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.

Cost analysis of eye bank versus surgeon prepared endothelial grafts.

BACKGROUND: Selective lamellar corneal transplantation (keratoplasty) has overtaken full thickness penetrating keratoplasty as the graft choice for endothelial failure. Even more recently eye bank prepared tissues are becoming increasing popular as a way to reduce the risks of tissue loss and stress during endothelial keratoplasty preparation in the surgical theatre. This study compares costs between surgeon and eye bank prepared tissues for Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK). METHODS: Retrospective study conducted at the Royal Liverpool University Hospital including endothelial keratoplasties with a minimum of 6 months follow-up time. Cost analysis included surgical expenses, tissue acquisition fees, cost of patient's ward admission and out-patient expenses, including cost of re-bubbling procedures, costs of visits, anterior segment imaging and optometrist visits within the first 6 months follow-up. RESULTS: Ninety-eight eyes of 98 patients were included in the study of which 42 underwent DSAEK surgery and 56 DMEK surgery. Cost analysis of surgical expenses in the DSAEK group showed a significant difference between using surgeon prepared and eye bank prepared tissue (£3866 ± 296 and £4389 ± 360, respectively; p < 0.01) and the same was found in the DMEK group (£3682 ± 167 and £4162 ± 167 for surgeon prepared and eye bank prepared tissues, respectively; p < 0.01). Cost of out-patient visits did not differ significantly in either group. CONCLUSIONS: At the Royal Liverpool University Hospital, eye bank prepared tissues had higher surgical expenses compared to those prepared by the surgeon, while the post-operative care expenses were similar between the two groups.

New forceps free injection technique for delivering descemet membrane endothelial keratoplasty preloaded endothelium-in grafts.

PURPOSE: To describe a new method for delivering DMEK grafts into the recipient's eye with endothelium inward configuration using a no-forceps injection technique. METHODS: We retrospectively review 11 patients that underwent DMEK surgery at our institution using a no-forceps injection technique. The graft was preloaded into an intraocular lens (IOL) cartridge and connected to an anterior chamber maintainer (ACM). A 5 ml non luer lock syringe was inserted into the other end of the ACM to create a one-flow system. The cartridge was inserted into the posterior end of an injector, and the graft was successfully delivered into the recipient's eye. RESULT: Twelve eyes of 11 patients were included. Mean follow-up was 9.16 ± 1.3 months. At baseline, mean best corrected visual acuity (BCVA) was 0.76 ± 0.13 logMAr and mean endothelial cell density (ECD) was 2619.00 ± 115.89 cells/mm2. At follow-up, BCVA significantly improved to 0.22 ± 0.05 logMAR (p = 0.003). Although we observed a significant reduction in ECD at follow-up (1688 ± 182.20, p = 0.002), our patients lost only 35.69 ± 6.36% of endothelial cells. CONCLUSION: Our technique can help surgeons safely deliver an endothelium-in graft into the recipient's eye. The method doesn't require the use of a forceps, minimizing the risk of endothelial cell loss or graft damage.

Thinning rate over 24 months in ultrathin DSAEK.

AIM: To describe the changes in corneal graft thickness following ultrathin Descemet's Stripping Automated Endothelial Keratoplasty (UT-DSAEK) comparing pre- and postoperative values over a 24-month period. METHODS: In this retrospective single-center case series, patients who received eye bank-prepared tissues for UT-DSAEK surgery were included. Preoperative and postoperative graft thickness measurements were determined in the eye bank and in clinic using anterior segment optical coherence tomography (AS-OCT) images. Graft thickness measurements and their percentage change between preoperative values and values at 1 day, 1 week and 1, 6, 12, 24 months were calculated. RESULTS: In total, 47 eyes of 47 patients with a mean age of 69 ± 11 years (29 males) were included. Twnty-three patients had Fuchs' endothelial dystrophy (49%) and the remaining 24 had pseudophakic bullous keratopathy (51%). In total, 29/47 eyes underwent UT-DSAEK alone (62%) and 18/47 received combined cataract surgery as a triple procedure (38%). Preoperative donor graft thickness was 92 ± 28 µm. Compared to preoperative values, where graft thickness increased to 194 ± 101.3 µm at 1 day, 151.1 ± 71.4 µm at 1 week, and 108.4 ± 52.5 µm at 1 month. Graft thickness continued to gradually decrease over time until 6 months (91.7 ± 33.6 µm), and then plateaued at 12 months (83.9 ± 25.0 µm), showing minimal changes at 2 years (101.4 ± 37.5 µm). CONCLUSION: Preoperative DSAEK graft thickness measurements as reported by the eye bank are a valid approximation of DSAEK graft thickness at 6 months after surgery and these measurements tend to stabilize over time up to 2 years after surgery.

Surgical goniolens for tag identification and removal in DMEK surgery.

INTRODUCTION: We describe a novel technique for identifying endothelial Descemet membrane (DM) tags remaining after descemetorhexis in patients undergoing Descemet membrane endothelial keratoplasty (DMEK) surgery. METHODS: A surgical goniolens is applied to the corneal surface after descemetorhexis in order to visualize the peripheral inner corneal layer at 360° and identify endothelial-DM tags. RESULTS: A detailed visualization of the peripheral inner corneal layer is possible using goniolens, without using any staining in the anterior chamber. CONCLUSION: The technique may be used to screen the posterior corneal surface for any retained endothelial-DM tags. It may to lower the risk of remaining tags and indirectly lower the incidence of DMEK graft detachment.

Deep Learning Using Preoperative AS-OCT Predicts Graft Detachment in DMEK.

Purpose: To evaluate a novel deep learning algorithm to distinguish between eyes that may or may not have a graft detachment based on pre-Descemet membrane endothelial keratoplasty (DMEK) anterior segment optical coherence tomography (AS-OCT) images. Methods: Retrospective cohort study. A multiple-instance learning artificial intelligence (MIL-AI) model using a ResNet-101 backbone was designed. AS-OCT images were split into training and testing sets. The MIL-AI model was trained and validated on the training set. Model performance and heatmaps were calculated from the testing set. Classification performance metrics included F1 score (harmonic mean of recall and precision), specificity, sensitivity, and area under curve (AUC). Finally, MIL-AI performance was compared to manual classification by an experienced ophthalmologist. Results: In total, 9466 images of 74 eyes (128 images per eye) were included in the study. Images from 50 eyes were used to train and validate the MIL-AI system, while the remaining 24 eyes were used as the test set to determine its performance and generate heatmaps for visualization. The performance metrics on the test set (95% confidence interval) were as follows: F1 score, 0.77 (0.57-0.91); precision, 0.67 (0.44-0.88); specificity, 0.45 (0.15-0.75); sensitivity, 0.92 (0.73-1.00); and AUC, 0.63 (0.52-0.86). MIL-AI performance was more sensitive (92% vs. 31%) but less specific (45% vs. 64%) than the ophthalmologist's performance. Conclusions: The MIL-AI predicts with high sensitivity the eyes that may have post-DMEK graft detachment requiring rebubbling. Larger-scale clinical trials are warranted to validate the model. Translational Relevance: MIL-AI models represent an opportunity for implementation in routine DMEK suitability screening.

Preoperative surgeon evaluation of corneal endothelial status: the Viability Control of Human Endothelial Cells before Keratoplasty (V-CHECK) study protocol.

INTRODUCTION: The success of keratoplasty strongly depends on the health status of the transplanted endothelial cells. Donor corneal tissues are routinely screened for endothelial damage before shipment; however, surgical teams have currently no means of assessing the overall viability of corneal endothelium immediately prior to transplantation. The aim of this study is to validate a preoperative method of evaluating the endothelial health of donor corneal tissues, to assess the proportion of tissues deemed suitable for transplantation by the surgeons and to prospectively record the clinical outcomes of a cohort of patients undergoing keratoplasty in relation to preoperatively defined endothelial viability. METHODS AND ANALYSIS: In this multicentre cohort study, consecutive patients undergoing keratoplasty (perforating keratoplasty, Descemet stripping automated endothelial keratoplasty (DSAEK), ultra-thin DSAEK (UT-DSAEK) or Descemet membrane endothelial keratoplasty) will be enrolled and followed-up for 1 year. Before transplantation, the endothelial viability of the donor corneal tissue will be evaluated preoperatively through trypan blue staining and custom image analysis to estimate the overall percentage of trypan blue-positive areas (TBPAs), a proxy of endothelial damage. Functional and structural outcomes at the end of the follow-up will be correlated with preoperatively assessed TBPA values. ETHICS AND DISSEMINATION: The protocol will be reviewed by the ethical committees of participating centres, with the sponsor centre issuing the final definitive approval. The results will be disseminated on ClinicalTrials.gov, at national and international conferences, by partner patient groups and in open access, peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05847387.

Update on Suture Techniques in Corneal Transplantation: A Systematic Review.

Effective suturing remains key to achieving successful outcomes in corneal surgery, especially anterior lamellar keratoplasty and full thickness transplantation. Limitations in the technique may result in complications such as wound leak, infection, or high astigmatism post corneal graft. By using a systematic approach, this study reviews articles and conducts content analysis based on update 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria). The aim of this paper is to summarize the state of the art of corneal suturing techniques for every type of corneal transplant and patient age and also their outcomes regarding astigmatism and complications. Future developments for corneal transplantation will be also discussed. This is important because especially the young surgeon must have knowledge of the implications of every suture performed in order to achieve consistent and predictable post-operative outcomes and also be aware of all the possible complications.

Changes in pupillometry associated with dissipated energy during phacoemulsification.

PURPOSE: To investigate the effect of ultrasound level during phacoemulsification on pupil dynamics. METHODS: Comparative retrospective study on patients who underwent routine cataract surgery at the Royal Liverpool University Hospital. Clinical parameters, anterior chamber measurements, axial length, surgeon grade, time of surgery, level of ultrasound used (cumulative dissipated energy, CDE), intra- and post-operative complications were collected. Pupil diameters were collected before and 4 ± 1 weeks after surgery in static scotopic, mesopic, photopic pupil conditions. Also, pupil dynamic measurements after luminous stimulus were recorded. Changes in static pupil diameters, relative dilation at 3.5 s after luminous stimulus, and time to reach 75% and 95% of maximum dilation were measured. RESULTS: Forty-eight eyes of 24 patients (13 males) were included with a mean age of 73.1 ± 14.6 years. Mean CDE value was 18.11 ± 10.56. Mean scotopic pupil diameters decreased by 0.24 ± 0.48 mm (p = 0.021) in the operated eye. Significant correlation was found between reduction in scotopic pupil diameter and CDE (p = 0.05). A generalized linear model confirmed that the level of CDE was significantly associated with reduction in scotopic pupil diameter (p = 0.026). Patients who underwent surgeries with lower CDE (0 < CDE ⩽ 10 and 10 < CDE ⩽ 20) did not experience significant changes in scotopic pupil diameter after surgery (p = 0.28 and p = 0.79, respectively) as opposed to those with higher CDE (CDE > 20; p = 0.03). CONCLUSION: Phacoemulsification cataract surgery and the cumulative dissipated energy may be associated with changes in pupil behaviour.

Impact of COVID-19 on keratoconus patients waiting for corneal cross linking.

PURPOSE: Royal College of Ophthalmologist recent guidance recommended delaying cross-linking services during the COVID-19 pandemic. This study investigates the effects of such delays in the delivery of cross-linking services in patients with keratoconus progression. METHODS: Retrospective observational study of 46 patients with keratoconus progression, whose cross-linking was delayed due to the COVID-19 pandemic. Demographic and clinical details were obtained from assessments on the day of listing, and subsequent review on the day of the procedure. Topographic indices included keratometry of the posterior and anterior corneal surface, maximum keratometry (Kmax), thinnest corneal thickness, ABCD progression and progression based on standard criteria recommendations (1.5 D Kmax & 20 microns thinning). RESULTS: A total of 46 eyes were analysed with an average time between being listed for CXL and having the procedure done was 182 ± 65 days. The delay due to COVID-19 was of 3 months. In this time period they had a significant worsening of all keratometric indices and lost almost one line of visual acuity (0.19 ± 0.19 to 0.26 ± 0.18 LogMAR, p: 0.03). Thirty two eyes (70%) demonstrated progression in accordance with the ABCD progression criteria, while 18 eyes (39%) showed either an increase in Kmax of more than 1.5D or a thinning in corneal thickness of at least 20 µm. CONCLUSIONS: The treatment delay for the keratoconus patients caused further progression and vision worsening. We recommend that corneal collagen crosslinking needs to be considered as a high priority intervention.

Rebubbling rate in preloaded versus surgeon prepared DSAEK.

PURPOSE: To compare the clinical outcomes of eye bank preloaded Descemet stripping automated endothelial keratoplasty (DSAEK) grafts and surgeon prepared. METHODS: In this retrospective study, the data were obtained from two groups (a) surgeon cut DSAEK where tissue was prepared by the surgeon immediately before surgery, and (b) preloaded DSAEK tissue shipped to the surgeon after preparation by the eye bank. Standard DSAEK preparations using Moria microkeratome with single pass method were performed. For the tissues prepared by the eye banks, they were preloaded in an iGlide device and shipped in transport media. Standard DSAEK surgery using bimanual pull-through technique was performed for all the grafts. Air was used as a tamponade. Main outcome measures included best corrected visual acuity (BCVA) and rebubbling rate. RESULT: Out of 107 eyes of 101 patients that underwent DSAEK surgery, 33 tissues were prepared by the surgeon (sc-DSAEK), while 74 were prepared by the eye bank (pl-DSAEK). sc-DSAEK showed a rebubbling rate of 9.1%, compared to the 16.2% for the preloaded DSAEK (p = 0.11). There was no statistical difference in postoperative BCVA between the two groups. Logistic regression analysis showed no association between detachment rate and cataract surgery, graft preparation method, graft diameter and reason for graft. CONCLUSION: Preloaded grafts have similar rebubbling rate and visual acuity achieved compared with surgeon prepared grafts.

Complications and Management of Prestripped Descemet Membrane Endothelial Keratoplasty Grafts.

Prestripped Descemet membrane endothelial keratoplasty is a relatively new technique that offers advantages in reduced surgical time and reduced tissue wastage compared with surgeon-stripped graft. Here, we report the following 2 types of prestripped Descemet membrane endothelial keratoplasty graft complications and their management: 1 free floating in the transport media and the other graft mispositioned.

Eye Banking: One Cornea for Multiple Recipients.

PURPOSE: Corneal transplantation is the most frequently performed transplant procedure. In much of the world, the demand for donor tissue heavily outstrips supply. With developments within lamellar corneal graft surgery, the use of split corneal donor tissue to increase donor tissue supply seems a pragmatic solution to reduce the supply and demand mismatch. This is especially important with tissue supply expected to be affected by the COVID-19 pandemic. METHODS: A literature review of techniques was performed, enabling multiple transplants to be derived from a single donor and simulation of a model to quantify the number of corneas potentially saved. RESULTS: Studies on splitting corneal donor tissue have demonstrated that up to 5 recipients may benefit from 1 donor scleral button. The impact of splitting donor tissue may provide a saving of up to 25.3% of donor graft tissue. CONCLUSIONS: Splitting and preparing the donor tissue within an eye bank will improve tissue validation and donor tissue availability and may increase surgeon efficiency.

Persistent loss of marginal corneal arcades after chemical injury.

Changes in the limbal microvasculature following a chemical eye injury are essential for prognosis and management. At the slit lamp, it can be difficult to assess, here using fluorescein and indocyanine green angiography we show that anterior segment angiography may be informative to assess objectively the limbal microvascular changes over the follow-up period.

Free-Floating DMEK in the Host Anterior Chamber: Surgical Management.

PURPOSE: To describe a method to visualize and manage a completely detached Descemet membrane endothelial keratoplasty (DMEK) tissue scroll in the anterior chamber. METHODS: A 56-year-old male patient with pseudophakic bullous keratopathy, who underwent uncomplicated DMEK surgery, had a complete graft detachment diagnosed at 1-week follow-up. The graft was reattached using a new technique, that is, the free-floating graft was stained in the anterior chamber with trypan blue, immediately followed by air injection to separate the host stroma from the dye. The stained DMEK graft was opened by gentle tapping and attached to the host stroma by air tamponade. RESULT: This technique allowed sufficient staining of DMEK tissue to further evaluate and correct the graft orientation inside the anterior chamber without compromising the stroma. The DMEK graft was attached 1 week after the reattachment procedure. The cornea cleared confirming the functionality of the endothelial cells. CONCLUSIONS: The technique described may be useful in the cases of complete detachment of DMEK tissue and poor visualization of the DMEK tissue orientation. Staining with trypan blue under a "protective" air bubble can provide sufficient visualization to ensure the unfolding of DMEK tissue and reduce the risk of host stromal staining.

Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty for Keratoconus: Multi-surgeon Results.

PURPOSE: To compare the clinical outcomes in femtosecond laser-assisted deep anterior lamellar keratoplasty (F-DALK) to manual non-laser deep anterior lamellar keratoplasty (M-DALK) for keratoconus in a multi-surgeon public healthcare setting. DESIGN: Single-center, comparative, retrospective interventional case series. METHODS: Population: Consecutive cases of keratoconus treated with big-bubble F-DALK from August 1, 2015, to September 1, 2018 and big-bubble M-DALK from September 1, 2012, to September 30, 2016. SETTING: Moorfields Eye Hospital, London. OBSERVATIONS: Data on preoperative status, operative details, intraoperative and postoperative complications, secondary interventions, and visual outcomes were archived on a customized spreadsheet for analysis. MainOutcomeMeasures: Rate of intraoperative perforation and conversion to penetrating keratoplasty (PK) and the percentage of patients, post removal of sutures (ROS), with corrected distance visual acuity (CDVA) ≥20/40. RESULTS: We analyzed 58 eyes of 55 patients who underwent F-DALK and 326 eyes of 309 patients who underwent M-DALK. Intraoperative perforation of Descemet membrane occurred in 15 of 58 (25.9%) F-DALK cases compared to 148 of 326 (45.4%) M-DALK cases (P = .006). Intraoperative conversion to PK was carried out in 2 of 58 (3.4%) F-DALK cases compared to 80 of 326 (24.5%) M-DALK cases (P = .001). Post ROS, 86.5% of F-DALK eyes had a CDVA of ≥20/40 (15 ± 7.3 months after surgery) compared to 83.7% of M-DALK eyes (24.9 ± 10.6 months) (P = .825). CONCLUSION: Laser automation of some steps in DALK for keratoconus may reduce the rate of intraoperative Descemet perforation and the conversion to PK in a multi-surgeon setting.

Clinical outcomes of pre-loaded ultra-thin DSAEK and pre-loaded DMEK.

OBJECTIVE: To compare clinical outcomes and complications between pre-loaded ultra-thin Descemet stripping automated endothelialkeratoplasty (pl-UT-DSAEK) and pre-loaded Descemet membrane endothelial keratoplasty (pl-DMEK). METHODS AND ANALYSIS: Comparative study in patients with endothelial dysfunction associated with Fuchs endothelial corneal dystrophy and pseudophakic bullous keratopathy who underwent pl-UT-DSAEK or pl-DMEK transplants. For both groups, the tissues were pre-loaded at the Fondazione Banca degli Occhi del Veneto (Venice, Italy) and shipped to The Royal Liverpool University Hospital (Liverpool, UK). Best corrected visual acuity (BCVA) and re-bubbling rates were the main outcome measures. RESULTS: 56 eyes of 56 patients were included. 31 received pl-UT-DSAEK and 25 received pl-DMEK. At 12 months, BCVA (LogMAR) was significantly better for pl-DMEK (0.17±0.20 LogMAR) compared with pl-UT-DSAEK (0.37±0.37 LogMAR, p<0.01). The percentage of people that achieved ≥20/30 was significantly higher in the pl-DMEK group. The rate of re-bubbling, however, was significantly higher for pl-DMEK (44.0%) than for Pl-UT-DSAEK (12.9%), p<0.01. CONCLUSION: Pl-DMEK offers better BCVA than pl-UT-DSAEK. The higher re-bubbling rate associated with pre-loaded DMEK is of concern.

Day 5 morning serum cortisol predicts hypothalamic-pituitary-adrenal function after transsphenoidal surgery for pituitary tumors.

BACKGROUND: Adrenal insufficiency is a complication of transsphenoidal surgery (TSS) for pituitary adenoma, and correct identification of patients requiring glucocorticoid replacement is important. Controversy exists over which early postoperative 9 AM cortisol concentration reliably predicts hypothalamic-pituitary-adrenal (HPA) axis reserve, as defined by the insulin tolerance test (ITT). METHODS: Data were reviewed for 36 patients undergoing TSS followed by day 5 postoperative 9 AM cortisol measurement and ITT 6 weeks postsurgery. All patients received postoperative glucocorticoid replacement, which was discontinued if the 9 AM serum cortisol was >300 nmol/L. RESULTS: Of 23 patients who failed the ITT (peak cortisol <500 nmol/L), 20 also had a day 5, 9 AM serum cortisol <300 nmol/L. Nine of 13 patients who passed the ITT had a day 5, 9 AM cortisol >300 nmol/L. The cutoff cortisol concentration of 300 nmol/L had 86.9% (66.4%-97.2%) diagnostic sensitivity, 69.2% (38.6%-90.9%) diagnostic specificity, and 83.3% (61.8%-94.5%) positive predictive value (PPV) for detecting secondary adrenal insufficiency. Increasing the cutoff to 392 nmol/L resulted in 100% (85.2%-100%) sensitivity, 46.1% (19.2%-74.9%) specificity, and 76.6% (57.3%-89.4%) PPV. Decreasing the cutoff to 111 nmol/L resulted in 100% (75.3%-100%) specificity and 100% (67.9%-100%) PPV, although sensitivity was 47.8% (26.8%-69.4%). CONCLUSIONS: A day 5 post-TSS 9 AM serum cortisol <111 nmol/L reliably detects secondary adrenal insufficiency, and concentrations >392 nmol/L support intact HPA function. Because concentrations of 111-392 nmol/L are poorly predictive of HPA function, glucocorticoid replacement should continue in such cases until definitive testing is performed using an ITT.

Deep Anterior Lamellar Keratoplasty for Keratoconus: Multisurgeon Results.

PURPOSE: To examine clinical outcomes in deep anterior lamellar keratoplasty (DALK) for keratoconus using contemporary techniques in a multisurgeon public healthcare setting. DESIGN: Consecutive, retrospective case series. METHODS: Setting: Moorfields Eye Hospital, London, United Kingdom. STUDY POPULATION: Consecutive cases of keratoconus treated with non-laser assisted DALK from September 1, 2012, to September 31, 2016. OBSERVATION PROCEDURE: Data on preoperative status, operative details, intraoperative and postoperative complications, secondary interventions, and visual outcomes were archived for analysis. MAIN OUTCOME MEASURES: Graft failure rate and percentage of patients with corrected distance visual acuity (CDVA) ≥20/40 within 1 year of surgery and at final review after suture removal. RESULTS: Three hundred fifty-seven eyes of 338 patients undergoing DALK (91.3% big-bubble technique attempted) were analyzed. A total of 4.2% (95% confidence interval [CI] 2.4%-6.8%) of corneal transplants had failed within the follow-up period (21.8 ± 11.4 months), and 75.9% of eyes had CDVA ≥20/40 within 1 year of surgery, rising to 81% after suture removal. Forty-two primary surgeons (31 trainees) participated. Intraoperative perforation of Descemet membrane occurred in 45.4% of eyes. A total of 24.1% were converted to penetrating keratoplasty (PK) intraoperatively. Conversion to PK increased the risk of transplant rejection (P = .026; odds ratio [OR] 1.94; 95% CI 1.1-3.5) and secondary glaucoma (P = .016; OR 4.0; 95% CI 1.3-12.4). Transplant rejection increased the risk of graft failure both overall (P = .017; OR = 3.9; 95% CI 1.4-11.0) and when cases converted to PK were excluded (P = .028; OR = 3.35; 95% CI 1.1-9.9). CONCLUSION: DALK for keratoconus achieves early results similar to those published for PK in a multisurgeon setting. Conservative management of intraoperative Descemet membrane perforation, where possible, may be safer than conversion to PK.