Editor: With great interest we read the article by Leon and associates evaluating risk factors for early graft detachments after Descemet membrane endothelial keratoplasty (DMEK) in 173 eyes.1 The ...authors conclude that cataract removal simultaneously with DMEK is a risk factor for early detachment and subsequent rebubbling. In a previous paper, we quantitatively compared graft detachments depending on the endotamponade used with optical coherence tomography (OCT) images.3 We demonstrate that sulfur hexafluoride 20% significantly reduces the rate of detachments.4,5 Therefore, the conclusion drawn by Leon and associates to separate DMEK and cataract surgery may only be valid for air tamponade DMEK. ...we published that all patients immediately after DMEK, if carefully investigated by high-density OCT scans and different OCT devices, show detachments, not requiring any rebubbling.6 Future studies should therefore focus on exact parameters indicating the need for a rebubbling and facilitate evaluation of complete graft attachment at the end of the surgery (eg, by intraoperative, microscope-integrated OCT).
The aim of this study was to compare the long-term outcome of Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous ...keratopathy (PBK).
Records of consecutive DMEK surgeries performed between 2015 and 2016 at the Department of Ophthalmology, Cologne, Germany, were retrospectively reviewed from the prospective Cologne DMEK Database. Eyes with either PBK or FECD with a complete 3-year follow-up were enrolled. Main outcome parameters included central corneal thickness (CCT), peripheral corneal thickness (PCT), best spectacle-corrected visual acuity (BSCVA, logarithm of the Minimum Angle of Resolution), and endothelial cell count (ECC) before and after DMEK.
Four hundred two eyes from 402 patients were included (FECD n = 371, PBK n = 31). Preoperatively, CCT (FECD: 681.91 ± 146.78 μm; PBK: 932.25 ± 319.84 μm) and PCT (FECD: 732.26 ± 98.22 μm; PBK: 867.54 ± 88.72 μm) were significantly higher in the PBK group (P < 0.01). Three years after DMEK, CCT (FECD: 526.56 ± 27.94 μm; PBK 663.71 ± 132.36 μm) was significantly lower in both groups compared with the preoperative values (P < 0.01), whereas PCT showed no significant difference. PCT increased during the course in the PBK group from month 12 after DMEK (12 mo: 783.73 ± 127.73 μm; 24 mo: 837.50 ± 110.19 μm; 36 mo: 857.79 ± 140.76 μm). The increase in PCT correlated with an accelerated ECC loss starting 12 months after DMEK (P = 0.036). Before DMEK, BSCVA in FECD was significantly higher (P < 0.001) compared with that in PBK. After 3 years, BSCVA improved in FECD and PBK eyes without significant difference (P = 0.239).
Visual acuity after DMEK in PBK and FECD seems to be comparable during the long-term follow-up. Peripheral and central corneal edema seems to recur faster in eyes with PBK than in those with FECD. Therefore, using a donor graft with higher ECC or possibly a larger graft could be a promising approach for PBK patients.
The purpose of this study was to investigate the impact of transient elevations in postoperative intraocular pressure (IOP) on the clinical outcome of Descemet membrane endothelial keratoplasty ...(DMEK) surgery in non-glaucoma patients.
Retrospective analysis from a prospective database of eyes without preexisting glaucoma that underwent DMEK with 90% anterior chamber and 20% sulfur hexafluoride endotamponade. Group A included eyes without postoperative IOP increase (IOP <30 mm Hg and a relative increase from preoperative value <10 mm Hg). Group B included eyes with IOP elevation (postoperative IOP ≥30 mm Hg or a relative increase from preoperative value ≥10 mm Hg) handled according to a standardized protocol. The impact of elevated IOP within 3 days after DMEK surgery was evaluated regarding best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell count (ECC) at 1, 3, and 6 months.
One hundred seventy-six eyes from 164 patients were included. An IOP increase after DMEK occurred in 20 eyes (11.3%; 19 patients, group B), and the mean peak IOP was 48 ± 12 mm Hg (range 32-69 mm Hg). There were no significant postoperative differences in BCVA, CCT, and ECC on comparing both groups. The BCVA increased significantly (P < 0.001, respectively), whereas CCT (P < 0.001, respectively) and ECC (P < 0.001, respectively) decreased significantly from preoperative values. The rebubbling rate tended to be higher in group B without statistical significance (6.4% vs. 10%, P = 0.648).
Temporary IOP elevation after DMEK may not affect functional and morphological outcomes in non-glaucoma patients. However, careful postoperative IOP monitoring and appropriate management are crucial to avoid irreversible ocular damage.
To explore the impact of iris color on the outcome of Descemet membrane endothelial keratoplasty (DMEK).
Consecutive cases of Fuchs endothelial dystrophy after DMEK were retrospectively analyzed from ...the prospective Cologne DMEK database between 2011 and 2017 at the University of Cologne, Germany. Iris pictures were graded by color into blue, green, or brown and compared regarding outcome parameters including best-corrected visual acuity (converted to logarithm of the minimal angle of resolution), central corneal thickness, endothelial cell density (ECD), each at preoperative (baseline) and postoperative 12 months, rebubbling rates, cystoid macular edema (CME), and immune rejections after surgery.
One thousand one hundred six eyes of 814 patients were included in this study that consisted of 354 blue eyes, 418 green eyes, and 244 brown eyes. There was no significant correlation between iris color and any parameter (best corrected visual acuity; P = 0.064 at preoperatively, P = 0.959 at 12 months) (ECD; P = 0.158 preoperatively, P = 0.859 at 12 months) (central corneal thickness; P = 0.148 preoperatively, P = 0.252 at 12 months). The loss of ECD at 12 months after surgery was 37.2% ± 1.0% in blue eyes, 37.2% ± 0.9% in green eyes, and 37.2% ± 1.2% in brown eyes (P = 0.999). Immune rejections were 1.7%, 2.9%, and 0.8% (P = 0.168) in blue, green, and brown eyes, respectively. Rebubbling rates and CME incidence were similar in each group (P = 0.129, and P = 0.552 respectively).
The iris color has no significant impact on the outcome after DMEK. Thus, DMEK can be applied effectively, regardless of the iris color.
Purpose
The COVID-19 pandemic has led to changes in global health care. Medical societies had to update guidelines and enhance new services such as video consultations. Cancer treatment had to be ...modified. The aim of this study is to ensure optimal care for cancer patients with the help of high-quality training even in times of crisis. We therefore conducted a nationwide survey of physicians in training in oncological disciplines during the pandemic to assess the impact on their education.
Methods
The survey was sent to tumour centres, hospitals, specialist societies, and working and junior research groups and distributed via newsletters and homepages. Interim results and a call for participation were published as a poster (DEGRO)
26
and in the German Cancer Society (DKG) journal
FORUM
42
. The survey contained 53 questions on conditions of education and training and on clinical and scientific work. Statistics were carried out with LimeSurvey and SPSS (IBM Corp., Armonk, NY, USA).
Results
Between February and November 2022, 450 participants answered the survey, with radio-oncologists being the largest group (28%). Most colleagues (63%) had access to digital training methods. Virtual sessions were rated as a good alternative, especially as multidisciplinary meetings (54%) as well as in-house and external training programs (48%, 47%). The time spent by training supervisors on education was rated as less than before the pandemic by 57%. Half of all participants perceived communication (54%), motivation (44%) and atmosphere (50%) in the team as bad. The participants felt strongly burdened by extra work (55%) and by a changed team atmosphere (49%). One third felt a change in the quality of training during the pandemic and rated it as negative (35%). According to 37% of the participants, this had little influence on their own quality of work. Additional subgroup analyses revealed significant differences in gender, specialty and education level.
Conclusion
In order to improve oncology training in times of crisis, access to digital training options and meetings should be ensured. Participants wish for regular team meetings in person to enable good team spirit, compensation for overtime work and sufficient time for training supervisors for discussion and feedback.
Purpose
Descemet membrane endothelial keratoplasty (DMEK) accounts for >50% of all corneal transplants in Germany. So far, no data from such a large multicenter study have been published.
Methods
...This retrospective study included 3200 DMEKs at seven departments performed for Fuchs endothelial corneal dystrophy (FECD) or bullous keratopathy (BK). We evaluated best corrected visual acuity (BCVA, logMAR), endothelial cell density (ECD, cells/mm2), minimal corneal thickness (CT, μm), rebubbling‐, primary transplant failure‐ and immune reaction‐rate. Changes over time were evaluated by linear mixed models for repeated measures and correlation with case number by center by weighted linear regression.
Results
For patients without vision‐limiting comorbidities (74% of all analysed eyes, n = 2270), mean BCVA improved from 0.6 ± 0.4 logMAR to 0.2 ± 0.2 logMAR 6 months (p < 0.001, n = 1441) and 0.1 ± 0.2 logMAR 12 months (p = 0.001, n = 1402) postoperatively. BK‐ had a worse BCVA compared to FECD‐patients (0.3 ± 0.5 vs. 0.1 ± 0.2 logMAR p < 0.001 at 1 year). ECD declined from 2465 ± 259 cells/mm2 (n = 2876 preoperatively) to 1587 ± 433 cells/mm2 after 12 months (p < 0.001, n = 1237). Mean rebubbling rate was 0.4 ± 0.7/eye. 784 eyes (25%) received at least one rebubbling. More rebubblings correlated with a lower ECD, a worse BCVA, a higher CT, and higher transplant failure and rejection rates (p < 0.001, p = 0.013 for BCVA at 12 months). A single rebubbling did not influence the BCVA (p = 0.785). Graft failure rate was 3% (n = 67), rejection rate 1.5% (n = 48).
Conclusion
Descemet membrane endothelial keratoplasty increases visual acuity with low transplant failure‐ and rejection‐rates. FECD has a better outcome than BK. Since a quarter of all patients need a rebubbling, this should be included in the informed consent. Remarkably, one rebubbling has no influence on the outcome.
The blood-aqueous barrier (BAB) separates immunoprivileged tissue of the eye from the blood circulation. Disruption of the BAB is therefore a risk factor for rejection after keratoplasty.
The present ...work provides a review of the work of our group and others on BAB disruption in penetrating and posterior lamellar keratoplasty and its implications for clinical outcome.
A PubMed literature search was performed to generate a review paper.
Laser flare photometry provides an objective and reproducible method to assess the integrity of the BAB. Studies of the flare after penetrating and posterior lamellar keratoplasty demonstrate a mostly regressive disruption of the BAB in the postoperative course, which is influenced in extent and duration by multiple factors. Persistently elevated flare values or an increase in flare after initial postoperative regeneration may indicate an increased risk of rejection.
In case of persistent or recurrent elevated flare values after keratoplasty, intensified (local) immunosuppression may potentially be useful. This could become important in the future, especially for the monitoring of patients after high-risk keratoplasty. Whether an increase of the laser flare is a reliable early indicator of an impending immune reaction after penetrating or posterior lamellar keratoplasty has to be shown in prospective studies.
BACKGROUNDTo report an unusual case of subperiosteal bleeding of nontraumatic etiology. CASE DESCRIPTIONA 48-year-old female presented with an acute protrusion of the left eye after nonaccomplished ...suicide by means of asphyxia using a cable around the neck. At the time of presentation, the MRI showed an orbital subperiosteal hematoma causing an exophthalmos. After conservative treatment, there was a complete remission of the lesion. CONCLUSIONNontraumatic subperiosteal bleedings without involvement of the intraocular structures and no vision-threatening intraorbital changes should be treated conservatively.
PDF