Endothelial Keratoplasty Research Articles

Glaucoma drainage devices: Indications, intraoperative management and postoperative follow-up

Glaucoma drainage devices (GDD) are used for patients with secondary glaucoma, such as uveitic or neovascular glaucoma, which is uncontrolled under local therapy. They are also used in patients with conjunctival scarring, for example after a previous vitrectomy or after unsuccessful previous glaucoma surgery, such as trabeculectomy. They are also a treatment option for congenital glaucoma, aphakic glaucoma or for the treatment of iridocorneoendothelial syndromes. The conventional GDD were the Baerveldt, Molteno or Ahmed glaucoma implant, whereby the first two were valveless and the latter had a valve. Newer GDD include the PAUL glaucoma implant, the Ahmed Clear Path and the EyeWatch system. Hypotony is a feared complication after GDD surgery, and there are various options for avoiding it: external ligation of the tube or intraluminal suture obstruction. However, low IOP may still occur postoperatively. If early postoperative hypotension occurs in combination with a shallow anterior chamber, the injection of a viscoelastic can be helpful. Late hypotension is usually treated with permanent occlusion or removal of the tube. Furthermore, GDD erosion and migration can occur postoperatively, in such cases a surgical revision is required. Corneal decompensation can also occur after GDD; Descemet's membrane endothelial keratoplasty (DMEK) is the treatment of choice in many centers and is performed more frequently than a penetrating keratoplasty. Finally, double vision is a possible complication after GDI. Most patients have short-term, self-limited diplopia or can be adequately treated with prism glasses; a few require strabologic surgery.

Treatment of Pseudophakic Bullous Keratopathy in Sclerocornea With Corneal Plana Using Descemet Stripping Automated Endothelial Keratoplasty

Abstract: We report the case of a 68-year-old man with sclerocornea with corneal plana who presented with progressive pseudophakic bullous keratopathy. He underwent Descemet stripping automated endothelial keratoplasty. Although a single air bubble was needed for the initial lenticule detachment, there was notable improvement in corneal clarity and visual acuity over the course of a year.

Endothelial Cell Viability of Nonscrolled "Endo-Out" Preloaded Descemet Membrane Endothelial Keratoplasty Graft.

The purpose of our paper is to report on the endothelial viability of a preloaded Descemet membrane endothelial keratoplasty (DMEK) graft that was found to be in a fully opened, nonscrolled configuration in the glass cannula. Case Report. The preloaded DMEK graft was found to be in an opened, nonscrolled configuration with the endothelial side facing outward in the micro Weiss glass cannula when the preloaded system was visualized in the operating room. As the opened graft was noted to be in a relatively immobilized state against the cannula wall, the decision was made to decline usage for transplantation and the tissue was returned to the eye bank for further assessment of endothelial viability. The DMEK graft underwent specular microscopy and Trypan Blue staining for cell damage assessment. The results demonstrated viable endothelial cells and the suitability of the DMEK graft for transplantation. We herein demonstrate that despite the DMEK graft being in a fully opened, nonscrolled configuration in the preloaded glass cannula, with the endothelial side facing outward, the endothelial cells were found to be viable. The evaluation and assessment of the DMEK graft were determined to be suitable for transplantation. We demonstrate that surgeons may likely accept such grafts with confidence.

Intraoperative Optical Coherence Tomography (OCT)-Guided Femtosecond Laser-Assisted Descemet Membrane Endothelial Keratoplasty (iFAD)

We describe retrospectively the indications and outcomes of nine patients who present with varying degrees of deep posterior stromal scarring or endothelial failure following deep anterior lamellar keratoplasty (DALK). These patients underwent a surgical strategy coined Intraoperative Optical Coherence Tomography Guided Femtosecond Laser-Assisted Descemet Membrane Endothelial Keratoplasty (iFAD). This strategy can be used to address suboptimal visual outcomes following primary DALK. Patients undergoing iFAD first had femtosecond laser-assisted trephination of the underlying posterior lamella using the liquid keratoplasty system on the Femto LDV Z8 platform (Zeimer Ophthalmic Systems AG, Port, Switzerland). A Descemet Membrane Endothelial Keratoplasty (DMEK) graft was subsequently transplanted in place of the removed lamella. Out of nine cases, major indications for seven included post-infective, blepharokeratoconjunctivitis (BKC) and deep stromal scarring related to stromal dystrophy. The remaining two had endothelial failure following primary DALK. The main benefits of this surgical approach are (1) Utilization of integrated real-time iOCT on the femtosecond laser platform allows for precise calibration of a wide range of vertical posterior trephination depths (96–329 microns) from the endothelial surface. (2) Femtosecond laser trephination utilizing a non-applanation liquid interface preserves trephination geometries and maximises precision-based surgical outcomes. (3) iFAD is a viable and straightforward technique for surgeons addressing patients who might otherwise require complex surgery to address residual deep stromal scars post-DALK.

Molecular Changes in Aqueous Humor Associated with Inflammation Following Cataract Surgery in Patients with Fuchs' Endothelial Corneal Dystrophy.

To evaluate the anterior chamber (AC) inflammation in the early postoperative period after cataract surgery and before Descemet membrane endothelial keratoplasty (DMEK) by quantifying oxidative stress and inflammatory mediators in aqueous humor of patients with Fuchs' endothelial corneal dystrophy (FECD). In this prospective single-center study, 15 patients with FECD underwent cataract surgery and DMEK in a two-stage procedure.Aqueous humor was collected from the AC at the beginning of cataract surgery and 3months later at the beginning of DMEK. In the control group, which consisted of 15 age-matched phakic patients without FECD, aqueous humor was only collected at the beginning of cataract surgery. Mediators of postoperative inflammation including TNF-α, VEGF, IL-2, IL-1 β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, GM-CSF, IFN-γ, CXCL5/ENA-78, FGF-basic, G-CSF, IL-1-α, IL-1-ra, IL-17, CCL2/MCP-1, CCL3/MIP-1a, CCL4/MIP-1b, TPO, TGF-β-1, TGF-β-2, and TGF-β-3 concentrations were measured using a Multiplex-Array-System. The concentration of TNF-α (p = 0.021), IL-6 (p = 0.005), IL-8 (p = 0.001), CXCL5/ENA78 (p = 0.002), CCL2/MCP-1 (p = 0.001) and CCL4/MIP-1b (p = 0.037) were significantly higher 3months after cataract surgery at the beginning of DMEK compared to control group at beginning of cataract surgery. The levels of IL-2, IL-5, IL-8, IL-10, and IL-1-α were significantly higher in phakic eyes in the control group (p < 0.05) before cataract surgery. The present study indicates significantly increased proinflammatory cytokines 3months after cataract surgery in eyes with FECD. Our findings suggest postoperative inflammation in the AC up to 3months after cataract surgery. Therefore, it may be reasonable to combine cataract surgery with DMEK in cataract patients with FECD.

Factors Influencing Corneal Endothelial Cell Density after Descemet Stripping Automated Endothelial Keratoplasty

Purpose: To identify determinants of corneal endothelial cell density at 12 months after Descemet stripping automated endothelial keratoplasty (DSAEK).Methods: This study included patients with bullous keratopathy who underwent DSAEK with internationally sourced donor corneas from March 2021 to March 2022. We assessed various preoperative factors in recipients (age, cause of bullous keratopathy, intraocular pressure, visual acuity, anterior chamber volume, depth and angle, pupil size, white-to-white corneal diameter, and preoperative corneal endothelial cell density) and donors (age, death to preservation time, preservation to transplantation time, death to transplantation time, corneal endothelial cell density, trephine size, and precut tissue thickness). We analyzed factors influencing corneal endothelial cell density up to 12 months after keratoplasty.Results: This study involved 53 patients, with an average recipient age of 65.9 ± 14.6 years prior to surgery. Donor corneas had an average endothelial cell density of 2,871.6 ± 271.6 cells/mm&lt;sup&gt;2&lt;/sup&gt;. At 6 and 12 months postoperatively, endothelial cell densities had decreased by 36.9% and 47.2%, respectively, compared with preoperative levels. Multivariate linear regression analysis indicated that endothelial cell densities at 3 and 12 months postoperatively were linked to recipient age and anterior chamber depth.Conclusions: Corneal endothelial cell density after DSAEK typically stabilized after initial decline; higher densities were found in older recipients and individuals with shallower anterior chambers.

Bagel sign and how to avoid it in DMEK surgery.

To provide a detailed description of the recommended surgical technique for gas injection during Descemet's Membrane Endothelial Keratoplasty (DMEK) surgery and highlight intraoperative sign that emerged in case of fluid retention in the interface. Gas injection recommended surgical technique is 2 steps procedure using a 1 ml syringe: the first step consists in injecting centrally to the graft and very slowly a bubble of gas smaller than the DMEK graft size, the second step, after checking the absence of fluid interface (no bagel sign), consists in enlarging the gas bubble to the desired filling. Bagel sign allows surgeons to look for interface fluid and correct for potential issues leading to graft detachment. The recommended surgical technique for gas injection also may help to prevent fluid retention in the interface and reduce the risk of graft detachment. Detecting a fluid interface retention at the end of DMEK surgery through iOCT or simply looking for the bagel sign may help to prevent post-operative complications.

Predictive factors of long-term visual outcomes after primary Descemet's membrane endothelial keratoplasty (DMEK): retrospective study.

To determine predictive factors of higher levels of best-corrected visual acuity (BCVA) in the long-term after primary Descemet's membrane endothelial keratoplasty (DMEK). Retrospective, single-surgeon case series of 129 successful primary DMEK eyes without graft failure and with a minimum postoperative follow-up of 12months. Mixed effect model for repeated measurements (MMRM) analysis was performed to determine recipient, donor, surgical and postoperative factors associated with BCVA ≤ 0.10 logMAR (≥ 20/25 Snellen). After primary DMEK, there was a statistically significant improvement in BCVA with a global reduction in logMAR BCVA (p < 0.00001). There was also a global tendency towards increasing proportion of eyes with BCVA ≤ 0.10 logMAR at all time points (p < 0.00001), from 1.6% before DMEK to 64.4% in eyes with more than 5years of F-U. Absence of retinal disease was associated with a decrease of 0.10 logMAR in postoperative BCVA after primary DMEK, maintaining constant the rest of variables (p < 0.001). The variables age (OR 0.960), postoperative time (OR 1.083), preoperative BCVA ≥ 0.375 logMAR (OR 0.162) and indication for DMEK (OR 5.412) were included in the predictive MMRM model of BCVA ≤ 0.10 logMAR. Primary DMEK is associated with statistically and clinically significant improvement in BCVA that occur early in the postoperative period and are continuous over time. Eyes with retinal comorbidities have increased risk of worse postoperative BCVA after DMEK. Younger recipient age, Fuchs' dystrophy eyes and eyes with better preoperative BCVA are more likely to achieve postoperative BCVA ≤ 0.10 logMAR.

Clinical characteristics, risk factor analysis and outcomes in 61 eyes with graft rejection after descemet stripping endothelial keratoplasty, with a review of literature.

To report the demographic profile, clinical characteristics, risk factors and outcomes of graft rejection after DSEK. A total of 3073 eyes had DSEK between 2012 and 2019, of which 1710 eyes that had follow up of more than one year. Sixty-one eyes who had graft rejection during this period were studied. Overall, incidence of graft rejection during the study period was 3.6% (61/1710 eyes) in those with follow up more than one year. The median age of patients was 58 (IQR 37.5-68) years. The indications were prior failed graft (34 eyes: 28 penetrating keratoplasty; 6 DSEK), post cataract surgery edema (12 eyes), Fuchs corneal endothelial dystrophy (6 eyes), corneal edema post inflammation (5 eyes) and iridocorneal endothelial syndrome (4 eyes). Of the 34 eyes with failed grafts, nine were post-rejection graft failures (two after endothelial keratoplasty and seven after penetrating keratoplasty), remaining 25 eyes were non-rejection graft failures. Ocular co-morbidities were noted in 41 eyes, of which secondary glaucoma was the most common (14 eyes). Clinical signs of graft rejection were diffuse edema, keratic precipitates and endothelial rejection line. Rejection episode occurred between 6-12months after surgery in 20 (33%) eyes, 12-24months in 15 (25%) eyes, 2-3years in 12 (20%) eyes, and beyond 3years in 14(23%) eyes. Graft clarity was restored in 55 (90%) eyes, which was complete in 41 (67%) eyes, partial in 14 (23%) eyes, and clarity was not restored in 6 (10%) eyes. The statistically significant risk factors for rejection were non-use of steroids (p value < 0.001), DSEK for failed graft (p value < 0.02) and DSEK for corneal edema post-inflammation (p value < 0.0014). DSEK for failed graft was a significant risk factor for graft failure after the rejection episode (p value < 0.05). Graft rejection may occur as late as 5years post-DSEK, emphasizing the need for long-term steroids instillation. Non-use of topical steroids, DSEK for failed graft and corneal edema post inflammation are risk factors for graft rejection. DSEK for failed graft was also seen as a risk factor for failure after the rejection episode The graft survival rate after the rejection episode was 90% at 6months, 50% at 2years and 10% at 5years.

Severe Corneal Flattening After Endothelial Keratoplasty: Collagen Compaction Syndrome.

The purpose of this study was to present a case series of patients with extreme corneal flattening after uneventful endothelial keratoplasty (EK): collagen compaction syndrome. Four patients (2 men, 2 women, mean age 64.8 ± 11.8 years) underwent successful EK after a period of chronic corneal edema (4-7.5 months): 3 received Descemet membrane endothelial keratoplasty after unsuccessful Descemet stripping only for Fuchs dystrophy and 1 received Descemet automated endothelial keratoplasty after prolonged pseudophakic bullous keratopathy. All patients developed significant corneal flattening, affecting their vision and inducing a large hyperopic refractive outcome, best-corrected visual acuities ranging from 20/40 to 20/200. Chronic corneal edema may result in severe corneal flattening after EK. Preoperative duration of stromal edema might affect the outcome of EK and should, therefore, be considered in the timing of surgery. In cases of dense focal edema, including post-Descemet stripping only surgery, rescue treatment at week 8 should be considered.

Graft detachment rates in surgeon-cut and pre-cut tissue for DSAEK transported in different mediums.

To analyse graft detachment rates after Descemet stripping automated endothelial keratoplasty (DSAEK) using surgeon-cut grafts and pre-cut grafts transported in different mediums. A retrospective study of graft detachment rates including 265 surgeries (240 patients) performed between 2019 and 2023. The DSAEK grafts were either surgeon-cut (n = 135) or pre-cut and transported in a dextran-containing medium (n = 82) or in a dextran-free medium (n = 48). All surgeries were performed by a single surgeon (I.G.). The surgeries were categorised according to whether the recipients' eyes had, or did not have, factors associated with an increased risk of graft detachment. Detachment rates were compared for all patients receiving the different kinds of graft, and only for those without risk factors. A significantly higher detachment rate was found among patients receiving pre-cut grafts transported in a dextran-containing medium (32.9%), compared to surgeon-cut grafts (14.1%, p = 0.002), and pre-cut grafts transported in a dextran-free medium (6.3%, p = 0.002) for all recipients (those with and without risk factors for graft detachment). When analysing recipients without risk factors for graft detachment, the detachment rate was still significantly higher with pre-cut tissue transported in a dextran-containing medium (26.9%), compared to surgeon-cut tissue (8.3%, p = 0.002) and pre-cut tissue transported in a dextran-free medium (3.6%, p = 0.01). The use of pre-cut DSAEK tissue transported in a dextran-containing medium significantly increases the risk of graft detachment requiring re-bubbling.

Efficacy of Sutureless Scleral Fixation of One-Piece T-Shaped Haptic Intraocular Lens in Maintaining Anterior Chamber Stability During Descemet Membrane Endothelial Keratoplasty in Vitrectomized Eyes: Leak Test and Iris Diaphragm Reconstruction.

Objectives: This study aimed to describe the outcomes of a staged procedure combining Descemet membrane endothelial keratoplasty (DMEK) and sutureless scleral fixation (SSF) of a one-piece intraocular lens (IOL) in a case series. Co-performing endothelial keratoplasty (EK) and SSF is associated with intraoperative and postoperative complications such as graft deployment difficulties, air migration, graft detachment, and IOL opacification or tilt, all of which are evaluated in this study. Methods: This is a retrospective observational case series. Clinical data were collected from eight eyes of eight patients who underwent DMEK for endothelial failure and had previously received an SSF with one-piece IOL following complete vitrectomy. During DMEK surgery, an air leak test was conducted to check for air migration into the posterior chamber. If instability was detected, pupilloplasty was performed. Intraoperative and postoperative data, including DMEK graft unfolding time, were collected. Corrected Distance Visual Acuity (CDVA), refraction, endothelial cell density (ECD), central corneal thickness (CCT), intraocular pressure (IOP), and complications were recorded over a 12-month follow-up period. Results: We performed pupilloplasty in four patients (50%). The median CDVA improved from preoperative 0.85 logMAR (range: 0.60 to 1.00) at baseline to 0.18 logMAR (range: 0.10 to 0.70, p = 0.012) at 12 months. The median refraction value changed significantly from -1.00 to -0.50 at 12 months. The median percentage reduction in ECD after 12 months was 33.4% (range 30 to 40). The median baseline CCT was 689 μm (range: 651 to 701) at baseline visit and 541.5 μm (range: 525 to 591, p = 0.008) at 12 months. The median IOP was reduced significantly during follow-up. The median graft unfolding time was 6 min (5 to 9). One patient required rebubbling for partial detachment on postoperative day one. No complications occurred within 12 months. Conclusions: The effective compartmentalization of the anterior and posterior chambers in vitrectomized eyes with an SSF one-piece IOL and pupilloplasty can facilitate critical steps of DMEK surgery in complex eyes. Additionally, the air leak test could prove useful in identifying the need for iris-lens diaphragm reconstruction.

Efficacy and Safety of Ab-Interno Canaloplasty in Post-Keratoplasty Patients: 3-Year Results.

To evaluate the effectiveness and safety of ab-interno canaloplasty (ABiC) for managing intraocular pressure (IOP) in patients following keratoplasty over a three-year period. This retrospective analysis focused on post-keratoplasty patients treated with ABiC with the iTrack microcatheter (Nova Eye Medical, Fremont, CA, USA) at a single institution. The study assessed the procedure's impact on IOP control, graft survival, and reliance on topical hypotensive medications, with additional observation for any postoperative complications. Surgical success criteria included the percentage of eyes with IOP ≤15mmHg, IOP ≤18mmHg, ≥20% IOP reduction, medication-free eyes, and eyes with concurrent IOP and medication reductions. ABiC was performed successfully in a cohort of 16 post-keratoplasty (7 penetrating keratoplasty and 9 endothelial keratoplasty (EK)) eyes. Preoperative mean IOP of 25.8±7.2mmHg was significantly reduced to 13.4±2.9mmHg (p<0.001) at 1 year postoperatively and maintained at 13.1±3.9mmHg (p=0.009) at 3 years postoperatively. The mean number of glaucoma medications was 3.5±1.7 at baseline, 2.8±1.3 at 1 year (p=0.107), and 2.5±1.2 at 3 years postoperatively (p=0.088). Eight eyes (66.7%) maintained IOP ≤ 15mmHg, and 10 eyes (83.3%) maintained ≥ 20% IOP reduction at 3 years. The mean IOP and medication reductions from baseline at 3 years were -49.2% and -28.6%, respectively. Graft clarity was preserved in all patients except for one case of late graft failure that necessitated a repeat EK procedure. Post-ABiC complications included transient hyphema in two patients, neither of which led to long-term adverse outcomes. ABiC appears to be an effective and safe surgical intervention for sustained IOP reduction in post-keratoplasty patients. Graft survival trends are encouraging, and there was a low incidence of complications over a three-year follow-up period.

Corneal Artificial Endothelial Layer (EndoArt): Literature Review and Our Experience.

Background/Objectives: The objective of this study was to examine the morphological corneal changes and outcomes following the implantation of an artificial endothelial layer (EndoArt) in patients with chronic corneal oedema. Methods: A systematic review of the literature was conducted alongside a detailed analysis of two clinical cases with chronic corneal oedema that were treated using EndoArt. Our experience with these two cases is included to provide practical insights and real-world outcomes. Results: Across the 24 cases reported (including the two presented here), an analysis was possible in 23 cases. Notably, 82% of patients had undergone at least one previous corneal transplant, with 39% having undergone three or more transplants. Additionally, 78% of cases had ocular comorbidities, with glaucoma surgery being the most prevalent (83%), which could have impacted visual outcomes. The follow-up period ranged from 3 to 17 months with a median of 3 months. After EndoArt implantation, the average reduction in the central corneal thickness (CCT) was 29%, and the rebubbling rate was 47.8%, with some cases requiring no rebubbling, while others required it up to 100% of the time. Visual acuity significantly improved from a mean best-corrected visual acuity (BCVA) value of 1.61 ± 0.5 logMAR to 1.07 ± 0.59 logMAR (p < 0.001). The CCT decreased from 771 ± 146 µm to 580 ± 134 µm (p < 0.001). These findings are consistent with our experience. Conclusions: EndoArt shows promise as an alternative treatment for chronic corneal oedema in complex cases where conventional corneal transplantation has failed or carries a high risk of failure. The morphological changes observed using anterior segment optical coherence tomography (OCT) and in vivo confocal microscopy (IVCM) were similar to those reported after endothelial keratoplasty, with the notable exception of the absence of the hyper-reflective donor-host interface.

Ten-Year Follow-Up After Descemet Membrane Endothelial Keratoplasty.

To examine clinical results up to 10 years after Descemet Membrane Endothelial Keratoplasty (DMEK) and Triple-DMEK. Prospective study including 201 eyes, of which 54 eyes [38 DMEKs and 16 Triple-DMEKs; Fuchs endothelial dystrophy (n = 45), pseudophakic bullous keratopathy (n = 9)] reached the minimum follow-up of 5 years and were followed up for up to 10 years. We evaluated best-corrected visual acuity (BCVA, logarithm of the minimum angle of resolution [logMAR]), endothelial cell density (ECD, cells/mm2), minimal central corneal thickness (CCT, μm), central retinal thickness (μm), rebubbling, graft survival and re-DMEK rate, chamber angle alterations, and incidence of glaucoma. Fifty-four eyes had a 5-year and 37 eyes an 8- to 10-year follow-up. Mean follow-up was 94.4 ± 12.1 months. Best-corrected visual acuity increased from 0.6 ± 0.3 logMAR to 0.1 ± 0.2 logMAR at 6 months (P ≤ 0.001) and was 539 ± 54 μm at long term. Endothelial cell density decreased from 2488 ± 320.9 (donor) to 980.1 ± 437 cells/mm2 with an average ECD loss/year of 4% and did not correlate with BCVA. Central corneal thickness decreased from 596.9 ± 82.2 μm to 498.6 ± 24.3 μm at 12 months (P ≤ 0.001) and remained stable (P = 1.000). Mean rebubbling rate was 0.3 ± 0.5/eye and did not correlate with BCVA. Eight eyes (14.8%) received at least 1 rebubbling. Primary graft failure/rejection rate was 1.5%/0% within the first postoperative year, and secondary graft failure rate was 12.4% at 7 years. Eight eyes (preoperative n = 3, de novo n = 5) had open-angle glaucoma without chamber angle changes (14.8%, P ≤ 0.001). Although ECD decreases continuously in the long-term follow-up, excellent visual acuity can be preserved 10 years after DMEK and Triple-DMEK. The final outcome can be estimated 6 months after surgery.

Off-Centered DMEK Grafts: Impact and Resolution.

The aim of this study was to assess the outcomes of off-centered Descemet membrane endothelial keratoplasty (DMEK) grafts compared to descemetorhexis. This is a retrospective case series of DMEK procedures conducted between June 2022 and July 2023 with postoperative graft decentration, characterized by a gap between the graft and descemetorhexis edge. Eight eyes of 8 patients met the inclusion criteria. The average gap between the descemetorhexis edge and DMEK graft was 911.2 μm (range 306-1468). The resulting focal peripheral edema overlying the gap resolved in all cases, with a median time of 3 months. Best-corrected visual acuity improved from 0.49 (±0.26) logarithm of the minimum angle of resolution to 0.01 (±0.02) logarithm of the minimum angle of resolution at 12 months (P = 0.003). Central corneal thickness decreased from 646.5 (±177.8) μm to 473.7 (±29.6) μm at 12 months (P = 0.05). One eye, in the overlapped area of host-donor Descemet membranes, had small peripheral partial graft detachment less than one-third of graft surface area. No eyes required graft rebubbling. A larger descemetorhexis to DMEK gap showed a trend toward longer resolution times (P = 0.06). Focal edema in the inferonasal periphery took longer to recover compared with the nasal position (P = 0.01). Larger descemetorhexis to DMEK gaps did not significantly influence the longitudinal visual acuity trend (P = 0.75). Decentered DMEK, characterized by a gap between the graft and descemetorhexis edge, leads to focal stromal edema that diminishes over time, with no impact on final visual acuity.

Influence of surgeon learning on outcomes in new ophthalmic procedures: quantified nationwide evidence in endothelial corneal transplantation

AimsTo investigate the impact of surgeon learning on endothelial keratoplasty (EK) procedure outcomes.MethodsA prospective nationwide registry study of EK grafts in patients aged at least 21 years with Fuchs endothelial...

Impact of postoperative intraocular pressure elevation on graft endothelial cells in non-preexisting glaucoma eyes undergoing descemet membrane endothelial keratoplasty: a cohort study

BackgroundDescemet membrane endothelial keratoplasty (DMEK) has become the dominant keratoplasty procedure. However, the impact of high intraocular pressure (IOP) on the DMEK prognosis in patients without preexisting glaucoma remains unknown.MethodsNon-glaucoma patients who underwent DMEK in Peking University Third Hospital between July 2017 and March 2023 with a follow-up duration longer than six months were included in this cohort study. Eyes were divided into three groups: Group A) normal IOP; Group B) early IOP elevation (IOP ≥ 30 mmHg or increase of more than 10 mmHg from baseline within 3 days); Group C) intermediate-term IOP elevation (IOP > 21 mmHg or increase of more than 10 mmHg from baseline after 14 days postoperatively). The postoperative IOP, endothelial cell density (ECD), central corneal thickness (CCT), best-corrected visual acuity (BCVA) and rate of graft failure were analysed.ResultsForty-seven eyes from forty-seven patients were included. Thirty-seven eyes were bullous keratopathy, and ten were Fuchs endothelial corneal dystrophy. Twenty-five eyes were classified as Group A, six as Group B and sixteen as Group C. The mean peak IOP was 49.00 ± 4.99 mmHg in Group B eyes and 31.89 ± 11.75 mmHg in Group C eyes. The postoperative BCVA significantly differed from that before surgery (P < 0.001). The ECD at 3 months after surgery in eyes with intermediate-term IOP elevation was lower (P = 0.032). Four eyes with intermediate-term IOP elevation developed graft failure (P = 0.001).ConclusionsIntermediate-term IOP elevation after DMEK may reduce the graft ECD and lead to graft failure within six months after surgery. However, early IOP elevation had no effect on the prognosis. Careful IOP monitoring and intermediate-term IOP management should be conducted for graft protection.

Cataract surgery with endothelial keratoplasty.

This review aims to provide an updated summary of the combined approach of cataract surgery with endothelial keratoplasty (EK), addressing key considerations, including intraocular lens (IOL) choice and calculation, decision between sequential and triple EK, and modifications in surgical techniques and postoperative management. Advances in imaging techniques (Scheimpflug tomography and anterior segment optical coherence tomography) have improved the ability to detect subclinical corneal edema, aiding in surgical decision-making for EK. Recent studies comparing sequential and triple-EK indicate that both methods yield similar visual outcomes. Though triple-EK offers quicker recovery, it may have higher complication rates. The use of gases like SF6 and C3F8 for anterior chamber tamponade is evolving, with conflicting findings on their efficacy in preventing graft detachment. Furthermore, IOL selection remains crucial, as hyperopic refractive surprises are common, and hydrophilic lenses should be avoided owing to the risk of opacification after EK. The combination of cataract surgery with EK has emerged as an effective treatment for patients with corneal endothelial diseases and cataract. Careful preoperative evaluation, appropriate IOL selection, and advances in surgical techniques contribute to better outcomes, although patient-specific factors must guide the choice between sequential and triple-EK procedures.

Changing indications for and trends of keratoplasty in a tertiary comprehensive hospital in northern part of China from 2002 to 2021: a 20-year review

ObjectiveTo investigate indications and surgical procedures of keratoplasty in a tertiary comprehensive hospital in northern part of China over a 20-year period.MethodsAll patients undergoing keratoplasty between January 1, 2002 to December 31, 2021 in a tertiary comprehensive hospital in northern part of China were retrospectively reviewed. The annual proportion of keratoplasty indications and surgical procedures was recorded and analyzed.ResultsA total of 8266 keratoplasty procedures were included. Leading indications were keratoleukoma (n = 2108, 25.50%), followed by regraft (n = 1453 ,17.58%), corneal endothelial dysfunction (n = 1085, 13.13%), and keratoconus (n = 922,11.15%). A decreasing trend was observed for keratoleukoma (P < 0.01) and an increasing trend for corneal endothelial dysfunction (P < 0.01), regraft (P = 0.012), corneal limbal dermoids (P < 0.01) and congenital corneal opacity (P < 0.01). From 2002 to 2021, the proportion of penetrating keratoplasty (PK) had decreased from 73.95% (2002 to 2006) to 53.49% (2017 to 2021). On contrary, anterior lamellar keratoplasty (ALK) (459–705, 26.05-31.96%, P = 0.034) and endothelial keratoplasty (EK) (0-321, 0.00-14.55%, P < 0.01) became more prevalent from 2002 to 2021. For cases with corneal endothelial dysfunction, EK became the preferred technique (74.72%) in the recent 5 years.ConclusionOver the past 20 years, keratoleukoma and regraft have been the leading indications for keratoplasty. A noticeable shift in surgical preference from PK to DSAEK and ALK is evident, with key indications for keratoplasty including keratoleukoma, regraft, limbal dermoids, endothelial dysfunction, and keratoconus, respectively.