Post-penetrating Keratoplasty Research Articles

Comparison of autologous serum and platelet-rich plasma in the treatment of severe dry eye and persistent epithelial defects

PurposeTo compare the efficacy of topical autologous serum and platelet-rich plasma (PRP) in patients with severe dry eye and persistent epithelial defects. MethodsSixty-seven eyes of 42 patients including 12 Sjogren, 11 meibomian gland dysfunction, 8 post penetrating keratoplasty, 5 acne rosacea, 5 chemical burn and 3 neurotophic keratopathy were analyzed. Best corrected visual acuity, Schirmer, Ocular Surface Disease Index (OSDI), tear break-up time, Oxford staining scores were measured before the treatment and 1 month. One month scores of two groups were compared. ResultsThirty three eyes received autologous serum and 34 received PRP. There was no statistically significant differences between two groups in ocular surface parameters at baseline. Statistically significant improvements were achieved in both groups in all parameters at 1 month (p < 0.05). Schirmer score improved from 7.9 ± 7.6 to 10.6 ± 8.4 mm in autologous serum (p < 0.001) and from 10.9 ± 9.5 to 13.3 ± 10.1 in PRP (p < 0.001); BUT from 4.3 ± 2.7 to 6.7 ± 3.4 s (p < 0.001) and 4.5 ± 3.0 to 6.0 ± 3.6 (p < 0.001); OSDI from 47.7 ± 14.7 to 25.7 ± 11.0 (p < 0.001) and from 54.1 ± 17.3 to 26.8 ± 11.0 (p < 0.001); Oxford score from 4.0 ± 1.0 to 1.3 ± 1.1 in (p < 0.001) and 3.9 ± 0.9 to 1.6 ± 1.3 (p < 0.001) respectively. Significant visual improvement was achieved with PRP from 0.81 ± 0.73 LogMAR to 0.72 ± 0.63 (p = 0.025), whereas insignificant with serum from 0.60 ± 0.65 to 0.57 ± 0.67 (p = 0.147). Mean epithelial healing time was 6.7 ± 4.7 (2–14) days in serum and 3.6 ± 1.9 (2–7) in PRP (p = 0.195). ConclusionsBoth treatments are equally effective in severe dry eye and persistent epithelial defects. Although, visual gain is higher in PRP, autologous serum may be preferable due to low cost.

Post-Penetrating Keratoplasty Assessment of Endothelial Function With a Scleral Lens Challenge.

Patients who have undergone penetrating keratoplasty may have corneal edema because of endothelial cell dysfunction. Scleral lens wear may exacerbate edema, particularly if lens fit is suboptimal. Distinguishing between edema because of inherent endothelial cell dysfunction and swelling because of scleral lens-related hypoxia can be challenging. It is necessary, however, to identify the most likely cause of increased corneal thickness to determine whether the patient simply needs refitting for a different lens design or needs additional surgical intervention. This case report describes the utility of corneal tomographic imaging before and after scleral lens wear both to estimate endothelial cell function and to direct decisions when designing a scleral lens for a post-transplant eye.

Femtosecond thin-flap laser assisted in situ keratomileusis for correction of post-penetrating keratoplasty ametropia: long-term outcome

PurposeTo evaluate the long-term clinical outcomes of femtosecond thin-flap LASIK (femto-LASIK) for correction of refractive error after penetrating keratoplasty in keratoconus-affected eyes.Settinga private ophthalmology clinic.DesignProspective interventional case series.MethodsThis prospective interventional case series enrolled 22 eyes of 22 patients who underwent femto-LASIK for the management of post-penetrating keratoplasty ametropia. The refractive error, uncorrected (UDVA), and corrected (CDVA) distance visual acuities and vector analysis were reported in short-term and long-term period after surgery.ResultsThe mean age was 32.7 ± 7.5 years (range, 23 to 47 years) at the surgery time. The average time between PK and femto-LASIK was 42.5 ± 31.7 months. The average follow-up duration after femto-LASIK was 81.2 ± 18.6 months. The mean preoperative UDVA significantly improved from 0.47 ± 0.15 logMAR to 0.35 ± 0.14 logMAR at 12 months (P = 0.048) and 0.4 ± 0.17 at final follow-up exam (P = 0.007). CDVA was 0.22 ± 0.1 at baseline which improved to 0.18 ± 0.15 and 0.15 ± 0.1 logMAR at 12 and 81 months, respectively. (Ps = 0.027, 0.014). The mean cylinder before surgery was − 5.04 ± 1.4D which significantly decreased to -1.5 ± 0.8 D at 12 months postoperatively. (P < 0.001). There was a significant increase in refractive astigmatism from 12 months to 81 months postoperatively (-3.1 ± 2.0, P = 0.002). At the final visit, the efficacy index was 0.83, and the safety index was 1.16.ConclusionsDespite the short-term outcome indicated that femo-LASIK was effective for correction of post-keratoplasty ametropia during short-term period, a notable regression in its effect was observed in the long-term follow-up. Therefore, the predictability of this technique might decrease in the long-term.

Surgery after corneal grafts

There is one available donor per 70 patients so we need to identify those whose vision would benefit from corneal transplantation and minimize risks that could jeopardize corneal graft survival possibility1.The two leading causes of graft failure post Penetrating Keratoplasty (PKP) are graft rejection and secondary glaucoma development. The existence of preoperative glaucoma increases two to three times the chances of graft rejections in any corneal transplantation2,3. The 10‐year Cornea Donor Study also confirmed that pre‐existing glaucoma is a risk factor for graft failure4. The 3‐year graft survival rate has been shown to be 71% in patients with preop glaucoma and 89% in patients without preop glaucoma5.In cases following Descemet Striping Endothelial Keratoplasty (DSAEK), Ocular Hypertension (OHT) ranges in otherwise healthy eyes from 29 to 47% and increases to 43 to 54% in cases with pre‐existing glaucoma or high‐risk eyes. Glaucoma can be presented in up to 15% in post‐DSAEK cases which increases twice the relative risk of rejection. Concurrent gonio‐synechiolysis is considered an additional risk factor whereas 18.6% of high IOP cases considered as secondary to steroid administration. Acute raise in IOP can be attributed in pupillary block at an estimated rate of 13%6,7.In cases of Descemet Membrane Endothelial Keratoplasty (DMEK) OHT or intraocular pressure (IOP) elevation is presented to 6.5 up to 11.1% and de novo glaucoma can be found from 2.8 to 6.5%, whereas progression of pre‐existing glaucoma is less than 2.5%8. In cases with simultaneous DMEK and cataract surgery there is greater likelihood of post‐op OHT or glaucoma. In DMEK cases the early postoperative increase in pressure is usually due to a combination of anterior (inferior) and posterior (superior) pupillary blocks when patient is sitting upright9.The late post‐DMEK IOP increase is attributed to Blockage of TM by inflammatory cells, PAS formation or steroid use. However, steroid‐induced glaucoma post‐DMEK is not as common as that in post‐PKP or post‐DSAEK due to the shortest steroid regime post‐DMEK cases. Treatment methods include medical treatment, trabeculectomy or tubes. Some cases with Xen®10 and Micropulse cyclodidode11 laser have been reported in endothelial cases, however with little degree of evidence.Controversy still exists to which surgical procedure is the best for graft survival and IOP control, as well as when is the best time of the surgery in patients with pre‐existing glaucoma, before, simultaneously or after, and if needed, graft surgery. Certainly a “try not to create glaucoma” strategy needs always to be followed by not producing additional iatrogenic risk factors with improved technique(s) and by respecting the tissue(s).

Intraoperative collagen imaging of sutured cornea: A way towards managing post-penetrating keratoplasty astigmatism

The birefringent nature of the human cornea plays an important role in comprehending its structural behavior in both diseased and surgical conditions. During corneal transplantation, irregular astigmatism is a common post-surgical complication that depends on the characteristics of suturing. Four human cadaver corneas are subjected to an in-vitro model of a typical full-thickness penetrating keratoplasty (PK) procedure using 16 simple interrupted 10–0 vicyrl sutures. The birefringence of these four corneas is analyzed using digital photoelasticity and compared with the control cornea (without PK). It is found that the sutures and their mutual interaction influence the morphology of the peripheral birefringence of the cornea. The findings of the present investigation are pertinent to intraoperative suture management during PK. Results suggest conserving the typical diamond-shaped morphology of peripheral birefringence would ensure uniform distribution of sutures. Therefore, birefringence imaging could be useful in suture management to ensure proper apposition of the graft-host junction, thus minimizing the risk of irregular astigmatism.

Endophthalmitis caused by Burkholderia cepacia complex (BCC): clinical characteristics, antibiotic susceptibilities, and treatment outcomes

PurposeTo report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.Study designRetrospective, observational case series.MethodsClinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed wisth culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.ResultsEndophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1 mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).ConclusionsEndophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

A Comprehensive Investigation Into the Outcomes of Descemet's Stripping Endothelial Keratoplasty (DSEK) as a Treatment for Corneal Endothelial Disorders.

Descemet's stripping endothelial keratoplasty (DSEK) has emerged as the preferred method for posterior lamellar keratoplasty, as it enables the replacement of the compromised host endothelium with a viable donor lamella. The objective of this study was to assess the impact of DSEK on surgical outcomes and visual acuity. The research was carried out from November 2019 to October 2021, encompassing a sample of 18 patients (18 eyes) who satisfied the inclusion criteria for DSEK. The pre-operative evaluation was performed once before the surgery, while post-operative evaluations were conducted at one, three, and six months after the surgical intervention. The main variables assessed in this study encompassed demographic characteristics, visual acuity, surgical techniques, and surgical complications employed during the surgical procedure. The collected data were statistically analyzed using IBM SPSS software version 21 (IBM Corp., Armonk, NY, USA). Patients in the study ranged in age from 25 to 70, with a mean age of 53.16 ± 14.19 years. The participants were 61% male and 39% female. The main reasons for DSEK use were pseudophakic bullous keratopathy (61%) and post-penetrating keratoplasty (PK) graft failure (17%). The other indications were aphakic bullous keratopathy (11%), bullous keratopathy with cataracts (5%), and Fuchs's endothelial dystrophy (5%). The study included 18 eyes: 14 eyes underwent DSEK, two underwent DSEK with small-incision cataract surgery (SICS) and posterior chamber intraocular lens (PCIOL) implantation, and two underwent DSEK with scleral-fixated FIL. A significant improvement in best-corrected visual acuity (BCVA) was observed at six-month follow-up (0.73 ± 0.37 vs. 1.73 ± 0.59 logMAR pre-operatively). During donor cornea dissection, buttonholing was the main concern, occurring 11% of the time. Descemet's perforation and donor preparation thickness variations were also observed. Reverse donor unfolding, incomplete DM stripping, and donor button displacement were quickly addressed and managed. Post-operative graft failure occurred in 22% of cases, while acute graft rejection occurred in 11%. Graft dislocation, pupillary block, and secondary glaucoma each had a 5% prevalence. Descemet's stripping endothelial keratoplasty is a safe and effective treatment for corneal endothelial disorders, particularly in cases where scarring is not present. Surgical skills are essential to achieving the desired results. Descemet's stripping endothelial keratoplasty is favored over conventional keratoplasty for endothelial dysfunction due to its technical advantages and manageable risks. Our research demonstrates a significant improvement in visual acuity through DSEK. Despite manageable post-operative complications, it is vital to educate patients and medical professionals on surgical complexities. Descemet's stripping endothelial keratoplasty appears promising for the treatment of endothelial disorders, but its long-term implications must be studied.

Management of Fuchs endothelial corneal dystrophy (FECD): a case series

Background: Fuchs endothelial corneal dystrophy (FECD) is the most common corneal dystrophy and often results in visual loss. This study aims to discuss the etiology, pathophysiology, diagnosis, and management of FECD. Case presentations: We reported three cases of FECD. The first patient was 60 years old female diagnosed with corneal scar post-penetrating keratoplasty (PK) and pseudophakia in the right eye (RE) and FECD grade II in the left eye (LE). The right and left eye (RLE) visual acuity was 6/18 and 6/12, respectively. The patient was managed thrice a day with lubricant eye drops in the RE and Phacoemulsification and Descemet membrane endothelial keratoplasty (DMEK) in the LE. The second patient was 80 years old female with RLE FECD grade II, LE Pseudophakia, and RE Immature Cataract. Visual acuity was light perception in the right eye and 1/60 in the LE. She was managed with Siloxane eye drop 2x1, Oculenta gel 1x1 in RLE, and DMEK in LE. The third patient was 73 years old male with pseudophakia, FECD grade III, and corneal neovascularization in the RE. Visual acuity in RE was hand movement, and LE was 6/6. He was planned for PK on RE, Diquafosol sodium (Diquas®) eye drop twice a day, and eye fresh plus eye drops 4x1 in RLE. Conclusion: FECD is the most common endothelial dystrophy and the main indication for corneal transplantation in the presence of visual disturbances. Medical therapy in the form of topical hyperosmotic agents can be given in the early phase and is useful for reducing corneal edema. The preferred management of FECD is currently Endothelial Keratoplasty (EK), such as DMEK, which has demonstrated excellent corneal clearance. Although the graft rejection rate in DMEK is low, there is a risk of rejection with the discontinuation of topical corticosteroids.

Management of Post-Penetrating Keratoplasty Astigmatism by Photorefractive Keratectomy

Management of Post-Penetrating Keratoplasty Astigmatism by Photorefractive Keratectomy

Laser in situ keratomileusis versus Artisan lens implantation in correcting ametropia after penetrating keratoplasty for keratoconus

PurposeTo compare the long-term safety and efficacy of laser in situ keratomileusis (LASIK) with Artisan phakic intraocular lens implantation to correct refractive errors after penetrating keratoplasty (PK) for keratoconus.MethodsThis retrospective comparative interventional case series included a total of 33 consecutive keratoconus eyes that had previous PK and received subsequent LASIK (n = 16) or Artisan lens implantation (n = 17) were included in this study. Outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive error, and complications.ResultsPostoperatively, the UDVA of ≥20/40 was achieved in none of the LASIK group compared to 62.5% of eyes in the Artisan group (P < 0.001); the respective values for CDVA of ≥20/40 were 87.5 and 94.1% (P = 0.51). Spherical equivalent refraction decreased from − 6.97 ± 1.50 D preoperatively to − 4.20 ± 2.05 D postoperatively in the LASIK group (P < 0.001) and from − 10.79 ± 2.15 D preoperatively to − 2.13 ± 1.23 D postoperatively in the Artisan group (P < 0.001). There was no significant change in the refractive astigmatism in LASIK group (P = 0.30) or Artisan group (P = 0.11). The efficacy and safety indices were significantly better for Artisan (0.82 ± 0.34 and 1.13 ± 0.30, respectively) than for LASIK (0.22 ± 0.17 and 0.85 ± 0.24, respectively, P ≤ 0.006 for both comparisons). While refractive error changed significantly from postoperative year 3 to the final visit in the LASIK group, it remained stable in the Artisan group through follow-up period. No significant complications were observed in any group.ConclusionArtisan lens implantation provided superior and stable visual outcomes compared to LASIK for the management of post PK refractive errors in keratoconus eyes.

A rare case of Exophiala dermatitidis graft infection

We report Exophiala dermatitidis graft infection in a 49-year-old female patient post penetrating keratoplasty. Microscopically, the slide culture showed abundant single-celled, oval, light-brown yeast-like cells that were arranged in chains. Also, a few septate hyphae with annelids bearing ellipsoidal conidia along with terminal and intercalary phialides were seen. To the best of our knowledge, this is the first such reported case in India. The infection was recalcitrant, and ultimately, visual recovery was not successful.

A 10-Year Retrospective Case Series on Wound Dehiscence Following Corneal Transplant.

Background and objectiveCorneal transplants are associated with multiple well-known complications, one of them being wound dehiscence. It results in unfavorable outcomes, such as ocular structure damage, graft failure, repeated surgeries, and possibly a poor prognosis in terms of vision quality. Although the wound site may appear well-healed clinically, as the strength at the graft-host junction is weak, the site is susceptible to dehiscence. Wound dehiscence can be secondary to suture removal and/or trauma. In this study, we assessed the incidence of wound dehiscence secondary to trauma following corneal transplant and evaluated its occurrence in terms of patient age, type of corneal transplant performed, duration between corneal transplantation and wound dehiscence, mechanism of injury, and final outcome.MethodsThis was a case series that included all patients who suffered from wound dehiscence secondary to trauma post-corneal transplant between January 1, 2009, and December 31, 2019, at Hospital Kuala Lumpur.ResultsA total of 492 patients underwent corneal transplant surgery during the 10-year study period. Based on specified inclusion and exclusion criteria, only 13 patients were eligible for inclusion in this study. The incidence of wound dehiscence secondary to trauma post-penetrating keratoplasty (PK) was low (2.64%). Twelve patients had undergone PK, while one patient had undergone deep anterior lamellar keratoplasty (DALK). Blunt ocular trauma post-transplant can cause wound dehiscence regardless of patient age and duration post-corneal transplantation. Males are at a higher risk as their active lifestyle contributes to higher exposure to ocular injury.ConclusionAs corneal transplant patients are at life-long risk of wound dehiscence post-transplant, they must be counseled about this possible risk and the need to take adequate precautions in their daily lives. Based on our findings, the use of newer technologies and partial- rather than full-thickness corneal transplants should be explored further.

Comparison of long-term outcomes of trabeculectomy and risk factors for failure in eyes post penetrating keratoplasty or Descemet's stripping endothelial keratoplasty.

Purpose:To evaluate the outcomes of trabeculectomy, graft survival, and risk factors for failure in post penetrating keratoplasty (PK) and Descemet’s stripping endothelial keratoplasty (DSEK) eyes.Methods:We reviewed charts of eyes that underwent trabeculectomy for post keratoplasty glaucoma PK [25 eyes] and DSEK [14 eyes] between 1993 and 2019. The demographics, clinical features, and surgical outcomes were evaluated. Success of trabeculectomy was defined as complete when the intraocular pressure (IOP) was >5 and ≤21 mmHg without antiglaucoma medications (AGM) and qualified with AGM. Clear and compact graft was considered for graft success.Results:Median (interquartile range [IQR] preoperative IOP in post-PK eyes and post-DSEK eyes was comparable, 32 (28–38) vs. 31.5 (25–36) mmHg, P = 0.38). Median number of preoperative AGMs was comparable (P = 0.78). Median postoperative follow-up was longer in post-PK, compared with post-DSEK, 2.5 (1.3–3.3) vs. 1 (0.3–2.9) years (P = 0.05). Kaplan–Meier survival estimates for complete and qualified success of trabeculectomy at 3 years were 23.7% and 73.3%, respectively, for PK and 45.8% and 71.6%, respectively, for DSEK. Kaplan–Meier survival estimates for graft survival were 91.8% up to 3 years for PK and 100% until 2 years and 77.8% at 3 years for DSEK. Higher IOP prior to trabeculectomy was a risk factor for failure of trabeculectomy (P = 0.03) and older age was a risk factor for graft failure (P = 0.05) in PK eyes. Number of prior corneal surgeries (P = 0.05) was associated with failure of trabeculectomy and graft failure in post-DSEK eyes.Conclusion:Trabeculectomy had moderate qualified success in post-PK and DSEK eyes at 3 years. Higher pretrabeculectomy IOP and higher number of prior corneal surgeries were significantly associated with failure of trabeculectomy in PK and DSEK eyes, respectively.

Incidence and risk factors for post-penetrating keratoplasty glaucoma.

Purpose:To carry out a prospective study to analyze the incidence and various preoperative, intraoperative, and postoperative risk factors for the development of PPKG.Methods:A total of 207 patients were analyzed prospectively, who were operated for penetrating keratoplasty (PK) in a tertiary eye care hospital between the time period of August 1, 2017 and February 28, 2018 and were followed up till the sixth month. Each patient was analyzed at every visit to determine the factors responsible for post-keratoplasty glaucoma.Results:Out of 207 eyes, post-PK glaucoma developed in 84 cases, which yielded an incidence of 41%. Incidence of PPKG (Post PK glaucoma) in various conditions was as follows: in repeat PK 62%, in perforated corneal ulcer 33%, in nonperforated corneal ulcer 29%, in corneal scar including adherent leukoma 37.2%, and in pseudophakic bullous keratopathy and aphakic bullous keratopathy, 14% and 80%, respectively. In age- and sex-adjusted multivariate analysis, the significant risk factors were age (P-value- 0.006), presence of PAS (P-value 0.001), and fellow eye glaucoma (P-value 0.04). Aphakia and combined surgery were not found to be significantConclusion:Our study recommends a meticulous examination of the fellow eye to assess the presence of glaucoma as it can increase the suspicion of glaucoma in the eye to be operated. The presence of PAS and age are important risk factors for developing PPKG. The risk of developing PPKG increases exponentially as the number of risk factors increases, but the presence of more than three risk factors does not add to the development of PPKG.

Case report and literature review of epithelial downgrowth post-penetrating keratoplasty

Case report and literature review of epithelial downgrowth post-penetrating keratoplasty

Post penetrating keratoplasty infectious keratitis: Clinico-microbiological profile and predictors of outcome.

To study the clinico-microbiological profile, outcomes and prognostic factors of post penetrating keratoplasty (PKP) infectious keratitis. Retrospective review of medical records of 78 patients with post PKP infectious keratitis presenting between January 2014 and December 2018. Demographic, clinical and microbiological profile was documented and predictors of treatment and graft success were evaluated using univariate and subsequent multivariate logistic regression analysis. Mean age of patients was 52.17 ± 15.51 years and mean infiltrate size was 19.39 ± 19.68 mm2. Mean duration of presentation with infection post PKP was 11.66 ± 10.65 months. Culture positivity was seen in 64 eyes (82.05%). Bacterial growth was observed in 47 eyes (60.25%), fungal growth in 17 (21.79%) and no microbiological growth in 14 eyes (17.94%). At 3 months the visual acuity (VA) improved in 37 eyes (47.44%), did not change in 27 (34.62%) and deteriorated in 14 (17.95%). Graft failure was noted in 53 eyes (73.08%). Surgical intervention was needed in 47 (60.25%) eyes of which most common was therapeutic PKP in 32 eyes (41.02%). Treatment failure was noted with fungal infection (p = 0.05), poorer vision at presentation (p = 0.02), larger infiltrate area (p = 0.002) and graft infection developing before 1 year (p = 0.02). Graft failure was noted with associated endophthalmitis (p = 0.02), poorer VA at presentation (p = 0.01) and larger infiltrate area (p = 0.02). Post PKP infectious keratitis is a sight threatening ocular condition. It is associated with high incidence of graft failure and frequently requires surgical intervention. Fungal etiology, larger infiltrate size, poorer vision at presentation and associated endophthalmitis carries a poorer prognosis.

Semiquantitative Criteria in the Eye Bank That Correlate with Cornea Guttata in Donor Corneas.

Cornea guttata may not be recognized in the eye bank and recent studies have displayed that guttae are transplanted in about 15% of cases in varying severities. The purpose of this study was to establish semiquantitative criteria for the detection of cornea guttata in donor corneas in the eye bank. In this retrospective cohort study, preoperative endothelial pictures of donor corneas were collected and classified according to the post-penetrating keratoplasty cornea guttata grade into three distinct groups: group 1 consists of healthy corneas with no guttae (guttata grade 0); group 2 constitutes corneas with mild asymptomatic cornea guttata (guttata grade +); and group 3 comprises corneas with advanced widespread cornea guttata (guttata grade ++/+++/++++). The preoperative pictures of each group were then individually analyzed using the following five semiquantitative criteria: The number and the area of the cell-depleted surfaces, the presence of less than 50% of the cells having a hexagonal or a circular shape, the presence of cell membrane defects and interruptions, the presence of blebs in the cell membrane, and the presence of groups of cells with a distinct whitish color. In total, 262 patients were included in this study, with a total number of 1582 preoperative donor corneal endothelial pictures. Out of those pictures, groups 1, 2, and 3 encompassed 995 (62.9%), 411 (26.0%), and 176 (11.1%) pictures, respectively. Three out of the five eye bank criteria were found to correlate with postoperative cornea guttata with a highly significant p value of < 0.001. These three criteria are the presence of less than 50% of the cells having a hexagonal or a circular shape, the presence of cell membrane defects and interruptions and, the presence of blebs. The presence of groups of cells with a distinct whitish color was only a weak predictive factor for cornea guttata (p = 0.069). There was no statistically significant correlation between the number and the area of cell-depleted surfaces and postoperative cornea guttata with a p = 0.181. Three semiquantitative criteria that can be detected in the eye bank using inverted light microscopy seem to correlate with postoperative cornea guttata: The presence of blebs, the presence of cell membrane defects and interruptions, as well as endothelial pictures with less than 50% of the cells having a hexagonal of circular shape. The presence of groups of cells with a distinct whitish color appears to be a weak predictor of cornea guttata.

Mini-Scleral Contact Lens for Asian Eyes Post-Penetrating Keratoplasty with Smaller Palpebral Aperture: Case Reports

PurposeTo report the use of miniscleral contact lenses (MSCLs) with diameter of 14.7 mm for Asian eyes to improve vision in patients after penetrating keratoplasty (PKP) surgery.MethodsTwo patients with high corneal astigmatism post-PKP were evaluated for a contact lens fitting. Visual acuity, slit lamp, and anterior segment OCT findings before and after fitted the lens of 14.7 mm diameter were recorded.ResultsA Kmax of case 1 and 2 were 52.8 D and 76.9 D, respectively at the first visit. Both patients were successfully fit with MSCLs, showing adequate corneal clearance of over 250 μm with no corneal touch on OCT and sufficient limbal clearance and edge alignment. MSCLs use resulted in improved comfort and visual acuity of 20/30 or better.ConclusionMSCLs with diameter of 14.7 mm can be considered a safe and effective option for patients with highly steep corneas post-PKP surgery in Asian eyes.

Non stripping descemet membrane endothelial keratoplasty in difficult cases: A case series

Endothelial keratoplasty (EK) has been increasingly used instead of penetrating keratoplasty (PK) in the management of post PK graft rejection. Both DSAEK and DMEK involve the surgical removal of the diseased host endothelial cell layer and Descemet's membrane (DM) (descemetorhexis) before transplantation, a technically challenging step, especially in post-PK eyes. Understandably, interest arose when non-stripping DMEK (nDMEK) was described in 2013, and recent studies suggested encouraging results without increased early postoperative failures or complications requiring rebubbling. The purpose of our series was to further study the feasibility and safety of nDMEK and to compare the results with traditional DMEK. This is a single center case series of 3 eyes which underwent nDMEK performed by experienced surgeons (C.P, A.M). Two eyes had nDMEK as a secondary procedure following a failed/rejected PK, while the third case underwent nDMEK on a virgin eye. Undiseased donor DM and a regular host endothelium were required to be eligible for nDMEK. The average change in CCT at last follow-up was -21.2% (±13.3). All required intracameral air injection (rebubbling) within the first few days, with a mean of 2.33 rebubblings per eye, the first one occurring at 6.33±2.52 days after surgery. Non-stripping DMEK surgery appears to be a feasible option, and results are satisfactory at mid to long term. However, in our series, the immediate postoperative period was marked by an increased rebubbling rate. While foreseeable particularly in high-risk cases, surgeons considering this technique should expect a higher risk of early rejection.

Acute corneal graft rejection following photorefractive keratectomy for post-penetrating keratoplasty high astigmatism.

Acute corneal graft rejection following photorefractive keratectomy for post-penetrating keratoplasty high astigmatism.