Phototherapeutic keratectomy versus epithelial debridement combined with anterior stromal puncture or diamond burr for recurrent corneal erosions.

OBJECTIVE: To compare outcomes of phototherapeutic keratectomy (PTK) versus epithelial debridement combined with anterior stromal puncture (ASP) or diamond burr for the treatment of recurrent corneal erosions (RCES) in a large tertiary centre. METHODS: Patients with a diagnosis of RCES secondary to trauma or epithelial basement membrane dystrophy who underwent a surgical procedure between 2009 and 2019 were included in the study. The following data were collected: demographics, ocular history, prior medical treatment, ocular surgeries, intervention, complete epithelialization at postoperative week 1, recurrences, and complications. Recurrence was defined as either an objective finding of a corneal epithelial defect or symptoms suggestive of recurrent epithelial erosion on history. Recurrence rate and time to epithelialization were compared between groups. RESULTS: A total of 97 eyes (73 patients) were included in the study. Mean patient age was 51 ± 16.1 years, and mean follow-up was 474 days. RCES was secondary to epithelial basement membrane dystrophy in 80% (n = 78 of 97), trauma (15%, n = 15 of 97), or idiopathic (4%, n = 4 of 97). Epithelial debridement with ASP was performed in 34 eyes (35%), diamond burr in 33 eyes (33%), and PTK in 30 eyes (31%). Compared with epithelial debridement with ASP (recurrence 29.4%), the recurrence rate was significantly lower for both the diamond burr (9.1%, p = 0.031) and PTK groups (10%, p = 0.048). The diamond burr and PTK groups also had a significantly higher rate of complete epithelialization at 1 week (p < 0.05). CONCLUSION: Compared with epithelial debridement with ASP, diamond burr and PTK have significantly lower rates of recurrence and time to epithelialization and may be considered first for surgical management of RCES.

Outcomes of femtosecond laser-assisted cataract and refractive lens surgery in patients with prior radial keratotomy.

PURPOSE: To investigate outcomes of femtosecond laser (FL)-assisted cataract surgery (FLACS) and refractive lens exchange (RLE) in patients with prior radial keratotomy (RK). SETTING: Single clinical practice. DESIGN: Retrospective observational case series. METHODS: All patients with prior RK undergoing FLACS- or FL-assisted RLE surgeries over a 6-year period were reviewed. Inclusion criteria were diurnal stability and stable manifest refraction. Exclusion criteria were any other incisional corneal surgery, macular or glaucomatous pathology, or vision loss due to any other cause. Data collected included demographics, visual acuity, laser settings, and complications. Main outcome measures were intraoperative and postoperative complications and visual outcomes. Safety and efficacy indices were evaluated. RESULTS: 16 eyes of 9 patients were included. Mean age and follow-up time were 59.9 ± 9.9 years (range 44 to 75 years) and 3.3 ± 2.5 months, respectively. The mean number of RK cuts was 11.8 ± 5.3 (range 8 to 20). Mean preoperative uncorrected (UDVA) and corrected distance visual acuity (CDVA) were 0.9 ± 0.4 logMAR (Snellen 20/160) and 0.2 ± 0.3 logMAR (Snellen 20/30), respectively. 2 intraoperative anterior capsule tears were identified. 1 postoperative intraocular lens dislocation occurred. Postoperatively, the mean UDVA and CDVA were 0.2 ± 0.2 logMAR (20/30) and 0.1 ± 0.1 logMAR (20/25), respectively. The safety index was 1.6, and the efficacy index was 1.2. CONCLUSIONS: FLACS- or FL-assisted RLE surgery in RK patients has a high risk for anterior capsule tear and should be avoided. Thickened incisional scars are potential sources of incomplete laser penetrance. Toric lens implantation in RK eyes provide unpredictable astigmatic correction and should also be avoided.

Sutureless dehydrated amniotic membrane for persistent epithelial defects.

PURPOSE: To report outcomes of a sutureless dehydrated amniotic membrane for persistent epithelial defects (PED). METHODS: This retrospective study included consecutive patients with a PED (⩾14 days) treated with a sutureless dehydrated amniotic membrane and bandage contact lens (BCL). Included were patients with an epithelial defect that did not respond to treatment with a BCL. Excluded were patients with a follow-up time of less than 3 months. RESULTS: Nine eyes of eight patients with a mean age of 54.6 ± 10.9 years (range 38-73 years) were included in this study. The main etiology of the PED was limbal stem cell deficiency (n = 5/9) due to Stevens-Johnson Syndrome (n = 2/5), glaucoma procedures (n = 1/5), graft-versus-host disease (n = 1/5) and severe allergic reaction (n = 1/5). Additional etiologies included neurotrophic cornea (n = 2/9), post keratoplasty and severe dry eye disease (n = 2/9). Time from PED presentation to amnion treatment was 65.9 ± 60.6 days (range 15-189 days) with the area of the PED being 11.0 ± 12.2 mm2 (range 1.0-36.0 mm2). The amnion was absorbed within 2 weeks in 100% of the cases. Following insertion of the amnion, resolution of the PED was achieved in 8/9 eyes (89%) without the need for additional interventions within 17.8 ± 9.6 days (range 7-35 days). LogMAR BCVA improved from 0.94 ± 0.88 to 0.37 ± 0.25 (p = 0.036) with no complications or recurrences recorded. CONCLUSIONS: Sutureless dehydrated amniotic membrane achieved resolution of PEDs secondary to various etiologies in 89% of eyes with a significant improvement in vision demonstrated. Further studies are needed to assess long term safety and effectiveness.

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.

Risk Factors for Repeat Descemet Membrane Endothelial Keratoplasty Graft Failure.

PURPOSE: To evaluate repeat Descemet membrane endothelial keratoplasty (re-DMEK) success rates and to identify risk factors for re-DMEK failure. DESIGN: Retrospective case series. METHODS: Settings: Institutional. PATIENTS AND INTERVENTIONS: A chart review was performed, including all eyes with primary DMEK failure that underwent re-DMEK between 2013 and 2019 at the Toronto Western Hospital and the Kensington Eye Institute (Toronto, Ontario, Canada) and had at least 6 months of follow-up. MAIN OUTCOME MEASURE: Predicting factors for re-DMEK outcome. RESULTS: Of 590 consecutive DMEK surgeries, 40 eyes (6.7%) were identified for having a secondary DMEK surgery after primary DMEK failure. Etiologies for primary DMEK were Fuchs endothelial corneal dystrophy (32.5%), pseudophakic bullous keratopathy (35%), previous failed graft (27.5%), and other indications (5%). Fifty-five percent of the cohort were categorized as having a complicated anterior segment including 11 eyes with previous glaucoma surgery, 7 eyes post-penetrating keratoplasty, 4 eyes post-Descemet stripping automated endothelial keratoplasty, 3 eyes peripheral anterior synechia, 3 eyes previous pars plana vitrectomy, 2 eyes aphakia, and 1 eye each with aniridia, anterior chamber intraocular lens, and iris-fixated intraocular lens. Re-DMEK failure was documented in 12 eyes (30%) of the entire cohort. The risk factor for re-DMEK failure was the presence of a complicated anterior segment (P = .01, odds ratio = 17.0 [95% confidence interval: 1.92-150.85]), with 50% re-DMEK failure rate in this subgroup. CONCLUSION: Re-DMEK is a viable option for cases of primary DMEK failure, especially for eyes with Fuchs endothelial corneal dystrophy as the indication for primary DMEK without other ocular morbidities; however, eyes categorized with a complicated anterior segment had high re-DMEK failure rates..

Four-Year Survival Comparison of Endothelial Keratoplasty Techniques in Patients With Previous Glaucoma Surgery.

PURPOSE: To compare 4-year survival outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet-stripping automated endothelial keratoplasty (DSAEK) in eyes with previous glaucoma surgery. METHODS: This is a retrospective, comparative case series, including patients with previous trabeculectomy or glaucoma drainage device implantation, who later underwent either DMEK (n = 48) or DSAEK (n = 41). Follow-up was limited to 12 to 60 months to prevent bias. Primary outcomes were graft survival and rejection. Secondary outcomes were best spectacle-corrected visual acuity (BSCVA), detachment/rebubble, endothelial cell loss, and intraocular pressure elevations. RESULTS: Baseline characteristics, follow-up duration, and preexisting glaucoma parameters did not differ significantly between the groups. Graft survival probability after DMEK and DSAEK was 75% and 75% at 1 year, 63% and 50% at 2 years, 49% and 44% at 3 years, 28% and 33% at 4 years, and 28% and 29% at 5 years, respectively (P = 0.899 between the groups). Graft rejection rates were 20.8% and 19.5%, respectively (P = 1.000). Primary failure, rebubbling, endothelial cell loss, and intraocular pressure elevation did not differ significantly between the groups. Preoperative BSCVA did not differ between the groups (P = 0.821). Postoperative BSCVA was significantly better in the DMEK group at 6, 12, and 24 months (P < 0.001, P = 0.022, and P = 0.047, respectively). In a multivariable model (R2 = 0.576), the type of surgery was the only significant factor affecting postoperative BSCVA, in favor of DMEK (coefficient value -0.518, P = 0.002). CONCLUSIONS: In eyes with previous glaucoma surgery, DMEK and DSAEK had comparably low survival and comparably high rejection rates. Postoperative visual acuity might be better after DMEK in this setting.

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.

Comparison of manual and femtosecond astigmatic keratotomy in the treatment of postkeratoplasty astigmatism.

PURPOSE: To compare the outcomes of femtosecond astigmatic keratotomy (FSAK) and manual astigmatic keratotomy (AK) in treatment of postkeratoplasty astigmatism. METHODS: A retrospective, comparative, pairwise-matched case series including 150 patients who underwent either FSAK (n = 75) or manual AK (n = 75) for the treatment of astigmatism (>3.00 D) following penetrating keratoplasty or deep anterior lamellar keratoplasty. Pairwise matching for baseline variables (age, visual acuity and astigmatism) was performed. RESULTS: Mean age was 57.5 ± 16.0 years. The FSAK group had significantly better postoperative best-corrected visual acuity (BCVA) (p = 0.010), uncorrected visual acuity (UCVA) (p = 0.049), corneal astigmatism (p = 0.020) and manifest astigmatism (p < 0.001) compared with the manual AK group. Gain of ≥3 lines in BCVA (logMAR) was seen in five eyes (6.7%) and 21 eyes (28.0%) in manual AK and FSAK, respectively (p = 0.005). Alpins vector analysis showed lower (closer to 0) index of success (0.50 ± 0.24 and 0.79 ± 0.48, p < 0.001) and higher (closer to 1) correction index (0.94 ± 0.45 and 0.74 ± 0.55, p = 0.020) in FSAK compared with manual AK. Corneal and manifest astigmatism improved significantly in both groups, while BCVA and UCVA improved significantly in FSAK only. Repeat AK rate was 32% (24 eyes) in manual AK and 4% (three eyes) in FSAK (p < 0.001). Overcorrection-related re-suturing rate was 0% in manual AK and 8% (six eyes) in FSAK (p = 0.037). There was one microperforation (1.3%) in FSAK, and there were no occurrences of graft dehiscence, infectious keratitis or graft rejection. CONCLUSIONS: Both manual AK and FSAK were safe and effective in reducing postkeratoplasty astigmatism. FSAK had superior visual and keratometric outcomes compared with manual AK.

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.

Surgical Management of the Ocular Surface in Neurotrophic Keratopathy: Amniotic Membrane, Conjunctival Grafts, Lid Surgery, and Neurotization.

PURPOSE: To review the surgical modalities available to treat Mackie stage 2 and stage 3 neurotrophic keratopathy. METHODS: Literature review and technique descriptions. RESULTS: The following procedures are described in detail with accompanying videos: temporary, permanent, and botox-assisted tarsorrhaphy; amniotic membrane transplant; keratoplasty with amniotic membrane and tarsorrhaphy augmentation; Gunderson and conjunctival pedicle flaps; buccal graft transplantation; and neurotization. CONCLUSION: A variety of surgical options exist to manage neurotrophic keratopathy when medical treatments alone fail to resolve epitheliopathy. Ongoing protection and optimization of the ocular surface health remains crucial to prevent recurrent epithelial breakdown.

Factors Associated With Improvement in Vision Following Femtosecond Astigmatic Keratotomy in Post-Keratoplasty Keratoconus Patients.

PURPOSE: To evaluate factors associated with improvement in vision following femtosecond astigmatic keratotomy (FSAK) in patients with keratoconus post-keratoplasty. DESIGN: Retrospective, interventional case series. METHODS: The study took place in an institutional setting. This was a retrospective study that included patients with keratoconus who underwent FSAK for astigmatism following penetrating (PKP) or deep anterior lamellar keratoplasty (DALK). Success was defined as improvement in 3 Early Treatment Diabetic Retinopathy Study lines (doubling of the visual angle) of uncorrected distance visual acuity (UDVA) or best spectacle-corrected visual acuity (BSCVA). RESULTS: A total of 56 eyes in 56 patients with keratoconus were included. Following FSAK, there was a significant improvement in UDVA (1.30 ± 0.49 to 0.87 ± 0.58 logarithm of minimal angle of resolution [logMAR]; P < .001), BSCVA (0.40 ± 0.26 to 0.27 ± 0.29 logMAR; P <.001), and corneal astigmatism (8.69 ± 2.72 to 3.92 ± 2.13 diopter [D]; P < .001). Success was achieved in 60.7% (34/56) of cases, and this group had a higher proportion of previous PKP (73.5% vs 45.5%; P = .03), worse preoperative UDVA (1.42 ± 0.47 vs 1.11 ± 0.47 logMAR; P = .03), and a greater preoperative manifest cylinder (7.56 ± 2.26 vs 5.72 ± 2.12 D; P = .01). In multiple regression analysis, PKP (vs DALK) (odds ratio [OR]: 8.52; P = .009), worse preoperative UDVA (OR: 9.08, P = .02), and greater preoperative cylinder (OR: 1.51; P = .04) were independently associated with success, and, when combined, led to a sensitivity and specificity of 84.6% and 93.8%, respectively, in predicting success. The optimal cutoff predicting success with a preoperative cylinder was a cylinder >6.75 D. CONCLUSION: Approximately 60% of patients with keratoconus post-keratoplasty experience doubling of the visual angle following FSAK. Patients with previous PKP and a greater cylinder are more likely to benefit from this procedure. Separate nomograms for DALK and PKP patients may be warranted.

Outcomes of Descemet Membrane Endothelial Keratoplasty in Aphakic and Aniridic Patients.

PURPOSE: To evaluate the outcomes of Descemet membrane endothelial keratoplasty (DMEK) in aphakic and aniridic eyes. METHODS: A retrospective chart review of either aphakic or aniridic patients who underwent DMEK at Toronto Western Hospital, Canada, between 2015 and 2019 was performed. Demographic characteristics, intraoperative and postoperative complications, and best corrected visual acuity (BCVA) were analyzed. RESULTS: Nine eyes of 9 patients, aged 51.0 ± 8.6 years, were included (3 aniridic, 5 aphakic, and 1 combined). The average follow-up was 15.7 ± 12.7 months. The best corrected visual acuities before surgery and 3 and 6 months after surgery were 1.28 ± 0.47, 1.33 ± 0.98, and 1.03 ± 0.56 LogMAR, respectively. Six eyes (67%) had graft detachment, with 3 of them larger than 30% of the graft area. One eye (11%) developed hyphema. The overall failure rate was 88% (8 of 9 eyes), meaning only one was viable at the last follow-up. Primary graft failure was seen in 4 eyes (44%) after detachment (n = 3) and intraoperative hyphema (n = 1). Secondary failure occurred in 4 eyes (44%) at 7, 12, 15, and 36 months. The secondary failure at 36 months was after rejection. Failures were managed with penetrating keratoplasty (n = 2), repeat DMEK (n = 3), Descemet stripping automated endothelial keratoplasty (n = 1), and observation because of poor vision potential (n = 2). Cumulative graft survival probabilities at 12 and 24 months were 44% and 17%, respectively. CONCLUSIONS: Aniridic and aphakic patients experienced unacceptably high detachment and failure rates after DMEK. Before performing DMEK, the risks and benefits should be carefully weighed and perhaps other keratoplasty techniques should be used.

Four-Year Survival of Descemet Membrane Endothelial Keratoplasty in Patients With Previous Glaucoma Surgery.

PURPOSE: To evaluate 4-year outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with previous glaucoma surgery. DESIGN: Retrospective, comparative case series. METHODS: Patients with previous trabeculectomy or glaucoma drainage device (GDD) implantation who later underwent DMEK (study group) were matched for follow-up duration with Fuchs dystrophy DMEK patients (control group). The minimum follow-up was 18 months. Primary outcomes included graft survival and rejection rates, and secondary outcomes included rates of detachment/rebubble, endothelial cell loss, best spectacle-corrected visual acuity, intraocular pressure, and glaucoma medications/surgeries. Subgroup analysis compared eyes with and without a GDD. RESULTS: Ninety-four eyes of 91 patients were included. There were 51 eyes of 49 patients in the study group (GDD = 32 eyes, no GDD = 19 eyes) and 43 eyes of 42 patients in the control group. The mean follow-up was 37.9 ± 15.2 and 33.8 ± 13.5 months, respectively (P = .322). Graft survival probability of the study group at 12, 24, 36, and 48 months was 75%, 60%, 43%, and 27%, respectively, compared with a consistent 88% in the control group (P < .001). Survival curves of study subgroups (GDD and no GDD) were significantly lower than the control group (P < .001). Rejection rates in the study and control groups were 19.6% and 2.3%, respectively (P = .010). Endothelial cell loss in the study group was 12%-22% higher than the control group at 12, 24, 36, and 48 months (P = .049, P = .027, P = .200, and P = .004). CONCLUSIONS: In eyes with previous glaucoma surgery, DMEK has good early outcomes, but longer-term rejection and failure rates are high. Physicians and patients should be cognizant of the high likelihood of graft failure in this setting.

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.

Comparison of Manual and Femtosecond Laser-Assisted Descemet Membrane Endothelial Keratoplasty for Failed Penetrating Keratoplasty.

PURPOSE: To compare outcomes of manual Descemet membrane endothelial keratoplasty (M-DMEK) and femtosecond laser-assisted Descemet membrane endothelial keratoplasty (F-DMEK) in treatment of penetrating keratoplasty (PK) graft failure. METHODS: Setting: Retrospective, interventional comparative case series. PatientPopulation: Included were all patients with a failed PK graft who underwent either F-DMEK (10 eyes of 10 patients) or M-DMEK (29 eyes of 29 patients) at Toronto Western Hospital and the Kensington Eye Institute between 2014 and 2019, and had 6 months of postoperative follow-up. OutcomeMeasures: Rates of graft detachment, rebubbling, rejection and failure, best spectacle-corrected visual acuity (BSCVA), and endothelial cell (EC) density. RESULTS: Rate of significant graft detachment (detachment requiring either rebubble or repeat keratoplasty) was 10.0% in F-DMEK and 65.5% in M-DMEK (P = .003). Rebubble rate was 10.0% in F-DMEK and 58.6% in M-DMEK (P = .011). Primary failure rate was 0% in F-DMEK and 27.6% in M-DMEK (P = .086). Rates of rejection and secondary failure did not differ between the groups (P = 1.000 for both). In a multivariable analysis, F-DMEK was found to be the only independent factor significantly associated with reduced postoperative detachment. Postoperative BSCVA at 6 months returned to prefailure levels in both groups, with no significant difference between the groups at any time point. EC loss rates were 43.8% in F-DMEK and 38.0% in M-DMEK at 6 months (P = .453). CONCLUSIONS: F-DMEK is a safe and effective procedure in failed PK patients, with outcomes comparable to M-DMEK, and with reduced detachment and rebubble rates. A trend towards reduced primary failure should be further studied.

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.