Donor Lenticule Research Articles

Femtosecond Laser-Assisted Keyhole Endokeratophakia: Correction of Hyperopia by Implantation of an Allogeneic Lenticule Obtained by SMILE From a Myopic Donor

To describe endokeratophakia in which a small incision lenticule extraction (SMILE) lenticule from a myopic patient is implanted into a recipient eye through a small incision to correct hyperopia. A 23-year-old aphakic woman presented following cataract surgery to remove a childhood congenital cataract with hyperopia of +12.00 -1.50 × 155, corrected distance visual acuity of counting fingers, and exotropia. A SMILE procedure using the VisuMax femto-second laser (Carl Zeiss Meditec, Jena, Germany) was performed on a donor patient with high myopia and the extracted lenticule was stored (power -10.50 diopter sphere, optical zone 5.75 mm, central lenticule thickness 127 μm). In the recipient eye, a pocket lamellar incision was created using the VisuMax SMILE software. The upper interface was separated and the donor lenticule was inserted through the small incision. One year postoperatively, retinoscopy refraction was +7.50 -3.00 × 150, a spherical equivalent refraction reduction of 5.25 diopters. Mean keratometric power increased by 2.91 diopters. The posterior surface elevation changed significantly with a central bulge into the anterior chamber. Central corneal thickness by Pentacam (Oculus Optikgeräte, Wetzlar, Germany) increased by 121 μm. Central lenticule thickness was 130 μm and central epithelial thickness was 43 μm measured by RTVue OCT (Optovue Inc., Fremont, CA). The cornea remained clear over the 1-year postoperative period. Endokeratophakia appears to be a viable procedure for correcting hyperopia on the cornea by implantation of an extracted myopic SMILE lenticule from a donor patient. However, posterior surface changes and epithelial remodeling resulted in only 50% of the intended correction. No adverse side effects were observed following implantation of donor tissue for 1 year.

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.

Effects of Graft Thickness and Asymmetry on Visual Gain and Aberrations After Descemet Stripping Automated Endothelial Keratoplasty

Understanding the contribution of graft thickness and asymmetry to visual gain and posterior corneal (PC) higher-order aberrations (HOAs) may assist optimizing visual outcomes after Descemet stripping automated endothelial keratoplasty (DSAEK). To investigate the effects of graft thickness and asymmetry on visual gain and aberrations after DSAEK. Retrospective analysis of an interventional case series of eyes undergoing DSAEK. Visual gain was defined as the difference between preoperative and 6-month postoperative best-corrected visual acuity in logMAR equivalents. Graft thickness was measured by anterior-segment optical coherence tomography. Corneal topography and HOAs were measured by Scheimpflug imaging. Raw posterior corneal (PC) elevation data were exported and fitted against a best-fitted sphere, providing a measure of donor lenticule asymmetry. Correlation analysis was performed among visual gain, graft thickness, graft asymmetry, and PC HOAs. University Eye Clinic Maastricht. Seventy-nine eyes with corneal endothelial dysfunction. All patients underwent DSAEK [corrected]. Visual gain, graft thickness, graft asymmetry, and PC HOAs. Mean best-corrected visual acuity improved from 0.63 logMAR equivalents preoperatively to 0.25 logMAR equivalents postoperatively (P < .001). Mean (SD) graft thickness of the series was 97 (25) (range, 39-145) μm. After excluding patients with vision-limiting comorbidities, visual gain significantly correlated with graft thickness (r = -0.35 [P = .02]). This correlation was strongest in patients with pseudophakic bullous keratopathy (r = -0.62 [P = .01]). Graft thickness significantly correlated with graft asymmetry in the 4- and 6-mm zones (r = 0.32 [P = .007] and r = 0.32 [P = .006], respectively), which in turn correlated with all but spherical PC HOAs. After DSAEK, visual gain shows a significant correlation with graft thickness in patients without vision-limiting comorbidities. This relationship is strongest in patients with pseudophakic bullous keratopathy. Graft thickness also correlates with graft asymmetry, which in turn correlates with all but spherical PC HOAs. These findings may assist surgeons in choosing DSAEK graft thickness and shape, particularly in eyes without vision-limiting comorbidities. Further randomized trials are needed to investigate the relationship between graft thickness and visual gain after DSAEK.

Effects of a Novel Push-through Technique Using the Implantable Collamer Lens Injector System for Graft Delivery during Endothelial Keratoplasty

PurposeTo investigate effects of a new push-through insertion method for donor lenticules using an injector system on endothelial viability ex vivo and in a clinical case series of endothelial keratoplasty.MethodsAn ex vivo delivery model was used with porcine corneoscleral rims. We compared the endothelial viability in a new push-through insertion method using the Visian Implantable Collamer Lens (ICL) injector versus that of standard forceps-assisted insertion for lenticule delivery. Twenty porcine corneal lenticules were divided into four groups by insertion method and wound size. Vital dye staining was performed and devitalized areas were semi-quantitatively assessed by digital imaging. In the clinical case series, Descemet's stripping endothelial keratoplasty (DSEK) using the push-through method was performed in seven patients and endothelial outcome was determined six months postoperatively.ResultsMean devitalized areas for the push-through method were significantly lower than for forceps-assisted insertion through 3.2 mm incision (23.99 ± 2.17% vs. 50.48 ± 5.07%, p = 0.009) in the ex vivo model. Average endothelial cell counts of donor tissues of patients who underwent DSEK were 26.4% lower six months postoperatively.ConclusionsPush-through delivery of donor lenticules using the Visian ICL injector system appears to be less harmful to endothelial cells than conventional forceps-assisted delivery.

Two separate methods of stem cell transplantation in both eyes of a single patient presented with bilateral stem cell deficiency following exposure to Euphorbia latex

Limbus is the most dynamic area of ocular surface which is the “home” of stem cells especially in the region of palisades of Vogt. Stem cell deficiency is manifested by ingrowth of vessels into the cornea with resultant corneal haze that results in decreased vision [1]. Stem cell deficiencies are treated by transplantation of stem cells. The methods are varied and includes transplantation from cadaveric tissue, from living related donor (in bilateral cases) and from fellow eye (in unilateral cases). In vitro cultured stem cells in human amniotic membrane (HAM) base may also be utilised. We report here the successful outcome of stem cell implantation in a patient with end stage limbal stem cell deficiency following exposure to the latex of Euphorbia. The Euphorbiaceae family includes trees, succulents and herbaceous plants. Different species of Euphorbia grow all over the world. The milky latex or sap is toxic and may cause intense inflammation of the skin and the eye [2, 3]. Ocular toxic reaction varies from mild conjunctivitis to keratouveitis to severe corneal vascularisation in neglected cases. Ocular toxicity can be caused by three different species of Euphorbia, namely, Euphorbia trigona (African milk tree), Euphorbia neriifolia (Indian Spurge tree) and Euphorbia milii (crown-of-thorns houseplant). In this present case, the patient (female, aged 45 years) with bilateral stem cell deficiency was treated by transplantation of stem cell from living related donor(mother) in the left eye and in vitro cultured stem cell on HAM base in the right eye. A normotensive, non-diabetic, patient (female, aged 45 years) presented to our clinic with loss of vision in both eyes. She gave a history of exposure to Euphorbia latex 5 months back in her both eyes. She neglected the condition and there was gradual decrease in his vision following the brief acute episode. Visual acuity in RE was 1/60, in LE it was finger counting at 2 m. There was no improvement in vision with refractive correction. Schirmer test values in both eyes measured 15 mm. Corneal sensation in both eyes were normal. Intraocular pressure in BE were 18 mmHg and USG (A+B) scans in both eyes were normal. Anterior segment of both eyes revealed 360° limbal vascularisation with diffuse stromal haze up to the extent that anterior chamber details including the pupil is barely visible (Fig. 1). Fig. 1 Right eye showing limbal vascularisation with diffuse stromal haze up to the extent that anterior chamber details including the pupil is barely visible A decision for transplantation of stem cells was made. She was put on systemic steroids (1 mg/kg/day) 3 days prior to admission. From the mother, two separate conjuctivolimbal lenticules were prepared [4 × 2 mm each], one from each eye to reduce chances of development of iatrogenic stem cell loss. The recipient bed in LE was prepared by marking two separate areas: one centred around 6 o’clock hours and the other around 12 o’clock region of the limbus. Peritomy was done and bleeding controlled by cauterisation. The donor lenticules were sutured to the recipient bed with interrupted 10-0 monofilament nylon sutures. In the post-operative period, the patient was put on systemic steroids (1 mg/kg/day) in a tapering dose, topical steroid (pred acetate 1 %), topical antibiotic (topical moxifloxacin) and artificial tears (carboxymethyl cellulose). Both topical and systemic steroids were tapered slowly over a period of 6 weeks and topical antibiotics were withdrawn after the first 2 weeks. The patient was advised weekly visit at the cornea clinic. Four months after the first operation, her RE was operated. Recipient bed was prepared as described before and in vitro cultured stem cells on HAM base were sutured at around 360° of limbus with interrupted 10-0 monofilament nylon sutures. The whole of cornea including transplanted discs were covered by preserved HAM and sutured to adjacent conjunctiva with interrupted 10-0 monofilament nylon. Patient was placed on same post-operative regimen as before. The patient also underwent cataract surgery in both eyes 5 months after her last operation in RE.

Descemet's Stripping Endothelial Automated Keratoplasty Using Tan Endoglide Endothelium Insertion System

The purpose of this study was to evaluate early visual and refractive outcomes of Descemet's stripping endothelial keratoplasty (DSAEK). Nine eyes of 7 male and 2 female patients, mean age 73 years, were treated with DSAEK. Eight had pseudophakic bullous keratopathy and 1 had advanced Fuch's syndrome. Patients were followed up for a mean of 11.4 months (range, 4-26). The DSAEK technique consisted of stripping Descemet's membrane and endothelium from a recipient cornea and transplanting the posterior stroma and endothelium of a donor cornea using the Tan EndoGlide. The mean operating time was 61.89 minutes (standard deviation [SD], 9.3). The median donor diameter was 8.375 mm (range, 8.25-8.75) and the mean donor thickness was 114.4 μm (range, 98-129). Mean preoperative sphere was -2.41 that changed postoperatively in -1.21. Mean endothelial cell loss was 25% (range, 23%-45%) at 6 months after surgery. Corneal pachymetry was reduced from 796.6 μm preoperatively to 535.5 μm postoperatively. Best corrected vicual acuity (BCVA) was 20/40 or better postoperatively and exceeded the preoperative BCVA in all eyes. No graft failure was present. Two partial graft dislocations (1st and 5th postoperative day) were observed. One graft was successfully attached after reinjecting an air bubble (rebubbling) in the anterior chamber and the other graft was reattached with 4 10/0 nylon sutures after failed rebubbling. The key to successful endothelial transplantation is the protection and preservation of as many donor endothelial cells as possible. The TAN EndoGlide is a device that consistently delivers a donor lenticule through a small incision with minimal endothelial loss, while making the insertion procedure relatively reliable and consistent, with the surgeon in full control of the donor at all stages of insertion. The endothelial cell loss during this technique is comparable (if not better) with other endothelial graft insertions systems.

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.

Severe and Recurrent Interface Hemorrhage after Endothelial Keratoplasty

To report the occurrence and management of recurrent hemorrhage after Descemet stripping endothelial keratoplasty (DSEK) in a patient with pseudophakic bullous keratopathy. An 84-year-old Chinese woman on two oral antiplatelet drugs underwent DSEK in her left eye. Preoperative best-corrected visual acuity was 20/30 OD and 14/200 OS. Intraoperative bleeding was noted from the iris root. Surgery was completed uneventfully, and interface was thoroughly irrigated in the end. Slit lamp examination on the first postoperative day showed a dense interface hemorrhage and an intraocular pressure of 24 mm Hg. Repeat interface irrigation was carried out on postoperative day 4, but the hemorrhage appeared again on the following day. Donor lenticule was well apposed to the corneal stroma, and visual acuity was hand motions in the operated eye. No further surgical interventions were performed. Corticosteroid eye drops were continued four times a day in the operated eye, and the patient was advised weekly follow-up. Over the next 4 weeks, the interface blood gradually started to clear from the central cornea. At the end of 4 months postoperatively, the interface hemorrhage disappeared completely. A final best-corrected visual acuity of 20/80 was achieved. Specular microscopy revealed an endothelial cell density of 1375 cells/mm2. Interface hemorrhage is a known complication after DSEK surgery. Recurrent hemorrhage may be expected in patients on oral antiplatelet treatment. In cases without associated graft dislocation, conservative management can still result in good visual outcome.

Graft profile and thickness as a function of cut transition speed in Descemet-stripping automated endothelial keratoplasty

To determine the profile of endothelial keratoplasty lenticules prepared using a microkeratome and evaluate the impact of varying cut transition speed on cut depth and profile using anterior segment optical coherence tomography (AS-OCT). Department of Cornea and External Diseases, Moorfields Eye Hospital, London. United Kingdom. Experimental study. Fourier-domain AS-OCT was used to image 25 corneal specimens before and after microkeratome dissection with a 350 μm head. A pilot series of 7 corneas were cut and imaged with the following 18 corneas divided into regular cut transition speed and slow cut transition speed groups (9 in each). Proximal, central, and distal precut corneal thickness and post-cut residual bed thickness were measured using the integrated caliper tools of the Fourier-domain AS-OCT device. Cut depth was calculated by subtraction. The slower microkeratome pass speed produced significantly thinner donor lenticules (mean 148 ± 45 μm [SD]) than the standard pass speed (mean 234 ± 35 μm) (P ≤.0001). In both groups, significant asymmetry was observed in donor lenticules with a deeper cut depth and a thinner lenticule at the beginning of the microkeratome pass (proximal stromal bed). The mean difference between the proximal and distal stromal bed thickness was 61 ± 63 μm in the standard group and 52 ± 22 μm in the slow-pass group (P=.159). Reducing the transition speed in microkeratome dissection produced thinner donor lenticules. Thickness asymmetry is an inherent flaw with current microkeratome dissection that cannot be easily corrected by altering preparation technique.

Intraoperative use of spectral-domain optical coherence tomography during Descemet&amp;rsquo;s stripping automated endothelial keratoplasty

PurposeTo evaluate the intraoperative changes in the donor lenticule, recipient cornea, and the reduction of interface fluid thickness during Descemet’s stripping and automated endothelial keratoplasty with EndoGlide™ (Angiotech Pharmaceuticals Inc, Vancouver, Canada) donor insertion, using intraoperative spectral-domain optical coherence tomography.MethodsProspective observational case series of patients underwent Descemet’s stripping and automated endothelial keratoplasty using the EndoGlide inserter. Spectral-domain optical coherence tomography (iVue; Optovue Inc, Fremont, CA) with a handheld probe was used to image the cornea and anterior chamber. Standardized software was used to measure interface fluid gap, host cornea, and donor lenticule thicknesses during the following surgical stages of Descemet’s stripping and automated endothelial keratoplasty: (1) after donor insertion and immediately before full air tamponade; (2) after air tamponade and expression of fluid from venting incisions; (3) at 6 minutes of air tamponade; and (4) at 10 minutes of air tamponade.ResultsTen patients with a mean age of 74.9 ± 11.8 years were recruited. Spectral-domain optical coherence tomography measurements of the interface fluid gap after fluid was expressed through the venting incisions (P < 0.001), at 6 minutes of air tamponade (P < 0.001) and at 10 minutes of air tamponade (P < 0.001 and P = 0.001, respectively), were significantly decreased compared to the measurements immediately before air tamponade. Donor thickness increased significantly at 6 minutes of air tamponade (P = 0.004) but reduced by 10 minutes compared to immediately before air tamponade.ConclusionSignificant intraoperative changes in the donor, recipient cornea, and interface fluid thickness occurred following endothelial keratoplasty donor insertion.

Descemet’s Stripping Endothelial Keratoplasty—Insertion Techniques for Endothelial Keratoplasty

Descemet’s stripping endothelial keratoplasty has emerged as the treatment of choice for primary and secondary endothelial failure. One of the most crucial portions of the procedure is introducing the donor lenticule into the anterior chamber. Numerous techniques and instruments have been developed in an attempt to simplify the incision and reduce endothelial cell loss.

Double-pass microkeratome technique for ultra-thin graft preparation in Descemet's stripping automated endothelial keratoplasty

Endothelial keratoplasty is evolving with increased attention placed on the optical qualities of the posterior donor lenticule. In efforts to improve visual outcomes, the effects of the thickness, smoothness, and planar profile are being studied. This paper describes a double-pass microkeratome technique to create ultra-thin (less than 100 μm) Descemet’s stripping automated endothelial keratoplasty grafts.

Descemet Stripping Automated Endothelial Keratoplasty: Effect of Intraoperative Lenticule Thickness on Visual Outcome and Endothelial Cell Density

To determine the correlation between the intraoperative donor lenticule thickness in Descemet stripping automated endothelial keratoplasty (DSAEK) and both the best-corrected visual acuity (BCVA) and endothelial cell density (ECD) at 6 months. To describe relevant surgical considerations with regard to the choice of microkeratome head. Prospective case series. Thirty-five patients (37 eyes) undergoing DSAEK were included in this prospective case series. Intraoperative donor lenticule thickness, assessed by ultrasound pachymetry, was compared with BCVA and ECD 6 months postoperatively. Mean BCVA logarithm of the minimal angle of resolution (logMAR) was 0.58 preoperatively and 0.29 6 months postoperatively. Three eyes were excluded from BCVA analysis. The average donor lamellae thickness was 175 μm. Mean ECD loss was 39% 6 months postoperatively compared with that preoperatively. There was no correlation between donor lamella pachymetry and BCVA logMAR and ECD at 6 months in this series (P = 0.13 and P = 0.09, respectively). Analogous to our findings, a review of published reports on donor pachymetry in DSAEK did not provide data to suggest a correlation between donor corneal thickness and postoperative BCVA or ECD. Donor lenticule thickness does not have a direct effect on 6-month postoperative visual acuity or endothelial cells. Efforts should be made to reduce surgical trauma to the lenticule rather than adhering to a strict depth when cutting the graft. We propose using the Moria 350 μm microkeratome head for corneal thickness more than 600 μm and the 300 footplate for corneal thickness less than 600 μm.

Impact of graft thickness on visual acuity after Descemet's stripping endothelial keratoplasty

ObjectiveTo evaluate the relationship, over time, between central graft thickness and visual acuity following Descemet's stripping endothelial keratoplasty (DSEK).MethodsA retrospective analysis of 70 consecutive cases of DSEK. All donor lenticules...

A Prospective Study Comparing EndoGlide and Busin Glide Insertion Techniques in Descemet Stripping Endothelial Keratoplasty

To compare a new insertion method using an EndoGlide (Angiotech/Network Medical Products) with the standard Busin glide (Moria USA) assisted insertion of the posterior lamellar corneal graft in Descemet stripping endothelial keratoplasty (DSEK). Prospective, consecutive, comparative, nonrandomized study. Surgery was performed between October 2008 and October 2010 in 52 eyes of 52 consecutive patients with endothelial dysfunction suitable for DSEK. Twenty-two consecutive eyes underwent the new EndoGlide-assisted insertion of donor lenticule and 30 eyes underwent the surgery using the Busin glide. Six-month follow-up data are available for all patients. Clinical details, best-corrected visual acuity, manifest refraction, intraoperative and postoperative complications, and corneal endothelial cell loss were assessed at 6 months after DSEK. At 6 months after surgery, the best-corrected visual acuity was similar in both groups (0.13 logarithm of the minimal angle of resolution in the EndoGlide eyes as compared with 0.15 logarithm of the minimal angle of resolution in the Busin group; P = .34). Mean spherical equivalent was 0.65 diopter (D) and 0.51 D, and mean refractory cylinder was 1.39 D and 1.08 D, respectively (P = .40). The endothelial cell loss was much lower in the EndoGlide group (25.76%) as compared with the Busin group (47.46%; P < .0001). In conclusion, the new EndoGlide results in significantly less endothelial cell loss than Busin glide donor insertion in DSEK. The visual outcomes and refractive changes were similar in both groups.

Clinical profile of graft detachment and outcomes of rebubbling after Descemet stripping endothelial keratoplasty

PurposeTo review the clinical profile of graft detachment following Descemet's stripping endothelial keratoplasty (DSEK) and analyse the outcomes of rebubbling for graft detachment.MethodsRetrospective review.Results27 of a total of 309 eyes...

Graft Thickness, Graft Folds, and Aberrations After Descemet Stripping Endothelial Keratoplasty for Fuchs Dystrophy

To determine whole-eye high-order aberrations (HOAs) in pseudophakic eyes after Descemet stripping endothelial keratoplasty (DSEK) for Fuchs dystrophy, and to establish relationships between graft thickness, HOAs, and visual acuity. Cross-sectional study. Whole-eye HOAs were measured in pseudophakic eyes at intervals through 24 months after DSEK, and in otherwise healthy pseudophakic control eyes implanted with the same type of spherical intraocular lens. Wavefront errors were assessed by a Hartmann-Shack aberrometer over a 4-mm-diameter optical zone. In DSEK eyes, central graft thickness and stromal graft folds were measured using confocal microscopy in vivo, and best-corrected visual acuity (BCVA) was determined by the electronic Early Treatment of Diabetic Retinopathy Study method. Total HOAs at 24 months after DSEK (0.28 ± 0.11 μm, mean ± SD, n = 17) were higher than those in pseudophakic controls (0.16 ± 0.07 μm, n = 25, P < .001); specifically, trefoil and quadrafoil were higher after DSEK. At 24 months, total HOAs (r = 0.69, P < .001) and graft folds (r = 0.41, P = .02) were correlated with central graft thickness, and BCVA was correlated with total HOAs (r = 0.39, P = .01) but not with graft thickness (r = -0.24, P = .20, n = 27). Whole-eye HOAs are higher after DSEK compared to untreated corneas. Thicker grafts are associated with increased HOAs and more graft folds, suggesting that the donor lenticule contributes, in part, to the wavefront errors. Although BCVA is weakly related to total HOAs after DSEK, it is not related to graft thickness.

Late-onset Candida Keratitis after Descemet Stripping Automated Endothelial Keratoplasty: Clinical and Confocal Microscopic Report

To report clinical and confocal microscopy features of late-onset Candida albicans keratitis after Descemet stripping automated keratoplasty (DSAEK). We performed clinical and confocal scan on a patient who underwent DSAEK and phacoemulsification for Fuchs endothelial dystrophy and cataract. A 76-year-old woman who underwent uneventful DSAEK and phacoemulsification presented with white to cream deposits 3 months after DSAEK. Confocal microscopy showed a hyperintense deposit at the lenticule and interface. Confocal scan also disclosed intense haze and inflammation at the interface and clusters of hyperreflective round structures resembling epithelial cells within the interface area. No signs of hyphae-like structures were seen. Late-onset symptoms misled us into a bacterial chronic endophthalmitis diagnosis, and the patient was started on topical and systemic antibiotics. Despite intense antibiotic therapy, the patient developed severe endophthalmitis, so we performed anterior vitrectomy and the donor lenticule was removed. Microbiology results from the removed lenticule showed infection by C albicans. Antifungal therapy with systemic and topical voriconazole controlled the infection. Candida interface keratitis is possible after DSAEK. The posterior location of infected tissue poses diagnostic and therapeutic challenges. In our case, the late onset of the symptoms and not performing corneoscleral rim cultures delayed correct diagnosis. This is the first reported case of post-DSAEK Candida keratitis with confocal microscopy images. A hyperintense granular deposit was seen at the lenticule and interface with confocal microscopy. We also observed intense haze, granular round structures resembling epithelial cells, and hyperreflective needle-shaped material at the interface. No hyphae-like structures were seen with confocal imaging.

Fibrin Glue Aided Sutureless Sclerokeratoplasty With Maintenance of Chamber Angle

We describe a technique of lamellar penetrating sclerokeratoplasty to treat a patient with total corneal ulcer with scleral extension along with impending perforation. The partial-thickness scleral and full-thickness corneal bed was prepared. A donor lenticule with partial-thickness sclera and full-thickness cornea was fixed on the prepared recipient bed with the help of fibrin glue. This technique is less painful, less time consuming, induces less postoperative inflammation, and seems safe and effective in managing such cases.

Femtosecond-UVA-riboflavin (FUR) cross-linking approach to penetrating keratoplasty and anterior lamellar keratoplasty

Purpose To introduce femtosecond laser wound design combined with riboflavin/ultraviolet light-A (UVA) collagen cross-linking at the wound for penetrating (PKP) and anterior lamellar keratoplasty (ALK). Primary outcomes were intraocular pressure (IOP in mmHg) at burst point for the PKP group, and tensile strength (kPa) until dehiscence for the ALK group. Methods Human corneoscleral rims ( N = 20) were mounted on artificial anterior chambers. PKP specimens underwent FUR, femtosecond laser-cut without cross-linking, or conventional corneal transplantation. PKP maximum burst IOP with progressive suture removal was assessed by a digital manometer, in triplicate and by three observers. ALK involved whole human globes ( N = 10) divided into three groups using a 200-micron, 8 mm diameter donor lenticule, with or without cross-linking. Cross-linked specimens were exposed to UVA light (3 mW/cm 2 irradiance, 3.4 J, 370 nm wavelength) for 30 min with 0.1% riboflavin (20% Dextran) applied every 2-min. ALK tensile strength was determined using a digital tensiometer. Results In PKP, burst IOP was 31.32 mmHg greater for corneas that underwent the UVA-riboflavin treatment than for those that did not ( p < 0.05). There was no significant relationship ( p = 0.719) established between cut design (femtosecond versus conventional). On multivariate analysis, there was a mean of 15.82 mmHg higher sustainable pressure for each stabilization suture present ( p < 0.0001). In ALK, specimens comprised of human donor and human recipient tissue combined with UVA-riboflavin therapy experienced the greatest level of adhesion strength (954.7 ± 290.4 kPa) as shown by the force required to separate the tissues, and compared to non-cross-linked specimens. Electron microscopy of ALK specimens showed non-fused and fused longitudinal cross-linked collagen fibers as well as bridges, densities, attachment plaques and primitive plasmalemmal densities. Conclusions Cross-linking effects of the FUR technique enable a stronger graft-recipient adhesion compared to conventional penetrating and anterior lamellar keratoplasty. Electron microscopy enabled visualization of cross-linked interface and potential bonding. The FUR approach may further lead to sutureless transplantation techniques in the future. Setting/venue ImagePlus Laser Eye Centre, Winnipeg, and University of Ottawa Eye Institute, Ottawa, Canada.