Penetrating Keratoplasty In Patients Research Articles

Herpetic geographic ulcer in a penetrating keratoplasty patient

Herpetic geographic ulcer in a penetrating keratoplasty patient

Does Systemic Hematological Therapy Influence the Course of Paraproteinemic Keratopathy?

The purpose of this article is to evaluate the course of paraproteinemic keratopathy (PPK) in patients undergoing systemic therapy for the underlying hematological disease. Baseline and follow-up examinations included hematological work-up, best-corrected visual acuity, slit-lamp biomicroscopy, and in vivo confocal laser scanning microscopy (IVCM). We included 22 patients with bilateral PPK (aged 68 ± 10.4 years, 11 males). Ten patients with multiple myeloma (MM) underwent on-label systemic therapy. During follow-up, we observed a regression of corneal opacities in three patients under slit-lamp examination and under IVCM, while PPK remained unchanged in seven patients. In three patients with monoclonal gammopathy of ocular significance (MGOS), systemic therapy was initiated off-label to reduce the serum paraprotein load before penetrating keratoplasty (PKP). These patients showed no signs of PPK recurrence for up to 24 months after PKP. In one patient without systemic therapy, a recurrence in corneal grafts occurred within 12 months of PKP. In eight patients without systemic therapy, PPK remained stable. In conclusion, systemic therapy for MM patients reduced corneal opacity in 30% of treated patients. Furthermore, systemic therapy performed before PKP in patients without conventional systemic therapy indication (MGOS) likely postpones PPK recurrence in the corneal graft.

Deep anterior lamellar keratoplasty and penetrating keratoplasty in macular corneal dystrophy: comparison of visual and topographic outcomes and complications.

This study aims to assess and compare the postoperative visual and topographic outcomes, complications, and graft survival rates following deep anterior lamellar keratoplasty and penetrating keratoplasty in patients with macular corneal dystrophy. In this study we enrolled 59 patients (23 male; and 36 female) with macular corneal dystrophy comprising 81 eyes. Out of these, 64 eyes underwent penetrating keratoplasty, while 17 eyes underwent deep anterior lamellar keratoplasty. The two groups were analyzed and compared based on best-corrected visual acuity, corneal tomography parameters, pachymetry, complication rates, and graft survival rates. After 12 months, 70.6% of the patients who underwent deep anterior lamellar keratoplasty (DALK) and 75% of those who had penetrating keratoplasty (PK) achieved a best-corrected visual acuity of 20/40 or better (p=0.712). Following surgery, DALK group showed lower front Kmean (p=0.037), and Q values (p<0.01) compared to the PK group. Postoperative interface opacity was observed in seven eyes (41.2%) in the DALK group. Other topography values and other complications (graft rejection, graft failure, cataract, glaucoma, microbial keratitis, optic atrophy) did not show significant differences between the two groups. The need for regrafting was 9.4% and 11.8% in the PK and DALK groups, respectively (p=0.769). Graft survival rates were 87.5% and 88.2% for PK and DALK; respectively (p=0.88 by Log-rank test). Both PK and DALK are equally effective in treating macular corneal dystrophy, showing similar visual, topographic, and survival outcomes. Although interface opacity occurs more frequently after DALK the visual results were comparable in both groups. Therefore, DALK emerges as a viable surgical choice for patients with macular corneal dystrophy without Descemet membrane involvement is absent.

Proteomic characterization of aqueous humor in corneal endothelial decompensation after penetrating keratoplasty

Corneal endothelial decompensation (CED) is the major cause of the long-term graft failure, but the underlying mechanisms remain unclear. The purpose of this study was to characterize the proteomic profile in CED aqueous humor (AH) after penetrating keratoplasty (PKP). We collected AH samples (n = 6/group) from CED patients underwent PKP and cataract patients, respectively. The label-free quantitative proteomic analysis was performed to identify the differentially-expressed proteins (DEPs). The biological functions of DEPs were evaluated using Gene Ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genome (KEGG) analysis. The protein-protein interaction (PPI) network construction was employed to distinguish the hub proteins of DEPs, and the selected proteins were validated by parallel reaction monitoring (PRM). The human peripheral blood mononuclear cells (PBMCs) were adopted to investigate the effect of biglycan (BGN) on inflammatory response, and the subsequent outcomes of inflammation on human corneal endothelial cells (HCECs). A total of 174 DEPs were identified in CED AH of patients underwent PKP, including 102 up-regulated proteins and 72 down-regulated proteins. Bioinformatics analysis revealed the significant enrichment of cytokine-mediated signaling pathway and extracellular matrix (ECM) organization in the up-regulated proteins, as well as the alterations of cellular components, including the increase of collagen and complement component C1 complex, and reduction in extracellular exosomes. A hub protein cluster of 15 proteins was determined by Molecular Complex Detection (MCODE), including FN1, BGN, COMP, COL11A1, COLA3A1, and COL1A1. Moreover, BGN promoted pro-inflammatory cytokine (such as TNF-α, IL-1β and IL-6) production in PBMCs through NF-κB signaling pathway, which subsequently resulted in HCECs death. These findings provided a systemic protein profile of AH in CED patients after corneal transplantation, with the alterations implicated in cytokine-mediated signaling, ECM, complement system, and exsomes. The identified proteins and signaling pathways probably paved the novel insight into understanding the pathogenesis of the disease.

Impact of pandemic COVID-19 lockdown on penetrating keratoplasty patients.

To study the impact of the COVID-19 lockdown on the regular follow-up of keratoplasty patients. This retrospective interventional case series included 30 patients who had immunological corneal endothelial rejection out of 190 patients who came for post-PKP follow-up between September 15, 2019, and September 30, 2020. The demographics, primary diagnosis, surgical technique, time of presentation, recovery of graft, associated ocular problems, and visual acuity at 1 month were analyzed. Forward stepwise (likelihood ratio) binary logistic regression was used to find significant variables. The study population had 19 males (63.33%) and 11 females (36.67%). The mean age of the study group was 42.83 ± 18.89 (8-80) years. Of 30 patients, 19 (63.3%) presented before and 11 (36.7%) after the COVID-19 lockdown. Overall, 23 (77%) showed a reversal of graft rejection. Logistic regression showed that preoperative indications, large-sized grafts, and deep corneal vascularization were significant risk factors for non-resolution of graft rejection. It was noted that patients who presented to the hospital late had poor recovery (P = 0.002). The delay in the presentation was a significant risk factor for non-resolution of graft rejection (P < 0.01). Z-test for proportions revealed that the difference in the non-resolution of rejection on immediate or delayed treatment in patients presenting during lockdown (P = 0.002) was significant. This article is to highlight the impact of the COVID-19 lockdown on graft rejection recovery of PKP patients due to delays in follow-up. Early treatment helps in the recovery of graft transparency and the reversal of immunological graft rejection. Also, primary diagnosis, deep vascularization, and large-sized grafts were significant risk factors for non-resolution of graft rejection.

Impact of vaccination on keratoplasty.

Corneal graft rejection has been reported after coronavirus disease 2019 (COVID-19) vaccination. The purpose of this review is to evaluate the literature regarding corneal graft rejection after vaccination, including rejection rates and risk factors. We aim to create a framework to identify patients who are at higher risk for graft rejection and may warrant consideration of prophylactic interventions. Graft rejection has been reported following administration of mRNA, viral vector, and inactivated whole-virion COVID-19 vaccines. Most cases had additional risk factors associated with rejection. Vaccination increases circulation of proinflammatory cytokines, CD4+ and CD8+ T-cell responses, and antispike neutralizing antibody, all of which may contribute to graft rejection. Two prospective studies have found no relationship between recent vaccination and rejection but 20% of cornea specialists report to have seen a vaccine-associated rejection and 22% recommend delaying vaccination in certain circumstances. Many specialists recommend prophylactic topical corticosteroids before and after vaccination to mitigate rejection risk but there is no evidence to support this practice on a wider scale. Our framework identified 96.8% of penetrating keratoplasty patients with vaccine-associated rejection as higher risk. Further research is needed in order to develop evidence-based guidelines.

The treatment of end-stage corneal disease: penetrating keratoplasty compared with Boston type 1 keratoprosthesis.

Penetrating keratoplasty (PKP) yields excellent results for restoring vision in end-stage corneal diseases. However, its success is limited to high-risk diseases such as aniridia, chemical burns, autoimmune corneal diseases, and herpetic eye disease. Boston type 1 keratoprosthesis (BKPro) offers another option to these patients. Since 1992, improvements in perioperative management and device construction have significantly increased the use of BKPro worldwide and challenged the therapeutic role of PKP in these patients. This review aims to evaluate BKPro's place in the treatment algorithm of these high-risk patients to assist surgeons' decision-making. PKP and BKPro are compared in three outcome categories: visual acuity, graft retention and failure, and complications profile. Special attention is given to comparing secondary BKPro versus repeated PKP as well as primary BKPro versus primary PKP. We conclude that secondary BKPro bears a better prognosis than repeated PKP in most high-risk patients. Similarly, primary BKPro likely confers improved outcomes over primary PKP in most high-risk recipients. However, current evidence is based on retrospective designs, and controlled prospective randomized trials are required to validate these conclusions.

Boston type I keratoprosthesis versus penetrating keratoplasty following a single failed corneal graft.

To compare long-term outcomes of the Boston type 1 keratoprosthesis (KPro) with penetrating keratoplasty (PKP) in patients with a failed first PKP. In this retrospective comparative case series, 48 eyes of 48 patients who underwent a second corneal replacement procedure after a first failed PKP at the Centre Hospitalier de l'Université de Montréal from 2008 to 2020 were included. Minimum follow-up duration was 5 years, and patients with keratoconus were excluded since such subjects are not candidates for KPro. Main outcome measures included best-corrected visual acuity (BCVA), postoperative complications, graft survival and subsequent interventions. Mean follow-up was 6.4 years for PKP and 9.6 years for KPro (p < 0.001). Preoperative BCVA was better in PKP patients (means 1.67 vs 2.13, p = 0.041). Visual outcomes were similar between groups. KPro patients developed 0.263 complication per patient-year (ppy) compared to 0.245 ppy or PKP. The most common complications for PKP were corneal complications (0.088 ppy) and glaucoma worsening (0.041 ppy). In KPro, glaucoma worsening (0.046 ppy), vitreoretinal complications (0.042 ppy) and retroprosthetic membrane (0.042 ppy) were the most frequent. Graft failure (69.6 vs 20.0%, p < 0.001) and reoperation rates (56.5 vs 12.0%, p = 0.001) were significantly higher for PKP. Failure mainly resulted from decompensation or rejection in PKP, while all five failures in KPro were caused by melt and/or extrusion. Both interventions showed similar visual outcomes. Complication profiles were different, with more posterior segment complications in the KPro group, and more corneal complications in the PKP group, often necessitating regraft.

Environmental Risk Factors Associated With the Need for Penetrating Keratoplasty in Patients With Keratoconus.

PurposeTo identify environmental risk factors associated with the need for penetrating keratoplasty (PKP) (full-thickness corneal transplantation) in patients with keratoconus in a Middle Eastern country.MethodsThis is a retrospective case-control study. This study included patients with keratoconus who underwent PKPor were waitlisted for PKP. Controls were patients diagnosed with keratoconus who did not reach a stage that necessitates PKP. Groups were matched by age and gender. Chi-square test was used to figure out the association between different risk factors including eye rubbing, vernal keratoconjunctivitis (VKC), smoking, paternal consanguinity, eye dryness, family history, asthma, eczema, and diabetes with the need for PKP.ResultsA total of 111 patients were included in this study, there were 48 (43.26%) men and 63 (56.75%) women. The case group included 42 subjects and the control group included 69 subjects. We found statistically significant differences between the two groups in relation to eye rubbing (p=0.0005), VKC (p=0.005), paternal consanguinity (p=0.02), and smoking rate (p=0.04), all being significant in the group in need of PKP. On the other hand, we did not find out a statistically significant difference between the two groups in relation to family history (p=0.31), dryness (p=0.58), asthma (p=0.15), eczema (p=0.28), or diabetes (p=0.29).ConclusionThis study has identified several risk factors associated with the need for PKP in patients with keratoconus, part of which are modifiable. These findings can benefit clinicians in community counseling and give recommendations that can help in preventing or - at least - delaying the need for PKP surgery in keratoconus, such as smoking cessation, aggressive treatment of VKC disease, eye rubbing avoidance, as well as raising awareness regarding the potential risks of paternal consanguinity in this disease entity.

Cost-effectiveness of Descemet stripping automated endothelial keratoplasty versus penetrating keratoplasty in patients with endothelial dysfunction in India.

Purpose:The aim of this study was to compare the cost-effectiveness and perform cost-utility analysis of Descemet stripping automated endothelial keratoplasty (DSAEK) vs. penetrating keratoplasty (PK) in Indian population.Methods:This was an institutional, ambispective, observational study. Patients who underwent PK or DSAEK for endothelial dysfunction were included and followed up for 2 years; those with other ocular comorbidities were excluded. The analysis was performed from the patient’s perspective receiving subsidized treatment at a tertiary care hospital. Detailed history, ophthalmic examination, total expenditure by patient, and clinical outcomes were recorded. The main outcome measures were best spectacle-corrected visual acuity (BSCVA), graft survival (Kaplan–Meier survival estimates), incremental cost-effectiveness ratio (ICER), and incremental cost-utility ratio (ICUR). Utility values were based on quality-adjusted life years (QALYs) associated with visual acuity outcomes. Statistical analysis was performed using SPSS software package, version 12.1; a value of P < 0.05 was considered statistically significant.Results:A total of 120 patients (PK: 60, DSAEK: 60) were included. At 2 years, for a similar logMAR BSCVA, [PK (0.32 ± 0.02), DSAEK (0.25 ± 0.02); P = 0.078], the overall cost for PK (13511.1 ± 803.3 INR) was significantly more than DSAEK (11092.9 ± 492.1 INR) (difference = 1952.6 INR; P = 0.01). ICER of DSAEK relative to PK was –39,052 INR for improvement in 1 logMAR unit BSCVA. ICUR of DSAEK relative to PK was –1,95,260 INR for improvement in 1 QALY.Conclusion:DSAEK was more cost-effective than PK in patients with endothelial dysfunction at 2 years.

Changing Trends in Penetrating Keratoplasty Indications between 2011 and 2018 – Histopathology of 2123 Corneal Buttons in a Single Center in Germany

ABSTRACT Purpose: To analyse the changing trends in penetrating keratoplasty indications between January 2011 and December 2018, at the Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany. Patients and Methods: This is a retrospective review of 2123 corneal buttons of 1776 patients (1993 eyes, 56.0% males, age at the time of surgery 57.6 ± 18.7 years), who underwent penetrating keratoplasty (PKP) between January 2011 and December 2018. The classification was performed based on histological analysis and using the priority scheme of Brady et al., supplemented by a group of “failed endothelial keratoplasty grafts”. Our groups were the following: pseudophakic or aphakic bullous keratopathy, regraft, failed endothelial keratoplasty graft, acute necrotizing and ulcerative keratitis, keratoconus, Fuchs’ dystrophy, corneal dystrophy other than Fuchs’, corneal scars and other diagnoses. Results: Between 2011 and 2018, keratoconus was the leading indication for PKP in 455 (21.5%) cases, followed by acute necrotizing and ulcerative keratitis in 384 (18.1%), regraft in 367 (17.3%), corneal scars in 350 (16.5%), pseudophakic or aphakic bullous keratopathy in 225 (10.6%), Fuchs’ dystrophy in 194 (9.1%), other diagnoses in 64 (3.0%), corneal dystrophy other than Fuchs’ in 52 (2.4%), and failed endothelial keratoplasty graft in 32 (1.5%) cases. Conclusions: With the introduction of posterior lamellar keratoplasty, keratoconus remains the leading PKP indication in our center with excimer laser-trephination on a routine basis. A trend towards increasing numbers can be observed regarding acute necrotizing and ulcerative keratitis patients and regrafts. However, the incidence of Fuchs’ dystrophy decreased dramatically within PKP patients, with the introduction of posterior lamellar keratoplasty.

Evaluation of thrombospondin-1 gene polymorphisms in corneal allograft rejection in Asian Indian patients.

Purpose:To evaluate the frequency and the association of Thrombospondin 1 (THBS1) gene single nucleotide polymorphisms (SNPs) in Asian Indian patients with optical full thickness corneal grafting surgery.Methods:Prospective case–control analysis of optical penetrating keratoplasty patients with and without immune rejection and controls for genotyping of 3 THBS1 gene SNPs (rs1478604 A>G; rs2228261 C>T; rs2228262 A>G) by Amplification Refractory Mutation System-Polymerase Chain Reaction (ARMS PCR).Results:Among 58 patients [45 with immune allograft rejection (DNA isolation was possible in 38 samples) and 13 without immune corneal allograft rejection] and 65 controls, allele frequencies observed for rs1478604 (A>G) are A: 69.7% and 72.6%, G: 30.2% and 27.3%; for rs2228261 (C>T) are T: 70.2% and 62.3%, C: 29.7% and 37.6%; and for rs2228262 (A>G) A: 97.4% and 98.4%; G 2.5% and 1.5% respectively. Genotype frequencies were rs1478604 (A>G) AA: 57.8% and 59.3%, AG 23.6% and 26.5%; GG 18.4% and 14%; for rs2228261 (C>T) TT: 40.5% and 33.8%, TC: 59% and 56.9%, CC: 0% and 9.2%; for rs2228262 (A>G) AA: 94.8% and 96.8%, AG: 5.1% and 3.1% in rejection and controls respectively. The allele and genotype frequency for the 3 described THSB1 SNPs did not show any difference between the corneal graft immune rejection patients and controls.Conclusion:Asian Indian population evaluated for THBS1 gene SNPs by ARMS PCR genotyping in Asian Indian population did not show any genetic association to immune rejection occurrence in our study.

Observation of topical tacrolimus on high-risk penetrating keratoplasty patients: a randomized clinical trial study

Background/ObjectivesTo evaluate the clinical efficacy of topical tacrolimus 0.1% and cyclosporine 1% on high-risk penetrating keratoplasty (PKP) patients.Subjects/MethodsA series of 49 high-risk PKP patients (49 eyes), 20 males, 29 females from the age of 4 months to 74 years of age with the mean of 32.5 from 2012 to 2017 were recruited in this study. The patients were randomly divided into two groups by receiving either topical tacrolimus 0.1% or cyclosporine 1% respectively. Twenty five patients were treated with topical tacrolimus 0.1% and 24 patients with topical cyclosporine 1%. The traditional baseline management on these two groups were Tobramycin and Dexamethasone eye drops in the first 3 weeks and then tapered off. Clinical procedures and postoperative follow-up were documented.ResultsAfter 6–54 months follow-up, with the average of 24 months, 11 of 24 high-risk patients (11 eyes) had graft rejection, the rejection rate was 45.8% in topical cyclosporine 1% group. The rejections occurred from 35 days to 20 months after PKP. Three patients had irreversible rejection. On topical tacrolimus 0.1% group, the rejection occurred in four patients (four eyes) with rejection rate of 16%, and no irreversible rejection was observed. The graft rejection episodes were documented between 23 days and 24 months. As compared with the topical cyclosporine 1%, topical tacrolimus 0.1%, a key immunosuppressant, significantly decreased corneal graft rejection rate (p = 0.02).ConclusionsTopical tacrolimus 01% on high-risk PKP patients significantly prevented corneal graft rejection, and it had less adverse effects and was very safe to high-risk patients as to topical cyclosporine 1%. Further case controlled randomized clinical trial studies are needed to establish the best management option for these high-risk patients.

Comparative Evaluation Of Clinical Characteristics And Visual Outcomes Of Traumatic And Non-Traumatic Graft Dehiscence Following Corneal Transplantation Surgery.

PurposeTo compare patient demographics, clinical associations and visual outcomes between traumatic and non-traumatic wound dehiscence, following corneal transplantation.MethodsRetrospective review of all patients presenting with post-keratoplasty wound dehiscence to the Royal Victorian Eye and Ear Hospital between January 2005 and December 2017. Patients with wound dehiscence following keratoplasty of any cause were included.ResultsOf 71 eyes from 71 patients included, 60 (85%) were penetrating keratoplasty patients. The mean age was 56.4 years (SD=22.7, range 17.6–97) and 62% (n = 44) of patients were male. There were 28 (39%) cases of traumatic dehiscence and 43 (61%) cases of non-traumatic dehiscence. The median time interval from keratoplasty to dehiscence was significantly less in non-traumatic patients than traumatic patients (0.2 years, IQR 0.1–2.0 vs 2.3 years, IQR 0.3–14.8, p=0.01). There was no significant difference in best-corrected visual acuity at 6 months between traumatic and non-traumatic dehiscence (6/60 vs 6/36, p=0.62), suture technique (continuous vs interrupted, p=0.12), or graft type (penetrating keratoplasty vs deep anterior lamellar keratoplasty) after adjusting for keratoconus (p=0.41).ConclusionPost-keratoplasty wound dehiscence is a serious complication and can cause significant loss of vision. While the risk of dehiscence is lifelong, the first 3 years post-keratoplasty carry the highest risk, with non-traumatic dehiscence tending to occur earlier than traumatic dehiscence.

Descemet's stripping endothelial keratoplasty (DSAEK) in failed penetrating keratoplasty patients: graft survival rate and its associated factors

Objective: To explore graft survival rate and its associated factors of DSAEK in patients with endothelial decompensation after penetrating keratoplasty (PKP). Methods: A retrospective case study was conducted, including 51 patients (51 eyes) that underwent DSAEK for endothelial decompensation after PKP in Department of Ophthalmology in Peking University Third Hospital from June 2009 to September 2017. The mean recipient age was (43.3±21.0) years. There were 36 males and 15 females. Data comprising demographic details,surgical methods, complications,follow-up durations,final states of grafts,preoperative and postoperative risk factors were collected. Kaplan-Meier analysis was used to determine the cumulative probability of graft survival. Cox regression model was developed to examine for factors associated with graft survival. Results: Among 51 eyes,the overall graft survival rate was 78%(40/51). The cumulative probability was 85% (95%CI: 0.73-0.96) and 69% (95%CI: 0.52-0.86) at 1 year and 2 years, respectively. The median survival time was 42 months. The diameter of DSAEK graft and postoperative intraocular pressure correlated with the long-term survival of graft. Larger diameter of DSAEK graft was a protective factor for graft survival (HR=0.29, 95%CI: 0.12-0.73), while postoperative high intraocular pressure was a risk factor (HR=1.08, 95%CI: 1.00-1.16, HR=1.10, 95%CI:1.01-1.12). Recipient age, sex, lens status, the number of previous PKPs and previous glaucoma surgery had no significant effect on long-term survival (P>0.05). Conclusions: DSAEK is an effective treatment for endothelial decompensation after PKP,with favorable graft survival rate. Larger diameter of graft is beneficial to the long-term survival,while high postoperative intraocular pressure is a risk factor for graft failure. (Chin J Ophthalmol, 2019, 55: 428-434).

Study of incidence of endophthalmitis in posttherapeutic keratoplasty patients at a secondary care hospital in Saurashtra Region, India

Background: Endophthalmitis is an infrequent but devastating intraocular infection. The objective of the present study was to detect the incidence of endophthalmitis in posttherapeutic keratoplasty patients. Materials and Methods: The study was conducted at a secondary-level government eye care center at Rajkot, Gujarat. The study included 71 eyes of 71 patients prospectively from January 2013 to December 2014. All the patients who underwent therapeutic keratoplasty for suppurative keratitis and descemetocele were included in this study. The study excluded all the patients who underwent optical penetrating keratoplasty and posttraumatic keratoplasty. The patients were followed up on the 1st, 7th, 15th, and 45th postoperative days for signs and symptoms of endophthalmitis. Results: There were 71 eyes of 71 patients including 44 (62.0%) males and 27 (38.0%) females. The mean age of the patients was 53.4 ± 18.9 years (range: 8–98 years). Out of the 71 eyes, 51 had preoperative ocular history including foreign body fall (15 [21.1%]), vegetative material trauma (20 [28.2%]), nonvegetative material trauma (11 [15.5%]), and previous keratoplasty (5 [7.0%]). Predominantly, bacterial infection was reported in 28 (39.4%) patients. Iritis was reported in all patients after keratoplasty followed by conjunctivitis (9.9%) and vitritis (7.0%). During follow-up examination on the 1st, 7th, 15th, and 45th postoperative days, zero incidence of endophthalmitis was reported. Conclusion: The present study reported zero incidence of endophthalmitis in therapeutic penetrating keratoplasty patients. Therapeutic penetrating keratoplasty is effective in the management of eye with suppurative keratitis and descematocoele.

Outcomes of the first 250 eyes of Descemet membrane endothelial keratoplasty: Canadian centre experience

ObjectiveTo report and analyze the clinical outcomes of the first 250 cases of Descemet membrane endothelial keratoplasty (DMEK). MethodsA retrospective case series was conducted on the first 250 DMEK cases. The cohort included eyes with previous trabeculectomy, pre-existing glaucoma drainage device, and previous vitrectomy. Outcomes measures were best spectacle-corrected visual acuity (BSCVA), endothelial cell loss (ECL), episodes of rejection, detachment, rebubbling rate, and the need for repeat transplantation. Subgroup analysis was performed between eyes with different etiologies and between different DMEK injectors. ResultsThe median BSCVA increased from 0.6 [0.4, 1.3] logMAR (Snellen equivalent, 20/80) before surgery to 0.3 [0.2, 0.5] logMAR (Snellen equivalent, 20/40) 6 months after DMEK (p < 0.001). The median ECL at 6 months after surgery was 26.1%. Thirty-nine eyes (15.6%) had graft detachment involving more than one third of the graft and required rebubbling. Two eyes (0.8%) had a graft rejection episode. Fifteen eyes (6%) had graft failure for which 13 eyes (5.2%) had repeat DMEK, 1 eye (0.4%) had repeat Descemet stripping automated endothelial keratoplasty (DSAEK), and 1 eye (0.4%) had repeat penetrating keratoplasty (PKP). Fuchs’ patients and failed PKP patients gained more vision at 6 months post-DMEK compared with other etiologies (pseudophakic bullous keratopathy and failed DSAEK) (p < 0.001). ConclusionsOur data suggest that DMEK is a safe and effective procedure with excellent visual outcomes. DMEK can be done in association with other co-morbidities such as post-trabeculectomy, glaucoma drainage device, previous vitrectomy, and failed corneal grafts with a good prognosis.

Observation on the efficacy of Tacrolimus eye drops for preventing rejection after high-risk corneal transplantation

Objective To observe the efficacy of Tacrolimus eye drops for preventing rejection after treatment of high-risk penetrating keratoplasty in patients with poor response to Cyclosporin A eye drops. Methods The data of 10 eyes of 9 patients with high-risk penetrating keratoplasty from Apr. 2008 to Jun. 2015 were analyzed retrospectively. Cyclosporine A eye drops were applied after the first penetrating keratoplasty. Five eyes were treated with Tacrolimus eye drops after secondary penetrating keratoplasty, and the other 5 eyes were treated with Cyclosporine A eye drops. Results Ten eyes were followed up for (41.70±8.53) months after corneal transplantating, rejection happened in 9 eyes(90.00%) . All eyes underwent penetrating keratoplasty due to grafts opacification. Five eyes were treated with Tacrolimus eye drops and followed up for (16.00±2.68) months. The rejection occurred in 2 eyes(40.00%). The other 5 eyes were treated with Cyclosporin A and followed up for (36.20±7.95) months. The rejection rate was 100.00%. After treatment of Tacrolimus eye drops, the grafts of 5 eyes were transparent and followed up for (13.40±3.17) months. In the follow-up period, rejection occurred in 1 eye(20.00%). Conclusion Tacrolimus eye drops is applied for preventing rejection in high-risk keratoplasty patients with poor response to Cyclosporin A eye drops, most patients can get better anti-immune rejection effects. Key words: Keratoplasty, penetrating; Eye drops, Tacrolimus; Rejection, immune; Efficacy

Stepwise Guided Photorefractive Keratectomy in Treatment of Irregular Astigmatism After Penetrating Keratoplasty and Deep Anterior Lamellar Keratoplasty.

To report the outcome of stepwise ablation using topography-guided photorefractive keratectomy to treat irregular astigmatism after either penetrating keratoplasty (PKP) or deep anterior lamellar keratoplasty (DALK). This is a retrospective, interventional analysis including patients with irregular astigmatism after either PKP or DALK, who underwent topography-guided photorefractive keratectomy. The entire cohort was analyzed, as well as the PKP and DALK groups separately. Analysis of factors associated with a better outcome was also performed. Thirty-four eyes of 34 patients (20 PKP patients and 14 DALK patients) aged 47.4 ± 15.9 years were included. Twenty-one patients underwent more than 1 ablation. Refractive stability and a minimal period of 5 months were required before repeat ablation. The average follow-up duration was 17.0 ± 6.0 months. Corrected distance visual acuity (CDVA) improved significantly from 0.22 ± 0.14 logarithm of the minimum angle of resolution (logMAR) to 0.14 ± 0.12 logMAR at final follow-up (P = 0.035). Uncorrected distance visual acuity (UDVA) improved significantly from 0.90 ± 0.54 logMAR to 0.57 ± 0.40 logMAR at final follow-up (P = 0.004). CDVA and UDVA improved by ≥1 Snellen lines in 54.2% and 70.8% of the eyes, respectively, and by ≥3 Snellen lines in 16.7% and 54.2% of the eyes, respectively. Statistically significant improvement was seen in optical aberrometry indices (total root mean square, higher-order aberration root mean square, defocus, coma, trefoil, and spherical aberration). The difference between PKP and DALK in either CDVA (P = 0.562) or UDVA (P = 0.384) improvement was nonsignificant. The stepwise topography-guided photorefractive keratectomy approach in cases of irregular astigmatism after PKP or DALK can help improve visual acuity outcomes. Patients should be appropriately counseled that more than 1 treatment will likely be needed.

Comparison of Long-term Clinical Outcomes between Descemet's Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty in Patients with Bullous Keratopathy.

PurposeTo compare 2-year clinical outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) in patients with bullous keratopathy.MethodsA retrospective chart review was performed to obtain 2 years of follow-up data of DSAEK or PK at a single center from March 2009 to September 2012. The study comprised 15 eyes of DSAEK and 11 eyes of PK. Outcome measures included best-corrected visual acuity (BCVA), spherical and keratometric changes, central corneal thickness, endothelial cell density, intraocular pressure, and postoperative complications. Graft survival rate was assessed by Kaplan-Meier survival analysis.ResultsThere were no differences in patient baseline characteristics between the two groups. At postoperative 2 years, better BCVA of 0.69 ± 0.51 logarithm of the minimum angle of resolution (logMAR) was found after DSAEK compared to 0.88 ± 0.48 logMAR after PK. Refractive cylinder in DSAEK and PK was −2.60 ± 1.53 and −6.00 ± 1.05 diopters (D), respectively, and keratometric cylinder was 3.27 ± 3.70 and 6.34 ± 3.51 D, respectively, at postoperative 2 years. The difference of mean spherical equivalents between postoperative 1 month and 2 years was 0.84 D after DSAEK and 2.05 D after PK. A hyperopic shift of 1.17 D was present after 2 years of DSAEK. The mean endothelial cell density at postoperative 2 years was 1,548 ± 456 cells/mm2 for DSAEK and 1,052 ± 567 cells/mm2 for PK, with a cell loss of 19.96% vs. 52.38%, respectively when compared to postoperative 1 month. No significant difference in central corneal thickness was found between DSAEK and PK (592 ± 75 vs. 563 ± 90 µm, respectively). Finally, the 2-year survival rate did not differ significantly between DSAEK and PK (93.3% vs. 81.8%, respectively, p = 0.344).ConclusionsCompared to PK, DSAEK provided more stable refractive errors with better visual outcome, lower endothelial cell loss, and a lower rate of graft rejection at postoperative 2 years in patients with bullous keratopathy.