Management of corneal melting after collagen cross-linking for keratoconus: a case report and a review of the literature.

PURPOSE: We describe the management of a case of severe corneal melting after corneal cross-linking (CXL) treated with a staged approach using a conjunctival flap followed by deep anterior lamellar keratoplasty (DALK). METHODS: A 12-year-old male developed severe corneal melting with pending perforation after an accelerated epithelium-off CXL protocol. We initially treated the patient with a conjunctival flap to prevent perforation. Three months later, we performed DALK to restore vision. RESULTS: Conjunctival flap surgery allowed us to avoid corneal perforation and penetrating keratoplasty (PK) à chaud. Once the inflammation had resolved, we recessed the conjunctiva and performed DALK for optical purposes. Twelve months later, the graft was clear and the corrected visual acuity was 20/25 (Snellen). No complications occurred after surgery. CONCLUSIONS: Although CXL is considered a safe procedure, in rare cases it can lead to serious complications, such as corneal haze, infectious and non-infectious keratitis, stromal melting and perforation. Corneal melting and perforation are usually managed by emergency PK. Herein we suggest a staged approach involving an emergency conjunctival flap followed by DALK at a later time that allowed us to avoid PK à chaud.

Corneal densitometry measurements comparison between anterior segment OCT and scheimpflug imaging.

PURPOSE: To evaluate and compare the repeatability of corneal densitometry (CD) measurements obtained using both an anterior-segment optical coherence tomography (AS-OCT) device and a Scheimpflug camera system, while also assessing the level of agreement. The study also sought to investigate the correlation of CD with age, gender, and central corneal thickness (CCT) in normal eyes. METHODS: CD measurements were obtained using the Casia 2 and the Pentacam AXL Wave. Data were collected on Total Corneal Densitometry and 4 concentric corneal annular areas, these are referred to as zone 1, denoting the central area, through to zone 4, designating the outermost peripheral region. Repeatability was assessed using intra-session test-retest variability, coefficient of variation (CoV), and intraclass correlation coefficient (ICC). The agreement was evaluated using Bland-Altman plots. Correlation analysis was performed between CD, age, gender, and CCT. RESULTS: The study included 96 healthy volunteers. The Casia 2 demonstrated high repeatability with ICC values exceeding 0.9 in all the corneal zones and lower CoV values compared to the Pentacam AXL Wave (ranging from 1.07% to 2.25% for Casia 2 and from 1.91% to 6.89% for Pentacam).95% LoA were within ± 2 standard deviation from the average mean except from zone 1 (± 2.42).However, the measurements showed a consistent bias among all the corneal zones. CD values were positively correlated with age, except for zone 1 with the Pentacam (p = 0.083). CONCLUSIONS: The findings suggest that the Casia 2 can be a reliable tool for assessing corneal transparency in healthy individuals, however its measurements are not interchangeable with those provided by the Pentacam. The AS-OCT device may be more sensitive in detecting subtle age-related changes in CD within the central zone.

Incidence and management of early postoperative complications in lamellar corneal transplantation.

PURPOSE: To provide a comprehensive review of the incidence, risk factors, and management of early complications after deep anterior lamellar keratoplasty (DALK), Descemet stripping automated keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK). METHODS: A literature review of complications, that can occur from the time of the transplant up to 1 month after the transplant procedure, was conducted. Case reports and case series were included in the review. RESULTS: Complications in the earliest postoperative days following anterior and posterior lamellar keratoplasty have shown to affect graft survival. These complications include, but are not limited to, double anterior chamber, sclerokeratitis endothelial graft detachment, acute glaucoma, fluid misdirection syndrome, donor-transmitted and recurrent infection, and Uretts-Zavalia syndrome. CONCLUSION: It is essential for surgeons and clinicians to not only be aware of these complications but also know how to manage them to minimize their impact on long-term transplant survival and visual outcomes.

Gonioscopy-assisted transluminal trabeculotomy for chronic angle-closure glaucoma: preliminary results.

PURPOSE: To report the preliminary results of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with chronic angle-closure glaucoma (CACG). METHODS: Retrospective, single-center, case series of GATT procedures is performed on patients with CACG. The primary outcome was intraocular pressure (IOP). Success was defined as IOP reduction >30% from baseline at 6 and 12 months with (qualified) or without (complete) glaucoma medication. Secondary outcomes were best-corrected visual acuity (BCVA), visual field (VF), peripheral anterior synechiae (PAS), medications, and complications. RESULTS: Fifteen eyes (15 patients) with a minimum follow-up of 1 year were included for the analysis. Preoperatively, the mean (±SD) IOP was 30.27 (±4.20) mmHg and 15.20 (±2.08) mmHg at 1 year postoperatively (p<0.001). The mean (±SD) percentage of IOP reduction from baseline was 49% (±9.41). At 6 and 12 months, the success rate complete and qualified was 93% (73% and 20%) and 100% (73% and 27%), respectively. BCVA and VF mean deviation were comparable before and after surgery (p=0.167 and p= 0.710, respectively). The median (range) number of glaucoma drugs decreased from 3 (3-4) before to 0 (0-2) after GATT (p<0.001). The absence of PAS was observed in 80% of patients after surgery. Transient hyphema was a common complication requiring aspiration in one case. CONCLUSION: At 12 months of follow-up, our preliminary results indicate that GATT in CACG effectively reduces the IOP and the number of medication with a low risk of complications. Following ab interno trabeculotomy, an open-angle without PAS was achieved in the majority of patients. TRIAL REGISTRATION NUMBER: nr. 2016/0010904.

Malignant glaucoma following gonioscopy-assisted transluminal trabeculotomy: a case report.

BACKGROUND: To report a case of malignant glaucoma that developed after gonioscopy-assisted transluminal trabeculotomy (GATT). CASE PRESENTATION: An 85-year-old male pseudophakic patient affected by pseudoexfoliative glaucoma (PEXG), unresponsive to medical glaucoma treatment, underwent uneventful GATT surgery. On the first day after surgery, the eye showed a shallow central and peripheral anterior chamber (AC) with a raised intraocular pressure (IOP) measured at 55 mmHg. Optical coherence tomography and ultrasound biomicroscopy confirmed the diagnosis of malignant glaucoma. Laser iridotomy, posterior capsulotomy and hyaloidotomy were performed, and the patient was treated with atropine sulphate 1%, maximum topical and systemic ocular hypotensive drugs with no improvement in the IOP. Subsequently, the patient underwent pars plana anterior vitrectomy, resulting in deepening of the AC with opening of the iridocorneal angle and decrease of the IOP. No further postoperative complications were recorded, and the IOP remained controlled 12 months after surgery without antiglaucoma medications. CONCLUSIONS: Despite the minimally invasive profile of GATT, malignant glaucoma may develop after this procedure. Early recognition and prompt treatment are mandatory for preventing permanent visual loss.

How direct measurements of worker eyes with a Scheimpflug camera can affect lensdose coefficients in interventional radiology.

The 2013/59/Euratom Directive reduced the occupational exposure limits for the lens. Since it has become crucial to estimate the dose absorbed by the lens, we have studied the individual variability of exposed workers' ocular conformations with respect to the data estimated from their personal dosimetry. The anterior eye conformations of 45 exposed workers were acquired using Scheimpflug imaging and classified according to their sight conditions (emmetropia, myopia or hypermetropia). Three eye models were computed, with two lens reconstructions, and implemented in an interventional radiology scenario using Monte Carlo code. The models were dosimetrically analysed by simulating setup A, a theoretical monoenergetic and isotropic photon source (10-150 keV) and setup B, a more realistic interventional setting with an angiographic x-ray unit (50, 75, 100 kV peak). Scheimpflug imaging provided an average anterior chamber depth of (6.4 ± 0.5) mm and a lens depth of (3.9 ± 0.3) mm, together with a reconstructed equatorial lens length of (7.1-10.1) mm. Using these data for model reconstruction, dose coefficients (DCs) were simulated for all ocular structures. Regardless of the eye model used, the DCs showed a similar trend with radiation energy, which highlighted that for the same energy and setup, no significant dependence on ocular morphology and workers' visual conditions was observed. The maximum difference obtained did not exceed 1% for all eye models or structures analysed. Therefore, the individual variabilities of worker ocular anatomy do not require any additional correction, compared to the personal dosimetry data measured with a dedicated lens dosimeter. To estimate the dose absorbed by the other eye structures, it is, instead, essential to know the spectrum of the source that has generated the irradiation, since there are differences between monoenergetic sources and more realistic angiographic units.

Excisional penetrating keratoplasty for fungal interface keratitis after endothelial keratoplasty: surgical timing and visual outcome.

PURPOSE: In this paper, we describe two cases of fungal interface infectious keratitis (IIK) developed after endothelial keratoplasty (EK) who underwent delayed therapeutic penetrating keratoplasty (TPK) with a poor visual outcome. Furthermore, we conducted a review of the literature and analyzed the visual outcomes of TPK in relation to the time from IIK diagnosis. METHODS: We searched the literature for fungal IIK cases occurred after EK and treated by TPK. We identified 17 cases of fungal IIK, mostly caused by Candida spp. (88%). RESULTS: Infection was diagnosed at a median time of 21 (range 1-90 days) days after EK. The median lag time between infection diagnosis and TPK was 30 (range 7-393) days. The median distance corrected visual acuity (DCVA) measured 4-12 months after surgery was 20/40 (range 20/200-20/20). When TPK was performed within one month from diagnosis, the final median DCVA was 20/30 (range 20/100-20/20), with 83% of patients achieving ≥ 20/40 vision. When TPK was carried out later, the final median DCVA was 20/50 (range 20/200-20/22) with 44% of patients achieving ≥ 20/40 vision. One patient in the early surgery and four patients in the late surgery group showed postoperative DCVA ≤ 20/100 despite clear grafts. CONCLUSION: TPK with removal of the sequestered infection is advocated as a safe and effective measure to treat a post-EK infection. Early surgery allows a reduced exposure time to infection and therefore may result in better visual outcomes and lower risk of complications caused by prolonged inflammation.

Iridocorneal endothelial syndrome in a patient with keratoconus - a case report.

BACKGROUND: To describe a case of a rare association of bilateral keratoconus and unilateral essential iris atrophy and to conduct a literature review of the current strategies of treatment of the corneal disease and glaucoma in patients with Iridocorneal Endothelial Syndrome (ICE). CASE PRESENTATION: We report a rare association of bilateral keratoconus and unilateral essential iris atrophy in a 38-year-old man. Diagnosis of bilateral keratoconus was confirmed by corneal topography. Slit-lamp examination showed extensive iris atrophy with corectopia and policoria in one eye. Corneal specular microscopy revealed an abnormal endothelium morphology in the same eye with extensive peripheral anterior synechiae and closure of the drainage angle at gonioscopy. Intraocular pressure was 26 mmHg, despite maximal topical therapy. Optic disc examination showed severe glaucomatous cupping. Surgery by glaucoma drainage device implantation was performed. CONCLUSION: Essential iris atrophy is a rare clinical variant of ICE syndrome characterized by profound anatomical alterations of the anterior segment associated with corneal edema and secondary glaucoma. In these patients, selective keratoplasties have replaced penetrating keratoplasty to treat corneal decompensation and glaucoma drainage devices are preferred to conventional trabeculectomy for the treatment of secondary glaucoma.

Increased expression of interleukin-22 in patients with giant cell arteritis.

Objectives: GCA is characterized by arterial remodelling driven by inflammation. IL-22 is an attractive cytokine which acts at the crosstalk between immune and stromal cells. We hypothesized that IL-22 might be induced in GCA and might be involved in disease pathogenesis. Methods: Patients subjected to temporal artery biopsies (TABs) naïve from therapy were enrolled: 27 biopsy-proven GCA, 8 biopsy-negative GCA, 21 biopsy-negative non-GCA patients. Expression of IL-22 was determined in TABs by immunohystochemistry, in plasma by ELISA, in peripheral blood mononuclear cells by real-time PCR and flow cytometry. Effects of IL-22 on viability and gene expression of primary cultures obtained from TABs were also evaluated. Results: Inflamed TABs from GCA patients showed a higher expression of IL-22 and IL-22 specific receptor subunit (IL-22R1) than non-inflamed TABs. IL-22 was expressed in infiltrating immune cells and spindle shaped cells, IL-22R1 was expressed in endothelial cells. Patients with biopsy-proven GCA showed increased levels of IL-22 in plasma than patients with biopsy-negative GCA, without GCA and healthy subjects. Peripheral blood mononuclear cells from GCA patients expressed higher IL-22 transcript than healthy subjects. After stimulation in vitro with phorbol 12-myristate 13-acetate and ionomycin, the frequencies of Th22 and IL-22+ CD4+ lymphocytes were similar between patients with and without GCA. Treatment with IL-22 of primary cultures obtained from TABs increased cell viability under stress conditions and expression of B-cell activating factor. Conclusion: IL-22 is increased in patients with GCA and affects viability and gene expression of arterial cells, supporting a potential role in disease pathogenesis.

MicroRNA markers of inflammation and remodelling in temporal arteries from patients with giant cell arteritis.

OBJECTIVES: There is increasing evidence that microRNAs (miRNAs) are deregulated in autoimmune and cardiovascular diseases. The present study aimed to identify if miRNAs are deregulated in giant cell arteritis (GCA), a vasculitis affecting large-sized and medium-sized arteries, and to determine if miRNA levels might allow to discriminate between patients with GCA and those without. METHODS: 58 patients who had temporal artery biopsy (TAB) for suspected GCA were included in the study and divided into three groups: patients with TAB-positive GCA showing a transmural inflammation (n=27), patients with TAB-negative GCA (n=8) and TAB-negative non-GCA patients with a final diagnosis different from GCA (n=23). To identify candidate miRNAs deregulated in GCA, we profiled the expression of 1209 miRNAs in inflamed TABs and normal TABs. Selected miRNAs were then validated by real-time PCRs and in situ hybridisation (ISH). RESULTS: MiR-146b-5p, -146a, -155, -150, -21 and -299-5p were significantly more expressed in inflamed TABs from patients with GCA. miRNAs were mainly deregulated at the tissue level because peripheral blood mononuclear cells and polymorphonuclear cells from the three groups of patients and age-matched healthy controls had similar levels of miRNAs. ISH showed that miR-21 was mainly expressed by cells in the medial and intimal layers of inflamed TABs. Patients with TAB-negative GCA had a miRNA profile similar to TAB-negative non-GCA patients. CONCLUSIONS: MiR-146b-5p, -146a, -21, -150, -155, -299-5p are overexpressed in the presence of inflammation in TABs from patients with GCA.

The purinergic P2×7 receptor is expressed on monocytes in Behçet's disease and is modulated by TNF-α.

The P2×7 receptor (P2×7r) is expressed in innate immune cells (e.g. monocyte/macrophages), playing a key role in IL-1ß release. Since innate immune activation and IL-1ß release seem to be implicated in Behçet's disease (BD), a systemic immune-inflammatory disorder of unknown origin, we hypothesized that P2×7r is involved in the pathogenesis of the disease. Monocytes were isolated from 18 BD patients and 17 healthy matched controls. In BD monocytes, an increased P2×7r expression and Ca(2+) permeability induced by the selective P2×7r agonist 2'-3'-O-(4-benzoylbenzoyl)ATP (BzATP) was observed. Moreover, IL-1ß release from LPS-primed monocytes stimulated with BzATP was markedly higher in BD patients than in controls. TNF-α-incubated monocytes from healthy subjects almost reproduced the findings observed in BD patients, as demonstrated by the increase in P2×7r expression and BzATP-induced Ca(2+) intake. Our results provide evidence that in BD monocytes both the expression and function of the P2×7r are increased compared with healthy controls, as the possible result, at least in part, of a positive modulating effect of TNF-α on the receptor. These data indicate P2×7r as a new potential therapeutic target for the control of BD, further supporting the rationale for the use of anti-TNF-α drugs in the treatment of the disease.

Predicting Long-Term Endothelial Cell Loss after Preloaded Descemet Membrane Endothelial Keratoplasty in Fuchs' Endothelial Corneal Dystrophy: A Mathematical Model.

(1) Background: This study offers a biexponential model to estimate corneal endothelial cell decay (ECD) following preloaded "endothelium-in" Descemet membrane endothelial keratoplasty (DMEK) in Fuchs' endothelial corneal dystrophy (FECD) patients; (2) Methods: A total of 65 eyes undergoing DMEK alone or combined with cataract surgery were evaluated. The follow-up period was divided into an early phase (first 6 months) and a late phase (up to 36 months). Endothelial cell count (ECC) and endothelial cell loss (ECL) were analyzed; (3) Results: The half time of the ECD was 3.03 months for the early phase and 131.50 months for the late phase. The predicted time-lapse interval to reach 500 cells/mm2 was 218 months (18.17 years), while the time-lapse interval to reach 250 cells/mm2 was 349 months (29.08 years). There was no statistically significant difference between the ECL in DMEK combined with cataract extraction and DMEK alone at 24 months (p ≥ 0.20). At the late phase, long-term ECL prediction revealed a lower ECC half time in patients undergoing DMEK combined with cataract surgery (98.05 months) than DMEK alone (250.32 months); (4) Conclusions: Based on the mathematical modeling, a predicted average half-life of a DMEK graft could reach 18 years in FECD. Moreover, combining cataract extraction with DMEK could result in excessive ECL in the long term.

Efficacy of the Combined Intrastromal Injection of Voriconazole and Amphotericin B in Recalcitrant Fungal Keratitis.

This study aims to report the efficacy of a combined intrastromal injection in optimizing the outcome of severe mycotic keratitis. Herein, we report a case series of 20 consecutive patients with positive fungal cultures not responding to topical antifungal treatment. Patients received cycles of intrastromal injections of voriconazole (50 µg/0.1 mL) and amphotericin B (2.5 µg/0.1 mL); all patients continued their topical antifungal therapy. The organisms isolated were Fusarium (n = 5), Aspergillus (n = 4), Candida (n = 4), Rhodotorula (n = 2), Penicillium (n = 2), Alternaria (n = 1), Bipolaris (n = 1), and Curvularia (n = 1). The size of the infiltrate varied from 6.5 to 1.5 mm. At presentation, the best corrected visual acuity (BCVA, namely, the best visual acuity achieved with glasses, if needed) was less than 20/400 in all patients, improving to better than 20/400 in eleven patients. Seven patients required surgical intervention; four of them underwent penetrating keratoplasty (PK) à chaud one month after the first intrastromal injection. Patients who underwent surgery achieved a BCVA of 20/40 or better. Combined intrastromal injections before therapeutic penetrating keratoplasty (TPK) effectively reduced ulcer size and graft diameter, preventing infection recurrence. Our results highlight the efficacy of combined intrastromal injections in optimizing outcomes for severe mycotic keratitis undergoing TPK.

Comparison of Keratometry and Total Corneal Power, as measured by a swept-source OCT-based optical biometer, for IOL power calculation in Asian eyes.

PURPOSE: To investigate whether standard keratometry (K) or total corneal power (TCP) lead to more accurate refractive outcomes for intraocular lens (IOL) power calculation. SETTING: Public hospital. DESIGN: Retrospective evaluation of a diagnostic test instrument. METHODS: Preoperatively all patients underwent optical biometry with the Anterion (Heidelberg), a swept-source optical coherence tomographer providing both K and TCP. The same IOL model was implanted in all cases. The whole sample was divided into a training dataset, used to optimize the formula constants, and a testing dataset, used to investigate the spherical equivalent prediction error (SEQ-PE) of 8 IOL power formulas. Trueness, precision and accuracy were evaluated by means of the robust two-sample t-test. Cochran's Q test was performed to assess whether the percentage of eyes with an SEQ-PE within each threshold was significantly different; in such an event, the McNemar test was then applied. RESULTS: Both the training and testing datasets included 317 eyes. No significant differences were detected for trueness, due to constant optimization. Precision and accuracy were better when K was entered, although a statistically significant difference was observed only with the EVO (precision: p = 0.02 and accuracy: p = 0.03) and Haigis formula (p <0.01 for both precision and accuracy). No significant differences were observed for the percentage of eyes with an absolute SEQ-PE within any threshold. CONCLUSIONS: With most formulas, IOL power calculation is not more accurate when TCP is used instead of K.

Retrolental cohesive ophthalmic viscoelastic injection for severe subluxated cataracts: a prospective study.

BACKGROUND: To assess anatomical and functional outcomes of retrolental cohesive ophthalmic viscoelastic injection ("Viscolift technique") in patients with severely subluxated cataracts. METHODS: In the present prospective study, we included patients older than 18 years with severely subluxated cataracts and phacodonesis. Full medical history was obtained at the baseline ophthalmological assessment. A single 25-gauge valved trocar was inserted 4 mm from the limbus and a 27G angled cannula was introduced through the trocar into the retrolental space, while cohesive viscoelastic was progressively injected, in order to center and elevate the cataract to facilitate capsulorhexis. After complete phacoemulsification, a 3-piece intraocular lens (IOL) with a scleral fixated Cionni ring or FIL-SSF scleral fixated IOL was implanted. Patients follow-up interval was 6 months after surgery. RESULTS: Thirteen eyes of 13 patients were enrolled in the study, mean age was 61.5 ± 9.4 years and 53.8% were females. The "Viscolift technique" resulted in centered and more stable cataracts in all cases (100%). After complete phacoemulsification, 61.5% of patients were implanted with a 3-piece IOL with Cionni ring, and 38.5% with a FIL-SSF scleral fixated IOL after complete 25G vitrectomy. Mean BCVA improved from 0.5 ± 0.1 LogMar (20/63 Snellen) to 0.1 ± 0.1 LogMar (20/25 Snellen) (p < 0.001) at the last follow-up. No major complications were noted. CONCLUSIONS: The "Viscolift technique" proved to be a safe and effective surgical approach for recentering and elevating subluxated cataracts, thus allowing the surgeon to perform an easier and better-centered capsulorhexis.

Systematic Preserflo MicroShunt Intraluminal Stenting for Hypotony Prevention in Highly Myopic Patients: A Comparative Study.

Transient hypotony is the most common early complication after Preserflo MicroShunt (PMS) implantation. High myopia is a risk factor for the development of postoperative hypotony-related complications; therefore, it is advisable that PMS implantation in patients should be performed while employing hypotony preventive measures. The aim of this study is to compare the frequency of postoperative hypotony and hypotony-related complications in high-risk myopic patients after PMS implantation with and without intraluminal 10.0 nylon suture stenting. This is a retrospective, case-control, comparative study of 42 eyes with primary open-angle glaucoma (POAG) and severe myopia that underwent PMS implantation. A total of 21 eyes underwent a non-stented PMS implantation (nsPMS), while in the remaining eyes (21 eyes), PMS was implanted with an intraluminal suture (isPMS group). Hypotony occurred in six (28.57%) eyes in the nsPMS group and none in the isPMS group. Choroidal detachment occurred in three eyes in the nsPMS group; two of them were associated with the shallow anterior chamber and one was associated with macular folds. At 6 months after surgery, the mean IOP was 12.1 ± 3.16 mmHg and 13.43 ± 5.22 mmHg (p = 0.41) in the nsPMS and isPMS group, respectively. PMS intraluminal stenting is an effective measure to prevent early postoperative hypotony in POAG highly myopic patients.

Double-flanged knotless technique for iris prosthesis and IOL implantation associated with keratoplasty.

INTRODUCTION: Anterior segment reconstruction and penetrating keratoplasty combined with iris prosthesis (IP) and intraocular lens (IOL) scleral fixation require prolonged open-sky surgery and complex suturing. Herein we present a novel double-flanged knotless surgical technique that minimizes the open sky duration and facilitates the fixation of the IP and IOL complex to the sclera. METHODS: After corneal trephination and removal, a temporary keratoprosthesis is fixated. Three 5.0 polypropylene suture segments are introduced in the anterior chamber transconjunctivally and then externalized through keratoprosthesis. Each suture is threaded through the eyelets of the IP and then flanged. The temporary keratoprosthesis is removed, and the IP and IOL complex is positioned in the sulcus. A donor cornea button is sutured in place and the IP is centred on the optical axis by adjusting the polypropylene sutures. Finally, the suture ends are shortened, flanged, and buried under the conjunctiva. RESULTS: Surgery was performed on three eyes of three patients. No intraoperative complications occurred, while cystoid macular edema and ocular hypertension occurred in two patients during the follow-up period. The best corrected visual acuity was 6/20, 8/20, and 13/20. So far the IPs remained stable in the three eyes with a maximum follow-up of 18 months. CONCLUSION: This novel technique of penetrating keratoplasty combined with an intraocular lens (IOL) and iris prosthesis implantation makes it possible to reduce open sky surgery time, avoid complex suturing, and ensure optimal IOL visual axis alignment by adjusting suture tension.

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

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

Yogurt Technique for Descemet Membrane Endothelial Keratoplasty Graft Preparation: Early Clinical Outcomes.

PURPOSE: The aim of this study was to evaluate the efficacy and safety of the Yogurt technique for Descemet membrane endothelial keratoplasty (DMEK) graft preparation. METHODS: This study included patients who underwent DMEK combined or not with phacoemulsification surgery using donor tissues prepared by a surgeon with the DMEK Tzamalis disposable punch at 2 referral hospitals between October 2019 and June 2021. Primary outcomes were duration of graft preparation, surgeon grading of graft quality, and endothelial cell density measured at 1 and 6 months after surgery. Secondary outcomes were best-corrected visual acuity (BCVA) measured at 1 and 6 months postoperatively and DMEK intraoperative and postoperative complications. RESULTS: Forty-nine patients were included in this study. The mean DMEK graft preparation time was 7.2 ± 1.4 minutes. Donor grafts were rated good in 67.3% of cases (33 of 49), sufficient in 24.5% (12 of 49), and poor in 8.2% (4 of 49). Donor mean endothelial cell density was 2580 ± 155 preoperatively, which were reduced to 2269 ± 191 ( P < 0.000) and 1697 ± 142 ( P < 0.0001) at 1 and 6 months, respectively. No significant difference was found in graft preparation outcome ( P = 0.543). The preoperative BCVA was 0.65 ± 0.44 logMAR, which improved to 0.31 ± 0.43 logMAR ( P < 0.0001) and 0.12 ± 0.14 logMAR ( P < 0.0001) at 1 and 6 months after surgery, respectively. CONCLUSIONS: This study shows that the DMEK Tzamalis punch can be used as an effective and safe method for DMEK graft preparation with a shallow learning curve that allows it to be successfully performed by relatively inexperienced surgeons.