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ZusammenfassungDie 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.

Background With the increasing demand for corneas, eye banks must optimize the tissue donation, collection, and selection process. This retrospective monocentric study analyzed the approval rates for corneal donation and the origin of and reasons for discarding donor corneas from 2010 to 2019. Methods Data included the number of deceased, approval or rejection by the family for corneal donation and contraindications. Corneal grafts were included from all deceased persons who were full-body and multi-organ donors at the Saarland University Medical Center (UKS) and from external institutions. Additional analyzed parameters included endothelial cell count (ECC), blood sample serology for infections, and conjunctival swab testing . Results A total of 1748 corneoscleral buttons were harvested from 10,265 deceased persons (17% with no contraindication) at the UKS between 2010 and 2019, with a consent rate of 23.3%. The number of keratoplasties increased from 136 in 2010 (15% of the deceased, total = 925) to 251 in 2019 (21%, total = 1214). Both the general and department-specific data showed similar percentages for corneal donation over the years, with intensive care and palliative units recently providing the most corneas. The increase in the number of corneas processed by the cornea bank over the years (368 in 2010 compared with 857 in 2019) was linked both to a better internal supply in 2010 (262, 71.2% of the total) compared with 2019 (519, 60.6%) and to an external supply by reinforcement of cooperation with external hospitals, including Luxembourg in 2010 (106, 28.8% of the total) compared with 2019 (338, 39.4%). A total of 195 of 377 corneas (52%) were discarded in 2009 compared with 260 out of 715 (36%) in 2019. The main reasons for discarding were low ECC (36% of discarded corneas in 2009; 11% in 2019), positive conjunctival swab (11% in 2009; 13% in 2019), and blood sample serology (6% in 2009 and in 2019). Conclusion Despite an increasing number of donors, the demand for corneas is still rising. Improved cooperation with internal departments and with external clinics has led to an increasing number of explanted corneas. The main reason for discarding corneas was low ECC, followed by a positive conjunctival swab for fungal or bacterial contamination and serology. Increased donation rates and continued improvements in collection and selection processes are necessary to cover the high demand for corneas.

Purpose For the treatment of macular edema, in addition to the use of antivascular endothelial growth factors, steroids are also used intravitreally and sub-Tenon. Side effects include among others cataract formation and elevation of intraocular pressure (IOP). The aim of this retrospective study was to elicit the IOP elevation after administration of various steroidal medication, the time of onset, and the efficacy of the administered IOP-lowering therapies. Methods We included 428 eyes with a postoperative (n = 136), diabetic (n = 148), uveitic macular edema (n = 61), and macular edema after retinal vein occlusion (n = 83). These patients were treated with one or more diverse steroidal agents once or multiple times. These drugs included: triamcinolone acetonide (TMC) as intravitreal injection (TMC IVI) or sub-Tenon (TMC ST), as well as dexamethasone (DXM) and fluocinolone acetonide (FA) intravitreally. An increase of IOP of ≥ 25 mmHg was designated as pathological. A steroid response in anamnesis, the time of onset of IOP rise from the first administration, and the therapy administered were documented. Results Of 428 eyes, 168 eyes (39.3%) had IOP elevation up to a mean of 29.7 (SD ± 5.6) mmHg, which occurred at a median of 5.5 months. Steroids most frequently leading to rise of IOP included DXM (39.1% of all eyes receiving that drug), TMC IVI (47.6%), TMC ST combined with DXM (51.5%), DXM with FA (56.8%), and TMC IVI with DXM (57.4%). A Kaplan–Meier analysis and the Log Rank test showed a significant difference (p < 0.001). IOP rise was treated as follows: 119 conservatively (70.8%), and 21 surgically (12.5%, cyclophotocoagulation 8.3%, filtering surgery 1.8%, in 4 the steroidal drug implant was removed 2.4%), and 28 eyes received no therapy (16.7%). Sufficient IOP regulation was achieved in 82 eyes (68.9%) with topical therapy. In 37 eyes (31.1%) with persistently elevated intraocular pressure, topical therapy had to be continued over the follow-up of 20 ± 7 months. Conclusions IOP increases after any type of steroid application are not rare. Results of our study let us suspect that especially therapy with intravitreal dexamethasone, either as a monotherapy or in combination with another steroid, tends to increase IOP more than other steroids. Regular IOP checks are necessary after each steroid administration, with possible initiation of long-term conservative and/or surgical therapy if necessary.