Deep Lamellar Endothelial Keratoplasty Research Articles

An Overview of Epithelial and Stromal Corneal Dystrophies

Principally, corneal dystrophies are a set of conditions that impact corneal transparency and distorts corneal structure. They are commonly bilateral, progressive, and differs from corneal degeneration as they are often inherited through autosomal dominant or recessive modes as well as x-linked modes. Several genes have been implicated in corneal dystrophies and will be elaborated on in the description of dystrophies in this article. Management of corneal dystrophies depend on severity of symptoms and require specialist input. Mildly symptomatic dystrophies do not warrant management. However, in those with progressive disease and/or poor vision, surgical options may be of use. Techniques commonly involved in the management of dystrophies include deep lamellar endothelial keratoplasty, penetrating keratoplasty, or the area of disease is ablated using a photo-therapeutic keratectomy.

Effects of corneoconjunctival transposition, posterior lamellar keratoplasty and modified deep lamellar endothelial keratoplasty on streak retinoscopy in equine cadaver eyes.

Evaluate the effects of corneoconjunctival transposition (CCT), posterior lamellar keratoplasty (PLK) and modified deep lamellar endothelial keratoplasty (DLEK) on streak retinoscopy in equine cadaver eyes. Intraocular pressure (IOP) was maintained at 25 ± 3 mmHg in 35 equine cadaver eyes. Streak retinoscopy was performed prior to (NO VISCO) and following (VISCO) intracameral injection of 1.0ml of viscoelastic. Following optical coherence tomography (OCT), an axial CCT [n=11] or PLK [n=12], or peripheral DLEK [n=12] was performed. Streak retinoscopy and OCT were repeated postoperatively. Postsurgical net meridional and spherical refraction for CCT [Horizontal (H): 3.4 (95% CI 2.4-4.4) diopters (D), p < .001, Vertical (V): 3.5 (95% CI 2.7-4.4) D, p < .001, Spherical: 3.5 (95% CI 2.6-4.3) D, p < .001] and PLK [H: 3.2 (95% CI 2.2-4.1) D, p < .001, V: 2.8 (95% CI 2.0-3.6) D, p < .001, Spherical: 3.0 (95% CI 2.2-3.8) D, p < .001] were significantly increased from presurgical (VISCO) values. No difference between presurgical (VISCO) and postsurgical values were identified for the DLEK. Postoperative OCT revealed space between anterior and posterior corneal grafts and corneal undulation associated with suture placement. Meridional and spherical refraction had a hyperopic shift following CCT and PLK, with a significantly higher value in the vertical meridian for the CCT. Pre- and postoperative refraction was not significantly different for the DLEK. This supports that the DLEK has a lesser effect on immediate postoperative refraction compared with CCT or PLK.

Эндотелиальная кератопластика вчера и сегодня (обзор литературы)

The article presents the literature review on the history and development of endothelial keratoplasty, which is one of the options for corneal transplantation. It includes different surgical techniques (posterior lamellar keratoplasty, with removal of the a circular section of the Descemet's membrane, deep lamellar endothelial keratoplasty, posterior lamellar keratoplasty (automated), etc.) used for the treatment of patients with pathology of the corneal endothelium and is characterized by replacement of it with corneal back layers of the donor graft. Ophthalmic surgical practice has convincingly shown a significant advantage of modern methods of endothelial keratoplasty in comparison with classical penetrating keratoplasty, which is a long-term standard in the treatment of corneal pathology. Key word: endothelial keratoplasty, the pathology of the corneal endothelium, corneal transplantation, posterior lamellar keratoplasty, deep lamellar endothelial keratoplasty.

Corneal transplant epidemiology in a reference center in Bogotá, Colombia (2010-2017)

Purpose: To describe the characteristics of the donor and recipient, indications, surgical techniques, and survival results obtained from patients with corneal transplants performed at Fundacion Oftalmologica Nacional (FUNDONAL) between 2010 and 2017. Methods: Descriptive, observational study. Medical records of patients who underwent corneal transplantation were reviewed. Demographic data, surgery indication, transplantation technique, graft transparency, and presence of rejection are evaluated. Statistical analysis was performed with the SPSS software version 21.0. Results: Seven hundred and twelve eyes from 690 patients who underwent corneal transplantation were analyzed. The median age of the recipient was 42 years (interquartile range 21.8 years) and 392 participants (56.8%) were men. Corneal ectasias was the first indication for transplantation. The technique performed most often was penetrating keratoplasty (PK) (89.6%), followed by deep anterior lamellar keratoplasty (5.3%), endothelial keratoplasty (3.5%), and sclerokeratoplasty (1.5%). 22.25% of the cases presented at least one rejection episode. Transparency of the graft is >80% up to 36 months from follow-up. Conclusions: In 712 eyes that underwent corneal transplantation between 2010 and 2017, the most frequent indications were corneal ectasias, pseudophakic/aphakic bullous keratopathy, and previous graft failure. Although the most common technique is PK, there is a tendency to perform more lamellar transplants over the years. Survival up to the last control was 78% with graft rejection at 22.23%, which are comparable with results reported in the scientific literature. This study constitutes the first corneal transplant registry in Colombia, with survival results and description of variables that will allow for the identification of risk factors for undesirable outcomes.

Indications for intraoperative anterior segment optical coherence tomography in corneal surgery

PurposeRecently, intraoperative optical coherence tomography (iOCT) has evolved in the field of ophthalmic surgery. So far, the use of iOCT was mainly focused to lamellar keratoplasty, especially deep anterior lamellar keratoplasty (DALK) and Descemet membrane endothelial keratoplasty (DMEK). The aim of this study was to report our experiences with iOCT to introduce new possibilities of this application.MethodsWe used iOCT in 18 patients who underwent the following surgeries: DALK, DMEK, penetrating keratoplasty, autologous limbal transplantation, transscleral suture fixation of a posterior chamber lens, pannus removal on corneal surface and newborn investigation in Peters’ anomaly. We obtained qualitative video data for all procedures.ResultsWith the iOCT, the cannula placement during DALK preparation of the recipient cornea and bubble formation could be visualized to improve the success rate of the big bubble injection. In DMEK, the iOCT enables the visualization of Descemet’s membrane removal in the recipient and graft orientation as well as better control of graft attachment. The iOCT enables intraoperative visualization of the graft–host interface during penetrating keratoplasty. During autologous limbal transplantation, transscleral suture fixation of a posterior chamber lens and removal of corneal surface pannus the iOCT is capable of showing the thickness of lamellar preparations to avoid penetrations and to save healthy recipient’s tissue.ConclusionThe iOCT is a helpful device for intraoperative anterior segment imaging not only for DALK and DMEK. It is also beneficial in penetrating keratoplasty and every other form of lamellar preparation during corneoscleral surgery.

Deep Lamellar Endothelial Keratoplasty Clinical Outcome: The 13- to 18-year Follow-up

Deep Lamellar Endothelial Keratoplasty Clinical Outcome: The 13- to 18-year Follow-up

Changing trends in corneal graft surgery: a ten-year review.

To review indications and corneal tissue use for penetrating and lamellar surgery between 2002 and 2011. The surgical reports of corneal grafts performed during 2002-2011, using tissues supplied by the Eye Bank of Piedmont (Italy), were reviewed retrospectively. Patient demographic data, date of intervention, indication for surgery, and surgical technique used were recorded. Surgical techniques included penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK) and endothelial keratoplasty (EK). The χ (2) test was used to compare the distribution of indications and types of surgical technique used, for corneal grafts done during 2002-2006 versus those done during 2007-2011. The number of corneal grafts increased by 30.7% from 2002-2006 to 2007-2011 (from 1567 to 2048). Comparing the two periods, both main indications and surgical techniques changed significantly. In 2007-2011, the proportion of interventions for aphakic/pseudophakic bullous keratopathy (from 16.8% to 21.3%), graft failure (from 16.4% to 19.1%) and Fuchs endothelial dystrophy (from 12.8% to 16.7%) all increased significantly (P<0.05), while those for keratoconus decreased significantly (from 35.6% to 27.3%; P<0.001). In 2007-2011, the proportion of PK decreased significantly (from 92.4% to 57.2%; P<0.001) while that of EK and DALK went from 0.4% to 30.2% (P<0.001) and from 7.2% to 12.6% (P<0.001) respectively. During 2002-2011 the number of interventions increased significantly for corneal endothelial diseases and graft failure. The growing demand for interventions for these diseases corresponded to the widespread adoption of EK techniques. The use of DALK also increased, but more moderately than EK procedures.

Femtosecond Laser-Assisted Deep Lamellar Endothelial Keratoplasty: A New Approach to a Forgotten Technique.

To review indications and clinical results for a hybrid deep lamellar endothelial keratoplasty (Femto-DLEK) technique combining contemporary donor tissue preparation and implantation techniques with femtosecond laser-assisted dissection of the host tissue. A retrospective analysis of consecutive cases of Femto-DLEK performed between 2011 and 2014 at Moorfields Eye Hospital, London, was conducted. All patients underwent manifest refraction and optical coherence tomography examination at their most recent review visit. Secondary interventions, graft rejection, and graft failure were recorded alongside corrected distance visual acuity. Femto-DLEK was performed in 7 eyes of 7 cases. Mean postoperative follow-up duration was 19 months. Indications included revision of deep anterior lamellar keratoplasty (n = 4), revision of failed Descemet stripping endothelial keratoplasty in cases with an anterior chamber intraocular lens (n = 2), and primary surgery in cases of dense posterior stromal copper deposition. All corneas were recorded as clear by 6 weeks after surgery. Median (range) preoperative corrected distance visual acuity was 6/60 (6/9-1/60), which improved to 6/9 (6/6-6/24) at final review. Tissue bridges requiring significant additional manual lamellar dissection were present in all 4 cases in which deep stromal femtosecond laser lamellar dissection was performed. Femtosecond laser host dissection in the remaining cases was restricted to only a posterior side-cut. Femto-DLEK is a useful alternative endothelial keratoplasty modality for a narrow range of indications. The femtolaser posterior side-cut facilitates DLEK, but further development of the Femto-DLEK technique is required to optimize the combination with deep lamellar host dissection.

Modified lamellar keratoplasties for the treatment of deep stromal abscesses in horses.

To describe a surgical modification of deep lamellar endothelial keratoplasty (DLEK) and posterior lamellar keratoplasty (PLK) procedures, to facilitate surgery on standing horses under-sedation. Four client-owned horses, for which the owners declined surgery under general anesthesia, underwent standing corneal lamellar keratoplasty procedures for the treatment of deep corneal stromal abscesses. All four horses were placed in stocks and sedated with detomidine. Local eyelid and retrobulbar blocks were performed to provide local analgesia and akinesia, and each horse's head was stabilized and supported by soft pads placed on a mobile cart. Deep lamellar endothelial keratoplasties (DLEKs) and posterior lamellar keratoplasties (PLKs) were performed on two horses each, for the treatment of deep stromal abscesses (DSA). Following the first DLEK, a mid-stromal two-step anterior lamellar keratectomy modification was used to facilitate rapid closure of the anterior chamber immediately following removal of the abscess. Each of the four horses had similar cosmetic and postoperative visual outcomes, compared to previously published results. Intra-operative complications were most prevalent in the first DLEK case (i.e., focal iris and lens damage and postoperative anterior chamber collapse) and were all but eliminated in the remaining three cases. Similar to previously reported findings, greater postoperative corneal fibrosis was observed in the DLEK cases. In horses with deep stromal or endothelial abscesses, for which general anesthesia is not an option, both the modified DLEK and PLK corneal procedures may be performed as an alternative to enucleation on the standing, sedated horse.

Vision-related Quality of Life Before and After Keratoplasty for Fuchs' Endothelial Dystrophy

To assess vision-related quality of life in Fuchs' dystrophy and changes in vision-related quality of life after 3 types of keratoplasty (penetrating keratoplasty [PK], deep lamellar endothelial keratoplasty [DLEK], and Descemet stripping endothelial keratoplasty [DSEK]). Prospective, observational case series. Sixty-three subjects with Fuchs' endothelial dystrophy: 12 subjects (12 eyes) received PK, 11 subjects (11 eyes) received DLEK, and 40 subjects (40 eyes) received DSEK. Subjects were examined before keratoplasty and at regular intervals through 3 years after keratoplasty. At each examination, vision-related quality of life was assessed using the 25-item National Eye Institute Visual Functioning Questionnaire; best spectacle-corrected and uncorrected visual acuities were measured by using the electronic Early Treatment of Diabetic Retinopathy Study protocol; keratometric cylinder was measured by a manual keratometer. Disability glare was measured with a straylight meter. Vision-related quality of life composite score. Vision-related quality of life composite score for all eyes with Fuchs' dystrophy before keratoplasty was 72 ± 11 (n = 63) and did not differ between groups (P = 0.88). Vision-related quality of life improved by 6 months (PK, P = 0.008; DLEK, P = 0.03; DSEK, P < 0.001), with continued improvement between 6 months and 3 years after PK (P = 0.01) and DSEK (P = 0.004). At 6 months, the composite score was higher after DSEK than after PK (P = 0.006). At 3 years, there were no differences in composite scores between the 3 treatments (P = 0.33; mean minimum detectable difference, 8 [α = 0.05; β = 0.20]). After keratoplasty, quality of life was correlated with uncorrected visual acuity at 1 year (r = -0.38; P = 0.001) and at 3 years (r = -0.36; P = 0.02), with disability glare at 3 years (r = -0.41; P = 0.02), and with best-corrected visual acuity at 6 months (r = -0.34; P = 0.03), but not thereafter. Vision-related quality of life in patients with Fuchs' endothelial dystrophy is significantly impaired but improves after keratoplasty, irrespective of the technique. The improvement is faster after DSEK than after PK, and this might be explained in part by rapid improvement in uncorrected visual acuity after DSEK. This study affirms an advantage of endothelial keratoplasty over PK with respect to patient-reported outcomes.

New Perspectives on Lamellar Keratoplasty

Lamellar (anterior and posterior) keratoplasty entails the surgical replacement of diseased-only corneal tissue, while healthy host corneal tissue is preserved. Selective keratoplasty offers several advantages in comparison to penetrating keratoplasty such as a lower rate of graft rejection, less endothelial cell loss, faster/superior visual rehabilitation and enhanced resistance to closed injury. The surgical approach of "partial corneal transplantation" may be divided into anterior and posterior: techniques including superficial and deep anterior lamellar keratoplasty (SALK and DALK, respectively) and endothelial keratoplasty as well as Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). These novel surgical procedures are rapidly becoming the preferred therapy option for specific corneal dysfunctions involving the corneal stroma (SALK, DALK), or corneal endothelium (DSAEK, DMEK). During the past decade, the continuing advancement of surgical techniques and the development of innovative surgical instruments have significantly enhanced corneal transplantation. Lamellar keratoplasty techniques facilitate corneal surgery, provide patients with superior outcomes and can successfully restore vision in corneal-related blindness. Nevertheless, more long-term evidence is needed to better evaluate these promising new techniques.

Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy

Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy

Correlation between visual acuity and interface reflectivity measured by pentacam following DSAEK

Descemet-stripping automated endothelial keratoplasty (DSAEK) is an advanced method of lamellar endothelial keratoplasty. In comparison with penetrating keratoplasty, visual rehabilitation seems to be faster. Final visual outcome of DSAEK, however, seems to be limited, especially in comparison with Descemet membrane endothelial keratoplasty (DMEK). DSAEK cases without graft failure often do not show any definite correlate for the reduced optical performance. In this study, we tried to correlate visual acuity following DSAEK with interface reflectivity as measured by a rotating Scheimpflug system. We examined 14 eyes of 13 patients with the pentacam for 2-11 months following DSAEK. Reflectivity of the interface region in the centre of the optical axis as well as central corneal thickness was determined. Statistical correlation between interface reflectivity and best spectacle-corrected visual acuity, central corneal thickness and follow-up time was drawn (multifactorial linear regression analysis). Statistically significant correlation between interface reflectivity and BSCVA as well as follow-up time was found. Reflectivity was highest in regions of interface (metal) particles. There was no statistically significant correlation between interface reflectivity and central corneal thickness. We present a measurable correlate for reduced visual outcome following DSAEK despite a clear graft. Inverse correlation between interface reflectivity and best spectacle-corrected visual acuity (BSCVA) indicates that irregularities or scarring in the interface region may influence the optical quality following DSAEK.

Cataract surgery in patients with corneal disease

Preexisting corneal disease can be exacerbated by cataract surgery and may prevent well tolerated cataract extraction. This article reviews the current literature and describes how corneal epithelial, stromal and endothelial disease may impact and be impacted by cataract surgery while highlighting recommendations for perioperative management and surgical technique. Modifications to surgical techniques can allow for improved intraoperative visualization and safer cataract removal. Cataract surgery can be safely performed in conjunction with newer forms of corneal transplantation such as deep anterior lamellar keratoplasty and endothelial keratoplasty; however, guidelines for when to perform combined surgery have not been established. Appropriate perioperative management and advances in surgical techniques and technologies allow for successful cataract surgery in patients with corneal disease. Signs of corneal disease should be identified preoperatively to allow for surgical planning and optimal visual outcomes.

Comparison of long-term clinical outcomes between descemet's stripping endothelial keratoplasty and deep lamellar endothelial keratoplasty

To investigate the differences of long-term clinical outcomes between two kinds of corneal endothelial keratoplasty (EK): DSEK and DLEK. Retrospective, comparative, clinical case series study. Twenty-six patients (26 eyes), undergoing DLEK and thirty-six patients (36 eyes), undergoing DSEK during the period of October 2005 to March 2008, were involved in this study. Before and at 6 month intervals after surgery, patients' data were collected to analyze the surgery success rate, graft dislocation rate, best corrected visual acuity (BSCVA), graft survival rate and endothelial cell density (ECD). The follow-up time was 3 to 5 years. The success rate of DLEK was 88.5% while DSEK was 86.1%. Average BSCVA of DLEK were similar to those of DSEK at each follow-up time after 12 months postoperatively. Graft survival rates of DLEK and DSEK were respectively 87% and 75.9%, where as ECD were respectively 1638 cells/mm(2) and 1874 cells/mm(2) at 36 month postoperatively, the data were similar in both ECD and graft survival rate between DLEK and DSEK at 60 months postoperatively. The success rate and long-term visual outcomes of DLEK were similar with those of DSEK. To obtain objective results, it is better to consider both ECD and graft survival rate instead of recording ECD only for its localization in evaluating the efficacy of EK.

The era of lamellar keratoplasty, evolving surgical techniques in corneal transplantation: the University of Toronto experience

ObjectiveTo analyze the changing trends in corneal transplantation techniques and the way selective lamellar transplantation has influenced our practice. DesignRetrospective survey of all corneal transplants performed by a single practice at Toronto Western Hospital. ParticipantsAll corneal transplants performed by our office since 2002, the year we performed our first lamellar transplant. MethodsWe retrospectively reviewed all keratoplasty procedures performed in our office between January 2002 and December 2010. Procedures were classified as penetrating keratoplasty (PKP); deep lamellar endothelial keratoplasty (DLEK); Descemet's stripping automated endothelial keratoplasty (DSAEK); or deep anterior lamellar keratoplasty (DALK). ResultsA total of 1104 procedures were performed in this period (average, 122.6 per year). Of these, 654 were PKPs (59.3%); 107 DLEKs (9.7%); 219 DSAEKs (19.8%); and 124 DALKs (11.2%). The number of PKPs performed decreased by 61.8% over this 9-year survey. For the last 4 years of the study, the proportions of PKP, DSAEK, and DALK procedures performed were 41%, 40%, and 19%, respectively. ConclusionsThis 9-year audit showed that in less than a decade since its introduction at our institution, selective lamellar transplantation has become the procedure of choice for corneal keratoplasty, accounting for 59% of all transplants performed over the past 4 years.

Comparison of the Surgical Outcomes of Various Methods of Endothelial Keratoplasty.

The objective of this study was to evaluate the outcomes of various techniques of endothelial keratoplasty (EK) including deep lamellar endothelial keratoplasty (DLEK), Descemet stripping endothelial keratoplasty (DSEK), and Descemet stripping automated endothelial keratoplasty (DSAEK). This was a retrospective comparative case series. The medical records of 48 consecutive patients who have undergone EK in a tertiary eye center between January 2005 and June 2011 were reviewed. Information related to demographics, visual acuity, corneal endothelial cell count, and postoperative complications was recorded. The series included 11 eyes with DLEK, 11 eyes with DSEK, and 26 eyes with DSAEK. There was no significant difference in visual outcomes, endothelial cell loss, and postoperative complications between the 3 groups 1 year after surgery. The mean logMAR visual acuity at 12 months was 0.54 (SD, 0.26) for DLEK, 0.55 (SD, 0.47) for DSEK, and 0.63 (SD, 0.48) for DSAEK, respectively. The 6-month endothelial cell density loss was 48.4%, 39.2%, and 47.5% for the DLEK, DSEK, and DSAEK groups, respectively. Early postoperative graft dislocation occurred in 1 (9%) of the DLEK cases, 2 (18%) of the DSEK cases, and 1 (4%) of the DSAEK cases. All of these cases were successfully repositioned. Despite the various evolution and surgical modifications and development in EK in the past few years, the visual outcomes and postoperative complications between DLEK, DSEK, and DSAEK were comparable.

Outcomes of Repeat Endothelial Keratoplasty in Patients With Failed Deep Lamellar Endothelial Keratoplasty

To report the outcomes of repeat endothelial keratoplasty (EK) in patients with previous failed deep lamellar endothelial keratoplasty (DLEK). This retrospective interventional case series involved the review of clinical records of patients with failed DLEK surgery who underwent repeat EK surgery. Ten eyes of 9 patients (2 men and 7 women) were included. The mean age at initial DLEK surgery was 71.2 ± 8.0 years (range, 59-80 years), and the duration to repeat EK was 47 ± 14.3 months (range, 16-63 months). Removal of the failed DLEK donor disc was performed in 7 eyes (70%); in 3 eyes (30%), repeat EK was performed without removal of the failed donor disc. The mean follow-up after repeat EK surgery was 21.7 months (range, 3-44 months). Improvements in corneal clarity and visual acuity were obtained in all eyes. Mean preoperative logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) was 1.46 (20/577; range, 20/100 to counting fingers) and improved to 0.64 (20/87; range, 20/30 to 20/300) at the final follow-up (P = 0.03). Four eyes had limited BCVA secondary to ocular comorbidites, including age-related macular degeneration, cystoid macular edema, and advanced glaucomatous optic neuropathy. No significant postoperative complications were noted after repeat EK surgeries. Repeat EK in patients with late DLEK failure is effective in improving corneal clarity and is a viable alternative to penetrating keratoplasty (PK). Surgery may be performed with or without removal of the failed donor disc. Visual outcomes may be limited by the existence of ocular comorbidities.

Sustainability of Routine Notification and Request legislation on eye bank tissue supply and corneal transplantation wait times in Canada

Objective To assess whether provinces with Routine Notification and Request (RNR) legislation have sustained increases in corneal tissue supply and decreases in wait times for corneal transplantation surgery. Design Cross-sectional survey of Canadian corneal transplant (CT) surgeons and eye banks. Participants Canadian CT surgeons and representatives from the 10 Canadian eye banks. Methods Voluntary and anonymous surveys were distributed between July and October 2009. Eligible CT surgeons were defined as ophthalmologists who practice in Canada; currently perform Penetrating keratoplasty (PKP), Deep anterior lamellar keratoplasty (DALK), Deep lamellar endothelial keratoplasty (DLEK), Descemet stripping endothelial keratoplasty (DSEK), or Descemet membrane endothelial keratoplasty (DMEK); and have obtained tissues from a Canadian eye bank. Results From 2006 to 2009, for provinces with RNR legislation and where data are available, mean wait times from date of diagnosis to date of CT surgery have increased: in Ontario, from 31 ± 34 weeks to 36 ± 27 weeks; in British Columbia, from 39 ± 20 weeks to 42 ± 35 weeks; in Manitoba, from 32 ± 23 weeks to 49 ± 36 weeks. In addition, the amount of corneal tissue in RNR provinces suitable for transplant, with the exception of British Columbia, has declined between 2006 and 2008: in Ontario, 1186 tissues to 999 tissues (16% decline); in Manitoba, 92 tissues to 83 tissues (10% decline); in New Brunswick, 129 tissues to 98 tissues (24% decline). Conclusion Although initially effective, RNR legislation has not sustained an increase in corneal tissue availability nor has it shortened wait times in most provinces. Incorporation of community hospitals into the RNR catchment, improved enforcement, and continued education of hospital staff regarding the RNR process may be effective in making this legislation more sustainable in the long term.

Secondary “Thin-DSEK” After Long-term Graft Failure in DLEK: A Double Transplanted Cornea

To describe a case of secondary "thin Descemet stripping endothelial keratoplasty" ("Thin-DSEK"), for borderline decompensation 6 years after an initial deep lamellar endothelial keratoplasty (DLEK). In a 31-year-old man, who initially underwent a DLEK for bullous keratopathy in the presence of a phakic intraocular lens, a secondary Thin-DSEK was performed, while leaving the entire DLEK graft (including the donor Descemet membrane and the endothelium) in situ. After the initial DLEK, the best-corrected visual acuity (BCVA) improved from 20/200 (0.1) to 20/25 (0.8). Six years later, the transplanted cornea showed intermittent decompensation with a decrease in BCVA again to 20/200 (0.1). After the secondary Thin-DSEK, the BCVA improved again to 20/25 (0.8) at 1 month postoperatively and remained stable thereafter. Our case may show that a secondary DSEK may be a simple and effective treatment to manage secondary graft failure after DLEK. Despite the presence of a "double" stromal interface in the visual axis, secondary Thin-DSEK may provide visual rehabilitation similar to that after primary Thin-DSEK.