Keratoplasty In Patients Research Articles

Clinical Outcome of Penetrating Keratoplasty in Patients 5 Years or Younger

To investigate and compare the clinical outcome of primary penetrating keratoplasty in pediatric patients with Peters anomaly and sclerocornea. Medical records of 20 eyes of 18 patients with Peters anomaly or sclerocornea who underwent primary penetrating keratoplasty when they were 5 years or younger were reviewed. The survival rates and median survival times of corneal grafts were evaluated to determine the surgical outcome. Demographics of patients, the preoperative characteristics of recipient eyes, surgical procedures, causes of graft failure, and postoperative complications were analyzed to identify the factors affecting graft survival. A total of 20 penetrating keratoplasties were performed in 18 patients. Eight patients had Peters anomaly, and 10 patients had sclerocornea. Overall, 50% of corneal grafts survived during the follow-up of 92.7 ± 10 months. The graft survival was 65% at 6 months and remained 50% at 12 months, 2 years, and 5 years after surgery. The mean survival time and survival rate were significantly different between patients with Peters anomaly and those with sclerocornea (the survival time, 135.6 ± 17.9 vs. 36.4 ± 16.1 months, P = 0.014; the survival rate, 87.5% vs. 25.0%, P = 0.02). The presence of opacity or vascularization in the limbus and in the peripheral cornea and the diameter of the recipient cornea were significantly correlated with graft failure. Penetrating keratoplasty in patients who were 5 years or younger had an excellent surgical outcome in patients with Peters anomaly, whereas the graft survival was poor in patients with sclerocornea.

Keratoplasty Postoperative Treatment Update

Immunosuppressive therapy is the main postoperative treatment for keratoplasty, but there are considerable differences in protocols for the use of steroids and other immunosuppressants. Therefore, we conducted 2 prospective randomized clinical trials and 1 prospective nonrandomized clinical trial on keratoplasty postoperative treatment. One study evaluated the efficacy and safety of long-term topical corticosteroids after a penetrating keratoplasty was performed. Patients who underwent keratoplasty and maintained graft clarity for >1 year were randomly assigned to either a steroid or a no-steroid group. At the 12-month follow-up, the no-steroid group developed significantly more endothelial rejection than did the steroid group. A second study elucidated the effectiveness and safety of systemic cyclosporine in high-risk corneal transplantation. The patients were assigned to a systemic cyclosporine or control group. At a mean follow-up of 42.7 months, no difference was observed in the endothelial rejection rates and graft clarity loss between the 2 groups. A third study elucidated the effectiveness and the safety of systemic tacrolimus in high-risk corneal transplantation. Of 11 consecutive eyes decompensated despite systemic cyclosporine treatment, there was no irreversible rejection in eyes treated with tacrolimus, which was significantly better than in previous penetrating keratoplasty with systemic cyclosporine treatment. Prognosis after keratoplasty in patients with keratoconus is relatively good, but special attention is required for patients with atopic dermatitis. Postkeratoplasty atopic sclerokeratitis (PKAS) is a severe form of sclerokeratitis after keratoplasty in atopic patients. Our retrospective study showed that 35 eyes of 29 patients from a total of 247 keratoconus eyes undergoing keratoplasty were associated with atopic dermatitis, of which 6 eyes of 5 patients developed PKAS. Eyes with PKAS had a significantly higher incidence of atopic blepharitis and preoperative corneal neovascularization, and therefore, we suggest systemic corticosteroids or cyclosporine to prevent PKAS in such high-risk cases.

Bitoric rigid gas permeable contact lenses in the optical management of penetrating keratoplasty

The purpose of this study was to evaluate the complexity and effectiveness of fitting bitoric rigid gas permeable contact lenses (RGPCLs), compared to spherical RGPCLS, when used in the correction of high amounts of post-penetrating keratoplasty astigmatism. Records of post-penetrating keratoplasty (PKP) patients being managed with bitoric RGPCLs were compared to controls (post-PKP patients managed with spherical RGPCLs). Factors that were analyzed included the number of diagnostic RGPCLs used to assess the initial fit, the number of RGPCLs ordered to finalize the fit and the number of total doctor visits to finalize the fit. Fourteen eyes of 14 patients satisfied the study criteria. The average amount of total astigmatism in this study group was 10.0D±5.0 compared to the control group which was 3.3D±2.6. The number of diagnostic RGPCLs used for the study group was 1.2±0.4 compared to 1.0±0.0 for the control group. The mean number of contact lenses ordered to complete the fitting for the study group was 1.9±0.7 compared to the control which was 2.1±0.8. The study group presented for an average of 6.3±1.6 visits whereas the control group presented for 4.9±1.1 visits. Contact lens corrected acuity for the study group was 0.101±0.11 (20/25) compared to the control group 0.08±0.12 (20/24). The complexity of fitting bitoric RGPCLs was found to be similar to fitting spherical RGPCLs on post-PKP eyes and the visual outcomes were not different.

Merkmale von traumatischen und spontanen Wunddehiszenzen nach perforierender Keratoplastik

After penetrating keratoplasty (PK) patients remain at risk for wound dehiscence at the graft-host junction even years after surgery. The aim of our study was, firstly, to assess the site-specific characteristics between traumatic and spontaneous wound dehiscence at the graft-host junction and, secondly, to determine the incidence of traumatic and spontaneous wound dehiscence. The medical records of all 243 patients who underwent a penetrating keratoplasty from 1 March 1996 to 1 March 2012 were retrospectively reviewed. During a 16-year period 9 eyes showed signs of open wound dehiscence after blunt ocular trauma and 7 eyes spontaneously after suture removal. Over the 16-year period, the incidence of traumatic wound dehiscence was 3.7 % (9 of patients), whereas the incidence of spontaneous wound dehiscence after suture removal was 2.9 % (7 of 243 patients). In traumatic cases the graft dehiscence occurred in 88.9 % (8 of 9 patients) in the nasal part, predominantly in the inferior nasal part. In one case (11.1 %), only the temporal part was affected. The average extent of wound dehiscence for traumatic cases was 96° of the total wound circumference in the nasal part, and only 30° of the circumference in the temporal part. Spontaneous dehiscence after suture removal mainly occurred at temporal site in 71.4 % (5 of 7 eyes), mostly temporal inferior. Only in one case was the nasal part affected (14.3 %). The average extent of wound dehiscence in spontaneous cases was 54° of the total circumference in the temporal part and 21° in the nasal part. The total average extent of dehiscence was significantly larger in traumatic cases, 126° (one third) for traumatic and 75° (one fifth) of the wound circumference for spontaneous cases. All of the re-sutured grafts retained clarity, except for 3 eyes among the traumatic cases. The difference between both groups was significant regarding the localisation, the extent and the clarity of the re-sutured grafts. The nasal inferior part was the most affected area in traumatic cases probably as a result of indirect, contrecoup injuries, and the temporal part in spontaneous wound dehiscence probably due to direct minor forces.

Two-Year Outcomes of an Initial Series of DSAEK Cases in Normal and Abnormal Eyes at an Inner-City University Practice

To report our initial series of Descemet stripping automated endothelial keratoplasty (DSAEK) patients with 2 years of follow-up and to compare the complications and outcomes between normal and abnormal eyes. Records of all patients who underwent DSAEK between April 2007 and April 2009 were reviewed. Eyes were categorized as "normal" or "abnormal" for comparison. Two risk factors, anterior chamber compromise and glaucoma tube/bleb, were analyzed for association with tissue detachment. Thirteen DSAEKs were performed on 13 "normal" eyes, and 18 DSAEKs were performed on 15 "abnormal" eyes. The lenticule detachment rates were 15.4% in the normal group and 41.2% in the abnormal group (P = 0.13). The difference in endothelial cell loss was not significant until 1.5 years postoperatively in favor of the abnormal group (P = 0.024). The mean starting vision was 20/115 for the normal group and 20/322 for the abnormal group (P = 0.06). At 2 years, the mean visual acuity was 20/47 for the normal group and 20/34 for the abnormal group (P = 0.44). Risk factor analyses indicated that glaucoma tubes/blebs were not related to lenticule detachment (P = 0.45), whereas anterior chamber compromise was related to lenticule detachment (P = 0.031). Complication rates for abnormal eyes are higher than those for normal eyes, and risk factor analyses suggest that marked anterior chamber compromise is related to lenticule detachment. However, if DSAEK is successful for these compromised eyes, the visual outcomes compare favorably with normal eyes through 2 years of follow-up.

Long-term Results of Keratoplasty in Patients With Herpes Zoster Ophthalmicus

To report the long-term results of keratoplasty in patients with herpes zoster ophthalmicus (HZO). All 14 patients underwent keratoplasty for a corneal scar or a perforated corneal ulcer due to HZO at the Wills Eye Institute from January 1999 to August 2011. We performed 9 penetrating keratoplasties and 1 deep anterior lamellar keratoplasty for corneal scarring, and 4 tectonic penetrating keratoplasties for perforated corneal ulceration due to HZO. Eight of the 14 eyes had a temporary tarsorrhaphy concurrent with graft. Postoperative follow-up time ranged from 12 to 132 months (mean 64 ± 38). Postoperatively, the most common complications were dense superficial punctate keratopathy and severe dry eye because of neuropathic keratopathy in 8 eyes, graft rejection in 5 eyes, and secondary glaucoma in 4 eyes. All grafts were clear, and best spectacle-corrected visual acuity was 20/40 or better in 6 eyes (42.8%) and 20/100 or better in 9 eyes at their final evaluation (64.2%). Although the sample size is small, we demonstrate that very good visual results in long-term follow-up can be achieved when keratoplasty is performed in patients with herpes zoster virus keratopathy. We believe that longer quiescent waiting period between active herpes zoster ocular involvement and keratoplasty may promote better visual results.

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

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

Novel Maneuver Facilitating Descemet Membrane Unfolding in the Anterior Chamber

To describe a new technique for unfolding of the Descemet membrane (DM) during Descemet membrane endothelial keratoplasty. DM and endothelium were stripped from donor corneas submerged in corneal storage solution. Donor DM diameters were 8.5 mm. The central 8 mm of DM was stripped from the recipient cornea. After staining with trypan blue to improve visualization, donor DM was inserted through a 2.75-mm incision. Unfolding was achieved with simultaneous digital pressure in the equatorial region and tapping of the corneal surface. This technique was performed in Descemet membrane endothelial keratoplasty patients with Fuchs endothelial dystrophy (n = 6) and bullous keratopathy (n = 4). In all cases, a fast attachment of the DM was achieved. The recurling was successfully hindered because of the simultaneous equatorial pressurization and induced fluid currents inside the anterior chamber by appropriate corneal tapping. In all cases, a rapid corneal clearance was achieved with significantly increased visual acuity (logarithm of the minimal angle of resolution visual acuity preoperative = 0.90, logarithm of the minimal angle of resolution visual acuity final assessment = 0.19, P < 0.001; follow-up 14 ± 5 weeks). Simultaneous digital pressure with corneal tapping is a helpful maneuver to unfold the DM inside the anterior chamber. This technique may reduce the need for unnecessary instrumental and noninstrumental manipulation of the graft.

Perioperative nursing for the keratoplasty patients with cataract

Objective To explore the nursing measures of keratoplasty patients complicated with cataract during the cataract surgery stage.Methods Perioperative nursing care were performed on 15 cases with cataract after keratoplasty surgery.Preoperative care such as reducing the fear and tension,the prevention of infection,taking anti-rejection drugs in advance,paying attention to preoperative mydriatic.Intraoperative care such as preparing surgical instruments,preparing mydriatic drugs,paying attention to intraoperative iris adhesion and so on.Postoperative nursing such as preventing rejection,anti-inflammation,preventing infection,observation.And the attentions for patients were educated to patients.Results Before surgery,among 15cases,33.3 percent of them had mydriatic ＜ 5 mm,and their intraocular pressure were normal.While after surgery,with follow up 6 months,no patients had rejection,and corneal planting piece were keep transparent,and patients' satisfaction were improved.Conclusions The situation of keratoplasty patients with cataract is much more complex and the rejections is incidental.And better clinical nursing is an important influencing factor of the success for surgery. Key words: Keratoplasty,penetrating; Cataract; Peri-operative nursing

Clinical Outcomes of Penetrating Keratoplasty in Patients Five Years or Younger

Clinical Outcomes of Penetrating Keratoplasty in Patients Five Years or Younger

Comparison of contrast sensitivity and visual acuity between deep anterior lamellar keratoplasty and penetrating keratoplasty in patients with keratoconus.

To evaluate postoperative visual acuity and contrast sensitivity results following deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) in patients with keratoconus (KC). All the patients' records with KC who had PK or DALK surgery between May 2010 and May 2011 were retrospectively reviewed. Sixty patients who underwent successful corneal transplantation for KC: 30 eyes underwent DALK and 30 eyes underwent PK were included in this study. Preoperative and postoperative mean logarithm of the minimum angle of resolution (logMAR) uncorrected visual acuity (UCVA), logMAR best spectacle-corrected visual acuity (BSCVA) and intraocular pressure (IOP) were evaluated. Contrast sensitivity tests (CS) were done preoperative and 2 months after all sutures had removed. All surgeries were performed under regional anesthesia (retrobulbar anesthesia) by 1 surgeon (B.K.) who was experienced in penetrating and lamellar keratoplasty techniques. The mean age of the DALK group was 29.67±4.95 (range 18-40) years and the PK group was 28.7±3.53 (range 18-39) years. Preoperatively there was no significant difference in the logMAR UCVA, logMAR BSCVA and IOP between the DALK (1.281±0.56; 0.97±0.85; 12.07±2.12mmHg) and PK (1.34±0.21; 0.98±0.21; 13±2.12mmHg) groups. One-year after surgery there was no significant difference in the mean logMAR UCVA and IOP between the DALK (0.46±0.37; 11.73±2.1mmHg) and PK (0.38±0.21; 12±2.12mmHg) groups. The mean contrast sensitivity was evaluated by CC-100 Topcon LCD at 1.5, 2.52, 4.23, 7.10 and 11.91 cycles per degree (cs/deg) spatial frequencies before and 2 months after the all sutures had removed. All patients with keratoconus in both DALK and PK groups performed good visual function postoperatively. The mean contrast sensitivity increased considerably at all spatial frequencies compared with preoperative levels in the DALK and PK groups.The mean post-operative evaluation of contrast sensitivity measurements was not significantly different between the two groups.

Outcomes of Repeat Endothelial Keratoplasty in Patients With Failed Descemet Stripping Endothelial Keratoplasty

To report the outcomes of repeat endothelial keratoplasty (EK) in patients with failed Descemet stripping endothelial keratoplasty (DSEK). The clinical records of patients with failed DSEK who underwent repeat EK surgery at a single institution were reviewed. A total of 20 eyes of 20 patients (8 men and 12 women) were included. The mean age at initial DSEK surgery was 69.9 ± 11.9 years (range, 41-83 years). The causes of DSEK failure included progressive endothelial failure (8 eyes; 40%), primary graft failure (8 eyes; 40%), and endothelial rejection (4 eyes; 20%). The mean duration from primary DSEK to repeat EK was 13.1 ± 10.3 months (range, 2-33 months). Removal of the failed DSEK donor disc was performed in all eyes. Mean preoperative corrected distance visual acuity (logMAR) before repeat EK surgery was 1.76, and this improved to 0.5 (P < 0.001) at the final follow-up at 27 months. Three eyes had limited corrected distance visual acuity secondary to ocular comorbidities (age-related macular degeneration and advanced glaucomatous optic neuropathy). Repeat EK in patients with DSEK failure is an effective treatment modality. This is the preferred management option compared with penetrating keratoplasty because the advantages of EK surgery are maintained with repeat EK surgery.

Descemet's stripping endothelial keratoplasty (DSEK) for children with congenital hereditary endothelial dystrophy: surgical challenges and 1-year outcomes

To evaluate the outcomes of Descemet's stripping endothelial keratoplasty (DSEK) in patients with congenital hereditary endothelial dystrophy (CHED). Retrospective, interventional case series of five eyes of five patients with congenital hereditary endothelial dystrophy (CHED) undergoing Descemet's stripping endothelial keratoplasty (DSEK) from June 2009 to June 2010 by a single surgeon. Patients were evaluated during the postoperative period for visual acuity, refraction, corneal clarity, lenticule status, and intraocular pressure. Anterior segment ocular coherence tomography (OCT) and confocal microscopy were performed when possible. Three male and two female children with an average age of 7.8 years (range 5-12 years) with CHED underwent DSEK. Surgery was uneventful in all patients and the lenticules stayed attached during the postoperative period. All the patients had 1-year follow-up. Corneal clarity improved in all the patients over the period of follow-up. Anterior segment OCT showed a gradual reduction in the thickness of the central corneal thickness and the graft over a period of time. DSEK is a viable alternative to penetrating keratoplasty in patients with CHED with distinct advantages of reduced postoperative astigmatism and potential reduction of postoperative complications.

Keratoplasty for Corneal Endothelial Disease, 2001–2009

To determine the rates of keratoplasty for corneal endothelial disease (CED) from 2001 to 2009 in a large managed care network in the United States, factors that affect which patients undergo this procedure and surgical outcomes. A retrospective review of data from a longitudinal cohort study. Beneficiaries with CED aged ≥ 40 years who were receiving eye care during 2001 to 2009. Rates of keratoplasty for CED were determined at 6-month intervals from January 2001 to December 2009. The mean number of postoperative visits and rates of severe adverse events in the year after keratoplasty surgery were monitored over the course of the decade. Univariable and multivariable logistic regression were performed to identify sociodemographic and other factors associated with undergoing keratoplasty for CED. Odds of undergoing keratoplasty with 95% confidence intervals, changes in the number of postoperative visits, and rates of adverse events in the year after keratoplasty. Of the 38 648 enrollees who met the inclusion criteria, 2187 underwent ≥ 1 keratoplasty surgeries from January 2001 to December 2009. After adjustment for confounding factors, individuals with CED had 47% increased odds of undergoing keratoplasty during 2007-2009 relative to 2001-2006. The mean number of postoperative visits to eyecare providers in the year after keratoplasty declined from 12.6 in 2001-2006 to 10.5 in 2007-2008. There was no difference in the proportion of enrollees who developed adverse events after keratoplasty over time. In this analysis of claims data, from 2001 to 2009, a period during which there was an increase in the rate of endothelial keratoplasty, we observed a trend of greater rates of keratoplasty in patients with CED and fewer visits for postoperative care in the later years of the decade compared with the earlier years, along with no change in rates of severe adverse events.

Graft Dislocation and Hypotony after Descemet's Stripping Automated Endothelial Keratoplasty in Patients with Previous Glaucoma Surgery

To determine if patients with prior glaucoma surgery experience higher rates of postoperative graft dislocation after Descemet's stripping automated endothelial keratoplasty (DSAEK) and to determine if postoperative hypotony may be a risk factor in these patients. Retrospective, comparative analysis of an interventional case series. Eight hundred fifty-four eyes (67 eyes with prior glaucoma surgery and 787 controls) from 582 patients who underwent DSAEK at 1 institution between January 2005 and April 2011. Groups were compared with regard to preoperative, intraoperative, and postoperative parameters. Continuous variables were compared using the independent samples t test or Mann-Whitney U test. Categorical variables were compared using the chi-square test or Fisher exact test. Frequencies of postoperative graft dislocation and postoperative hypotony. Study eyes before surgery differed from control eyes with regard to corneal thickness (768 vs. 655 μm; P<0.001) and intraocular pressure (13 vs. 16 mmHg; P<0.001). Postoperative graft dislocation occurred significantly more frequently in study eyes compared with control eyes (9% vs. 2%; P = 0.008). Among eyes in which dislocation occurred, postoperative hypotony was present in 5 study eyes (83%) and 0 control eyes. Previous glaucoma surgery was associated with a significantly increased rate of graft dislocation compared with control eyes. Dislocation was related strongly to postoperative hypotony in eyes with prior glaucoma surgery. Proprietary or commercial disclosure may be found after the references.

Do topical ophthalmic corticosteroids suppress the hypothalmic-pituitary-adrenal axis in post-penetrating keratoplasty patients?

To establish whether hypothalmic-pituitary-adrenal axis suppression is possible secondary to long-term topical ophthalmic corticosteroid use in patients who have undergone penetrating keratoplasty (PKP). Patients who had undergone a PKP and had been using corticosteroid-based eye drops continuously for more than 6 months, with no history of concomitant steroid (oral, inhaled, or cutaneous) use, were included within the study. A low-dose short Synacthen (LDSST) test was performed in each patient followed later by a short Synacthen test (SST). The mean SST and LDSST after 30 min were calculated along with their corresponding 95% confidence intervals (CIs). Correlation between both baseline SST and baseline LDSST with duration of treatment was determined using Spearman's correlation. In all, 20 patients were included within the study. The mean duration treatment was 28.2 months (range 11-96 months). All patients had normal baseline cortisol levels in both SST and LDSST tests. The mean 30 min SST was 753.8 nmol/l (95%CI: 696.6 nmol/l, 811.0 nmol/l) and no patients displayed inadequate adrenal response. The mean 30 min LDSST was 709.8 nmol/l (95%CI: 665.1 nmol/l, 754.5 nmol/l) and only one patient had an inadequate adrenal response. There was no correlation between baseline SST or LDSST and duration of treatment. This study found no evidence that patients using continuous long-term corticosteroid eye drops after PKP experienced inadequate adrenal response. We did not find any evidence of a negative correlation between length of treatment and SST or LDSST measurements at baseline.

Outcomes of Descemet Stripping Automated Endothelial Keratoplasty in Patients With Previous Glaucoma Drainage Device Insertion

To report the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with a previously inserted glaucoma drainage device (GDD). The clinical records of patients who had DSAEK surgery with a history of GDD insertion were reviewed. Eleven eyes of 10 patients (7 men and 3 women) were included. The mean age for DSAEK surgery was 67.2 ± 20.4 years (range, 22-93 years). The mean follow-up after DSAEK surgery was 20.2 ± 10.7 months (range, 3-37 months). Preoperative mean logarithm of the minimum angle of resolution (logMAR)-corrected distance visual acuity was 1.8 ± 0.6 (range, 20/100 to hand motions), and this improved to 0.9 ± 0.8 (range, 20/40 to hand motions) at the final follow-up (P < 0.01). There was no statistical difference in mean pre-DSAEK versus final post-DSAEK intraocular pressure (P = 0.88). Six of 11 eyes (54.5%) had double GDD insertion before DSAEK surgery. GDD tubes were trimmed in 6 eyes (54.5%), and no eyes required further glaucoma surgical intervention after DSAEK surgery. Postoperative complications included early postoperative graft dislocation in 4 eyes (36.4%) that were successfully repositioned. Four eyes (36.4%) had an episode of endothelial rejection, with 2 patients (18.2%) requiring repeat endothelial keratoplasty for endothelial failure. The mean donor endothelial cell count was 2740 cell per square millimeter preoperatively and reduced to 858 cells per square millimeter at the final follow-up, a significant mean reduction of 69%. This was significantly greater than previously reported endothelial cell loss after DSAEK alone at our institution. Although surgery may be more challenging, the presence of GDD is not a contraindication to DSAEK surgery. In this series, there was a high rate of dislocation that was successfully managed with rebubbling. DSAEK seems to be a reasonable alternative to penetrating keratoplasty for corneal decompensation after GDD.

Ceratoplastia lamelar anterior profunda pela técnica da "big-bubble"

To evaluate the efficacy, safety, and complications related to the deep anterior lamellar keratoplasty (DALK) using the big-bubble technique. A prospective study of patients submitted to DALK using the big-bubble technique was conducted. After the procedure, uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), spherical equivalent (SE), corneal topography, endothelial cell density, and intraoperative and postoperative complications were evaluated. Fifty-nine eyes of 55 patients were included in this study. Mean follow-up period was 16 ± 7.4 months. Baseline mean UCVA (logMAR) and BCVA was 1.60 ± 0.33 and 1.00 ± 0.43, respectively. After 12 months, the mean UCVA and BCVA improved to 0.86 ± 0.39 and 0.17 ± 0.14, respectively. Mean SE improved from -8.21 ± 3.91 to -1.82 ± 3.62 at 12 months. Mean topographic astigmatism improved from -7.9 ± 3.7 to -2.21 ± 1.7 at 12 months. Mean preoperative endothelial cell density was 2,377.98 ± 263.56 cells/mm², after 12 months of surgery the mean endothelial cell density reduced to 1,851.32 ± 397.61 cells/mm². Intraoperative microperfuration occurred in 6 cases (10.2%). One patient developed stromal rejection, and one patient developed fixed dilated pupil (Urrets-Zavalia Syndrome) after the procedure. Nevertheless, deep anterior lamellar keratoplasty is more technically challenging, yet rewarding choice of surgery for keratoplasty patients who have a healthy endothelial cell count. ClinicalTrials.gov Identifier: NCT00887900.

Graft Rejection After Descemet's Stripping Automated Endothelial Keratoplasty: Graft Survival and Endothelial Cell Loss

To evaluate the effects of graft rejection episodes after Descemet's stripping automated endothelial keratoplasty surgery (DSAEK) on long-term endothelial cell density (ECD) decline and graft survival. Retrospective, comparative analysis of an interventional case series. We included 615 eyes of 415 Fuchs' dystrophy patients at a single institution with ≥ 6 months follow-up and without comorbidities known to influence postoperative ECD. All patients were enrolled as part of an ongoing, institutional review board-approved clinical protocol for a long-term, prospective study of endothelial keratoplasty in patients with endothelial dysfunction. Preoperative specular microscopy of donor corneal tissue was performed. Postoperative specular microscopy measurements were recorded at 6 and 12 months, and yearly thereafter. The percentages of endothelial cell loss recorded at 1, 2, 3, and 4 years were compared with the Mann-Whitney U test. Percentage ECD declines were calculated at each time point from the results of the preoperative and postoperative specular microscopy. Patients with graft rejection episodes and late endothelial failure were identified. Graft rejection was defined as findings of keratic precipitates with or without corneal edema, or anterior chamber cell and flare with or without corneal edema after the initial resolution of perioperative inflammation. We identified 45 cases of graft rejection. The greatest number of rejections occurred between postoperative months 12 and 18. Eyes with a graft rejection episode had a higher median percentage decline in ECD at all time points compared with eyes without graft rejection episodes. This was statistically significant at 2 and 3 years postoperatively. There is a trend toward a greater percentage of ECD loss with time in eyes experiencing graft rejection after DSAEK surgery. Proprietary or commercial disclosure may be found after the references.

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

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