Giant corneal keloid following Descemet stripping automated endothelial keratoplasty for the treatment of corneal decompensation secondary to trauma.

PURPOSE: This report aims to present a case of corneal keloid caused by chronic corneal insult after trauma and Descemet stripping automated endothelial keratoplasty (DSAEK). CASE PRESENTATION: A 35-year-old male with a history of vision loss in the right eye was referred to our hospital. The patient underwent Ahmed Glaucoma Valve Implantation to alleviate elevated intraocular pressure after ocular trauma to the same eye. One year following the procedure, the eye developed endothelial failure, leading to the performance of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) with repositioning of the shunt tube. Upon initial examination, a well-circumscribed elevated white opaque lesion involving the central corneal surface of the RE was observed. Based on the patient's clinical history, slit lamp examination, and UBM findings, the diagnosis of corneal keloid was established. Superficial keratectomy was performed. Histopathological analysis confirmed the diagnosis of corneal keloid. Following the procedure, BCVA improved slightly. However, 3 months later, the patient underwent a penetrating keratoplasty for visual rehabilitation. CONCLUSION: Corneal keloids should be considered following any form of ocular trauma, particularly in cases involving ocular surgery. Diagnosing corneal keloids can sometimes be challenging due to the variety of potential differentials; however, by carefully evaluating the patient's medical history and clinical presentation, we can effectively narrow down the differential diagnosis of corneal conditions.

Assessment of Generative Artificial Intelligence (AI) Models in Creating Medical Illustrations for Various Corneal Transplant Procedures.

PURPOSE: This study aimed to task and assess generative artificial intelligence (AI) models in creating medical illustrations for corneal transplant procedures such as Descemet's stripping automated endothelial keratoplasty (DSAEK), Descemet's membrane endothelial keratoplasty (DMEK), deep anterior lamellar keratoplasty (DALK), and penetrating keratoplasty (PKP).  Methods: Six engineered prompts were provided to Decoder-Only Autoregressive Language and Image Synthesis 3 (DALL-E 3) and Medical Illustration Manager (MIM) to guide these generative AI models in creating a final medical illustration for each of the four corneal transplant procedures. Control illustrations were created by the authors for each transplant technique for comparison. A grading system with five categories with a maximum score of 3 points each (15 points total) was designed to objectively assess AI's performance. Four independent reviewers analyzed and scored the final images produced by DALL-E 3 and MIM as well as the control illustrations. All AI-generated images and control illustrations were then provided to Chat Generative Pre-Trained Transformer-4o (ChatGPT-4o), which was tasked with grading each image with the grading system described above. All results were then tabulated and graphically depicted. RESULTS: The control illustration images received significantly higher scores than produced images from DALL-E 3 and MIM in legibility, anatomical realism and accuracy, procedural step accuracy, and lack of fictitious anatomy (p<0.001). For detail and clarity, the control illustrations and images produced by DALL-E 3 and MIM received statistically similar scores of 2.75±0.29, 2.19±0.24, and 2.50±0.29, respectively (p=0.0504). With regard to mean cumulative scores for each transplant procedure image, the control illustrations received a significantly higher score than DALL-E 3 and MIM (p<0.001). Additionally, the overall mean cumulative score for the control illustrations was significantly higher than DALL-E 3 and MIM (14.56±0.51 (97.1%), 4.38±1.2 (29.2%), and 5.63±1.82 (37.5%), respectively (p<0.001)). When assessing AI's grading performance, ChatGPT-4o scored the images produced by DALL-E 3 and MIM significantly higher than the average scores of the independent reviewers (DALL-E 3: 10.0±0.0 (66.6%) vs. 4.38±1.20 (29.2%), p<0.001; MIM: 10.0±0.0 (66.6%) vs. 5.63±1.82 (37.5%), p<0.001). However, mean scores for the control illustrations between ChatGPT-4o and the independent reviewers were comparable (15.0±0.0 (100%) vs. 14.56±0.13 (97.1%); p>0.05). CONCLUSION: AI is an extremely powerful and efficient tool for many tasks, but it is currently limited in producing accurate medical illustrations for corneal transplant procedures. Further development is required for generative AI models to create medically sound and accurate illustrations for use in ophthalmology.

Magnetic field control device for transplantation of corneal endothelial tissue with magnetic filaments.

The corneal endothelial transplantation involves the transfer and attachment of a single-layered corneal endothelial tissue to the narrow space between the cornea and iris. Given the high risk of damage to the endothelial tissue and surrounding corneal tissues when using sharp instruments inserted externally to apply force during the process, the development of a device capable of transferring corneal endothelial tissue using a magnetic field became necessary. This study aims to develop a magnetic control device for transferring corneal endothelial tissue with attached magnetic particles to the transplant site, validate its appropriate transfer capabilities, and assess its applicability to corneal endothelial transplantation. For this purpose, a magnetic field-generating manipulation device equipped with four electromagnets controlled by a joystick and microcomputer was developed. Through simulated experiments, the strength of the magnetic field and the attraction force on the tissue were predicted, and the actual magnetic field strength was measured for validation. To measure the magnetic transfer force, experiments were conducted by towing corneal endothelial tissue fixed with 6 mg, 12 mg, and 18 mg plastic weights. Subsequently, the tissue's transfer speed was measured after applying continuous and pulsed magnetic fields. The results confirmed the feasibility of tissue transfer using the magnetic control device, and it was observed that pulsed magnetic fields led to faster transfer speeds and easier control compared to continuous magnetic fields. Exploratory animal experiments using rabbits were conducted to simulate real surgical conditions, confirming the feasibility of corneal endothelial tissue transfer and attachment.

The progress and future of corneal endothelial transplantation.

Endothelial transplantation has recently been accepted worldwide, in the long history of corneal transplantation. The introduction of endothelial keratoplasty (Descemet stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty) has enabled us to expand the surgical indications owing to the low incidence of rejection and quick recovery of visual function. New technologies have been developed to ensure stable postoperative outcomes with a shorter learning curve, such as transplantation using cultured human endothelial cells and induced pluripotent stem cells (iPS) or new devices such as artificial endothelium. This review discusses the history and characteristics of corneal transplantation alongside new treatment options that may offer hope for patients with endothelial disease in the future.

Andalusian Public Eye-Banks: a decade of continuous improvement.

OBJECTIVES: To show donation data, number of keratoplasties and the changes in transplant indications and techniques that occurred in Andalusia in the period from 2013 to 2022. MATERIALS AND METHODS: The present work is a retrospective and descriptive study that included all keratoplasties performed between January 2013 and December 2022 in Andalusia, as well as the evolution of the cornea donation and transplant activity of the public and private hospitals pertaining to the waiting list management system of the Public Health System of Andalusia. Transplants performed in private centers with corneas from outside Andalusia were excluded. RESULTS: Cornea donation activity in Andalusia in the decade 2013-2022 has experienced a growth of more than 126%, while overall transplant activity has increased by 157% in public hospitals. Penetrating keratoplasty has decreased from 83% in 2013 to 43% in 2022, while lamellar techniques have increased from 17% to 57% in this same period. Since 2018, more lamellar transplants are performed than penetrating transplants. Regarding indications, endothelial conditions already represent the first cause of transplantation. In 2022 alone, the public Andalusian Eye Banks evaluated 1,054 corneas and prepared 281 endothelial grafts. CONCLUSION: In the decade from 2013 to 2022 in Andalusia there has been an increase in donation activity and the number of keratoplasties. The public Eye Banks implementation in this period has played a key role in the widespread adoption of lamellar keratoplasty techniques and has enabled the transition to perform a greater number of lamellar keratoplasties compared to penetrating keratoplasty.

Rapid Corneal Calcification Following Endothelial Keratoplasty: A Case Report.

Corneal calcification typically progresses slowly but can occasionally advance rapidly. This report details severe stromal calcification following repeat Descemet's stripping automated endothelial keratoplasty (DSAEK) in a 75-year-old patient with diabetes, hypertension, and prior ocular surgeries, including cataract surgery, intraocular lens extraction with suturing, and trabeculectomy. Persistent epithelial defects after the surgery led to rapid central stromal calcification within four weeks, significantly reducing visual acuity. Management included switching from betamethasone sodium phosphate to fluorometholone, facilitating complete epithelial recovery within two months. However, persistent stromal opacity necessitated a subsequent penetrating keratoplasty. Infrared absorption spectrophotometry identified calcium phosphate as the primary component of the calcification. This case highlights the importance of vigilant monitoring and proactive management of epithelial defects to prevent rapid calcification following endothelial keratoplasty.

A Functional and Immunologic Point of View on Corneal Endothelial Transplantation: A Systematic Review and Meta-Analysis.

Background: To systematically review and meta-analyze the immunologic aspects and outcomes of various endothelial keratoplasty (EK) techniques, specifically comparing Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK), Ultra-Thin Descemet's Stripping Automated Endothelial Keratoplasty (UT-DSAEK), and Descemet's Membrane Endothelial Keratoplasty (DMEK). Methods: Systematic review and meta-analysis. Main outcomes were the proportion of patients achieving a best spectacle-corrected visual acuity (BSCVA) of 20/20 at 6 months after keratoplasty, rejection rate one year after surgery, BSCVA at last follow up, and postoperative immunomodulating regimen. Results: A higher proportion of DMEK patients achieved a BSCVA of 20/20 after 6 months. UT-DSAEK and DMEK showed similar rejection rates with a lower risk of re-bubbling for UT-DSAEK (4% vs. 20%). Conclusions: DMEK showed faster visual recovery than UT-DSAEK but a similar rejection rate and long-term visual acuity. One-year postoperative slow tapering steroid regimen has a positive but not (yet) significant effect on rejection risk and visual outcomes.

3D Heads-up digital filters for cataract surgery and corneal transplantation.

PURPOSE: To describe the advantages of Ngenuity 3D digital filters for enhancing visualization during cataract and corneal transplant surgery. METHODS: All surgeries were performed by the same experienced surgeon (L.M.) using the Ngenuity 3D heads-up visualization system connected to a microscope. Images were simultaneously captured with and without the filter in each of the following phases: endothelial evaluation, capsulorhexis, capsule rupture, vitreous leak, cortex removal, visco removal, corneal suture, descemetorhexis, DMEK graft preparation and insertion. RESULTS: In cataract surgery, green and monochrome filters facilitate capsulorhexis in difficult situations by highlighting the anterior capsule and can improve visualization of a posterior capsular tear. The enhanced contrast of the monochrome filter is also useful for cortex and viscoelastic removal. In corneal surgery, the green filter highlights the rim of the DMEK graft during tissue preparation, the yellow filter enhances the contrast of the stained DMEK graft in the anterior chamber, the monochrome filter simplifies descemetorhexis by improving visualization of the Descemet/endothelial layer and allows a better view in red saturated images while performing sutures. CONCLUSIONS: Ngenuity digital filters have the potential to enhance tissue visualization during cataract and corneal surgeries, especially in poor visibility conditions.

Post-Keratoplasty Microbial Keratitis in the Era of Lamellar Transplants-A Comprehensive Review.

Microbial keratitis in a post-transplant cornea should be considered a distinct entity from microbial keratitis in a non-transplant cornea. Firstly, the use of immunosuppressive treatments and sutures in corneal transplants changes the etiology of keratitis. Secondly, corneal transplant has an impact on corneal biomechanics and structure, which facilitates the spread of infection. Finally, the emergence of lamellar transplants has introduced a new form of keratitis known as interface keratitis. Given these factors, there is a clear need to update our understanding of and management strategies for microbial keratitis following corneal transplantation, especially in the era of lamellar transplants. To address this, a comprehensive review is provided, covering the incidence, risk factors, causes, and timing of microbial keratitis, as well as both clinical and surgical management approaches for its treatment in cases of penetrating and lamellar corneal transplants.

Changes in the Visual Field Test after Descemet Stripping Automated Endothelial Keratoplasty in Advanced Glaucoma.

Background: To evaluate changes in the visual field (VF) after Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with advanced glaucoma and previous trabeculectomy. Methods: Changes in VF, best-corrected visual acuity (BCVA), intraocular pressure (IOP), and number of glaucoma medications were analyzed before and after DSAEK in 19 eyes. The VFs were evaluated using the 10-2 program of the Humphrey Field Analyzer (HFA) and/or Goldmann perimetry (GP). Results: In nine eyes, the MD improved from -22.24 ± 6.5 dB to -18.36 ± 5.1 dB in HFA. In five out of nine eyes, postoperative MD improved >1 dB compared to preoperative MD. In GP testing, 10 out of 15 eyes showed an improvement, that is, greater than 20° in VF enlargement by the isopter of I-4e and/or new detection of a smaller or darker isopter. Overall, improvement in VF with the HFA and/or GP test was observed in 12/19 (63.2%) eyes after DSAEK. Postoperative BCVA improved by more than two lines in logMAR VA in 18 of 19 (94.7%) eyes. There were no significant differences between the preoperative and postoperative IOP and the number of glaucoma medications. Conclusions: DSAEK may produce subjective improvement in the visual field as well as improved visual acuity, even in advanced glaucomatous eyes.

One-year Outcomes of Ultrathin Descemet Stripping Automated Endothelial Keratoplasty Combined with Cataract Surgery in the Korean Population.

PURPOSE: To evaluate the refractive outcomes after ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) combined with phacoemulsification and intraocular lens implantation (triple procedure) in the South Korean population. METHODS: This retrospective observational study included 37 eyes of 36 patients who underwent the UT-DSAEK triple procedure between 2012 and 2021 in a single tertiary hospital. Preoperative and postoperative refractive outcomes and endothelial parameters at 1, 3, 6, and 12 months were observed. RESULTS: At the final postoperative 12-month period, the average best-corrected visual acuity was 0.4 ± 0.5 in logarithm of the minimum angle of resolution. The mean endothelial cell density at 12 months was 1,841.92 ± 731.24 cells/mm2, indicating no significant endothelial cell loss compared to the baseline (p = 0.128). The mean postoperative central corneal thickness at 12 months was 597.41 ± 86.26 µm. The postoperative mean absolute error at 12 months was 0.96 ± 0.89 diopters (D) and mean error was 0.89 ± 0.97 D. CONCLUSIONS: The results of our South Korean cohort study on UT-DSAEK triple surgery showed favorable and safe outcomes. Regardless of graft thickness, it should be noted that a hyperopic shift of 1.00 to 2.00 D needs to be considered in the case of UT-DSAEK triple surgery.

Intraocular pressure-related side-effects after endothelial keratoplasty.

PURPOSE: To investigate circumpapillary retinal nerve fibre layer (RNFL) thickness, pupillary function and diameter after phacoemulsification and lens implantation alone or combined with endothelial keratoplasty (EK). METHODS: This study was a secondary analysis of data from a randomized, single-masked trial, that included 72 patients with Fuchs' endothelial dystrophy and cataract, equally allocated (1:1) to ultrathin Descemet's stripping automated endothelial keratoplasty or Descemet's membrane endothelial keratoplasty. The cataract extraction (CE) group included 40 patients undergoing cataract surgery only. All patients were treated with phacoemulsification and lens implantation. RESULTS: RNFL thickness was significantly lower in the CE group than after EK for the global (p < 0.01), nasal (p = 0.04), and temporal sectors (p = 0.01) 12 months after surgery. RNFL thickness was comparable between patients treated with rebubbling and others (p ≥ 0.16 for all comparisons) after 12 months. The CE group and patients treated with EK demonstrated a comparable scotopic (p = 0.34) and photopic pupil diameter (p = 0.95) as well as a comparable maximum (p = 0.83) and average pupillary constriction velocity (p = 0.95) after 12 months. In contrast, patients treated with rebubbling had a significantly smaller scotopic pupil diameter (p = 0.04). CONCLUSION: In this study, no evidence was found indicating a negative impact on the RNFL thickness after EK when compared to CE 12 months after surgery. Iris function and pupil diameter were comparable between the CE group and patients treated with EK after 12 months.

CTG18.1 expansion in transcription factor 4 (TCF4) in corneal graft failure: preliminary study.

Fuchs endothelial corneal dystrophy (FECD) is caused by a corneal endothelial cell loss, leading to corneal edema and visual impairment. The most significant genetic risk factor for FECD is an expansion of the CTG18.1 locus in transcription factor 4 (TCF4). The current treatment for severe FECD is corneal transplantation, with Descemet stripping automated keratoplasty (DSAEK) as a common surgical method. Although successful in most cases, the risk for transplant failure due to diverse causes must be considered. In this study, we investigated if presence of TCF4 CTG18.1 expansion with more than 31 (n ≥ 31) repeats in donated corneal grafts could be a reason for corneal transplant failure after DSAEK. For this, nine consecutively failed DSAEK corneal grafts were genotyped for CTG18.1 repeat length. One-sided Mann-Whitney U test was performed to evaluate if failed DSAEK corneal grafts had longer CTG18.1 repeats than healthy controls from the same population. All failed corneal grafts had CTG18.1 n ≤ 27 with a median of 18 (IQR 8.0) repeats for the longest allele. There was no statistical difference in CTG18.1 repeat lengths between failed corneal grafts and the geographically matched healthy control group. In conclusion, none of the nine failed corneal grafts in our material had CTG18.1 repeat lengths ≥ 31, a cut-off known to have a biological relevance in FECD. Thus, our results suggest that the assessment of donors and inspection of the corneal tissue before the decision for procurement is sufficient, in terms of recognizing FECD in the donor.

Identification and Analysis of Primary Cilia in the Corneal Endothelial Cells of Patients with Bullous Keratopathy.

PURPOSE: To identify primary cilia in human corneal endothelial cells (CECs) obtained from patients with bullous keratopathy (BK). METHODS: This study involved CEC specimens obtained from 10 eyes of 10 consecutive patients (three males and seven females; mean age: 74.5 years, range: 68-90 years) with BK who underwent Descemet's stripping automated endothelial keratoplasty at Baptist Eye Institute, Kyoto, Japan between August 2019 and September 2020. Three corneal buttons obtained from 3 patients who underwent penetrating keratoplasty for keratoconus were used as 'non-BK' controls. All specimens were evaluated with immunofluorescence staining using an antibody against acetylated α-tubulin. RESULTS: Ciliary expression was observed in six of the 10 CEC specimens; i.e. in two specimens obtained from BK patients after glaucoma surgery (trabeculectomy), in two specimens obtained from patients with Fuchs endothelial corneal dystrophy, and in two specimens obtained from a patient with BK after laser iridotomy for primary angle closure. There was acetylated α-tubulin staining but no hair-like structures in two specimens, and ciliary expression was unknown in two specimens due to the absence of cells. The length of the primary cilia varied between all specimens. In contrast, no primary cilia were observed in the corneal buttons obtained from the three keratoconus patients. CONCLUSION: The findings in this study clearly demonstrate the expression of primary cilia in the CECs of patients afflicted with BK.

Scheimpflug Corneal Densitometry Patterns at the Graft-Host Interface in DMEK and DSAEK: A 12-Month Longitudinal Comparative Study.

BACKGROUND: To compare corneal densitometry (CD) patterns at the graft-host interface between Descemet Membrane Endothelial Keratoplasty (DMEK) and Descemet Stripping Automated Endothelial Keratoplasty (DSAEK). Corneal densitometry is a quantitative assessment that objectively evaluates corneal clarity and optical quality by measuring the light backscatter from the cornea. METHODS: Fifty-one eyes that received DMEK or DSAEK surgery for corneal endothelium dysfunction were evaluated. The primary endpoint included CD patterns at the graft-host interface, which were assessed by the Pentacam HR device at the center point of the corneal horizontal meridian (CDcentral), and at six points on the central circumference of the cornea (with a total diameter of 4 mm) (CDI,II,III,IV,V,VI). Secondary endpoints included the best-corrected distance visual acuity (BCDVA), central corneal thickness (CCT), and graft thickness (GT). All of the evaluations were performed at follow-up appointments one, three, six and twelve months after the procedure. RESULTS: DMEK showed a significant overall CD reduction of -7.9 ± 8.5 grayscale unit (GSU) compared to DSAEK (p < 0.001). In addition, the DMEK group showed significantly lower CDCentral,I,II,III,IV,V,VI values at follow-up appointments one, three, six and twelve months after the procedure compared to the DSAEK group (p < 0.001). BCDVA, CCT and GT were in favor of the DMEK group with a mean value of 0.39 ± 0.35 LogMar, 552.2 ± 71.1 µm and 11.03 ± 1.4 µm, respectively (p < 0.001). CONCLUSIONS: CD patterns at the graft-host interface seem to be different depending on the endothelial keratoplasty procedure. This provides specific insight into CD changes in this critical region of surgery, which may provide a better understanding of the postoperative evolution of these patients.

Combined Cataract and Corneal Transplantation Surgery Without Viscosurgical Devices.

Background: The most common complications after performing the triple Descemet's stripping automated endothelial keratoplasty (DSAEK), which combines the cataract phacoemulsification, intraocular lens implantation and DSAEK procedure, are detachment or decentration of the donor lamella and postoperative interface haze. One reason for this is the retained viscoelastic used during surgery. Objective: This study aimed to describe triple DSAEK procedure without the usage of viscoelastic and to discuss its potential benefits on surgical outcomes. Methods: The surgical procedures and outcomes of patients with Fuchs' dystrophy and lens opacification who underwent the triple DSAEK were retrospectively reviewed. The surgical procedure was described, and postoperative complications were studied. Results: The study included 10 eyes of 10 patients. Capsulorhexis and IOL implantation performed in locally potentiated anesthesia compared to general anesthesia did not significantly differ (P > 0,05). The mean preoperative best-corrected visual acuity was 0.75 LogMar. The mean postoperative best-corrected visual acuity was 0.2 LogMar. The central graft thickness before surgery was 129.6 µm and 6 months after surgery was 114.2 µm. Successful attachment of the donor lamellae was observed in all 10 patients. None of the patients had postoperative interface haze or any other possible viscoelastic caused complication. Conclusion: Although viscoelastic can facilitate certain aspects of the triple DSAEK procedure, we conclude that this procedure can be performed completely without its use. If performed by a trained surgeon, the procedure can be feasible without the complications of donor lamella detachment, decentration, or interface haze.

Hemi-Ultrathin Descemet Stripping Automated Endothelial Keratoplasty (Hemi-UT-DSAEK) Using Pediatric Donor Corneas: A Case Series.

OBJECTIVE: We sought to evaluate the clinical outcomes of hemi-UT-DSAEK grafts from the pediatric donor corneas of patients affected by Fuchs Endothelial Corneal Dystrophy (FECD). METHODS: A prospective, interventional case series was conducted at the Ophthalmology Department of Venice Civil Hospital and the Veneto Eye Bank Foundation (Venice, Italy). Six eyes of six patients affected by FECD received large-diameter, semicircular hemi-UT-DSAEK grafts obtained from three pediatric donor corneas using the standard pull-through method. Endothelial cell density (ECD), central corneal thickness (CCT), best-corrected visual acuity (BCVA) and intraoperative and postoperative complications were recorded at different time intervals up to 12 months. RESULTS: The average donor age was 64.6 ± 8.6 years, and the pre-operative ECD was 3266 ± 225 cells/mm2. At 12 months postoperatively, the average ECD was 1376 ± 509 cells/mm2 with a mean decrease of 56.8 ± 19.1% from the preoperative donor count. At 12 months, four out of six eyes had significantly improved and reached a BCVA of ≥20/25 (Snellen equivalent). The mean CCT significantly decreased from 788 ± 138 µm before surgery to 576 ± 30 µm at 12 months postoperatively (p < 0.01). CONCLUSIONS: Hemi-UT-DSAEK grafts using pediatric donor corneas are surgically feasible and can provide similar clinical outcomes compared to conventional UT-DSAEK. Transplanting pediatric donor tissues with high ECD into two patients could potentially increase the donor tissue pool to treat endothelial disease.

Spokewise iridotomy combined with Descemet stripping automated endothelial keratoplasty in iridocorneal endothelial syndrome.

Purpose: Iridocorneal endothelial (ICE) syndrome is a progressive anterior segment disorder that can be tricky to treat. Keratoplasty is commonly used to treat corneal edema in ICE syndrome. However, glaucoma is an important risk factor affecting graft survival. To address this question, we designed a retrospective cohort study to evaluate the effect of Spokewise Iridotomy (SI) on Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) Grafts in Iridocorneal Endothelial (ICE) Syndrome. Methods: This was a retrospective cohort study. A total of 29 patients were included; 31 eyes with ICE syndrome underwent DSAEK at Peking University Third Hospital between June 2015 and June 2022, including 11 eyes with combined SI during DSAEK. The aim was to explore the effect of SI on vision, glaucoma control, complications, peripheral anterior synechiae recurrence, endothelial cell count, and graft survival. Results: The median follow-up time was 30.83 months (mo.) in the SI+Endothelial Keratoplasty (EK) group and 6.17 mo in the EK group. The 2-year cumulative survival rate of grafts in the SI+EK group was 100%, compared with the 6-month and 1-year cumulative survival rates of 80.2 and 63.2%, respectively, in the EK group (p = 0.043). The SI+EK group had a lower incidence of immediate postoperative complications (p = 0.005), fewer postoperative anti-glaucoma medications (AGMs) (p = 0.029), smaller peripheral anterior synechiae recurrence (p = 0.001), and significant visual acuity improvement (p < 0.05). More AGMs were used in failed grafts (p = 0.002). Conclusion: SI can help control intraocular pressure, improve visual acuity, and increase graft survival after DSAEK in ICE syndrome patients.

Concomitant sutureless scleral fixation of intraocular lens with keratoplasty: Review of surgical techniques.

Sutureless scleral fixation of intraocular lens (sSFIOL) is a commonly employed method of optical rehabilitation of aphakic patients with deficient capsular support, and corneal transplant surgeries can be simultaneously combined with sSFIOL to handle aphakic corneal opacities. A single-stage procedure circumvents the need for repeat intraocular procedures and carries lower risk of graft endothelial damage, endophthalmitis, and macular edema associated with sequential surgeries. However, it mandates surgical expertise and increases the chances of postoperative inflammation. A basket of options is available with the corneal surgeons regarding the manner of host and donor preparation as well as the approaches to scleral fixation and certain intraoperative modifications along with postoperative vigilance may enhance the surgical outcomes. Most of the studies pertaining to keratoplasty with sSFIOL categorize to case reports/series, surgical techniques, and retrospective studies with very limited prospective data available currently. The purpose of the present review is to consolidate all available literature on concomitant sSFIOLs and keratoplasty procedures.

The Biologic Character of Donor Corneal Endothelial Cells Influences Endothelial Cell Density Post Successful Corneal Transplantation.

Purpose: Corneal endothelial cell density (ECD) gradually decreases after corneal transplantation by unknown biologic, biophysical, or immunologic mechanism. Our purpose was to assess the association between donor corneal endothelial cell (CEC) maturity in culture and postoperative endothelial cell loss (ECL) after successful corneal transplantation. Design: Prospective cohort study. Participants: This cohort study was conducted at Baptist Eye Institute, Kyoto, Japan, between October 2014 and October 2016. It included 68 patients with a 36-month follow-up period who had undergone successful Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty. Methods: Human CECs (HCECs) from remaining peripheral donor corneas were cultured and evaluated for maturity by surface markers (CD166+, CD44-/dull, CD24-, and CD105-) using fluorescence-activated cell sorting. Postoperative ECD was assessed according to the mature-differentiated HCEC contents: high-maturity group: > 70%, middle-maturity group: 10% to 70%, low-maturity group: < 10%. The successful rate of ECD maintained at 1500 cells/mm2 at 36 months postoperative was analyzed using the log-rank test. Main Outcome Measures: Endothelial cell density and ECL at 36 months postoperative. Results: The 68 included patients (mean [standard deviation] age 68.1 [13.6] years, 47.1% women, 52.9% DSAEK). The high, middle, and low-maturity groups included 17, 32, and 19 eyes, respectively. At 36 months postoperative, the mean (standard deviation) ECD significantly decreased to 911 (388) cells/mm2 by 66% in the low-maturity group, compared with 1604 (436) by 40% and 1424 (613) cells/mm2 by 50% in the high and middle-maturity groups (P < 0.001 and P = 0.007, respectively) and the low-maturity group significantly failed to maintain ECD at 1500 cells/mm2 at 36 months postoperative (P < 0.001). Additional ECD analysis for patients who underwent DSAEK alone displayed a significant failure to maintain ECD at 1500 cells/mm2 at 36 months postoperative (P < 0.001). Conclusions: The high content of mature-differentiated HCECs expressed in culture by the donor peripheral cornea was coincident with low ECL, suggesting that a high-maturity CEC content predicts long-term graft survival. Understanding the molecular mechanism for maintaining HCEC maturity could elucidate the mechanism of ECL after corneal transplantation and aid in developing effective interventions. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.