Previous Penetrating Keratoplasty Research Articles

Descemet Stripping Automated Endothelial Keratoplasty After Failed Penetrating Keratoplasty

To report the rate of graft dislocation, surgical anatomic success, and postsurgical complications associated with Descemet stripping automated endothelial keratoplasty (DSAEK) after previous primary failed penetrating keratoplasty (PK). Institutional review board-approved, single-center, retrospective chart review study of 30 eyes of 30 patients with prior failed PK who underwent DSAEK with a minimum of 3 months follow-up. Primary outcomes measured included rates of anatomic success and failure, postoperative complications, lenticle size, visual acuity, intraocular pressure change, and a report of external factors that may affect success. Thirty eyes of 30 patients were identified. The primary dislocation rate was 16.7%. Five primary DSAEKs detached; 1 was successfully rebubbled in the office, 2 had repeat successful DSAEKs, and 2 failed on a second attempt and had a subsequent PK. Despite successful anatomic attachment, 1 eye had primary graft failure, 3 that cleared initially failed within 6 months, and 1 that successfully cleared had subsequent graft rejection resulting in failure at 6 months. The 2 eyes requiring PK were excluded from the visual outcomes analysis, leaving 28 eyes with successfully attached lenticles. At 3 months postoperatively, of the 28 eyes, 19 showed an improvement in visual acuity, 6 had no change in vision from preoperative data, and 1 had worsening of vision (anatomic attachment but endothelial failure). Two of the 28 eyes had no data at that time point. DSAEK eyes after failed PK demonstrated improved vision with a low complication rate in a majority of patients. The graft dislocation rate and postoperative complications rates are comparable with the primary DSAEK dislocation rates in our own published series and in the literature.

Lattice dystrophy complicated by Cryptococcus curvatus infection

AbstractPurpose To present a novel case of Cryptococcus curvatus (CC) keratitis in a patient with Lattice dystrophy (LD).Methods A 57 year old lady with a family history of LD had a right re‐graft for suspected recurrent lattice dystrophy. Her initial penetrating keratoplasty (PK) was in 2004 after which she kept good vision. 5 years later she developed a small ulcer caused by presumable Candida which healed completely following topical miconazole and short course of oral fluconazole. In 6 months she developed gutter, increasing astigmatism, recurrent erosions without inflammation and progressive peripheral opacities leading to a 2nd PK.Results Histology of the 2nd PK revealed amyloid deposits in both host and graft elements confirming recurrent LD. In addition the graft contained numerous yeasts within epithelium and stroma along scars from previous PK. The capsulated fungi were seen on PAS, grocott and mucicarmine stains. No inflammatory response was associated with the fungi. Microbiology confirmed these as (CC). On review of findings from initial infection, it seemed that Cryptococcus instead of Candida was indeed the causative agent of her previous ulcer. Interestingly, she had no history of local trauma prior to her first corneal ulceration and there was never evidence of infection elsewhere. Unfortunately, 2 years after the 2nd PK the graft developed new opacities that lead to a 3rd PK which revealed recurrent (CC) keratitis again without any inflammatory response. The left eye also had a corneal graft in 2009 given her underlying LD and mercifully has never been infected.Conclusion To our knowledge Cryptococcus curvatus keratitis was never described in English literature.In fact, it seems that this is the first description of ocular infection by this species.

Early Ahmed glaucoma valve implantation after penetrating keratoplasty leads to better outcomes in an Asian population with preexisting glaucoma.

BackgroundTo evaluate the efficacy of Ahmed Glaucoma Valve (AGV) surgery and the optimal interval between penetrating keratoplasty (PKP) and AGV implantation in a population of Asian patients with preexisting glaucoma who underwent PKP.Methodology/Principal FindingsIn total, 45 eyes of 45 patients were included in this retrospective chart review. The final intraocular pressures (IOPs), graft survival rate, and changes in visual acuity were assessed to evaluate the outcomes of AGV implantations in eyes in which AGV implantation occurred within 1 month of post-PKP IOP elevation (Group 1) and in eyes in which AGV implantation took place more than 1 month after the post-PKP IOP evaluation (Group 2). Factors that were associated with graft failure were analyzed, and the overall patterns of complications were reviewed. By their final follow-up visits, 58% of the patients had been successfully treated for glaucoma. After the operation, there were no statistically significant differences between the groups with respect to graft survival (p = 0.98), but significant differences for IOP control (p = 0.049) and the maintenance of visual acuity (VA) (p<0.05) were observed. One year after surgery, the success rates of IOP control in Group 1 and Group 2 were 80% and 46.7%, respectively, and these rates fell to 70% and 37.3%, respectively, by 2 years. Factors that were associated with a high risk of AGV failure were a diagnosis of preexisting angle-closure glaucoma, a history of previous PKP, and a preoperative IOP that was >21 mm Hg. The most common surgical complication, aside from graft failure, was hyphema.Conclusions/SignificanceEarly AGV implantation results in a higher probability of AGV survival and a better VA outcome without increasing the risk of corneal graft failure as a result of post-PKP glaucoma drainage tube implantation.

Femtosecond Laser–Assisted Keratoplasty in Failed Penetrating Keratoplasty and Globe Trauma

To demonstrate feasibility and present postoperative outcomes for femtosecond laser-assisted keratoplasty (FLAK) in the setting of previous failed conventional penetrating keratoplasty (PK) and previous open-globe trauma with corneal laceration. In this retrospective case series, data were collected for 12 consecutive patients at the Casey Eye Institute (Oregon Health and Science University, Portland, OR) with the primary diagnosis of either failed PK or open-globe trauma with corneal laceration that underwent zigzag incision FLAK. Outcome measures included topographic astigmatism, best spectacle-corrected visual acuity, uncorrected visual acuity, pinhole visual acuity, intraocular pressure, and timing of selective suture removal (or adjustment) over various follow-up intervals up to 18 months postoperatively. Mean follow-up was 10.42 months. Mean postoperative topographic astigmatism ranged between 3.56 and 6.81 diopters (D). Mean best spectacle-corrected visual acuity (BSCVA) in logarithm of minimal angle of resolution (logMAR) equivalents ranged between 0.18 and 0.61 as compared with 1.28 for preoperative BSCVA (P = 0.0064). Thirty-three percent (4 of 12) of patients had significantly increased intraocular pressure develop during the first year of follow-up that required glaucoma therapy. No adverse events or complications occurred as a result of either the femtosecond laser procedure itself or during the transportation of the patient from the laser suite to the operating room. FLAK is a feasible transplantation technique in the setting of previous failed PK and open-globe trauma with corneal laceration. Significant globe pressure associated with laser applanation did not cause rupture of old corneal wounds among our case series. Postoperative astigmatism is within previous reported limits in the literature under varying suturing techniques. Development of ocular hypertension within 1 year of follow-up was comparable with historically reported rates for PK in the setting of previous trauma and failed grafts.

Endothelial cell loss after phacoemulsification in eyes with previous penetrating keratoplasty, previous deep anterior lamellar keratoplasty, or no previous surgery

To compare phacoemulsification-related endothelial cell loss in eyes with previous penetrating keratoplasty (PKP), previous deep anterior lamellar keratoplasty (DALK), or no previous corneal surgery. Ophthalmology Clinic, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey. Comparative case series. Eyes with previous PKP (Group 1), previous DALK (Group 2), or no previous ocular surgery (Group 3) had extracapsular cataract extraction by phacoemulsification. The endothelial cell count was evaluated 1, 3, 6, and 12 months after cataract surgery. Group 1 comprised 16 eyes and Group 2 and Group 3, 20 eyes each. The endothelial cell density (ECD) decreased progressively throughout the follow-up in all groups (P<.01). The amount of change in ECD was significantly greater in Group 1 than in Group 2 and Group 3 from preoperatively to 1 month postoperatively, from 1 to 3 months postoperatively, from 3 to 6 months postoperatively, and from 6 to 12 months postoperatively (all P<.01). The changes were similar in Group 2 and Group 3 at all time points (P>.05). Eyes with previous PKP had significantly greater endothelial cell loss than eyes with previous DALK or no previous surgery. Preservation of the patient's endothelium seems to be an advantage of DALK in terms of increasing corneal safety in future intraocular surgery. No author has a financial or proprietary interest in any material or method mentioned.

Photorefractive keratectomy with mitomycin-C after corneal transplantation for keratoconus

To evaluate the efficacy of photorefractive keratectomy (PRK) for residual refractive error after penetrating keratoplasty (PKP) for keratoconus. Private ophthalmic clinic. Case series. Consecutive patients who had PRK augmented with topical mitomycin-C (MMC) after PKP for keratoconus were retrospectively reviewed. Patients were divided into a a low cylinder group (refractive cylinder ≤ 6.00 D) and a high cylinder group (refractive cylinder >6.00 D). Visual acuity, refraction, and keratometry were analyzed preoperatively and 1, 3, 6, and 12 months postoperatively. The study comprised 47 eyes (41 patients). The spherical equivalent (SE) decreased from -4.24 D ± 3.23 (SD) preoperatively to -0.71 ± 1.03 D 12 months postoperatively in the low cylinder group and from -4.19 ± 3.54 D to -2.45 ± 3.42 D, respectively, in the high cylinder group. The refractive cylinder decreased from -4.27 ± 1.4 D to -1.71 ± 1.55 D, respectively, in the low cylinder group and from -7.78 ± 1.21 D to -4.6 ± 2.54 D, respectively, in the high cylinder group. By the last follow-up, 8.3% of patients had lost 2 lines of corrected distance visual acuity. There were no cases of corneal haze greater than 2+ or of graft rejection. Penetrating keratoplasty with adjunctive MMC decreased several refractive variables in patients with previous PKP. These results compare well with those in the published literature and suggest PRK is as effective as, and probably safer than, laser in situ keratomileusis in treating refractive error in these cases. No author has financial or proprietary interests in any material or method mentioned.

Descemet's Stripping Endothelial Keratoplasty Under Failed Penetrating Keratoplasty: Visual Rehabilitation and Graft Survival Rate

To evaluate graft survival, risk factors for failure, complications, and visual rehabilitation in patients who underwent Descemet's stripping endothelial keratoplasty (DSEK) under a failed penetrating keratoplasty (PK). Retrospective interventional case series. Sixty eyes (60 patients) treated at Price Vision Group, Indianapolis, Indiana. Graft diameters ranged from 8 to 9 mm and were ∼1 mm larger than the previous PK. The Descemet's membrane was not stripped in the majority (54, 84%). The graft was inserted using forceps or a Busin funnel glide (Moria, Anthony, France). The probability of graft survival was calculated by Kaplan-Meier survival analysis. Graft survival, best-corrected visual acuity (BCVA), and complications. The mean recipient age was 68 years (range, 17-95 years). Forty eyes had 1 previous failed PK, 14 eyes had 2 previous failed PKs, and 6 eyes had 3 previous failed PKs. Thirty-one eyes (52%) had preexisting glaucoma, and 16 eyes (27%) had prior glaucoma surgery (trabeculectomy in 4, shunt procedure in 12). Fifty-five grafts were performed for visual rehabilitation, and 5 grafts were performed for pain relief. Median follow-up was 2.3 years (range, 2 months to 6 years). Median preoperative BCVA was 1.23 logarithm of the minimum angle of resolution (logMAR) (range, 0.2-3, Snellen 20/340), and median postoperative visual improvement was 0.6 logMAR (6 lines), range -0.3 to +2.7. Four eyes had graft detachment (6.6%), 7 eyes (10.5%) had endothelial rejection, and 10 eyes (16.6%) had graft failure (primary failure in 2, secondary failure in 8). The overall secondary graft survival rates were 98%, 90%, 81%, and 74% at 1, 2, 3, and 4 years, respectively. Prior glaucoma shunt was the principal risk factor for graft failure. The graft survival rates were 100%, 96%, 96%, and 96% in eyes without a prior shunt versus 93%, 74%, 44%, and 22% with a prior shunt at 1, 2, 3, and 4 years, respectively (P=0.0005; relative risk = 20). Peripheral anterior synechiae (P=0.14), neovascularization (P=0.88), endothelial rejection (P=0.59), and number of prior PKs (P=0.13) were not independent risk factors for graft failure. Endothelial keratoplasty under a previous failed PK is a useful alternative to a repeat standard PK, particularly in eyes with an acceptable topography and refractive outcome before failure. Proprietary or commercial disclosure may be found after the references.

Endothelial keratoplasty without Descemet's stripping in eyes with previous penetrating corneal transplants

AimsTo evaluate techniques, outcomes and complications of endothelial keratoplasty (EK) without Descemet's stripping in eyes with previous penetrating keratoplasty (PK).MethodsA retrospective, consecutive analysis of patients who underwent EK in eyes...

Retrospective Review of Graft Dislocation Rate Associated With Descemet Stripping Automated Endothelial Keratoplasty After Primary Failed Penetrating Keratoplasty

To report the rate of graft dislocation in patients who underwent Descemet stripping automated endothelial keratoplasty (DSAEK) after a previous penetrating keratoplasty (PKP). Institutional review board-approved, multicenter, retrospective chart review. Inclusion criteria included: prior failed PKP and subsequent DSAEK. The primary outcomes measured in this study were the presence of a graft dislocation, rate of rebubble, and graft attachment. Additional variables included: presence of a prior glaucoma drainage device, graft-to-host size disparity, number of sutures remaining in PKP, and stripping of the Descemet membrane at the time of DSAEK surgery. Ninety patients (97 eyes) were included in the study. In 31% (30 of 97), the endothelial graft dislocated after surgery. All 30 cases required a rebubble except 1, which reattached spontaneously. Ninety-eight percent (95 of 97) of all grafts remained attached for the duration of the follow-up period. Only 2 eyes (2.2%) required repeat graft. Endothelial grafts dislocated in 67% of patients with glaucoma draining devices. The dislocation rate for grafts larger than the host was 12 of 49 (24%), equal to the host was 3 of 17 (18%), and smaller than the host was 8 of 19 (42%). Dislocations occurred in 5 of 21 (24%) of grafts with sutures remaining and 22 of 76 (29%) of those with all sutures out. Five of 12 (42%) cases of grafts performed without stripping the Descemet had dislocations. The graft dislocation rate in DSAEK procedures after PKP is comparable to that after primary DSAEK cases. Donor grafts that are smaller than the host PKP and the presence of prior glaucoma drainage devices are risk factors for higher rates of graft dislocation.

Femtosecond Thin-flap LASIK for the Correction of Ametropia After Penetrating Keratoplasty

To evaluate the outcomes of LASIK with thin femtosecond laser flaps for the treatment of refractive errors after penetrating keratoplasty (PK). Eleven consecutive eyes underwent femtosecond thin-flap LASIK 51.6+/-42.1 months (range: 13 to 156 months) after the initial PK. A full ophthalmic assessment was performed before femtosecond LASIK and 6 months after surgery. Postoperative retreatments were also noted. No intra- or postoperative complications were observed. The outcomes of nine eyes that completed at least 6 months' follow-up and had no retreatment during that period were evaluated. Mean preoperative myopia decreased from -3.60+/-1.60 diopters (D) to +1.00+/-2.70 D 6 months after surgery, and mean hyperopia decreased from +3.50+/-1.30 D preoperatively to +0.30+/-0.70 D 6 months after surgery. Mean preoperative astigmatism decreased from -6.60+/-3.60 D to -2.90+/-2.00 D 6 months after surgery. At 6 months, the mean preoperative myopic spherical equivalent refraction (SE) decreased from -6.40+/-2.00 D to -0.02+/-2.20 D, and mean hyperopic SE from +0.80+/-2.80 D to -0.60+/-0.60 D. At 6 months postoperatively, 67% (6/9) of eyes were within 1 line of preoperative best spectacle-corrected visual acuity and 33% (3/9) gained > or =2 lines. Femtosecond thin-flap LASIK is a safe procedure in eyes with previous PK. This procedure is reasonably predictable, especially for the spherical component of the refraction. Creating the flap with the femtosecond laser and performing excimer laser ablation within the corneal graft limits without involving the graft-host junction provides the advantage of performing the entire procedure in one step.

Long-term Intraocular Pressure Control and Corneal Graft Survival in Eyes With a Pars Plana Baerveldt Implant and Corneal Transplant

To investigate long-term intraocular pressure (IOP) control and corneal graft survival in eyes with a valveless Baerveldt glaucoma drainage implant (GDI) through the pars plana (PP) and a penetrating keratoplasty (PK). We reviewed the medical records of 48 patients (51 eyes) who underwent PP placement of a GDI and a PK between July 1996 and June 2006 at the University of Virginia. The GDI was inserted during the same operation as the PK in 26 eyes (51.0%). Glaucoma control was assessed by IOP and the need for further glaucoma medication or surgery. Corneal grafts were assessed for clarity. Mean follow-up was 38.4 months. IOP was successfully controlled in 88%, 85%, and 82% of eyes at 12, 24, and 48 months, respectively. Corneal grafts were clear in 89%, 67%, and 41% of eyes at 12, 24, and 48 months, respectively. Corneal graft failure was significantly higher in eyes with an anterior chamber intraocular lens (P<or=0.01), and in eyes with a diagnosis of chronic angle closure glaucoma (P=0.04). PP insertion of a valveless GDI tube, in eyes with a previous or concurrent PK, is an effective way to control IOP in eyes with medically uncontrolled glaucoma.

Superficial Keratectomy as a Prelude for Endothelial Keratoplasty in Severe Bullous Keratopathy With Anterior Stromal Scarring

Endothelial keratoplasty is usually contraindicated in end-stage forms of bullous keratopathy with extensive anterior stromal scarring, as a good visual result is not expected. We describe the use of superficial keratectomy as an initial surgical stage in performing successful endothelial keratoplasty in severe bullous keratopathy with anterior stromal scarring in a patient with previous failed penetrating keratoplasty, which resulted in a good visual outcome.

Long-term Outcomes of Keratolimbal Allograft for Total Limbal Stem Cell Deficiency Using Combined Immunosuppressive Agents and Correction of Ocular Surface Deficits

To determine the long-term outcomes of keratolimbal allograft (KLAL). Scores of such risks as infrequent blinking, blink-related microtrauma, conjunctival inflammation, elevated intraocular pressure, dry eye, symblepharon, lagophthalmos, and previous KLAL or penetrating keratoplasty (PKP) failure were calculated and recorded before, during, and after KLAL. Prolonged oral mycophenolate mofetil and tacrolimus and short-term prednisone and acyclovir were administered in 12 eyes (10 consecutive patients) with total limbal stem cell deficiency after KLAL. Ten eyes underwent subsequent PKP. More corrective measures were required in eyes with higher risk scores. During a follow-up of 61.2 months (standard deviation [SD], 18.2; range, 36-91 months) after KLAL, postoperative epithelial breakdown due to exposure occurred late in the period after PKP and remained a primary risk. Mean daily doses of 1.4 g of mycophenolate mofetil and 1.6 mg of tacrolimus were administered for 52.7 months (SD, 22.5; range, 23-91 months) with few adverse effects and reached trough levels of 1.6 microg/mL (SD, 0.6 microg/mL) and 4.5 ng/mL (SD, 2 ng/mL), respectively. Keratolimbal allograft and PKP rejection was noted in 2 and 3 eyes, respectively, though there was a reversal in 1 eye in each group, yielding final KLAL and PKP survivals in 10 and 8 eyes, respectively, and ambulatory visual acuity of up to 20/20 in 10 eyes for 67.2% of the entire follow-up period. Correction of ocular surface deficits combined with an immunosuppressive regimen further improves the long-term outcome of KLAL in eyes with total limbal stem cell deficiency.

Outcomes of LASIK and PRK in Previous Penetrating Corneal Transplant Recipients

To evaluate the safety and efficacy of excimer laser refractive surgery in correcting refractive error in eyes that have undergone previous penetrating keratoplasty (PK). Twenty-three keratorefractive procedures on 16 eyes from 16 consecutive subjects were evaluated between 2002 and 2008. Each patient presented a previous history of a PK with subsequent postoperative myopia and astigmatism. Keratometric value, manifest refraction, best-corrected visual acuity, uncorrected visual acuity, and complications were determined. There were a total of 14 photorefractive keratectomy (PRK) procedures performed on 11 eyes and 9 laser in situ keratomileusis (LASIK) procedures performed on 5 eyes. In the PRK group, the preoperative post-PK manifest refractive spherical equivalent and cylindrical error were -6.22 +/- 6.23 diopter and 5.23 +/- 2.26 D, respectively. The PRK postoperative manifest refractive spherical equivalent and cylindrical error were -3.61 +/- 4.23 D (P=0.25) and 3.21 +/- 1.78 D (P=0.02), respectively. In the LASIK group, the preoperative post-PK manifest refractive spherical equivalent and cylindrical error were -3.05 +/- 3.29 D and 4.11 +/- 2.38 D, respectively. The LASIK postoperative manifest refractive spherical equivalent and cylindrical error were -1.51 +/- 2.02 D (P=0.24) and 2.08 +/- 1.26 D (P=0.03), respectively. There was a 2-line or greater improvement of uncorrected visual acuity in 8 of the 14 PRK treatments and 5 of the 9 LASIK treatments. There were two episodes of acute graft rejection. One of the episodes resolved with topical and oral corticosteroids, and the other episode required a repeat corneal transplantation. PRK and LASIK are effective tools in reducing surgically induced astigmatism after penetrating corneal transplantation in most patients in this case series. The reduction of astigmatism may allow improved contact lens or spectacle fitting to achieve best-corrected binocular visual acuity.

Deep Anterior Lamellar Keratoplasty Over Penetrating Keratoplasty for Host Rim Thinning and Ectasia

To describe the technique and evaluate the outcomes of patients who had deep anterior lamellar keratoplasty (DALK) for ectasia within or outside the graft-host interface in a previous penetrating keratoplasty (PK). Retrospective review of interventional case series. Seven eyes that underwent DALK for corneal ectasia after previous PK. DALK encompassing the area of ectasia and the previous PK. Uncorrected visual acuity, best spectacle-corrected visual acuity, keratometry and topography, and complications. Seven eyes had DALK, 4 developed Descemet membrane tears, and 2 eyes had deep graft-host dehiscence from the previous PK intraoperatively. At 12 months, mean uncorrected visual acuity (logarithm of the minimum angle of resolution) improved from 1.157 to 0.74. Mean best spectacle-corrected visual acuity improved from 0.82 to 0.37 at 12 months. DALK can be successfully performed over a previous PK. Intraoperative Descemet tears or dehiscence of Descemet at the previous graft-host interface can complicate surgery, but if successfully managed can produce a significant improvement in visual acuity.

Deep Anterior Lamellar Keratoplasty on a Previously Failed Full-Thickness Graft

To report a case of deep anterior lamellar keratoplasty (DALK) on a previously failed full-thickness graft in a case of herpetic keratitis. A 70-year-old patient with a history of penetrating keratoplasty for herpetic keratitis performed 30 years ago presented with blurry vision in her left eye. She had corneal stromal scarring secondary to herpetic keratitis. The endothelium was spared. We performed a DALK with big-bubble technique. Postoperatively, corneal edema was noticed initially, which resolved in 3 months. Her best-corrected visual acuity is 6/12 in her left eye. DALK on a previous penetrating keratoplasty is a technical possibility when there is a functioning endothelium.

Femtosecond laser‐assisted penetrating re‐keratoplasty

Editor, Penetrating keratoplasty has usually been performed taking a trephine for the sagittal excision of the corneal donor button and for the preparation of the recipient corneal bed. The disadvantages of this sagittal cutting technique are a lack of rotational stability and a lack of sagittal stability. With the introduction of the femtosecond laser into clinical ophthalmology (Jonas & Vossmerbaeumer 2004; Hoffart et al. 2008; Mastropasqua et al. 2008; Por et al. 2008; Price & Price 2008), a new cutting technique has emerged that offers the possibility of creating non-circular and angled incisions. According to preliminary results, this new technique can markedly reduce postoperative keratoplasty and enhance the overall stability of the wound because of the increased and angled surface of the interface between the graft and the host tissue. Because the femtosecond laser is based on an optical principle with the laser beam penetrating the corneal tissue, it necessitates sufficient transparency of the corneal stroma to allow the laser beam to penetrate to the deep corneal layer and Descemet’s membrane. Previous studies have shown that an intrastromal corneal oedema caused by a corneal endothelial insufficiency has not been an obstacle for the femtosecond laser beam (Hoffart et al. 2008; Por et al. 2008; Price & Price 2008). However, so far it has been unclear whether dense intracorneal scars, particularly after previous corneal surgery, may prevent the use of the femtosecond laser for keratoplasty. Therefore, in this article I report on the feasibility of the technique for a patient who underwent femtosecond laser keratoplasty after a previous keratoplasty had failed. A 48-year-old patient had undergone conventional trephine-guided penetrating keratoplasty as treatment of keratoconus in 1991. The diameter of the graft trephined from the endothelial side was 8.0 mm; the diameter of the excised corneal button in the host cornea was 7.8 mm. The graft was centred onto the optical axis. With an initially clear corneal graft, best-corrected visual acuity was 20/20. Seventeen years after the keratoplasty, the graft started to develop intrastromal oedema, particularly in the late afternoon, because of a progressive age-related insufficiency of the corneal endothelium of the graft. Using a commercially available femtosecond laser (Advanced Medical Optics; Intralase, Santa Ana, California, USA), a penetrating rekeratoplasty was carried out. A top-hat cutting configuration (Price & Price 2008) was chosen. The diameters of the superficial and deep parts were 7.0 mm and 8.5 mm, respectively; a lamellar cut was made at a depth of 250 μm. The lamellar overlapped the superficial part and the deep part by 0.3 mm, so that its outer diameter was 8.8 mm and its inner diameter was 6.7 mm. As per the previous corneal graft, the regraft was centred onto the optical axis. Despite the dense corneal opacities in the zone of the interface between the previous graft and the host cornea, the femtosecond laser was able to cut the corneal tissue unremarkably. The central corneal button precut by the laser could be removed without further use of a knife or scissors. The graft was fixated with a double running suture with buried knots in the interface (Fig. 1). Three months after the intervention, visual acuity was 20/20 with a regular corneal astigmatism of 2.0 dioptres (Fig. 1). Clinical photograph showing an eye 3 months after a femtosecond laser-assisted penetrating homologous keratoplasty 17 years after a previous penetrating keratoplasty. The scar of the interface between the former graft and the recipient cornea (remnants of the former scar: arrows) did not impede the femtosecond laser cutting of the cornea. These results suggest that the femtosecond laser is able to perform incisions in the superficial and deep corneal layers including Descemet’s membrane through dense intracorneal opacities such as scars in the interface after a previous penetrating keratoplasty. A previous keratoplasty is not a contradiction against a femtosecond laser-assisted keratoplasty.

Amniotic membrane transplantation for persistent corneal epithelial defects in eyes after penetrating keratoplasty

To determine the primary success and recurrence rate of amniotic membrane transplantation (AMT) for the treatment of persistent corneal epithelial defects (PEDs) in eyes after penetrating keratoplasty (PK). Retrospective, non-randomized, observational case series. AMT was performed in 24 eyes of 24 patients with erosions (n=6) or ulcers (n=18), which were resistant to medical therapy. All eyes had undergone one (42%) or more PKs before AMT. After the removal of epithelium and pannus (if present), one or more layers of AM ('graft' (n=3), 'patch' (n=5), 'sandwich'=combination of graft/patch (n=16)) were transplanted. Main outcome measures included 'surgical success' (epithelium closed within 4 weeks after AMT), and 'recurrence' (new epithelial defect developing during follow-up after surgical success). The rate of surgical success was 70% and was found to be inversely proportional to the number of previous PKs. Defects limited only to the centre of the graft had a higher success rate (central: 100%, non-central: 61%). A total of 44% successful eyes (erosions: 75% vs ulcers: 33%) had a recurrence after a mean follow-up of 16+/-13 months. The rate of surgical success was highest (81 vs 67 vs 25%) and the rate of recurrence was lowest (38 vs 90 vs 100%) with the sandwich technique in contrast to the graft or patch techniques used alone. AMT may be beneficial in the treatment of PEDs after PK, especially when applying the sandwich technique. Recurrences seem to be more frequent, if PK preceded AMT.

Descemet Stripping and Automated Endothelial Keratoplasty (DSAEK) in Eyes With Failed Penetrating Keratoplasty

To report our results of using Descemet stripping and automated endothelial keratoplasty (DSAEK) in eyes with failed penetrating keratoplasty (PK). An institutional review board-approved, prospective, surgical case series of 7 eyes of 7 consecutive patients undergoing DSAEK for graft failure after 1 or more PKs at 1 academic eye center. The mean follow-up period was 13.3 months (range, 9-18 months). One eye suffered recurrent donor graft dislocation and elected to undergo repeat PK instead of repeat DSAEK. Of the remaining 6 patients, the average preoperative visual acuity (VA) was 20/851 compared with a best-corrected visual acuity (BCVA) of 20/65 postoperatively (P = 0.008). After DSAEK, 6 (100%) eyes showed improved BCVA, and 4 of 6 eyes (67%) achieved a BCVA of 20/40 or better. All 6 grafts remained clear at the last follow-up visit. Two eyes showed graft dislocation on the first postoperative day and underwent repositioning of the lenticule with good results. Two other eyes were diagnosed with primary iatrogenic graft failure within 1 week of DSAEK and underwent repeat DSAEK with new donor tissue with good results. One eye experienced acute graft rejection that was successfully treated with topical steroids. This pilot series of DSAEK in eyes with graft failure from previous PK shows favorable VA and graft clarity outcomes. The complications observed were similar to those observed for DSAEK for Fuchs dystrophy and pseudophakic bullous keratopathy and include graft dislocation, iatrogenic graft failure, and homograft rejection.

Flap-induced Refraction Change in LASIK After Penetrating Keratoplasty

To further analyze the refractive and topographic changes occurring with microkeratome lamellar keratotomy and to investigate possible factors associated in eyes with previous penetrating keratoplasty (PK). The Hansatome microkeratome was used to create a lamellar corneal flap in 21 eyes of 19 patients after PK. The laser ablation was not performed in the first stage. Pre- and postoperative refractions and corneal topographies were compared to evaluate possible changes induced by the keratotomy. Twenty-one eyes were analyzed in this study. Mean time between PK and lamellar keratotomy was 36.63 +/- 28.23 months (range: 12 to 120 months). No microkeratome-related flap complications occurred. Previous to the keratotomy, the mean spherical equivalent refraction was -4.26 +/- 3.41 diopters (D), mean refractive astigmatism was -4.71 +/- 2.27 D, and mean topographic astigmatism was 5.28 +/- 2.94 D. After keratotomy, eyes showed statistically significant changes in spherical equivalent refraction from preoperative values (P = .025), with 3 eyes showing changes > 2.00 D. Average refractive and topographic astigmatism did not change significantly from before to after keratotomy. However, surgically induced astigmatism (SIA) calculated through vector analysis was > 1.01 in 11 (52.4%) eyes. A statistically significant correlation was found between the SIA values and preoperative refractive astigmatism (P = .025). Lamellar keratotomy as part of two-stage LASIK in eyes with prior PK led to refractive changes that justify the use of this technique, especially in eyes with high degrees of preoperative astigmatism.