Outcomes of cataract operations in extreme high axial myopia.

PURPOSE: To analyse the outcomes of phacoemulsification in extreme axial myopia METHODS: Consecutive cases of phacoemulsification in eyes with axial length ≥ 30.0 mm from January 1, 2010 to Dec 31, 2013 in a tertiary referral eye hospital were retrospectively reviewed. A single intraocular lens (IOL) type was used for all cases. Main outcome measures included perioperative complications and refractive outcome. RESULTS: Two hundred and twenty-one eyes were identified. Intraoperatively, two eyes (0.9 %) had unstable capsular bag and three (1.4 %) had posterior capsular rupture. At a mean follow-up duration was 27.4 ± 14.6 months, three eyes (1.5 % of 198 eyes with no history of retinal detachment or macular hole) developed retinal detachment. There was an overall hyperopic shift with a mean biometry error of 0.45 ± 1.21 D in all eyes. The mean absolute biometry prediction error was 0.98 ± 0.83 D in all eyes, 1.11 ± 0.86 D and 0.85 ± 0.82 D in eyes receiving negative- and positive-power IOL, respectively (p = 0.042). A total of 61.2 % of eyes had refractive outcome within ± 1.0 D of target spherical equivalent. Regression analysis showed low IOL power as an independent predictor for greater postoperative absolute biometry error (p = 0.014). CONCLUSIONS: We showed no increase in perioperative complications in eyes with extreme high axial myopia. In eyes with long axial length, implantation of IOL with lower power was associated with more hyperopic shift, which was more pronounced with negative-power IOL.

Intraocular lens explantation in Chinese patients: different patterns and different responses.

The aim of the study was to evaluate the indications and outcomes of intraocular lens (IOL) explantation in Chinese patients. The medical records of all Chinese patients who underwent IOL explantation in Hong Kong Eye Hospital, from January 2008 to March 2013, were reviewed. A total of 98 IOLs were explanted over the study period. The main reasons for lens removal included lens malposition (71.4%), isolated uveitis-glaucoma-hyphema (UGH) syndrome (9.1%), refractive surprise (6.1%), and pseudophakic bullous keratopathy (4.1%). "In-the-bag" IOL malposition was associated with intraocular complications during cataract extraction (28.9%) and high myopia (22.2%). Sulcus implantation of a single-piece acrylic (SPA) IOL resulted in UGH syndrome in all cases, while sulcus-fixated 3-piece lenses had such complication in only 7.1% of cases. Importantly, the problem persisted despite the removal of the SPA IOL from the ciliary sulcus. Majority of the patients had resolution of the original problems after lens removal or exchange and had the same or improved visual acuity after surgery. Lens malposition was the major indication of intraocular lens explantation in our case series. Resolution of symptoms and visual acuity can be achieved with IOL explantation. Implantation of SPA in ciliary sulcus is not recommended.

Accelerated corneal collagen cross-linking in progressive keratoconus: Five-year results and predictors of visual and topographic outcomes.

Purpose: To analyze the 5-year results of accelerated corneal collagen crosslinking (CXL) for progressive keratoconus and identify preoperative characteristics predictive of visual and topographic outcomes. Methods: A prospective interventional case series. Nineteen eyes of 19 patients receiving accelerated CXL with settings of 18 mW/cm2 for 5 min were included. Clinical and topographic parameters were assessed. Linear regression and logistic regression were used to compare the R2 and odds ratio (OR), respectively, between baseline characteristics and postoperative outcomes. Results: Corrected distance visual acuity (CDVA) remained stable from 0.28 ± 0.21 to 0.25 ± 0.18 logMAR (P = 0.486). The mean cylindrical refraction was stable (P = 0.119). The maximal keratometry (Kmax) decreased from 61.99 ± 10.37 to 59.25 ± 7.75 D (P < 0.001), flattening in the flattest and steepest meridians and mean keratometry were also observed (P ≤ 0.040). The mean anterior elevation at the apex reduced from 21.42 ± 16.69 to 18.53 ± 12.74 µm (P = 0.013) and changes in posterior elevation were non-significant (P = 0.629). Preoperative Kmax best predicted the postoperative change in Kmax (R2 = 0.55, P < 0.001) compared to the other baseline characteristics (P ≤ 0.028), whereas preoperative CDVA was the only significant predictor of postoperative change in CDVA (R2 = 0.41, P = 0.003). Accelerated CXL is less likely to fail in eyes with a steeper preoperative Kmax (OR = 0.74, P = 0.040) or greater posterior elevation at the apex (OR = 0.91, P = 0.042). Conclusion: Kmax significantly decreased following accelerated CXL. Eyes with worse preoperative CDVA and higher Kmax were more likely to have an improvement in visual acuity and corneal flattening.

Evaluation of Meibomian Gland Dysfunction Among Ophthalmic Healthcare Workers.

PURPOSE: To evaluate the prevalence of meibomian gland dysfunction (MGD) among ophthalmic healthcare workers. SETTING: A tertiary ophthalmic center. DESIGN: Prospective, observational study. METHODS: Forty-four volunteer ophthalmologists and ophthalmic nurses were recruited. Information including demographics, contact lens wear, history of refractive surgery and symptom score based on Standardized Patient Evaluation of Eye Dryness (SPEED) II Questionnaire for Dry Eye Disease/Ocular Surface Disease were recorded. Lipid layer thickness (LLT), meibomian glands dropout and dilation grades, and proportion of partial blinking were evaluated using an ocular surface interferometer with dynamic meibomian imaging (LipiView, Johnson & Johnson). Based on the chance of MGD, meibomian gland dropout and dilation, selected subjects also underwent treatment with a thermal pulsation system (LipiFlow, Johnson & Johnson) in one or both eyes. RESULTS: Eighty-eight eyes of 44 volunteers were evaluated during the study period. The mean LLT was 60.0nm. Twenty-seven (61.4%) subjects had a 90% or high chance of MGD and their mean lower lid meibomian gland dropout and dilation grades were 1.2 and 1.7, respectively. Twenty-eight eyes of 16 volunteers received treatment with the thermal pulsation system. Following treatment, the mean LLT improved from 50.3nm to 61.0nm (Wilcoxon's signed rank test, p=0.001). CONCLUSION: Despite being more knowledgeable to MGD and more accessible to treatment, MGD is a highly prevalent condition among ophthalmic healthcare workers, with a 61.4% prevalence among the recruited subjects. This is similar to reported prevalence in Asian populations of up to 74.5%. Targeted therapy based on dynamic meibomian imaging is effective in improving both objective and subjective measures of MGD.

Ophthalmology in the time of COVID-19: experience from Hong Kong Eye Hospital.

AIM: To review international guidelines and to share our infection control experience during the coronavirus disease 2019 (COVID-19) pandemic at a tertiary eye centre in Hong Kong. METHODS: Infection control guidelines and recommendations from international ophthalmological bodies are reviewed and discussed. The measures at our hospital were drawn up as per international and local health authorities' guidelines and implemented with the collaboration of doctors, nurses and administrative staff. RESULTS: The aims of our infection control measures are to 1) minimize cross-infection within the hospital; 2) protect and support hospital staff; 3) ensure environmental control. To minimize the risk of cross-infection, outpatient attendance and elective surgery have been reduced by 40%, and general anesthesia procedures were reduced by 90%. Patients entering the hospital are screened for fever, travel history, contact and cluster history, and COVID-19 related symptoms. To protect and support hospital staff, we ensure provision of adequate personal protective equipment (PPE) and provide clear guidelines on the level of PPE needed, depending on the clinical situation. Other protective measures include provision of work uniforms, easy access to alcohol-based hand rub, opening new lunch areas, implementation of self-monitoring and self-reporting systems, and communication via online education and updates. Finally, environmental control is achieved by ensuring regular disinfection of the hospital premise, enhancing ventilation, and usage of disposable ophthalmic instruments. CONCLUSION: Our multi-pronged approach to infection control is, so far, successful in minimizing infection risks, while allowing the maintenance of essential ophthalmic services.

Repositioning of free cap four days after LASIK.

PURPOSE: To report management and outcome of late repositioning of flap dislodgement after LASIK. METHODS: A 27-year-old man underwent LASIK in the right eye for correction of myopia, which was complicated by free cap. The flap was repositioned, but dislodged 2 days later. The dislodged flap was stored in balanced salt solution for 48 hours and repositioned 4 days after initial surgery. RESULTS: Postoperatively, the flap remained apposed, but diffuse lamellar keratitis and epithelial ingrowth developed, which was managed with topical steroids and topical mitomycin C. Stromal haze gradually decreased by 16 months postoperatively, resulting in best spectacle-corrected visual acuity of 20/20. CONCLUSIONS: Flap dislodgement > 48 hours postoperatively can be repositioned with good visual outcome. The flap should be preserved in the event of such complication.

Topical anesthesia-induced keratopathy after laser-assisted subepithelial keratectomy.

A 42-year-old woman had uneventful bilateral laser-assisted subepithelial keratectomy (LASEK) to correct myopia. She experienced intense pain in the first postoperative week and obtained topical oxybuprocaine for pain relief. Subsequently, she developed bilateral persistent corneal epithelial defects, epithelial edema, and bullae that failed to heal with bandage contact lens and topical lubricants. Over the next 4 months, there was progressive corneal stromal thinning and descemetocele formation in 1 eye, requiring application of cyanoacrylate glue, and stromal edema and scarring in the other eye, which resulted in a visual acuity of counting fingers. Investigations did not reveal associated infection or an underlying immunological disorder; however, the patient admitted to excessive use of topical anesthetic eyedrops in the post-LASEK period. She subsequently had penetrating keratoplasty and lens extraction with IOL implantation in the right eye. The left eye healed with central corneal scarring. This case illustrates that serious sight-threatening complications may occur after LASEK due to abuse of topical anesthetic agents.

Quality of reporting of key methodological items of randomized controlled trials in clinical ophthalmic journals.

PURPOSE: To evaluate the reporting quality of key methodological items in randomized controlled trials (RCTs) in four general clinical ophthalmology journals. METHODS: The reporting of 11 key methodological items in RCTs published in American Journal of Ophthalmology, Archives of Ophthalmology, British Journal of Ophthalmology and Ophthalmology in the year 2005 was assessed. RESULTS: Sixty-seven eligible RCTs were assessed and the mean number of items reported was 6.3 per RCT. No significant difference in the mean number of items reported was found between the four journals (P=0.20). The most frequently reported item was ethics approval and informed consent (97.0%), followed by masking status (85.1%), description of withdrawals (76.1%), adverse events (73.1%), and intention-to-treat analysis (71.6%). Details on sequence generation, randomization restriction, allocation concealment, allocation implementation, patient flow diagrams, and sample size calculation were reported in <50% of the RCTs assessed. Both sample size and page length of the RCTs correlated with the number of methodological items reported (P=0.024 and P=0.008, respectively). CONCLUSIONS: Similar to other specialties, rooms for improvement exist in the reporting of key methodological items of RCTs in clinical ophthalmic journals. Stricter adoption of the CONSORT statement might enhance the reporting quality of RCTs in ophthalmic journals.

Surgical management of double-head pterygium by using a novel technique: conjunctival rotational autograft combined with conjunctival autograft.

PURPOSE: To describe a novel technique for the surgical management of double-head pterygium and to evaluate its safety and efficacy. METHODS: A prospective noncomparative interventional case series was conducted. Patients with primary double-head pterygium underwent pterygium excision, followed by conjunctival rotational autograft (CRA) combined with conjunctival autograft (CA). CRA was harvested from the larger pterygium and placed over the bare scleral defect of the smaller pterygium with 180-degree rotation. The bare scleral defect of the larger pterygium was covered with CA harvested from the superior bulbar conjunctiva. Patients were followed up for 1 year, and the outcomes and recurrence rates were noted. RESULTS: Twenty patients were recruited into the study, of which 7 (35%) were men and 13 (65%) were women. The mean age was 63.8 years. No intraoperative complication was encountered. Postoperatively, there was significant improvement in best-corrected visual acuity (P = 0.005) and reduction in magnitude of astigmatism (P = 0.016). At 1 year after operation, there were 7 cases of recurrence (35%), but 4 were 1 mm. The main postoperative complication was persistent CRA injection in 9 cases. CONCLUSIONS: CRA combined with CA is a safe alternative in the management of double-head pterygium. Further modifications of the surgical techniques are warranted to decrease prolonged hyperemia of the CRA.

Trends and Determinants of Familial Consent for Corneal Donation in Chinese.

PURPOSE: Corneal transplantation is the treatment of choice for many corneal diseases. At present, there is a global shortage of corneal transplant tissues, and failure to obtain consent from families of potential donors is a major limiting factor in tissue procurement. METHODS: All family members of potential donors after cardiac death approached by the local eye bank staff members from January 2008 to December 2014 in Hong Kong were included. Reasons for consent or refusal and sociodemographic details of the deceased and the family members approached were reviewed. Trends in consent rates from 2008 to 2014 were examined. Multivariable logistic regression was performed to examine determinants of donation among cases from 2013 to 2014. RESULTS: A total of 1740 cases were identified. The overall consent rate was 36.8%, and the consent rate did not change significantly over the 7-year study period (P = 0.24). The most common reason for consent by family members was "the wish to help others" (86.0%), and the most common reason for refusal was "traditional Chinese culture to keep the body intact after death" (42.7%). From the multivariable analysis in the subset of cases from 2013 to 2014 (n = 628), family members were more likely to consent when the deceased was female (adjusted odds ratio 1.45, P = 0.03), with a do-not-resuscitate order (adjusted odds ratio 2.27, P < 0.001). CONCLUSIONS: The consent rate for eye donation did not change significantly from 2008 to 2014. Our findings suggest that health education and promotion campaigns need to address cultural barriers to organ donation.

How evidence-based are publications in clinical ophthalmic journals?

PURPOSE: To evaluate the methodological quality and level of evidence of publications in four leading general clinical ophthalmology journals. METHODS: All 1919 articles published in the American Journal of Ophthalmology, Archives of Ophthalmology, British Journal of Ophthalmology, and Ophthalmology in 2004 were reviewed. The methodological rigor and the level of evidence in the articles were rated according to the McMaster Hedges Project criteria and the Oxford Centre for Evidence-Based Medicine levels of evidence. RESULTS: Overall, 196 (24.4%) of the 804 publications that were included for assessment met the Hedges criteria. Articles on economics evaluation and those on prognosis achieved the highest passing rate, with 80.0% and 74.4% of articles, respectively, meeting the Hedges criteria. Publications on etiology, diagnosis, and treatment fared less well, with respective passing rates of 28.3%, 20.2%, and 14.7%. Published systematic reviews and randomized controlled trials were uncommon in the ophthalmic literature, at least in these four journals during 2004. According to the Oxford criteria, 57.6% of the articles were classified as level 4 evidence compared with 18.1% classified as level 1. Articles on prognosis had the highest proportion (43.0%) rated as level 1 evidence. Generally, articles that reached the Hedges threshold were rated higher on the level-of-evidence scale (Spermans rho = 0.73; P < 0.001). CONCLUSIONS: The methodological quality of publications in the clinical ophthalmic literature was comparable to that in the literature of other specialties. There was substantial heterogeneity in quality between different types of articles. Future methodological improvements should focus on the areas identified as having the largest deficiencies.

Prioritization of cataract surgery: visual analogue scale versus scoring system.

BACKGROUND: The purpose of the present paper was to evaluate the variability of using a visual analogue scale (VAS) and to assess the feasibility of a priority-setting scoring system for prioritizing elective cataract surgery. METHODS: Consecutive cases listed for cataract surgery were prospectively recruited. Ophthalmologists listed patients to undergo early or normal surgery and were asked to rate the urgency of surgery using a VAS. Patients were then reassessed and a cataract surgery prioritization (CSP) score was calculated based on the New Zealand priority criteria for cataract surgery. Correlation coefficients between VAS and CSP scores were calculated to determine the variability among ophthalmologists in using the VAS in prioritizing surgery. Further analyses were performed to assess the potential impact of implementing the CSP system. RESULTS: A total of 326 patients were recruited. There was a positive correlation between VAS and CSP scores (Spearman rho= 0.407, P < 0.001). A high degree of variation among ophthalmologists in the use of VAS was found. Patients with poor binocular vision were not listed as early, whereas patients with poor vision in the eye listed for cataract surgery but good vision in the fellow eye were more likely to be prioritized to have early operation. These findings suggest that patients with severe impairment in binocular visual function were not adequately accounted for during cataract surgery listing. CONCLUSIONS: The use of a VAS for prioritizing cataract surgery may be suboptimal due to high subjectivity. Adoption of an objective criteria-validated priority-setting scoring system may allow better stratification of patients to ensure better service provision.

One-year outcomes of conventional and accelerated collagen crosslinking in progressive keratoconus.

We compared one-year outcomes of conventional (3 mW/cm(2), 365-nm ultraviolet-A light, 30 minutes) and accelerated (18 mW/cm(2), 365-nm ultraviolet-A light, 5 minutes) collagen crosslinking (CXL) in patients with progressive keratoconus. Main outcome measures were change in keratometry, uncorrected visual acuity (UCVA), and best-corrected visual acuity (BCVA). Nineteen patients in each group completed 1-year follow-up. Preoperatively, there were no inter-group differences for age, keratometry, corneal thickness, and spherical equivalent (p > 0.127). One year postoperatively, maximum and minimum keratometry were flattened by 1.6 diopters (p < 0.023) and 2 diopters (p < 0.047) respectively after conventional CXL, and, 0.47 diopters (p = 0.471) and 0.19 diopters (p = 0.120) respectively after accelerated CXL. Association analysis showed significant negative association between baseline maximum keratometry and change in maximum keratometry after accelerated CXL (p = 0.002) but not after conventional CXL (p = 0.110). Corneal thickness was reduced significantly in both groups (p = 0.017). An improvement in UCVA (p < 0.001) and BCVA (p < 0.022) was noted in both groups along with a reduction in spherical equivalent postoperatively (p < 0.026). There were no inter-group differences for any of the parameters postoperatively (p > 0.184). Although no statistically significant differences were observed between both treatment modalities, a more effective topographic flattening was observed with conventional CXL as compared to accelerated CXL in this study.

Different Topographic Response Between Mild to Moderate and Advanced Keratoconus After Accelerated Collagen Cross-linking.

PURPOSE: To evaluate the clinical and topographic effects after accelerated corneal collagen cross-linking (CXL) in keratoconus. METHODS: This was a prospective interventional study in 25 eyes of 24 Asian patients with keratoconus, where 10 eyes in group 1 had mild to moderate keratoconus with the steepest keratometry reading (Kmax) < 58 diopters (D), and 15 eyes in group 2 had advanced keratoconus with Kmax ≥ 58.0 D. The patients underwent accelerated CXL with 18 W/cm UV-A light for 5 minutes. Clinical and topographic parameters were obtained before and 1 year after treatment. RESULTS: Overall, spectacle-corrected distance visual acuity, refraction, average keratometry readings, Kmax, anterior elevation at the apex, and corneal endothelial cell density remained stable (P < 0.102). Posterior elevation at the apex increased at 1 year (P = 0.002). The thinnest pachymetry readings also showed significant reduction (P < 0.001). Kmax in group 1 increased by 1.00 ± 1.63 D (range, -2.2 to 5.4 D; P = 0.012), whereas Kmax in group 2 reduced by 1.69 ± 2.61 D (range, -8.4 to 3.2 D; P = 0.013) at 1 year after accelerated CXL. The change in Kmax between the 2 groups was significantly different (P < 0.001). There was no intergroup difference for the change in other parameters. A significant correlation was found between the preoperative Kmax and postoperative change in Kmax at 1 year (r = -0.648; P < 0.001). CONCLUSIONS: Accelerated CXL seems to be effective in preventing progression and causing topographic flattening in advanced cases of keratoconus but not as effective in the less progressed counterparts.

Orthokeratology-associated infectious keratitis in a tertiary care eye hospital in Hong Kong.

PURPOSE: To analyze cases of orthokeratology-associated infectious keratitis managed in a tertiary care eye hospital in Hong Kong between 2003 and 2013. DESIGN: Retrospective study. METHODS: Case records of patients with infectious keratitis attributable to orthokeratology contact lenses were analyzed. Data analyzed included clinical features, microbiological evaluation, and treatment outcomes. RESULTS: A total of 23 patients were included (16 female, 7 male, mean age: 15.0 ± 4.2 years; range: 9-23 years). All patients were using overnight orthokeratology for an average of 2.7 ± 2.8 years (range: 3 months - 10 years) before the onset of infection. Clinical features included corneal infiltrate (n = 14, 60.9%) and corneal perineuritis (n = 12, 52.2%). Fifteen eyes (65.2%) had a positive microbiological culture obtained from corneal scrapings. The most commonly isolated organism was Pseudomonas aeruginosa (n = 6), followed by coagulase-negative Staphylococcus (n = 5) and Acanthamoeba (n = 3). Five cases of Pseudomonas aeruginosa and 5 cases of Acanthamoeba were identified from contact lenses or contact lens solution. The mean duration from disease onset to remission was 31.9 ± 34.9 days (range: 6-131 days). All patients responded to medical treatment, and no emergency surgical intervention was needed. The best-corrected logMAR visual acuity improved significantly from 0.62 ± 0.51 (20/83 Snellen) to 0.15 ± 0.20 (20/28 Snellen) (Wilcoxon signed rank test, P < .001). CONCLUSIONS: Orthokeratology-associated infectious keratitis continues to be a serious problem, especially in regions with high prevalence of myopia. Early clinical and microbiological diagnosis and intensive treatment can improve final visual outcomes.

The Association of Delayed Corneal Surface and Visual Recovery After Corneal Transplantation With Longer Donor Storage Time-A Prospective Analysis.

PURPOSE: This study aimed to assess the influence of donor corneal storage time on endothelial cell count (ECC), corneal epithelial recovery, and visual rehabilitation after corneal transplantation in the first postoperative year. DESIGN: A collaborative prospective study involving a local eye bank and a tertiary ophthalmic unit was conducted. METHODS: Donor cornea buttons were stored in Optisol-GS (Chiron Ophthalmics Inc, Irvine, Calif) storage media for a maximum of 14 days before transplantation. Before corneal distribution, the eye bank collected information on death-to-harvesting time, death-to-surgery time, donor central corneal thickness, and donor ECC at various time points. Subjects who underwent penetrating keratoplasty and endothelial keratoplasty were recruited and monitored for 1 year. Postoperative epithelial healing, visual acuity, ECC, and hospital stay were evaluated. RESULTS: Thirty-one eyes of 31 patients completed the study. There was a significant positive correlation between donor storage time and epithelial healing (Spearman ρ = 0.39, P = 0.031). Faster epithelial healing was significantly correlated with posttransplantation visual improvements at months 1, 3, and 6 and shorter hospital stay (Spearman ρ = 0.74, P < 0.001). Mean ECC loss was 23.8% at 12 months posttransplantation. There was no significant correlation between storage time and ECC loss preoperatively and posttransplantation. CONCLUSIONS: The duration of graft storage in Optisol-GS storage media up to 14 days had no significant effects on long-term visual acuity and ECC postoperatively. Shorter storage time had significant correlation with earlier epithelial healing and faster visual rehabilitation.

Intraoperative pachymetry using spectral-domain optical coherence tomography during accelerated corneal collagen crosslinking.

PURPOSE: To evaluate the role of spectral-domain optical coherence tomography (SDOCT) to measure corneal thickness during accelerated corneal crosslinking (CXL). METHODS: Intraoperative pachymetry was performed using SDOCT and ultrasound pachymetry (USP) in 6 eyes of 6 patients with keratoconus. Pachymetry readings were obtained at baseline, after epithelium removal and after 30 minutes of riboflavin instillation. SDOCT measurements of eyes with and without lid speculum during riboflavin instillation were compared. RESULTS: There was no statistically significant difference in central corneal thickness (CCT) measurements between SDOCT and USP (P > 0.05 for all). A significant decrease in both CCT (P = 0.031) and the thinnest corneal thickness (TCT) (P = 0.031) was observed during CXL. There was a greater reduction in CCT (38 ± 6%) with the use of lid speculum as compared to the no-speculum eyes (18 ± 9%) (P = 0.100). TCT was also reduced by a greater extent with the use of lid speculum (40 ± 5% versus 26 ± 7%; P = 0.100). CONCLUSION: SDOCT can be successfully used to measure intraoperative corneal pachymetry during corneal CXL. SDOCT measurements demonstrated corneal thinning intraoperatively during CXL, which was further accentuated by the use of a lid speculum during the procedure.

Comparison of the Surgical Outcomes of Various Methods of Endothelial Keratoplasty.

PURPOSE: The objective of this study was to evaluate the outcomes of various techniques of endothelial keratoplasty (EK) including deep lamellar endothelial keratoplasty (DLEK), Descemet stripping endothelial keratoplasty (DSEK), and Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: This was a retrospective comparative case series. METHODS: The medical records of 48 consecutive patients who have undergone EK in a tertiary eye center between January 2005 and June 2011 were reviewed. Information related to demographics, visual acuity, corneal endothelial cell count, and postoperative complications was recorded. RESULTS: The series included 11 eyes with DLEK, 11 eyes with DSEK, and 26 eyes with DSAEK. There was no significant difference in visual outcomes, endothelial cell loss, and postoperative complications between the 3 groups 1 year after surgery. The mean logMAR visual acuity at 12 months was 0.54 (SD, 0.26) for DLEK, 0.55 (SD, 0.47) for DSEK, and 0.63 (SD, 0.48) for DSAEK, respectively. The 6-month endothelial cell density loss was 48.4%, 39.2%, and 47.5% for the DLEK, DSEK, and DSAEK groups, respectively. Early postoperative graft dislocation occurred in 1 (9%) of the DLEK cases, 2 (18%) of the DSEK cases, and 1 (4%) of the DSAEK cases. All of these cases were successfully repositioned. CONCLUSIONS: Despite the various evolution and surgical modifications and development in EK in the past few years, the visual outcomes and postoperative complications between DLEK, DSEK, and DSAEK were comparable.