. The overall mean difference between GAT and EYEMATE-SC measurements was 1.31 mm Hg (lower limit of agreement (LoA) 7.55 mm Hg; upper LoA -4.92 mm Hg). The maximum difference of 2.5 mm Hg ±3.96 (LoA 0.30-2.29) was reached on day 10 and continuously improved to an agreement of -0.15 mm Hg ±2.28 (LoA -1.24 to 0.89) after 6 months. Accordingly, the percentage of eyes within an IOP difference of ±5 mm Hg improved from 78% (day 3) to 100% (6 months).

CONCLUSIONS

After 6 months, the EYEMATE-SC sensor was safe and well tolerated, and allowed continual IOP monitoring.

TRIAL REGISTRATION NUMBER

NCT03756662.

Safety and performance assessment of hyaluronic acid-based vitreous substitutes in patients with phthisis bulbi

PURPOSE

To assess the safety and performance of hyaluronic acid-based vitreous substitutes in phthitic eyes.

METHODS

In this retrospective interventional study a total of 21 eyes from 21 patients with phthisis bulbi were treated at the Eye Clinic Sulzbach between August 2011 and June 2021. Patients who underwent a 23G pars plana vitrectomy received a vitreous substitute composed of (I) a non-crosslinked hyaluronic acid (Healon GV), (II) a crosslinked hyaluronic acid-based hydrogel (UVHA), or (III) silicone oil (SO-5000). Main outcome measures were the intraocular pressure (IOP), the visual acuity and the structural integrity of the retina and choroid assessed by optical coherence tomography.

RESULTS

An increase in IOP ≥ 5 mmHg was achieved with SO-5000 in 5/8 eyes (6/10 interventions, 60.0%) for 36.4 ± 39.5 days, with Healon GV in 4/8 eyes (7/11 interventions, 63.6%) for 82.6 ± 92.5 days and with UVHA in 4/5 eyes (5/6 interventions, 83.3%) for 93.6 ± 92.5 days. Visual acuity increased in 5/21 eyes (23.8%), remained constant in 12/21 eyes (57.1%) and decreased in 4/21 eyes (19.0%). No enucleations were required during the mean follow-up time of 192 ± 182 days. The OCT images indicated the preservation of retinal structures, while choroidal folds were only diminished in UVHA eyes.

CONCLUSIONS

Hyaluronic acid-based hydrogels are biocompatible vitreous substitutes in humans and can increase and stabilize IOP in patients with phthisis bulbi for about 3 months.

Efficacy of a new fragmentation pattern in femtosecond laser-assisted cataract surgery with the Ziemer FEMTO LDV Z8

PURPOSE

To determine the efficacy of different fragmentation patterns in femtosecond laser-assisted cataract surgery (FLACS) using Ziemer FEMTO LDV Z8.

METHODS

We compared three different types of surgery: conventional cataract surgery (CCS), FLACS with conventional radial slices (named No-Spiderweb), and FLACS with a novel fragmentation pattern (radial slices combined with one or two rings) called "Spiderweb." Visual acuity (VA), nuclear opacity (NO) according to the Lens Opacities Classification System (LOCS lll), effective phacoemulsification time (EPT) and vacuum time were obtained for 845 eyes.

RESULTS

Using FLACS (Spiderweb + No-Spiderweb), EPT was significantly reduced by 26% compared to CCS (FLACS: 2.46 ± 2.60 s; CCS: 3.34 ± 2.89 s; ΔM = - 0.88 s, p < .001). Furthermore, EPT as a function of progression of lens opacity was found to be not only lower in Spiderweb compared to CCS, but also in comparison with No-Spiderweb. At NO3, a significant reduction of 65% in EPT was observed by using Spiderweb compared to CCS (Spiderweb: 0.68 ± 1.23 s; CCS: 1.96 ± 1.53 s; ΔM = - 1.28 s, p <.001). Interestingly, EPT at NO3 was also significantly reduced by 57% in Spiderweb compared to No-Spiderweb (Spiderweb: 0.68 ± 1.23 s; No-Spiderweb: 1.57 ± 1 .59 s; ΔM  = - 0.90 s, p <.001). The use of Spiderweb only marginally extends the vacuum time compared to No-Spiderweb by 11 s (Spiderweb: 209.13 ± 35.83 s; No-Spiderweb: 198.35 ± 36.84 s; p = .003) and the postoperative improved VA showed no significant difference among the different types of surgery (all ps ≥ .05).

CONCLUSION

FLACS significantly reduces EPT compared to CCS. Furthermore, the novel Spiderweb pattern significantly reduces EPT in patients with a cataract of NO3 compared to CCS, but also to FLACS with the existing radial pattern (No-Spiderweb).

Recurrent corneal erosions related to an ocular injury 15 years before presentation

Purpose

To report the case of a patient who presented with recurrent corneal erosions caused by an undetected plastic foreign body in the upper eyelid, which had remained asymptomatic for nearly 15 years following an ocular injury.

Observations

A 39-year-old patient presented with recurrent corneal erosions and frontal headaches of unknown aetiology over the preceding eight months. The patient had previously been seen by twelve different ophthalmologists and had been treated over a 6-month period with a bandage contact lens, and therapeutic corneal scraping had been performed twice. However, the corneal erosion had repeatedly reappeared after removal of the bandage contact lens. On clinical examination prior to a planned phototherapeutic keratectomy, we extracted a 1.5 cm plastic foreign body, localised in the subtarsal area of the upper conjunctival fornix. Upon specific questioning, the patient denied any recent trauma, but reported a work-related accident with an accompanying eye injury 15 years before presentation.

Conclusions and importance

Posttraumatic foreign bodies in the eye may remain asymptomatic for prolonged periods before giving rise to clinical signs such as recurrent corneal erosions. Hence, a thorough clinical examination with meticulous eyelid eversion should always be performed in such patients.

Translation of hyaluronic acid–based vitreous substitutes towards current regulations for medical devices

PURPOSE

Hydrogel-based vitreous substitutes have the potential to overcome the limitations of current clinically used endotamponades. With the goal of entering clinical trials, the present study aimed to (I) transfer the material synthesis of hyaluronic acid-based hydrogels into a routine, pharmaceutical-appropriate production and (II) evaluate the properties of the vitreous substitutes in terms of the current regulations for medical devices (MDR/ISO standards).

METHODS

The multistep manufacturing process of the vitreous substitutes, including the modification of hyaluronic acid with glycidyl methacrylate, photocopolymerization with N-vinylpyrrolidone, and successive hydrogel purification, was developed under laboratory conditions, characterized using ¹ H-NMR, FT-IR and UV/Vis spectroscopies and HPLC, and transferred towards a pharmaceutical production environment considering GMP standards. The optical and viscoelastic characteristics of the hyaluronic acid-based hydrogels were compared with those of extracted human vitreous and silicone oil. The effect of the hydrogels on the metabolic activity, proliferation and apoptosis of fibroblast (MRC-5, BJ, L929), retinal pigment epithelial (ARPE-19, hiPSC-derived RPE) and photoreceptor cells (661W) was studied as well as their mucosal tolerance via a HET-CAM assay.

RESULTS

Hyaluronic acid-based hydrogels having a suitable purity, sterility, high transparency (>90%), appropriate refractive index (1.3365) and viscoelasticity (G' > G″) were prepared in a standardized manner under controlled process conditions. The metabolic activity, proliferation and apoptosis of various cell types as well as egg choroid were unaffected by the hyaluronic acid-based vitreous substitutes, demonstrating their biocompatibility.

CONCLUSIONS

The present study demonstrates the successful transferability of the crucial synthesis steps of hyaluronic acid-based hydrogels into a routine, GMP-compliant production process while achieving the optical and viscoelastic properties, biocompatibility and purity required for their clinical use as vitreous substitutes.

Temporary iris-lens diaphragm to assist descemet membrane endothelial keratoplasty in aphakic patients

Purpose

Presenting a simple technique using an inversely implanted contact lens to create a temporary diaphragm to assist DMEK surgery in aphakic, partially aniridic and vitrectomized eyes.

Observations

The postoperative course was without pressure abnormalities and the anterior chamber remained deep. The cornea completely cleared within 3 weeks and remained clear after removal of the contact lens showing a corneal thickness of 544 μm and an intact endothelial cell pattern on endothelial cell microscopy after 3 months.

Conclusion and Importance

The inversely implanted contact lens provides an easily accessible temporary diaphragm, making DMEK surgery a safer procedure even in complex eyes without an adequate posterior barrier.

[Modifications of canaloplasty : Strong pressure-lowering effect with a low risk profile]

Trabeculectomy still achieves the strongest intraocular pressure (IOP) reduction of all glaucoma surgical techniques, but with the drawback of a significant risk profile. Against this background, canaloplasty has established itself as a much gentler alternative which achieves sufficient IOP reduction and enables a significant reduction in postoperative glaucoma medication. However, approximately half of patients are not completely medication free. In response, a number of modifications have been developed with the goal of further enhancing the IOP-lowering effect of canaloplasty, but without the risk of serious complications. By combining canaloplasty with the newly developed suprachoroidal drainage, a uveoscleral drainage is created in addition to the trabecular outflow improvement, which seems to have an additive effect. Thus, for the first time, an IOP-lowering effect comparable to successful trabeculectomy can be achieved. Numerous other modifications with implants also enhance the potential of canaloplasty or offer other additional benefits such as the possibility of telemetric IOP self-measurement by the patient. The additional creation of a subconjunctival drainage with or without use of cytostatic drugs also seems promising. Ab interno procedures, on the other hand, have limited pressure-lowering potential but may provide some additional benefit in mild glaucoma and in the setting of cataract surgery.

Vitreous Substitutes as Drug Release Systems

Vitreous substitutes are traditionally used to stabilize the retina after vitrectomy. In recent years, various approaches have been developed for using the vitreous substitute not only as a tamponade but also as a drug release system to tackle ocular diseases. This review provides an overview of the requirements for vitreous substitutes and discusses the current clinically applied as well as novel polymer-based vitreous substitutes as drug delivery systems, including their release mechanisms, efficiencies, challenges, and future perspectives.

Measurement of intraocular temperature in glaucoma: week-day and seasonal fluctuations

PURPOSE

To evaluate long-term intraocular temperature (IOT) variations in eyes with primary open-angle glaucoma (POAG) using an intraocular telemetric sensor.

METHODS

This prospective, open-label, multicentre observational study analysed the IOT variations in 22 eyes of 22 patients with POAG. All enrolled patients underwent implantation of an intraocular pressure (IOP) sensor during cataract surgery. The telemetric system uses a built-in temperature sensor to control measured IOP for temperature. Each time a patient measures their IOP, both the IOP and IOT are recorded in the reader device. Patients were instructed to self-measure their IOP as often as desired, but at least four times daily. Recorded readings were retrieved and analysed using mixed effect models and pairwise comparisons using Bonferroni correction to assess the statistical significance of average IOT variations between each individual weekday and calendar month.

RESULTS

The mean age of patients was 67.8±6.8 years and 36.4% were women. A total of 132 745 readings over 21 102 measurement-days were obtained. On average, IOT was significantly higher on Sundays (34.57°C; 95% CI 34.37 to 34.78) than on any other day of the week (p<0.001). Mean IOT on other weekdays ranged from 34.48°C to 34.51°C. Over the year, IOT followed a clear seasonal pattern, reaching its maximum in July (34.8°C; 95% CI 34.56 to 34.97) and its minimum in January (34.4°C; 95% CI 34.15 to 34.56; p<0.001).

CONCLUSIONS

This study demonstrates the feasibility of continual and long-term measurement of IOT using intraocular sensors. The results show significant short-term and long-term fluctuations of IOT. Research is warranted to understand the impact of IOT variations on IOP, ocular perfusion and glaucoma progression.

Erworbene Katarakte

Weitaus seltener und daher weniger bekannt als die altersbedingte Katarakt ist die sekundär erworbene Katarakt, die eine diagnostische und chirurgische Herausforderung darstellen kann. Dieser Beitrag gibt einen Überblick über die häufigsten Subtypen vor allem bei Erwachsenen und beleuchtet die chirurgischen Besonderheiten einschließlich perioperativer Charakteristika.

Erworbene Katarakte

Weitaus seltener und daher weniger bekannt als die altersbedingte Katarakt ist die sekundär erworbene Katarakt, die eine diagnostische und chirurgische Herausforderung darstellen kann. Dieser Beitrag gibt einen Überblick über die häufigsten Subtypen vor allem bei Erwachsenen und beleuchtet die chirurgischen Besonderheiten einschließlich perioperativer Charakteristika.

Influence of the scleral indentation technique on the re-detachment rate following retinal detachment surgery

Purpose

The aim of this study was to determine whether the choice of scleral indentation technique during primary rhegmatogenous retinal detachment surgery has an influence on the risk of re-detachment.

Methods

We included retrospectively 154 eyes with a primary rhegmatogenous retinal detachment treated in the Eye Clinic Sulzbach/Saar Germany, who were operated on by two experienced surgeons using the same basic surgical setup. Surgeon A performed an external 360° indentation, shaved the vitreous base using the light pipe cap, and used the operating microscope (opm) for direct visualization. Surgeon B performed an external 360° indentation, shaved the vitreous base using a simple indentor, and used an endoillumination (light pipe) with the opm and a handheld widefield lens for direct visualization.

Results

Comparing both indentation procedures, 15.66% (13/83) of patients operated on by surgeon A and 9.86% (7/71) of patients operated on by surgeon B had a retinal re-detachment within a follow-up period of 6 months (adj. p = 0.64, two-proportion Z-test).

Conclusion

The rate of retinal re-detachment could be influenced by the indentation technique at the end of surgery favoring external indentation and internal visualization with an endoilluminator (chandelier light). We attribute this to the better visualization of the vitreous base facilitated by endoillumination. However, many variables play a role in the development of retinal re-detachment, requiring further studies with a larger number of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00362-8.

What we already know:

Scleral indentation is widely recognized as an important step in rhegmatogenous retinal detachment surgery via pars-plana vitrectomy.

There are several surgical techniques for scleral indentation, however the procedures are neither standardized, nor have they ever been compared to one another to the best of our knowledge.

What this study adds:

This study shows that the rate of retinal re-detachment could be influenced by the indentation technique at the end of surgery favoring external indentation and internal visualization with an endoilluminator (chandelier light).

We attribute this to the better visualization of the vitreous base facilitated by endoillumination.

REVISED PREDICTIVE BIOMARKER FOR OCRIPLASMIN THERAPY IN VITREOMACULAR TRACTION DISORDERS

PURPOSE

To determine a statistically optimal limit of adhesion size in vitreomacular traction (VMT) syndrome for ocriplasmin treatment.

METHODS

In this retrospective, consecutive, interventional study, we included 106 patients treated with ocriplasmin injection because of VMT between July 2013 and January 2018. A univariate and multivariate risk analysis was performed with grouped factors and continuous factors. We used a receiver operating characteristic curve to measure the prognostic relevance of each continuous factor for therapy success and determined the statistically optimal cutoff value at which specificity and sensitivity are simultaneously maximized.

RESULTS

Among the grouped factors, only a phakic lens status showed a highly significant positive influence on the resolution of the VMT. For the continuous factors, only the adhesion diameter before injection was a good predictor of anatomical success. The statistically optimal threshold value for the adhesion size was calculated to be 480 µm. Eyes below this limit had a 6.84-fold better chance of VMT resolution compared with eyes with a larger adhesion diameter.

CONCLUSION

The threshold value of the VMT diameter for ocriplasmin therapy could be statistically defined as 480 µm and may thus be a new quantitative biomarker to predict treatment success.

Comparative cytotoxic and antiproliferative profile of methotrexate and fluorouracil on different ocular cells

PURPOSE

To analyse the cytotoxic and antiproliferative effect of methotrexate (MTX) and fluorouracil (5-FU) in vitro on fibroblasts, retinal pigment epithelial (RPE) and photoreceptor cells as an adjunct for reducing the incidence of proliferative vitreoretinopathy (PVR) after rhegmatogenous retinal detachment surgery.

METHODS

Methotrexate and 5-FU were dissolved separately in balanced salt solution (BSS) with concentrations ranging from 0-8000 µg/ml and 0-4000 µg/ml, respectively. All solutions were analysed in terms of pH and osmolarity and applied for 1 h to fibroblasts (BJ), RPE (ARPE-19) and photoreceptor (661W) cell lines adherently cultivated in 96-well cell culture plates (10 000 cells/well). 24 h after incubation, the proliferative (BrdU), metabolic (CellTiter-Glo) and apoptotic (Caspase 3/7) activity of the cells were examined in vitro.

RESULTS

5-FU had an antiproliferative effect on BJ and ARPE-19 cells starting from low concentrations (2 µg/ml). However, the viability of 661W cells decreased and apoptosis was induced with increasing 5-FU concentration. In contrast, MTX up to a concentration of 266 µg/ml did neither result in a significant loss of viability nor in increased caspase 3/7 activity of BJ, ARPE-19 and 661W cells and inhibited the proliferation of ARPE-19 already at low concentrations starting from 8 µg/ml.

CONCLUSIONS

Methotrexate dissolved in BSS is biocompatible up to a concentration of 266 µg/ml and may act as an intraoperative rinse solution to inhibit RPE proliferation in PVR-diseased eyes. Contrary, the use of 5-FU within the posterior segment of the eye is limited by its cell-damaging effect on photoreceptor cells.

Clinical results after single asymmetrical shark fin for graft orientation in DMEK

PURPOSE

Evaluating the effect of a single peripheral triangular mark to ensure the correct anterior-posterior graft orientation in DMEK.

METHODS

Retrospective study of patients scheduled for DMEK due to Fuchs endothelial dystrophy and divided into 2 study groups: Group -M (n = 184) had no mark of the EDM (Endothelial Descemet membrane) and group + M (n = 193) had a triangular peripheral mark. Follow-up time was 1 year after surgery.

RESULTS

The postoperative graft turning and Re-DMEK rate could be significantly reduced by the use of a peripheral mark (p = 0.002, p = 0.001, respectively). Re-DMEK due to primary graft failure was significantly associated with prior graft turning (p < 0.001). Both groups showed comparable values for visual acuity, central corneal thickness and endothelial cell count after a follow-up of 1 year.

CONCLUSION

Single peripheral triangular marking is a simple and cost-saving addition to EDM preparation to ensure the correct orientation of the graft intraoperatively and could lead to a significant reduction in graft turning and re-DMEK rate in this study.

Cleavage plane after liquid-bubble preparation of Descemet's membrane

PURPOSE

To investigate the ultrastructure of the cleavage plane of human cornea after liquid-bubble-prepared tissue for Descemet's membrane endothelial keratoplasty (DMEK).

METHODS

Experimental study with scanning electron microscopy (SEM) and block-face SEM of 18 corneal specimens. Fresh human research donor corneoscleral discs (n = 12) were prepared with liquid-bubble technique or examined as untreated controls (n = 3). In addition, Descemet's membrane samples, n = 3, were obtained in DMEK surgery.

RESULTS

The cleavage plane after liquid-bubble Descemet's membrane (DM) preparation was consistently located between interfacial matrix and posterior stromal collagen lamellae, providing a largely smooth surface exposing the amorphous interfacial zone without any significant amounts of adherent stromal remnants. No demarcation of a distinct pre-DM layer could be detected.

CONCLUSION

The DMEK graft preparation performed by liquid-bubble technique showed a smooth cleavage plane and could not reveal any demarcation of a distinct pre-DM layer.

Effectiveness of ocriplasmin in real-world settings: A systematic literature review, meta-analysis, and comparison with randomized trials

Purpose

Effectiveness of ocriplasmin for vitreomacular traction (VMT) varies depending on the presence of common ocular conditions and patient selection criteria. We carried out a systematic literature review and meta‐analysis of ocriplasmin studies conducted in real‐world settings (RWS) and compared outcomes with those from randomized controlled trials (RCTs).

Methods

We included prospective and retrospective studies from RWS documenting effectiveness of ocriplasmin in patients with VMT with or without MH, and RCTs of ocriplasmin versus control. Key end‐points were vitreomacular adhesion resolution (VMAR), nonsurgical MH closure, need for vitrectomy and safety. We conducted meta‐regression on pooled results to evaluate effects of baseline covariates and study design on outcomes.

Results

Thirty RWS (2402 patients) and 5 RCTs (737 patients) were included epiretinal membrane (ERM) and broad VMA were more prevalent in RCTs. Primary VMAR, vitrectomy and MH closure rates were comparable between RWS and RCTs. Rates of nsVMAR were significantly higher in RWS than RCTs (odds ratio 1.66; 95% confidence interval [CI]: 1.18–2.34). nsVMAR rates were inversely associated with ERM prevalence (odds ratio 0.20; 95% CI: 0.08–0.51). Compared with the recent OASIS trial, RWS reported a higher incidence of new/worsening subretinal fluid cases and less photophobia, photopsia, vitreous floaters, electroretinogram abnormalities and MH progression.

Conclusions

Ocriplasmin was significantly more effective in achieving nsVMAR in RWS than in RCTs. Lower ERM prevalence in RWS was the single significant explanatory variable for this difference. Conclusions on ocriplasmin safety in RWS are limited due to inconsistent reporting.

The impact of limbus detection, arcus lipoides and limbal vessels on the primary patency of clear cornea incisions in femtosecond laser-assisted cataract surgery

PURPOSE

To analyse the factors influencing the primary patency of clear corneal incisions in femtosecond laser-assisted cataract surgery (FLACS).

METHODS

In this prospective single-centre study, the graphical user interfaces of 159 patients undergoing femtosecond laser-assisted cataract surgery were documented by video. Subsequently, the quality of limbus detection along with the incidence of vessels and an arcus lipoides were assessed by a grading system and analysed in relation to the primary patency of the incisions. In particular, the differences between a superior and a temporal main incision were analysed.

RESULTS

The designed grading system could be applied in all cases without any problems. Limbus detection was highly inhomogeneous but had no influence on the patency of the incisions (46.3% poor, 18.4% moderate, 35.1% good). The characteristics of the arcus lipoides had little influence on the patency of the main incisions. Pronounced vascular ingrowth caused more tissue bridges but did not reduce the patency of the incisions. Temporal access was generally easier to open than a superior one (97.1% versus 88.9%).

CONCLUSION

We showed a patency rate of superior FLACS incisions of over 97% with the Femto LDV Z8 in our study. Temporal main incision is preferable to superior main incision in more difficult situations. The new grading system is suitable for further studies to provide information on the quality of the incision.

Selective Large-Area Retinal Pigment Epithelial Removal by Microsecond Laser in Preparation for Cell Therapy

Purpose

Cell therapy is a promising treatment for retinal pigment epithelium (RPE)-associated eye diseases such as age-related macular degeneration. Herein, selective microsecond laser irradiation targeting RPE cells was used for minimally invasive, large-area RPE removal in preparation for delivery of retinal cell therapeutics.

Methods

Ten rabbit eyes were exposed to laser pulses 8, 12, 16, and 20 µs in duration (wavelength, 532 nm; top-hat beam profile, 223 × 223 µm²). Post-irradiation retinal changes were assessed with fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). RPE viability was evaluated with an angiographic probit model. Following vitrectomy, a subretinal injection of balanced salt solution was performed over a lasered (maximum 13.6 mm2) and untreated control area. Bleb retinal detachment (bRD) morphology was then evaluated by intraoperative OCT.

Results

Within 1 hour after irradiation, laser lesions showed FA and ICGA leakage. OCT revealed that large-area laser damage was limited to the RPE. The angiographic median effective dose irradiation thresholds (ED50) were 45 µJ (90 mJ/cm2) at 8 µs, 52 µJ (104 mJ/cm2) at 12 µs, 59 µJ (118 mJ/cm2) at 16 µs, and 71 µJ (142 mJ/cm2) at 20 µs. Subretinal injection over the lasered area resulted in a controlled, shallow bRD rise, whereas control blebs were convex in shape, with less predictable spread.

Conclusions

Large-area, laser-based removal of host RPE without visible photoreceptor damage is possible and facilitates surgical retinal detachment.

Translational Relevance

Selective microsecond laser-based, large-area RPE removal prior to retinal cell therapy may reduce iatrogenic trauma.

Novel vitreous substitutes: the next frontier in vitreoretinal surgery

PURPOSE OF REVIEW

After removing the native vitreous during vitreoretinal surgery, an adequate substitute is required to ensure homeostasis of the eye. Current clinically used endotamponades (silicone oil, gases, semifluorinated alkanes) are effective in promoting retinal reattachment, but lead to complications such as emulsification, prolonged inflammation, blurred vision, raised intraocular pressure, cataract formation or the need for revision surgery. The aim of this review is to provide an update on novel vitreous substitutes with a focus on polymer-based systems.

RECENT FINDINGS

Polymeric hydrogels provide favourable properties such as high water content, optical transparency, suitable refractive indices and densities, adjustable rheological properties, injectability, biocompatibility and their ability to tamponade the retina via viscosity and swelling pressure, comparable to the native human vitreous body. Here, vitreous replacement strategies can be divided into chemically or physically crosslinked hydrogel systems that are applied as preformed or in-situ gelling matrices.

SUMMARY

Several hydrogel-based vitreous substitutes have already been positively evaluated in preclinical tests and have the potential to enter the clinical phase soon.

Functional and structural outcome after vitrectomy combined with subretinal rtPA Injection with or without additional intravitreal Bevacizumab injection for submacular hemorrhages

Background

To analyze the functional and anatomical outcome after vitrectomy with subretinal rtPA (recombinant tissue plasminogen activator) combined with or without an intravitreal Bevacizumab injection.

Patients and methods

Retrospective, consecutive case series of 31 pseudophakic patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (AMD) treated with vitrectomy, subretinal rtPA and pneumatic air displacement with or without an additional intravitreal Bevacizumab injection. The primary endpoints were best-corrected visual acuity (BCVA), and central macular thickness (CMT) measured by SD‑OCT. The secondary endpoint was a displacement of hemorrhage from the subretinal space three months after surgery.

Results

31 eyes of 31 patients were treated with vitrectomy and subretinal rtPA. 17/31 were treated simultaneously with an intravitreal Bevacizumab injection (group +B) and 14/31 without (group -B). The mean visual acuity improved significantly in both groups (from 1.37±0.39 to 1.03±0.57 logMAR in +B and from 1.48±0.48 to 1.01±0.38 logMAR in group –B, p<0.05). The mean CMT decreased in group +B from 607±179 μm to 424±205 μm (p = 0.2) and in group –B from 722±216 μm to 460±202 μm (p<0.05). A central displacement of the hemorrhage could be achieved in 47% in group +B, whereas in group -B displacement could be achieved in 50% (p = 0.44).

Conclusions

Vitrectomy with subretinal rtPA injection and air tamponade with or without simultaneous intravitreal Bevacizumab injection displaces SMH and improves BCVA effectively. In comparison, the postoperative outcome is comparable regardless of whether or not intravitreal bevacizumab is applied simultaneously.

[Postoperative endophthalmitis-a review of literature]

Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.

New optical coherence tomography grading system for macula-off rhegmatogenous retinal detachment: how off is off?

Background/Aims

The classification of retinal detachment is currently still based on many objective criteria such as duration of symptoms and funduscopic macular status, which leaves some important questions unanswered. The most important factor is the macular status, which is determined using direct or indirect ophthalmoscopy. Optical coherence tomography (OCT) has become a standard tool in clinical practice and enables detecting the exact extent of subretinal fluid in macula-off/on retinal detachment. We introduce a new and simple OCT-based grading system for macular detachment to provide a basis for further investigations to determine the optimal timing for surgery.

Methods

We retrospectively included 155 patients who were treated for retinal detachment. We defined the extent of the macular detachment in six stages based on the Early Treatment Diabetic Retinopathy Study (ETDRS) grid of the OCT scan.

The outermost ring of the ETDRS grid was defined as zone 1, the middle ring as zone 2 and the inner ring as zone 3. Only zone 3 differed in the retinal detachment height grades (grade a <250 µm vs grade b >250 µm). Retinal detachment heights that could not be measured were considered grade 4 (ungradable) detachments.

Results

Forty-seven patients had no macular involvement (grade 0). Regarding macular detachment, 14 patients had grade 1, 20 had grade 2, 9 had grade 3a, 29 had grade 3b and 36 had grade 4.

Conclusion

The newly developed OCT grading system for macular involvement following retinal detachment is a crucial tool to objectively classify a retinal detachment in order to be able to make better statements in the future, like for defining the optimal time for surgical intervention. A secondary benefit of this grading system would be that it improves predicting postoperative visual acuity.

Intraocular Pressure Telemetry for Managing Glaucoma during the COVID-19 Pandemic

PURPOSE

To evaluate in glaucoma patients the feasibility and use of remote monitoring of intraocular pressure (IOP) with an implanted telemetry sensor during the coronavirus disease 2019 (COVID-19) lockdown.

DESIGN

Cross-sectional study.

PARTICIPANTS

Patients previously implanted with a telemetric IOP sensor (Eyemate; Implandata GmbH) were included.

METHODS

Intraocular pressure measurements acquired by the patients during the lockdown were collected by physicians who were located remotely. A questionnaire was sent to 10 participating study centers to evaluate the clinical impact of remote monitoring of IOP via the IOP sensor system.

MAIN OUTCOME MEASURES

Number of patients who obtained home IOP measurements.

RESULTS

Data were available from all centers and from 37 eyes of 37 patients (16 patients with a sulcus-based sensor and 21 patients with a suprachoroidal sensor). Thirty-four patients obtained IOP measurements during the lockdown. Mean age of the patients was 69.3 ± 9.6 years, and 48.6% were women. A total of 8415 IOP measurements from 370 measurement days were obtained. Based on remote IOP measurements, treatment was changed in 5 patients. In another 5 patients, treatment change was considered when physicians received the IOP measurements after the lockdown. Nine of the 10 study centers judged remote IOP measurements to have a clinical impact.

CONCLUSIONS

These results show the feasibility of patient-acquired measurement of IOP in conjunction with remote IOP monitoring by physicians with an implantable sensor. The data obtained impacted clinical decision making, including adjustment of ocular hypotensive therapy and avoiding unnecessary office visits during the COVID-19 pandemic.