Treatments for Ocular Diseases in Pregnancy and Breastfeeding: A Narrative Review.

Pregnancy is a medical condition in which the physiological changes in the maternal body and the potential impact on the developing fetus require a cautious approach in terms of drug administration. Individual treatment, a thorough assessment of the extent of the disease, and a broad knowledge of the therapeutic options and different routes of administration of ophthalmic drugs are essential to ensure the best possible results while minimizing risks. Although there are currently several routes of administration of drugs for the treatment of eye diseases, even with topical administration, there is a certain amount of systemic absorption that must be taken into account. Despite continuous developments and advances in ophthalmic drugs, no updated data are available on their safety profile in these contexts. The purpose of this review is both to summarize the current information on the safety of ophthalmic treatments during pregnancy and lactation and to provide a practical guide to the ophthalmologist for the treatment of eye diseases while minimizing harm to the developing fetus and addressing maternal health needs.

High Astigmatism Secondary to Peripheral Ectasia Recurrence in Postpenetrating Keratoplasty Eyes Managed With Miniscleral Contact Lenses.

OBJECTIVES: After penetrating keratoplasty (PK) for keratoconus, vision can be impaired by high-degree astigmatism, particularly in those patients with recurrent peripheral ectasia. Scleral contact lenses (CLs) have long been used in the management of keratoconus both in treatment-naive corneas and those postcorneal transplants. We report the use of miniscleral CLs and their related visual and clinical outcomes in a series of patients with post-PK peripheral rim ectasia. METHODS: In this retrospective case series, 5 patients (7 eyes) presented because of reduced visual acuity with their spectacles/CLs and/or reduced comfort with their existing rigid gas-permeable lenses. All patients in this series underwent PK more than two decades ago for keratoconus (mean 28.7 years±7.2). All patients demonstrated characteristic thinning at the graft-host junction, with anterior chamber deepening. Central corneas had remained clear in all patients inferring high visual potential. Contact lenses used were No 7 Comfort 15 miniscleral and the Onefit MED scleral with 14.5 mm and 15.6 mm diameters, respectively. RESULTS: All eyes achieved a best-corrected visual acuity of 6/9 or greater. One case had difficulty with insertion and removal and has since discontinued wearing lens at this time. All others are successfully wearing the lenses regularly. CONCLUSION: Despite advances in CL design, surgical management is still required in some patients. Miniscleral CLs are effective in the refractive management of peripheral ectasia in keratoconic post-PK eyes and should be considered in such eyes before proceeding with repeat surgical intervention.

Safety and clinical outcomes of omitting same and next day review after DMEK performed with an inferior peripheral iridotomy.

BACKGROUND/OBJECTIVES: To determine the incidence of day one postoperative complications after Descemet Membrane Endothelial Keratoplasty (DMEK) performed with intraoperative inferior peripheral iridotomy (PI), and whether their early detection influences postoperative intervention. SUBJECTS/METHODS: 70 eyes of 70 consecutive patients that underwent DMEK from August 2019 to August 2021 at a single UK centre were retrospectively analysed. Cases that did not have an inferior PI were excluded. Any action taken at day one and week one postoperative review was noted. RESULTS: No pupil block or other major adverse events were found at day one review. At one week, 14 eyes (20%) required re-bubbling, all of which had been fully attached at the day one review. CONCLUSIONS: This series suggests that inferior PI performed alongside DMEK alone or triple DMEK effectively minimizes the risk of pupil block. Since no early complications occurred in this cohort requiring immediate intervention, it may be safe to defer review of these patients to a later time point.

High Astigmatism After Conventional Diameter Deep Anterior Lamellar Keratoplasty in Keratoconus Can Be Successfully Managed With Repeat Wide Diameter Deep Anterior Lamellar Keratoplasty.

PURPOSE: The aim of this study was to describe a new surgical technique to replace a conventional diameter (≤8 mm) deep anterior lamellar keratoplasty (DALK) graft with associated high astigmatism refractory to corneal-based astigmatic procedure/intolerance to contact lenses with a larger diameter (≥9 mm) DALK graft to improve best spectacle-corrected visual acuity (BSCVA). METHODS: Two eyes from 2 keratoconic patients at Southend University Hospital between December 2019 and June 2021 with a minimum follow-up of 17 months were evaluated. The primary outcome of interest was Snellen BSCVA with a secondary outcome of topographic cylinder. RESULTS: Patient 1 had undergone initial 8 mm diameter DALK, with residual keratometric astigmatism of nearly 12 diopters (D) postoperatively despite numerous astigmatic interventions, with a BSCVA of 6/60, before undergoing 9 mm diameter repeat modified DALK. After suture removal and subsequent in-the-wound blunt manual relaxing incisions, the patient had a final keratometric astigmatism of 3.5 D, manifest refraction of plano/-3.50 × 175, and a BSCVA of 6/9. Patient 2 had undergone initial 7.75 mm diameter DALK, with residual keratometric astigmatism of 10.5 D with a BSCVA of counting fingers. The patient underwent 9 mm repeat modified DALK with final residual keratometric astigmatism of 3.1 D after suture removal, manifest refraction of -1.00/-2.75 × 25, and BSCVA of 6/9. CONCLUSIONS: Wide diameter DALK (>9 mm) is effective in the management of conventional diameter DALK (≤8 mm) associated high astigmatism in keratoconus. Creation of a peripheral posterior stromal shoulder also allows safe further titration of residual astigmatism if needed.

Intravitreal dexamethasone to manage post endothelial keratoplasty cystoid macular oedema refractory to topical therapy.

BACKGROUND/OBJECTIVES: To describe the visual and clinical outcomes of patients with post endothelial keratoplasty (EK) cystoid macular oedema (CMO) refractory to topical treatment with intravitreal sustained-release dexamethasone implant (Ozurdex). SUBJECTS/METHODS: 131 eyes from 111 patients undergoing solitary or combined EK (52 DSAEK (40.0%) and 79 DMEK (60.0%)) at Southend University Hospital between January 2020 and February 2022 with a minimum follow-up of 6 months were evaluated. Patients suspected of having CMO underwent spectral-domain macular optical coherence tomography (SD-OCT) Patients with diabetes were not included in this series. RESULTS: CMO was identified in 5.3% (n = 7) of cases, with 2 of these patients responding to topical corticosteroid treatment. The remaining 5 patients underwent intravitreal dexamethasone implant, with 1 patient requiring repeat implant due to CMO recurrence. All presented within 2 months postoperatively. 4 out of 5 eyes treated with intravitreal dexamethasone achieved a Snellen BCVA ≤6/9.5. 1 patient had an uncontrolled rise in intraocular pressure (IOP) despite maximal medical treatment requiring an urgent PreserFlo Ab-Externo MicroShunt. CONCLUSIONS: The use of intravitreal sustained-release dexamethasone implant in the management of post EK CMO refractory to topical therapy is effective and safe in most cases, but patients should be monitored and treated promptly for any secondary IOP response.

Analysis of microbial keratitis incidence, isolates and in-vitro antimicrobial susceptibility in the East of England: a 6-year study.

BACKGROUND/OBJECTIVES: To report the incidence, microbiological profile and in-vitro antimicrobial susceptibilities of microbial keratitis (MK) in the East of England (EoE) over a 6-year period. SUBJECTS/METHODS: A retrospective study of patients diagnosed with MK who underwent corneal scraping at participating trusts, within the EoE, between 01/01/2015-01/07/2020. Analysis was performed on MK isolate profiles, in-vitro anti-microbial sensitivities and trends over time. RESULTS: The mean incidence of IK, in the EoE, was estimated at 6.96 per 100 000 population/year. 1071 corneal scrapes were analysed, 460 were culture positive (42.95%) of which 87.2% were bacteria (50.3% gram-positive and 49.7% gram-negative), 2.4% polymicrobial, 9.3% fungi and 1.1% acanthamoeba. The most common organisms were pseudomonas spp (29.57%). There was a non-statistically significant trend (NST) in increasing incidence of pseudomonas spp, staph aureus and serratia (p = 0.719, p = 0.615, and p = 0.099 respectively) and a declining NST in Fungi (p = 0.058). Susceptibilities in-vitro to, penicillin classes, fluoroquinolone and aminoglycosides were 76.7% and 89.4%, 79.2% and 97.2% and 95.4 and 96.1% to gram-positive and gram-negative bacteria respectively. Gram-negative organisms were increasingly resistant to cephalosporins with a 19.2% reduction in sensitivity over time. (p = 0.011). Ceftriaxone showed the greatest decrease in sensitivity of 41.67% (p = 0.006). CONCLUSION: In the EoE, MK is relatively prevalent though likely underestimated. Profiles are similar to other UK regions with the exception of a higher fungal and lower acanthamoeba incidence. Common first and second-line antimicrobial selection provides, on the whole, good coverage. Nevertheless, anti-microbial resistance, to cephalosporins, was observed so selection should be carefully considered when treating MK empirically.

Factors predictive of cystoid macular oedema following endothelial keratoplasty: a single-centre review of 2233 cases.

AIMS: To describe the incidence of postoperative cystoid macular oedema (CMO) after endothelial keratoplasty (EK) and to identify its contributory risk factors. METHODS: 2233 patients undergoing EK at Ospedali Privati Forlì 'Villa Igea', between January 2005 to October 2018 for Descemet stripping automated endothelial keratoplasty (DSAEK) and June 2014 to August 2018 for Descemet membrane endothelial keratoplasty (DMEK) with a minimum follow-up of 18 months were evaluated. Univariate and multivariate analyses were conducted to identify and quantify contributory risk factors. Receiver operating characteristic (ROC) curve analysis were performed to determine ideal cut-off points of continuous variables. RESULTS: CMO was identified in 2.82% (n=63) of the cases. CMO occurred in 2.36% of DSAEK eyes and in 5.56% of DMEK eyes (p=0.001). Average onset of CMO was 4.27±6.63 months (range: 1-34 months) postoperatively. Compared with those who did not develop CMO, a higher proportion of patients in the CMO group had diabetes (24.2% vs 9.8%, p<0.001) (OR=3.16, 95% CI: 1.72 to 5.81, p<0.001), a higher proportion of patients who underwent DMEK rather than DSAEK (28.6% vs 14.1%, p=0.001) (OR=2.42, 95% CI: 1.35 to 4.33, p=0.003) and were older (70.5±10.0 vs 67.1±14.3 years, p=0.01). Using the cut-off of 67 years as identified by ROC curve analysis, subjects aged >67 years (OR=2.35, 95% CI: 1.30 to 4.26, p=0.005) were more likely to develop CMO. There were no other significant differences between the groups. CONCLUSIONS: Older age (>67 years), diabetes mellitus and DMEK have been identified as independent risk factors for postoperative CMO following EK. Close observation is necessary during the first postoperative year after EK, particularly in patients with risk factors.

A lack of an association between COVID-19 vaccination and corneal graft rejection: results of a large multi-country population based study.

PURPOSE: The aim of the study was to present the rates of corneal transplant rejection from 2018 to 2022 at both Moorfields Eye Hospital UK, and Ospedali Privati Forli (OPF) "Villa Igea", Italy and evaluate the purported association between COVID-19 vaccination and rejection. METHODS: We performed a retrospective review of rejection cases presenting to the two units. Monthly rates were correlated against regional vaccination programme rates. At OPF, conditional Poisson regression model was employed to estimate the incidence risk ratio (IRR) of graft rejection following COVID-19 vaccination risk period compared with the control period. RESULTS: Between January 2018 and March 2022, there were 471 (Moorfields), 95 (OPF) episodes of rejection. From the start of vaccination programme in the UK in late January 2021, the median number of graft rejections per month at Moorfields was 6 (range: 5-9), which was not significantly different to post-lockdown, pre-vaccination programme (March 2020-January 2021), p = 0.367. At OPF, the median rates of rejection before and after initiation of the vaccination programme were not significantly different (p = 0.124). No significant increase in incidence rate of rejection in the risk period following COVID-19 vaccination was found (IRR = 0.53, p = 0.71). CONCLUSION: No notable increase in rates of transplant rejection was noted in year 2021 when COVID-19 vaccination was broadly implemented. The apparent temporal relationship between COVID-19 vaccination and corneal graft rejection highlighted in several case reports may not represent a causative association.

Selective Laser Trabeculoplasty for Steroid-Induced Ocular Hypertension following Endothelial Keratoplasty.

Purpose: To examine the safety and efficacy of selective laser trabeculoplasty (SLT) in patients responding to topical steroids with elevated intraocular pressure following endothelial keratoplasty.Methods: Patients that underwent Descemet Membrane Endothelial Keratoplasty (DMEK) or Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) were offered SLT as first-line therapy if they presented with steroid response and met inclusion criteria. Patient demographics, best-corrected visual acuity (BCVA), steroid and glaucoma regimens were recorded before and after SLT.Results: Twelve eyes of eight patients were recruited to the study. All patients demonstrated a reduction in IOP and only one patient remained on anti-glaucoma drops after SLT. The mean (±SD) reduction in IOP following SLT was 8.8 (±4.9) mmHg (p < 0.0001). BCVA remained stable and no adverse events following treatment were observed.Conclusions: SLT may be a safe and effective treatment option that reduces topical antihypertensive burden while allowing continuance of corticosteroids in steroid-responsive eyes at high risk of rejection following endothelial keratoplasty. Larger randomized studies are needed to compare SLT efficacy with topical medication in this patient group and to review any impact on graft survival and glaucoma progression.

Stromal peeling for deep anterior lamellar keratoplasty in post-penetrating keratoplasty eyes.

BACKGROUND/AIMS: To evaluate the clinical outcomes of deep anterior lamellar keratoplasty performed by stromal peeling in eyes that have previously undergone penetrating keratoplasty (PK) for keratoconus. METHODS: Standardised stromal exchange included (1) 9 mm trephination of the recipient bed outside the old PK wound, (2) creation of a partial anterior corneal flap through lamellar dissection across the PK wound, (3) opening the stromal component of the old PK wound using blunt-tipped Vannas scissors until a plane of separation is reached, (4) severing the attachment of the PK surgical scar from the recipient host, (5) peeling the stroma of the PK graft from the underlying tissue and (6) suturing the donor anterior corneal lamella prepared by microkeratome dissection (450 µm depth, 9 mm diameter). Main outcome measures were success rate, best spectacle-corrected visual acuity (BSCVA) and endothelial cell loss (ECL). RESULTS: Of 21 post-PK eyes, stromal exchange succeeded in all but three cases, which were converted to a two-piece mushroom PK. After complete suture removal, mean BSCVA significantly improved from 0.95±0.39 logMAR preoperatively to 0.23±0.17 logMAR (p<0.001). Mean ECL was 5.4±23.2%. Double anterior chamber formation occurred in eight cases (44%), which all resolved after a single re-bubbling. CONCLUSION: In post-PK eyes, stromal exchange can be performed by means of simple peeling without deep anterior lamellar dissection of the previous PK graft. Large-diameter (9 mm) repeat keratoplasty through stromal peeling yields excellent visual outcomes and minimal ECL. Double anterior chamber formation may complicate the postoperative course, but prompt intervention allows successful management.

Sutureless Tectonic Mini-Descemet's Stripping Automated Endothelial Keratoplasty ("mini-DSAEK") for the management of corneal perforations.

PURPOSE: To report the outcomes of a new technique, pull-through sutureless 'mini-DSAEK', to manage corneal perforations secondary to different aetiologies including trauma, neurotrophic ulcer following penetrating keratoplasty (PK), herpes simplex keratitis and microbial keratitis. METHODS: In this retrospective case series, we report the clinical outcomes of five cases of sutureless tectonic mini-DSAEK performed in patients presenting with large corneal perforations to Southend University Hospital between November 2019 and October 2020. One corneal perforation was sufficiently peripheral for the tectonic mini-DSAEK graft to be successfully positioned outside of the central visual axis. Four corneal perforations were central or paracentral for which the tectonic grafts involved the visual axis. RESULTS: Anterior chambers remained deep and formed with no evidence of leak in all subsequent follow ups in all patients representing 100% tectonic success. All tectonic grafts remained attached except one partially detached graft. One patient underwent uneventful phacoemulsification with intraocular lens implant 8 months after the primary intervention with excellent visual outcome. Two patients underwent two-piece mushroom PK and one patient underwent triple procedure (cataract extraction + intraocular lens + PK) for visual rehabilitation 2-6 months after the primary intervention with good visual outcome. CONCLUSION: Sutureless tectonic pull-through mini-DSAEK is a useful technique in the management of corneal perforations, with a number of advantages compared with conventional techniques.

Long-Term Outcomes of Two-Piece Mushroom Keratoplasty for Traumatic Corneal Scars.

PURPOSE: To report the outcomes of 2-piece microkeratome-assisted mushroom keratoplasty (MK) for eyes with full-thickness traumatic corneal scars and otherwise functional endothelium following corneal penetrating injury. DESIGN: This was an interventional case series. METHODS: In this single-center study, 41 consecutive eyes with traumatic corneal scars that underwent 2-piece microkeratome-assisted mushroom keratoplasty were evaluated. The 2-piece mushroom graft consisted of an anterior lamella 9 mm in diameter and a posterior lamella 6 mm in diameter. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, and postoperative complication rates. RESULTS: Of the 41 total cases, 38 eyes (93%) reached Snellen vision ≥20/100, 36 (88%) reached ≥20/60, 29 (71%) reached ≥20/40, and 13 (32%) reached ≥20/25 2 years following MK. Excluding eyes with vision-impairing comorbidities, baseline logMAR BSCVA (1.41 ± 0.73) significantly improved annually during the first 2 years (P < 0.001), reaching 0.16 ± 0.13 at year 2, which subsequently remained stable up to 10 years (P = .626). The RA exceeded 4.5 diopters in 2 cases (5%) after wound revision for high-degree astigmatism in 5 cases. Endothelial cell loss was 35.1% at 1 year, with an annual decline of 2.9% over 10 years. Elevation in IOP was observed postoperatively in 7 eyes, of which 6 had pre-existing glaucoma. The 10-year cumulative risk for graft rejection and failure was 8.5% and 10%, respectively. CONCLUSION: Two-piece microkeratome-assisted MK for traumatic corneal scars can allow excellent visual rehabilitation with relatively stable ECL and low rates of immunologic rejection and graft failure.

Early Endothelialization of Ab Interno Stromal Tectonic Patch in the Management of Corneal Perforation Secondary to Bacterial Keratitis.

PURPOSE: The purpose of this study was to describe a novel surgical technique using an ab interno stromal patch to treat corneal perforation and to present the histological findings of the patch after its removal during definitive mushroom keratoplasty. METHODS: The endothelium had already been removed with the submerged cornea using backgrounds away (SCUBA) technique. RESULTS: The patient was managed successfully with a sutureless ab interno stromal tectonic patch. Two months later, definitive mushroom keratoplasty was performed and the patch was sent for histological examination. Immunohistochemistry revealed a reactive endothelium covering the posterior surface of the graft. Nine months later, her best-corrected visual acuity was 6/9. CONCLUSIONS: This is the first case to our knowledge demonstrating that stromal tectonic grafts without the endothelium can successfully attach to the host tissue and seal a perforation. The stroma may undergo reendothelialization and begin to restore vision, even before penetrating keratoplasty.

Ultrastructural Alterations of Grafted Corneal Buttons: The Anatomic Basis for Stromal Peeling Along a Natural Plane of Separation.

PURPOSE: To examine the ultrastructure of the natural plane of separation in grafted corneas and evaluate the outcomes of stromal peeling. DESIGN: Interventional case series. METHODS: In this multicenter study, stromal peeling was attempted in 96 consecutive eyes with unsatisfactory vision following penetrating keratoplasty (PK) for keratoconus (n = 79), herpetic keratitis (n = 11), and granular dystrophy (n = 6). Stromal exchange was performed by (1) 9 mm partial-thickness trephination; (2) creation of a corneal flap across the PK wound; (3) opening of the stromal component of the PK wound until a smooth, translucent natural plane was identified; (4) severing the attachment of the PK scar; (5) stromal peeling along the identified plane; and (6) suturing of donor lamella. Grafted corneas from cases that mandated conversion to PK were processed for transmission electron microscopy. RESULTS: The natural plane of separation was identified in all cases. Stromal exchange was successfully completed in 84 cases (87.5%). Snellen visual acuity ≥20/40 and ≥20/25 was reached in 93% and 72% of cases at 3 years (n = 49) and 86% and 62% at 4 years (n = 21) postoperatively. Mean endothelial cell loss at 1 year was 6.6% ± 9.5%. Stromal peeling occurred along a plane lined with a continuous layer of keratocytes separating pre-Descemet membrane (DM) stroma, DM, and endothelium from the anterior stroma. Pre-DM stroma was made of poorly organized lamellae containing widely spaced, randomly arranged collagen fibrils. CONCLUSIONS: Ultrastructural alterations in the stromal microarchitecture of grafted corneas provide evidence of a natural plane of separation identified intraoperatively. Stromal peeling can be successfully performed in post-PK eyes with various stromal pathology.

Interface Drainage and Antimicrobial Irrigation Avoid Repeat Keratoplasty for Post-DSAEK Cold Interface Abscess.

PURPOSE: To describe a surgical technique for the diagnosis and treatment of post-Descemet stripping automated endothelial keratoplasty (DSAEK) infectious interface keratitis presenting as a cold abscess. METHODS: This study included 2 eyes of 2 patients that developed delayed-onset interface infections after DSAEK. Through an anterior keratotomy, diagnostic samples for microbial culture and histopathology examination were collected, and empiric antibiotic therapy was delivered directly to the site of the infection at the graft-host interface. RESULTS: In both cases, microbiological examinations confirmed a fungal etiology consistent with Candida. Resolution of infection was achieved, and no signs of posterior segment involvement or recurrence of infection were observed. Both corneas remained clear with final visual acuity of 20/25 and 20/32. No case required additional surgical intervention or repeat keratoplasty after more than 15 months of follow-up. CONCLUSIONS: Interface drainage with antimicrobial irrigation may be considered for the management of post-DSAEK interface infections presenting as a peripheral cold abscess. By avoiding intraocular seeding of infectious pathogens, the anterior approach can achieve clinical resolution of infection, maintain visual function, and preserve the DSAEK graft, thereby obviating the need for a therapeutic keratoplasty.

Tectonic Mini-DSAEK Facilitates Closure of Corneal Perforation in Eyes With Healthy Endothelium.

PURPOSE: The purpose of this study was to report a surgical technique for closure of a traumatic corneal perforation in a patient with healthy endothelium. METHODS: A 69-year-old male patient presented to Southend University Hospital with a 2.5 mm round temporal corneal perforation caused by a metallic foreign body from an industrial accident. Best-corrected visual acuity at presentation was 6/36. The patient received a tectonic small diameter Descemet stripping automated endothelial keratoplasty (mini-DSAEK) to close the perforation. The patient subsequently developed traumatic cataract and underwent cataract surgery 8 months later. Clinical outcomes at 1 week, 1 month, 3 months, 6 months, and 9 months were evaluated. The primary outcomes of interest were successful sustained closure of the perforation and surgical complications, with secondary outcomes of best-spectacle corrected visual acuity (BSCVA, Snellen) and keratometric astigmatism (KA, Pentacam). RESULTS: The anterior chamber was reformed by the graft, restoring the globe's mechanical integrity. The bare stroma reepithelized by 1 week. Neither intraoperative nor postoperative surgical complications were reported. The anterior chamber remained deep and formed during subsequent follow-ups through 9 months. At the 9-month follow-up, final best spectacle-corrected visual acuity was 6/6-1 (Snellen fraction). Keratometric astigmatism was 1.1 diopters. CONCLUSIONS: Tectonic mini-Descemet stripping automated endothelial keratoplasty is a safe technique in the management of corneal perforations too large for tissue adhesives, with a low astigmatic profile and rapid visual recovery.

Pneumatic Dissection for Large-Diameter (9-mm) Deep Anterior Lamellar Keratoplasty in Eyes With Previous Anterior Lamellar Keratoplasty.

PURPOSE: To evaluate the surgical and 3-year clinical outcomes of modified big-bubble 9-mm deep anterior lamellar keratoplasty (DALK) in eyes with previous ALK (ALK). METHODS: In this interventional case series, 21 consecutive eyes with unsatisfactory vision after ALK (superficial ALK n = 9; laser-assisted ALK n = 7; and epikeratophakia n = 5) underwent large-diameter (9-mm) DALK. The surgery involved deep trephination based on the anterior segment optical coherence tomography pachymetry measurement at 9-mm diameter, pneumatic dissection from the base of the trephination and limited stromal clearance of the optical zone (6 mm). Main outcome measures were success rates of pneumatic dissection, best spectacle-corrected visual acuity, and complication rates. RESULTS: Pneumatic dissection with type 1 bubble formation succeeded in 19 (90%) eyes. In the 2 remaining cases, the 6-mm optical zone was cleared by manual dissection. Perforation occurred in one of the latter cases; no procedure was converted to penetrating keratoplasty. One month after complete suture removal, the preoperative mean best spectacle-corrected visual acuity (0.75 ± 0.23 logMAR) improved to 0.09 ± 0.10 logMAR (P < 0.001) and remained stable up to 3 years after surgery. At the final follow-up, refractive astigmatism was ≤4.5 and <6 D in 20 (95%) and 21 (100%) eyes, respectively. Stromal rejection was observed in 2 eyes (10%) and was treated successfully with steroids. CONCLUSIONS: Even in eyes with previous ALK, pneumatic dissection can be achieved through a modified DALK technique with a low risk of complications and excellent visual and refractive outcomes.