Rapid resolution of a third nerve palsy from pituitary apoplexy.

A 49-year-old man presented with new onset headache and diplopia, with right ptosis and limitation of extraocular movements consistent with a third nerve palsy. He had a known diagnosis of a non-functioning pituitary adenoma, and his presentation and neuroimaging were consistent with ischaemic pituitary apoplexy. The patient was otherwise stable with no signs of optic neuropathy or endocrine abnormality. He was observed with close interval follow-up and reported resolution of symptoms within 4 days after onset. Pituitary apoplexy is a potentially life-threatening condition often managed with initial medical stabilisation followed by neurosurgical decompression. The guidelines regarding the utility of surgery in patients with isolated ocular motility disorders are unclear, and recent retrospective studies suggested that outcomes may be similar in patients managed conservatively. This case demonstrates that rapid resolution of an isolated third nerve palsy may occur in this setting, and that observation is a reasonable initial management strategy.

Descemet Membrane Endothelial Keratoplasty versus Descemet Stripping Automated Endothelial Keratoplasty in Complicated Vitrectomized Eyes.

PURPOSE: Vitrectomized eyes pose a technical challenge when performing endothelial keratoplasty (EK). The aim of the study was to compare outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in complex eyes undergoing pars plana vitrectomy (PPV) prior to or during surgery. METHODS: This retrospective study included consecutive eyes that underwent pars plana infusion-assisted DMEK or pull-through DSAEK which underwent PPV prior to or during the EK at a tertiary center. Included were eyes with at least 1-year follow-up. The main outcome measures were best-corrected visual acuity (BCVA) and serious adverse events. RESULTS: Fifty-two eyes (n = 52) with a mean follow-up time of 24.6 ± 7.4 months were included. Both groups were similar in terms of baseline characteristics although the DMEK group had a significantly larger proportion of Fuchs' patients (p = .009). There was no significant difference in postoperative logMAR BCVA between groups at each visit (p > .05 for all). There was a significantly higher proportion of overall serious adverse events (50.0% versus 15.4%, p = .02), retinal detachments (19.2% versus 0.0%, p = .05) and cystoid macular edema (23.1% versus 0.0%, p = .02) following DMEK. Graft detachment occurred more often following DMEK (53.9% versus 11.5%, p = .001) with no significant difference in rebubbling rates (23.1% versus 11.5%, p = .27). CONCLUSIONS: A significant and similar improvement in BCVA was achieved following DMEK and DSAEK in complex vitrectomized eyes. Patients should be advised regarding the higher rates of potential serious complications associated with a pars plana infusion DMEK in this situation.

Assessment of response to multimodal management of neurotrophic corneal disease.

PURPOSE: To characterize patients with neurotrophic keratopathy (NK) and describe treatment outcomes. METHODS: Setting: Two institutional tertiary cornea clinics. PATIENTS: Medical record review of 37 consecutive patients (37 eyes) with NK. INTERVENTION: Management of NK. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), epithelial defects (ED), re-epithelialization time, number of perforations, need for penetrating keratoplasty and tarsorrhaphy. RESULTS: Average age was 64.4 ± 15.0 years, with 59.5% male patients. Average follow up time was 20.8 ± 32.6 months. Moderate to severe NK (Mackie Stage) was present in 62.1% of patients. Herpetic, neurosurgical and pars plana vitrectomy were the top three causes in each Mackie Stage. 72.9% used topical steroids to treat inflammatory ocular disease. Mean number of EDs was 1.6 per patient averaging 85 days to heal. Persistent EDs affected 56.7%. Corneal perforation (18.9%) was more likely with advanced age, herpetic cause and Stage 3 presentation. Tarsorrhaphy was performed in 35% of patients and were more likely with Stage 3 presentation. Referral for neurotization occurred in 10.8%. Evisceration was required in 2 eyes. BCVA of 20/40 or better was achieved in 21.6% of eyes at last follow up. CONCLUSIONS: NK is chronic, frequently visually disabling with multiple contributing factors requiring different treatment modalities. Herpetic, pars plana vitrectomy and neurosurgical causes constitute a significant proportion of NK. Persistent epithelial defects should be rapidly managed as corneal perforation is a serious complication. Advanced age, herpetic cause and Mackie Stage 3 at diagnosis are significant risk factors for corneal perforation.

Outcomes of Ipsilateral Simple Limbal Epithelial Transplantation, Tenonectomy, Mitomycin and Amniotic Membrane Transplantation for Treatment of Recurrent Pterygium.

PURPOSE: To report on the outcomes of recurrent pterygium treated by ipsilateral simple limbal epithelial transplantation (SLET), mitomycin, tenonectomy, and amniotic membrane transplantation. METHODS: A retrospective, interventional study was conducted including all patients with recurrent pterygium who underwent SLET surgery under a single surgeon using ipsilateral donor tissue with a minimum 6-month follow-up at Toronto Western Hospital, Canada. Outcome measures included the following: recurrence rates, best spectacle-corrected visual acuity, and postoperative complications. RESULTS: Ten eyes of 10 patients, aged 60.7 ± 18.5 years (range 23-79) with a mean follow-up time of 15.2 ± 10.0 months of which 50% (n = 5) were men, were included. Eight eyes (80%) had a history of 2 or less pterygium operations. Two patients had 3 and 5 previous pterygium operations, respectively. Concurrent limbal stem cell disease was noted in 6 eyes (60%). Average number of pterygium recurrences per eye was 1.9 ± 1.3 (range 1-5). Mean pre-op best-corrected visual acuity was 0.5 LogMAR (Snellen equivalent 20/60, range 20/20 to counting fingers). Best-corrected visual acuity remained the same or improved in 6 eyes (60%). Recurrence was noted in 1 eye (10%) with a history of 5 previous pterygium excisions and remained stable at the last follow-up. No patients required a second operation. CONCLUSIONS: Ipsilateral SLET with mitomycin, tenonectomy, and amniotic membrane transplantation is a novel technique to address recurrent pterygium. Concurrent limbal stem cell diseases are often present. Initial results demonstrate low recurrence. Visual improvement is modest. Stabilization of the ocular surface to improve vision is possible.

Descemet membrane endothelial keratoplasty in patients with prior glaucoma surgery.

OBJECTIVE: To present outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with prior trabeculectomy or a glaucoma drainage device (GDD). METHODS: A retrospective case series, including patients that had previously undergone trabeculectomy and/or GDD implantation, who later underwent DMEK between 2013 and 2016 at Toronto Western Hospital and the Kensington Eye Institute. Outcome measures: best spectacle-corrected visual acuity (BSCVA), endothelial cell (EC) density, intraoperative and postoperative complications. RESULTS: Twenty-seven eyes of 27 patients were included. All DMEK procedures were uneventful. Mean follow-up time was 14.6 ± 6.1 months. In eyes with no visually limiting comorbidities (n = 16), BSCVA improved from 1.34 ± 0.65 logMAR (Snellen equivalent ~20/440) preoperatively to 0.51 ± 0.24 logMAR (Snellen equivalent ~20/65) and 0.50 ± 0.33 logMAR (Snellen equivalent ~20/65) at 6 and 12 months, respectively (p < 0.001 for both). In eyes with visually limiting comorbidities (n = 11), BSCVA improved from 1.92 ± 0.72 logMAR (Snellen equivalent ~20/1665) preoperatively to 1.43 ± 0.83 logMAR (Snellen equivalent ~20/540) and 1.37 ± 0.99 logMAR (Snellen equivalent ~20/470) at 6 and 12 months, respectively (p = 0.008 and p = 0.037).Graft detachment rate was 24.1% and rebubble rate was 17.2%. Primary and secondary graft failure rates were 3.7% and 10.3%, respectively. Rejection rate was 17.2%. EC-loss rate at 6 months and 12 months was 36.7% and 50.5%, respectively. CONCLUSIONS: DMEK performed in eyes with previous trabeculectomy or a GDD is more challenging than conventional DMEK, but has good outcomes. Higher rates of graft rejection and secondary graft failure in this setting should be further evaluated in long-term studies.

Long-Term Outcomes of Descemet Membrane Endothelial Keratoplasty in Postvitrectomized Eyes With the Use of Pars Plana Infusion.

PURPOSE: To evaluate the use of pars plana infusion as part of Descemet membrane endothelial keratoplasty (DMEK) in eyes of patients who underwent vitrectomy. METHODS: A retrospective chart review was conducted of patients at Toronto Western Hospital (Toronto, Canada) who had undergone DMEK with pars plana infusion, with a minimum follow-up of at least 12 months. Collected data included postoperative best-corrected visual acuity (BCVA), intraoperative complications, and postoperative complications such as graft detachment, rejection and failure, and rate of endothelial cell loss. RESULTS: Fifteen eyes of 14 patients were included in this study. The mean follow-up time was 23.9 ± 5.7 months. Four grafts required rebubbling within the first month of surgery, and one graft required repeat DMEK right away. Two grafts failed secondarily at 24 months, and there was one episode of graft rejection. Five eyes had retinal complications including retinal detachment, retinoschisis, and cystoid macular edema. BCVA improved significantly from 1.7 ± 0.77 logarthim of the minimum angle of resolution (LogMAR) (mean Snellen 20/1000) preoperatively when compared with postoperative BCVA at 6 months (0.95 ± 0.74 LogMar, mean Snellen 20/180, P = 0.02, n = 10), 12 months (0.93 ± 0.6,P = 0.01, mean Snellen 20/170, n = 11), and 24 months (1.01 ± 0.68, mean Snellen 20/200 P = 0.046, n = 7). CONCLUSIONS: Although pars plana infusion is a helpful technique for DMEK in vitrectomized eyes, such cases are still quite difficult to perform compared with standard DMEK and use of an infusion may increase the risk of retinal complications. Descemet Stripping Automated Endothelial Keratoplasty may be the preferred technique in these challenging vitrectomized eyes.

Outcomes of difluprednate treatment for corneal graft rejection.

OBJECTIVE: To evaluate outcomes of difluprednate treatment in penetrating keratoplasty (PK) graft rejection DESIGN: Retrospective, interventional case series. PARTICIPANTS: Patients treated with difluprednate for acute endothelial rejection after PK. METHODS: Data were collected on resolution of rejection, treatment regimen used, best spectacle-corrected visual acuity (BSCVA), intraocular pressure (IOP), and side effects. MAIN OUTCOME MEASURE: rate of rejection resolution. SECONDARY OUTCOME MEASURES: BSCVA change and side-effect rates. RESULTS: Thirty-three eyes of 33 patients aged 56.7 ± 17.9 years were included. Twenty-four grafts (72.7%) were high-risk grafts. Complete treatment success was achieved in 19 of 33 grafts (57.6%) over 1.8 ± 1.4 months. Non-high-risk grafts had 100% treatment success rate (9 of 9 grafts). All treatment failures occurred in high-risk grafts, which had a significantly lower treatment success rate of 41.7% (10 of 24 grafts) compared with non-high-risk grafts (p = 0.004). Mean BSCVA in the treatment-success group improved from 1.07 ± 0.74 logMAR at the time of rejection to 0.44 ± 0.33 logMAR after treatment (p = 0.003). High-dose difluprednate (every 1-3 hours while awake) was used in 93.9% of eyes. IOP elevation and toxic epitheliopathy were each seen in 21.2% of patients. IOP elevation was managed successfully with topical medication and/or difluprednate discontinuation. Epitheliopathy resolved in all cases after completion of difluprednate treatment, except for one case complicated by an infected ulcer. CONCLUSIONS: High-dose difluprednate was effective in treating PK graft rejection, especially in non-high-risk grafts. Adjunct treatment may be required in high-risk grafts. Monitoring for IOP elevation and for toxic epitheliopathy is recommended.

Stepwise Combination of Femtosecond Astigmatic Keratotomy With Phacoemulsification and Toric Intraocular Lens Implantation in Treatment of Very High Postkeratoplasty Astigmatism.

PURPOSE: To report the outcomes of stepwise combined femtosecond astigmatic keratotomy (FSAK) and phacoemulsification with toric intraocular lens (IOL) implantation in the treatment of very high astigmatism after either penetrating keratoplasty or deep anterior lamellar keratoplasty. METHODS: This is a retrospective, interventional case series including 8 eyes of 6 patients with very high astigmatism [≥8.00 diopter (D)] after either penetrating keratoplasty or deep anterior lamellar keratoplasty who underwent FSAK, followed by phacoemulsification and toric IOL implantation. Outcome measures were corneal and manifest astigmatism and uncorrected and best spectacle-corrected visual acuity (UCVA, BSCVA). RESULTS: The average age was 58.9 ± 5.1 years. The average follow-up time was 40.9 ± 43.8 months. Outcome measure changes after both FSAK and toric IOL implantation were: corneal astigmatism improved from 13.56 ± 4.81 D to 4.48 ± 2.83 D (P < 0.001), manifest astigmatism improved from 9.15 ± 3.86 to 1.46 ± 0.88 D (P = 0.011), UCVA improved from 1.69 ± 0.45 LogMAR (Snellen equivalent ∼20/980) to 0.23 ± 0.11 LogMAR (Snellen equivalent ∼20/33, P < 0.001), and BSCVA improved from 1.01 ± 0.71 LogMAR (Snellen equivalent ∼20/200) to 0.19 ± 0.11 LogMAR (Snellen equivalent ∼20/30, P = 0.015). BSCVA and UCVA at the last follow-up were 20/40 or better in all patients. All procedures were uneventful. Two eyes underwent photorefractive keratectomy after FSAK to regularize and further reduce astigmatism before toric IOL implantation. One patient underwent temporary compression suturing because of FSAK overcorrection. CONCLUSIONS: Combined stepwise use of FSAK and phacoemulsification with toric IOL implantation was an effective and apparently safe approach in patients with very high postkeratoplasty astigmatism. Additional treatment using photorefractive keratectomy may be beneficial in some cases.

Outcomes of femtosecond laser-assisted Descemet membrane endothelial keratoplasty for failed penetrating keratoplasty.

OBJECTIVE: To analyze the outcomes of femtosecond laser-enabled Descemet membrane endothelial keratoplasty (FE-DMEK) in treatment of failed penetrating keratoplasty (PK) grafts. STUDY DESIGN: Retrospective, interventional case series. PARTICIPANTS: Patients with a failed PK graft who underwent FE-DMEK at Toronto Western Hospital, Canada, between 2014 and 2016. METHODS: Outcome measures were best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), rates of graft detachment, rebubbling, rejection, and failure. RESULTS: Eight eyes of 8 patients were included. Mean age was 64.7 ± 14.5 years. Average follow-up time was 27.5 ± 8.6 months (range 15-36 months). There were no intraoperative complications and no issues with the creation of the descemetorhexis-all descemetorhexis cuts were complete. There were no significant graft detachments and no need for rebubbling. There were no primary or secondary graft failures and all grafts were viable at the final follow-up. BSCVA worsened from 0.41 ± 0.33 logMAR (Snellen equivalent ∼20/50) to 1.37 ± 0.91 logMAR (Snellen equivalent ∼20/460) after PK failure (p = 0.012), and improved significantly after FE-DMEK to 0.34 ± 0.14 logMAR (Snellen equivalent ∼20/45), 0.42 ± 0.12 logMAR (Snellen equivalent ∼20/50), 0.27 ± 0.14 logMAR (Snellen equivalent ∼20/35), and 0.25 ± 0.16 logMAR (Snellen equivalent ∼20/35) at 6 months, 12 months, 24 months, and at final follow-up, respectively (p = 0.013, p = 0.027, p = 0.022, and p = 0.008, respectively). ECD decreased from 2837 ± 229 cells/mm2 preoperatively to 1069 ± 413 cells/mm2 (61.4% cell-loss rate) and 974 ± 344 cells/mm2 (64.8% cell-loss rate) at 12 months and 24 months, respectively (p < 0.001). Cell loss was higher than in historical controls. CONCLUSIONS: FE-DMEK was effective in the management of PK graft failure, showing very low detachment and rebubble rates.

Comparison of Descemet Stripping Automated Endothelial Keratoplasty and Descemet Membrane Endothelial Keratoplasty in the Treatment of Failed Penetrating Keratoplasty.

PURPOSE: To compare the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with Descemet membrane endothelial keratoplasty (DMEK) for the treatment of failed penetrating keratoplasty (PKP). METHODS: This is a retrospective chart review of patients with failed PKP who underwent DMEK or DSAEK. The median follow-up time for both groups was 28 months (range 6-116 months). Data collection included demographic characteristics, number of previous corneal transplants, previous glaucoma surgeries, best-corrected visual acuity, endothelial cell density, graft detachment and rebubble rate, rejection episodes, and graft failure. RESULTS: Twenty-eight eyes in the DMEK group and 24 eyes in the DSAEK group were included in the analysis. Forty-three percent of eyes in the DMEK group and 50% of eyes in the DSAEK group had to be regrafted because of failure (P = 0.80). The most common reason for failure was persistent graft detachment (58%) in the DMEK group and secondary failure (58%) in the DSAEK group; hence, the time between endothelial keratoplasty and graft failure differed significantly between the groups (P = 0.02). Six eyes (21%) in the DMEK group and 7 eyes (29%) in the DSAEK group developed graft rejection (P = 0.39). Rejection was the cause of failure in 67% and 71% in the DMEK and DSAEK groups, respectively. The best-corrected visual acuity 6 months after surgery was better in the DMEK group compared with the DSAEK group (P = 0.051). CONCLUSIONS: Both DSAEK and DMEK have a role in treating PKP failure. Primary failure due to persistent graft detachment was significantly higher in the DMEK group, although the overall failure rate in the medium term was similar.

Three-Year Outcome Comparison Between Femtosecond Laser-Assisted and Manual Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate 3-year outcomes of femtosecond laser-assisted Descemet membrane endothelial keratoplasty (F-DMEK) compared with manual Descemet membrane endothelial keratoplasty (M-DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS: A retrospective, interventional study, including eyes with FECD and cataract that underwent either F-DMEK or M-DMEK combined with cataract extraction at either the Toronto Western Hospital or Kensington Eye Institute, and that had at least 18 months' follow-up was conducted. EXCLUSION CRITERIA: complicated anterior segments, previous vitrectomy, previous keratoplasty, corneal opacity, or any other visually significant ocular comorbidity. RESULTS: Included were 16 eyes of 15 patients in the F-DMEK group (average follow-up 33.0 ± 9.0 months) and 45 eyes of 40 patients in the M-DMEK group (average follow-up 32.0 ± 7.0 months). There were no issues with the creation of femtosecond descemetorhexis (in the F-DMEK group)-all descemetorhexis cuts were complete. Best spectacle-corrected visual acuity improvement did not differ significantly between the groups at 1, 2, and 3 years (P = 0.849, P = 0.465 and P = 0.936, respectively). Rates of significant detachment in F-DMEK and M-DMEK were 1 of 16 eyes (6.25%) and 16 of 45 eyes (35.6%) (P = 0.027). Rebubbling rates were 1 of 16 eyes (6.25%) and 15 of 45 eyes (33.3%) (P = 0.047). Cell-loss rates following F-DMEK and M-DMEK were 26.8% and 36.5% at 1 year (P = 0.042), 30.5% and 42.3% at 2 years (P = 0.008), 37% and 47.5% at 3 years (P = 0.057), respectively. Graft failure rate was 0% in F-DMEK and 8.9% in M-DMEK (all were primary failures; P = 0.565). CONCLUSIONS: F-DMEK showed good efficacy with reduced detachment, rebubble, and cell-loss rates, compared with M-DMEK.

Evaluation of Big Bubble Technique for Deep Anterior Lamellar Keratoplasty in Patients With Radial Keratotomy.

PURPOSE: To report the outcome of deep anterior lamellar keratoplasty (DALK) and success rates of the big-bubble (BB) technique or manual dissection after a failed use of the BB technique in eyes that underwent prior radial keratotomy (RK). METHODS: A retrospective chart review of patients who underwent DALK after RK at Toronto Western Hospital, Canada, between 1999 and 2017 was performed. Demographic characteristics, success rates of the BB technique and manual dissection, intraoperative and postoperative complications, and best spectacle-corrected visual acuity before and after corneal transplant were analyzed. RESULTS: Ten eyes of 9 patients were included in the analysis. The average age was 64 ± 10 years (range 49-82). The average time between the RK surgery and the corneal transplant was 20 ± 5 years (range 8-24). Indications for corneal transplant were significant irregular astigmatism in 5 eyes (50%), central scarring or haze in 4 eyes (40%), and progressive hyperopia with visual fluctuation in one eye (10%). BB was successfully achieved in one eye (10%). In 6 eyes (60%), manual dissection was performed, and in 3 eyes (30%), DALK surgery was converted to penetrating keratoplasty. The average best spectacle-corrected visual acuity on the last follow-up visit was 0.26 ± 0.08 logMAR (Snellen equivalent 20/36). One eye that underwent manual DALK and one eye that underwent penetrating keratoplasty developed a rejection episode 4 and 2 months after keratoplasty, respectively. In both cases, rejection resolved with topical steroids. CONCLUSIONS: In eyes that underwent prior RK, DALK by manual dissection should be considered as a preferable surgical technique.

Wavefront-Guided Photorefractive Keratectomy in the Treatment of High Astigmatism Following Keratoplasty.

PURPOSE: To report the outcome of wavefront-guided photorefractive keratectomy (WG-PRK) in the treatment of high astigmatism following keratoplasty. METHODS: A retrospective, interventional analysis including patients with high astigmatism following either penetrating keratoplasty or deep anterior lamellar keratoplasty, who underwent WG-PRK. RESULTS: Thirteen eyes (7 right eyes) of 12 patients (10 male) aged 35.1 ± 5.9 years were included. Preoperative astigmatism ranged between 3.00 and 5.00 D. Average follow-up time was 14.0 ± 6.2 months. Uncorrected distance visual acuity (UDVA) improved from 0.97 ± 0.58 logarithm of the minimum angle of resolution (logMAR) (Snellen equivalent ∼20/187) preoperatively to 0.13 ± 0.15 logMAR (Snellen equivalent ∼20/27) at 6 months and 0.14 ± 0.16 logMAR (Snellen equivalent ∼20/28) at the final follow-up (P = 0.001 and P = 0.002, respectively). UDVA ≥20/40 increased from 1 eye (7.7%) preoperatively to 13 eyes (100%) at 6 months and 12 eyes (92.3%) at the final follow-up (P < 0.001 for both). UDVA ≥20/25 increased from 1 eye (7.7%) preoperatively to 6 eyes (46.2%) at 6 months and at the final follow-up (P = 0.027 for both). Mean astigmatism improved from -3.98 ± 0.75 D to -1.27 ± 0.82 D and -1.40 ± 1.04 at 6 months and at the last follow-up, respectively (P = 0.001 for both). Preoperative astigmatism was ≥3.00 D in all eyes and was reduced to ≤2.50 D in all eyes at 6 months postoperatively, with 7 eyes (63.6%) having ≤1.00 D of astigmatism at both 6 months and the final follow-up. CONCLUSIONS: WG-PRK was safe and effective in the treatment of high and regular postkeratoplasty astigmatism.

Bilateral BrightOcular iris implants necessitating explantation and subsequent endothelial keratoplasty.

PURPOSE: To demonstrate the dangers associated with the BrightOcular iris implant, a model that had initially been touted as safer than its predecessors. OBSERVATIONS: A 41-year-old male presented with decreased vision in both eyes, approximately two years following bilateral BrightOcular cosmetic iris implantation performed in Mexico. On initial consultation, he was found to have bilateral corneal decompensation with stromal edema and a significantly reduced endothelial cell count (ECC). On follow up 5 weeks later, his vision and corneal edema had further detriorated. In the following month, he underwent explantation of the cosmetic iris implants in both eyes. Significant corneal edema persisted in the right eye several months post-operatively, to the point of necessitating endothelial keratoplasty. CONCLUSIONS AND IMPORTANCE: Despite numerous reports in the literature of the significant ocular complications that can arise secondary to cosmetic iris implantation, individuals continue to willingly undergo this surgery. Our intention with presenting this case to the ophthalmologic community is two-fold: to highlight the ongoing clinical risk that BrightOcular devices pose, despite being marketed as safer than the older NewColourIris models, and to stress the urgency with which cosmetic iris implants should be removed from the eye.

Simple limbal epithelial transplantation for recurrent pterygium: A case series.

PURPOSE: Pterygium recurrence is a common complication of pterygium removal. Multiple surgical and medical approaches have been utilized to reduce recurrence rates. The present case series proposes a novel way to treat recurrent pterygia, by using the simple limbal epithelial transplantation (SLET) technique. OBSERVATIONS: The cases of four patients who presented with recurrent pterygium were reviewed. In all four of the cases reported, the SLET procedure went without complication. There were no significant recurrences at each of the patient's most recent follow-up visits. CONCLUSIONS AND IMPORTANCE: This is the first report of SLET being used as a treatment modality for recurrent pterygium. Further studies are required to more reliably demonstrate the utility of the procedure in this clinical circumstance, but our results are encouraging that in select patients, this may be a viable option in treating aggressive recurrent pterygia.

Descemet Membrane Endothelial Keratoplasty After Penetrating Keratoplasty: Features for Success.

PURPOSE: To evaluate Descemet membrane endothelial keratoplasty (DMEK) in the setting of failed penetrating keratoplasty (PKP) and to identify factors associated with DMEK success and failure after PKP. METHODS: A retrospective chart review of patients who underwent DMEK for failed PKP at Toronto Western Hospital, Canada, between 2014 and 2017 was performed. Demographic characteristics, number of previous transplants, intraoperative and postoperative complications, best spectacle-corrected visual acuity (BSCVA), and endothelial cell density were analyzed. RESULTS: Twenty-eight eyes were included in the study. Rebubbling intervention was performed in 12 eyes (43%) within the first postoperative weeks. Five eyes (18%) developed graft rejection episodes. Twelve eyes (43%) had to be regrafted after DMEK surgery and were deemed failures (because of persistent Descemet membrane detachment, rejection episode that led to secondary failure, and infection). BSCVA before DMEK was significantly worse in the eyes that failed than those that did not [1.97 ± 0.85 and 1.2 ± 0.56 logMAR, respectively, (P = 0.01)]. Rebubbling was required in 75% of eyes in the failure group compared with 19% in the success group (P = 0.002). Six of the 16 eyes (37.5%) in the success group underwent femtosecond laser-enabled DMEK, whereas this technique was not used in any of the eyes in the failure group (P = 0.017). CONCLUSIONS: DMEK is a viable option for cases of failed PKP. DMEK failure after PKP might be associated with lower visual acuity before DMEK surgery, higher number of rebubble interventions, and manual descemetorhexis rather than femtosecond laser-enabled DMEK.