Clear Corneal Graft Research Articles

Feasibility Study the Effectiveness of Self-care Promoting Program on Self-care Behavioral and Clinical Outcomes in People with Corneal Transplantation: A Quasi-experiment Study

Corneal transplantation is the most effective treatment for visual impairment caused by corneal blindness and can improve patients’ quality of vision. However, pre- and post-operative self-care is necessary to reduce the risk of complications and graft rejection. This one-group, quasi-experimental design with repeated measures aimed to determine the feasibility and effectiveness of self-care promoting programs on self-care behavior, anxiety, and clinical outcomes in individuals with corneal transplantation. Thirty participants who met the inclusion criteria were purposively recruited from a corneal excellence center in Bangkok, Thailand, from October 2021 to August 2022. The data collection instruments included the Demographic and Health Data Forms, the Self-Care Behavior Questionnaire, and the Self-Rating Anxiety Scale. The data were analyzed using descriptive statistics, paired t-tests, and Friedman and Wilcoxon signed-rank tests. The program was found to be feasible, with all participants able to attend for 30 days postoperation. In terms of effectiveness, participants demonstrated improved self-care behavior and reduced anxiety compared to pre-program levels. Visual acuity also showed improvement 30 days postoperation, with 83.3% of participants having a clear corneal graft. These findings are significant for nursing practice, as they suggest that this program could be a promising tool for enhancing self-care behavior in individuals undergoing corneal transplantation. Nurses could potentially use this program to promote self-care behavior, alleviate anxiety, and enhance clinical outcomes. However, further research with randomized control is necessary before widespread implementation can be recommended.

Analysis of long-term outcomes of penetrating keratoplasty for congenital corneal opacity

Objective: To investigate the long-term outcomes of corneal grafts after penetrating keratoplasty(PK) for congenital corneal opacity(CCO) in children aged 0 to 5 years and the related influencing factors. Methods: It was a retrospective series case study. Data of 39 children (55 eyes) who underwent PK surgery due to CCO in the keratology Department of Beijing Tongren Hospital from April 2014 to April 2018 and were followed up for more than 30 months were collected. Among them, there were 17 males (43.6%) and 22 females (56.4%). The age at operation was (16.2±13.3) months, and the follow-up time was (46.4±13.8) months. Clinical data such as basic information, preoperative diagnosis, operation age, operation method and postoperative complications were recorded. The corneal graft transparency was analyzed according to preoperative diagnosis, corneal neovascularization area, age at surgery, monocular or binocular surgery interval, primary surgery type and further surgery, and postoperative complications were observed. Results: At 12 months, 24 months and the last follow-up after PK, 78.2% (43/55), 70.9% (39/55) and 58.2% (32/55) of the affected eyes had clear corneal grafts, respectively.There was no statistical significance between Peters anomaly and sclerocornea (P>0.05), while the extent of neovascularization in the limbus had a significant effect on corneal graft transparency, and graft opacity was more likely to occur in patients with vessel area exceeding 2 quadrants (P<0.05).The highest corneal graft transparency was found in children aged 1 to 3 years 80.8%(21/26) (P<0.05), followed by children younger than 6 months (7/15).The translucency rate of the corneal graft was higher in patients undergoing unilateral surgery than in those undergoing bilateral surgery (P<0.05).Translucency of corneal graft was higher in children with simple surgery than with combined surgery (P<0.05), however, cataract surgery after PK had no significant effect on corneal graft transparency (P>0.05).The postoperative complications mainly included immune rejection in 19 eyes (34.5%), complicated cataract in 13 eyes (23.6%), glaucoma in 7 eyes (13.2%), persistent corneal epithelial defect in 7 eyes (13.2%). Conclusions: After PK in children with CCO, the transparent rate of corneal grafts decreases gradually with time, but the long-term translucency of corneal grafts can still be obtained. The range of corneal neovascularization, age at the time of surgery, whether the surgery was binocular and whether the surgery was combined had an effect on the transparency of corneal graft.

Case Report: Simultaneous penetrating keratoplasty with autologous simple limbal epithelial transplantation as an alternative to keratoprosthesis

Introduction and importance: This case report highlights the multidisciplinary approach required to achieve successful anatomical and functional outcomes, in an eye with total limbal stem cell deficiency (LSCD) associated with underlying corneal scarring and thinning. Presentation of case: A 59-year-old gentleman had poor visual recovery in the right eye (RE) following accidental carbide blast, 1-year before presenting to us. The visual acuity was counting fingers and clinical examination revealed cicatricial entropion involving the upper eyelid, total LSCD, corneal scarring with a central descemetocele and cataract in the RE. Prior to ocular surface reconstruction, entropion correction was performed. Three months later, penetrating keratoplasty combined with cataract surgery and intraocular lens implantation (penetrating keratoplasty (PK) triple), with autologous simple limbal epithelial transplantation (SLET) was performed. The visual acuity was 20/100, 18 months after the surgery, with a clear well-epithelized corneal graft and stable ocular surface. Discussion: LSCD is caused by a decrease in the population and /or function of the limbal epithelial stem cells. Limbal stem cell transplantation (LSCT) is warranted in eyes with total LSCD. In eyes with coexisting corneal scarring, LSCT alone may be inadequate to restore the vision. These eyes require simultaneous or sequential lamellar or full-thickness corneal transplantation for visual rehabilitation. Though, the existing literature favors a sequential approach, where LSCT is performed first followed by corneal transplantation, under certain circumstances such as a thin underlying cornea like in our case, corneal transplantation may have to be combined with LSCT to achieve optimal outcomes. Conclusion: Combining autologous SLET with PK can be performed for visual rehabilitation in eyes with unilateral total LSCD and underlying corneal thinning. Corneal and limbal graft survival is prolonged if existing adnexal comorbidities are addressed before any surgical intervention is planned and adequate time interval is allowed for the surface inflammation to subside.

Combined Penetrating Keratoplasty and Vitreoretinal Surgery With Temporary Keratoprosthesis

Purpose: The aim of this study was to evaluate outcomes of vitreoretinal surgery with temporary keratoprosthesis combined with penetrating keratoplasty. Setting: The study was conducted at a university-based corneal and retinal disease referral practice, Ann Arbor, MI. Methods: This study is a retrospective analysis of 43 patients who underwent vitreoretinal surgery with a temporary keratoprosthesis combined with penetrating keratoplasty. Functional (best-corrected visual acuity and corneal transplant survival rate) and anatomical (clear corneal graft and retinal attachment) outcomes were measured. Results: Both corneal transplant and retinal attachment outcomes were evaluated. There was no difference in visual acuity, retinal attachment rates, or corneal transplant survival rates when comparing adult age, sex, and graft size. Pediatric eyes, however, were more likely to have a poor corneal transplant outcome. After an initial combined procedure with a temporary keratoprosthesis, 15 of 43 corneas (35%) remained clear and 23 (53%) retinas remained attached. With additional surgery, 19 of the corneas (44%) and 32 of the retinas (74%) had satisfactory outcomes. Best-corrected visual acuity (BCVA) initially improved in 23 patients (53%), with lasting improvement at final follow-up in 12 patients (28%). Twenty-five patients (58%) obtained equal or improved vision at last follow-up as compared to the presenting vision. The primary causes of poor visual acuity outcome were phthisis (49%) and retinal detachment (26%). Corneal decompensation and hypotony were often associated with phthisis and, therefore, resulted in a poor visual outcome. Trauma (53%) also resulted in an increased rate of phthisis. However, those eyes sustaining trauma, which did not become phthisical, had better visual outcomes. Silicone oil usage improved retinal reattachment rates and had no deleterious effects on corneal transplant survival. Conclusions: The combined procedures of vitreoretinal surgery with temporary keratoprosthesis and penetrating keratoplasty can salvage severely damaged eyes and provide functional vision in some patients. Factors predicting worse final visual outcome include preoperative total retinal detachment, severe chronic retinal pathology in the absence of trauma, and postoperative phthisis or retinal detachment.

Case Report: Simultaneous penetrating keratoplasty with autologous simple limbal epithelial transplantation as an alternative to keratoprosthesis

Introduction and importance: This case report highlights the multidisciplinary approach required to achieve successful anatomical and functional outcomes, in an eye with total limbal stem cell deficiency (LSCD) associated with underlying corneal scarring and thinning. Presentation of case: A 59-year-old gentleman had poor visual recovery in the right eye (RE) following accidental carbide blast, 1-year before presenting to us. The visual acuity was counting fingers and clinical examination revealed cicatricial entropion involving the upper eyelid, total LSCD, corneal scarring with a central descemetocele and cataract in the RE. Prior to ocular surface reconstruction, entropion correction was performed. Three months later, penetrating keratoplasty combined with cataract surgery and intraocular lens implantation (penetrating keratoplasty (PK) triple), with autologous simple limbal epithelial transplantation (SLET) was performed. The visual acuity was 20/100, 18 months after the surgery, with a clear well-epithelized corneal graft and stable ocular surface. Discussion: LSCD is caused by a decrease in the population and /or function of the limbal epithelial stem cells. Limbal stem cell transplantation (LSCT) is warranted in eyes with total LSCD. In eyes with coexisting corneal scarring, LSCT alone may be inadequate to restore the vision. These eyes require simultaneous or sequential lamellar or full-thickness corneal transplantation for visual rehabilitation. Though, the existing literature favors a sequential approach, where LSCT is performed first followed by corneal transplantation, under certain circumstances such as a thin underlying cornea like in our case, corneal transplantation may have to be combined with LSCT to achieve optimal outcomes. Conclusion: Combining autologous SLET with PK can be performed for visual rehabilitation in eyes with unilateral total LSCD and underlying corneal thinning. Corneal and limbal graft survival is prolonged if existing adnexal comorbidities are addressed before any surgical intervention is planned and adequate time interval is allowed for the surface inflammation to subside.

Comparison of culture-positive and culture-negative severe infectious keratitis leading to hospitalization: a tertiary referral center experience

Aim: To compare the predisposing factors, surgical interventions, length of hospital stay (LOHS), and treatment outcomes of culture-positive (CP) versus culture-negative (CN) severe infectious keratitis (IK) resulting in hospitalization in a tertiary referral clinic. &#x0D; Material and Method: We retrospectively reviewed the medical and microbiological records of 287 patients clinically diagnosed with severe keratitis over a 4-year period. &#x0D; Results: Of 287 study participants, 141 (49.1%) had positive CP results. The most common ocular risk factor was a previous ocular surgery (45.6%), and keratoplasty was the first among these ocular surgeries (90.8%). Staphylococcus epidermidis (22.7%) was the most commonly isolated microorganism followed by fungi (17.7%). The initial and final visual acuities did not differ significantly between the CP and CN groups. Major and minor surgical interventions did not significantly differ between the groups (p=0.05). The rates of clear corneal graft in the CP group (p =0.002) were significantly higher than the rates of graft failure in the CN group (p=0.033). No significant difference was noted in the mean LOHS between groups (p=0.66). Logistic regression analyses showed that surgery during admission, S. epidermidis infection, and connective tissue diseases were independent risk factors for a prolonged hospital stay. &#x0D; Conclusion: The initial and final visual acuities, surgical interventions, and LOHS were similar between the CP and CN groups. However, graft failure rates were significantly higher in patients with CN keratitis than in those with CP keratitis.

Management of an unresponsive case of HSV keratouveitis with trabeculectomy and DSAEK: A case report

Introduction and importanceThis case demonstrates an unusual presentation of Herpes simplex virus (HSV) ocular infection and the challenges faced during the management of its complications.Presentation of the caseA thirty year-old lady, a steroid responder with HSV keratouveitis, was referred for non-response to treatment with the prophylactic dose of oral acyclovir and acetazolamide. She presented with large epithelial bullae, anterior chamber reaction, and raised intraocular pressure in her right eye. Initially, she responded to the therapeutic dose of oral acyclovir, but on follow-up visits, she developed high intraocular pressures of up to 45 mmHg on maximum medical therapy. Hence, trabeculectomy with mitomycin-C was performed. One year later, she developed corneal endothelial decompensation, for which a Descemet's stripping automated endothelial keratoplasty (DSAEK) was done. Eight months post-operatively, she had a best corrected visual acuity of 20/20, clear corneal graft, quiet anterior chamber, and well-controlled intraocular pressures.DiscussionHSV trabeculitis is associated with inflammation of the anterior chamber, endothelitis and raised intra-ocular pressure. A combination of anti-viral, anti-inflammatory, and anti-glaucoma medications helps in the management. However, glaucoma filtration surgery is often needed to the control intra-ocular pressure. Chronic recurrent episodes eventually lead to endothelial failure and demand endothelial keratoplasty (EK). It is prudent to adopt certain measures to perform EK in these phakic eyes without causing any iatrogenic damage to the filtration bleb as well as to the clear crystalline lens.ConclusionThis case highlights the difficulties of treating HSV-related keratouveitis with uncontrolled glaucoma, problems of associated steroid response, and complexities in performing corneal endothelial procedures in young phakic patients especially post-trabeculectomy.

Long-Term Outcomes of Big Bubble Deep Anterior Lamellar Keratoplasty in Mucopolysaccharidoses: A Retrospective Case Series and Review of the Literature.

The purpose of this study was to report the long-term surgical and visual outcomes of patients with mucopolysaccharidoses (MPS) after big bubble deep anterior lamellar keratoplasty (BB-DALK). This was a retrospective case series of patients with MPS who underwent BB-DALK at a single academic institution. All patients had corneal clouding secondary to MPS limiting visual acuity for which keratoplasty was indicated. Each patient was evaluated and underwent surgery by a single surgeon. Reported data included age at keratoplasty, sex, MPS type, best spectacle-corrected visual acuity, change in pachymetry, ocular comorbidities, surgical complications, and MPS-related medication use. Outcomes of 12 eyes from 7 patients with MPS type I (Hurler, Scheie, and Hurler-Scheie) are reported using the newest nomenclature. The mean follow-up was 5.58 years (range: 1-10 years). All cases underwent BB-DALK with a type 1 big bubble during the surgery. Two cases (16.6%) required rebubbling because of partial Descemet membrane detachment. One case was complicated by a suture abscess and required a penetrating keratoplasty. No episodes of rejection occurred. Statistically significant improvement in the best spectacle-corrected visual acuity (from a mean 0.85-0.33 logarithm of the minimum angle of resolution, P = logarithm of the minimum angle of resolution 0.0054) and pachymetry (mean reduction of -145.4 μm, P = 0.0018) was observed. BB-DALK seems to be an acceptable long-term surgical option in patients with MPS. Our findings suggest that this technique is reproducible and can achieve clear corneal grafts with good visual results on a long-term follow-up.

Feasibility and Outcomes of Corneal Transplantation Performed at Rural Centers: An Extension of the Pyramidal Model of Enhanced Eye Care at Rural Outreach.

The aim of this study was to report on the feasibility of setting up a system of corneal transplants at rural outreach centers and report the outcomes of the first 111 cases. Retrospective analysis of the outcomes of corneal transplantation performed on patients with optical indications between March 2016 and September 2019 at 4 secondary (rural) centers. The centers are a part of a network in the pyramidal model developed by L V Prasad Eye Institute. The graft clarity and best-corrected visual acuity (BCVA) at 1-year follow-up were analyzed. Of the 111 patients, 34.23% underwent penetrating keratoplasty and 65.77% endothelial keratoplasty. The mean age was 59.4 ± 15.0 (range-17-86 years); 47.75% were men and 52.25% were women. The indications for surgery were bullous keratopathy (54.05%), corneal scar/adherent leukoma (23.42%), and repeat grafts (13.51%). At the end of 1 year, 69.37% grafts remained clear. Factors associated with graft failure included poor socioeconomic status and graft infiltrate in both univariate and multivariate analyses. Surgical technique of endothelial keratoplasty was associated with failure on multivariate analysis only. Of the 77 eyes with clear corneal grafts at 1 year, the preoperative mean logMAR BCVA was 1.91 ± 0.06, which improved to 0.90 ± 0.08 postoperatively. Overall, 84.4% had preoperative BCVA of <3/60. Postoperatively, 40% had BCVA of 6/18 or better. Our study showed that close to 70% grafts remained clear at 1 year. Graft failure was associated with poor socioeconomic status and graft infiltrates. This study established a viable model for delivery of corneal transplant surgery and care in a rural setup.

Acute corneal edema decades after penetrating keratoplasty for keratoconus in eyes wearing scleral contact lenses

PurposeTo report three cases of acute corneal edema occurring decades after penetrating keratoplasty (PK) for keratoconus in eyes wearing scleral contact lenses (ScCLs) with previously clear corneal grafts. MethodsRetrospective chart review of three ScCL wearers presenting for sudden onset pain and blurred vision. Data extracted included clinical presentation, year and reason for PK, ocular medications and comorbidities, contact lens wearing history, results of any ancillary testing available including corneal topography, anterior segment optical coherence tomography (OCT), and specular microscopy surrounding the event, treatment and outcomes of intervention. The number of PK eyes fit with ScCLs in the author’s practice was determined to estimate the prevalence of this event. ResultsThe three patients each had a longstanding PK for keratoconus performed between 33–35 years prior to presentation and recurrent ectasia. Each patient presented with an acute, painful eye and reduced vision either 3 days, 4 months or 9 years after refitting into ScCLs. Each eye had well demarcated focal microcystic epithelial and stromal edema within the graft and crossing the wound margin onto the host cornea. Although a definitive break or detachment of Descemet’s membrane was not visualized, the presentations suggest these were episodes of acute hydrops. ConclusionsLongstanding PKs with recurrent ectasia and acute focal edema suggestive of corneal hydrops is demonstrated in this case series of ScCL wearers. Although similar events have occurred as part of the natural history of post-PK corneas for keratoconus, the proximity of ScCL refitting to two of the events suggests some association.

VISUAL REHABILITATION AFTER PENETRATING KERATOPLASTY

Introduction: Astigmatism is the most common cause of suboptimal vision after corneal transplantation despite a clear corneal graft.1 Based on several studies, 15–31% of patients undergoing penetrating keratoplasty (PK) may develop postoperative astigmatism greater than 5 diopters (D).2,3 Commonly practiced techniques for visual rehabilitation after PK consist of postoperative suture manipulation, optical correction consisting of spectacles and contact lenses, relaxing incisions, compression sutures, laser refractive surgery, insertion of intrastromal corneal ring segments, wedge resection, toric phakic intraocular lenses, and finally regrafting.4 The aim of this study was to report our management strategies and their results performed for visual rehabilitation and management of astigmatism after PK. Patients and Methods: The records of 104 eyes of 98 patients (54male/44 female) who underwent PK between January 2013 and January 2015 in Baskent University Faculty of Medicine, Department of Ophthalmology were reviewed. The age, the indication for PK, interventions performed for visual rehabilitation, the duration of follow-up, the topographic and refractive astigmatism at the end of follow-up and the final BCVA were recorded. Results: The mean age of the patients was 54±23 years. The indications for PK included keratoconus, Fuch’s endothelial dystrophy, pseudophakic bullous keratopathy and corneal scarring (Figure 1).Fig. 1. The mean duration of follow up was 23±11.5 months. Suture adjustment and selective suture removal were performed 2 to 6 weeks and after 3 months in eyes with more than 3 D of corneal astigmatism. Spectacle correction was performed in 86 eyes (83%) and contact lenses including rigid gas permeable and scleral lenses were fitted in 18 eyes (17%) who were unsatisfied with spectacle correction mostly due to higher order aberrations or high anisometropia (Figure 2).Fig. 2. Relaxing corneal incisions were performed in 23 eyes (22%) and toric intraocular lens implantation was performed in 34 eyes (33%) with cataracts. The mean topographic and absolute refractive astigmatism at the end of follow up was 3.4±2.6 D and 3.6± 1.9 D, respectively. Discussion: Intraoperative and postoperative suture manipulation have been described for minimising early postoperative astigmatism.5,6 After PK, sutures should be kept for at least one year. During this period, astigmatism >4 D can be reduced by suture manipulation consisting of selective interrupted suture removal and tension adjustment of running sutures.4 If significant astigmatism remains after suture removal, which cannot be corrected by optical means such as spectacle correction or contact lenses, surgical procedures can be performed.4 Conclusion: Although general guidelines are useful, it is important to individualize the management based on corneal topography and patient expectations for successful visual rehabilitation.

Evaluation of Phacoemulsification Cataract Surgery Outcomes After Penetrating Keratoplasty.

BACKGROUND:Cataract is one of the reasons which causes impaired visual acuity (VA) of the eyes after penetrating keratoplasy (PK), which can be treated by cataract surgery after PK or triple procedure. Cataract surgery after PK has advantages that parameters of the eyes such as axial length, anterior chamber depth (ACD) as well as corneal curvature are stabilized after removing all sutures postoperatively, and intraocular lens (IOL) power can be calculated correctly. Therefore, postoperative VA will be improved significantly. In Vietnam, there have not been any study about cataract surgery after PK, therefore we conduct this research.AIM:To evaluate the outcomes of phacoemulsification cataract surgery following primary PK.METHODS:Non-randomized controlled intervention study. Ninteen eyes (19 patients) that underwent phacoemulsification plus IOL insertion after initial PK in Cornea department, Vietnam National Institute of Ophthalmology, from December 2013 to September 2014.RESULTS:All patients presented with reduced VA, including 17 eyes (89.9%) with VA ≤ 20/200, mean astigmatism was 7.9 ± 1.0 D. Clear corneal grafts in 16 eyes while corneal opacity was seen in 3 eyes. All eyes with cataract were diagnosed from grade 2. After cataract surgery, improved VA > 20/200 was achieved in 72.22% of cases. There was a markable reduce of postoperative astigmatism with 1.8 ± 0.8 D (p < 0.05). However, the immunologic graft reaction was presented in one eye, and two edematous corneas also reported after cataract surgery. After treatment, there was one cornea achieved its clarity.CONCLUSION:Phacoemulsification cataract surgery following initial PK showed good outcomes with improved postoperative VA, reduced astigmatism, and the ultimate graft survival rate was high.

A peculiar case of corneal autograft in a patient with bilateral advanced glaucoma

The technique of autograft employs the use of a clear corneal graft from an otherwise blind eye that is transplanted to the fellow eye, which has a visual potential in the same patient. A patient with advanced glaucoma in both eyes presented to us with pseudophakic bullous keratopathy with Ahmed glaucoma valve in the right eye, and cataract and patent peripheral iridotomy with no perception of light in the left eye. The autograft and allograft corneas for bilateral penetrating keratoplasty (PK) were obtained from the contralateral eye and a cadaver eye, respectively. Central corneal button was used for PK. One year after the surgery, the graft host junction was well apposed with no vascularization, corneal surface was clear, sutures were intact, and best corrected visual acuity improved in right eye to 1 logMAR. Bilateral simultaneous PK with autograft in one eye and allograft in the other was done to decrease the chances of rejection.

Clinical Results in Patients with Combined Penetrating Keratoplasty and Vitreoretinal Surgery Using Landers Wide-field Temporary Keratoprosthesis

Objectives:To evaluate the clinical results of combined pars plana vitrectomy (PPV) with Landers wide-field temporary keratoprosthesis and penetrating keratoplasty (PK).Materials and Methods:From January 2016, traumatic eyes with coexisting corneal and vitreoretinal diseases that underwent combined keratoprosthesis/PPV/PK surgery were retrospectively evaluated. Demographic characteristics, visual acuity (VA), intraocular pressure (IOP) and clinical findings of the cornea, lens, and retina were recorded during the follow-up. Cases with clear corneal graft, attached retina, normotonic IOP, and improved or stable VA were considered successful.Results:Eight eyes were enrolled in the study. The mean follow-up time was 21.1±8.20 months. Surgery was performed a mean of 23 (10-40) days after trauma. Preoperative VA ranged from no light perception to counting fingers from 50 cm. Postoperatively, corneal graft was clear in 5 patients (62.5%) and retina was attached in 6 eyes (75%). Chronic hypotonia developed in 3 patients (37.5%). VA was unchanged in 3 patients and improved in 5 patients. A total of 5 cases (50%) were considered successful. Shorter interval between trauma and surgery was associated with higher likelihood of success (p=0.043). No significant difference was observed between the groups in terms of type or location of trauma (p=1; p=0.143).Conclusion:Although the functional results are not very satisfactory, the combined procedure provides a final opportunity for preserving remaining vision and anatomic reconstruction in eyes that will otherwise result in phthisis due to severe anterior and posterior segment pathologies.

Graft rejection-like reactions in the early postoperative period after deep anterior lamellar keratoplasty for keratoconus: a retrospective study.

BackgroundDeep anterior lamellar keratoplasty (DALK) is indicated to correct high astigmatism in patients with keratoconus (KC) and no evidence of Descemet’s membrane rupture. However, some patients with KC experience graft rejection-like inflammatory reactions within 2 months (usually in the first week) after DALK. The aim of this study was to identify the characteristics and influencing factors of these reactions by reviewing the records of patients who underwent DALK or penetrating keratoplasty (PKP) for KC or other corneal problems.MethodsWe retrospectively reviewed the medical records of patients who underwent DALK for KC (DALK/KC), PKP for KC (PKP/KC), or DALK for other corneal problems (DALK/non-KC) at Ban Buntane Hotokukai Hospital between January 2006 and December 2015 and who were followed for more than 1 year. We collected data on the characteristics and incidence of severe inflammatory graft reactions in the early postoperative phase (ie, within 2 months after keratoplasty) and visual outcomes after these inflammatory reactions.ResultsPostoperative inflammatory reactions characterized by persistent epithelial defects, loose suture with infiltration, and vessel invasion occurred in seven of eleven DALK/KC patients, three of 50 DALK/non-KC patients, and none of five PKP/KC patients. These reactions were nonresponsive to topical steroids, and suture removal was required. Although a clear corneal graft in the pupillary area was obtained and best-corrected visual acuity was good after the resolution of inflammation, a risk of corneal astigmatism remained.ConclusionThe incidence of these reactions in the early postoperative period is high after DALK for KC. These reactions do not respond well to topical steroids, and suture removal may be required, which may cause high astigmatism after the inflammation subsides. Lamellar keratoplasty should be considered carefully for patients with KC.

Clear corneal grafts with subcritical endothelial cell count after 1 year of penetrating keratoplasty

Endothelial cell loss after penetrating keratoplasty leads to graft failure. The critical limit of the endothelial cell count for corneal decompensation is thought to be 700 cells/mm2. Clinical specular microscopy indicates that inspite of low endothelial cell density, the corneal graft can be maintained in a relatively dehydrated state. This study reports 4 cases of clear corneal graft having low endothelial cell count. The low endothelial cell count was associated with polymegathism and pleomorphism; inspite of this, the clarity of the graft was maintained.

Intrastromal Corneal Ring Segments for Astigmatism Correction after Deep Anterior Lamellar Keratoplasty.

Background. To evaluate the change in corneal astigmatism after intrastromal corneal ring segment (ICRS) implantation in keratoconus patients with previous deep anterior lamellar keratoplasty (DALK). Design was a longitudinal, retrospective, interventional study. The study included 25 eyes of 24 patients with keratoconus who had DALK performed at least two years prior to ICRS implantation. All patients had a clear corneal graft with up to 8.00 D of corneal astigmatism and intolerance to contact lenses. The studied parameters were age, sex, corrected distance visual acuity (CDVA), maximum keratometry (K1), minimum keratometry (K2), spherical equivalent, and astigmatism. There was a statistically significant decrease in the postintervention analysis as follows: 3.5 D reduction in K1 (p < 0.001); 1.53 D in K2 (p = 0.005); and 2.52 D (p < 0.001) in the average K. The spherical equivalent reduced from −3.67 D (±2.74) to −0.71 D (±2.35) (p < 0.001). The topographic astigmatism reduced from 3.87 D preoperatively to 1.90 D postoperatively (p < 0.001). The CDVA improved from 0.33 (±0.10) to 0.20 (±0.09, p < 0.001). ICRS implantation is a useful option for the correction of astigmatism after DALK as it yields significant visual, topographic, and refractive results.

Advances in Confocal Microscopy of the Eye.

This special issue focuses on the recent advances on in vivo confocal microscopy (IVCM), a technique used to investigate eye structures at the cellular level without tissue damage. In 1985 Lemp and coworkers were the first to study ex vivo corneas by confocal microscopy and to suggest a possible in vivo use [1]. In the early 1990s, the groups directed by Cavanagh and Kaufman published the first IVCM in humans; thereafter the scientific interest in ocular IVCM rapidly increased. In the last decade, IVCM progressively gained a relevant role in the clinical setting, being of help in the diagnosis and management of a number of conditions such as toxicity induced by preservatives [2, 3] and different eye treatments [4, 5], iatrogenic damage [6], infections [7], and dystrophies [8], pathology of the conjunctiva [9–11] and limbus [12], ocular surface tumors [13], and corneal deposits [14, 15]. IVCM is a valuable tool for enhancing our understanding of anterior segment physiology and pathology, as pointed out by Dr. V. Fasanella et al. in their paper investigating meibomian gland changes occurring with aging and a number of ocular surface diseases. Examples of the usefulness of IVCM in detecting early corneal changes can be found in the paper by Dr. D. Wang et al., who highlighted that a higher-than-normal immune activity may be observed in a subgroup of patients with clear corneal grafts in the absence of any other clinical signs. Dr. P. Song et al. studied the confocal and histopathological features of the stromal scar in keratoconus and suggested that IVCM is capable of detecting subtle keratocyte activation associated with fibrosis. In recent years, IVCM has become increasingly useful in evaluating corneal innervation (which is of key importance in regulating ocular surface homeostasis) [16] and corneal immune and inflammatory responses [17]. In this special issue, three papers explored the changes occurring in corneal innervation in both local and systemic diseases. The paper by Dr. E. F. Wang et al. reviewed the impact of various systemic diseases on corneal innervation and discussed the potential use of IVCM as a noninvasive marker of peripheral neuropathy. The reports by Dr. R. Shetty et al. and Dr. N. K. Pahuja et al. investigated nerve changes occurring, respectively, in dry eye disease and keratoconus. Finally, IVCM plays a role in studying the therapeutic effects of topical eye treatments, as shown in this issue by the paper of Dr. A. M. Fea et al. This special issue provides a useful update on the advances in the rapidly evolving field of IVCM and highlights the contribution of this technology to our understanding of the anterior segment in health and disease. Paolo Fogagnolo Michele Iester Hong Liang Dipika V. Patel

The first case of endophthalmitis due to Rhinocladiella basitona in an immunocompetent patient

Rhinocladiella, a genus of black yeast–like fungi, is related to many infections in humans, including not only mild cutaneous lesions but also fatal brain infections. However, endophthalmitis caused by Rhinocladiella has never been reported by far. Herein, we present the first case of endophthalmitis due to Rhinocladiella basitona. The diagnosis was based on histopathology, mycology, and molecular identification. A 53-year-old female was struck by a piece of wood in her right eye. The wound in the central cornea became an ulcer and was aggravated continuously. Hyphae were found in the corneal scraping smear. Then endophthalmitis occurred and could not be controlled by the combined intravitreal antibiotic injections and vitrectomy. Finally, penetrating keratoplasty combined with retinal reattachment surgery was performed. Topical and systemic antifungal agents were administered for more than 1month. The patient was cured, with improved visual acuity and clear corneal graft.

Indications for and Outcomes of Deep Anterior Lamellar Keratoplasty in Mucopolysaccharidoses

To describe the outcome of deep anterior lamellar keratoplasty (DALK) for visually significant corneal clouding in patients with mucopolysaccharidoses (MPS). A retrospective consecutive case series of patients with MPS and corneal clouding were analyzed at a tertiary eye hospital. A review of the English literature regarding MPS and DALK was performed. The main outcomes measures of the study were intraoperative surgical complications, change in visual acuity, and postoperative DALK-related complications. Four eyes from 2 patients with MPS I (Hurler's syndrome and Hurler-Scheie syndrome) and a history of DALK met inclusion criteria for the case series. Using the "big-bubble" technique, DALK was performed successfully in all eyes. Completed Descemet's membrane baring was achieved in 3 or 4 eyes and a pre-Descemet's membrane dissection in 1 eye. The mean age at the time of DALK was 17.3 years (range: 15.4 to 19.5 years). Mean follow-up time after DALK was 16.7 months (range: 6 to 31 months). Mean visual acuity before DALK was 20/80 (0.59 ± 0.12 logMAR). Mean visual acuity at the last visit for all 4 eyes was 20/50 (0.41 ± 0.17 logMAR). Visual acuity improved in all eyes. Recurrence of MPS corneal clouding was not noted in any of the corneal grafts. DALK is a beneficial and preferable intervention in appropriate patients with significant corneal clouding due to MPS I. Improvement in vision can be obtained with stable, clear corneal grafts, although other ophthalmic manifestations may limit vision.