Lamellar Corneal Research Articles

How do intraocular lens materials influence the outcome of cataract surgery?

This review summarizes the evidence on the effect of intraocular lens (IOL) material on the outcomes of cataract surgery, as well as on the surgical procedure itself. Differences in capsular biocompatibility between IOL materials lead to variations in capsular stability and posterior capsule opacification (PCO), while differences in uveal biocompatibility affect postoperative inflammatory response. Refractive outcomes are affected by both incision size and the rotational stability of toric IOLs. Small incision sizes favour hydrophilic IOLs. Rotational stability of hydrophobic and hydrophilic IOLs were comparable in recent studies. Visual outcomes are affected by chromatic aberrations, dysphotopsia, lens opacifications and PCO. Hydrophilic IOLs are associated with reduced chromatic dispersion. Hydrophobic IOL opacifications are caused by sub-surface glistenings, while hydrophilic IOL opacifications are due to surface calcifications. Some surgeries, including pars plana vitrectomy and lamellar corneal transplants, were shown to increase the risk of IOL calcifications, although the mechanism is still unknown. Hydrophilic IOLs have greater ease of manipulation, greater resistance to IOL damage, and higher uveal biocompatibility. Hydrophobic IOLs show better PCO prevention than hydrophilic IOLs, and should be preferred in highly myopic eyes where Nd:YAG capsulotomy might increase the risk of retinal detachment.

EndoArt®: results in patients with glaucoma drainage devices

EndoArt® (Eye Yon Medical, Ness Ziona, Israel) is anovel artificial corneal inner layer transplant and an innovative treatment alternative for patients at high risk for graft failure after posterior lamellar corneal transplantation (EK). We present the initial results of the EndoArt® implantation in patients with glaucoma drainage devices (GDD). In this study 12eyes with GDD were retrospectively evaluated. All had ahigh risk of transplant rejection in cases of EK (previous other glaucoma surgery in addition to GDD, n = 8, condition following Descemet membrane endothelial keratoplasty, DMEK, n = 9, uveitis, n = 2, or synechiae, n = 2). The EndoArt® was secured with agas bubble and one to three holding sutures. The preoperative and postoperative best spectacle-corrected visual acuity (BSCVA) and central corneal thickness (CCT) were determined. The need for additional gas injections (rebubbling) was analyzed. Octafluoropropane (C3F8) 12% was used in nine patients and sulfur hexafluoride (SF6) 20% in three patients as anterior chamber tamponade to ensure adhesion of the EndoArt®. At least one rebubbling was necessary in four eyes. The preoperative BSCVA was 1.6 (± 0.5) logMAR and significantly improved to 1.1 (± 0.6) logMAR after 12weeks (p = 0.028). The preoperative CCT was 719 µm ± 145.7, which significantly decreased to 622.4 µm ± 174.9 after six weeks (p = 0.004) and to 591.7 µm ± 190.8 after 12weeks (p = 0.096). In one eye, the prosthesis was explanted due to a suspected fibrotic remodelling of the cornea following multiple previous DMEKs. EndoArt® led to asignificant improvement in BSCVA and reduction in CCT; however, there was ahigh rebubbling rate in patients with GDD. In high-risk patients, the use of EndoArt® may be advantageous in avoiding graft failure after EK.

Focus on seed cells: stem cells in 3D bioprinting of corneal grafts.

Corneal opacity is one of the leading causes of severe vision impairment. Corneal transplantation is the dominant therapy for irreversible corneal blindness. However, there is a worldwide shortage of donor grafts and consequently an urgent demand for alternatives. Three-dimensional (3D) bioprinting is an innovative additive manufacturing technology for high-resolution distribution of bioink to construct human tissues. The technology has shown great promise in the field of bone, cartilage and skin tissue construction. 3D bioprinting allows precise structural construction and functional cell printing, which makes it possible to print personalized full-thickness or lamellar corneal layers. Seed cells play an important role in producing corneal biological functions. And stem cells are potential seed cells for corneal tissue construction. In this review, the basic anatomy and physiology of the natural human cornea and the grafts for keratoplasties are introduced. Then, the applications of 3D bioprinting techniques and bioinks for corneal tissue construction and their interaction with seed cells are reviewed, and both the application and promising future of stem cells in corneal tissue engineering is discussed. Finally, the development trends requirements and challenges of using stem cells as seed cells in corneal graft construction are summarized, and future development directions are suggested.

Post-Keratoplasty Microbial Keratitis in the Era of Lamellar Transplants-A Comprehensive Review.

Microbial keratitis in a post-transplant cornea should be considered a distinct entity from microbial keratitis in a non-transplant cornea. Firstly, the use of immunosuppressive treatments and sutures in corneal transplants changes the etiology of keratitis. Secondly, corneal transplant has an impact on corneal biomechanics and structure, which facilitates the spread of infection. Finally, the emergence of lamellar transplants has introduced a new form of keratitis known as interface keratitis. Given these factors, there is a clear need to update our understanding of and management strategies for microbial keratitis following corneal transplantation, especially in the era of lamellar transplants. To address this, a comprehensive review is provided, covering the incidence, risk factors, causes, and timing of microbial keratitis, as well as both clinical and surgical management approaches for its treatment in cases of penetrating and lamellar corneal transplants.

Retrospective Analysis of a New Intrastromal Dissection Technique Using the Retinal Reflex for Deep Anterior Lamellar Keratoplasty.

The purpose of this study was to describe a new surgical technique for deep anterior lamellar keratoplasty. All pupils in the recipient eyes were dilated preoperatively. Vertical grooving was performed using a crescent blade with a width of 5 mm and a depth of one-third to half corneal thickness on the temporal side of the limbus. Stromal dissection was performed as close as possible to Descemet membrane by observing the gap between the gold line by retinal reflex and the front edge of the crescent blade. Lamellar dissection was performed along the lamellar plane using corneal dissectors. The ophthalmic viscoelastic device was injected into the intrastromal pocket to separate the anterior and posterior stroma and an anterior corneal lamella was excised. A donor cornea was sutured into the recipient bed. In 18 eyes, none of the patients had Descemet membrane rupture during surgery. The mean postoperative residual stromal thickness was 80 ± 31 μm. The mean central corneal thickness after surgery was 660 ± 69 μm. At the last follow-up, the cornea was cleared in all 18 eyes on slit-lamp examination. We estimated the residual stromal thickness based on the gap between the gold line by the retinal reflex and crescent blade, and intrastromal lamellar dissection was performed using a smooth corneal dissector. Consequently, the surface of stromal dissection was smooth, and the residual stromal thickness was even.

Traumatic intracorneal cyst and review of literature

A 32-year-old male was referred to us with complaints of a progressively increasing white spot in his right eye, following a lamellar corneal tear. A diagnosis of traumatic intracorneal cyst was made. The cyst was successfully treated by chemical cauterization using 96% ethanol. At the final follow-up, no recurrence of cyst was noted. We conclude that lamellar corneal tears should be sutured to avoid complications like development of intracorneal cyst. Aspiration of cyst content followed by repeated irrigation of cyst cavity with 96% ethanol and balanced salt solution can help in successful resolution without recurrence.

The pre-Descemet's layer (Dua's layer, also known as the Dua-Fine layer and the pre-posterior limiting lamina layer): Discovery, characterisation, clinical and surgical applications, and the controversy.

The pre-Descemet's layer/Dua's layer, also termed the Dua-Fine layer and the pre-posterior limiting lamina layer, lies anterior to the Descemet's membrane in the cornea, is 10 μm (range 6-16) thick, made predominantly of type I and some type VI collagen with abundant elastin, more than any other layer of the cornea. It has high tensile strength (bursting pressure up to 700mm of Hg), is impervious to air and almost acellular. At the periphery it demonstrates fenestrations and ramifies to become the core of the trabecular meshwork, with implications for intraocular pressure and glaucoma. It has been demonstrated in some species of animals. The layer has assumed considerable importance in anterior and posterior lamellar corneal transplant surgery by improving our understanding of the behaviour of corneal tissue during these procedures, improved techniques and made the surgery safer with better outcomes. It has led to the innovation of new surgical procedures namely, pre-Descemet's endothelial keratoplasty, suture management of acute hydrops, DALK-triple and Fogla's mini DALK. The discovery and knowledge of the layer has introduced paradigm shifts in our age old concepts of Descemet's membrane detachment, acute corneal hydrops in keratoconus and Descemetoceles, with impact on management approaches. It has been shown to contribute to the pathology and clinical signs observed in corneal infections and some corneal dystrophies. Early evidence suggests that it may have a role in the pathogenesis of keratoconus in relation to its elastin content. Its contribution to corneal biomechanics and glaucoma are subjects of current investigations.

Экспериментальное обоснование использования 1% раствора гидроксипропилметилцеллюлозы для защиты эндотелия заднего послойного трансплантата роговицы при его выкраивании низкоэнергетическим фемтосекундным лазером по инвертированной методике

Purpose. To evaluate experimentally endothelial cell loss of animal's cornea during inverted posterior lamellar corneal graft preparation technique by low-energy femtosecond laser with and without ophthalmic viscosurgical device (OVD) – 1% hydroxypropyl methylcellulose (HPMC) solution application. Material and methods. Posterior lamellar corneal grafts were created using a femtosecond laser (FSL). In the control group (n=16), a few drops of corneal storage solution were applied to the endothelium just before applanation, in the experimental group (n=16) – 1% HPMС. The quality of the applanation were monitored using an integrated in laser OCT system. The endothelial viability was determined using live/dead cells assay and the grafts were examined on a confocal laser scanning microscope. The obtained images were analyzed to count live and dead endothelial cells (EC). To assess the state of collagen fibers of the stromal side of the graft, samples from the control and experimental groups were examined using a scanning electron microscope (SEM). Results. According to the OCT, in all samples of both groups, a flat profile of the contact zone between the laser head and the endothelial monolayer was observed during applanation. The difference between the number of live and dead ECs was statistically significant between both groups. There were 2854 [2819; 2879] live cells/mm² in the control group, and 3477 [3426; 3719] live cells/mm² in the experimental group (p<0.001). Thus, the number of dead ECs in the control group was 710 [649; 728] cells/mm² . The number of dead ECs in the experimental group was 402 [366; 427] cells/mm² (p<0.001). When analyzing the images obtained on a SEM, the preservation of the architectonics of the graft collagen fibers with their single defibrations in both groups was observed. Conclusion. Application of 1% HPMC provides protection for endothelial cells from damage during posterior laser dissection using an FSL. In the study group, the number of endothelial cells was 9.92% higher than in the control group. The presence of the OVD layer in the interface between the head of the FSL and the EC did not affect the formation of an effective laser cut and did not reduce the quality of the stromal surface of the graft. The inverted technique FSL cut using a 1% solution of HPMC on the surface of the endothelium may be recommended for use in clinical practice. Key words: endothelium, keratocytes, corneal transplantation, keratoplasty, posterior lamellar keratoplasty, femtosecond laser, ophthalmic viscosurgical device, hydroxypropyl methylcellulose, confocal microscopy, scanning electron microscopy

Liquid-phase Integrated 3d Printed Biological Lenses for Lamellar Corneal Substitute.

Compared to traditional biological lenses that are used to correct and repair optical systems, such as contact lenses, vision correction surgery, and corneal and lens replacement, three-dimensional (3D) printed biological lenses can be customized according to user needs. However, the layer-by-layer principle of 3D printing leads to a staircase effect, which cannot meet the critical requirements of surface quality during the manufacturing process of biological lens, particularly with soft materials. Here, a liquid-phase printing strategy and a surface tension-dependent (STD) post-processing method are proposed that use the surface tension of the liquid to reconstruct the air-liquid interface. This eliminates the staircase effect caused by the stacking of units during 3D printing. The coordinates of integrated printing enable high-accuracy shape control of soft materials. Based on this method, using a typical biological lenses as an example, the surface quality of printed lamellar corneal substitute (LCS) was improved from ±20.0μm to ±0.2μm, and the thickness feature size was reduced from ±500μm to ±150μm. It can be used to fit the curvature and thickness of the human cornea. The visible light transmittance reaches the level of the natural cornea (∼85%) and is biocompatible. Liquid-phase 3D printed biological lenses performed better in vivo in rabbit eyes than the molded group. This method can potentially boost research on artificial biological lens printing technology and has good potential for use in future clinical applications. This article is protected by copyright. All rights reserved.

Evaluation of Mooren's corneal ulcer by anterior segment optical coherence tomography

BackgroundThis study evaluates the use of anterior segment optical coherence tomography (AS-OCT) to identify focal changes and inform surgical plans in eyes with Mooren's ulcer. MethodsA total of 18 eyes of 17 patients with Mooren's ulcer were examined prospectively using the AS-OCT system. ResultsOptical hyperreflectivity noted on AS-OCT images was in accordance with corneal ulceration, neovascularization, fibrovascular membranes, the junction of the native stromal bed, and the overlying lamellar corneal grafts. Focal corneal ectasia was observed in 13 eyes with a decrease in corneal thickness to ≤0.39 mm. There was a cut-off value of 0.39 mm in corneal thickness between the eyes with and without focal corneal ectasia in the thinned corneal area (Fisher = 0.383, χ2 = 14.873, P = 0.000). Based on the AS-OCT findings, six eyes were subjected to an individualized lamellar corneal graft. The thickness of the residual cornea after surgery was 47 ± 34 μm less than the presumed healthy corneal thickness before surgery (t = 3.376, P = 0.02). A small corneal perforation covered by a pseudopterygium in Mooren's ulcer was found through AS-OCT but undetectable by slit-lamp biomicroscopy. ConclusionsAS-OCT is a valuable non-contact technique for monitoring corneal thinning in Mooren's ulcer, and assisting surgical design. A decrease in peripheral corneal thickness to ≤0.39 mm may cause focal corneal ectasia.

Clinical outcomes of Descemet’s stripping endothelial keratoplasty using a manual or automated procedure at Undaan Eye Hospital Surabaya, Indonesia: with one-year follow up

Background: Endothelial keratoplasty (EK) is a selective lamellar corneal transplantation technique that replaces damaged endothelium while preserving the patient's corneal stroma. Donor graft preparation can be done using Descemet stripping endothelial keratoplasty (DSEK) or Descemet stripping automated endothelial keratoplasty (DSAEK). Research on EK in Indonesia is currently underreported, but it is crucial for developing strategies to treat corneal blindness in the future. This study aimed to present visual acuity, graft survival, and complications after DSEK or DSAEK at Undaan Eye Hospital Surabaya. Methods: This study involved 17 eyes, treated with DSEK or DSAEK surgery between 2017 and 2022. Patients with other ocular diseases and incomplete medical records were excluded. Best corrected visual acuity (BCVA) was documented before the surgery, and at 1 day, 1, 3, 6 months, and 1 year after. Data in this study were analyzed using multiple techniques, including Wilcoxon, Kaplan-Meier survival, and bivariate logistic regression analysis. Results: The postoperative mean BCVA significantly increased to 1.36 ± 0.57 logMAR (p=0.012) at 1 day, 1.02 ± 0.62 logMAR (p=0.002) at 1 month, 0.94 ± 0.66 logMAR (p=0.002) at 3 months, 0.72 ± 0.66 logMAR at 6 months (p=0.000), and 0.74 ± 0.74 logMAR (p=0.001) at 1-year compared to preoperative BCVA of 1.84 ± 0.39 logMAR. The graft could survive 100% within 1 day to 6 months and 76% within 1 year after surgery. Bivariate logistic regression showed donor origin had a statistically significant effect with p-value = 0.031 and odds ratio = 1.8, 95% confidence interval (CI) = 1.003 - 3.229. Corneal edema was the most common complication in the early and late postoperative periods. Conclusion: DSEK or DSAEK surgery is safe, effective, and viable. It shows good visual outcomes and becomes the most used EK treatment for corneal endothelial dysfunction.

Descemet Stripping Automated Endothelial Keratoplasty versus Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy: A National Registry-Based Comparison

To compare the outcome between posterior lamellar corneal transplant procedures for Fuchs endothelial corneal dystrophy, taking preoperative patient characteristics in consideration. Surgical methods compared were Descemet membrane endothelial keratoplasty (DMEK), Descemet stripping automated endothelial keratoplasty (DSAEK), and DSAEK with concomitant cataract surgery (phacoemulsification plus DSAEK). Registry-based study with propensity score matching. One thousand six hundred seventy-seven patients from all Swedish corneal transplantation units treated from 2012 through2019. All patients undergoing endothelial keratoplasty performed from 2012 through 2019 with completed 2-year follow-up data reported to The Swedish Corneal Transplant Register were included, totaling 1677 patients. Three comparable groups (DMEK, DSAEK, and phacoemulsification plus DSAEK) with 216 patients in each group were generated with propensity score matching based on preoperative visual acuity, age, sex, year of surgery, and preoperative risk factors such as inflammation, vascularization, and glaucoma. Best-corrected visual acuity (BCVA) at the 2-year follow-up, frequency of graft dislocation, graft rejection episodes, and graft failure within 2 years including primary graft failure. The preoperative corneal status was affected more severely in the DSAEK group before matching. In the matched groups, the median BCVA 2 years after surgery was 0.1 logarithm of the minimum angle of resolution (logMAR) in both the DMEK and the phacoemulsification plus DSAEK groups and 0.15 logMAR in the DSAEK group (P= 0.001). The frequency of graft dislocation was higher among the patients undergoing phacoemulsification plus DSAEK, but the frequency of graft failure and primary graft failure was higher in the DMEK group. Visual acuity improved in most patients (90%) with all 3 surgical methods. However, DMEK and phacoemulsification plus DSAEK reached higher levels of visual acuity 2 years after surgery, and phacoemulsification plus DSAEK was superior considering graft survival rate. All 3 surgical procedures showed both strengths and weaknesses, suggesting that the choice of surgical method should be individualized, taking into consideration not only the cornea, but each patient's complete medical status as well as the entire course of postoperative medical care. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Case Report: Simultaneous penetrating keratoplasty with autologous simple limbal epithelial transplantation as an alternative to keratoprosthesis

Introduction and importance: This case report highlights the multidisciplinary approach required to achieve successful anatomical and functional outcomes, in an eye with total limbal stem cell deficiency (LSCD) associated with underlying corneal scarring and thinning. Presentation of case: A 59-year-old gentleman had poor visual recovery in the right eye (RE) following accidental carbide blast, 1-year before presenting to us. The visual acuity was counting fingers and clinical examination revealed cicatricial entropion involving the upper eyelid, total LSCD, corneal scarring with a central descemetocele and cataract in the RE. Prior to ocular surface reconstruction, entropion correction was performed. Three months later, penetrating keratoplasty combined with cataract surgery and intraocular lens implantation (penetrating keratoplasty (PK) triple), with autologous simple limbal epithelial transplantation (SLET) was performed. The visual acuity was 20/100, 18 months after the surgery, with a clear well-epithelized corneal graft and stable ocular surface. Discussion: LSCD is caused by a decrease in the population and /or function of the limbal epithelial stem cells. Limbal stem cell transplantation (LSCT) is warranted in eyes with total LSCD. In eyes with coexisting corneal scarring, LSCT alone may be inadequate to restore the vision. These eyes require simultaneous or sequential lamellar or full-thickness corneal transplantation for visual rehabilitation. Though, the existing literature favors a sequential approach, where LSCT is performed first followed by corneal transplantation, under certain circumstances such as a thin underlying cornea like in our case, corneal transplantation may have to be combined with LSCT to achieve optimal outcomes. Conclusion: Combining autologous SLET with PK can be performed for visual rehabilitation in eyes with unilateral total LSCD and underlying corneal thinning. Corneal and limbal graft survival is prolonged if existing adnexal comorbidities are addressed before any surgical intervention is planned and adequate time interval is allowed for the surface inflammation to subside.

Case Report: Simultaneous penetrating keratoplasty with autologous simple limbal epithelial transplantation as an alternative to keratoprosthesis

Introduction and importance: This case report highlights the multidisciplinary approach required to achieve successful anatomical and functional outcomes, in an eye with total limbal stem cell deficiency (LSCD) associated with underlying corneal scarring and thinning. Presentation of case: A 59-year-old gentleman had poor visual recovery in the right eye (RE) following accidental carbide blast, 1-year before presenting to us. The visual acuity was counting fingers and clinical examination revealed cicatricial entropion involving the upper eyelid, total LSCD, corneal scarring with a central descemetocele and cataract in the RE. Prior to ocular surface reconstruction, entropion correction was performed. Three months later, penetrating keratoplasty combined with cataract surgery and intraocular lens implantation (penetrating keratoplasty (PK) triple), with autologous simple limbal epithelial transplantation (SLET) was performed. The visual acuity was 20/100, 18 months after the surgery, with a clear well-epithelized corneal graft and stable ocular surface. Discussion: LSCD is caused by a decrease in the population and /or function of the limbal epithelial stem cells. Limbal stem cell transplantation (LSCT) is warranted in eyes with total LSCD. In eyes with coexisting corneal scarring, LSCT alone may be inadequate to restore the vision. These eyes require simultaneous or sequential lamellar or full-thickness corneal transplantation for visual rehabilitation. Though, the existing literature favors a sequential approach, where LSCT is performed first followed by corneal transplantation, under certain circumstances such as a thin underlying cornea like in our case, corneal transplantation may have to be combined with LSCT to achieve optimal outcomes. Conclusion: Combining autologous SLET with PK can be performed for visual rehabilitation in eyes with unilateral total LSCD and underlying corneal thinning. Corneal and limbal graft survival is prolonged if existing adnexal comorbidities are addressed before any surgical intervention is planned and adequate time interval is allowed for the surface inflammation to subside.

Comparison of Graft Survival Between Full-Thickness and Lamellar Pig-to-Monkey Corneal Xenotransplantation from the Same Genetically Engineered Pig Model with Minimal Immunosuppression

The graft survival rate of full-thickness corneal xenotransplantation (XTP) with minimal immunosuppression in genetically engineered pigs is unknown, whereas lamellar corneal XTP shows satisfactory results. We compared graft survival between full-thickness and lamellar transplantations in the same genetically engineered pig. Six pig-to-monkey corneal transplantations were performed on 3 transgenic pigs. Two corneas harvested from 1 pig were transplanted into 2 monkeys using full-thickness and lamellar corneal xenotransplantation. The transgenic donor pigs used were α1,3-galactosyltransferase gene-knockout+membrane cofactor protein (GTKO+CD46) in one recipient and GTKO+CD46+ thrombomodulin (TBM) in the other. The graft survival time for GTKO+CD46 XTP was 28 days. With the addition of TBM, the survival differences between lamellar and full-thickness XTP were 98 days versus 14 days and >463 days (ongoing) versus 21 days, respectively. An excessive number of inflammatory cells was observed in failed grafts, but none were in the recipient's stromal bed. Unlike full-thickness corneal XTP, lamellar xenocorneal transplantation does not exhibit surgical complications, such as retrocorneal membrane or anterior synechia. The graft survival of lamellar XTP in this study was not as good as in our previous experiments, although the survival period was superior to that of full-thickness XTP. The difference in graft survival based on transgenic type is not definitive. Further studies using transgenic pigs and minimal immunosuppression need to focus on improving graft survival of lamellar XTP and using a larger sample size to determine the potential of full-thickness corneal XTP.

A case of bilateral corneal ulcer after left eye cataract extraction surgery

The patient is a 73-year-old female who developed bilateral corneal ulcers one month after cataract surgery in her left eye. The diagnosis is bilateral conjunctival pemphigoid. She underwent a left-eye amniotic membrane transplant and a right-eye lamellar corneal transplant, and was treated with oral immunosuppressants. The patient's condition is stable.

Clinical and Histopathologic Characteristics and Template of the TGFBI p.(His626Arg) Missense Variant Lattice Corneal Dystrophy.

The aim of this study was to define, following the IC3D template format, the clinical and histopathologic phenotype of the p.(His626Arg) missense variant lattice corneal dystrophy (LCDV-H626R), the most common variant lattice dystrophy, and to record long-term outcome of corneal transplantation in this dystrophy. A database search and a meta-analysis of published data on LCDV-H626R were conducted. A patient diagnosed with LCDV-H626R who underwent bilateral lamellar keratoplasty followed by rekeratoplasty of 1 eye is described, including histopathologic examination of the 3 keratoplasty specimens. One hundred forty-five patients from at least 61 families and 11 countries diagnosed with LCDV-H626R were found. This dystrophy is characterized by recurrent erosions, asymmetric progression, and thick lattice lines that extend to corneal periphery. The median age is 37 (range, 25-59) years at the onset of symptoms, 45 (range, 26-62) years at the time of diagnosis, and 50 (range, 41-78) years at the time of the first keratoplasty, suggesting a median interval from the first symptoms to diagnosis and to keratoplasty of 7 and 12 years, respectively. Clinically unaffected carriers have been of age 6 to 45 years. Central anterior stromal haze and centrally thick, peripherally thinner branching lattice lines in the anterior to midstroma of the cornea were noted preoperatively. Histopathology of the host anterior corneal lamella showed a subepithelial fibrous pannus, a destroyed Bowman layer, and amyloid deposits extending to the deep stroma. In the rekeratoplasty specimen, amyloid localized to scarring along the Bowman membrane and to the margins of the graft. The IC3D-type template for LCDV-H626R should help diagnose and manage variant carriers. The histopathologic spectrum of findings is broader and more nuanced than what has been reported.

Technique for the Management of Extensive Ocular Surface Lipodermoid Involving the Cornea of Children.

Ocular surface lipodermoids with corneal involvement may require surgical intervention; if deep, ocular surface reconstruction with lamellar corneal tissue or amniotic membrane may be needed. We describe a staged technique using autologous ipsilateral simple limbal epithelial transplantation. After verifying sparing of Descemet membrane, the conjunctival portion of the lipodermoid was debulked in the first stage. Six weeks later, the corneal portion was excised, followed by autologous ipsilateral simple limbal epithelial transplantation to promote rapid reepithelialization of the residual stromal bed. Temporary tarsorrhaphy was used for patient comfort and to expedite ocular surface healing. Three eyes of 3 children with grade III large ocular surface lipodermoids that encroached the visual axis and hindered proper eyelid closure underwent surgery without complications. In all cases, the visual axis was cleared and eyelid closure was improved. At the last follow-up (mean 35.7 months, median 36.0 months), the bed of the original dermoid showed minimal haze in 1 case, while 2 eyes developed small pseudopterygium; best spectacle-corrected visual acuity improved from 20/200 to 20/70 in the first case, from fix and follow to 20/50 in the second case, and remained fix and follow in the last case, but this child had congenital hydrocephalus with severe developmental delay. This surgical technique is a promising option for children with grade III large ocular surface lipodermoids given its effectiveness in clearing the visual axis and in improving eyelid closure. Moreover, it does not require lamellar corneal transplantation or intervention to the fellow eye.

Bilateral peripheral ulcerative keratitis

A 13-year-old girl presenting with mucopurulent conjunctivitis (left > right) was diagnosed with Behçet's disease. Intraoperatively, the left eye had 360° culture-negative marginal corneal ulcer with scleral necrosis, managed with a scleral patch graft. Postoperatively, the right eye also developed a peripheral corneal lesion that resolved with immunosuppressants along with the skin lesions. Subsequently, wound gaping and uveal prolapse were noted in the left eye and was managed with a lamellar corneal graft and later with a corneoscleral patch graft. Following this, the patient improved very well in terms of visual acuity. Peripheral ulcerative keratitis can be a clinical presentation in pediatric Behçet's disease despite the unusual occurrence. Hence, any pediatric case with peripheral ulcerative keratitis should be thoroughly investigated for Behçet's disease, for which immunosuppressants may prove to be beneficial.

Effect of the position of the corneal lamella on the frequency of its detachment.

To determine the influence of gaps [places where neither the donor's nor the recipient's Descemet's membrane (DM) is present] and overlaps (places where the recipient's DM is covered by the donor's DM) on the frequency of postoperative detachment of DM endothelial keratoplasty (DMEK) lamellae. Totally 64 eyes of 64 patients with Fuchs' endothelial dystrophy or bullous keratopathy indicated for DMEK were randomly divided in two groups. The diameter of the implanted DMEK lamella was the same in both groups (8 mm), but we changed the diameter of the removed recipient DM. In the first group (32 eyes), the circular area was approximately 8.5 mm (gaps); in the second group (32 eyes), the diameter was 7.5 mm (overlaps). Postoperatively we noted all cases of detachment visible on the slit lamp and these cases we indicated for rebubbling. We also measured the uncorrected distance visual acuity (UDVA) as well as corrected distance visual acuity (CDVA) in decimal and postoperative endothelial cell density (ECD). The minimum follow-up time was 6mo. The number of rebubbling procedures in the entire group of patients was 13, i.e., 20.3%, with 6 eyes (18.7%) in the gap group, and 7 eyes (21.9%) in the overlap group. Lamella replacement (re-DMEK) was required in 3 (gap group) and 2 patients (overlap group), respectively. The difference between the groups was statistically insignificant. The UDVA was 0.54±0.21 in the gap group and 0.58±0.24 in the overlap group. The CDVA was 0.74±0.22 and 0.80±0.16, respectively. ECD was 1920±491 and 2149±570 cells/mm2. The small differences between both groups were not statistically significant. We do not notice any difference in the group of patients with overlaps or gaps of DM. The presence of small areas of gaps or overlaps does not affect the frequency of detachment of the DMEK lamellae.