PURPOSE:This retrospective study aimed to evaluate age, sex, intervortex vein anastomosis|intervortex vein anastomoses (IVA), and subfoveal choroidal thickness (SFCT) across different entities of the pachychoroid spectrum (PCS). METHODS:A total of 147 eyes were analyzed, including: 65 chronic central serous chorioretinopathy, 29 uncomplicated pachychoroid (UCP), 25 pachychoroid pigment epitheliopathy (PPE), 15 pachychoroid neovasculopathy (PNV), nine aneurysmal choroidal neovascularization Type 1 (ACNV-1), and four peripapillary pachychoroid syndrome. Subfoveal choroidal thickness was assessed by optical coherence tomography and IVA by indocyanine green angiography. RESULTS:Neovascular PCS entities (PNV, ACNV-1) were significantly older (61 ± 10 vs. 54 ± 12 years, P = 0.003) and had a higher female prevalence (57% vs. 22%, P < 0.001) than their nonneovascular counterparts. Intervortex vein anastomosis|intervortex vein anastomoses differed only between UCP and PPE (31% vs. 64%, P = 0.03), with a trend toward lower SFCT in IVA-positive eyes. While ANOVA showed SFCT differences among PCS entities, multivariable regression identified age ( P < 0.001) and neovascular status ( P = 0.01) as independently and inversely associated with SFCT. CONCLUSION:Neovascular PCS entities were characterized by older age, higher female prevalence, and reduced SFCT. Both age and neovascularization independently associated with reduced SFCT, suggesting a potential role in choroidal remodeling. Intervortex vein anastomosis|intervortex vein anastomoses showed a limited discriminatory value but was associated with a trend toward lower SFCT.

Bakterielle Infektionen sind in Ländern mit hohem Einkommen bei Weitem die häufigste Ursache für die infektiöse Keratitis. Das klinische Erscheinungsbild kann je nach Art und Spezies der Bakterien sehr unterschiedlich sein und reicht von kleinen oberflächlichen Infiltraten bis hin zu nekrotisierenden Formen. Die zahlreichen Klassen verfügbarer Antibiotika machen den therapeutischen Spielraum vielfältig und komplex, insbesondere bevor der Erreger spezifiziert und die Empfindlichkeit gegenüber Antibiotika getestet wurde. Neue therapeutische Ansätze zur Verringerung der Virulenz sind in Forschung. Dieser DFP-Artikel befasst sich mit den klinischen, diagnostischen und therapeutischen Ansätzen zur Erkennung und Behandlung der bakteriellen Keratitis.

Fungal keratitis is still a relatively rare but very serious ophthalmological condition with a potentially vision-threatening course, possibly including even loss of the eye. Similar to acanthamoeba keratitis, it is often initially misdiagnosed at the slit lamp. For more than 20 years an increase in the incidence of fungal keratitis has been observed, also in Germany, possibly due to the increased use of soft contact lenses and climate change. This article provides an overview of the typical clinical signs and symptoms of keratomycosis and presents the latest findings in the field of diagnostics as well as drug and, in particular, microsurgical treatment. A special focus is placed on the indications and technique of emergency keratoplasty (à chaud) for fungal keratitis and its postoperative care.

PURPOSE:Corneal crosslinking (CXL) using riboflavin and ultraviolet A (UV-A) illumination is widely used to stabilize progressive ectatic corneal disorders such as keratoconus. However, the photochemical reaction generates oxidative stress and may induce apoptosis, while potential differences between healthy human corneal fibroblasts (HCF) and human corneal fibroblasts derived from keratoconus corneas (KC-HCF) remain insufficiently understood. This study examined in-vitro changes in pro- and anti-apoptotic markers in HCF and KC-HCF following riboflavin-UV-A illumination. METHODS:Cell cultures of HCFs (n = 5) and KC-HCFs (n = 5) were incubated with 0.01% or 0.1% riboflavin-dextran solutions (RF) for subsequent crosslinking and either placed in a dark chamber or illuminated with UV-A light (250 s, 375 nm, 2 J/cm2). The expression profiles of pro-apoptotic markers (BCL-2 homologous antagonist/killer (BAK), BCL-2 associated agonist of cell death protein (BAD), caspase-9 (CASP9) and cytochrome c (CYCS)) and the anti-apoptotic marker Baculoviral IAP Repeat Containing 5 (BIRC5) were analyzed using quantitative reverse transcription polymerase chain reaction (RT-PCR) (0.01%/0.1% RF; n = 5; for 2 h (h), 4 h, n = 3; for 24 h) and Western blot (0.1% RF; n = 4 for 24 h). Cell proliferation was assessed after 2 h, and ultrastructural changes were examined by transmission electron microscopy (TEM) after 24 h (0.1% RF; n = 1). RESULTS:Cell proliferation was significantly reduced in HCFs and KC-HCFs after 2 h in both treatment groups (0.01%/0.1% RF). Gene expression analysis showed a significant increase in BAK and BAD expression in KC-HCFs after 24 h with 0.01% RF, but not after 0.1% riboflavin-UV-A illumination. For CYCS and CASP9 gene expression levels remained unchanged for HCFs and KC-HCFs in both treatment groups. BIRC5 was significantly reduced in HCFs (0.01%/0.1% RF) and in KC-HCFs (0.1% RF). Protein expression analysis revealed a significant increase in BAK and CYCS after 24 h in HCFs and KC-HCFs, while CASP9 expression was significantly decreased. TEM showed some ultrastructural features of apoptosis after 24 h (0.1% RF). CONCLUSION:Riboflavin-UV-A illumination induced a time- and dose-dependent cellular response in both HCFs and KC-HCFs with KC-HCFs showing an increased sensitivity to photochemical stress.

A 59-year-old woman presented with a four-month history of progressive visual loss and floaters in her left eye. Her medical history included hypothyroidism, psoriasis, and type 2 diabetes. Fundus examination revealed choroidal folds, an amelanotic lesion temporal to the fovea, and an exudative retinal detachment. Optical coherence tomography (OCT) demonstrated a choroidal mass without subretinal fluid, while indocyanine green angiography (ICGA) showed a hypocyanescent lesion with no intrinsic vascularity. B-scan ultrasonography revealed an inhomogeneous choroidal mass with retrobulbar fluid (positive T-sign). Blood tests revealed elevated C-reactive protein (CRP) and liver enzymes levels, together with positive antinuclear antibodies (ANA), while the chest X-ray was normal. The overall clinical and imaging findings were consistent with nodular granulomatous scleritis. Choroidal melanoma, uveal lymphoma, primary vitreoretinal lymphoma, and choroidal hemangioma were excluded based on their imaging characteristics. Treatment with systemic corticosteroids resulted in rapid visual improvement and complete resolution of the lesion. This case demonstrates how inflammatory choroidal lesions can mimic intraocular tumors. Recognizing characteristic multimodal imaging features (choroidal folds, preserved choroidal vasculature on ICGA, positive T-sign on ultrasonography) can enable a confident diagnosis without biopsy, avoiding unnecessary treatment and delays in cancer diagnosis.

Purpose To evaluate whether the lens status of donor eyes (phakic vs. pseudophakic) influences graft preparation, graft handling, and postoperative outcomes in Descemet membrane endothelial keratoplasty (DMEK). Methods Retrospective analysis of 1171 DMEK cases, comparing phakic (n = 870) and pseudophakic (n = 301) donor eyes. Graft preparation characteristics, surgical complications, and postoperative outcomes including endothelial cell count (ECC), visual acuity (VA), central corneal thickness (CCT), rebubbling and repeat keratoplasty rates were assessed with a three-year follow-up. Results Pseudophakic donor tissue was significantly more difficult to prepare, with higher rates of tissue tears and need for manual dissection (both p < 0.001), though preparation times did not differ significantly. These challenges were linked to increased repeat keratoplasty risk (p = 0.041) and lower postoperative ECC (p = 0.047 at 1 year), while CCT and VA remained comparable. Intraoperative difficulties in graft manipulation occurred more frequently during implantation in the pseudophakic group (p = 0.14) and were associated with a significantly lower endothelial cell count after one year (p = 0.08) as well as a significantly higher risk of graft failure (p = 0.028). Overall, rebubbling (37% vs. 26%, p < 0.001) and repeat keratoplasty (12% vs. 7%, p = 0.045) were significantly more frequent in the pseudophakic group. Despite these complications, both groups showed comparable and significant visual improvement (p < 0.001). Conclusion Although pseudophakic donor tissue increases the technical complexity of DMEK resulting in significantly higher rates of rebubbling and repeat keratoplasty, successful grafts yield comparable visual outcomes to those from phakic donors. Pseudophakic corneas should therefore be considered a valuable additional donor source in times of tissue scarcity, provided that preparation and implantation are performed by experienced surgeons.

Fungal keratitis is still a relatively rare but very serious ophthalmological condition with a potentially vision-threatening course, possibly including even loss of the eye. Similar to acanthamoeba keratitis, it is often initially misdiagnosed at the slit lamp. For more than 20 years an increase in the incidence of fungal keratitis has been observed, also in Germany, possibly due to the increased use of soft contact lenses and climate change. This article provides an overview of the typical clinical signs and symptoms of keratomycosis and presents the latest findings in the field of diagnostics as well as drug and, in particular, microsurgical treatment. A special focus is placed on the indications and technique of emergency keratoplasty (à chaud) for fungal keratitis and its postoperative care.

Introduction Outpatient cataract surgery is one of the most frequently performed surgical procedures worldwide. Reducing its carbon footprint without compromising hygiene and patient safety offers substantial potential for mitigating healthcare-related greenhouse gas emissions. This multicentre study quantified the carbon footprint of outpatient cataract surgery across ten heterogeneous German tertiary centres and examined inter-centre variability in emissions as well as the extent to which current data support transparent, standardised reporting. Methods Between December 2022 and March 2023, standardised on-site assessments collected data on staff and patient travel, electricity consumption, disposable material use, and waste generation. Data were converted into carbon dioxide equivalents (CO₂e) using emission factors from national environmental agencies. Since detailed life cycle and sterilisation data could not be obtained for instrument manufacture and reprocessing, these components were modelled for all centres. Results The centres showed substantial inter-site variation in all major emission categories. Disposable materials (2.53-8.30 kg CO2e) and sterilisation (2.62-7.13 kg CO2e) were the dominant contributors, together accounting for 56.6-84.6% of total emissions. Electricity use contributed 1.0% to 18.5%, whereas waste disposal remained low (≤0.4%). Based on the combination of measured and modelled components, the estimated carbon footprint averaged 14.09 kg CO₂e per cataract procedure (95% CI: 12.08-16.11 kg), with centre-level values ranging from 10.07 to 18.70 kg. Conclusion Substantial emission reductions can be achieved by streamlining material use and improving sterilisation workflow. Transparent reporting that defines system boundaries, specifies uncertainties, and provides access to data collection methods is essential for comparability and for establishing reliable benchmarks in sustainable surgical practice. This study provides a comprehensive multicentre carbon footprint analysis for outpatient cataract surgery in Germany and offers a transparent framework that guides targeted reduction strategies.

Eine 59-jährige Patientin stellte sich mit seit vier Monaten progredienter Visusminderung und Mouches volantes am linken Auge vor, ohne Augenbewegungsschmerzen oder Gelenkbeschwerden. Anamnestisch bestanden Hypothyreose, Psoriasis und Diabetes mellitus Typ II. Funduskopisch zeigten sich am linken Auge Aderhautfalten, eine amelanotische, temporal der Fovea gelegene Läsion sowie eine exsudative Ablatio retinae. Die optische Kohärenztomographie (OCT) zeigte eine choroidale Raumforderung ohne subretinale Exsudation, die Indocyaningrünangiographie (ICGA) eine hypocyaneszente, gefäßfreie Läsion. Sonographisch fand sich eine inhomogene Raumforderung mit retroskleraler Flüssigkeit (positives T-Zeichen). Laborchemisch bestanden ein erhöhtes C-reaktives Protein (CRP), erhöhte Leberwerte und positive antinukleäre Antikörper (ANA). Der Röntgen-Thorax war unauffällig. Diese Befunde stützten die Verdachtsdiagnose einer nodulären granulomatösen Skleritis. Differentialdiagnostisch wurden Aderhautmelanom, uveales Lymphom, primäres vitreoretinales Lymphom und chorioidales Hämangiom erwogen. Unter Kortisontherapie mit Prednisolon zeigten sich rasche Visusbesserung und vollständige, stabile Rückbildung der Läsion. Der Fall verdeutlicht, dass die Abgrenzung entzündlicher von neoplastischen intraokularen Raumforderungen zu den schwierigsten Situationen der Ophthalmoonkologie zählt und klinische Erfahrung sowie konsequente multimodale Bildgebung erfordert, um Übertherapie und Verzögerungen der Tumordiagnostik zu vermeiden. Das Vorliegen von wichtigen Befunden in der multimodalen Diagnostik (Aderhautfalten, normalen Aderhautgefäßen in der ICGA, T-Zeichen im Ultraschall) können die korrekte nicht-invasive differentialdiagnostische Einordnung ermöglichen.

Hintergrund Die Beschreibung von Studienpopulationen mit Begriffen wie „kaukasisch/Caucasian“ ist in medizinischen Publikationen weiterhin verbreitet, oft ohne Definition und ohne nachvollziehbare Operationalisierung. Dies kann die Reproduzierbarkeit der Rekrutierung, die Vergleichbarkeit zwischen Studien und die externe Validität beeinträchtigen. Als Fallbeispiel dient die erste deutsche klinische Atropin-Studie zur Myopiekontrolle bei Kindern: „Low-dose AtropIne for Myopia Control in Children“ (AIM). Methode Kommentierender, nichtempirischer Beitrag auf Basis einer Analyse öffentlich zugänglicher Unterlagen zur AIM-Studie (Protokoll/publizierte Informationen) sowie einer strukturierten Literatur- und Dokumentenrecherche (PubMed, Leitlinien/Statements, regulatorische Dokumente) zu „race/ethnicity reporting“, „Caucasian“ und fairer Teilnehmendenauswahl. Ergebnisse Am Fallbeispiel der deutschen ophthalmologischen AIM-Studie („Low-dose Atropine for Myopia Control in Children“) wird gezeigt, dass die Zielpopulation als „kaukasisch“ beschrieben wird, während Definition und Zuordnungslogik in öffentlich zugänglichen Dokumenten nicht transparent sind. Dies erschwert die Einordnung der Übertragbarkeit der Ergebnisse und die Nachnutzung der Kohorte (z. B. für genetische Substudien). Diskussion Die Analyse ordnet die Verwendung des Begriffs entlang wissenschaftlicher (Validität/Operationalisierung), ethischer (faire Auswahl), rechtlicher (Gleichbehandlung/Diskriminierungsrisiken) und regulatorischer (Zielpopulation/Übertragbarkeit) Dimensionen ein. Dabei wird zwischen sozialen Kategorien, geografischer Rekrutierung und biologischen Hypothesen (z. B. Pharmakogenetik) klar unterschieden; wo biologische Mechanismen diskutiert werden, sind geeignete Variablen und transparente Begründungen erforderlich. Schlussfolgerung Für Studienprotokolle und Publikationen sollten Begriffe wie „kaukasisch“ nur verwendet werden, wenn sie definiert, begründet und methodisch sauber erhoben werden. Als Alternativen werden präzisere, prüfbare Angaben zur Rekrutierung (Ort/Setting), zur Erhebungsmethode (z. B. Selbstzuschreibung nach Standard), zu relevanten sozialen Determinanten sowie – bei biologischen Hypothesen – genetische bzw. Ancestry-bezogene Variablen empfohlen.

PURPOSE:To assess visual and refractive outcomes of intracapsular and add-on toric intraocular lens (tIOL) implantation in postkeratoplasty astigmatism. SETTING:Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany. DESIGN:Retrospective observational analysis. METHODS:This study analyzed postkeratoplasty eyes which underwent either intracapsular (G1) or supplementary sulcus-fixated tIOL implantation (G2). Refractive outcomes were assessed by performing vector analysis. RESULTS:134 eyes of 117 patients with previous penetrating (n = 129, 96.3%) or deep anterior lamellar keratoplasty (n = 5, 3.7%) were included. Intracapsular tIOL implantation was performed in phakic eyes (n = 115, 85.8%), while add-on tIOL implantation in the ciliary sulcus was performed in pseudophakic eyes (n = 19, 14.2%). Data were obtained for 102 eyes (76%) at 6 weeks and for 121 eyes (90%) at 10 months. Mean IOL cylinder power was 8.4 ± 2.6 diopters (D) for G1 and 5.7 ± 0.5 D for G2. Mean uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA, logMAR/Snellen) in G1 significantly improved from 1.1 ± 0.4 (∼20/250) to 0.5 ± 0.3 (∼20/63) and from 0.5 ± 0.3 (∼20/63) to 0.2 ± 0.2 (∼20/32), respectively (both P < .001). In G2, mean UDVA and CDVA significantly improved from 1.1 ± 0.2 (∼20/250) to 0.5 ± 0.1 (∼20/63) and from 0.5 ± 0.2 (∼20/63) to 0.3 ± 0.2 (∼20/40, both P < .001), respectively. Mean refractive cylinder decreased from -6.9 ± 2.6 to -2.6 ± 1.8 D in G1 and from -8.0 ± 2.7 to -4.2 ± 1.9 D in G2 (both P < .001). CONCLUSIONS:Intracapsular and add-on tIOL implantation can effectively reduce moderate to high mostly regular postkeratoplasty astigmatism while improving visual acuity.

PURPOSE:Direct ophthalmoscopy (DO) teaching in medical curricula may be performed as classical or simulator-based DO. This interventional study evaluated both options. METHODS:110 medical students received a multiple-choice questionnaire (four theory questions, six fundus photographs) prior to simulator-based (EyeSi Direct, Haag-Streit Simulation, Germany) and classical DO training (Heine BETA200, Heine Optotechnik GmbH, Germany). Training was performed in groups of eight students. Thereafter, they underwent an objective standardised clinical examination containing questions about (1) pupil dilation, (2) mydriasis contraindication, (3) ophthalmoscope adjustment and a practical test checking whether (1) optic nerve head, (2) macula, (3 - 6) upper/lower vessel arcade nasally versus temporally were identified correctly. Subsequently, classic DO was performed mutually and they reported the recognised funduscopic structures. Finally, the questionnaire was repeated one week later in combination with an evaluation of simulator-based versus classic DO. RESULTS:Students improved from an average of 4.0 ± 1.5/10 before to 8.8 ± 1.5/10 correctly answered questions after training (p < 0.0001, Wilcoxon matched-pairs test). 87|34|61 students named pupil dilating time|mydriasis contraindication and adjusted the ophthalmoscope correctly. They successfully identified the optic nerve head (n[simulator]|n[classic] DO: 110|68, p < 0.0001, Fisher's exact test), the macula (93|22, p < 0.0001), the upper (98|75, p = 0.0002) and lower temporal vessel arcade (101|91, p = 0.0672), the upper (84|56, p = 0.0001) and lower nasal vessel arcade (87|48, p < 0.0001). They wished for more simulator-based training, indicated more interest in ophthalmology after training and indicated an improvement in their ophthalmoscopy skills. CONCLUSION:A standardised simulator-based approach improves medical students' skills in ophthalmoscopy and arouses professional interest in ophthalmology.

To evaluate the refractive and anatomical lens position (ALP) predictability of the Aspira aXA (7 mm optic, cutout haptics) and Sensar One AAB00 IOLs (6 mm optic, C-loop haptics) in phacovitrectomy in a prospective, non-randomized cohort study. Preoperative biometry, 3-month subjective refraction, and swept-source optical coherence tomography were analyzed. ALP was the distance from the corneal endothelium to the IOL equator. Multivariate mixed-effects analysis was performed. A total of 102 eyes from 97 patients were included (54 Aspira aXA; 48 Sensar One). The increase in the Aspira aXA lens thickness (LT) per diopter was 3.14 times greater than that of the Sensar One, yet showing a decrease from 1300 to 1100 μm at 23 D. The anterior chamber depth (ACD) increased from preoperatively to postoperatively—to a greater extent for the Sensar One (1.74 vs. 1.50 mm, p <0.0001)—while the axial length (AL) decreased, also to a greater degree for the Sensar One (p <0.05). Holladay 1 achieved the lowest mean absolute error (MAE) (Aspira aXA: 0.24; Sensar One: 0.23 D) and, with the SRK/T and Haigis formulas, the highest accuracy within ± 0.25 D. Preoperative ACD, AL, LT, and Km influenced the mean numerical error (MNE) and MAE inconsistently. The IOL type affected the MNE and MAE only for Haigis, whereas the ALP significantly influenced the MNE, but not the MAE, in all formulas except Hill-RBF and SRK/T. Notably, the endotamponade type impacted the MNE and MAE in several modern formulas, but not in traditional vergence formulas. In contrast to AL and Km, the ACD and LT were strong predictors of ALP (Aspira aXA: R² = 0.697, Sensar One: 0.881). Preoperative ACD and LT reliably predict ALP. The Aspira aXA IOL introduces variability owing to its thickness profile. The endotamponade type exerts a significant influence. Traditional vergence formulas show greater robustness. Formula developments should integrate lens- and surgery-specific information.

INTRODUCTION:The purpose of this study was to investigate the long-term visual outcome after vitrectomy for idiopathic epiretinal membrane (ERM) according to the preoperative stage of the disease, focusing on central bouquet abnormalities (CBAs). METHODS:Our retrospective study included 280 eyes of 241 patients with idiopathic ERM who underwent pars plana vitrectomy with membrane peeling and internal limiting membrane peeling between 2016 and 2021. The best corrected visual acuity (BCVA) in logMAR, the CBAs, and the thickness of the ectopic inner foveal layer (EIFL) were documented using spectral-domain optical coherence tomography one day before surgery, 6 weeks, 6 months, and at the last available follow-up after surgery. RESULTS:Mean BCVA improved significantly at each postoperative follow-up compared to baseline (p < 0.001). Patients with stage 2 ERM showed the greatest improvement in BCVA compared to other patients (p < 0.001). The postoperative visual outcome has been negatively affected by higher ERM stage (p < 0.001), preoperative presence of subfoveal detachment (p = 0.033), preoperative presence of vitelliform lesions (p = 0.021), and the presence (p < 0.001) and thickness (p < 0.001) of EIFL. CONCLUSION:The earlier surgical treatment of ERM at stage 2 may result in better visual outcomes and a greater increase in vision. The preoperative presence of CBAs and a thick EIFL is associated with worse postoperative visual results.