To assess the morphological and functional outcome of oral eplerenone for treatment of patients with chronic central serous chorioretinopathy (CSC) in a real life experience. In this retrospective study, we reviewed the clinical files of 30 patients with chronic CSC. All patients were treated with eplerenone for a period of 6 weeks or 3 months depending on the clinical response. Main outcome measures included: best corrected visual acuity (BCVA), central macular thickness (CMT) and height of the subretinal fluid (SRF). Comparisons between responders and non-responders were performed to identify factors that were predictive of the treatment response. All patients were treated with eplerenone 18 ± 20 weeks after onset of the first symptoms. BCVA (LogMAR) improved from 0.2 ± 0.2 to 0.13 ± 0.18 at 6 weeks (p = 0.01) and to 0.09 ± 0.15 at 3 months (p = 0.01). Mean CMT decreased from 409 ± 136 to 323 ± 87 µm at 6 weeks (p = 0.001) and to 298 ± 98 µm at 3 months (p = 0.01). Mean height of SRF decreased from 153 ± 126 to 73 ± 79 µm at 6 weeks (p = 0.001) and to 49 ± 88 µm at 3 months (p = 0.005). Complete resolution of SRF was achieved in 20 patients after 3 months (67%). Reported stress in the medical history was the only statistical significant predictive factor associated with a positive treatment response. This study showed a statistically significant improvement of the best corrected visual acuity and a significant reduction of macular thickness and subretinal fluid in patients with chronic CSC treated with oral eplerenone, especially in patients under stress.

Background: To evaluate the outcomes of intravitreal faricimab (IVF) for refractory neovascular age-related macular degeneration (nAMD) and investigate the impact of baseline optical coherence tomography, biomarkers for total IVF injections are needed. Methods: A retrospective analysis of 33 eyes of patients who completed one year (52 W) of treatment with IVF. The eyes received four IVF injections (6 mg/0.05 mL) as the upload phase. Thereafter, the treatment interval was extended to 8 or 12 weeks if disease activity was not recorded. The outcome measures included best-corrected visual acuity (BCVA), central macular thickness (CMT), subfoveal choroidal thickness (SFCT), and retinal fluid distribution. Results: A total of 33 eyes were included. CMT decreased significantly at 52 W (p < 0.01). BCVA and SFCT did not change significantly at 52 W (p > 0.05). The number of eyes with subretinal fluid decreased significantly at 52 W (p < 0.01). Complete fluid resolution was achieved in 20 eyes (60%). The total number of injections was significantly negatively correlated with the presence of hyperreflective dots at baseline (HRDs, p < 0.01) and SFCT at baseline (p < 0.01). Conclusions: IVF led to a significant reduction in CMT with stabilization of BCVA. The total number of injections was lower in eyes with HRDs and increased SFCT at baseline. This might provide clues regarding response to IVF for future studies.

Zusammenfassung: Die Hornhauttransplantation ist das weltweit am häufigsten durchgeführte Verfahren zur Transplantation von menschlichem Gewebe. Aufgrund der großen Anzahl von Transplantationen hat sich das Versagen von Hornhauttransplantaten aus immunologischen und nicht immunologischen Gründen (z. B. Rezidiv der Grunderkrankung, hoher Augendruck, transplantierte Guttae, übertragene HSV- oder CMV-Infektion) zu einer der häufigsten Indikationen für Hornhauttransplantationen entwickelt. Die relativ neuen lamellären Transplantationstechniken haben bestimmte potenzielle Komplikationen mit sich gebracht, die zu einem Transplantatversagen führen und andere Ansätze als die perforierende Keratoplastik für eine erneute Transplantation erforderlich machen können. Andererseits bieten diese neuen lamellären Techniken auch neue Möglichkeiten zur Rettung fehlgeschlagener perforierender Transplantate, mit potenziellen Vorteilen gegenüber aufeinanderfolgenden perforierenden Keratoplastiken, wie z. B. geringere intraoperative Risiken, schnellere visuelle Rehabilitation und reduziertes Abstoßungsrisiko. Heute stellt bei gutem Heilungsverlauf der mit seinem Transplantat vor der endothelialen Dekompensation zufriedene Patient mit geringem Astigmatismus und ohne stromale Narben die optimale Voraussetzung für die DMEK nach PKP dar. Diese kann auch mit einer Phakoemulsifikation kombiniert werden (sog. Triple-DMEK). Anderenfalls erfolgt eine perforierende Re-Keratoplastik mit einem größeren Transplantat (typischerweise Excimerlaser-Re-PKP 8,5/8,6 mm), um gleichzeitig Ödem, Narben und Verkrümmung zu therapieren. Die Anamnese hat bei dieser Entscheidung Gewicht! Eine Re-DMEK bei Transplantatversagen nach DMEK und DSAEK bedarf keiner Modifikation der Standardtechnik und führt bei raschem Vorgehen zu guten Visusergebnissen. Bei eindeutiger stromaler Vernarbung nach multiplen (externen) DMEKs kann auch eine PKP zur Bereinigung der Situation erwogen werden. Bei ansonsten grundlos rezidivierenden Transplantatversagen muss man an eine herpetische oder CMV-Endotheliitis denken und nach PCR-Analyse des Kammerwasseraspirats entsprechend medikamentös therapieren.

Purpose To evaluate the results and complications of Descemet membrane endothelial keratoplasty (DMEK) in previously vitrectomized eyes. Design Retrospective study of 35 eyes that had undergone DMEK, due to Fuchs endothelial corneal dystrophy (FECD), at our department with a follow-up after 6 months postoperatively. We compared the intraoperative procedure, complications, and results of DMEK between 14 previously vitrectomized pseudophakic eyes (group 1) and a control group of 21 pseudophakic non-vitrectomized eyes (group 2). Results The unfolding time (in minutes) was significantly longer in group 1 than in group 2 (10.5 ± 6.4 vs. 3.2 ± 1.5, p < 0.01). A single re-bubbling was needed in 8 patients in group 1 (57.1%) and in 3 patients in group 2 (14.2%) (p < 0.01). Repeated re-bubbling (≥ 1 time) was performed in only 5 patients of group 1 (35.7%). There was significant postoperative improvement in best-corrected visual acuity (BCVA, in LogMAR) in both groups (p = 0.04 in group 1 and p < 0.01 in group 2). The central corneal thickness (CCT, in µm) did not differ significantly between the two groups preoperatively (p = 0.4) or postoperatively (p = 0.1). However, the CCT decreased significantly postoperatively in both groups (p < 0.01 in both groups). The postoperative endothelial cell density (ECD in cell/mm²) was significantly lower in group 1 than in group 2 (p = 0.03). Conclusion DMEK in previously vitrectomized eyes presents a surgical challenge, which requires special, and sometimes unpredictable, intraoperative maneuvers, but good functional and morphological results can be achieved. The use of the endothelial Descemet membrane lamellae (EDML) of older donors might be recommended to facilitate the intraoperative unfolding process. Ziel Evaluierung der Ergebnisse und Komplikationen der Descemet-Membran-Endothel-Keratoplastik (DMEK) in zuvor vitrektomierten Augen. Design Retrospektive Studie von 35 Augen, die aufgrund Fuchsʼscher endothelialer Hornhautdystrophie (FECD) in unserer Abteilung einer DMEK unterzogen wurden, mit einem Follow-up von mindestens 6 Monaten postoperativ. Ergebnisse Die Entfaltungszeit (in Minuten) war in Gruppe 1 signifikant länger als in Gruppe 2 (p < 0,01). Ein einmaliges Re-Bubbling war bei 8 Patienten in Gruppe 1 (57,1%) und bei 3 Patienten in Gruppe 2 (14,2%) erforderlich (p < 0,01). Ein wiederholtes Re-Bubbling (≥ 1 Mal) wurde nur bei 5 Patienten der Gruppe 1 (35,7%) durchgeführt. Postoperativ zeigte sich in beiden Gruppen eine signifikante Verbesserung der bestkorrigierten Sehschärfe (BCVA, in logMAR) (p = 0,04 in Gruppe 1 und p < 0,01 in Gruppe 2). Die zentrale Hornhautdicke (CCT, in µm) unterschied sich präoperativ (p = 0,4) und postoperativ (p = 0,1) nicht signifikant zwischen den beiden Gruppen. Allerdings nahm die CCT postoperativ in beiden Gruppen signifikant ab (p < 0,01 in beiden Gruppen). Die postoperative Endothelzelldichte (ECD in Zellen/mm²) war in Gruppe 1 signifikant niedriger als in Gruppe 2 (p = 0,03). Schlussfolgerung Die DMEK in zuvor vitrektomierten Augen stellt eine chirurgische Herausforderung dar, die spezielle, manchmal unvorhersehbare, intraoperative Manöver erfordert, aber es können gute funktionelle und morphologische Ergebnisse erzielt werden. Die Verwendung der endothelialen Descemet-Membran-Lamellen (EDML) älterer Spender könnte empfohlen werden, um den intraoperativen Entfaltungsprozess zu erleichtern. Received: 19 January 2021 Accepted: 20 May 2021 Publication Date: 26 July 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Introduction Until now, the double-running cross-stitch according to Hoffmann used in penetrating keratoplasty (PKP) has been routinely carried out by simply using a sense of proportion. As a result, the estimation of the precisely defined entry and exit points of the sutures and, by extension, the success of the running cross-stitch suture was completely dependent on the practical experience of the surgeon. Therefore, we introduced the cross-stitch marker as a supporting instrument for PKP surgery. Methods Description of the Homburg cross-stitch marker with an exact step-by-step guide on how the instrument is implemented while performing a PKP to mark entry and exit points for sutures including a video to demonstrate the use of this instrument. Results The new Homburg cross-stitch marker ensures the precise localisation of the entry and exit points of the suture. This new instrument allows inexperienced surgeons in particular to feel very confident when performing the running sutures. Conclusion Surgeons with little experience can completely avoid using their still imprecise sense of proportion and significantly shorten the learning curve for this procedure.

Purpose: Evaluating the learning curve of individual surgeons for Descemet Membrane Endothelial Keratoplasty (DMEK) and Triple-DMEK and assessing outcome with experience. Methods: The first 41 and the last 41 surgeries of each of the four surgeons were retrospectively included. Surgery duration and graft preparation time were recorded. Corrected distance visual acuity (CDVA, logMAR) and central corneal thickness (CCT, µm) were collected preoperatively after 6 and 12 months, as well as postoperative complications, e.g., re-bubbling or repeat penetrating keratoplasty. Results: Surgical duration for Triple-DMEK and DMEK decreased significantly by 21 min and 14 min between the two periods (p < 0.001; p < 0.001). Graft preparation time decreased significantly from 13.3 ± 5.2 min (95%CI 12.8–14.3) in period 1 to 10.7 ± 4.8 min (95%CI 10.2–11.4) in period 2 (p = 0.002). The postoperative changes in CDVA and CCT over both periods were not significant (p = 0.900; p = 0.263). The re-bubbling rate decreased significantly from 51.2% in period 1 to 26.2% in period 2 (p < 0.001). The repeat penetrating keratoplasty (PKP) was 7.3% in period 1 and 3.7% in period 2 (p = 0.146). Re-DMEK was necessary in 6.1% in period 1 and 4.9% in period 2 (p = 0.535). Several parameters showed significant differences between the surgeons in both periods (surgical duration: period 1: p < 0.001, period 2 p < 0.001; graft preparation: period 1: p < 0.001, period 2 p < 0.001). Conclusion: Significant decrease in surgery duration, graft preparation time, and the re-bubbling rate can be attributed to gained individual experience.