Podcast on Cross-speciality Perspectives on Practical Management of Atopic Dermatitis-Associated Ocular Surface Diseases.

There is a growing awareness among dermatology providers of ocular comorbidities in patients with the chronic inflammatory skin disease atopic dermatitis (AD). For example, the prevalence of ocular surface diseases (OSD) such as conjunctivitis is higher in patients with AD than in the general population, and the use of some AD treatments may be associated with OSD. In a recent review published in the Journal of the American Academy of Dermatology, dermatologists and ophthalmologists provided an overview of the different types, etiology, pathophysiology, and practical management of OSD associated with AD. This review included a suggested treatment algorithm that champions a partnership between dermatology providers and eye care providers for optimal screening, diagnosis, and care. In this podcast article, a dermatologist and ophthalmologist who were authors on this review are joined by a nurse practitioner moderator to discuss how these concepts can be adapted to clinical practice, inclusive of dermatologists, eye care providers, and relevant advanced practice providers. This podcast focuses on the authors' clinical experiences and highlights the key aspects of optimal care, including exploring additional questions to answer with future research.

Mediators of Visual Acuity in Descemet Membrane Endothelial Keratoplasty and Ultrathin Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: The aim of this study was to investigate mediators of visual acuity in ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) compared with Descemet membrane endothelial keratoplasty (DMEK). METHODS: This was a prespecified secondary analysis of the Descemet Endothelial Thickness Comparison Trial, a prospective, randomized controlled trial comparing UT-DSAEK with DMEK. Subjects with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy presenting to 2 academic centers were enrolled and randomized to either UT-DSAEK (n = 25 eyes) or DMEK (n = 25 eyes). Higher order aberrations (HOAs) and corneal densitometry were measured with Pentacam Scheimpflug imaging at 3, 6, 12, and 24 months. RESULTS: The posterior corneal surface at the 6.0-mm optical zone had significantly less total HOAs (P <0.001) in the DMEK group compared with UT-DSAEK at 24 months. Anterior and posterior corneal densitometry improved from baseline to 24 months for both UT-DSAEK and DMEK, but there was no significant difference between the 2 groups. Corneal densitometry and posterior HOAs were both associated with best-corrected visual acuity (P <0.05). DMEK had 1.3 logarithm of the minimum angle of resolution better visual acuity compared with UT-DSAEK at 24 months. Approximately 64% of this effect was mediated through posterior HOAs, whereas none was mediated through anterior HOAs or densitometry. CONCLUSIONS: Decreased posterior HOAs mediate better visual acuity and account for improved vision after DMEK compared with UT-DSAEK. Corneal light scatter as measured by densitometry is similar between UT-DSAEK and DMEK, indicating that the increased thickness and stromal-stromal interface in UT-DSAEK do not significantly affect visual acuity.

Cyclodialysis Cleft After Secondary Intraocular Lens Placement With Yamane Technique.

PURPOSE: The purpose of this study was to report a rare case of cyclodialysis cleft after secondary intraocular lens (IOL) placement using the Yamane flanged intrascleral haptic fixation technique. METHODS: This study is an observational case report. RESULTS: A 74-year-old man with an ocular history of spontaneously dislocated IOL and subsequent anterior chamber IOL (ACIOL) placement presented with monocular diplopia secondary to ACIOL subluxation. The patient underwent explantation of the subluxed ACIOL and placement of a scleral-fixated IOL using the Yamane technique. The postoperative course was complicated by persistent hypotony, prompting ultrasound biomicroscopy, which revealed a cyclodialysis cleft adjacent to one of the externalized IOL haptics. The haptic was discovered in the involved supraciliary space while performing direct cyclopexy. The cyclodialysis cleft closed with return to physiologic intraocular pressure. CONCLUSIONS: Cyclodialysis cleft formation is a possible complication of scleral IOL fixation and should be suspected in cases of prolonged postoperative hypotony. Extended longitudinal tracking of the needle and haptic through the supraciliary space may be one mechanism for cyclodialysis cleft formation in the Yamane technique.

Descemet membrane endothelial keratoplasty in complex eyes.

PURPOSE OF REVIEW: To review the current literature on Descemet membrane endothelial keratoplasty (DMEK) in complex eyes. RECENT FINDINGS: DMEK surgery has become a standardized procedure in Fuchs endothelial dystrophy and simple bullous keratopathy. But eyes with more complex disease present unique intraoperative and postoperative challenges to the DMEK surgeon. Poor visualization during surgery, complex anterior segment anatomy, altered anterior chamber dynamics, glaucoma shunts, and congenital or iatrogenic missing or altered iris and lens make DMEK surgery extremely difficult to accomplish. SUMMARY: DMEK is feasible in complex eyes, including advanced bullous keratopathy, eyes with history of glaucoma or vitreoretinal surgery, previous penetrating keratoplasty, uveitis, pediatric, and congenital anterior segment disorders. The tools and methods reported in the literature to accomplish DMEK in complex eyes vary widely with no particular consensus or standardization of techniques. The outcomes noted for some of these conditions demonstrate the difficulty of the surgery and the uncertainty of long-term graft survival in complex eyes. Both surgical standardization and randomized prospective data will better help elucidate DMEK's role in the corneal rehabilitation of complex eyes.

Acute Corneal Epithelial Rejection of LR-CLAL After SARS-CoV-2 Vaccination.

PURPOSE: The purpose of this study was to report a case of acute corneal epithelial rejection of living-related conjunctival limbal allograft (LR-CLAL) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. OBSERVATIONS: A 27-year-old woman developed acute epithelial rejection of LR-CLAL 2 weeks after receiving the SARS-CoV-2 vaccine. She received the LR-CLAL transplant 4 years and 7 months previously and had a stable clinical course with no history of rejection. She had an ABO blood group and human leukocyte antigen compatible donor, no systemic comorbidities, and no rejection risk factors. CONCLUSIONS: The novel SARS-CoV-2 vaccine upregulates the immune system to produce an adaptive immune response. The SARS-CoV-2 vaccine may potentially be associated with increased risk of rejection in those with ocular surface transplants.

Predictors of Vision-Related Quality of Life After Endothelial Keratoplasty in the Descemet Endothelial Thickness Comparison Trials.

PURPOSE: To determine which baseline characteristics are associated with vision-related quality of life (QOL) after endothelial keratoplasty. METHODS: A patient- and outcome-masked randomized clinical trial. Consecutive patients presenting with isolated endothelial disease requiring endothelial keratoplasty at Oregon Health Sciences University and Stanford University. Study eyes randomized to one of the 2 types of endothelial keratoplasty were given the national eye institute vision function questionnaire 25 at baseline and 12 months. In this prespecified secondary outcome, we assessed the role of recipient and donor characteristics as predictors of the 12-month national eye institute vision function questionnaire 25 change score. RESULTS: The mean vision function questionnaire (VFQ) score was 74 (SD 14) at baseline and increased to 82 (SD 12) at 3 months and 87 (SD 10) at 12 months. We were unable to find a difference in vision-related QOL in study participants who underwent Descemet membrane endothelial keratoplasty compared with ultrathin Descemet stripping endothelial keratoplasty [coef -0.98, 95% confidence interval (CI) -9.27 to 7.31; P = 0.82]. In multivariable analysis, patients who underwent endothelial keratoplasty in 2 eyes had approximately 8 points higher VFQ at 12 months after the second eye than those who had only one eye enrolled (95% CI 0.10-15.72; P = 0.047). Posterior densitometry produced an approximately 1-point increase each in the VFQ change score for each 1 grayscale unit increase at baseline (95% CI 0.26-1.81; P = 0.009). Although the sample size was small, a diagnosis of pseudophakic bullous keratopathy had approximately 19-points more improvement on average compared with Fuchs (95% CI 7.68-30.00; P = 0.001). CONCLUSIONS: Bilateral endothelial keratoplasty resulted in higher vision-related QOL compared with unilateral. Baseline densitometry, objective measure of corneal haze that predicts vision-related QOL, may play a role in monitoring disease progression.

Early Complications With Preloaded Descemet Membrane Endothelial Keratoplasty Are Not Dependent on Optisol-GS Washout or Trypan Blue Restaining.

PURPOSE: To describe the intraoperative and early postoperative complications using preloaded Descemet membrane endothelial keratoplasty (DMEK) grafts with intraocular injection of the graft in Optisol-GS and omission of trypan blue restaining. METHODS: This is a retrospective case series of 132 consecutive eyes with Fuchs endothelial dystrophy or endothelial failure who underwent DMEK using preloaded donor tissue prepared as previously described. The graft was not restained with trypan blue by the surgeon, and Optisol-GS was injected with the graft into the eye instead of being rinsed from the injector. Early postoperative complications (0-8 wk) including intraoperative fibrin formation, intraocular inflammation, elevated intraocular pressure, partial graft detachment requiring rebubble, and early graft failure were recorded. RESULTS: No eyes developed intraoperative fibrin formation or postoperative inflammation (such as toxic anterior segment syndrome) or elevated intraocular pressure. For eyes with Fuchs corneal dystrophy, our rebubble rate was 21% (22/106 eyes). Early graft failure was noted in 2% (3/132 eyes), which is similar to previous reports. CONCLUSIONS: Our results suggest that injection of Optisol-GS into the anterior chamber during DMEK graft injection does not lead to increases in intraoperative or early postoperative complications. Trypan blue restaining is not necessary for intraoperative visualization. This simplification can reduce graft manipulation and save time and resources for this procedure.

Femtosecond laser-assisted deep anterior lamellar keratoplasty.

PURPOSE OF REVIEW: A survey of the recent literature of deep anterior lamellar keratoplasty using femtosecond laser technology. RECENT FINDINGS: There are several recent reports in the literature assessing technique and outcomes of deep anterior lamellar keratoplasty done with a femtosecond laser trephination. Most of these reports are laboratory studies and small case series with short-term outcomes. The laser technology is expensive and may not produce better results than conventional manual techniques. However, there are several theoretical advantages to femtosecond laser incisions in deep anterior lamellar keratoplasty that should be explored, including possible increased success of Descemet's membrane separation from stroma during surgery as well as postsurgical astigmatism benefits, earlier suture removal, and increased wound strength and healing. SUMMARY: Femtosecond laser trephination in the setting of DALK may improve the technique by decreasing the number of descemet's membrane ruptures and improving short-term and long-term outcomes as compared with manual techniques. However, there is no consensus on a standardized approach for wound design or postoperative management. The literature would benefit from a prospective randomized controlled trial.

Corneal Higher-Order Aberrations in Descemet Membrane Endothelial Keratoplasty versus Ultrathin DSAEK in the Descemet Endothelial Thickness Comparison Trial: A Randomized Clinical Trial.

PURPOSE: To compare corneal higher-order aberrations (HOA) after ultrathin Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). DESIGN: Patient- and outcome-masked randomized controlled clinical trial. PARTICIPANTS: Patients with damaged or diseased endothelium from Fuchs endothelial dystrophy or pseudophakic bullous keratopathy who were good candidates for DMEK or ultrathin DSAEK. METHODS: Corneal anterior and posterior surface HOA were measured with Scheimpflug imaging before surgery and at 3, 6, and 12 months after surgery. HOA after ultrathin DSAEK and DMEK were compared; correlation was performed between best spectacle-corrected visual acuity (BSCVA) and HOA at each time point. MAIN OUTCOME MEASURES: Higher-order aberrations of the anterior and posterior cornea, expressed as the root mean square deviation from a best fit sphere reference surface. RESULTS: At 3, 6, and 12 months after surgery, the posterior corneal surface had significantly less coma (P ≤ 0.003) and total HOA (P ≤ 0.001) in DMEK compared with ultrathin DSAEK (4.0- and 6.0-mm OZ). Posterior trefoil (P ≤ 0.034), secondary astigmatism (P ≤ 0.042), and tetrafoil (P ≤ 0.045) were lower in DMEK than ultrathin DSAEK at 3, 6, or 12 months (either 4.0- or 6.0-mm OZ). There were no significant differences in anterior surface HOA between DMEK and ultrathin DSAEK at any post-surgical time. Compared with baseline, total posterior HOA was increased (P ≤ 0.036) in ultrathin DSAEK at 3, 6, and 12 months, in contrast to DMEK, where it was decreased (P ≤ 0.044) at 6 and 12 months (4.0- or 6.0-mm OZ, or both). At 6 and 12 months, posterior corneal total HOA correlated with BSCVA (ρ ≤ 0.635, P ≤ 0.001; 4.0- and 6.0-mm OZ). There were no moderate or strong correlations between anterior or combined corneal surface HOA at any time point after surgery. CONCLUSIONS: Descemet membrane endothelial keratoplasty results in less posterior corneal HOA compared with ultrathin DSAEK. Descemet membrane endothelial keratoplasty decreases and ultrathin DSAEK increases posterior corneal HOA compared with presurgical values. Total posterior corneal HOA correlates with 6- and 12-month postoperative visual acuity and may account for the better visual acuity observed after DMEK.

Intraoperative Optical Coherence Tomography to Guide Corneal Biopsy: A Case Report.

PURPOSE: To report on a new application of intraoperative optical coherence tomography (OCT) as a real-time imaging tool to help guide corneal biopsy. METHODS: Single case report. After the negative result of a corneal biopsy, we used intraoperative OCT during repeat biopsy to assist in depth and acquisition of an anterior stromal opacity suspected to be immunoglobulin deposits. RESULTS: The use of intraoperative OCT is a novel tool, which assisted in successful identification and conservative biopsy of corneal immunoglobulin deposits. CONCLUSIONS: Intraoperative OCT is a novel tool that assists in the identification and location of corneal pathology for biopsy.

Characterization of corneal deposition keratopathy in the setting of blood cell dyscrasia and a minimally invasive technique to clear the cornea in a single case.

PURPOSE: To report 3 cases of corneal protein deposition occurring in association with systemic disease, with one case demonstrating a novel technique for clearing corneal deposits. OBSERVATIONS: Three patients presented with corneal deposits associated with systemic disease. Corneal involvement was noted prior to diagnosis of systemic disease in two patients, leading to subsequent diagnosis of multiple myeloma or monoclonal gammopathy of undetermined significance. OCT revealed protein deposition at various corneal levels, including at different stromal depths in the two cases of multiple myeloma. A novel technique of posterior endothelial scraping was performed in one case with deep stromal deposits, leading to significant corneal clearing. CONCLUSIONS AND IMPORTANCE: This case series demonstrates that recognition of corneal deposits may precede the diagnosis of systemic disease. It incorporates the use of anterior segment OCT to characterize corneal deposits, and demonstrates a novel surgical technique for clearing certain types corneal deposits.

Time Requirements for Electronic Health Record Use in an Academic Ophthalmology Center.

Importance: Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics. Objective: To examine ophthalmologist time requirements for EHR use. Design, Setting, and Participants: A single-center cohort study was conducted between September 1, 2013, and December 31, 2016, among 27 stable departmental ophthalmologists (defined as attending ophthalmologists who worked at the study institution for ≥6 months before and after the study period). Ophthalmologists who did not have a standard clinical practice or who did not use the EHR were excluded. Exposures: Time stamps from the medical record and EHR audit log were analyzed to measure the length of time required by ophthalmologists for EHR use. Ophthalmologists underwent manual time-motion observation to measure the length of time spent directly with patients on the following 3 activities: EHR use, conversation, and examination. Main Outcomes and Measures: The study outcomes were time spent by ophthalmologists directly with patients on EHR use, conversation, and examination as well as total time required by ophthalmologists for EHR use. Results: Among the 27 ophthalmologists in this study (10 women and 17 men; mean [SD] age, 47.3 [10.7] years [median, 44; range, 34-73 years]) the mean (SD) total ophthalmologist examination time was 11.2 (6.3) minutes per patient, of which 3.0 (1.8) minutes (27% of the examination time) were spent on EHR use, 4.7 (4.2) minutes (42%) on conversation, and 3.5 (2.3) minutes (31%) on examination. Mean (SD) total ophthalmologist time spent using the EHR was 10.8 (5.0) minutes per encounter (range, 5.8-28.6 minutes). The typical ophthalmologist spent 3.7 hours using the EHR for a full day of clinic: 2.1 hours during examinations and 1.6 hours outside the clinic session. Linear mixed effects models showed a positive association between EHR use and billing level and a negative association between EHR use per encounter and clinic volume. Each additional encounter per clinic was associated with a decrease of 1.7 minutes (95% CI, -4.3 to 1.0) of EHR use time per encounter for ophthalmologists with high mean billing levels (adjusted R2 = 0.42; P = .01). Conclusions and Relevance: Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.

Selecting Fuchs patients for drug trials involving endothelial cell proliferation.

PURPOSE: Fuchs endothelial corneal dystrophy (FECD) might be managed by drug treatment before becoming severe enough to require surgery. For a clinical trial of such a drug, we hypothesize that selecting an adequate number of patients with FECD with only moderately compromised cell densities will be challenging. Thus, the purpose of the present study was to measure the prevalence of patients with FECD exhibiting moderately decreased corneal cell densities. METHODS: A retrospective data mining study (cross-sectional study) was performed on patient charts presenting at a large US northwestern academic health center by searching for diagnosis ICD-9 code 371.57 and Fuchs corneal dystrophies, including those with prior cataract surgeries and/or existing glaucoma. Patients with prior corneal transplants were excluded. Noncontact specular photomicroscopic data (Topcon 2000) were obtained from the central region whenever possible, and individual eyes were grouped according to cell density (cells/mm2): severe (<800), moderate (800-1,500), and mild (>1,500). RESULTS: The values for 98 eyes from 61 patients with FECD were as follows (mean ± SD): corneal thickness 573 ± 59 µm, cell size 627 ± 336 µm2/cell, coefficient of variation 23 ± 7, and density 1,883 ± 703 cells/mm2. The moderate subgroup with cell density values averaging 1,184 ± 212 (26) comprised 27% of the total FECD patient pool. CONCLUSIONS: Only approximately 1 out of 4 patients with FECD will show moderately compromised corneal cell densities. A moderate level of damage may be optimal for clinical trials for testing topical drugs on endothelial cell viability. Thus, investigators will need to initially screen a fourfold excess of all patients with FECD.

Eye Bank-Prepared Femtosecond Laser-Assisted Automated Descemet Membrane Endothelial Grafts.

PURPOSE: The aim of this study was to investigate the use of a femtosecond laser (FL) in the eye bank preparation of corneas for Descemet membrane (DM) automated endothelial keratoplasty (fDMAEK) and to compare endothelial cell death in graft preparations between fDMAEK, Descemet stripping endothelial keratoplasty (DSEK), and DM endothelial keratoplasty (DMEK). METHODS: Twenty cadaveric tissues were used to test the fDMAEK method. A 9.0-mm-diameter lamellar incision was made using the FL with a 6.0-mm perpendicular anterior ring cut that enabled a stromal rim by acting as a venting incision for bubble expansion. DM was pneumodissected off the central 6.0 mm of the tissue. The fDMAEK grafts were trephined and stained with a viability dye, calcein AM. The entire stained endothelial surface was digitally captured and the endothelial cell loss (ECL) was calculated using trainable segmentation software. For comparison, a series of 6 DSEK grafts and 8 DMEK grafts were created and analyzed. RESULTS: Six of 20 tissues (30%) were lost during fDMAEK preparation. In the 14 successful tissues, the average ECL was 30.4% [95% confidence interval (CI), 25.3-35.6] compared with 21.1% (95% CI, 13.2-28.9, P = 0.09) in the 6 DSEK grafts and 22.5% (95% CI, 18.0-27.0, P = 0.04) in the 8 DMEK grafts. CONCLUSIONS: FLs are useful in preparing DMAEK tissue at the eye bank and may promote predictable and precise big bubbles and stromal rims. The fDMAEK preparation success improved with experience and laser adjustments. In fDMAEK, the ECL is higher than was previously reported in DMEK and DSEK, likely due to greater tissue manipulation, although not significantly higher than DSEK controls.

Imaging and quantification of endothelial cell loss in eye bank prepared DMEK grafts using trainable segmentation software.

PURPOSE: To improve accuracy and efficiency in quantifying the endothelial cell loss (ECL) in eye bank preparation of corneal endothelial grafts. METHODS: Eight cadaveric corneas were subjected to Descemet Membrane Endothelial Keratoplasty (DMEK) preparation. The endothelial surfaces were stained with a viability stain, calcein AM dye (CAM) and then captured by a digital camera. The ECL rates were quantified in these images by three separate readers using trainable segmentation, a plug-in feature from the imaging software, Fiji. Images were also analyzed by Adobe Photoshop for comparison. Mean times required to process the images were measured between the two modalities. RESULTS: The mean ECL (with standard deviation) as analyzed by Fiji was 22.5% (6.5%) and Adobe was 18.7% (7.0%; p = 0.04). The mean time required to process the images through the two different imaging methods was 19.9 min (7.5) for Fiji and 23.4 min (12.9) for Adobe (p = 0.17). CONCLUSIONS: Establishing an accurate, efficient and reproducible means of quantifying ECL in graft preparation and surgical techniques can provide insight to the safety, long-term potential of the graft tissues as well as provide a quality control measure for eye banks and surgeons. Trainable segmentation in Fiji software using CAM is a novel approach to measuring ECL that captured a statistically significantly higher percentage of ECL comparable to Adobe and was more accurate in standardized testing. Interestingly, ECL as determined using both methods in eye bank-prepared DMEK grafts exceeded 18% on average.

Descemet stripping automated endothelial keratoplasty after 2 previously rejected femtosecond laser-assisted keratoplasties.

PURPOSE: To report on a patient with a welding flash burn with subsequent scarring and edema who twice underwent femtosecond laser-assisted keratoplasty (FLAK). Both grafts failed due to endothelial decompensation. He subsequently underwent successful Descemet stripping automated endothelial keratoplasty (DSAEK) under the second FLAK graft to decrease rejection risk and prevent further full-thickness keratoplasty. METHODS: A 51-year-old man with a history of 2 FLAK procedures with subsequent graft failures likely from noncompliance with postoperative medications had diffuse microcystic edema with a visual acuity of counting fingers at 5 feet. The patient underwent DSAEK procedure 4 months after the second FLAK procedure. RESULTS: No dehiscence occurred during second laser trephination of cornea. Sections of mild misalignment between the first and second FLAK graft trephinations were noted on optical coherence tomography. Post-DSAEK, the patient had a rapidly clearing, well-attached graft with mild temporal overlap of the graft-host interface. All sutures were removed from the overlying FLAK graft by 3 months after DSAEK (7 months after repeat FLAK). At 9 months post-DSAEK, the patient's uncorrected visual acuity was 20/40 and best spectacle-corrected visual acuity was 20/30. CONCLUSIONS: Early secondary femtosecond laser trephination after first FLAK is possible even if the second graft is misaligned. A crescent remnant of the original graft was well-healed into the host cornea 7.5 months after the original surgery. The 3-month-old second FLAK graft was able to support a DSAEK surgery and rapid postoperative visual recovery. All sutures were removed from the cornea by 7 months after the second FLAK surgery.

Femtosecond laser-assisted keratoplasty in failed penetrating keratoplasty and globe trauma.

PURPOSE: To demonstrate feasibility and present postoperative outcomes for femtosecond laser-assisted keratoplasty (FLAK) in the setting of previous failed conventional penetrating keratoplasty (PK) and previous open-globe trauma with corneal laceration. METHODS: In this retrospective case series, data were collected for 12 consecutive patients at the Casey Eye Institute (Oregon Health and Science University, Portland, OR) with the primary diagnosis of either failed PK or open-globe trauma with corneal laceration that underwent zigzag incision FLAK. Outcome measures included topographic astigmatism, best spectacle-corrected visual acuity, uncorrected visual acuity, pinhole visual acuity, intraocular pressure, and timing of selective suture removal (or adjustment) over various follow-up intervals up to 18 months postoperatively. RESULTS: Mean follow-up was 10.42 months. Mean postoperative topographic astigmatism ranged between 3.56 and 6.81 diopters (D). Mean best spectacle-corrected visual acuity (BSCVA) in logarithm of minimal angle of resolution (logMAR) equivalents ranged between 0.18 and 0.61 as compared with 1.28 for preoperative BSCVA (P = 0.0064). Thirty-three percent (4 of 12) of patients had significantly increased intraocular pressure develop during the first year of follow-up that required glaucoma therapy. No adverse events or complications occurred as a result of either the femtosecond laser procedure itself or during the transportation of the patient from the laser suite to the operating room. CONCLUSIONS: FLAK is a feasible transplantation technique in the setting of previous failed PK and open-globe trauma with corneal laceration. Significant globe pressure associated with laser applanation did not cause rupture of old corneal wounds among our case series. Postoperative astigmatism is within previous reported limits in the literature under varying suturing techniques. Development of ocular hypertension within 1 year of follow-up was comparable with historically reported rates for PK in the setting of previous trauma and failed grafts.