Predicting the extent of corneal edema resolution after Descemet membrane endothelial keratoplasty (DMEK) may help in preoperative decision-making by identifying patients who may benefit from restoring endothelial function.OBJECTIVE To develop and validate a predictive model for edema resolution after DMEK using Scheimpflug tomographic imaging. DESIGN, SETTING, AND PARTICIPANTSTwo prospective studies recruited participants with advanced Fuchs dystrophy at a university-based tertiary referral center between July 1, 2017, and August 31, 2019. Analyses were designed in November 2019 and completed on June 30, 2020. Development of a predictive model using linear least absolute shrinkage and selection operator regression was conducted in a derivation cohort (100 eyes). Overall performance, discrimination, and calibration were tested in the separate validation cohort (32 eyes).EXPOSURES Preoperative Scheimpflug parameters and patient-reported visual disability were considered as potential predictors of edema resolution: (1) tomographic features (irregularity of lines of equal corneal thickness, displacement of the thinnest point of corneal thickness from the inferior-temporal quadrant, and absolute amount of focal posterior corneal depression), (2) standardized anterior and posterior corneal backscatter, (3) preoperative central corneal thickness, and (4) Fuchs dystrophy-specific visual disability. MAIN OUTCOMES AND MEASURES Decrease in central corneal thickness after DMEK indicative of edema resolution. RESULTSOf the 88 patients included in the analysis, 54 were women (61%); median age was 68 years (interquartile range [IQR], 59-76 years). A median of 13 months after DMEK (IQR, 9-16 months), median corneal thickness was 77 μm lower (IQR, 51-94 μm) in the derivation cohort and 75 μm lower in the validation cohort (IQR, 54-96 μm) than before surgery. Per 10-μm edema resolution, eyes gained 0.66 Early Treatment Diabetic Retinopathy Study letters (95% CI, 0.09-1.23) in best-corrected visual acuity. Three tomographic features were present in 68 of 100 eyes (68%) in the derivation cohort and in 18 of 32 eyes (56%) in the validation cohort before DMEK and in only 1 of 132 eyes (1%) after DMEK. To predict edema resolution after DMEK based on preoperative assessment, 5 variables were selected by the statistical learning algorithm: nonparallel isopachs, focal posterior depression, anterior and posterior corneal backscatter, and central corneal thickness. In the separate validation cohort, the model showed high overall performance, discrimination, and calibration.CONCLUSIONS AND RELEVANCE These post hoc analyses of prospective cohorts support a model for use in the prediction of edema resolution after DMEK using Scheimpflug measurement to identify patients benefitting most from DMEK.

To develop and apply a neural network for quantification of endothelial corneal graft detachment using anterior segment (AS) OCT.Design: Training and validation of a neural network and application within a prospective cohort.Participants: Patients two weeks after Descemet membrane endothelial keratoplasty. Methods: Investigators manually labeled the posterior cornea and the graft in cross-sectional images of rotational AS OCT scans. Neural networks for image segmentation were trained to identify the area of graft detachment on cross-sectional images. The best-performing neural network with the lowest misclassification (Youden index) and highest spatial overlap with the ground truth (Dice coefficient) was selected and evaluated in a separate dataset. Three-dimensional maps of the area and volume of graft detachment were calculated. For application, the neural network's rating on the detachment was compared with slit-lampebased ratings of cornea specialists on the same day as the AS OCT imaging took place.Main Outcome Measures: Youden index and Dice coefficient.Results: Neural networks were trained on 27 AS OCT scans with 6912 labeled images. Among 48 combinations of probability thresholds and epoch states, the best-performing neural network showed a Youden index of 0.99 and a Dice coefficient of 0.77, indicating low misclassification and good spatial overlap on individual image segmentation. In the validation set unknown to the neural network with 20 scans (5120 images), the Youden index was 0.85 and the Dice coefficient was 0.73, and a high overall performance compared with the manually labeled ground truth (R 2 ¼ 0.90). In the application set with 107 eyes, the neural network estimated the mean percent detachment larger than the cornea specialist (mean difference, 8.2 percentage points; 95% confidence interval, 6.2e10.2). Masked review of 42 AS OCTs with more than AE10 percentage points difference in ratings showed that clinicians underestimated the true detachment in cases with significant detachment requiring intervention.Conclusions: Deep learning-based segmentation of AS OCT images quantified the percent and the volume of DMEK graft detachment with high precision. Fully automated 3-dimensional quantification of graft detachment is highly sensitive, particularly in corneas with a significant amount of detachment, and may support decision making.

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Purpose: The posterior cornea is rotationally asymmetric, and Descemet membrane endothelial keratoplasty (DMEK) grafts preferentially scroll vertically. This prospective study assessed whether graft attachment after DMEK differed depending on the rotational alignment of the donor graft in the recipient eye. Methods: Pseudo-randomization and blinding of the graft orientation in the recipient's eye were possible by procedural separation: (1) The eye bank recorded the position of an orientation marker in the donor cornea; (2) the surgeon preparing the DMEK graft recorded an upside-down marker relative to the eye bank marker; and (3) the surgeon assessed the position of the upside-down marker in the recipient after DMEK. Surgeons were masked towards the eye bank marker. Using mixed-effects models, we assessed graft attachment relative to the rotational alignment of the donor graft. Results: Postoperatively, the graft was not fully attached in 59 of 179 eyes (33%). A second air fill (rebubbling) was performed in 11%. The graft axis was in line with the recipient cornea axis in 40%, oblique in 28% and orthogonal in 32%. We did not detect an elevated risk of incomplete attachment (odds ratio [OR], 1.16; 95% CI, 0.61-2.20), risk of rebubbling (OR, 1.25; 95% CI, or larger areas of graft detachment in non-aligned grafts compared to aligned grafts. Conclusion: Rotational alignment was not strongly associated with the risk of incomplete graft attachment, although modestly elevated risks cannot be ruled out. Efforts are needed to reduce the need for rebubbling after DMEK and to identify modifiable risk factors for graft detachment.

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Corneal oedema results from an underlying pathology, which can be diverse in origin, and may be mechanical, dystrophic, or inflammatory, and affect any layer of the cornea. Diagnostic tools such as Scheimpflug imaging and anterior segment optical coherence tomography have standardised quantification of corneal oedema and have become important aids in clinical practice. Timely diagnosis and treatment are key to preventing irreversible damage to the corneal ultrastructure, such as anterior corneal fibrosis or endothelial cell damage. The oedema usually resolves quickly when the underlying cause has been addressed. Symptomatic treatment using hyperosmolar agents has failed to show any benefits in oedema resolution or improvement in visual acuity compared to placebo. In contrast, rho-associated protein kinase (ROCK) inhibitors offer a promising option for medical treatment in cases of endothelial dysfunction, but their safety and efficacy must be further validated in large scale clinical trials. Until then, endothelial or penetrating keratoplasties remain the mainstay treatment where structural changes to the cornea have occurred.

ZUSAMMENFASSUNG Hintergrund. Zur Sicherstellung eines effizienten Ressourceneinsatzes im Rahmen ambulanter Versorgungsangebote ist die Planung und Gewährleistung eines konstanten Patientenstroms durch eine optimale Ausgestaltung des Angebots an den Wünschen und Bedürfnissen relevanter Anspruchsgruppen von elementarer Bedeutung. Material und Methoden. Die vorliegende Studie untersucht, wie die Bedürfnisse sowie die Zufriedenheit von Patienten und zuweisenden niedergelassenen Fachärzten im Rahmen eines ambulanten Katarakt-Angebots ermittelt werden und welche Schlüsse für die Ausgestaltung des Leistungsangebots gezogen werden können. Zur Ermittlung der Bedürfnisse und Zufriedenheit wurden ein Patienten-Fragebogen und ein Zuweisenden-Fragebogen entwickelt. Promotoren und Detraktoren der Wahl bzw. Zuweisung wurden in Anlehnung an das Konzept des Net-Promoter-Scores, einem Markforschungsinstrument, identifiziert. Ergebnisse. 339 (38%) Patienten und 26 (45%) Zuweisende der Hauptzuweisergruppe füllten im Befragungszeitraum die ausgehändigten Fragebögen aus. Die wichtigsten Eigenschaften für die Einweisungsempfehlung der Zuweisenden waren die Behandlungsqualität, die Patientenzufriedenheit sowie die Kommunikation bei Rückfragen und die Schnelligkeit der Übersendung des Arztbriefs. Die Patienten priorisierten vor allem den fachlichen Ruf, die bisherigen Erfahrungen mit der Klinik sowie die Empfehlung ihres Augenarztes und die wunschgerechte Terminvergabe als wichtigste Eigenschaften für deren Auswahlentscheidung eines Katarakt-Zentrums. Schlussfolgerung. Beide Gruppen beeinflussen sich in ihrer Empfehlungs- bzw. Wahlabsicht. Eine simultane Evaluation beider Anspruchsgruppen zur Gewährleistung eines konstanten Patientenstroms ist folglich unumgänglich. In der durchgeführten Studie weisen die Patienten und Zuweisenden eine hohe Gesamtzufriedenheit mit dem Katarakt-Angebot des Universitätsklinikums auf, jedoch konnten auch verschiedene Verbesserungspotentiale entdeckt werden. Insgesamt liefert die vorgestellte Vorgehensweise einen umfassenden Ansatz zur Durchführung von Bedarfs- bzw. Zufriedenheitsanalyen von Patienten und Zuweisenden im Rahmen eines ambulanten Versorgungsangebots, um die Patientenversorgung nachhaltig zu verbessern. ABSTRACT Background. To ensure efficient use of resources within outpatient services, constant patient flow is vital. This can be achieved by addressing the wishes and needs of all relevant stakeholders. Materials and methods. The present study aims to show how the needs and present satisfaction of patients and referring physicians can be determined in the context of an outpatient cataract service. It presents the conclusions that can be drawn for the design of the service. To assess needs and satisfaction, we developed a patient questionnaire and a referring physician questionnaire. Promoters and detractors for referral were identified following the concept of the net promoter score, a market research instrument. Results. 339 (38%) patients and 26 (45%) referring physicians of the main referring group answered the questionnaires. The most important characteristics for referring physicians were quality of treatment, patient satisfaction, and communication in case of queries as well as speed of sending the doctor's letter. When making their decision on a cataract centre, the patients prioritised professional reputation, previous experience with the clinic, and recommendation of their ophthalmologist as well as customary appointment scheduling . Conclusion. The two groups influence each other's recommendation or choice. Simultaneous analysis of patients and referring physicians is therefor essential. Overall, patients and referring physicians are highly satisfied with the cataract service of the university medical centre. Beyond that, however, various potentials for improvement could be identified. In summary, this report describes a comprehensive approach to assess needs and satisfaction of patients and referring physicians in an outpatient clinic trying to sustainably improve patient care.

Purpose:Patients with advanced Fuchs endothelial corneal dystrophy frequently report poor vision in the morning, which improves as the day progresses. This study quantified the amount of variation in near and distance visual acuity and refraction over the course of a day.Methods:This was a prospective cohort study. Best-corrected distance visual acuity and near visual acuity were tested in participants with clinically advanced Fuchs dystrophy and in controls with healthy corneas. Subjective refraction and autorefraction were conducted in a presumed steady state in the afternoon. Measurements were repeated directly after eye opening in the hospital the next morning. In a subgroup, measurements were repeated every 30 minutes for up to 2 hours.Results:In Fuchs dystrophy, the mean distance visual acuity was worse by −3 letters (95% confidence interval, −4 to −1) directly after eye opening in the morning compared with late afternoon. No such difference was seen in healthy corneas. In Fuchs dystrophy, visual acuity improved over the course of the study. Visual acuity in the morning could be improved with fine tuning of refraction, and refractive changes were exclusive to Fuchs dystrophy (0.5–1.0 D in spherical equivalent in 30%, >1.0 D in 2% of eyes).Conclusions:Distance and near visual acuity and refraction changes over the course of the day in patients with advanced Fuchs dystrophy. Although small changes in refraction may not usually require a second set of glasses for the first hours of the day, diurnal variation should be considered when determining disease severity in routine practice and in clinical trials.