Evaluation of a Novel Non-Diffractive Extended Depth of Focus Intraocular Lens : First Results from a Prospective Study

Purpose: To evaluate a novel hydrophobic, non-diffractive, extended depth of focus (EDOF) intraocular lens (IOL) design in comparison to two monofocal aspheric lenses. Methods: Inclusion criteria for this prospective, monocentric cohort study were opacification of the crystalline lens and patients’ wishes for surgery. In the case of the EDOF IOL, patients asked for a presbyopia correction. All patients received surgery on both eyes. Corrected and uncorrected distance visual acuity (CDVA, UCDVA), uncorrected and distance corrected intermediate visual acuity (UIVA, DCIVA) and defocus curves (all monocular and binocular) were compared three months postoperatively. Results: Fifty-six eyes were implanted with an EDOF IOL (LuxSmartTM, Bausch & Lomb GmbH, Berlin, Germany), 50 eyes with a monofocal aspheric IOL: 32 eyes with a clear IOL (PolylensVR AS 61, Polytech Domilens, Roßdorf, Germany), 16 eyes with a yellow IOL (iSertVR 251, Hoya Surgical Optics GmbH, Frankfurt, Germany). Three months postoperatively, UCDVA was comparable with the EDOF IOL, versus the monofocal IOL (P> 0.9). Binocular DCIVA in the EDOF IOL was significantly higher than in the monofocal IOL (P¼ 0.001). Monocular DCIVA better than 20/23 Snellen was achieved in 10% with the monofocal IOL and in 68% (P< 0.0001) with the EDOF IOL. Defocus curves showed a depth of focus at 20/23 Snellen of 1.6 vs. 0.83 diopters (D) in the EDOF IOL, vs. the monofocal IOL. No patient reported halos or starbursts in non-standardized questioning. Conclusion: This non-diffractive EDOF IOL provided comparably high UCDVA and significantly higher DCIVA than the mono-focal lenses, causing only mild optical phenomena

Rescue Technique to Solve Postoperative Refractory Double Anterior Chamber in Deep Anterior Lamellar Keratoplasty

Purpose: The purpose of this study was to describe a simple rescue technique to solve postoperative double anterior chamber refractory to rebubbling in deep anterior lamellar keratoplasty (DALK). Methods: This study analyzed consecutive patients who underwent DALK between June 2014 and March 2018 and required a postoperative reattachment of Descemet membrane because of macroperforation-led persistent double chambers. The technique entails placing anchoring sutures to attach Descemet membrane to the donor's posterior stroma. Anchoring sutures were removed within 1 month of surgery. The postoperative best spectacle-corrected visual acuity (BSCVA) [converted to logarithm of the minimum angle of resolution (logMAR) units], endothelial cell density (cells/mm(2)), graft survival, postoperative complications, and corneal astigmatism (diopters) were evaluated. Results: Five eyes from 5 patients were included in this study [5 women, 63.6 +/- 6.0 yrs (32-80 yrs); mean follow-up duration, 72.0 +/- 23.3 mo (30-100 mo)] (mean +/- SD). The grafts survived successfully in all patients without primary or secondary graft failure. The best spectacle-corrected visual acuity improved from 1.26 +/- 0.66 logMAR preoperatively to 0.25 +/- 0.15 logMAR postoperatively (n = 5, P = 0.042). The endothelial cell density was 1468 +/- 810 cells/mm(2) at the last visit. Conclusions: Macroperforation of Descemet membrane during DALK with incomplete removal of the stroma can lead to persistent double anterior chamber. This complication could be solved by the technique devised by this study

Tolerance and Adherence to Cationic 0.1% Cyclosporine in Ocular Graft-versus-Host Disease

Introduction: Anti-inflammatory, topical therapy of severe keratitis in dry eye disease (DED) and ocular graft-versus-host disease (oGvHD) includes steroids, cyclosporine (Cs), and others. In Germany, a commercial product containing 0.1% Cs in a cationic formulation is available since 2015. Objective: The aim of this study was to present real-life data using cationic 0.1% Cs in oGvHD patients. Methods: This was a retrospective study of 26 oGvHD and 41 DED patients with corneal staining of at least Oxford grade III. Parameters analyzed were Ocular Surface Disease Index, corneal staining, intraocular pressure, tear film break-up time, Schirmer, and visual acuity. In addition, it was evaluated how different Cs formulations were tolerated. Results: Corneal staining improved significantly in 1 eye in DED but not in oGvHD. In DED, cationic 0.1% Cs was not tolerated by 32% of the patients, in contrast to 0.05% Cs in castor oil not tolerated by 47% and liposomal 0.05% Cs by 63%. In oGvHD patients, cationic 0.1% Cs was not tolerated by 62%, 0.05% Cs in castor oil by 33%, and liposomal 0.05% Cs by 39% of the patients. Conclusions: This study demonstrates differences between the tolerance of different Cs formulations depending on the underlying cause of severe keratitis. Cationic 0.1% Cs is considerably less tolerated in oGvHD, and its use should be considered with care

Intraoperative Optical Coherence Tomography Enables Noncontact Imaging During Canaloplasty

Purpose: Here we describe intraoperative optical coherence tomography (iOCT) as a novel noncontact imaging tool for intraoperative monitoring and procedure evaluation during canaloplasty, as a nonpenetrating surgical technique to treat primary open angle glaucoma. Materials and Methods: Retrospective case report of a patient (63 y, female), who underwent traditional canaloplasty, using a commercially available 840nm OCT device, mounted to an operating microscope (Rescan 700). Main outcome measures were the intraoperative visibility of chamber angle structures and the ability to conduct surveillance of the surgical procedure through the prepared Descemet window, especially correct suture positioning and visible changes of the Schlemm canal after suture tensioning. Results: iOCT delivered high-resolution images during canaloplasty after deep sclerectomy through the prepared Descemet window. All structures of the chamber angle, including the Schlemm canal were visible. Moreover iOCT enabled intraoperative noncontact procedure monitoring and a direct control of the correct localization and changes of the Schlemm canal after suture positioning and tensioning. Conclusions: iOCT seems to be a helpful intraoperative imaging tool during canaloplasty. iOCT allows for noncontact online evaluation of Schlemm canal localization and noncontact evaluation of suture tension. Shadowing of scleral tissue can be avoided by imaging through the routinely prepared Descemet window to visualize chamber angle structures including the implanted suture

Mini-Descemet Membrane Endothelial Keratoplasty for the Early Treatment of Acute Corneal Hydrops in Keratoconus

Purpose: To describe a new surgical option for the treatment of acute corneal hydrops in keratoconus and to present the first results. Methods: This is a retrospective analysis of 3 patients who presented to our clinic with a massive corneal hydrops in acute keratoconus and were treated by mini-Descemet membrane endothelial keratoplasty (DMEK). According to the size and the shape of the gap in the patient's Descemet membrane (DM), 1 DMEK graft was trephined with a round 5-mm punch. The other grafts were trimmed with a razor blade to a width of about 3 mm and a length adjusted to the length of the defect of the recipients' DM. The graft was inserted with a regular intraocular lens shooter. Correct unfolding of the graft was controlled by using intraoperative optical coherence tomography. At the end of the surgery, the graft was attached to the posterior corneal surface by a small air bubble. Thereafter, the complete anterior chamber was filled with 20% SF6 gas. Results: All 3 patients (age 32 +/- 3 years on average) showed a rapid increase in uncorrected visual acuity from the logarithm of the minimum angle of resolution (LogMAR) 1.66 (+/- 0.46) before mini-DMEK to the LogMAR 1.2 (+/- 0.3) within 6 to 8 weeks after mini-DMEK. The thickest corneal point within the edematous cornea decreased in all 3 patients (1088 +/- 280 mu m before surgery vs. 630 +/- 38 mu m 1 week after surgery). One mini-DMEK failed in a first attempt. In this patient, the recipient DM was under strong tension and showed a pronounced dehiscence. Therefore, a small part of the recipient's DM around the preexisting gap in DM was removed before a second mini-DMEK graft was placed successfully. The other 2 patients developed partial graft detachment within 1 to 2 weeks after surgery. However, the corneas of these patients were dehydrated to physiological levels after mini-DMEK, and despite partial detachment, there was no relapse of the hydrops. Conclusions: Mini-DMEK could be helpful in patients with larger defects and detachments of DM in very ectatic corneas in the acute phase of corneal hydrops in acute keratoconus. These patients may not be successfully treated by intracameral gas application alone or in combination with pre-Descemetal sutures. Further investigations are needed to identify factors helping to decide on the best surgical approach in hydrops in acute keratoconus

Lutein and Brilliant Blue-Based Dye for Donor Preparation and Transplantation in Descemet Membrane Endothelial Keratoplasty

Purpose: Trypan blue (TB) is used for visualization of the endothelium-Descemet membrane graft during Descemet membrane endothelial keratoplasty (DMEK). However, TB is assumed to have a dose-dependent toxic effect on the corneal endothelium. We retrospectively compared a lutein/zeaxanthin and Brilliant Blue (LZ/BB)-based dye for preparation and transplantation of the graft in DMEK to TB. Methods: In 20 patients, a dye composed of 1% LZ /0.025% BB was used, and in 22 patients, 0.06% TB was used for graft visualization in DMEK. We evaluated the rebubbling rate, best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), and endothelial cell density (ECD) before and 3 and 6 months after transplantation. Results: Staining of endothelium-Descemet membrane with LZ/BB was faint but sufficient. There was no significant difference between both groups, except in CCT after 3 months, which was lower in the LZ/ BB group (P = 0.02). In the LZ/BB group, BSCVA improved from 0.48 +/- 0.39 before DMEK to 0.19 +/- 0.09 after 6 months (P < 0.05) (20% rebubbling rate). Donor ECD decreased from 2735 +/- 259 cells/m(2) preoperatively to 1876 +/- 316 cells/mm(2) (P < 0.0001) at 6 months (31.4%). CCT decreased from 642 +/- 130 mu m preoperatively to 519.8 +/- 38 mm (P < 0.0001) at 6 months. In the TB group, BSCVA improved from 0.43 +/- 0.27 to 0.17 +/- 0.14 (P = 0.0003) at 6 months (30% rebubbling rate). ECD decreased from 2825 +/- 263 to 1777 +/- 302 cells/ mm(2) (P < 0.0001) after 6 months (36.3%), CCT from 638 +/- 48 mu m preoperatively to 531 +/- 48 mu m (P < 0.0001) at 6 months. Conclusions: LZ/BB-based dyes are suitable for DMEK with outcomes comparable to TB. However, available formulas result in faint staining, discouraging their routine use in donors with assumed difficult preparation

Microscope-Integrated Optical Coherence Tomography-Guided Drainage of Acute Corneal Hydrops in Keratoconus Combined With Suturing and Gas-Aided Reattachment of Descemet Membrane

Purpose: The treatment of acute corneal hydrops due to keratoconus has so far been limited to awaiting the spontaneous resorption of corneal edema, supportive care, and finally keratoplasty. A recent publication describes the surgical reattachment of Descemet Membrane (DM) facilitated by pre-Descemetic sutures and anterior chamber air/gas filling. Here, we present a novel microscope-integrated intraoperative optical coherence tomography (MI-OCT)guided technique for the immediate reattachment of DM in corneal hydrops due to keratoconus in 2 male patients with small central DM defects. Methods: Case series of 2 consecutive patients with acute corneal hydrops due to keratoconus. The novel technique consists of the MI-OCT-guided puncture and drainage of intrastromal fluid pockets combined with anterior chamber sulfur hexafluoride-fill and pre-descemetic sutures using a commercially available MI-OCT (iOCT; Haag Streit Surgical, Wedel, Germany). Results: After uneventful surgery, corneal edema showed fast resolution and DM was reattached to the corneal stroma. In both patient's central corneal thickness decreased after surgery and visual acuity improved. Conclusions: MI-OCT guided micropuncture of stromal edema combined with compression sutures and SF6 tamponade is a new therapeutic option in acute corneal hydrops with small Descemet membrane defects