Purpose:To develop an artificial intelligence (AI) algorithm enabling corneal surgeons to predict the probability of rebubbling after Descemet membrane endothelial keratoplasty (DMEK) from images obtained using optical coherence tomography (OCT).Methods:Anterior segment OCT data of patients undergoing DMEK by 2 different DMEK surgeons (C.C. and B.B.; University of Cologne, Cologne, Germany) were extracted from the prospective Cologne DMEK database. An AI algorithm was trained by using a data set of C.C. to detect graft detachments and predict the probability of a rebubbling. The architecture of the AI model used in this study was called EfficientNet. This algorithm was applied to OCT scans of patients, which were operated by B.B. The transferability of this algorithm was analyzed to predict a rebubbling after DMEK.Results:The algorithm reached an area under the curve of 0.875 (95% confidence interval: 0.880-0.929). The cutoff value based on the Youden index was 0.214, and the sensitivity and specificity for this value were 78.9% (67.6%-87.7%) and 78.6% (69.5%-86.1%).Conclusions:The development of AI algorithms allows good transferability to other surgeons reaching a high accuracy in predicting rebubbling after DMEK based on OCT image data.

Purpose To evaluate sensitivity and specificity of swept source-optical coherence tomography angiography (SS-OCTA) en face images versus cross-sectional OCTA versus a combination of both for the detection of macular neovascularization (MNV). Design Prospective cohort study. Participants Consecutive patients with various chorioretinal diseases and subretinal hyperreflective material (SHRM) and/or pigment epithelial detachment (PED) on OCT possibly corresponding to MNV in at least one eye. Methods 102 eyes of 63 patients with fluorescein angiography (FA), OCT and SS-OCTA performed on the same day were included. FA images, the outer retina to choriocapillaris (ORCC) OCTA en face slab, a manually modified en face slab (‘custom slab’), cross-sectional OCTA and a combination of OCTA en face and cross-section were evaluated for presence of MNV. Main outcome measures Sensitivity and specificity for MNV detection, as well as the concordance was calculated using FA as the reference. Results OCTA en face imaging alone yielded a sensitivity of 46.3% (automated)/78.1% (custom) and specificity of 93.4% (automated)/88.5% (custom) for MNV detection. Cross-sectional OCTA (combination with en face) resulted in a sensitivity of 85.4% (82.9%) and specificity of 82.0% (85.3%). Concordance to FA was moderate for automated en face OCTA ( κ = 0.43), and substantial for custom en face OCTA ( κ = 0.67), cross-sectional OCTA ( κ = 0.66) and the combination ( κ = 0.68). Conclusion Segmentation errors result in decreased sensitivity for MNV detection on automatically generated OCTA en face images. Cross-sectional OCTA allows detection of MNV without manual modification of segmentation lines and should be used for evaluation of MNV on OCTA.

Purpose: To report a case of bilateral diffuse uveal melanocytic proliferation over 30 months follow-up. Methods: Multimodal imaging including ultra-wide-field color fundus photography, blue light fundus autofluorescence, swept-source optical coherence tomography, fluorescein angiography, and indocyanine green angiography. Results: A 49-year-old woman presented with decreased vision 2 months after bladder cancer surgery. Exudative retinal detachment and leopard spot pattern chorioretinopathy were observed in the right eye. Chemotherapy and cystectomy were initiated. Progressive bilateral vision loss occurred with melanocytic proliferation, choroidal thickening, subretinal fibrosis, fluid extravasation, rapid development of mature cataract, multiple iris cysts, and rubeosis, despite plasmapheresis and IV immunoglobulins. After cataract surgery, massive fibrin reaction resulted in a ciliolenticular block. One year later, positron emission tomography–computed tomography revealed absence of metastases. At Month 23, choroidal thickness increased in line with tumor progression. Palliative systemic therapy was initiated. Secondary macular neovascularization was treated with intravitreal antivascular endothelial growth factor injections. Visual acuity was light perception in the right eye and 20/200 in the left eye at last follow-up. Conclusion: Bilateral diffuse uveal melanocytic proliferation results in progressive melanocyte proliferation and exudation, leading to severe visual loss. In our case, visual acuity was preserved at a low level in one eye under continuous systemic treatment. Systemic corticosteroids are recommended for cataract surgery in the setting of bilateral diffuse uveal melanocytic proliferation to prevent massive fibrin reaction. Intravitreal antivascular endothelial growth factor injections may be indicated if secondary macular neovascularization develops.

Purpose To assess corneal densitometry in patients with Fabry disease (FD) and to compare corneal densitometry differences in FD patients to different corneal manifestations. Methods Ten participants (20 eyes) with FD and 10 age-matched healthy volunteers (20 eyes) were recruited. All participants were assessed by standardized ophthalmic examinations and the corneal densitometry analysis by Pentacam HR. Densitometry measurements were analyzed in standardized grayscale units. Results Seven patients developed conjunctival vessel tortuosity, cornea verticillata appeared in 6 patients, and two patients had Fabry cataract. Retinal vessel tortuosity occurred in 4 patients, and dilation of retinal vessels appeared in 3 patients, all symptoms occurred in both eyes. The first diagnosis of FD up to examination was 4.7 ± 3.23 years, and first ERT up to examination was 2.6 ± 2.27 years. The initial time to diagnosis was negatively related to the corneal densitometry value of the 0–2-mm ( r = − 0.556, p = 0.011) and 2–6-mm ( r = − 0.482, p = 0.032) zones in the posterior layer. FD group have significantly higher corneal densitometry in anterior 0–2-mm zone and 2–10-mm zone anterior and posterior layer than the control group ( p ≤ 0.035, respectively). When divided into two groups by the existence of cornea verticillata, there was a statistically significant difference in the anterior layer, 6–10-mm zone ( p = 0.031); in the central layer, 0–2 mm ( p = 0.012), 2–6 mm ( p = 0.001), 6–10 mm ( p = 0.002), and total ( p = 0.002); and in the posterior layer, 6–10 mm ( p = 0.004) and total ( p = 0.002). Conclusions FD patients show higher corneal densitometry, and corneal densitometry may have potential for early diagnosis and reminding progress of FD.

PURPOSE:To evaluate the presence and appearance of blood and lymphatic vessels in non-functioning bleb capsules of glaucoma drainage devices (GDD).MATERIALS AND METHODS:Non-functioning (n=14) GDD-bleb capsules of 12 patients were analyzed by immunohistochemistry for blood vessels (CD31, vascular endothelium), lymphatic vessels (lymphatic vessel endothelial hyaluronan receptor-1 [LYVE-1] and podoplanin) and macrophages (CD68).RESULTS:CD31+++ blood vessels and CD68+ macrophages were detected in the outer layer of all specimens. LYVE-1 immunoreactivity was registered in single non-endothelial cells in 8 out of 14 (57%) bleb capsule specimens. Podoplanin-immunoreactivity was detected in all cases, located in cells and profiles of the collagen tissue network of the outer and/or the inner capsule layer. However, a colocalization of LYVE-1 and podoplanin as evidence for lymphatic vessels was not detected.CONCLUSIONS:We demonstrate the presence of blood-vessels but absence of lymphatic vessels in non-functioning bleb capsules after GDD-implantation. While the absence of lymphatic vessels might indicate a possible reason for drainage device failure, this needs to be confirmed in upcoming studies, including animal experiments.

BACKGROUND AND OBJECTIVE: Descemet membrane endothelial keratoplasty (DMEK) has increased in popularity since its introduction over 10 years ago. This article presents a summary of the experiences of the past years collected at the Department of Ophthalmology at the University of Cologne. METHODS: A literature review of DMEK studies primarily from the Department of Ophthalmology at the University of Cologne, Germany was carried out. Own experiences in the fields of donor selection and graft preparation, DMEK surgery, complication management and postoperative treatment are summarized. RESULTS: Since the introduction of DMEK experience has been gained and ongoing improvements have occurred ranging from donor-recipient allocation to postoperative follow-up. These led to a better reproducibility of the intervention for the surgeon, to a better postoperative result and to a reduction of the complication rate. DISCUSSION: The DMEK represents a safe and individualized procedure for endothelial transplantation for corneal endothelial dysfunction. Continuing development of the method leads to optimization and safer results.

Die „Descemet membrane endothelial keratoplasty“ (DMEK) erfreut sich seit ihrer Einführung vor über 10 Jahren weltweit zunehmender Beliebtheit in der Therapie der Fuchs-Dystrophie. Im vorliegenden Beitrag sollen am Zentrum für Augenheilkunde der Universität zu Köln gesammelte Erfahrungen der vergangenen Jahre in einer Übersicht dargestellt werden.

PURPOSE:To evaluate the course of corneal biomechanical properties (corneal hysteresis and corneal resistance factor) after Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial dystrophy (FECD).METHODS:In this prospective study, we consecutively included 49 patients with FECD with an indication for DMEK. Central corneal thickness, measured using the Oculus Pentacam, and corneal hysteresis (CH) and corneal resistance factor (CRF), both measured using the Reichert Ocular Response Analyzer, were examined preoperatively, 3 months, and 6 months after DMEK.RESULTS:CH was significantly increased 6 months postoperatively (8.66 ± 2.50 mm Hg) compared with preoperative baseline (7.43 ± 1.56 mm Hg). Preoperative CRF (7.89 ± 1.68 mm Hg) increased significantly 6 months after DMEK (8.49 ± 1.71 mm Hg). Preoperative central corneal thickness showed a significant decrease from 629 ± 58 μm to 550 ± 40 μm after 3 months and 535 ± 40 μm after 6 months postoperatively.CONCLUSIONS:DMEK affects both measured corneal biomechanical properties in patients with FECD: CH and CRF. This has to be taken into account for the accuracy of intraocular pressure measurements.

Purpose: To evaluate the sensitivity and specificity for the detection of choroidal neovascularization (CNV) using automatically generated versus manually modified swept-source OCT angiography (SS-OCTA) en face images. Design: Prospective cohort study. Participants: Consecutive patients with various chorioretinal diseases and subretinal hyperreflective material (SHRM) or pigment epithelial detachments (PEDs) on OCT possibly corresponding to CNV in at least 1 eye. Methods: A total of 102 eyes of 63 patients were included in this study. Fluorescein angiography (FA) and SS-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec, Dublin, CA) were performed at the same day. OCTA en face images were generated using the "retina," "avascular," "choriocapillaris," and "outer retina to choriocapillaris (ORCC)" slabs automatically provided by the software. In addition, a custom slab was created by manual modification of the automatically provided boundary "retinal pigment epithelium fit" positioned at the level of Bruch's membrane and anterior to any SHRM or PED to ensure that a possible CNV was captured in its entirety. Two graders independently evaluated OCTA en face images for the presence of CNV masked to all other images of the patient. Main Outcome Measures: Sensitivity and specificity for detection of CNV using FA as the reference. Results: In 40% of cases (41/102), a CNV was detected on FA. Automatically provided OCTA en face slabs revealed the highest sensitivity for the "ORCC" slab (46.3%), followed by the "retina" slab (22.0%), "avascular" slab (17.1%), and "choriocapillaris" slab (14.6%). Specificity ranged between 93.4% for "ORCC" and 100% for the "retina" and "avascular" slabs. Sensitivity could be increased to 78.1 % using the custom slab with a specificity of 88.5%. Concordance between FA and OCTA en face slabs was moderate for the "ORCC" slab (K = 0.43; range, 0.41-0.60) and substantial for the custom slab (K = 0.67; range, 0.61-0.80). Conclusions: Segmentation artifacts and incomplete coverage of CNV on SS-OCTA en face images may impede identification of CNV. Manual modification of the position of automatically generated segmentation lines anterior and posterior to any suspected CNV (SHRM or PED) increases the sensitivity of CNV detection compared with automatically generated slabs. (C) 2019 by the American Academy of Ophthalmology

Eine 75-jährige Patientin stellte sich mit progredientem Visusverlust auf rechts Handbewegungen und links 1/50 Metervisus vor. Die SD-OCT zeigte beidseits eine Verdünnung der äußeren Netzhaut. Bei Verdacht auf Autoimmunretinopathie wurde im Rahmen des Tumorscreenings ein neuroendokrines Karzinom des Uterus diagnostiziert. Unter systemischer Kortisontherapie kam es zu einem Visusanstieg auf rechts 0,1 und links 0,25. Bei der karzinomassoziierten Retinopathie (CAR) handelt es sich um eine Autoimmunretinopathie paraneoplastischer Genese.

Eine vollständige Atrophie der Bindehaut im Bereich der Filterzone stellt eine sehr seltene Komplikation nach Trabekulektomie mit Mitomycin-C-Applikation und subkonjunktivaler Kollagen-Matrix-Implantation (Ologen®, Aeon Astron Corporation, Taipei, Taiwan) dar. Klinisch-morphologisch kann die Atrophie einer Blebitis ähneln. Wir berichten über einen Fall einer 71-jährigen Patientin, bei welcher wir die atrophe Bindehaut resezierten und mithilfe eines Amnionmembran-Patches eine neue Filterzone aufbauten.

Zusammenfassung Eine 75-jährige Patientin stellte sich mit progredientem Visusverlust auf rechts Handbewegungen und links 1/50 Metervisus vor. Die SD-OCT zeigte beidseits eine Verdünnung der äußeren Netzhaut. Bei Verdacht auf Autoimmunretinopathie wurde im Rahmen des Tumorscreenings ein neuroendokrines Karzinom des Uterus diagnostiziert. Unter systemischer Kortisontherapie kam es zu einem Visusanstieg auf rechts 0,1 und links 0,25. Bei der karzinomassoziierten Retinopathie (CAR) handelt es sich um eine Autoimmunretinopathie paraneoplastischer Genese.

Allgemeines Das European Board of Ophthalmology (EBO) ist ein Zusammenschluss von jeweils 2 Repräsentanten aus den EUMitgliedstaaten und hat sich das Ziel gesetzt, höchstmögliche Standards in der augenärztlichen Ausbildung und Versorgung der EU-Mitgliedstaaten durchzusetzen. Im Rahmen dessen wurde unter anderem das EBO Diplom (EBOD) als (in der Regel) freiwilliges Examen eingeführt. Dieses soll theoretisches Wissen sowie klinische Fähigkeiten prüfen und zum Erreichen hoher Standards in der Krankenhaussowie ambulanten Versorgung beitragen. Einige Länder (z. B. Schweiz) haben bereits ihre Facharztprüfung durch das EBOD ersetzt.

Zusammenfassung Hintergrund und Ziel der Arbeit Die „Descemet membrane endothelial keratoplasty“ (DMEK) erfreut sich seit ihrer Einführung vor über 10 Jahren weltweit zunehmender Beliebtheit in der Therapie der Fuchs-Dystrophie. Im vorliegenden Beitrag sollen am Zentrum für Augenheilkunde der Universität zu Köln gesammelte Erfahrungen der vergangenen Jahre in einer Übersicht dargestellt werden. Methoden Es erfolgte eine Literaturübersicht von Studien zur DMEK primär aus dem Zentrum für Augenheilkunde der Universität zu Köln. Es werden eigene Erfahrungen in den Bereichen der Spenderauswahl und Transplantatpräparation, der DMEK-Chirurgie, des Komplikationsmanagements und der postoperative Therapie zusammengefasst. Ergebnis Seit Einführung der DMEK haben Erfahrungszuwachs und fortwährende Verbesserungen von der Spender-Empfänger-Allokation bis hin zur postoperativen Nachsorge stattgefunden. Diese führen zur besseren Reproduzierbarkeit des Eingriffs für den Chirurgen, zum besseren postoperativen Ergebnis und zur Reduktion der Komplikationsrate am Patienten. Diskussion Die DMEK stellt ein sicheres und individualisiertes Verfahren zur Endotheltransplantation bei kornealer endothelialer Dysfunktion dar. Kontinuierliche Weiterentwicklungen des Verfahrens führen zu optimaleren Ergebnissen.

PURPOSE:To analyze the clinical outcomes, complications, comparability, and predictors of sequential bilateral Descemet membrane endothelial keratoplasty (DMEK).METHODS:Retrospective analyses were completed on 60 patients (120 eyes) with corneal endothelial disorders who underwent bilateral sequential DMEK. Main outcome measures were best-corrected visual acuity (BCVA), pachymetry, endothelial cell density, rebubbling frequency, and graft or nongraft-associated complications-as measured 6 and 12 months after surgery.RESULTS:BCVA, pachymetry, and endothelial cell loss did not differ significantly 6 and 12 months after surgery in first versus fellow eyes (P > 0.05, respectively). Graft and nongraft-associated complications such as graft detachment, graft failure, graft rejection, anterior chamber inflammation, and intraocular pressure decompensation did not differ significantly between first and fellow eyes (P > 0.05, respectively). The BCVA of first eyes 6 and 12 months after surgery correlates significantly with the 12-month BCVA of fellow eyes (r = 0.454, P = 0.031; r = 0.602, P = 0.001, respectively). Nevertheless, it was not possible to identify BCVA as an influencing variable on fellow eye outcome in regression modeling. Early sequential DMEK did not increase patients' risk of early immune reactions in their fellow eyes.CONCLUSIONS:The clinical outcomes of first and fellow eyes were comparable in patients after DMEK. This suggests patients will experience good fellow eye outcomes after successful first eye DMEK. When certain quality characteristics are maintained, donor differences do not significantly affect DMEK results. We found no significant correlation in postoperative complications in first and fellow eye DMEK surgeries.

To analyze the clinical outcomes, complications, comparability, and predictors of sequential bilateral Descemet membrane endothelial keratoplasty (DMEK).Retrospective analyses were completed on 60 patients (120 eyes) with corneal endothelial disorders who underwent bilateral sequential DMEK. Main outcome measures were best-corrected visual acuity (BCVA), pachymetry, endothelial cell density, rebubbling frequency, and graft or nongraft-associated complications-as measured 6 and 12 months after surgery.BCVA, pachymetry, and endothelial cell loss did not differ significantly 6 and 12 months after surgery in first versus fellow eyes (P > 0.05, respectively). Graft and nongraft-associated complications such as graft detachment, graft failure, graft rejection, anterior chamber inflammation, and intraocular pressure decompensation did not differ significantly between first and fellow eyes (P > 0.05, respectively). The BCVA of first eyes 6 and 12 months after surgery correlates significantly with the 12-month BCVA of fellow eyes (r = 0.454, P = 0.031; r = 0.602, P = 0.001, respectively). Nevertheless, it was not possible to identify BCVA as an influencing variable on fellow eye outcome in regression modeling. Early sequential DMEK did not increase patients' risk of early immune reactions in their fellow eyes.The clinical outcomes of first and fellow eyes were comparable in patients after DMEK. This suggests patients will experience good fellow eye outcomes after successful first eye DMEK. When certain quality characteristics are maintained, donor differences do not significantly affect DMEK results. We found no significant correlation in postoperative complications in first and fellow eye DMEK surgeries.