[Pathogenesis of Fuchs endothelial corneal dystrophy, the fibrillar layer and individualized treatment]. / Pathogenese der Fuchs-Endotheldystrophie, die fibrilläre Schicht und individualisierte Therapie.

Fuchs endothelial corneal dystrophy (FECD) is a genetic and age-associated corneal disease characterized by an accelerated loss of corneal endothelial cells and an increased subendothelial deposition of extracellular matrix (ECM). Clinically, advanced disease leads to corneal edema with subsequent reduction in visual acuity. In the majority of patients with advanced FECD, a fibrillar layer (FL) appears on the posterior corneal surface. This FL is mostly localized in the inferotemporal corneal quadrant, marks areas with significantly reduced endothelial cell density and increased corneal thickness in the sense of edema and can be visualized and measured using Scheimpflug backscatter analysis due to increased backscatter. FECD is currently the most common indication for corneal transplantation worldwide, usually in the form of Descemet membrane endothelial keratoplasty (DMEK). New treatment approaches include variations of DMEK surgery such as hemi- or quarter DMEK with individualized and smaller grafts or Descemet membrane stripping only (DSO). In the future, clinical imaging of the FL as a particularly affected endothelial area could be important for FECD progression assessment and planning of surgical interventions. This article provides an overview of the current state of research on the clinical aspects, pathogenesis, fibrillar layer and individualized treatment of FECD.

Pseudophakic corneal edema caused by Descemet membrane detachment using high-resolution swept-source OCT imaging.

Background: Small Descemet membrane detachments after cataract surgery are relatively common and most cases do not require any secondary surgical intervention and can be treated conservatively. However, in case of advanced Descemet membrane detachment (DMD), it needs to be recognized and treated appropriately. The advent of anterior segment imaging using optical coherence tomography (OCT) technology has made diagnosing pathologies of the anterior segment accurate and time efficient and has proven as an invaluable tool to guide decision making. Case presentation: A 71-year-old patient presented after complicated cataract surgery with decreased visual acuity and cloudy vision. On examination, best corrected visual acuity was 1.5 logMAR. A high-resolution swept-source OCT (Anterion, Heidelberg Engineering, Heidelberg, Germany) was used to better evaluate and visualize the extent of DMD. An anterior chamber gas bubble was injected to reattach the Descemet membrane (DM) to the corneal stroma. The success of the surgery was visualized using the high-resolution swept-source OCT. This revealed a completely attached Descemet membrane. Conclusions: Clinically, it can be difficult to distinguish the etiology of epithelial and stromal edema post cataract surgery. This case demonstrated the clinical usefulness using high resolution swept source imaging to guide clinical decision making in evaluating timing and treatment success of pneumodescemetopexy after complicated cataract surgery.

Descemet's membrane transplantation for the treatment of recurrent high myopic macular hole associated with retinal detachment : Descemet's membrane for myopic macular hole.

PURPOSE: To report the efficacy of Descemet's Membrane (DM) transplantation over the macular hole in patients with recurrent high myopic macular hole (HMMH) associated with retinal detachment (RD). METHODS: Six eyes of six patients with wide posterior staphyloma including MH and recurrent HMMH associated with RD were included to this retrospective study. All patients underwent pars plana vitrectomy and DM obtained from eye bank was placed over the macular hole during the surgery. Silicone oil endotamponade was used as endotamponade and removed within 6 months following surgery. Pre-operative and post-operative ophthalmologic examination and optical coherence tomography findings were recorded. RESULTS: The mean follow-up time was 18.53 ± 7.36 months. Macular hole closure was achieved in all patients (100%). Best-corrected visual acuity was improved from 1.51 ± 0.55 logMAR to 1.08 ± 0.50 logMAR (p = 0.043). No complications due to surgery or DM during follow-up. No DM dislocation or hole re-opening occurred after surgery. CONCLUSION: DM transplantation during vitrectomy may be an effective treatment for the recurrent HMMH associated with RD. KEY MESSAGES: What is known Various surgical techniques have been tried for recurrent high myopic macular hole associated with retinal detachment, but satisfactory anatomical and functional success rates have still not been achieved. WHAT IS NEW: The study demonstrates that Descemet's membrane transplantation is a safe and effective option for treating recurrent high myopic macular hole associated with retinal detachment. This is a novel technique that may overcome the limitations of existing approaches. The findings suggest that Descemet's membrane transplantation could become a promising addition to the surgical options for recurrent high myopic macular hole associated with retinal detachment.

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.

Splenectomy as a Risk Factor for Graft Rejection Following Endothelial Transplantation: Retrospective Study.

BACKGROUND: Anterior chamber-associated immune deviation (ACAID) is an active immunotolerance mechanism, which is induced by placing antigen into the anterior eye chamber as long as a major surgical trauma is avoided. For this reason, ACAID may be a major contributor to the favorable immunologic outcomes in Descemet membrane endothelial keratoplasty (DMEK). Rodent models have demonstrated the importance of a functional spleen for the development of an ACAID. OBJECTIVE: This study aimed to investigate whether splenectomy leads to increased rejection rates after DMEK in humans. METHODS: A retrospective evaluation was conducted on the course following DMEK at the Eye Center, Medical Center, University of Freiburg, for patients with a self-reported history of splenectomy compared to patients without this condition. Potential study patients were contacted by mail. A questionnaire to self-report splenectomy and the time thereof was sent out. The medical records of all consenting patients at the Eye Center were reviewed for graft survival and immune reactions. RESULTS: We asked 1818 patients after DMEK to report their history of splenectomy. A total of 1340 patients responded and were included in the study. Of these 1340 patients, 16 (1.2%) reported a history of splenectomy (ie, 26 DMEKs, with 10 patients being transplanted in both eyes and 6 patients being transplanted in 1 eye; median age at surgery 73.7, range 66.7-76.1 y). The remaining patients (1324 patients, ie, 1941 eyes) served as controls, with 1941 DMEKs (median age at surgery 71.5, range 64.1-77.2 y). Five (19%) out of the 26 eyes from the splenectomy group required a second transplant due to dislocation (n=2.8%), failure (n=2.8%), and rejection (n=1.4%). Kaplan-Meier analysis revealed no relevant difference compared with controls. CONCLUSIONS: Our results suggest that splenectomy has no major effect on the outcome following DMEK. Subsequent, ACAID may not be the main reason for the favorable immunological outcomes in DMEK, or the camero-splenic axis may be subordinate in humans. However, we only included 16 patients who underwent splenectomy, so it might be possible that we missed a minor effect.

Busin Glide-Assisted Pull-Through Insertion of Artificial Corneal Endothelium (EndoArt).

Background: Currently, the push-in technique through the corneal tunnel using a blunt-tip spatula is used to insert an artificial corneal endothelium (EndoArt) into the anterior chamber (AC). The device is useful for patients with bullous keratopathy; however, it may be difficult to manipulate the very thin implant through hazy cornea. Unlike DMEK graft, it cannot be stained and the F-mark is faint. So, visualizing and orienting the implant is a real challenge especially through a hazy cornea and inadequate AC visualization. Therefore, alternative EndoArt implantation techniques are needed in patients with advanced endothelial dysfunction to avoid complications. Purpose: To report an alternative technique for EndoArt implantation using a Busin glide. Technique: The EndoArt was loaded onto the Busin glide with the concave side of the EndoArt facing upward and was then pulled/pushed into the Busin glide opening. After the Descemet's membrane and endothelium were detached and removed in a circular fashion in a patient with advanced corneal endothelial decompensation, the Busin glide was inserted into the corneal incision, and the EndoArt was slowly pulled into the AC using retractor forceps. Finally, the air was injected into the AC. Conclusion: The Busin glide-assisted pull-through technique smoothly and securely inserted the EndoArt into the AC without upside-down attachment. This alternative technique can be useful for patients with a history of repeat intraocular surgeries or trauma with severe corneal edema to avoid potential complications such as epithelial implantation cysts or downgrowth.

Blocking Air in the Filtering Bleb: Effects on Graft Adhesion After Descemet's Stripping Automated Endothelial Keratoplasty.

BACKGROUND: To evaluate the outcome of Descemet's stripping automated endothelial keratoplasty (DSAEK) with "blocking air" in the filtering bleb in patients with previous trabeculectomy. METHODS: In total, 299 eyes in 283 patients who underwent DSAEK were retrospectively reviewed. Endothelial graft adhesion, intraocular pressure (IOP), and air volume in the anterior chamber with (group A) or without (group B) a filtering bleb were compared between the groups. Group A was divided into two subgroups according to the presence (group A1) or absence (group A2) of air in the filtering bleb; the same three factors were compared between the subgroups. RESULTS: The graft detachment rate was significantly higher in group A (14.3%) than in group B (6.5%) (p = 0.04). IOP was significantly lower in group A than in group B before surgery (p = 0.01), at the end of surgery (p = 0.04), at three hours (p < 0.001), and one week postoperatively (p = 0.02). The graft detachment rate did not significantly differ between groups A1 and A2. There were no differences in IOP at each follow-up time, whereas there was a statistically significant increase in IOP from the preoperative measurement to the end of surgery in group A1 (21.0±7.0 mmHg) compared with group A2 (14.2±8.6 mmHg) (p = 0.02). CONCLUSIONS: The presence of blocking air in the filtering bleb helps ensure increased IOP during the early postoperative period but had no significant effect on graft detachment rates.

Comparison of rebubbling rate between preloaded endothelium-in and preloaded no-touch endothelium-out Descemet membrane endothelial keratoplasty transplantation.

BACKGROUND: To compare the difference in rebubbling rates between patients undergoing Descemet membrane endothelial keratoplasty (DMEK) with endothelium-in using a standard IOL cartridge and those with endothelium-out DMEK utilizing a no-touch technique with borosilicate glass cartridge transplantation. METHODS: This retrospective study included all eyes that underwent preloaded endothelium-in or endothelium-out DMEK transplantation from June 2019 to December 2023 at the Hanusch Hospital, Vienna, Austria. All DMEKs were harvested, prepared and preloaded at the European Eye Bank of Venice, Italy. DMEK surgeries were done by one experienced surgeon and the procedure was completed by air tamponade of the anterior chamber. RESULTS: Overall, 32 eyes each of 31 endothelium-out patients and of 29 endothelium-in patients were included. 32 preloaded endothelium-in procedures were followed by 32 preloaded endothelium-out procedures. Rebubbling rate for endothelium-in was 15/32 (47%) and for endothelium-out was 7/25 (28%) (p = 0.035, Pearson's chi-squared test). Donor age was the most important variable for rebubbling in a random forest algorithm model (ROC: 0.69). CONCLUSIONS: Rebubbling rate in endothelium-out DMEK was less than two-thirds compared to endothelium-in DMEK favoring no-touch endothelium-out DMEK as the preferred technique of DMEK transplantation.

DMEK Surgery at a Tertiary Hospital in Sweden. Results and Complication Risks.

Purpose: This study reports clinical outcomes up to 6 years after Descemet's membrane endothelial keratoplasty (DMEK) performed at the Department of Ophthalmology, Örebro University Hospital, Örebro, Sweden. Methods: The study has a cross-sectional and case series design. Inclusion criteria were all DMEK-operated eyes during 2013-2018 until repeat keratoplasty. Results: Altogether 162 eyes from 120 patients were enrolled. Among eyes without preoperative comorbidities, examined 1-6 years after DMEK, 85.8% achieved visual acuity of 0.1 logMAR or better. The median endothelial cell density (ECD) loss was 27% in a cohort of eyes examined 1-2 years post-DMEK, 31% at 2-3 years, 42% at 3-4 years, and > 60% at 4-6 years post-DMEK. ECD at the examination timepoint was correlated with donor ECD (as expected) and time since surgery. Conclusion: The results from DMEK surgeries in Örebro, Sweden, are promising. Further studies with even longer follow-up are needed to evaluate graft sustainability.

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.

Simultaneous Muraine Sutures and Excimer Laser-Assisted Penetrating Keratoplasty for Acute Keratoconus.

Background: Acute keratoconus (acute KC), which affects approximately 1.6-2.8% of keratoconus (KC) patients, is a pathological condition of the cornea characterized by stromal edema due to entry of aqueous humor through a tear in Descemet's membrane. Methods: We present a novel combination of surgical procedures that allows swifter visual recovery in a consecutive, retrospective case series. The new surgical procedure for acute KC consists of a combination of Muraine corneal sutures to smooth the corneal curvature and Excimer laser-assisted penetrating keratoplasty and was performed in six acute KC patients from 2019 to 2022 at the Department of Ophthalmology, University Hospital of Martin-Luther-University Halle-Wittenberg (UMH), Germany. We monitored data on preoperative status, operative details, intraoperative and postoperative complications and visual outcomes were analyzed. Results: The mean age was 41.5 ± 13.5 years (3 OD, 3 OS). Neurodermatitis was present in 3 patients (50%). All patients received significant visual benefits from the procedure. Preoperative BCVA was hand motion (logMAR 3.0) in all patients; postoperatively, BCVA improved significantly logMAR 0.03 ± 0.09 [range: 0.2-0.4; p < 0.001, FUP 20+/-10 months). Visual acuity remained stable throughout the roughly biannual follow-ups. One patient developed endothelial graft rejection after 2 years. During the last examination, all eyes had clear grafts and stable curvatures, K1 and K2 being 42.43 ± 4.17 D and 44.95 ± 4.07 D, respectively, and mean corneal astigmatism was 2.61 ± 1.74 D. The thinnest corneal thickness was 519 ± 31 µm. A graft size of 8.0 × 8.1 mm was the most beneficial. Conclusions: in patients with acute KC and hydrops, a penetrating keratoplasty with Muraine corneal sutures is successful in terms of graft clarity and visual outcome. Combining the procedures allows quicker visual recovery. Patients with a history of neurodermatitis should have preoperative and postoperative dermatologic treatment and close follow-up for possible complications.

Enhanced Migration of Fuchs Corneal Endothelial Cells by Rho Kinase Inhibition: A Novel Ex Vivo Descemet's Stripping Only Model.

Descemet's Stripping Only (DSO) is a surgical technique that utilizes the peripheral corneal endothelial cell (CEnC) migration for wound closure. Ripasudil, a Rho-associated protein kinase (ROCK) inhibitor, has shown potential in DSO treatment; however, its mechanism in promoting CEnC migration remains unclear. We observed that ripasudil-treated immortalized normal and Fuchs endothelial corneal dystrophy (FECD) cells exhibited significantly enhanced migration and wound healing, particularly effective in FECD cells. Ripasudil upregulated mRNA expression of Snail Family Transcriptional Repressor (SNAI1/2) and Vimentin (VIM) while decreasing Cadherin (CDH1), indicating endothelial-to-mesenchymal transition (EMT) activation. Ripasudil activated Rac1, driving the actin-related protein complex (ARPC2) to the leading edge, facilitating enhanced migration. Ex vivo studies on cadaveric and FECD Descemet's membrane (DM) showed increased migration and proliferation of CEnCs after ripasudil treatment. An ex vivo DSO model demonstrated enhanced migration from the DM to the stroma with ripasudil. Coating small incision lenticule extraction (SMILE) tissues with an FNC coating mix and treating the cells in conjunction with ripasudil further improved migration and resulted in a monolayer formation, as detected by the ZO-1 junctional marker, thereby leading to the reduction in EMT. In conclusion, ripasudil effectively enhanced cellular migration, particularly in a novel ex vivo DSO model, when the stromal microenvironment was modulated. This suggests ripasudil as a promising adjuvant for DSO treatment, highlighting its potential clinical significance.

A technique to treat Descemet's membrane detachment following cataract surgery.

We describe a technique to reattach the detached Descemet's membrane, following cataract surgery. From the main clear corneal cataract incision, aqueous humor is ejected completely by apposition of the cornea to the iris for approximately 3 s. This ensures the fluid in the space between the stroma and Descemet's membrane is ejected and the detached Descemet's membrane returns to its original position. Sterile air is injected through a paracentesis 180 degrees away from the Descemet's membrane detachment, to maintain a complete air-filled chamber. Full air tamponade is maintained for 20 min, following which one-third of the air is ejected from the chamber to prevent an increase of postoperative intraocular pressure.

Laboratory exploration of the use of ripasudil in descemetorhexis with a human ex vivo model.

The aim of the study was to investigate the effect of ripasudil on corneal endothelial cell survival and migration after two types of descemetorhexis on a human ex vivo model. Eleven human corneoscleral buttons were incubated in either 50 ml organ culture medium containing 10 µM ripasudil or 50 µl dimethyl sulfoxide (DMSO), the vehicle in ripasudil for 2 days prior to wound creation then for 14 days after. The wound was created with either full trephination scoring or by shallow trephination plus manual peeling. At day 14, immunohistochemistry with vimentin and Na+/K+/ATPase markers was conducted. Tissues were assessed at day 3, 7 and 14 for morphology, cell migration, cell viability and cell density. Full trephination scoring created more damage on tissues compared to shallow trephination with full Descemet membrane peeling. In the full trephination scoring group, no differences in cell viability were noted when ripasudil and DMSO were compared. With the peeling method, Ripasudil could protect the endothelial cell death and maintain the morphology compared to the control. At day 14, no differences in the peripheral cell viability and density were found between ripasudil and DMSO, although the ripasudil group presented significantly increased central cell count and cell viability. Increased cell migration was noted with ripasudil and the initial cell morphology of those migrated cells was similar to that of fibroblasts. In conclusion, ex vivo modelling suggested that peeling resulted in less cell damage than scoring and ripasudil maintained better morphology and promoted migration. These effects might be via transformation of endothelial cells into a more motile spindle-like phenotype.

Postoperative Astigmatism after Keratoplasty: A Systematic Review Meta-Analysis Based on PRISMA.

Background: The number of corneal transplants is rising, with the aim to treat a spectrum of diseases ranging from dystrophies to corneal opacities caused by trauma or chemical burns. Refractive outcomes after this procedure are often impossible to predict and associated with high levels of astigmatism. However, there are many techniques that affect the reduction of astigmatism and improve the quality of life of patients. Objectives: The aim was to compare the improvement in postoperative visual acuity (logMAR) and amount of corneal astigmatism (Diopters) after corneal keratoplasty in patients who additionally underwent a surgical procedure, which affects the reduction in postoperative astigmatism, and to determine the most effective method. Search Methods and Selection Criteria: A thorough search was carried out across online electronic databases including PubMed, Embrase, Ovid MEDLINE, Scopus, and Web of Science, using combinations containing the following phrases: postoperative astigmatism, post-keratoplasty astigmatism, anterior lamellar keratoplasty (ALK), deep anterior lamellar keratoplasty (DALK), posterior lamellar keratoplasty, endothelial keratoplasty (EK), penetrating keratoplasty (PK), corneal transplant, keratoplasty, refractive surgery, kerato-refractive surgery, laser in situ keratomileusis (LASIK), and femtosecond LASIK. This was to determine all English-language publications that discuss refractive operations for postoperative or post-keratoplasty astigmatism. These bibliographies were searched for English-language publications published between 2010 and 2023. We proceeded to review each detected record's reference list. Data Extraction: Study characteristics such as study design, sample size, participant information, operations performed, and clinical outcomes were all extracted. Data Statistical Analyses: The Comprehensive Meta-Analysis software (version 3.3.070, 2014) was used to perform the analysis. The threshold of 0.05 for p-values was considered statistically significant. All effect sizes are reported as standardized differences (Std diff) in means with a 95% confidence interval (CI) and visualized graphically as forest plots. Publication bias is presented as a funnel plot of standard error by Std diff in means. Four methods were used to evaluate the heterogeneity among the studies: Q-value, I2, chi-square (χ2), and tau-squared. Main Results: We included 21 studies that randomized 1539 eyes that underwent corneal transplantation surgery either by PKP, DALK, or DSEAK techniques. The results showed the most significant improvement in the visual acuity and significant decrease in the corneal astigmatism after laser surgery procedures, like femtosecond-assisted keratotomy after DALK and PKP and LASIK after DSEAK.

A Detailed Analysis of Individuals Having Graft Failure After Corneal Transplantation.

PURPOSE: To describe demographic and clinical characteristics of patients with graft failure after keratoplasty, determine the cause of graft failure and outcomes. METHODS: The charts of patients between 2008-2013 in the Cornea Service at Wills Eye Hospital with a history of a corneal transplant before the end of 2012 were retrospectively reviewed. Included were patients who had graft failure after corneal transplantation and had at least one year of follow-up after transplantation. Penetrating keratoplasty (PK) and Descemet's stripping endothelial keratoplasty (DSEK) patients were analyzed separately. RESULTS: A total of 186 eyes of 170 patients with graft failure after a PK (156) or DSEK (30) procedures were identified. The baseline characteristics included 100 female and 70 male patients with an age between 0 and 90 years (median 63 years). At the time of surgery, 38% had three or more systemic diseases and 68% were using three or more systemic medicines. Mean follow up time for PK was nearly four times of DSEK. Only 2 DSEK eyes (7%) underwent a 3rd DSEK graft, while 47 (30%) PK eyes underwent a 3rd PK and 15 (10%) PK eyes underwent more than three PK procedures. CONCLUSIONS: Most DSEK failures occurred in 1st year, while graft failure in PKs is scattered over years. Failure in DSEK is mostly due to graft or surgical risk factors but in PK mostly due to factors in the host. DSEK does not appear to be as affected by the patients' demographic and clinical characteristics as much as PK.

[Modern techniques and features of selective keratoplasty]. / Sovremennye tekhnologii i vozmozhnosti selektivnoi keratoplastiki.

Selective keratoplasty involves replacing the affected layers of the cornea with similar donor tissue. In case of pathological changes in the middle and posterior stroma, deep anterior lamellar keratoplasty (DALK) is performed. Chronic corneal edema caused by endothelial dysfunction is an indication for endothelial keratoplasty - Descemet membrane endothelial keratoplasty (DMEK) or Descemet Stripping Endothelial Keratoplasty (DSAEK). Compared to penetrating keratoplasty (PK), these operations are characterized by a low risk of damage to intraocular structures and a relatively short rehabilitation period. Complications of selective keratoplasty include the formation of a false chamber between the lamellar graft and the recipient's cornea, ocular hypertension during anterior chamber air tamponade. Persistent epithelial defect can be a sign of primary graft failure in DALK, DSAEK and DMEK. Selective keratoplasty is characterized by a lower incidence of immune rejection than PK. In some cases, DALK can be complicated by corneal changes related to suture fixation of the graft. Long-term postoperative use of topical glucocorticoids can cause ocular hypertension and cataracts.

Descemet's membrane endothelial keratoplasty rejection after SARS-COV2 infection or vaccination: 2-year retrospective study.

PURPOSE: To assess the incidence of Descemet's membrane endothelial keratoplasty (DMEK) rejection potentially associated with coronavirus disease 2019 (COVID-19) infection or vaccination, and its association with known rejection risk factors during the first two years of the pandemic. METHODS: This retrospective study included patients with DMEK rejection between January 2020 and December 2021. Diagnostic criteria were based on symptoms, visual acuity, and other clinical assessments. Risk factors for graft rejection were considered, and a telephone survey was conducted to identify possible preceding COVID-19 infection or vaccination. RESULTS: Of 58 patients, 44 were included. Six patients (14%) reported COVID-19 infection, with one immediate endothelial graft rejection (EGR) post-infection. After vaccine availability, 13 of 36 patients had EGR at an average of 2.7 months post-vaccination. Five (38%) had immediate EGR following vaccination, four of which had concomitant risk factors for rejection. CONCLUSION: Although the risk of endothelial graft rejection (EGR) associated with COVID-19 infection or vaccination appears to be extremely low, there may be a causative relationship, especially in patients with pre-existing risk factors for EGR. A temporary increase in anti-rejection treatment following COVID-19 infection or vaccination is recommended, especially in patients with pre-existing risk factors, along with closer monitoring during the subsequent 4 to 8 weeks.

Pre-Descemet's endothelial keratoplasty with glued intraocular lens implantation with pinhole pupilloplasty in a case of ocular comorbidity in achromatopsia.

Ocular comorbidities can happen as congenital defective gene associations. We present a 37-year-old female patient who was mentally challenged and had coexisting achromatopsia gene abnormality on genetic analysis. She was operated in childhood for congenital cataract, and posterior chamber intraocular lens (IOL) was implanted at 10 years of age elsewhere. The patient presented 27 years later with luxated IOL with endothelial decompensation. There was a coexisting steep and thin cornea noted on corneal topography. She was managed with pre-Descemet's endothelial keratoplasty with transpositioning of posterior chamber IOL to glued IOL with single-pass four-throw pupilloplasty. Postoperatively, the cornea was clear with centered glued IOL. The lesser postanesthetic challenges and faster rehabilitation are obtained in combination procedures with reduced complications in such rare scenarios.

Phakic anterior chamber intraocular lens removal with simultaneous posterior chamber phakic intraocular lens implantation and Descemet membrane endothelial keratoplasty.

The purpose of this study was to describe a case and clinical course of simultaneous anterior chamber phakic intraocular lens (AC-pIOL) removal, implantation of a posterior chamber phakic intraocular implantable collamer lens (ICL), and Descemet membrane endothelial keratoplasty (DMEK). This was a case report of a 44-year-old male with a unilateral decompensated cornea from a displaced Duet-Kelman lens on his left eye that underwent pIOL extraction and implantation of a posterior chamber phakic intraocular ICL and simultaneous DMEK. After 6 months, the cornea of the left eye had regained clarity, the Descemet membrane was graft stable, and the ICL implanted was centered with good vault. Postoperative anisometropia was avoided. There was no development of cataracts or other complications. The simultaneous pIOL extraction, ICL implantation, and DMEK in our case showed good results with full restoration of anterior segment anatomy and return of transparency of the cornea. The current case shows the feasibility of the simultaneous approach instead of sequential as an alternative for patients with endothelial disease associated with AC pIOLs, restoring vision and anatomy and also avoiding postoperative anisometropia.