Martin Dirisamer | University of Munich (original) (raw)

Papers by Martin Dirisamer

Spektrum der Augenheilkunde, 2015

ABSTRACT Hintergrund Evaluierung der ersten klinischen Ergebnisse einer neuen Methode für eine ti... more ABSTRACT Hintergrund Evaluierung der ersten klinischen Ergebnisse einer neuen Methode für eine tiefe anteriore lamelläre Hornhauttransplantation (FALKe). Material und Methode Diese neuartige Methode verbindet die Vorteile unterschiedlicher Techniken für eine tiefe anteriore lamelläre Keratoplastik. Zuerst wird mit dem Femtosekundenlaser ein circulärer bzw. lamellärer Schnitt bis ca. 4/5 Stromatiefe durchgeführt. Mit Hilfe der von Dr. Melles entwickelten Technik wird kontrolliert bis unmittelbar vor die Descemet Membran (unter optischer Kontrolle) präpariert und schließlich mit einer Kanüle Luft ins posteriore Stroma insuffliert, um eine sogenannte „Big Bubble“ zu erreichen. Resultate Alle (Vor)-Behandlungen mit dem Femtosekundenlaser ließen sich komplikationslos durchführen. Eine erfolgreiche „Big Bubble“ konnte in 12 von 20 Fällen (60 %) erreicht werden. Da es in 2 Fällen trotz erfolgreicher „Big Bubble“ zu einer größeren Perforation kam, mussten insgesamt 10 Fälle in eine perforierende Keratoplastik konvertiert werden. Nach 6 Monaten postoperativ erreichten 74 % der Patienten einen best-korrigierten Brillenvisus von mindestens 0,5 oder höher. Einen best-korrigierten Brillenvisus von mindestens 0,8 oder mehr konnte bei insgesamt 47 % der Patienten erreicht werden. Und immerhin 13 % der Patienten erlangten eine best-korrigierte Sehschärfe von 1,0. Schlussfolgerung Unter Berücksichtigung der Lernkurve einer neuen OP-Technik sind die ersten Ergebnisse dieser neuen Methode (FALKe) sehr vielversprechend. Die bekannten Schwierigkeiten einer reproduzierbaren Technik einer tiefen anterioren lamellären Keratoplastik könnten damit deutlich reduziert werden.

Spektrum der Augenheilkunde, 2015

Spektrum der Augenheilkunde, 2015

ABSTRACT Die excimerlaserbasierte ablative Hornhautchirurgie - sei es die „Advanced Surface Ablat... more ABSTRACT Die excimerlaserbasierte ablative Hornhautchirurgie - sei es die „Advanced Surface Ablation“ oder die „Laser in Situ Keratomileusis“ - dominiert seit Jahrzenten die refraktive Hornhautchirurgie. Inzisionale Verfahren konnten sich bislang nicht durchsetzen. Mit der Small Incision Lenticule Extraction (SMILE) gibt es nunmehr seit wenigen Jahren ein neues inzisionales Korrekturverfahren, welches das Potential hat, die bisherigen Verhältnisse zu verändern. Der Übersichtsartikel stellt die Vor- und Nachteile der SMILE dar. Summary Excimerlaser based refractive corrections of the cornea—as advanced surface ablation techniques or laser in situ keratomileusis—have dominated the market of corneal refractive surgery for decades. Incisional techniques never showed comparable potentials. In recent years small incision lenticule extraction (SMILE), an incisional technique of corneal refractive surgery, has shown the potential of changing the balance of power in corneal refractive surgery. This review article describes the advantages and disadvantages of SMILE.

Spektrum der Augenheilkunde, 2015

ABSTRACT Hintergrund Phake Patienten mit gleichzeitiger Fuchs Endotheldystrophie (FED) stellen ei... more ABSTRACT Hintergrund Phake Patienten mit gleichzeitiger Fuchs Endotheldystrophie (FED) stellen eine Herausforderung hinsichtlich der Entscheidung über Zeitpunkt und Reihenfolge einer Descemet Membran Endothelkeratoplastik (DMEK) und/oder Katarakt-Operation dar. Material und Methode Klinischer Erfahrungsbericht basierend auf mehr als 500 konsekutiven DMEK-Operationen, die in unserer Klinik durchgeführt wurden. Resultate Patienten mit signifikanter Katarakt profitieren primär von einer Katarakt-Operation im ersten Schritt und bei unzureichender Visusverbesserung infolge einer signifikanten Hornhautdekompensation von einer DMEK im zweiten Schritt. Bei Patienten mit inzipienter Katarakt ist eine Identifikation der Hauptursache der Sehverschlechterung (Hornhaut oder Linse) unter Berücksichtigung der subjektiven Beschwerden und der objektiven Diagnostik hilfreich. Auf der anderen Seite profitieren insbesondere junge emmetrope Patienten mit signifikanter FED aber noch relativ klarer Linse von einer alleinigen DMEK, wobei das Risiko postoperativ eine signifikante Katarakt zu entwickeln, relativ gering ist. Schlussfolgerung Bei phaken Patienten ist, abhängig vom Ausmaßβ der Linsentrübung und der gleichzeitigen endothelialen Hornhautdystrophie individuell zu entscheiden, ob und in welcher Reihenfolge eine Katarakt-Operation und/oder DMEK zur signifikanten und zufriedenstellenden Visusbesserung am wahrscheinlichsten beitragen wird.

Spektrum der Augenheilkunde, 2008

Klinische Monatsblätter für Augenheilkunde, 2011

The aim of this study was to evaluate the functional outcome of Brilliant Blue G (BBG) and the st... more The aim of this study was to evaluate the functional outcome of Brilliant Blue G (BBG) and the staining properties in macular surgery. BBG was applied during vitrectomy for macular holes (n = 21) or epiretinal membranes (n = 18) in a prospective, non-comparative consecutive series of patients (Brilliant Peel®; Fluoron® GmbH, Neu-Ulm, Germany). Before and after surgery all patients underwent a complete clinical examination including measurement of best corrected visual acuity and intraocular pressure, perimetry, fundus photography and optical coherence tomography. Vitrectomy was performed in combination with a cataract operation in 14 patients. All macular holes were closed successfully. Visual acuity was in average 0.16 preoperatively in macular hole cases and increased up to 0.4 after 6 months. Visual acuity of patients with epiretinal membranes changed on average from 0.3 to 0.45 after 6 months. The retina thickness in patients with epiretinal membranes was initially 402.6 µm according to the OCT and 304.7 µm after 6 months postoperatively. No toxic effects attributable to the dye were noted during patient follow-up, especially all perimetry tests were normal. Brilliant blue provides a sufficient and selective staining of the ILM. No retinal toxicity or adverse effects related to the dye were observed in this study. The long-term safety of this dye will have to be evaluated in larger patient series and a longer follow-up.

Journal of Cataract & Refractive Surgery, 2014

To compare inflammatory cell response and morphological aspects of femtosecond laser-created corn... more To compare inflammatory cell response and morphological aspects of femtosecond laser-created corneal incisions. Department of Ophthalmology, Goethe-University, Frankfurt am Main, Germany. Experimental study. In 16 of 22 human corneoscleral buttons, clear corneal tunnel incisions were created using a femtosecond laser (Lensx) with 7 μJ laser pulse energy on the outer periphery and manually using a phaco knife on the respective opposite side (180 degrees). In 6 corneas, no treatment was performed (controls). Corneas were then kept in organ culture for 12 or 48 hours, and the inflammatory reaction was evaluated using standard immunofluorescence analyses for monocytes (CD11b) and for dendritic cells (HLA-DR). For morphological analyses and apoptosis, van Gieson staining and terminal deoxynucleotidyl transferase deoxy-UTP-nick end labeling was performed. There were no statistically significant differences in inflammatory cell response between femtosecond laser corneal incisions and manually performed incisions. Apoptosis was significantly more pronounced in the femtosecond incisions. The ratio of dendritic cells between femtosecond incisions and manual incisions was 1:2 (12 hours and 48 hours; P=.07), the ratio of monocytes was 1:2 (12 hours and 48 hours; P=.08), and the ratio of apoptotic cells was 1:5 (12 hours) and 1:6 (48 hours) (P=.02). Femtosecond laser incisions showed a more sawtooth-like cutting edge than manual incisions. Femtosecond laser-created corneal incisions in human corneas showed no differences in inflammatory cell response but a significantly higher cell death rate than manually performed incisions, indicating an upregulated postoperative wound-healing response. Proprietary or commercial disclosures are listed after the references.

Cornea, 2011

To describe a case of secondary "thin De... more To describe a case of secondary "thin Descemet stripping endothelial keratoplasty" ("Thin-DSEK"), for borderline decompensation 6 years after an initial deep lamellar endothelial keratoplasty (DLEK). In a 31-year-old man, who initially underwent a DLEK for bullous keratopathy in the presence of a phakic intraocular lens, a secondary Thin-DSEK was performed, while leaving the entire DLEK graft (including the donor Descemet membrane and the endothelium) in situ. After the initial DLEK, the best-corrected visual acuity (BCVA) improved from 20/200 (0.1) to 20/25 (0.8). Six years later, the transplanted cornea showed intermittent decompensation with a decrease in BCVA again to 20/200 (0.1). After the secondary Thin-DSEK, the BCVA improved again to 20/25 (0.8) at 1 month postoperatively and remained stable thereafter. Our case may show that a secondary DSEK may be a simple and effective treatment to manage secondary graft failure after DLEK. Despite the presence of a "double" stromal interface in the visual axis, secondary Thin-DSEK may provide visual rehabilitation similar to that after primary Thin-DSEK.

Cornea, 2012

To describe corneal clearance after reendothelialization of the recipient posterior stroma, by a ... more To describe corneal clearance after reendothelialization of the recipient posterior stroma, by a "free-floating" donor Descemet roll in the recipient anterior chamber after Descemet membrane endothelial keratoplasty (DMEK), as a potential new approach in managing corneal endothelial disorders. An 80-year-old woman underwent DMEK for Fuchs endothelial dystrophy. Within hours after the surgery, a "free-floating" Descemet roll was observed in the recipient anterior chamber. Because the operated eye had low visual potential, the patient requested to await the clinical outcome, which was monitored by biomicroscopy, and endothelial cell density (ECD) and pachymetric measurements were evaluated. Within the first few weeks after DMEK, the transplanted cornea showed diffuse corneal edema with a central pachymetry of more than 1000 μm. From 1 month onward, the transplanted cornea started to clear in the inferior quadrants. At 6 months, only remnant edema was present in the superior far periphery, pachymetry across the cornea had returned to normal, and ECD measured 830 cells per square millimeter. The performance of a descemetorhexis followed by the implantation of a "free-floating" Descemet roll in the recipient anterior chamber, tentatively named Descemet membrane endothelial transfer, may have potential as a "no-keratoplasty" surgical concept in the management of corneal endothelial disorders.

Archivos de la Sociedad Española de Oftalmología, 2011

To assess the clinical outcomes of DMEK in the first series of 120 eyes operated for the treatmen... more To assess the clinical outcomes of DMEK in the first series of 120 eyes operated for the treatment of Fuchs endothelial dystrophy in terms of visual acuity and endothelial cell density. The first 120 consecutive eyes that underwent DMEK (i.e. transplantation of an isolated donor Descemet membrane with its endothelium) were evaluated. In all eyes, the best corrected visual acuity (BCVA) before and at 1, 3 and 6 months after surgery, as well as the endothelial cell density (ECD) before and at 6 months were measured. In eyes with a functional DMEK graft and good visual potential (n=96), the BCVA was ≥ 20/40 (≥ 0.5) in 77% after 1 month, 92% after 3 months, and 95% after six months; ≥ 20/25 (≥ 0.8) in 50%, 63%, and 73% of the cases, and ≥ 20/20 (≥ 1.0) in 23%, 34%, and 45% of the cases at 1, 3, and 6 months respectively. In this group, ECD averaged 2610 (± 185) cells/mm(2) before, and 1770 (± 520) cells/mm(2) at six months after surgery (n=96). In 15 eyes, a secondary Descemet stripping endothelial keratoplasty (DSEK) was performed. In this group, 91% of patients reached a BCVA of ≥ 20/40 (≥ 0.5) and only one patient achieved a BCVA of 0.8 at 6 months after surgery (n=11). Furthermore, ECD averaged 2580 (± 185) cells/mm(2) before and 1310 (± 740) cells/mm(2) at six months (n=13). DMEK provides a fast and high visual rehabilitation. Endothelial cell density loss may be similar to earlier types of endothelial keratoplasty.

Archives of Ophthalmology, 2012

To describe the prevention and management of various types of graft detachment after Descemet mem... more To describe the prevention and management of various types of graft detachment after Descemet membrane endothelial keratoplasty. In 150 consecutive eyes that underwent Descemet membrane endothelial keratoplasty, the incidence and type of graft detachment were studied at 1, 3, 6, 9, 12, and 24 months after surgery in a nonrandomized, prospective clinical study at a tertiary referral center. Four groups of detachments were identified: a partial detachment of one-third or less of the graft surface area (n = 16; group 1); a partial detachment of more than one-third of the graft surface area (n = 8; group 2); a graft positioned upside down (n = 4; group 3); and a free-floating Descemet roll in the host anterior chamber (n = 8; group 4). Partial or complete graft detachment was found in 36 cases (24%), of which 18 (12%) were clinically significant. All 24 eyes with a partial detachment (groups 1 and 2) showed spontaneous corneal clearance, and all but 6 of these eyes (75%) reached visual acuity of 20/40 or better (≥0.5). A reversed clearance pattern and interface spikes were observed in eyes with the graft positioned upside down (group 3). Eyes with a free-floating graft (group 4) showed persistent corneal edema. Detachments were associated with inward folds (12 eyes [33%]), insufficient air-bubble support (7 eyes [19%]), upside-down graft positioning (4 eyes [11%]), use of plastic materials (2 eyes [6%]), irido-graft synechiae (1 eye [3%]), poor endothelial morphology (1 eye [3%]), and stromal irregularity under the main incision (1 eye [3%]); 14 (58%) of the partial detachments were localized inferiorly. Awaiting spontaneous clearance may be advocated in eyes with a partial detachment. Minor adjustments in surgical protocol as well as careful patient selection may further reduce the incidence of graft detachment after Descemet membrane endothelial keratoplasty to 4% or less. clinicaltrials.gov Identifier: NCT00521898.

American Journal of Ophthalmology, 2011

To describe various endothelial migration healing patterns after Descemet membrane endothelial ke... more To describe various endothelial migration healing patterns after Descemet membrane endothelial keratoplasty (DMEK), and to determine the contribution of the donor and host endothelium in the clearance of a transplanted cornea. Nonrandomized, prospective clinical study. In a total of 150 consecutive eyes that underwent DMEK (ie, transplantation of an isolated Descemet graft, for Fuchs endothelial dystrophy), re-endothelialization patterns were studied. Of these eyes, 36 showed a "stromal gap" between the "descemetorhexis edge" and the graft, or (partial) graft detachment. Endothelialization patterns of the host posterior stroma were documented at 1, 3, 6, 9, 12, and 24 months after surgery with Pentacam imaging, specular microscopy, optical coherence tomography, confocal microscopy, and slit-lamp biomicroscopy. Complete corneal clearance was seen in 28 of 36 eyes (78%) with a stromal gap, or (partial) detachment, progressing from the periphery toward the center; and 27 of 34 eyes (79%) with normal visual potential reached a visual acuity of ≥20/40 (≥0.5) or better. In 3 eyes that had the Descemet graft implanted upside-down, a "reversed corneal clearance pattern" was observed (ie, persistent edema where the graft was attached), while the area overlying the detachment cleared. One case that had a "descemetorhexis" performed without endothelial graft implantation showed persistent stromal edema. The presence of donor endothelium in the recipient anterior chamber may be required for endothelial migration and/or recovery of corneal clarity. Re-endothelialization may be associated with massive endothelial migration and some form of cell signaling to draw donor endothelial cells toward the recipient posterior stroma ("homing").

American Journal of Ophthalmology, 2012

To describe corneal clearance after re-endothelialization of the recipient posterior stroma throu... more To describe corneal clearance after re-endothelialization of the recipient posterior stroma through Descemet membrane endothelial transfer (DMET) (ie, a "free-floating" donor Descemet graft in the recipient anterior chamber after descemetorhexis), in managing corneal endothelial disorders. Nonrandomized prospective study at a tertiary referral center. Twelve eyes enrolled in our study, 7 suffering from Fuchs endothelial dystrophy and 5 with bullous keratopathy. The clinical outcome was monitored by biomicroscopy, optical coherence tomography, confocal microscopy, endothelial cell density, and pachymetry measurements. All eyes operated on for Fuchs endothelial dystrophy showed corneal clearance, with pachymetry values returning to normal (533 ±47 μm). The denuded recipient stroma re-endothelialized with an average endothelial cell density of 797 (± 743) cells/mm(2) at 6 months after surgery. In contrast, none of the bullous keratopathy eyes showed any improvement throughout the follow-up period. DMET may be effective in the management of Fuchs endothelial dystrophy (primarily a Descemet membrane disorder), but not in bullous keratopathy (primarily an endothelial depletion). Apparently, the indication for surgery (ie, a "dystrophy" vs a "depletion" of recipient endothelial cells) relates to the capacity of the cornea to clear. This suggests that the remaining rim of recipient endothelium (after descemetorhexis) is involved in the re-endothelialization of the recipient posterior stroma after DMET.

American Journal of Ophthalmology, 2011

of peripapillary retinal nerve fiber layer in preterm children. Am J Ophthalmol 2012;153(5):850 -... more of peripapillary retinal nerve fiber layer in preterm children. Am J Ophthalmol 2012;153(5):850 -855. 2. Bendschneider D, Tornow RP, Horn FK, et al. Retinal nerve fiber layer thickness in normals measured by spectral domain OCT. J Glaucoma 2010;19(7):475-482. 3. Chen TC, Tsai TH, Shih YF, et al. Long-term evaluation of refractive status and optical components in eyes of children born prematurely. Invest Ophthalmol Vis Sci 2010;51(12): 6140 -6148. 4. Wu WC, Lin RI, Shih CP, et al. Visual acuity, optical components, and macular abnormalities in patients with a history of retinopathy of prematurity. Ophthalmology. Forthcoming.

Acta Ophthalmologica, 2013

To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial kera... more To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and to determine whether such eyes can be successfully 'repaired' with a secondary Descemet membrane endothelial keratoplasty (DMEK). Twelve eyes of 12 patients, who underwent secondary DMEK to manage poor visual outcome after initial DSEK/DSAEK, were evaluated with biomicroscopy, Pentacam imaging, and specular and confocal microscopy, before and at 1, 3 and 6 months after DMEK. Four causes of reduced optical quality of the transplanted host cornea could be identified in DSEK/DSAEK: five eyes (42%) showed large host-Descemet remnants within the visual axis during surgery; six eyes (50%) irregular graft thickness; six eyes subtle 'stromal waves'; and nine eyes (75%) high reflectivity at the donor-to-host interface. After DMEK graft replacement, all corneas cleared and achieved a best corrected visual acuity of ≥20/25 (≥0.8), except for one with a partial Descemet graft detachment. Pachymetry values decreased from 670 (±112) μm before to 517 (±57) μm after secondary DMEK. Higher-order aberrations (Coma and Trefoil) at the posterior surface tended to be lower (p = 0.07) in DMEK grafts than in DSEK/DSAEK grafts. Host-Descemet remnants at the donor-to-host interface, interface reflectivity, graft thickness irregularity and donor stromal contraction may contribute to poor visual outcome after DSEK/DSAEK, without causing permanent host corneal damage, as in most cases, complete visual recovery could be achieved by performing a secondary DMEK.

JAMA Ophthalmology, 2014

Surgeons starting to perform Descemet membrane endothelial keratoplasty (DMEK) should be informed... more Surgeons starting to perform Descemet membrane endothelial keratoplasty (DMEK) should be informed about the learning curve and experience of others. To document the clinical outcome of standardized "no-touch" DMEK and its complications during the learning curves of experienced surgeons. Retrospective multicenter study. A total of 431 eyes from 401 patients with Fuchs endothelial dystrophy (68.2%) and bullous keratopathy (31.8%) underwent DMEK performed by 18 surgeons in 11 countries. Descemet membrane endothelial keratoplasty. Best-corrected visual acuity (BCVA), endothelial cell density, and intraoperative and postoperative complications. Of 275 eyes available for BCVA pooled analysis, BCVA improved in 258 eyes (93.8%), remained unchanged in 12 (4.4%), and deteriorated in 5 (1.8%). Two hundred seventeen eyes (78.9%) reached a BCVA of at least 20/40 (≥0.5), 117 (42.5%) at least 20/25 (≥0.8), and 61 (22.2%) at least 20/20 (≥1.0). Eyes with at least 6 months of follow-up (n = 176) reached similar BCVA outcomes. Mean (SD) decrease in endothelial cell density at 6 months was 47% (20%) (n = 133 [P = .02]). Intraoperative complications were rare, including difficulties in inserting, unfolding, or positioning of the graft (1.2%) and intraoperative hemorrhage (0.5%). The main postoperative complication was graft detachment (34.6%); 20.4% underwent a single rebubbling procedure, occasionally requiring a second (2.6%) and a third rebubbling (0.7%), and 17.6% underwent a second keratoplasty. Our multicenter study showed that the standardized no-touch DMEK technique was feasible in most hands. The main challenges for surgeons starting to perform the procedure may be (1) to decide whether graft preparation is outsourced or performed during surgery, (2) to limit the number of graft detachments and secondary procedures, and (3) to obtain organ cultured donor corneal tissue.

Spektrum der Augenheilkunde, 2015

ABSTRACT Hintergrund Evaluierung der ersten klinischen Ergebnisse einer neuen Methode für eine ti... more ABSTRACT Hintergrund Evaluierung der ersten klinischen Ergebnisse einer neuen Methode für eine tiefe anteriore lamelläre Hornhauttransplantation (FALKe). Material und Methode Diese neuartige Methode verbindet die Vorteile unterschiedlicher Techniken für eine tiefe anteriore lamelläre Keratoplastik. Zuerst wird mit dem Femtosekundenlaser ein circulärer bzw. lamellärer Schnitt bis ca. 4/5 Stromatiefe durchgeführt. Mit Hilfe der von Dr. Melles entwickelten Technik wird kontrolliert bis unmittelbar vor die Descemet Membran (unter optischer Kontrolle) präpariert und schließlich mit einer Kanüle Luft ins posteriore Stroma insuffliert, um eine sogenannte „Big Bubble“ zu erreichen. Resultate Alle (Vor)-Behandlungen mit dem Femtosekundenlaser ließen sich komplikationslos durchführen. Eine erfolgreiche „Big Bubble“ konnte in 12 von 20 Fällen (60 %) erreicht werden. Da es in 2 Fällen trotz erfolgreicher „Big Bubble“ zu einer größeren Perforation kam, mussten insgesamt 10 Fälle in eine perforierende Keratoplastik konvertiert werden. Nach 6 Monaten postoperativ erreichten 74 % der Patienten einen best-korrigierten Brillenvisus von mindestens 0,5 oder höher. Einen best-korrigierten Brillenvisus von mindestens 0,8 oder mehr konnte bei insgesamt 47 % der Patienten erreicht werden. Und immerhin 13 % der Patienten erlangten eine best-korrigierte Sehschärfe von 1,0. Schlussfolgerung Unter Berücksichtigung der Lernkurve einer neuen OP-Technik sind die ersten Ergebnisse dieser neuen Methode (FALKe) sehr vielversprechend. Die bekannten Schwierigkeiten einer reproduzierbaren Technik einer tiefen anterioren lamellären Keratoplastik könnten damit deutlich reduziert werden.

Spektrum der Augenheilkunde, 2015

Spektrum der Augenheilkunde, 2015

ABSTRACT Die excimerlaserbasierte ablative Hornhautchirurgie - sei es die „Advanced Surface Ablat... more ABSTRACT Die excimerlaserbasierte ablative Hornhautchirurgie - sei es die „Advanced Surface Ablation“ oder die „Laser in Situ Keratomileusis“ - dominiert seit Jahrzenten die refraktive Hornhautchirurgie. Inzisionale Verfahren konnten sich bislang nicht durchsetzen. Mit der Small Incision Lenticule Extraction (SMILE) gibt es nunmehr seit wenigen Jahren ein neues inzisionales Korrekturverfahren, welches das Potential hat, die bisherigen Verhältnisse zu verändern. Der Übersichtsartikel stellt die Vor- und Nachteile der SMILE dar. Summary Excimerlaser based refractive corrections of the cornea—as advanced surface ablation techniques or laser in situ keratomileusis—have dominated the market of corneal refractive surgery for decades. Incisional techniques never showed comparable potentials. In recent years small incision lenticule extraction (SMILE), an incisional technique of corneal refractive surgery, has shown the potential of changing the balance of power in corneal refractive surgery. This review article describes the advantages and disadvantages of SMILE.

Spektrum der Augenheilkunde, 2015

ABSTRACT Hintergrund Phake Patienten mit gleichzeitiger Fuchs Endotheldystrophie (FED) stellen ei... more ABSTRACT Hintergrund Phake Patienten mit gleichzeitiger Fuchs Endotheldystrophie (FED) stellen eine Herausforderung hinsichtlich der Entscheidung über Zeitpunkt und Reihenfolge einer Descemet Membran Endothelkeratoplastik (DMEK) und/oder Katarakt-Operation dar. Material und Methode Klinischer Erfahrungsbericht basierend auf mehr als 500 konsekutiven DMEK-Operationen, die in unserer Klinik durchgeführt wurden. Resultate Patienten mit signifikanter Katarakt profitieren primär von einer Katarakt-Operation im ersten Schritt und bei unzureichender Visusverbesserung infolge einer signifikanten Hornhautdekompensation von einer DMEK im zweiten Schritt. Bei Patienten mit inzipienter Katarakt ist eine Identifikation der Hauptursache der Sehverschlechterung (Hornhaut oder Linse) unter Berücksichtigung der subjektiven Beschwerden und der objektiven Diagnostik hilfreich. Auf der anderen Seite profitieren insbesondere junge emmetrope Patienten mit signifikanter FED aber noch relativ klarer Linse von einer alleinigen DMEK, wobei das Risiko postoperativ eine signifikante Katarakt zu entwickeln, relativ gering ist. Schlussfolgerung Bei phaken Patienten ist, abhängig vom Ausmaßβ der Linsentrübung und der gleichzeitigen endothelialen Hornhautdystrophie individuell zu entscheiden, ob und in welcher Reihenfolge eine Katarakt-Operation und/oder DMEK zur signifikanten und zufriedenstellenden Visusbesserung am wahrscheinlichsten beitragen wird.

Spektrum der Augenheilkunde, 2008

Klinische Monatsblätter für Augenheilkunde, 2011

The aim of this study was to evaluate the functional outcome of Brilliant Blue G (BBG) and the st... more The aim of this study was to evaluate the functional outcome of Brilliant Blue G (BBG) and the staining properties in macular surgery. BBG was applied during vitrectomy for macular holes (n = 21) or epiretinal membranes (n = 18) in a prospective, non-comparative consecutive series of patients (Brilliant Peel®; Fluoron® GmbH, Neu-Ulm, Germany). Before and after surgery all patients underwent a complete clinical examination including measurement of best corrected visual acuity and intraocular pressure, perimetry, fundus photography and optical coherence tomography. Vitrectomy was performed in combination with a cataract operation in 14 patients. All macular holes were closed successfully. Visual acuity was in average 0.16 preoperatively in macular hole cases and increased up to 0.4 after 6 months. Visual acuity of patients with epiretinal membranes changed on average from 0.3 to 0.45 after 6 months. The retina thickness in patients with epiretinal membranes was initially 402.6 µm according to the OCT and 304.7 µm after 6 months postoperatively. No toxic effects attributable to the dye were noted during patient follow-up, especially all perimetry tests were normal. Brilliant blue provides a sufficient and selective staining of the ILM. No retinal toxicity or adverse effects related to the dye were observed in this study. The long-term safety of this dye will have to be evaluated in larger patient series and a longer follow-up.

Journal of Cataract & Refractive Surgery, 2014

To compare inflammatory cell response and morphological aspects of femtosecond laser-created corn... more To compare inflammatory cell response and morphological aspects of femtosecond laser-created corneal incisions. Department of Ophthalmology, Goethe-University, Frankfurt am Main, Germany. Experimental study. In 16 of 22 human corneoscleral buttons, clear corneal tunnel incisions were created using a femtosecond laser (Lensx) with 7 μJ laser pulse energy on the outer periphery and manually using a phaco knife on the respective opposite side (180 degrees). In 6 corneas, no treatment was performed (controls). Corneas were then kept in organ culture for 12 or 48 hours, and the inflammatory reaction was evaluated using standard immunofluorescence analyses for monocytes (CD11b) and for dendritic cells (HLA-DR). For morphological analyses and apoptosis, van Gieson staining and terminal deoxynucleotidyl transferase deoxy-UTP-nick end labeling was performed. There were no statistically significant differences in inflammatory cell response between femtosecond laser corneal incisions and manually performed incisions. Apoptosis was significantly more pronounced in the femtosecond incisions. The ratio of dendritic cells between femtosecond incisions and manual incisions was 1:2 (12 hours and 48 hours; P=.07), the ratio of monocytes was 1:2 (12 hours and 48 hours; P=.08), and the ratio of apoptotic cells was 1:5 (12 hours) and 1:6 (48 hours) (P=.02). Femtosecond laser incisions showed a more sawtooth-like cutting edge than manual incisions. Femtosecond laser-created corneal incisions in human corneas showed no differences in inflammatory cell response but a significantly higher cell death rate than manually performed incisions, indicating an upregulated postoperative wound-healing response. Proprietary or commercial disclosures are listed after the references.

Cornea, 2011

To describe a case of secondary "thin De... more To describe a case of secondary "thin Descemet stripping endothelial keratoplasty" ("Thin-DSEK"), for borderline decompensation 6 years after an initial deep lamellar endothelial keratoplasty (DLEK). In a 31-year-old man, who initially underwent a DLEK for bullous keratopathy in the presence of a phakic intraocular lens, a secondary Thin-DSEK was performed, while leaving the entire DLEK graft (including the donor Descemet membrane and the endothelium) in situ. After the initial DLEK, the best-corrected visual acuity (BCVA) improved from 20/200 (0.1) to 20/25 (0.8). Six years later, the transplanted cornea showed intermittent decompensation with a decrease in BCVA again to 20/200 (0.1). After the secondary Thin-DSEK, the BCVA improved again to 20/25 (0.8) at 1 month postoperatively and remained stable thereafter. Our case may show that a secondary DSEK may be a simple and effective treatment to manage secondary graft failure after DLEK. Despite the presence of a "double" stromal interface in the visual axis, secondary Thin-DSEK may provide visual rehabilitation similar to that after primary Thin-DSEK.

Cornea, 2012

To describe corneal clearance after reendothelialization of the recipient posterior stroma, by a ... more To describe corneal clearance after reendothelialization of the recipient posterior stroma, by a "free-floating" donor Descemet roll in the recipient anterior chamber after Descemet membrane endothelial keratoplasty (DMEK), as a potential new approach in managing corneal endothelial disorders. An 80-year-old woman underwent DMEK for Fuchs endothelial dystrophy. Within hours after the surgery, a "free-floating" Descemet roll was observed in the recipient anterior chamber. Because the operated eye had low visual potential, the patient requested to await the clinical outcome, which was monitored by biomicroscopy, and endothelial cell density (ECD) and pachymetric measurements were evaluated. Within the first few weeks after DMEK, the transplanted cornea showed diffuse corneal edema with a central pachymetry of more than 1000 μm. From 1 month onward, the transplanted cornea started to clear in the inferior quadrants. At 6 months, only remnant edema was present in the superior far periphery, pachymetry across the cornea had returned to normal, and ECD measured 830 cells per square millimeter. The performance of a descemetorhexis followed by the implantation of a "free-floating" Descemet roll in the recipient anterior chamber, tentatively named Descemet membrane endothelial transfer, may have potential as a "no-keratoplasty" surgical concept in the management of corneal endothelial disorders.

Archivos de la Sociedad Española de Oftalmología, 2011

To assess the clinical outcomes of DMEK in the first series of 120 eyes operated for the treatmen... more To assess the clinical outcomes of DMEK in the first series of 120 eyes operated for the treatment of Fuchs endothelial dystrophy in terms of visual acuity and endothelial cell density. The first 120 consecutive eyes that underwent DMEK (i.e. transplantation of an isolated donor Descemet membrane with its endothelium) were evaluated. In all eyes, the best corrected visual acuity (BCVA) before and at 1, 3 and 6 months after surgery, as well as the endothelial cell density (ECD) before and at 6 months were measured. In eyes with a functional DMEK graft and good visual potential (n=96), the BCVA was ≥ 20/40 (≥ 0.5) in 77% after 1 month, 92% after 3 months, and 95% after six months; ≥ 20/25 (≥ 0.8) in 50%, 63%, and 73% of the cases, and ≥ 20/20 (≥ 1.0) in 23%, 34%, and 45% of the cases at 1, 3, and 6 months respectively. In this group, ECD averaged 2610 (± 185) cells/mm(2) before, and 1770 (± 520) cells/mm(2) at six months after surgery (n=96). In 15 eyes, a secondary Descemet stripping endothelial keratoplasty (DSEK) was performed. In this group, 91% of patients reached a BCVA of ≥ 20/40 (≥ 0.5) and only one patient achieved a BCVA of 0.8 at 6 months after surgery (n=11). Furthermore, ECD averaged 2580 (± 185) cells/mm(2) before and 1310 (± 740) cells/mm(2) at six months (n=13). DMEK provides a fast and high visual rehabilitation. Endothelial cell density loss may be similar to earlier types of endothelial keratoplasty.

Archives of Ophthalmology, 2012

To describe the prevention and management of various types of graft detachment after Descemet mem... more To describe the prevention and management of various types of graft detachment after Descemet membrane endothelial keratoplasty. In 150 consecutive eyes that underwent Descemet membrane endothelial keratoplasty, the incidence and type of graft detachment were studied at 1, 3, 6, 9, 12, and 24 months after surgery in a nonrandomized, prospective clinical study at a tertiary referral center. Four groups of detachments were identified: a partial detachment of one-third or less of the graft surface area (n = 16; group 1); a partial detachment of more than one-third of the graft surface area (n = 8; group 2); a graft positioned upside down (n = 4; group 3); and a free-floating Descemet roll in the host anterior chamber (n = 8; group 4). Partial or complete graft detachment was found in 36 cases (24%), of which 18 (12%) were clinically significant. All 24 eyes with a partial detachment (groups 1 and 2) showed spontaneous corneal clearance, and all but 6 of these eyes (75%) reached visual acuity of 20/40 or better (≥0.5). A reversed clearance pattern and interface spikes were observed in eyes with the graft positioned upside down (group 3). Eyes with a free-floating graft (group 4) showed persistent corneal edema. Detachments were associated with inward folds (12 eyes [33%]), insufficient air-bubble support (7 eyes [19%]), upside-down graft positioning (4 eyes [11%]), use of plastic materials (2 eyes [6%]), irido-graft synechiae (1 eye [3%]), poor endothelial morphology (1 eye [3%]), and stromal irregularity under the main incision (1 eye [3%]); 14 (58%) of the partial detachments were localized inferiorly. Awaiting spontaneous clearance may be advocated in eyes with a partial detachment. Minor adjustments in surgical protocol as well as careful patient selection may further reduce the incidence of graft detachment after Descemet membrane endothelial keratoplasty to 4% or less. clinicaltrials.gov Identifier: NCT00521898.

American Journal of Ophthalmology, 2011

To describe various endothelial migration healing patterns after Descemet membrane endothelial ke... more To describe various endothelial migration healing patterns after Descemet membrane endothelial keratoplasty (DMEK), and to determine the contribution of the donor and host endothelium in the clearance of a transplanted cornea. Nonrandomized, prospective clinical study. In a total of 150 consecutive eyes that underwent DMEK (ie, transplantation of an isolated Descemet graft, for Fuchs endothelial dystrophy), re-endothelialization patterns were studied. Of these eyes, 36 showed a "stromal gap" between the "descemetorhexis edge" and the graft, or (partial) graft detachment. Endothelialization patterns of the host posterior stroma were documented at 1, 3, 6, 9, 12, and 24 months after surgery with Pentacam imaging, specular microscopy, optical coherence tomography, confocal microscopy, and slit-lamp biomicroscopy. Complete corneal clearance was seen in 28 of 36 eyes (78%) with a stromal gap, or (partial) detachment, progressing from the periphery toward the center; and 27 of 34 eyes (79%) with normal visual potential reached a visual acuity of ≥20/40 (≥0.5) or better. In 3 eyes that had the Descemet graft implanted upside-down, a "reversed corneal clearance pattern" was observed (ie, persistent edema where the graft was attached), while the area overlying the detachment cleared. One case that had a "descemetorhexis" performed without endothelial graft implantation showed persistent stromal edema. The presence of donor endothelium in the recipient anterior chamber may be required for endothelial migration and/or recovery of corneal clarity. Re-endothelialization may be associated with massive endothelial migration and some form of cell signaling to draw donor endothelial cells toward the recipient posterior stroma ("homing").

American Journal of Ophthalmology, 2012

To describe corneal clearance after re-endothelialization of the recipient posterior stroma throu... more To describe corneal clearance after re-endothelialization of the recipient posterior stroma through Descemet membrane endothelial transfer (DMET) (ie, a "free-floating" donor Descemet graft in the recipient anterior chamber after descemetorhexis), in managing corneal endothelial disorders. Nonrandomized prospective study at a tertiary referral center. Twelve eyes enrolled in our study, 7 suffering from Fuchs endothelial dystrophy and 5 with bullous keratopathy. The clinical outcome was monitored by biomicroscopy, optical coherence tomography, confocal microscopy, endothelial cell density, and pachymetry measurements. All eyes operated on for Fuchs endothelial dystrophy showed corneal clearance, with pachymetry values returning to normal (533 ±47 μm). The denuded recipient stroma re-endothelialized with an average endothelial cell density of 797 (± 743) cells/mm(2) at 6 months after surgery. In contrast, none of the bullous keratopathy eyes showed any improvement throughout the follow-up period. DMET may be effective in the management of Fuchs endothelial dystrophy (primarily a Descemet membrane disorder), but not in bullous keratopathy (primarily an endothelial depletion). Apparently, the indication for surgery (ie, a "dystrophy" vs a "depletion" of recipient endothelial cells) relates to the capacity of the cornea to clear. This suggests that the remaining rim of recipient endothelium (after descemetorhexis) is involved in the re-endothelialization of the recipient posterior stroma after DMET.

American Journal of Ophthalmology, 2011

of peripapillary retinal nerve fiber layer in preterm children. Am J Ophthalmol 2012;153(5):850 -... more of peripapillary retinal nerve fiber layer in preterm children. Am J Ophthalmol 2012;153(5):850 -855. 2. Bendschneider D, Tornow RP, Horn FK, et al. Retinal nerve fiber layer thickness in normals measured by spectral domain OCT. J Glaucoma 2010;19(7):475-482. 3. Chen TC, Tsai TH, Shih YF, et al. Long-term evaluation of refractive status and optical components in eyes of children born prematurely. Invest Ophthalmol Vis Sci 2010;51(12): 6140 -6148. 4. Wu WC, Lin RI, Shih CP, et al. Visual acuity, optical components, and macular abnormalities in patients with a history of retinopathy of prematurity. Ophthalmology. Forthcoming.

Acta Ophthalmologica, 2013

To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial kera... more To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and to determine whether such eyes can be successfully 'repaired' with a secondary Descemet membrane endothelial keratoplasty (DMEK). Twelve eyes of 12 patients, who underwent secondary DMEK to manage poor visual outcome after initial DSEK/DSAEK, were evaluated with biomicroscopy, Pentacam imaging, and specular and confocal microscopy, before and at 1, 3 and 6 months after DMEK. Four causes of reduced optical quality of the transplanted host cornea could be identified in DSEK/DSAEK: five eyes (42%) showed large host-Descemet remnants within the visual axis during surgery; six eyes (50%) irregular graft thickness; six eyes subtle 'stromal waves'; and nine eyes (75%) high reflectivity at the donor-to-host interface. After DMEK graft replacement, all corneas cleared and achieved a best corrected visual acuity of ≥20/25 (≥0.8), except for one with a partial Descemet graft detachment. Pachymetry values decreased from 670 (±112) μm before to 517 (±57) μm after secondary DMEK. Higher-order aberrations (Coma and Trefoil) at the posterior surface tended to be lower (p = 0.07) in DMEK grafts than in DSEK/DSAEK grafts. Host-Descemet remnants at the donor-to-host interface, interface reflectivity, graft thickness irregularity and donor stromal contraction may contribute to poor visual outcome after DSEK/DSAEK, without causing permanent host corneal damage, as in most cases, complete visual recovery could be achieved by performing a secondary DMEK.

JAMA Ophthalmology, 2014

Surgeons starting to perform Descemet membrane endothelial keratoplasty (DMEK) should be informed... more Surgeons starting to perform Descemet membrane endothelial keratoplasty (DMEK) should be informed about the learning curve and experience of others. To document the clinical outcome of standardized "no-touch" DMEK and its complications during the learning curves of experienced surgeons. Retrospective multicenter study. A total of 431 eyes from 401 patients with Fuchs endothelial dystrophy (68.2%) and bullous keratopathy (31.8%) underwent DMEK performed by 18 surgeons in 11 countries. Descemet membrane endothelial keratoplasty. Best-corrected visual acuity (BCVA), endothelial cell density, and intraoperative and postoperative complications. Of 275 eyes available for BCVA pooled analysis, BCVA improved in 258 eyes (93.8%), remained unchanged in 12 (4.4%), and deteriorated in 5 (1.8%). Two hundred seventeen eyes (78.9%) reached a BCVA of at least 20/40 (≥0.5), 117 (42.5%) at least 20/25 (≥0.8), and 61 (22.2%) at least 20/20 (≥1.0). Eyes with at least 6 months of follow-up (n = 176) reached similar BCVA outcomes. Mean (SD) decrease in endothelial cell density at 6 months was 47% (20%) (n = 133 [P = .02]). Intraoperative complications were rare, including difficulties in inserting, unfolding, or positioning of the graft (1.2%) and intraoperative hemorrhage (0.5%). The main postoperative complication was graft detachment (34.6%); 20.4% underwent a single rebubbling procedure, occasionally requiring a second (2.6%) and a third rebubbling (0.7%), and 17.6% underwent a second keratoplasty. Our multicenter study showed that the standardized no-touch DMEK technique was feasible in most hands. The main challenges for surgeons starting to perform the procedure may be (1) to decide whether graft preparation is outsourced or performed during surgery, (2) to limit the number of graft detachments and secondary procedures, and (3) to obtain organ cultured donor corneal tissue.