Repeat Endothelial Keratoplasty Research Articles

Early Outcomes of an Artificial Endothelial Replacement Membrane Implantation After Failed Repeat Endothelial Keratoplasty.

The purpose of this study was to report the outcomes of a novel artificial endothelial replacement membrane implant for treating corneal edema after failed repeat endothelial keratoplasty (EK). This was a retrospective interventional case series. Patients with chronic corneal edema underwent removal of the EK graft and implantation of an artificial endothelial replacement membrane (EndoArt, EyeYon Medical, Israel) several months after 2 or more Descemet stripping endothelial keratoplasty procedures. The implant was secured to the posterior corneal surface using an air-gas bubble. Outcome measures included corrected distance visual acuity (logMAR), central corneal thickness, device-related complications, and ocular discomfort. Five eyes of 5 patients underwent EndoArt implantation. Six months after surgery, the synthetic endothelial replacement membrane was well-centered and adherent to the posterior corneal surface, with improvement in central corneal transparency in all patients. Corrected distance visual acuity increased from mean 1.26 ± 0.25 (logMAR) preoperatively to 0.74 ± 0.44 (logMAR) postoperatively (P = 0.06). Central corneal thickness significantly decreased from a mean of 805 ± 135 μm (excluding the EK graft) preoperatively to 588 ± 60 μm (excluding the EndoArt) postoperatively (P = 0.015). No severe device-related complications developed after surgery, although most patients required more than 1 air-gas bubble injection to achieve complete implant adhesion. All patients experienced preoperative reduction in subjective ocular pain. Synthetic endothelial replacement membrane implantation improves central corneal transparency and visual acuity in patients with failed EK and guarded prognosis for repeat keratoplasty. No significant implant-related adverse events occurred after surgery.

Association Between Indication for Descemet Stripping Automated Endothelial Keratoplasty and Rural Residency.

Residing in rural locations can be a barrier to health care access. This study investigated the impact of residing in rural and small town (RST) areas on Descemet stripping automated endothelial keratoplasty (DSAEK) indications and outcomes in Atlantic Canada. A retrospective cohort analysis examined consecutive DSAEKs performed in Nova Scotia between 2017 and 2020. Patient rurality was determined by the Statistical Area Classification system developed by Statistics Canada. Univariate and multivariate logistic regression models were used to assess for factors associated with DSAEK indication, including repeat keratoplasty, RST residence status, and travel time. Of 271 DSAEKs during the study period, 87 (32.1%) were performed on the eyes of RST residents. The median postoperative follow-up time was 1.6 years. Undergoing DSAEK for a previous failed keratoplasty was not associated with a higher odds of RST residency (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.19-1.16; P = 0.13) but was associated with travel time (OR, 0.78 for each increasing hour of travel; 95% CI, 0.61-0.99; P = 0.044). RST residency was not associated with the occurrence of graft failure (OR, 0.48; 95% CI, 0.17-1.17; P = 0.13). Residing in a rural area in Atlantic Canada was not associated with DSAEK graft failure. Repeat endothelial keratoplasty was associated with shorter travel time for corneal surgery but not rural residency status. Further research in this field could inform regional health strategies aimed at improving equity and accessibility to ophthalmology subspecialist care.

Reticular Epithelial Edema in a Postkeratoplasty Eye Due to Ripasudil.

A 34-year-old female underwent phacoemulsification with Descemet stripping endothelial keratoplasty (Supplementary Digital Content, Fig. 1A, B, http://links.lww.com/APJO/ A132) under a failed previous therapeutic penetrating keratoplasty. The visual acuity was restored to 20/50. At 2 years postoperative period, she developed raised intraocular pressure of 30 mm Hg despite being on 2 antiglaucoma medications, and hence ripasudil was initiated as an additional antiglaucoma medication. The endothelial cell density was 920 cells/mm.1Figure 1: Slitlamp image (A) and anterior segment optical coherence tomography (B) illustrating reticular edema in superficial cornea after 4 months of ripasudil use.Her intraocular pressure at 1 month of starting ripasudil was 12 mm Hg. Subsequently, 3 months later, she presented with counting finger vision, honeycomb edema in the superficial cornea (Fig. 1). Ripasudil was discontinued and 1 month later, although the epithelial net-like pattern disappeared, the graft was diffusely edematous and failed to recover the clarity until a follow-up of 3 months (Supplementary Digital Content, Fig. 1C, D, http://links.lww.com/APJO/A132) when repeat endothe-lial keratoplasty was planned. Rho kinase inhibitors have gained popularity in the management of glaucoma and corneal endothelial diseases.2 Ripasudil and netarsudil are Rho kinase inhibitors approved for clinical use. Reticular bullous epithelial edema has been reported with the use of 0.02% netarsudil, which improves in some eyes after the medication is discontinued.1 In our patient, similar pattern of edema was noted with 0.4% ripasudil after 4 months of treatment, which failed to resolve on discontinuing ripasudil. The reticular epithelial edema during ripasudil treatment should be distinguished from graft rejection. The medication should be stopped promptly if cornea edema is noted. The likelihood of nonclearance of edema should be explained to the patients.

Fungal Infection After Descemet Membrane Endothelial Keratoplasty: Incidence and Outcomes.

The aim of the study was to describe the incidence, presentation, management, and outcomes of fungal infection after Descemet membrane endothelial keratoplasty (DMEK). Retrospective case series of culture-proven fungal infections after DMEK reported in the literature, directly by surgeons, and to the Eye Bank Association of America from January 1, 2011, to December 31, 2020. The domestic incidence of fungal infections, fungal keratitis, and fungal endophthalmitis after DMEK from 2011 to 2020 was 3.5, 1.3, and 2.2 per 10,000 cases, respectively, with no significant increasing trend. Thirty-four cases were identified, 14 (41.2%) published and 20 (58.8%) unpublished. Donor tissue fungal cultures were performed in 20 of the 34 (58.8%) cases and were positive in 19 of the 20 (95.0%), all but one Candida species. Recipient fungal cultures were performed in 29 of the 34 (85.3%) cases and were positive in 26 of the 29 (89.7%), all but one Candida species. Infection presented a mean of 33 ± 38 days (median 23, range 2-200, outlier 949) after transplantation: 25 (73.5%) with endophthalmitis and 9 (26.5%) with keratitis. Topical, intrastromal, intracameral, intravitreal, or systemic antifungal therapy was used in all 27 eyes with treatment data. Surgical intervention (DMEK explantation or partial removal, repeat endothelial keratoplasty, penetrating keratoplasty, and/or pars plana vitrectomy) was required in 21 of the 27 (77.8%) eyes. The corrected distance visual acuity at the last follow-up was ≥20/40 in 13 of the 27 (48.1%) eyes and counting fingers or worse in 6 of the 27 (22.2%) eyes. Fungal infection is a rare but serious complication of DMEK that results in counting fingers or worse corrected distance visual acuity in nearly a quarter of eyes.

Modified dagger-tip Sheets glide to facilitate 2-point fixation across the anterior chamber in aniridic aphakic eyes.

Presented is a modified technique for removing a failed endothelial allograft in an aniridic aphakic eye that reduces the risk of posterior dislocation. This technique involves the creation of an artificial iris plane using a Sheets glide by trimming it into the shape of a dagger so that it can be pulled through the anterior chamber and fixated by both its passage through a paracentesis incision and the main incision. The Sheets glide then acts as a physical barrier, or scaffold, to allow safe removal of the failed endothelial allograft and subsequent repeat endothelial keratoplasty while avoiding posterior dislocation of the tissue into the vitreous cavity.

DMEK in Super-Seniors: Clinical Outcomes of Descemet Membrane Endothelial Keratoplasty Performed in Patients ≥ 90 Years Old

ABSTRACT Purpose/Aims of the study To evaluate the clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed in the “oldest old” patients, i.e. ≥ 90 years. Materials and Methods Between the years of 2009 and 2019, 20 consecutive eyes of 17 patients aged ≥ 90 underwent DMEK for endothelial dysfunction. Best corrected visual acuity (BCVA), central corneal thickness (CCT), endothelial cell density (ECD), graft survival, and intra- and postoperative complications were assessed. Results Except in one case in which the DMEK surgery could not be completed, all operated eyes experienced an improvement in BCVA, although only 50% achieved ≥ 20/40 (0.5) by 1 year postoperatively. One year after surgery, median CCT had declined from 641(±161) μm to 480 (±34) μm, and median endothelial cell density was reduced by 53%, from 2574 (±286) to 1226 (±404) cells/mm2. Six of 19 eyes receiving DMEK grafts (32%) developed partial graft detachments requiring re-bubbling. One eye experienced a secondary graft failure at 6 months and underwent repeat endothelial keratoplasty. Conclusion DMEK is technically feasible in the oldest old patients and may yield significant visual improvements, although an elevated risk of some postoperative complications including graft detachment with corresponding need for re-bubbling may be anticipated.

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

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

Endothelial Keratoplasty Without Descemet Stripping After Failed Penetrating Keratoplasty

To evaluate outcomes of endothelial keratoplasty (EK) without Descemet membrane stripping for treatment of failed penetrating keratoplasty (PKP). Retrospective cohort study of all eyes that underwent EK without Descemet membrane stripping for failed PKP at one institution between May 2008 and June 2010, with follow-up to 12 months. Main outcome measures were best-corrected visual acuity (BCVA), dislocation rate, and graft failure. Twenty-two eyes of 22 patients underwent non-Descemet stripping EK with a mean follow-up of 8.8 months (±3.41; range, 3-12 months). The mean preoperative BCVA was logarithm of the minimum angle of resolution (logMAR) 1.43 (±0.72; range, 0.3-3; Snellen, 20/537; N = 22). The mean postoperative BCVA was logMAR 0.97 (±0.88; range, 0-3; N = 21) at 1 month, 0.76 logMAR (±0.74; range, 0.1-3; N = 21) at 3 months, 0.75 (±0.77; range, 0-3; N = 17) at 6 months, and logMAR 0.55 (±0.38; range, 0.18-1; Snellen, 20/70; N = 9) at 1 year. Eight eyes (36.6%) had graft dislocations requiring one rebubbling procedure in 6 of 8 eyes and 2 rebubblings in the other 2 eyes. All grafts were successfully reattached. Graft failure occurred in 2 of 22 eyes (9%), with 1 eye (5%) undergoing repeat EK and 1 eye (5%) undergoing PKP. EK without Descemet membrane stripping is an effective option for management of eyes with failed PKP and may be a preferable alternative to a repeat PKP.

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

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

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

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

Corneal Regrafting After Endothelial Keratoplasty

To determine the incidence of corneal regrafting after endothelial keratoplasty (EK) and to explore the possible reasons for repeat EK and subsequent penetrating keratoplasty (PK). This retrospective cohort study examined the occurrence of corneal regrafts among 803 eyes of 751 patients who underwent initial EK from January 2004 through February 2009 using donor corneas distributed by a single eye bank. Regression models and life tables evaluated the effects of donor corneal characteristics on the probability of a regraft. Corneal regrafting after EK occurred in 119 eyes (15%), including 68 with repeat EK and 51 with subsequent PK. Ninety-five regrafts (80%) occurred within 1 year of EK, with 39 (33%) during the first postoperative month. Three years after EK, the cumulative probability of repeat EK was 11% and was 9% for subsequent PK. The secular trend in regrafting indicated an average 4% decline per year from 2005 to 2008. The odds of regrafting occurred less often (P = 0.004) with 202 eye bank-processed corneas than with 601 surgeon-prepared tissues. The cumulative probability of repeat EK was increased if donor corneas were maintained in preservation medium for more than 7 days (P = 0.02). Older donor age, death-to-preservation interval, or lower endothelial density was not significantly associated with repeat keratoplasty. Regrafting after EK is becoming less common, possibly because of surgical experience and technical innovations such as eye bank processing of precut tissues. Timely screening and distribution of donor corneas may foster graft survival.

Secondary Graft Failure and Repeat Endothelial Keratoplasty after Descemet's Stripping Automated Endothelial Keratoplasty

To identify the causes of secondary graft failure after Descemet's stripping automated endothelial keratoplasty (DSAEK) and to evaluate the clinical outcomes of repeat endothelial keratoplasty (REK) in this patient population. Retrospective case series. Patients of a private practice Price Vision Group in Indianapolis, Indiana. An initial consecutive series of primary DSAEK procedures performed by a single surgeon between October 2004 and December 2008 was reviewed to identify reasons for and outcomes of REK. Visual acuity and causes of secondary graft failure. In a consecutive series of 1050 primary DSAEK procedures, REK for secondary graft failure was performed in 37 eyes (3.5%). The most common reason for REK in this group was unsatisfactory visual acuity relative to the anticipated vision potential (n = 28/37; 76%). Unsatisfactory visual acuity was associated with abnormalities of donor tissue within the pupillary area, including wrinkles or folds, irregular graft thickness, and opacity in the interface. In the 28 eyes with unacceptable visual acuity after initial DSAEK, the median best spectacle-corrected visual acuity (BSCVA) before and after REK was 20/60 (range, 20/40-20/400) and 20/30 (range, 20/20-20/100), respectively, and 75% had BSCVA 20/40 or better after REK. The mean corneal thickness in the 28 eyes regrafted for unsatisfactory vision before and after REK was 809 μm (range, 642-979 μm) and 657 μm (range, 549-801 μm), respectively. Secondary graft failure caused by endothelial decompensation was the reason for repeat endothelial graft in the remaining 9 eyes (9/37; 24%). Eight eyes had a history of glaucoma, and 6 of them had glaucoma surgery. An episode of immune rejection reaction was documented in 6 of 9 eyes with endothelial decompensation. Our data suggest that the most common reason for REK after DSAEK is unsatisfactory vision. Patient and physician expectations for visual acuity are higher with DSAEK compared with penetrating keratoplasty. Repeat endothelial keratoplasty can provide improved vision in selected patients.

Histopathology of Posterior Lamellar Endothelial Keratoplasty Graft Failure

To describe the histopathologic findings and relevant clinical details of 3 patients undergoing penetrating keratoplasty (PK) after failure of posterior lamellar endothelial keratoplasty (EK). Retrospective clinicopathologic case series. Patients 1 and 2 underwent EK for pseudophakic bullous keratopathy. Patient 3 underwent EK for persistent corneal edema secondary to a Descemet membrane (DM) detachment after cataract extraction. Patient 1 had persistent diffuse corneal edema and broad, long-standing iridocorneal adhesions that precluded repeat EK. Patient 2 had high intraocular pressure and severe anterior chamber inflammation 1 day postoperatively with subsequent noncorneal clearing and elected PK over repeat EK. Progressive corneal edema with resultant poor visual acuity after EK was the reason for PK in patient 3. Histopathologic examination disclosed thickened, edematous corneas with attenuated endothelium consistent with graft failure caused by endothelial decompensation in all 3 cases. Although various degrees of posterior lamellar graft detachment were observed in each instance, significant parts of each graft remained adherent to the host stroma or to segments of residual host DM. The wounds in the adherent areas, although discernible, were relatively inconspicuous, resembling those seen at the flap-stromal interface after laser in situ keratomileusis. The donor graft endothelium was atrophic in all cases, and a delicate retrocorneal fibrous membrane was present in 2 cases. Most of the graft in cases 1 and 2 remained adherent, with small areas of peripheral detachment. In contrast, the graft in case 3 adhered peripherally but had separated from the stroma centrally, forming a thin cleft. Histopathology suggests endothelial decompensation, incomplete graft adherence, and the formation of retrocorneal fibrous membranes as possible etiologies for EK failure. The adherence of endothelial grafts to residual host DM suggests that it may not be necessary to remove optically clear DM before endothelial graft placement. The inconspicuous nature of the EK interface suggests that it may not play a large role in image degradation, although more study is needed.