Ten Years of Experience With Buprenorphine in a Private Psychiatric Outpatient Practice.

BACKGROUND AND OBJECTIVES: There have been few reports of buprenorphine treatment of opioid use disorder in private psychiatric practice. This report describes such a patient population and the outcomes obtained. METHODS: Chart reviews were performed on 285 patients seen over a 10-year period in the author's solo private psychiatric practice. Quantitative and qualitative data were reviewed and analyzed. RESULTS: Comorbidity of psychiatric disorders was high (75%), while comorbidity of substance use disorders was low (5%, alcohol only). Fourteen percent of patients completed treatment (tapered off of buprenorphine and remained opioid-free for up to 7 years). Forty-eight percent of the sample had good outcomes (remaining on buprenorphine and abstinent of other opioids), 28% had poor outcomes, and 10% dropped out of prolonged successful treatment with unknown final outcomes. The group achieved a relatively high rate of smoking cessation during the study (22%). There were high rates of language disorder (21.6%) and autism spectrum disorder (8.6%) in children of mothers in the study. DISCUSSION AND CONCLUSION: Outcomes were excellent compared with those reported in other treatment settings. Rates of smoking cessation were also notable. The treatment of comorbid psychiatric conditions, the setting to develop a strong physician-patient relationship, patients choosing whether to taper off of buprenorphine, and the slow rate of taper all likely contributed to successful outcomes. Further investigation is needed regarding possible increased rates of developmental disorders in children of mothers treated with buprenorphine. SCIENTIFIC SIGNIFICANCE: Private psychiatric practice is a highly successful domain for the treatment of opioid use disorder. (Am J Addict 2020;29:508-514).

Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern(®) Guidelines.

UNLABELLED: COMPREHENSIVE ADULT MEDICAL EYE EVALUATION® PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern® (PPP) guidelines, discussing the rationale and components of an ophthalmic evaluation for adult patients with and without risk factors.

Impact of freshwater river reconnection on porewater salinity and ammonium availability in coastal brackish marsh soils.

Restoring freshwater flows to wetland ecosystems is an increasingly common tool for reversing saltwater intrusion/chronic salinization. Hydrologic restoration projects can deliver large volumes of sediment and fresh water to coastal basins, episodically exposing brackish and salt marsh vegetated soils to low surface water salinities. Yet little is known about the impacts of river reconnection/diversions to porewater salinity of the active root zone (0-30 cm) and salinity dependent soil biogeochemical processes like sorption. Intact soil cores from a brackish marsh site in mid-Barataria Basin, LA were subjected to a simulated river diversion opening to examine how porewater salinity and ammonium (NH4+) availability change with depth and time. Quadruplicate soil cores were inundated with continuously flowing fresh (0 salinity) water for 0, 7, or 28 d then measured for porewater salinity and NH4+ partition coefficient (exchangeable NH4+:porewater NH4+) every 2 cm for the top 10 cm of soil. Porewater salinity decreased in the 0-4 cm interval between 0 and 7 d of the simulated river diversion and increased in the 8-10 cm interval between 7 and 28 d. Overall, depth-averaged porewater salinity of the top 10 cm did not significantly change between 0 and 28 d of the simulated river diversion. Ammonium partition coefficients increased only in the 0-2 cm interval between 0 and 7 d of the simulated river diversion, likely due to freshening-induced NH4+ adsorption. These results indicate that the physicochemical environment of brackish marsh soils is relatively resistant to a single surface water freshening over one month. Models utilized by the state of Louisiana may be overpredicting freshening of the marsh soil porewater in Mid-Barataria Basin in response to the episodic operation of the Mid-Barataria Sediment Diversion. This study demonstrates the importance of measuring diffusive-adsorptive flux of major cations and anions when modeling vertical salt transfer in brackish marsh soils.

Achromobacter xylosoxidans keratitis masquerading as recurrent erosion after LASIK.

PURPOSE: To describe the clinical stages and management of Achromobacter xylosoxidans keratitis with post-LASIK epithelial ingrowth in two patients. METHODS: Retrospective chart review. RESULTS: Both patients had been treated with topical antibiotics and corticosteroids for several weeks prior to presentation. Examination at presentation revealed significant areas of epithelial ingrowth without signs of acute inflammation, prompting an erroneous initial diagnosis of recurrent corneal erosion. A corneal infiltrate was eventually observed and A. xylosoxidans was cultured from both patients. Clinical resolution occurred with treatment consisting of topical fortified antibiotics. In one patient, the flap was lifted to obtain cultures and irrigate the stromal bed with fortified antibiotics. CONCLUSIONS: Post-LASIK epithelial ingrowth may have served as a risk factor for A. xylosoxidans infection. Classic signs of infectious keratitis were absent, delaying the diagnosis. Three clinical stages described herein may assist the clinician with diagnosis and customized management obviating the need for penetrating keratoplasty.

Topical Ripasudil for the Treatment of Segmental Corneal Edema: A Case Series.

PURPOSE: Ripasudil, a rho-kinase inhibitor, has gained popularity as an adjunctive therapy after Descemet stripping only to hasten visual recovery. Ripasudil has been shown to increase corneal endothelial cell proliferation and intercellular adhesion, and decrease endothelial cell apoptosis. We present 4 cases in which persistent corneal edema after various anterior segment surgeries was successfully treated with topical ripasudil, and 1 case in which corneal edema did not improve with use of ripasudil. METHODS: Retrospective chart review revealed 5 patients treated with topical ripasudil for persistent corneal edema that failed to improve with conventional, nonsurgical treatments. RESULTS: In each case, the patient had symptomatic, persistent, focal corneal edema which followed a surgical procedure in the anterior segment. The various etiologies of corneal edema included graft failure after Descemet stripping endothelial keratoplasty, a failed penetrating keratoplasty, and 3 cases of pseudophakic corneal edema. These patients experienced improved vision and partial or complete resolution of corneal edema after 2 to 4 weeks of topical ripasudil administered 4 times daily. One patient with pseudophakic bullous keratopathy had edema that initially improved on topical ripasudil, but after cessation of the medication, developed progressive corneal edema and required endothelial keratoplasty. CONCLUSIONS: In patients with focal corneal edema resulting from surgical trauma to the endothelium who failed to clear over time with conservative measures, topical ripasudil was shown to be an effective treatment option that in most cases improved vision and helped reduce the need for endothelial transplantation.

Which intraocular lens would ophthalmologists choose for themselves?

PURPOSE: Contemporary cataract surgery is increasingly customizable with the advent of presbyopia-correcting intraocular lenses (IOLs) and the femtosecond laser. The purpose of this study was to determine the types of IOLs ophthalmologists choose for themselves and whether demographic characteristics, surgical experience, and attitudes of ophthalmologists might influence their decision-making. Additional goals included evaluating the use of femtosecond laser use in cataract surgery and investigating surgeon IOL preferences for their patients. METHODS: We distributed a 29-question Survey Monkey survey to senior ophthalmology residents and practicing ophthalmologists and received 347 responses during a 1-month period. We analyzed 328 surveys using chi-square tests and Fisher's exact tests. RESULTS: Main outcome measures included surgeons' personal preferences for choice of IOL, femtosecond laser-assisted cataract surgery, and IOL preference for patients. In the setting of no astigmatism, 61.3% of respondents would choose a monofocal IOL set for either distance or monovision for their own surgery. For corneal astigmatism >1.25 D, 60.3% of respondents would choose a toric monofocal lens and only 6.9% would want a femtosecond laser or manual LRI for their own surgery. Of the respondents, 34.6% perform femtosecond laser-assisted cataract surgery, but only 15.3% would want femtosecond cataract surgery performed on themselves. Also, 67.7% implant presbyopia-correcting IOLs (diffractive echelette, multifocal, or accommodative). When correcting for patients' corneal astigmatism >1.25 D, 65.7% of respondents preferred a toric monofocal IOL. CONCLUSION: Ophthalmologists value quality of vision and are risk averse. Overall, a surgeons' personal preference for their own surgery is correlated with past surgical experience with patients.

Partial Scleral Rupture Presenting 4 Years After Laser in Situ Keratomileusis.

PURPOSE: To report a case of partial scleral rupture after laser in situ keratomileusis (LASIK) surgery. METHODS: This is a retrospective case report describing a late complication of LASIK surgery. RESULTS: A 32-year-old white woman with a history of LASIK surgery performed with a mechanical microkeratome 4 years previously presented for evaluation of partial bilateral scleral ruptures. An arcuate filtering bleb along the contour of the cornea was found on the right eye with associated hypotony and corneal astigmatism. There were no signs or symptoms of prior inflammation, and rheumatologic workup was negative. Imaging revealed scleral microbreaks in the absence of adjacent thinning. CONCLUSIONS: The pattern and location of thinning without findings consistent with inflammatory disease suggest that the partial bilateral scleral rupture was because of mechanical damage at the time of LASIK, possibly compounded by the hormonal changes of pregnancy.

A Multicenter Study Evaluating the Risk Factors and Outcomes of Repeat Descemet Stripping Endothelial Keratoplasty.

PURPOSE: Descemet stripping endothelial keratoplasty (DSEK), currently the most common procedure for managing corneal endothelial dysfunction, may be repeated following DSEK failure from a variety of causes. This multicenter study reports the risk factors and outcomes of repeat DSEK. METHODS: This was an institutional review board-approved multicenter retrospective chart review of patients who underwent repeat DSEK. Twelve surgeons from 5 Midwest academic centers and 3 private practice groups participated. The Eversight Eye Bank provided clinical indication and donor graft data. We also assessed the role of the learning curve by comparing cohorts from the first and second 5-year periods. RESULTS: A total of 121 eyes from 121 patients who underwent repeat DSEK were identified. The average age of the patients was 70 ± 12 years. The most common indication for repeat DSEK was late endothelial graft failure without rejection (58%, N = 63). Average preoperative and 12-month postoperative repeat DSEK corrected distance visual acuities were 20/694 and 20/89, respectively. Visual acuity outcomes, endothelial cell density, and cell loss did not significantly vary between the 2 cohorts. Initial graft rebubble rates for the first and second cohorts were 51% and 25%. The presence of glaucoma, prior glaucoma surgery, or a history of penetrating (full thickness) keratoplasty did not significantly affect visual outcomes. The median, mean, and range of intraocular pressures before repeat DSEK were 15.0, 15.7, and 6 to 37 mm Hg, respectively. Patients with higher intraocular pressures before repeat DSEK had improved postoperative corrected distance visual acuities. CONCLUSIONS: Repeating DSEK improves vision following failed or decompensated DSEK surgery. Higher preoperative repeat DSEK IOPs were associated with improved visual outcomes, and initial graft rebubble rates, which decreased over time, were likely due to surgeon experience.

Suture reaction masquerading as a conjunctival malignancy.

CASE REPORT: We report a case of conjunctival inflammation secondary to a retained suture masquerading as a neoplastic lesion. Excisional biopsy was performed in the right eye on a superior bulbar conjunctival lesion that appeared to be a conjunctival malignancy. A past history of ptosis surgery was obtained. Careful repeated examination with anesthesia, applying traction to the forniceal conjunctiva, revealed an occult polypropylene suture. Despite clinical features typical of malignancy, histologic examination revealed only chronic inflammatory cells. COMMENTS: Patients with suspicious conjunctival lesions and a history of ptosis surgery should be carefully explored for retained suture fragments. Examination with anesthesia may be needed to find an occult suture.

Standardized approach to training for cataract surgery skill evaluation.

PURPOSE: To assess interrater reliability in grading cataract surgery performance of ophthalmology residents and attending physicians before and after rater skill training. SETTING: Metropolitan Chicago, Illinois, USA. DESIGN: Prospective interventional test design. METHODS: Video versions of a previously validated scoring key for rating cataract surgery were created for participant training. All participants received 2 frame-of-reference training sessions lasting 2 hours each. Participants graded 4 videorecorded cataract surgeries before training (pretest) and 4 more after training (posttest). Intraclass correlation coefficients (ICCs), which measured the degree of rater agreement, were calculated before and after training. Participants completed a subjective confidence questionnaire at the beginning and at the end of the study. RESULTS: The study participants included 9 postgraduate year (PGY)-3 residents, 8 PGY-4 residents, and 5 ophthalmology attending physicians from 4 medical centers in metropolitan Chicago. The rater training sessions had the greatest increase in ICCs among PGY-3 residents. The ICC improvement between the PGY-4 residents and attending physicians was uneven. After training, all residents felt more confident about their ability to rate and to perform cataract surgery. CONCLUSIONS: Learning to effectively grade performance of cataract surgery by reviewing video clips has the potential to be an important part of ophthalmology residency education. The benefit of such a protocol was greatest in the early stages of residency education and might provide a guideline for quality assessment that accelerates surgical skill development. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Epithelial Ingrowth Following Endothelial Keratoplasty.

PURPOSE: To present a large case series of epithelial ingrowth or implantation following endothelial keratoplasty (EK) with the purpose of identifying the common causes as well as the various clinical presentations. We aim to determine the typical clinical course and the most effective treatment for this rare but serious complication. METHODS: This is a retrospective study of 13 patients who developed epithelial ingrowth or implantation post-EK. Slit lamp photographs were independently examined along with other diagnostic imaging and histopathology to confirm the diagnosis. Patient medical records including operative reports were reviewed to determine the number of surgeries that occurred before EK and details of surgical technique, for example, whether venting incisions were performed. Records from follow-up visits were reviewed to determine the natural progression and management of these cases. The literature was reviewed and a meta-analysis was performed. RESULTS: The patients were divided into 5 groups according to the type of epithelial presentation. Eight patients had involvement within the interface away from the visual axis. One patient had ingrowth in the interface within the visual axis, 2 had retrocorneal involvement, and 1 had anterior chamber involvement. One had both retrocorneal and anterior chamber involvement. Venting incisions were performed in 8 patients, but only 1 had ingrowth related to the venting incision. Nine patients were observed without evidence of significant progression. Four patients had surgical treatment to remove the epithelium. CONCLUSIONS: Epithelial ingrowth or implantation occurs most commonly within the interface away from the visual axis and typically does not progress. The presentation of a homogeneous gray-white interface opacity is characteristic. Ingrowth can result from venting incisions, but rarely does. Other causes are eccentric trephination or loose donor or host epithelium being dragged into the eye at the time of surgery.

Pupil response to tropicamide following laser in situ keratomileusis.

PURPOSE: To investigate the effect of corneal thinning after laser in situ keratomileusis (LASIK) on the corneal penetration of topical eye medication. SETTING: Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA. METHODS: Laser in situ keratomileusis surgery was performed in 19 eyes of 10 patients enrolled in this prospective study. Measurements were made before surgery and 3 months postoperatively. After instillation of tropicamide 1%, the change in pupil size over time was measured with a Colvard pupillometer. Central corneal thickness (CCT) was measured with ultrasonic pachymetry before and 3 months after LASIK. The corneal epithelial condition was also examined by fluorescein dye staining. RESULTS: The mean CCT decreased significantly from 564 microm +/- 33 (SD) before LASIK surgery to 514 +/- 48 microm 3 months postoperatively (P<.0001). Pupil diameter 10, 15, and 20 minutes after tropicamide 1% instillation was significantly larger 3 months after surgery than preoperatively (P=.0083, P=.0043, and P=.0144, respectively). The mean time to reach a pupil diameter of 6.0 mm decreased significantly from 14.4 +/- 4.3 minutes in preoperative eyes to 11.5 +/- 2.3 minutes in postoperative eyes (P=.0281). Mild punctate corneal epithelial staining (fewer than 5 spots) were observed in 4 eyes at the 3-month postoperative examination. CONCLUSIONS: Pupil dilation after tropicamide 1% instillation was significantly faster after LASIK surgery. Corneal thinning that resulted from LASIK enhanced corneal penetration of tropicamide 1%.

Baseline donor characteristics in the Cornea Donor Study.

PURPOSE: The Cornea Donor Study (CDS) is an ongoing study that is being conducted to determine whether donor age is related to long-term corneal graft survival. Characteristics of the donor population have been evaluated with respect to donor age, endothelial cell density, and death to preservation interval. METHODS: Within the context of a prospective, double-masked, controlled trial, 1101 donor corneas were assigned without regard to donor age. RESULTS: Slit-lamp characteristics of the donor corneas showed little variation with donor age, except for the presence of corneal arcus. As death to preservation time decreased, fewer epithelial abnormalities and a lower frequency of stromal edema and Descemet folds were observed. There was little change in the mean of the endothelial cell density with donor age beyond age 60, despite variation. CONCLUSION: With respect to donor age, there was little difference in either the slit-lamp characteristics or endothelial cell density of the donor corneas. Fewer epithelial abnormalities were observed with shorter death to preservation time.

Factors associated with corneal graft survival in the cornea donor study.

IMPORTANCE: The Cornea Donor Study (CDS) showed that donor age is not a factor in survival of most penetrating keratoplasties for endothelial disease. Secondary analyses confirm the importance of surgical indication and presence of glaucoma in outcomes at 10 years. OBJECTIVE: To assess the relationship between donor and recipient factors and corneal graft survival in the CDS. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective, double-masked, controlled clinical trial conducted at 80 clinical sites. One hundred five surgeons enrolled 1090 participants undergoing corneal transplant for a moderate-risk condition, principally Fuchs dystrophy or pseudophakic or aphakic corneal edema (PACE). Forty-three eye banks provided corneas. INTERVENTIONS: Corneas from donors younger than 66 years and donors 66 years or older were assigned, masked to donor age. Surgery and postoperative care were performed according to the surgeons' usual routines. Participants were followed up for as long as 12 years. MAIN OUTCOMES AND MEASURES: Graft failure, defined as a regrafting procedure or a cloudy cornea for 3 consecutive months. RESULTS: The 10-year cumulative probability of graft failure was higher in participants with PACE than in those with Fuchs dystrophy (37% vs 20%; hazard ratio [HR], 2.1 [99% CI, 1.4-3.0]; P < .001) and in participants with a history of glaucoma before penetrating keratoplasty, particularly with prior glaucoma surgery (58% with prior glaucoma surgery and use of medications to lower intraocular pressure at the time of surgery vs 22% with no history of glaucoma surgery or medication use; HR, 4.1 [99% CI, 2.2-7.5]; P < .001). We found trends toward increased graft failure in recipients who were 70 years or older compared with those younger than 60 years (29% vs 19%; HR, 1.2 [99% CI, 0.7-2.1]; P = .04) or were African American (HR, 1.5; P = .11) or who had a history of smoking (35% vs 24%; HR, 1.6 [99% CI, 0.9-2.8]; P = .02). Lower endothelial cell density (ECD) and higher corneal thickness (CT) at 6 months (6% vs 41% for ECD ≥2700 vs <1700 cells/mm2 [P < .001]; 14% vs 36% for CT <500 vs ≥600 µm [P = .001]), 1 year (4% vs 39% for ECD ≥2700 vs <1700 cells/mm2 [P < .001]; 18% vs 28% for CT <500 vs ≥600 µm [P = .04]), and 5 years (2% vs 29% for ECD ≥1500 vs <500 cells/mm2 [P < .001]; 7% vs 34% for CT <550 vs ≥650 µm [P < .001]) were associated with subsequent graft failure. CONCLUSIONS AND RELEVANCE: Most penetrating corneal grafts for Fuchs dystrophy or PACE remain clear at 10 years. The risk for failure is greater for graft recipients with PACE and those with a history of glaucoma. Measurements of ECD and CT during the course of postkeratoplasty follow-up are associated with a risk for failure. However, even with very low ECD and high CT at 5 years, most corneas remain clear at 10 years.

Predictive formula for calculating the probability of LASIK enhancement.

PURPOSE: To develop a formula to predict a patient's need for laser in situ keratomileusis (LASIK) enhancement. SETTING: Northwestern Laser Vision Center, Department of Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA. METHODS: In this retrospective study, charts of patients who received LASIK with the Visx Star excimer laser for myopia and myopic astigmatism were reviewed. Laser in situ keratomileusis enhancement was performed in 130 of 720 eyes. Variables such as age, keratometry, spherical power, power and axis of astigmatism, and surgeon factor were compared in patients who required retreatment and those who did not. Multivariate logistic regression analysis was used to determine a formula for the probability of enhancement surgery. RESULTS: Age (P<.0001), preoperative cycloplegic sphere (P<.0001), and surgeon (P<.0001) were the statistically significant factors for predicting retreatment. The predictive formula derived from these factors had a sensitivity of 79%, a specificity of 61%, and positive and negative predictive values of 31% and 93%, respectively. CONCLUSIONS: Older age, higher preoperative cycloplegic sphere, and surgeon significantly influenced a patient's likelihood for LASIK retreatment. A formula based on these predisposing factors helps to more accurately predict the need for retreatment.

Increased expression of secreted frizzled-related protein-1 and microtubule-associated protein light chain 3 in keratoconus.

PURPOSE: To study the expression of secreted frizzled-related protein-1 (SFRP-1) and microtubule-associated protein light chain 3 (LC3), an autophagy marker, in keratoconus. METHODS: Under an institutional review board-approved protocol, de-identified and/or surgically discarded normal donor (n = 10) and keratoconus corneas (n = 10) were obtained. The corneal samples were fixed in formalin and embedded in paraffin. Immunohistochemical staining using SFRP-1 and LC3 antibodies was performed. RESULTS: The majority of expression of SFRP-1 was seen in the epithelium; however, in 3 tissues that showed high expression, staining was also present in the stroma and endothelium. Like SFRP-1, the LC3 expression in keratoconus tissues occurred at 3 different levels: low, medium, and high. Collectively these data suggest that there are differences in the expression levels of SFRP-1 and LC3 in keratoconus tissue compared with the normal tissue. Low expressivity of SFRP-1 seemed to correspond to low expressivity of LC3, whereas medium to high expressivity of SFRP-1 corresponded to medium to high expressivity of LC3. CONCLUSIONS: Increased expression of SFRP-1 and LC3 was observed in keratoconus corneas. Keratocyte autophagy seen with keratoconus may play a role in the pathogenesis of keratoconus.

Textural interface opacity after descemet stripping automated endothelial keratoplasty: a report of 30 cases and possible etiology.

PURPOSE: Descemet stripping automated endothelial keratoplasty (DSAEK) has its own set of complications including interface abnormalities. This case series presents the largest number of patients who developed textural interface opacity (TIO) at the graft-host interface after DSAEK. METHODS: This is a retrospective multicenter case series of 30 patients from 7 institutions with the finding of TIO. Clinical information collected included donor preparation details, recipient information, and surgical technique. Clinical outcomes included best-corrected visual acuity and status of TIO appearance at the last follow-up visit. Slit-lamp photographs were analyzed and compared. RESULTS: The majority of the patients (73%) had a best-corrected visual acuity of 20/40 or better. Four of the donor tissues were prepared with a microkeratome blade with the same lot number. Six patients had a central interface space between host and donor stromal surfaces--presumed interface fluid but potentially viscoelastic. A slight majority (57%) of patients had improvement in the severity of TIO, with 20% noted to have a complete resolution of TIO (mean follow-up of 11.9 months). Two clinical types of TIO were seen: an elongated type and a punctate type. CONCLUSIONS: Most patients with TIO after DSAEK obtain good visual outcomes. TIO spontaneously improves or even resolves during follow-up without intervention. The etiology of this condition is unknown, but we propose 2 different mechanisms. The elongated type could be secondary to an irregular cut of the donor with the microkeratome blade. The punctate type may be secondary to retained viscoelastic.

Effect of donor and recipient factors on corneal graft rejection.

PURPOSE: To assess the relationship between donor and recipient factors and corneal allograft rejection in eyes that underwent penetrating keratoplasty in the Cornea Donor Study. METHODS: Overall, 1090 subjects undergoing corneal transplantation for a moderate risk condition (principally Fuchs dystrophy or pseudophakic corneal edema) were followed for up to 5 years. Associations of baseline recipient and donor factors with the occurrence of a probable or definite rejection event were assessed in univariate and multivariate proportional hazards models. RESULTS: Eyes with pseudophakic or aphakic corneal edema (n = 369) were more likely to experience a rejection event than eyes with Fuchs dystrophy (n = 676) [34% ± 6% vs. 22% ± 4%; hazard ratio = 1.56; 95% confidence interval (CI), 1.21-2.03]. Among eyes with Fuchs dystrophy, a higher probability of a rejection event was observed in phakic posttransplant eyes compared with those that underwent cataract extraction with or without intraocular lens implantation during penetrating keratoplasty (29% vs. 19%; hazard ratio = 0.54; 95% CI, 0.36-0.82). Female recipients had a higher probability of a rejection event than male recipients (29% vs. 21%; hazard ratio = 1.42; 95% CI, 1.08-1.87) after controlling for the effect of preoperative diagnosis and lens status. Donor age and donor recipient ABO compatibility were not associated with rejection. CONCLUSIONS: There was a substantially higher graft rejection rate in eyes with pseudophakic or aphakic corneal edema compared to that in eyes with Fuchs dystrophy. Female recipients were more likely to have a rejection event than male recipients. Graft rejection was not associated with donor age.