ZusammenfassungIm Jahr 2020 ist die DMEK („Descemet membrane endothelial keratoplasty“) in Deutschland der Goldstandard zur Behandlung von endothelialen Hornhauterkrankungen. Die weitverbreitete Verwendung der DMEK war initial eingeschränkt aufgrund von Problemen mit der Spendervorbereitung und der Schwierigkeit, die Endothel-Descemet-Membran (EDM) korrekt und schonend in der Vorderkammer zu entfalten. Wir beschreiben zum einen nach der situativen Spenderauswahl die sichere einhändige Spenderpräparation der Hornhaut ohne Ein- oder gar Zerreißen der EDM einschließlich der unabdingbaren peripheren Halbkreismarkierungen zur Orientierung. Zum anderen stellen wir Schritt für Schritt die atraumatische Beladung der Glaskartusche, die Einführung der EDM-Rolle in die Vorderkammer und ihr sicheres, schrittweises Entfalten durch (1) die sequenzielle Verwendung von Flüssigkeitsstößen, (2) das Klopfen auf die periphere/zentrale Hornhaut, (3) die kontrollierte Abflachung der Vorderkammer, (4) die Luftbläscheneingabe definierter Größe dar sowie das Anlegen der EDM in korrekter Orientierung an die Rückseite der Wirtshornhaut mithilfe einer Gasblase. Nachdem bei der DMEK jeder falsche Einzelschritt weitreichende Konsequenzen für Patient und Operateur haben kann, sollte mit dieser schrittweisen pragmatischen Vorgehensweise das Auftreten von Spendergewebeschädigung und Fehlschlägen bei den Patientenmanövern minimiert werden.
Purpose: To assess the morphological and functional outcomes within the first year of treatment with intravitreal brolucizumab for refractory neovascular age-related macular degeneration (nAMD).Methods: This retrospective study included 21 eyes from 19 patients with refractory nAMD followed for 12 months. All patients were switched to brolucizumab after treatment with at least two other anti-vascular endothelial growth factors (VEGF). All eyes received 3x brolucizumab 6 mg/0.05 ml intravitreal injections (IVI) monthly as an upload phase. Then eyes received an IVI every 8 weeks with interval adjustment to every 12 weeks if disease activity was not present. Main outcome measures: best corrected visual acuity (BCVA), central macular thickness (CMT) and retinal fluid distribution. In addition, we reported the adverse event rate.Results: The number of previous anti-VEGF IVIs/eye was 36 ± 22 before switching to brolucizumab. BCVA (ETDRS) was 51 ± 16 before treatment and 50 ± 19 at week 52 (p = 0.6). CMT was 374 ± 158 μm before treatment and 298 ± 92 μm at week 52 (p = 0.01). The number of IVIs/eye decreased from 9.6 ± 1.9 IVIs in the last year before switching to 6.4 ± 0.9 IVIs in the first year after switching to brolucizumab (p < 0.001). The rate of eyes with subretinal fluid and pigment epithelial detachment decreased at week 52. Finally, two cases of intraocular inflammation were observed as adverse events.Conclusion: In the first year of treatment, intravitreal brolucizumab was able to stabilize visual acuity with significantly less IVIs in patients with refractory nAMD. It also improved anatomic outcomes in these patients, particularly reducing subretinal fluid and pigment epithelial detachment and subsequently central macular thickness. However, two cases of intraocular inflammation were observed as adverse events.
Pre-stripped tissue for DMEK preserved in dextran-free medium led to better visual recovery, thinner postoperative corneas, a higher endothelial cell density, and a lower rate of repeat keratoplasty, indicating that dextran has an unfavorable impact on the preservation of pre-stripped DMEK tissue.
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