Corneal Graft Clarity Research Articles

Corneal endothelial regeneration in human eyes using endothelium-free grafts

BackgroundTo report on corneal endothelial regeneration, graft clarity, and vision recovery when using endothelium-free grafts.MethodsWe evaluated the donor’s cell viability using trypan blue staining and dual staining with calcein acetoxy methyl ester and ethidium homodimer-1. To preserve eyeball integrity, we performed therapeutic penetrating keratoplasty using cryopreserved donor tissue without endothelium on 195 consecutive patients who suffered from corneal perforation due to progressive primary corneal disease such as herpes simplex keratitis, fungal keratitis, ocular thermal burns, keratoconus, and phlyctenular keratoconjunctivitis. Of these, 18 eyes recovered corneal graft clarity and underwent periodic slit-lamp microscopy, A-scan pachymetry, and in vivo confocal microscopy to observe the clinical manifestations, variations in corneal thickness, and repopulation of the corneal endothelial cells on the donor grafts.ResultsNo viable cells were detected in the cryopreserved corneas. After the therapeutic penetrating keratoplasty, notable corneal graft edema was observed in all 18 eyes for 1–4 months, and no corneal endothelial cells were detected on the grafts during this period. Thereafter, we observed gradual and progressive regression and final resolution of the stromal edema, with complete recovery of corneal graft clarity. Through periodic confocal microscopy, we observed the corneal endothelium’s regenerating process, along with single cells bearing multiple nuclei and cell division-like morphology. The regenerated endothelium on the grafts reached a mean cell density of 991 cells/mm2. Remarkable vision rehabilitation was achieved in all 18 patients.ConclusionsWe obtained conclusive evidence that host-derived endothelial cells can regenerate a new endothelium over the endothelium-free graft, which possesses normal functions for corneal clarity and vision recovery.

Surgical outcome of optical penetrating keratoplasty in a rural tertiary care hospital

Introduction: Optical Penetrating Keratoplasty (OPKP) is the gold standard surgical treatment for full-thickness corneal lesions and it is a well-established effective and safe technique. We conducted this study to verify the surgical outcome of OPKP at our rural hospital. Aims and Objectives: To study the surgical outcome of OPKP in relation to corneal graft Clarity, Best Corrected Visual Acuity (BCVA), and Post-Operative Complications (POC) Material and Methodology: In this prospective longitudinal hospital-based study we obtained postoperative data from patient’s records operated for OPKP from August 2018 to October 2019 after taking permission from IEC and patient’s consent. We included 22 patients who completed a minimum one-year follow-up. Results: Out of 22 OPKPs, 50.00% were males. 18.18% of patients were in the 41-50 yrs age group. 1) Graft clarity was seen in 59.09%. 2) BCVA > 6/18was observed in 9.09% pts. 3) POC – Graft failure was seen in 18.18%. Epithelial defect, Raised IOP, Uveitis, Cataract and Corneal vascularization were other problems. Conclusion: Though graft failure is a major complication, OPKP gives good BCVA and faster visual rehabilitation.

The Surgical Outcomes of Limbal Allograft Transplantation in Eyes Having Limbal Stem Cell Deficiency.

Purpose:To report the limbal allograft transplantation and penetrating keratoplasty (PK) results in limbal stem cell deficiency (LSCD)-developed eyes because of chemical or thermal injury.Methods:Medical records of 18 eyes of 14 patients who had undergone keratolimbal allograft (KLAL) or living-related conjunctival limbal allograft (lr-CLAL) with or without PK and followed up at least 1 year postoperatively were evaluated retrospectively. The preoperative LSCD grade was noted in all patients. Rejection incidents, recurrence of LSCD, and corneal graft clarity along with a visual improvement during the follow-up were noted. The complications rate due to surgery or injury itself, for instance, glaucoma and cataract, were evaluated. The limbal allograft tissue survival analysis and corneal allograft survival analysis were done to reveal the differences in both the procedures. The existence of normal corneal epithelium and improvement in visual acuity were accepted as the surgical success criteria.Results:In the limbal allograft transplantation group, the survival rates of the allograft tissue were 65 ± 10.7% at 1 year and 36.6 ± 11.4% at 3 years in lr-CLAL and 66.7 ± 15.7% at 12 months and 53.3 ± 17.3% at 18 months in KLAL-transplanted eyes. The survival rate of corneal allograft at the 5th postoperative year was lower in the simultaneous procedure compared to the staged procedure, but it was not statistically significant (25.7 ± 25.8% vs. 62.5 ± 17.1%, P = 0.75). The ambulatory vision was achieved in 10 eyes (56%) after a mean follow-up time of 93.8 ± 37.8 months. The visual acuity level has increased in 12 eyes (67%) in which the limbal allograft transplantation was applied. The ambulatory visual acuity level was achieved (≤1.0 logMar [20/200]) in 10 eyes (56%). In addition, two or more Snellen lines’ gain in the best corrected visual acuity was observed in 12 eyes of 18 (67%) at the last follow-up, and there was not any significant difference between the KLAL and lr-CLAL.Conclusions:Ocular surface integrity was longer in KLAL than in lr-CLAL transplantation, but it was not statistically significant. The staged procedure was more convenient than the simultaneous procedure in terms of corneal allograft clarity maintenance in limbal allograft-employed eyes.

The long-term surgical outcomes of conjunctival-limbal autograft procedure with or without penetrating keratoplasty in eyes with unilateral limbal stem cell deficiency.

AIM:The aim of the study is to report the results of conjunctival-limbal autograft (CLAU) transplantation and penetrating keratoplasty (PK) in eyes with limbal stem cell deficiency (LSCD) due to chemical or thermal injury.METHODS:Thirty-one eyes of the 31 patients, who had unilateral LSCD due to chemical or thermal injury, were included in the study. Bilaterally affected cases and LSCD due to Steven-Johnson syndrome and mucous membrane pemphigoid were excluded from the study. All patients underwent a complete ophthalmologic examination. The surgical procedures, postoperative complications, ocular surface status, and visual outcomes were noted.RESULTS:In the CLAU group, regular corneal epithelium and ambulatory vision (≤1.0 logarithm of the minimum angle of resolution [20/200]) were achieved in 81% of eyes, including 22 eyes (71%) that were assessed after a mean follow-up period of 58 months, respectively. The 5-year survival rate of corneal allograft was 33%, 4 ± 13.9 in the CLAU applied eyes. In addition, the corneal graft clarity maintenance rate was found to be higher in patients having ≥12 months duration between CLAU and PK, which is statistically significant (62% vs. 23%, P = 0.046).CONCLUSION:Waiting at least 1 year after CLAU transplantation to perform PK increases corneal clarity. Eyelid problems, even if the eyelids were reconstructed properly, remain a major risk factor for the development of the epithelial disorder in the early and late postoperative period in CLAU applied eyes.

Blood Vessels and Lymphatic Vessels in the Cornea and Iris After Penetrating Keratoplasty.

To detect early growth of blood and lymphatic vessels in the mouse cornea and iris after penetrating keratoplasty. Penetrating keratoplasty was performed with C57BL/6 mice as donors and BALB/c mice as recipients. Graft transparency and neovascularization were examined by slit-lamp microscopy. Whole mounts of the cornea and iris were processed for detection of the outgrowth of blood and lymph vessels. On day 3 after surgery, all corneal grafts were slightly edematous, and blood vessels in the corneoscleral limbus dilated. LYVE-1 lymphatic vessels and CD31 blood vessels were distributed in the peripheral cornea. In the iris, the density of blood vessels increased, and LYVE-1 cells nearly vanished. On day 7, the grafts became opaque, and blood vessels grew into the recipient bed. A great quantity of lymph vessels invaded the cornea. LYVE-1 arborescent cells were found around the lymphatic vessels. In the iris, blood vessels became bulky and stiff, and arborescent LYVE-1 cells increased in number. On day 14, corneal neovascular regression and graft clarity were found. Lymphatic vessels regressed more slowly than blood vessels in the cornea. In the iris, blood vessels remained coarse. Increasing arborescent LYVE-1 cells were also noted in the ciliary body. Our findings suggest that the iris-ciliary body could amplify immune signals and in part promote initiation of immune rejection after keratoplasty by providing a pathway for macrophages, which might participate in corneal lymphangiogenesis.

Comparison of Short-term Outcomes of Aurolab Aqueous Drainage Implant with Ahmed Glaucoma Valve in Post–Penetrating Keratoplasty Glaucoma: A Retrospective Follow-up Study at a Tertiary Care Center

Comparison of short-term outcomes of the Aurolab aqueous drainage implant (AADI) with the Ahmed glaucoma valve (AGV) in post-penetrating keratoplasty glaucoma (PPKG). Retrospective study design. We analyzed the data of patients who underwent glaucoma drainage device (GDD) implantation for PPKG between the time period of 2008 to 2017. A total of 57 eyes of 55 patients were included. Parameters including age, sex, corneal graft clarity, duration between the keratoplasty and glaucoma surgery, visual acuity (VA), intraocular pressure (IOP), the number of antiglaucoma drugs (topical and oral) before surgery, and type of GDD were studied. The patients were divided into 2 groups: group I, patients undergoing AADI implantation; and group II, patients undergoing AGV implantation. Patients with at least 6 months follow-up were included. The postoperative VA and IOP were analyzed on day 1 and at 1 week, 4 weeks, 6 weeks, 3 months, and 6 months. The success of GDD was defined as complete success (IOP > 5 mmHg or <21 mmHg without topical antiglaucoma drug) or qualified success (IOP > 5 mmHg or <21 mmHg with up to 2 topical antiglaucoma drugs). Failure was defined as IOP < 5 mmHg or >21 mmHg with or without antiglaucoma medication; IOP < 21 mmHg with 3or more topical medications or use of systemic medications irrespective of the IOP; loss of perception of light; and/or need for further glaucoma surgery. Nineteen eyes in group I (mean age= 40.16±16.36 years) and 38 eyes in group II (mean age= 56.61±19.35 years) were studied. The mean baseline IOP in group I and group II was not significantly different (28.63±11.21 vs. 30±14.61 mmHg, P= 0.72). Mean postoperative IOP at 6 months was not significantly different in the 2 groups (12.11±4.86 mmHg vs. 14.95±6.35 mmHg, P= 0.2). There was statistically significant fall in IOP at each visit compared to preoperative IOP in both the groups (P= 0.001), but there was no significant difference between the 2 groups at any time point (P > 0.05). At 6 months overall success rate was 84.21% in both groups (P= 1.00), though the complete success was slightly higher in group II, which was nonsignificant (31.58% vs. 39.47%, P= 0.56). There was no significant difference between baseline and final VA in either group. Both AADI and AGV are equally effective in controlling IOP in post-penetrating glaucoma. The AADI, being a cost-effective implant, may be more suitable for developing countries.

Suture related astigmatism after penetrating keratoplasty

Purpose: The purpose of the study was to evaluate the influence of various factors on the astigmatism before and after suture removal after penetrating keratoplasty. Methods: This observational study was conducted in which we reviewed retrospectively the records of 51 eyes of 50 patients who underwent PK for optical purposes in between March 2013 to February 2016. Various recipient parameters like age, sex, lens status , indications of PK, grading and size of recipient graft, pre and post suture removal (SR), best-corrected visual acuity (BCVA) refractive and keratometric astigmatism(KA) with axis, central corneal thickness(CCT), IOP, and graft clarity were noted. Results: Average age of the recipient was 51.16±18.53 years. Major indication of PK was corneal opacity in 47 (54.02%). B+ grade and graft size of ≥8 mm was used in maximum cases 79 (90.80%), 50 (57.47%) respectively. Pre SR refractive and KA were 4.85±1.04D and 5.24±1.08D respectively and post SR refractive and KA were 2.56±0.74D and 2.87±0.80D respectively. Pre SR in maximum cases 67 (77.01%) refractive astigmatism was seen with in 3-6 D and post SR maximum cases 53 (60.91%) were seen with refractive astigmatism <3 D. Indications of PK showed significant relationship with KA before SR with p value of 0.01. Size of graft showed significant relationship with pre SR refractive astigmatism, pre and post SR KA (P = 0.00,0.00,0.00) respectively. Conclusion: Indications of PK and size of the graft influence astigmatism both pre and post SR after PK.

Pars Plana-Modified versus Conventional Ahmed Glaucoma Valve in Patients Undergoing Penetrating Keratoplasty: A Prospective Comparative Randomized Study

ABSTRACTPurpose: To compare the outcome of pars-plana-modified Ahmed glaucoma valve (AGV) versus limbal-based conventional AGV into the anterior chamber, in patients undergoing penetrating keratoplasty (PK) for glaucoma with coexisting corneal diseases.Method: In this prospective randomized clinical trial, 58 eyes of 58 patients with glaucoma and coexisting corneal disease were divided into two groups. Group 1 (29 eyes of 29 patients) included patients undergoing limbal-based conventional AGV into the anterior chamber (AC) along-with PK and group 2 (29 eyes of 29 patients) included those undergoing pars-plana-modified AGV along-with PK. Outcome measures included corneal graft clarity, intraocular pressure (IOP), number of antiglaucoma medications, and postoperative complications. Patients were followed up for a minimum period of 2 years.Results: Out of 58 eyes (58 patients), 50 eyes (50 patients: 25 eyes of 25 patients each in group 1 and group 2) completed the study and were analyzed. Complete success rate for AGV (group 1: 76%; group 2: 72%; p = 0.842) and corneal graft clarity (group 1: 68%; group 2: 76%; p = 0.081) were comparable between the two groups at 2 years. Graft failure was more in conventional AGV (32%) as compared to pars plana-modified AGV (24%) but not statistically significant (p = 0.078) at 2 years.Conclusion: Though both procedures were comparable in various outcome measures, pars-plana-modified AGV is a viable option for patients undergoing PK, as it provides a relatively better corneal graft survival rate and lesser complications that were associated with conventional AGV.

Combined deep sclerectomy and descemet stripping automated endothelial keratoplasty.

The aim of this study was to evaluate a novel surgical combination of Descemet stripping automated endothelial keratoplasty (DSAEK) and deep sclerectomy (DS) for the management of concomitant corneal endothelial decompensation and uncontrolled glaucoma. This retrospective case series noncomparative study included 9 eyes of 6 consecutive patients with coexistence of corneal edema resulting from Fuchs dystrophy or pseudoexfoliation keratopathy and medically uncompensated glaucoma; these patients underwent combined DSAEK and DS with mitomycin C and an absorbable collagen implant. Corneal graft clarity, endothelial cell density, visual acuity, intraocular pressure (IOP), and identification of complications were assessed over a 2-year follow-up. All eyes obtained graft clarity throughout the follow-up, with a final average endothelial cell decrease of -36% from baseline, and showed improved vision and good IOP control without hypotensive therapy. Measured at 3 and 24 months postoperation, the mean visual acuity improvement was 154% and 372% and IOP decrease was 51.1% and 46.4%, respectively. Two anterior segment complications occurred in 2 (22%) patients' eyes. This consisted of a graft dislocation and a modest IOP elevation, treated successfully. Combined DSAEK and DS was longitudinally associated with good corneal graft survival and IOP control, with few complications. These findings suggest that this surgical approach is a viable option for patients with coexisting glaucoma and corneal endothelial dysfunction. Our study should stimulate a multicenter, randomized, controlled trial of our technique.

Efficacy and safety of systemic tacrolimus in high-risk penetrating keratoplasty after graft failure with systemic cyclosporine.

The aim of this study was to investigate the efficacy and safety of systemic tacrolimus for the treatment of eyes that developed graft failure despite treatment with cyclosporine (CsA). Ten eyes of 10 patients who underwent high-risk penetrating keratoplasty (PKP) and developed graft failure despite treatment with systemic CsA were included in this study. The patients underwent PKP and were treated with systemic tacrolimus according to the standardized protocol. Treatment with tacrolimus was continued for 18.1 ± 13.9 months. The median duration of corneal graft clarity was 34.5 months. Graft rejection occurred in 2 of 10 eyes during a mean follow-up period of 48.9 ± 22.9 months. Kaplan-Meier survival plots showed significantly fewer graft rejection episodes (P = 0.033) and longer graft survival (P = 0.042) after treatment with tacrolimus compared those with CsA. Tacrolimus was discontinued in 2 patients; 1 had renal dysfunction and the other had muscle pain and fatigue. These side effects subsided after discontinuation of tacrolimus. Treatment with systemic tacrolimus is possibly safe and effective in reducing graft rejection and prolonging graft survival in patients with high-risk PKP after graft failure with systemic CsA.

Clinical Results and Influential Factors of Modified Large-Diameter Lamellar Keratoplasty in the Treatment of Total Limbal Stem Cell Deficiency

To analyze the clinical results and potential influential factors of modified large-diameter lamellar keratoplasty in patients with total limbal stem cell deficiency. Thirty-six eyes of 35 patients were included in this study. Best-corrected visual acuity, ocular surface stability, central corneal graft clarity, and postoperative complications were recorded. Related influential factors were evaluated using Cox regression analysis. At the final follow-up (mean, 48.1 ± 43.2 months), 21 eyes (58.3%) had an improvement in best-corrected visual acuity of at least 1 line. Twenty-seven eyes (75.0%) had a stable ocular surface. The survival of ocular surface stability was 74.4% ± 7.4%, 58.9% ± 8.5%, 51.1% ± 9.0%, and 39.3% ± 9.2% at 1, 2, 5, and 7 years after surgery, respectively. Twenty-one eyes (58.3%) maintained a clear graft. The survival of central graft clarity was 74.4% ± 7.4%, 59.5% ± 8.4%, 55.2% ± 8.8%, and 46.7% ± 9.3% at 1, 2, 5, and 7 years after surgery, respectively. Thirteen eyes (36.1%) developed persistent epithelial defects, and immune rejection occurred in 9 eyes (25.0%). The Cox regression analysis revealed that previous eyelid reconstruction [relative risk (RR) = 0.035] and combination with subconjunctival implantation of a cyclosporine A drug delivery system (RR = 0.170) were protective factors. Preoperative persistent epithelial defects (RR = 3.443) and decreased Schirmer test (RR = 6.770) were risk factors associated with ocular surface stability. The modified large-diameter lamellar keratoplasty seems to be effective in reconstructing an ocular surface with long-term stability. Improvement in tear production, reconstruction of eyelid abnormalities, and combination with subconjunctival implantation of an immunosuppressive drug delivery system can help to maintain a stable ocular surface.

Ab Interno Management of Blocked Ahmed Valve in the Posterior Segment

To report a case of late failure of a posterior segment placed Ahmed valve in a uveitic eye with a corneal graft and a minimally invasive, ab interno approach in restoring valve function, pressure control, and preservation of vision. Case report. A 25 gauge trans-conjunctival 3-port pars plana vitrectomy was performed to inspect and clean the ostium of the Ahmed valve of any vitreous debris. The Ahmed valve was not disturbed externally and conjunctival dissection was not performed. A 27-gauge blunt cannula was introduced through the vitrector site and used to cannulate the tube and flush it with balanced salt solution. A bleb was immediately re-established and all instruments were removed requiring no sutures. Intraocular pressure returned to target levels and a filtration bleb was re-established. Corneal graft clarity was restored with resolution of preoperative microcystic edema. Postoperative inflammation was minimal and vision was restored. A nonfunctioning tube shunt residing in the vitreous cavity may be revised ab interno without disturbing the shunt placement or the conjunctiva under which it resides to re-establish filtration.

Clinical Results with the Use of a Temporary Keratoprosthesis in Combined Penetrating Keratoplasty and Vitreoretinal Surgery

To evaluate surgical outcomes using a temporary intraoperative keratoprosthesis (KP) in patients undergoing combined pars plana vitrectomy (PPV) and penetrating keratoplasty (PKP). From January 2001 to August 2008, medical records of 23 patients undergoing combined KP/PPV/PKP for traumatic and nontraumatic corneal and retinal pathologies were studied. Only patients with >or=6 months follow-up were included. Patient characteristics, diagnoses, visual acuity, intraocular pressure, and status of the retina and cornea at baseline, and postoperatively on day 1, months 1 and 6, and yearly until the last follow-up, were collected. Functional (best-corrected visual acuity: improved, stable, worsened) and anatomic outcomes (clear corneal graft, retinal reattachment) were defined prior to review. Twenty-four eyes underwent combined KP/PPV/PKP (mean follow-up 36 months). At final follow-up, best-corrected visual acuity improved in 8 (40%) eyes, remained stable in 8 (40%), and worsened in 4 (20%). Corneal graft was clear in 18 (79%) eyes; 5 (21%) had graft failure. Retinal reattachment occurred in 22 (92%) eyes; 2 (8%) developed a localized traction retinal detachment not warranting additional surgery. Derangement in intraocular pressure was common (13 [54%] eyes). Three eyes (13%) showed signs of phthisis preoperatively that resolved with reestablishment of normal intraocular pressure postoperatively. Temporary KP during PPV/PKP surgery allowed surgical intervention in eyes with complex anterior and posterior segment disease. Corneal graft clarity and successful retinal reattachment was possible in the majority of eyes.

Clinical observation on the individuated treatments of corneal perforation

Objective To explore the indication and efficacy of different types of surgery for corneal perforation. Methods In our nonrandomized retrospective case series, thirty six cases (36 eyes)with corneal perforation,in which eight bacterial keratitis, six fungal keratitis, four corneal chemical injuries, three exposure keratitis, and keratoconus, Morren corneal ulcer, after foreign body removal of 2, underwent penetrationg keratoplasty,anterior segment reconstruction, lamellar keratoplasty, amniotic membrane transplantation, according to the cause of corneal perforation, size, location and other comprehensive situation. Postoperative perforation healing, visual acuity, corneal graft clarity and complications were studied during a follow-up of 5 to 20 months. Results All perforation was closed,postoperative visual acuity was improved in 36 cases (100%) in varying degrees,and none of the primary keratopathy recurred. 12 grafts of penetrating keratoplasty were transparent, 4 were semi-transparent,2 were cloudy because of rejection. 5 grafts of lamellar keratoplasty were transparent,4 were semi-transparent. 4 grafts receiving anterior segment reconstruction restored the anatomy of anterior segment, without serious rejection. Conclusion In patients with corneal perforation, operation should be done according to the cause of corneal perforation, size, location and other comprehensive situation. It is an effective approach for treatment of primary disease,infection control, preservation of eyeballs and restoration of visual function. Key words: Corneal perforation; Individuation; Surgery; Corneal transplantatinon

Ab-externo cyclodialysis enhanced trabeculectomy for intractable post-penetrating keratoplasty glaucoma

To evaluate the efficacy of cyclodialysis-enhanced Mitomycin c (MMC) trabeculectomy in post-keratoplasty glaucoma. Prospective, non-comparative, interventional case series. A total of 45 eyes of 45 consecutive patients with refractory glaucoma after penetrating glaucoma underwent a cyclodialysis-augmented trabeculectomy with MMC. The visual acuity, intraocular pressure (IOP), corneal clarity, and graft failure were evaluated over a minimum follow-up of 2 years. The mean age of the patients was 55.4+/-9.4 years. The cyclodialysis-augmented MMC trabeculectomy procedure resulted in a mean reduction of IOP from 38.9+/-3.9 mmHg (95% confidence interval (CI) 35.9-42.2) at baseline to 11.3+/-2.8 mmHg (95% CI 9.5-12.9), at final follow up (P=0.002). Blebs were avascular, diffuse, and extended posteriorly. Postoperative UBMs revealed the presence of a cyclodialysis with a small associated suprachoroidal effusion and a subconjunctival filtering bleb in all cases. Cyclodialysis-augmented MMC trabeculectomy provides a safe and effective method of lowering IOP in intractable glaucoma following penetrating keratoplasty, without compromising the corneal graft survival and clarity.

Whole Globe Enucleation Versus In Situ Excision for Donor Corneal Retrieval-A Prospective Comparative Study

The purpose of this study was to compare the results after changing from conventional whole globe enucleation to in situ excision of donor corneas. Donor corneal tissue retrieved by enucleation (n = 50) and in situ excision (n = 50) was quantitatively evaluated prospectively, and the main parameters evaluated were endothelial cell counts, ultrasonic corneal pachymetry, microbial contamination, graft clarity, and postoperative median visual acuity at the end of 3 months. Mean preoperative donor endothelial cell densities were 2174 +/- 123 and 2132 +/- 149 cells per millimeter square after enucleation and in situ excision, respectively (P = 0.13). The preoperative disease distribution and visual potential of recipients were comparable between the 2 groups. Corneal pachymetry was lower in the whole globe group at the end of 3 months (528 microm, enucleation group; and 539 microm, in situ group; P = 0.01). The mean postoperative endothelial cell counts were comparable in both groups at 3 months (1708 +/- 104.8/mm for whole globe group, measured in 40 eyes, vs 1674 +/- 117.4/mm in in situ group, recorded in 39 eyes; P = 0.18). The number of positive corneoscleral rim cultures postkeratoplasty was statistically comparable in both groups (20% in enucleation group and 24% in in situ group; P = 0.62). At 3 months, 98% and 92% of grafts had a graft clarity of >or=3+ in whole globe and in situ groups, respectively (P = 0.16). Seventy-two percent of patients in whole globe group and 67% in in situ group achieved a best-corrected visual acuity of >or=0.1. Postoperative graft infection developed in 2 cases in the in situ group. Changeover from whole globe enucleation technique to in situ excision technique of harvesting donor corneas demonstrated that in situ excision is a viable alternative.

The role of the Femtosecond (FS) laser in lamellar keratoplasty

Abstract Purpose: To evaluate the safety and feasibility of the FS laser for the preparation of posterior lamellar discs and to evaluate the first clinical results of a new technique – Femtosecond Laser Descemet Stripping Endothelial Keratoplasty (FS‐DSEK) – for surgical treatment of corneal diseases.Setting: Department of Ophthalmology, Academic Hospital, Maastricht, The Netherlands. Cornea Bank, Amsterdam, The Netherlands. University Medical Center, Groningen, The Netherlands. University Medical Center St. Radboud, Nijmegen, The Netherlands, Eye Hospital Rotterdam. Methods: A 30 kHz FS laser (IntraLase Corp., Irvine, CA) was used to prepare a lamellar cut in the cornea of human donor eyes. After FS laser preparation of a 9.5 mm wide lamellar cut at a depth of 400 micron, the corneoscleral button was stored in organ culture medium. The endothelial viability was assessed after preparation of the lamellar cut and after dissection of the donor posterior lamellar disc (PLD) from the anterior cornea. In ten eyes of ten patients with pseudophakic bullous keratopathy the PLDs were used for endothelial keratoplasty. The follow‐up ranged from 13 to 26 weeks. Results: The mean±sd endothelial cell loss after FS preparation of the lamellar cut (n=4) was 3.4%±3.5% and after dissection of the posterior lamellar disc (n=5) was 6.5%±3.2%. There was no significant difference in endothelial cell loss between FS and non‐FS laser treated corneas after organ culture (p=0.46).All eyes had a clear graft with functioning endothelium. In 4 eyes BCVA was 20/40 to 20/50. In the other 6 eyes BCVA ranged from 20/200 to 20/40 and 5/6 eyes had pre‐existing maculopathy. The surgically induced astigmatism was 2.1 D. Longer‐term results will be presented to assess graft clarity and visual outcomes in the other eyes. Conclusions: FS laser preparation of posterior lamellar discs is safe and feasible for performing FS‐DSEK. We believe that FS‐DSEK offers a great potential for facilitating endothelial keratoplasty in a more standardized, automated fashion. Longer‐term follow‐up will be necessary to assess final corneal graft clarity and visual outcome.

Long-term outcome of combined penetrating keratoplasty and vitreoretinal surgery using temporary keratoprosthesis

To evaluate the long-term outcome of combined penetrating keratoplasty (PKP) and vitreoretinal surgery using temporary keratoprosthesis (TKP). A retrospective study of 107 eyes with coexisting corneal and vitreoretinal diseases that underwent combined PKP and vitreoretinal surgery using TKP. Corneal graft clarity, intraocular pressure, and anatomical reattachment of retina were followed. The mean follow-up time was 25 months, the longest being 8 years. Successful surgical outcome was defined as maintenance of clear graft, anatomic reattachment of retina, and controlled intraocular pressure. A total of 78 eyes (72.9%) fulfilled these criteria. Surgical intervention within 1 month of ocular injury was associated with higher success rate (81.9%) than intervention at 1 month or more after injury (54.3%). Success rate for reattachment of retina was 95.8% when preoperative proliferative vitreoretinal retinopathy (PVR) was absent compared with 83.1% when preoperative PVR was present. Unsatisfactory postoperative visual acuity was due to graft failure, recurrent PVR, or secondary glaucoma. Combined PKP and vitreoretinal surgery is best performed within 1 month of ocular injury for best surgical outcome. Careful selection of cases plays an important role in reducing the risks of complications. TKP is a useful adjunct in the surgery.

The long-term results of keratoplasty in eyes with a glaucoma drainage device

Purpose To study the outcome of penetrating keratoplasty (PK) in eyes with a glaucoma drainage device (GDD). Design Retrospective case-controlled study. Methods We reviewed all patients who underwent PK from December 1986 to September 2002 at the University of California, Davis (n = 1,974). We identified 33 patients (40 grafts) who were treated with a GDD and followed up for 6 months or more after PK. Graft survival and glaucoma control were compared with grafts in patients without glaucoma (n = 40) and patients with medically controlled glaucoma (n = 17). Kaplan-Meier survival analysis, log rank test, repeated-measures analysis of variance (ANOVA), Fisher exact test, and χ 2 were used in group comparisons. Multivariate analysis was performed using the Cox proportional hazards model. Results The percentages of clear grafts in the glaucoma drainage device group were 58.5% and 25.8% at 1 and 2 years, respectively. At these time points, glaucoma was controlled in 74.0% and 63.1% of the eyes, respectively. Both medically controlled glaucoma patients and nonglaucomatous patients had higher graft survival percentages at comparable time points. The presence of a GDD was an important factor influencing graft survival (Hazard ratio = 6.8). Conclusion A GDD implant is an independent risk factor for graft failure. Although these devices are effective in controlling intraocular pressure (IOP) in the majority of eyes in the presence of PK, corneal graft clarity is often compromised.

Pars plana tube insertion of glaucoma drainage implants and penetrating keratoplasty in patients with coexisting glaucoma and corneal disease.

To determine the efficacy and associated complications of glaucoma drainage implant (GDI) surgery with pars plana tube insertion and penetrating keratoplasty (PK) in eyes with glaucoma and corneal disease. Retrospective, interventional case series. All patients who underwent both GDI surgery with pars plana tube insertion and PK before September 1997 were included. The medical records of 34 consecutive patients (34 eyes) who had undergone GDI (Baerveldt, Pharmacia & Upjohn, Kalamazoo, MI; Molteno, IOP INC:, Costa Mesa, CA; Krupin, Hood Laboratories, Pembroke, MA; or Ahmed, New World Medical, Rancho Cucamonga, CA) insertion before, concurrent with, or after PK were reviewed retrospectively. All corneal grafts were clear before GDI surgery for patients who underwent glaucoma surgery after PK. Outcomes were evaluated using Kaplan-Meier life-table analysis. Clinical outcome assessment included corneal graft clarity, intraocular pressure (IOP), visual acuity, and identification of complications. Mean follow-up after completion of both GDI surgery and PK was 12.1 +/- 8.4 months (range, 0-31.8 months). Twelve- and 24-month life-table rates for complete success after both GDI and PK were 63% and 33%, respectively. Twelve- and 24-month life-table success rates for IOP control and corneal graft clarity were 85% and 62%, and 64% and 41%, respectively. Final postoperative visual acuity was the same as or better than (> or =2 Snellen lines) the preoperative level in 29 patients (85%). One or more posterior segment complications occurred in 15 (44%) patients. Pars plana tube insertion of GDIs is a reasonable option for patients who have undergone PK or in whom PK is anticipated, despite the need for a complete pars plana vitrectomy. Although complications related to limbal tube placement are avoided, the incidence of posterior segment complications may be higher for pars plana insertion. The potential for enhanced corneal graft survival with pars plana versus anterior segment tube placement warrants further investigation.