Donor Button Research Articles

Correlation Between Corneal Button Size and Intraocular Pressure During Femtosecond Laser–Assisted Keratoplasty

To evaluate changes in intraocular pressure (IOP) in recipient and donor eyes during femtosecond laser-assisted keratoplasty (FLAK) and to assess for differences in the diameter of trephinated corneal buttons according to changes in pressure. Twenty porcine whole eyes (recipient model) and 20 porcine-corneoscleral rims (donor model) were prepared, and anterior chamber pressures were measured using a fiberoptic sensing device (Opsens, Quebec, Canada) during the femtosecond laser corneal cutting process. To determine the diameter of corneal buttons, 10 porcine whole eyes (recipient model) and 12 corneoscleral rims (donor model) of each baseline IOP were cut with the femtosecond laser programmed to the following pattern: "vertical side cut"; 1200 μm (depth), 8 mm (diameter). Digital photographs were obtained using microscopy and subsequently analyzed. The IOP (mean ± SD) for the recipient model was 10.2 (±0.9) mm Hg at baseline and ranged from 96.6 (±4.5) to ∼138.4 (±3.8) mm Hg during the corneal cutting process. This shows that the maximum IOP during FLAK increased 13.5 times compared with baseline. In the donor model, the mean pressure elevation from baseline artificial anterior chamber (AAC) pressure to corneal cutting was 15.8 (±5.4) mm Hg. This showed a positive correlation with baseline IOP [correlation coefficient (CC) = 0.827, P = 0.006]. As the baseline IOP in the recipient eye increased, trephinated corneal button size was reduced by up to 3.9% in diameter (CC = -0.945, P = 0.015). In addition, in donor eyes, the diameter was decreased by up to 11.7% as the baseline AAC pressure increased (CC = -0.934, P = 0.006). During the FLAK procedure, the IOP increases in both recipient and donor eyes. The diameter of the trephinated donor and recipient corneal buttons was decreased as the initial baseline IOP increased. Ophthalmic surgeons can determine the AAC pressure based on the baseline IOP in the recipient patient.

This issue of ACTA, printed and electronic

The cover photograph shows the effect of eye drops on diabetic macular oedema. The dexamethasone cyclodextrin nanoparticle eye drops are described by Ohira et al. in this issue of Acta. Kessel et al. review the literature and conclude that cataract surgery does not increase the risk of progression of AMD to the exudative stage. Jellema et al. in the Netherlands and Switzerland review strabismus surgery in patients with Graves' disease and find the field to be poorly standardized. They propose new criteria for measuring surgical success. Ohira et al. in Japan, Sweden and Iceland describe novel eye drops containing dexamethasone in cyclodextrin nanoparticles. The eye drops improve visual acuity and decrease retinal thickness in patients with diabetic macular oedema. Rassmussen et al. in Copenhagen found that delay in diagnosis and treatment of exudative AMD results in poorer visual outcome. Vottonen et al. in Finland associate increased amplitude of visually evoked potential with improved visual acuity and decreased retinal thickness following anti-VEGF treatment in wet AMD. Ceynowa et al. in Sweden found morning glory anomaly in 3/100 000 children. This was frequently associated with macular oedema, cerebral abnormalities and cutaneous vascular abnormalities. Raffa et al. in Sweden and Saudi Arabia found increased ocular morbidity in moderate to late preterm infants. They found a correlation between gestational age and visual acuity. van Leeuwen et al. in the Netherlands examined rehabilitation needs of visually impaired young adults. Need for employment was most prevalent, followed by peer interaction and social and civic life. Thomseth et al. in Denmark found no association between ocular use of chloramphenicol in first trimester of pregnancy and congenital malformations. Stenwall et al. in Uppsala point out that cytokine content of serum influences the anti-inflammatory effect of serum eye drops. Nielsen et al. in Aarhus used mass spectroscopy to characterize proteins that adhere to contact lenses. Ramberg et al. in Copenhagen find squamous cell dysplasia of the conjunctiva to be relatively rare and mostly in old men. It tends to recur and may progress to carcinoma. Van Bergen et al. in Belgium recommend bevacizumab to complement mitomycin-C in glaucoma filtering surgery. Sundelin and Dafgård Kopp in Stockholm found high complication rates in secondary orbital implants and 28% needed reoperation. Uusitalo et al. in Finland describe an infected tarsal cyst. The following articles and letters are published electronically only and are accessible on www.actaophthalmologica.com as all are articles published in ACTA from the beginning. Jonas et al. in China and Germany correlate high cerebrospinal pressure with retinal vein occlusions. Lopez Torres et al. in Switzerland associate reduced retinal vessel diameter in the peripapillary area with reduced responses on multifocal ERG. Debellemanière et al. in France used adaptive optics imaging to observe cone loss related to subclinical hydroxychloroquine toxicity. Pastor-Idoate et al. in Spain, Portugal, UK and the Netherlands describe possible genetic biomarkers that predict proliferative vitreoretinopathy. Ji et al. in China describe increasing macular pigment density with age in healthy people. Lens opacities affect the one-wavelength reflectometry. Chen et al. in China measured vascular endothelial growth factor and placenta growth factor and aqueous humour of patients with neovascular glaucoma. Munk et al. in USA, Austria and Switzerland found vitreoretinal adhesion to slow resolution of cystoid macular oedema in uveitis, but not affect visual outcomes. Jiang et al. in China study pterygium surgery and recommend a sutureless limbal conjunctival autograft using tissue glue. Yuksel et al. in Turkey compared two methods to obtain corneal donor buttons. ‘Morgue trephination technique’ resulted in less donor disfigurement than ‘classic sclerocorneal removal technique’, while transplant quality and outcome was similar. Bittersohl et al. in Germany found retinal nerve fibre thickness not to be a reliable diagnostic tool for Parkinson's disease. Gupta et al. in Singapore report thin choroid in high myopia. Chihaia et al. in Germany comment on the recent paper by Jarventauata et al. on peripheral hypertrophic subepithelial corneal degeneration. They add their experience and dispute the nomenclature. Yoo et al. in Korea and USA suggest that sleeping position may influence asymmetrical glaucoma damage. Shiraya et al. in Japan report greater burn expansion with endolaser compared to transpupillary retinal photocoagulation. Sugihara et al. in Japan describe pseudoexfoliation material on intraocular lenses. Jouve et al. in France used intravitreal anti-VEGF treatment in a pregnant woman and discuss pros and cons. Pratyusha and Votruba in the United Kingdom describe retinal changes in acquired lipodystrophy. Cinar et al. in Turkey found myelinated nerve fibres on fundus photographs in 0.3% of people. Clemens et al. in Germany describe microrips in retinal pigment epithelium that may precede RPE tears. Mittal et al. in India and United Kingdom show histopathology of lymphoma with crystal storing histiocytosis. Stoyanova et al. in the Netherlands recommend bandage and scleral contact lenses for ocular graft-versus-host disease. I hope you enjoy this issue of Acta.

Microkeratome-assisted two-stage technique of superficial anterior lamellar keratoplasty for Reis-Bücklers corneal dystrophy.

The aim of this study was to describe a microkeratome-assisted 2-stage technique of superficial anterior lamellar keratoplasty (SALK) to manage Reis-Bucklers corneal dystrophy (RBCD). A microkeratome was used to create a 9-mm, 140-μm-thick corneal flap in the first stage. Four weeks later, in the second stage, a Hessberg-Baron suction trephine was used to perform a 7.0-mm central trephination up to a depth of 150 μm, within the corneal flap. Donor lamellar tissue was prepared using a microkeratome system, after which a vacuum punch was used to trephine a 7.0-mm lamellar button. This donor button was used to replace the central corneal flap in the recipient cornea without using any sutures. A bandage contact lens was applied for 2 weeks. This modified technique of staged sutureless SALK was used in 4 eyes of 2 patients with RBCD. Postoperatively, all eyes experienced an improvement in both uncorrected and best spectacle-corrected visual acuities. The average best spectacle-corrected visual acuity was 20/30 at the last follow-up (19 months, range 16-22 months). The cornea remained clear in all eyes until the last follow-up without any evidence of recurrence of RBCD. The staged technique of microkeratome-assisted SALK allows the replacement of superficial corneal stroma without the necessity for any sutures and seems to be a safe and effective method for the treatment of RBCD.

Enfermedad de Carrión: Inoculaciones de Seres Humanos con Bartonella bacilliformis, Una Revisión

El 5 de Octubre de 1885, a la sazón hace 112 años, sucumbió Daniel Alcides Carrión, estudiante del 6to año de Medicina, a consecuencia de la hasta entonces no conocida forma febril anemizante de la Verruga Peruana que hubo sido adquirida por él mediante autoinoculación voluntaria. Veintiún días después de la autoinoculación que fue practicada en dos escarificaciones de cada uno de sus brazos con exudado sanguinolento obtenido de un botón verrucoso del donador, se declaró un cuadro febril con anemia galopante que le produjo la muerte al 19no día. El recuento de glóbulos rojos realizado un día antes de su muerte arrojó apenas 1 085 000 por mm3. La transfusión de sangre que hubo sido aconsejada no se llevó a cabo debido a que por entonces no era todavía un recurso técnicamente manuable. De su lecho de muerte impartió Carrión un mensaje a los médicos peruanos: "Aún no he muerto amigos míos; a Uds. les toca continuar la obra siguiendo el camino que les he trazado". El mensaje de Carrión ha sido captado y cumplido a lo largo de los 112 años que han seguido a su muerte y continuará vigente en los siglos venideros.

Clinicopathologic Correlation of Textural Interface Opacities in Descemet Stripping Automated Endothelial Keratoplasty

The aim of this study was to describe the clinicopathologic correlation of textural interface opacities (TIOs) in a Descemet stripping automated endothelial keratoplasty (DSAEK) donor button after its removal. A 75-year-old woman underwent combined phacoemulsification with intraocular lens placement and DSAEK in her right eye. She had TIOs 1 week postoperatively and continued to have poor visual acuity 8 months postoperatively. The original DSAEK graft was removed, and a repeat DSAEK procedure with a new donor disc was performed. A control corneal button was obtained from a 79-year-old woman who suffered chronic rejection and had a failed DSAEK. Both corneal specimens were sent for light and electron microscopy. Light microscopy of the donor tissue from the patient with TIOs showed stromal irregularities projecting from the cut anterior surface and the expected decrease in the endothelial cell density associated with the procedure and with artifacts. Electron microscopy examination showed irregular collagen fibrils of varying lengths at the stromal surface. Light and electron microscopy examination of the donor tissue from the control patient showed a smooth anterior stromal surface without projecting collagen fibrils. The histopathology of the endothelial disc from the patient with TIOs demonstrated variably irregular lamellae that extended from the anterior donor corneal stromal surface. These extending lamellae were absent on the anterior stromal surface of the control corneal disc, suggesting that they are one possible cause of TIOs and the subsequent suboptimal best-corrected visual acuity and quality of vision experienced by a subset of DSAEK-operated patients.

Novel spatula and dissector for safer deep anterior lamellar keratoplasty

Objective: We describe a novel spatula and dissector to facilitate the big-bubble technique in deep anterior lamellar keratoplasty (DALK). Methods: A 29-year-old man who was diagnosed with bilateral keratoconus underwent deep anterior lamellar keratoplasty (DALK). After 350μm partial thickness incision of the recipient cornea, the Bonfadini dissector was inserted at the deepest point in the peripheral incision and could be advanced to the center of the cornea safely because of its semi-sharp tip. After achieving the big-bubble (BB) separation of Descemet membrane (DM) from the overlying stroma, the anterior stromal disc was removed. Viscoelastic material was placed on the stromal bed to prevent uncontrolled collapse and perforation of DM during the paracentesis blade incision into the BB. We could detect the safe opening of the BB using the Bonfadini dissector by the leakage of air bubbles into the viscoelastic material. After injecting viscoelastic material into the BB space, we inserted the Bonfadini spatula into the bigbubble safely because of its curved profile and blunt edges. The groove along the length of the Bonfadini spatula enables safe and efficient incision or the residual stromal tissue using the pointed end of a sharp blade while protecting the underlying DM. After removal of posterior stroma, the donor button was sutured with 16 interrupted 10-0 nylon sutures. Results: This technique and the use of the Bonfadini spatula and dissector facilitate exposure of Descemet membrane. Conclusion: The smooth Bonfadini DALK spatula and dissector facilitate safe and efficient completion of DALK surgery.

Immediate Endothelial Cell Loss After Penetrating Keratoplasty

To report the pattern and the extent of corneal endothelial cell loss immediately after a penetrating keratoplasty (PK) is performed. Ten donor corneal-scleral tissues with healthy endothelium were used to perform 10 PK surgeries on cadaver eyes. An 8.25-mm donor graft was placed into an 8.00-mm trephinated recipient bed of the cadaver eye. A 10-0 nylon suture was used with a 16-interrupted suture closure technique to secure each donor button. Viscoelastic was used to protect the endothelium in every case. The corneal donor buttons were removed and stained using trypan blue and alizarin red dyes. Digital high-definition photographs were obtained to record the pattern and quantity of stain resulting from endothelial damage and cell loss. Percent endothelial loss was calculated using the digital planimetry of our previously described Adobe Photoshop technique. The immediate mean percent cell loss across the whole graft was 25.7% ± 7.5% (Range, 18-39). There was a distinct pattern of loss, with 58.3% of the loss in the peripheral 0.75 mm, and 12.4% of the loss in the central 3.00 mm. The immediate total endothelial cell loss after the PK was performed was about 25%. The immediate cell loss after the PK was consistent with areas of trephination and suture placement.

Laser welding in penetrating keratoplasty and cataract surgery in pediatric patients: Early results

To evaluate the efficacy of diode laser welding to close corneal wounds in penetrating keratoplasty (PKP) and cataract surgery in pediatric patients. Ophthalmology Department, Bambino Gesù Children's Hospital, Rome, Italy. Prospective observational study. Patients had surgery for congenital cataract (Group 1) or femtosecond laser-assisted PKP (Group 2). The surgery was followed by corneal wound closure using diode laser welding of the stroma. In Group 1, no standard suturing was used. In Group 2, the donor button was sutured onto the recipient using 8 single nylon sutures or a 10-0 nylon running suture (12 passages). Laser welding was then used as an adjunct to the traditional suturing procedure. Group 1 comprised 7 eyes (7 patients; mean age 8.1 years ± 5.3 [SD], range 1 to 15 years) and Group 2, 5 eyes (5 patients; mean age 10.6 ± 3.3 years, range 6 to 15 years). The adhesion of the laser-welded tissues was perfect; there were no collateral effects, and restoration of the treated tissues was optimum. Seidel testing showed no wound leakage during the follow-up. Postoperative astigmatism did not change significantly from the first day after cataract surgery and shifted moderately 3 months after PKP. Laser welding of corneal tissue appeared to be safe and effective in children for whom a sutureless surgical procedure is important to reduce the use of anesthesia for suture management, prevent endophthalmitis, and improve the antiamblyopic effect.

Preliminary clinical results of deep anterior lamellar keratoplasty in the treatment deep infectious purulent keratitis

To evaluate the clinical results of deep anterior lamellar keratoplasty (DALK) assisted by big bubble technique in the treatment of deep infectious purulent keratitis. Seventeen patients (17 eyes) with deep infectious purulent keratitis received DALK surgery in Shandong Eye Hospital from January 2011 to March 2012. Case selection:Patients with purulent keratitis, the infection or infiltrate depth was more than four fifth corneal thickness; Use DALK assisted by big bubble technique to cut off the lesions and expose the Descemet's membrane. The prepared donor which stored in D-X medium or in glycerine preoperatively was oversized by 0.25 mm, and after stripping of Descemet's membrane, the donor button was interrupted sutured with 10-0 nylon suture. The perioperative complications, recurrence, graft status and visual recovery were evaluated. The mean follow up time were 9 months.17 patients with average age of (46 ± 13) year old received DALK surgery, including 14 cases of fungal keratitis and 3 cases of bacteria keratitis. Perioperative complications:Two cases suffered micro perforation and were continuing performed DALK surgery after injecting air bubble in the anterior chamber. Three cases suffered double anterior chamber, one was resolved after graft resuture, and the other two were absorbed automatically.One patient suffered fungal recurrence and cured with secondary penetrating keratoplasty. Graft status:All grafts attached closely to the recipients, slit lamp and AS-OCT examinations were difficult to distinguish the interface. All of grafts were transparent. Visual acuity:before the operation best corrected visual acuity (BCVA) in patients with HM/20 cm to 3.7, after the surgery patients' BSCVA improved to 4.5-5.0. The mean astigmatism postoperatively of 16 cases received successful DALK finally was (4.53 ± 2.35) D . For patients with deep infectious purulent keratitis, big bubble technique assistants DALK surgery is still a safe and effective method.

Complicações em transplantes endoteliais realizados por estagiários de córnea

To report early complications in endothelial keratoplasty performed by cornea fellows. Retrospective study of endothelial keratoplasty performed by second-year cornea fellows. Described the early complications and its treatments. Thirty four endothelial keratoplasty were performed by cornea fellows, from July 2007 to August 2008. From this, 29 were Descemet stripping endothelial keratoplasty and 5 Descemet stripping automated endothelial keratoplasty; 14 combined with phacoemulsification and 1 with extracapsular cataract surgery. The main indication was Fuchs' dystrophy (18 cases), followed by bullous keratopathy (11 cases), primary failure after endothelial keratoplasty (4 cases) and congenital hereditary endothelial dystrophy (1 case). Main surgery complication was donor button detachment in 8 eyes (23.5%), followed by primary graft failure in 7 eyes (20.6%) and acute glaucoma after pupillary block in 1 eye (2.9%). The complication rate in this series, which were the first ever in a group of six cornea fellows, was high. This shows the steep learning curve for this surgical procedure. The assistance of an experienced surgeon could help to achieve a less steep learning curve with a lower complication rate.

Spontaneous Corneal Clearance Despite Graft Removal in Descemet Stripping Endothelial Keratoplasty in Fuchs Endothelial Dystrophy

To report spontaneous corneal clearing with improved visual acuity and central endothelial cell repopulation after the removal of a dislocated donor button following Descemet stripping endothelial keratoplasty (DSEK). Interventional case report. An 84-year-old woman with decreased visual acuity in the right eye secondary to Fuchs endothelial dystrophy and cataract underwent combined cataract extraction, intraocular lens implantation, and DSEK. After primary graft failure, the resulting detached, opaque, and retracted donor lenticule was removed from the eye 2 months after the initial surgery and not replaced. The cornea started to clear after the donor button removal with central endothelial cell repopulation. Corneal deturgescence is not strictly dependent on donor lenticule adhesion to the host posterior stromal surface. Endothelial cell migration and repopulation of the central cornea can occur after DSEK and after the removal of the failed endothelial graft, with corneal clearing and improved visual outcomes.

Contact-lens related keratitis caused by an atypical organism

This is a case report of contact-lens related, infectious keratitis with a subsequentperforation. A tectonic penetrating keratoplasty was performed and Sphingomonas paucimobiliswas cultured from the corneal button. One week post surgery, the patient developed are-infection involving the donor button. This was treated based on culture and sensitivity of thecorneal button and the infection resolved. Two months post surgery, the patient’s vision wascounting fingers in the affected eye. The corneal infection had completely resolved, but the grafthad failed despite the use of topical steroids.

In Vitro Evaluation of Endothelial Cell Loss Using the Neusidl Corneal Inserter

To determine the immediate endothelial cell loss (ECL) resulting from insertion of a precut donor button using the Neusidl Corneal Inserter (NCI) and compare it with the previously published ECL resulting from insertion of a folded donor button using non-coapting forceps. Ten corneas were precut for Descemet stripping automated endothelial keratoplasty and trephinated to a diameter of 8.0 mm (n = 5) or 8.5 mm (n = 5). Each tissue was placed onto the platform of a new NCI spatula and inserted into a cadaveric whole globe through a 5.2 mm incision. The tissue was carefully removed and stained with trypan blue and alizarin red to detect damaged endothelium. ECL was estimated using Adobe Photoshop planimetry. Mean ECL was compared with previously reported studies of forceps insertion with a one-sample t test, using SPSS v. 19. Geographic patterns of ECL were also documented. Mean ECL was 15.6% (95% confidence interval, 13.8-17.4). We were unable to detect a difference in ECL compared with previous insertion methods studied (P < 0.001). The pattern of damage from the NCI was different than that previously seen with forceps insertion. Immediate endothelial damage resulting from use of the NCI for insertion of Descemet stripping automated endothelial keratoplasty tissue is comparable with that seen with a standard forceps technique, but with a different damage pattern.

Boston type 1 keratoprosthesis outcomes in ocular burns

To report the outcomes of Boston type I keratoprosthesis (BKPro) in the management of ocular burn injuries. This was a prospective study including all cases of BKPro implantation for ocular burns at the External Diseases and Cornea Service of the Federal University of São Paulo, between February 2008 and February 2010. Ten patients (10 eyes) were enrolled. Procedures performed to manage ocular injury were identified, and data were collected regarding patients' ocular history, surgical procedure(s) performed, and postoperative outcomes, including visual acuity, retention, complications and required surgical procedures. A total of 11 Type 1 BKPro were implanted in 10 eyes of 10 patients. The mean follow-up period was 25.7 ± 10.8 months. Preoperative best-corrected visual acuity (BCVA) ranged from count fingers to light perception. Postoperative BCVA was better than 20/200 in 90% of the patients and better than 20/60 in 60% of the patients. The overall BKPro retention rate was 90%. The most common complications were retroprosthetic membrane formation (50%) and persistent corneal epithelial defect evolving to corneal melting (40%). Patients who underwent ocular surface procedures such as limbal transplantation prior to BKPRo implantation had a lower incidence of corneal melting/thinning (p = 0.07), although this was not statistically significant. The anatomical and functional results identified in this study support the use of BKPro in managing bilateral limbal stem cell deficiency secondary to ocular burns.

Der Melanozyt und das Auge: eine Übersicht unter besonderer Berücksichtigung der Kornea

Hintergrund: Verschiedene Arbeiten insbesondere aus der Dermatologie haben in den letzten Jahren deutlich werden lassen, dass der Melanozyt ein „Multitalent“ ist, dessen Bedeutung über die reine UV-Protektion hinausgeht. Neben (neuro-)humoralen und immunologischen Funktionen könnten Melanozyten auch eine Rolle als Fänger von freien Radikalen sowie bei der Druckperzeption spielen und so unter Umständen Teil des zu vermutenden „intraokularen Drucksensors“ sein. Es wird gemeinhin angenommen, dass es in der Kornea unter physiologischen Bedingungen keine Melanozyten gibt. Eine systematische Untersuchung zu diesem Sachverhalt anhand einer größeren Zahl von Proben hat es unseres Wissens bisher aber noch nicht gegeben. Methodik: Es wurden insgesamt 103 korneale Gewebsproben (ganze Augen, Hornhautexplantate mit verschiedenen Erkrankungen, korneosklerale Spendersegmente) sowie 13 Pterygien (korneale Anteile) mit dem Melanozyten-spezifischen monoklonalen Antikörper Melan A immunhistochemisch untersucht. Ergebnisse: In gesunder Kornea finden sich Melanozyten regelhaft im Bereich des Limbus, um sich dann zentralwärts in ca. 1 mm Limbusabstand zu verlieren. Das Epithel der mittelperipheren und zentralen Hornhaut ist Melanozyten-frei. Unter pathologischen Bedingungen (Dystrophien, Narben, Ulzera u. a.) kommt es ausnahmsweise zu einer aberranten melanozytären Besiedelung der mittelperipheren, aber nur sehr selten der zentralen Hornhaut. In mehr als der Hälfte der Pterygien sind Melanozyten nachweisbar. Schlussfolgerungen: Melanozyten können unter bestimmten, pathologischen Bedingungen zentralere Bereiche des Hornhautepithels besiedeln, sodass die wenigen, in der Literatur beschriebenen „kornealen Melanome“ theoretisch „vor Ort“ entstanden sein könnten. Die Hornhaut besitzt offenbar Mechanismen, um die Invasion von Melanozyten trotz der zentripetalen Epithelmigration zu verhindern. Hypothetischerweise geschieht dieses durch einen „CoMeSuF“ („Corneal Melanocyte Suppression Factor“), dessen Identifizierung Aufgabe der kommenden Jahre sein soll. Dieses vor allem auch deshalb, weil ein „CoMeSuF“ potenziell zur Behandlung melanozytärer Proliferationen (Melanome) herangezogen werden könnte.

Spontaneous Reattachment of a Posteriorly Dislocated Endothelial Graft: A Case Report

A thirty-year-old Chinese man with a history of severe trauma to his right eye, with secondary sectoral aniridia and multiple operations including intraocular lens insertion more than fifteen years ago, underwent an uneventful Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for his pseudophakic bullous keratopathy in a tertiary hospital in Hong Kong. The nature of his previous operations was unknown to the surgeon at the time of transplant. On postoperative day one, the graft was not present in the anterior chamber. Fundal view was limited because of corneal oedema. B-scan ultrasonography could not detect any definite presence of a donor button in the posterior segment as gas was present in the vitreous cavity. The patient was instructed to lie prone full time, and on postoperative day three, the graft was found to be reattached to the stroma with spontaneous resolution of corneal oedema, indicating restoration of pump function of endothelium graft. This is the first case of spontaneous reattachment of a posteriorly dislocated endothelial graft without surgical intervention or abandonment of the grafted endothelial button.

Stromal Lamellar Dissection of the Donor Disc

To describe a surgical technique to decrease the incidence and potential complications of an eccentric trephination and improve graft adherence during Descemet stripping automated endothelial keratoplasty. Technique description. After resection of the anterior lamella with the microkeratome, the corneoscleral rim in the artificial anterior chamber (AC) is brought under view of the operating microscope and the deep dissection plane of the microkeratome is extended 360 degrees as far peripherally as permitted by the Moria artificial anterior chamber using a crescent blade and 0.12-mm Colibri forceps. The central stroma is marked with gentian violet, and the donor button is released from the AC and then carefully placed and centered on the punching block endothelial side up using the gentian violet mark as a guide and trephined to the desired diameter. The donor graft may then be inserted by the surgeon's preferred technique. This simple technique allows the surgeon to consistently increase the lamellar dissection diameter while reducing the peripheral graft thickness, which becomes particularly important when the trephination is eccentric. This technique may lead to improved donor adherence and a decrease in the incidence of donor lenticule configuration -related complications.

Descemet stripping automated endothelial keratoplasty in a child after failed penetrating keratoplasty

Use of Descemet stripping automated endothelial keratoplasty (DSAEK) has been reported in children for the treatment of postoperative endothelial decompensation and Descemet membrane break after forceps delivery. Rapid visual recovery and minimally induced postoperative astigmatism make DSAEK preferable to penetrating keratoplasty for the management of isolated endothelial disorders in this age group. We present a case of DSAEK in a 4-year-old boy for the management of irreversible endothelial rejection after penetrating keratoplasty. Three months after the procedure, the cornea remained clear with the donor button in place.

Simultaneous Interface Candida Keratitis in 2 Hosts Following Descemet Stripping Endothelial Keratoplasty With Tissue Harvested From a Single Contaminated Donor and Review of Clinical Literature.

The objective of this study was to report 2 cases of interface fungal keratitis in 2 separate patients following Descemet stripping automated endothelial keratoplasty (DSAEK) with tissue harvested from the same donor. This was a retrospective simultaneous interinstitutional hosptial-based case reports. Two patients with corneal infections following DSAEK were identified from 2 individual practices. Both patients had undergone DSAEK from the same donor. Preoperative and postoperative eye examination included visual acuity, anterior and posterior segment evaluations, and clinical follow-up course from the time of surgery. Methods of medical therapy and surgical intervention are additionally discussed. The 2 patients presented in our series present with interface fungal keratitis postoperatively in the face of the original source coming from a single donor (patient 1: 7 days postoperatively and patient 2: 7 weeks postoperatively). As medical treatment failed in both cases, surgery was undertaken in both cases (therapeutic penetrating keratoplasty). With prompt recognition as well as medical and surgical treatment, patient 1 achieved best corrected visual acuity of 20/30 at 6 months postoperatively, and patient 2 had best corrected visual acuity of 20/80 at 10 months postoperatively. Fungal keratitis following DSAEK occurs in a sequestered space and therefore represents a treatment challenge with potentially devastating outcome. We recommend an aggressive surgical approach with early removal of the donor button and irrigation with intracameral antifungal agents.

Perspektiven der Femtosekundenlaser-assistierten Keratoplastik

The femtosecond laser technique allows completely new trephination procedures in penetrating and lamellar keratoplasty. With femtosecond laser-assisted penetrating keratoplasty it is possible to perform profiled trephination, such as top hat and mushroom profiles. Thus, it is easier to get a watertight wound closure intraoperatively and due to the larger wound surface wound healing is faster and allows early complete suture removal. In lamellar keratoplasty the femtosecond laser enables the surgeon to cut to any depth in the corneas resulting in thin corneal donor buttons, e.g. for DSAEK. In this manuscript an overview is given of the state of the art and of the perspectives of femtosecond laser keratoplasty.