Comparison of keratoplasty outcomes at the scar versus edema stages of keratoconus.

PURPOSE: To assess the outcomes of deep anterior lamellar keratoplasty or penetrating keratoplasty at the scar and the edema stages. METHODS: Forty-five patients (45 eyes) with keratoconus scar stage (scar group, n=26; penetrating keratoplasty a subgroup, n=7; deep anterior lamellar keratoplasty b subgroup, n=19) and keratoconus edema stage (edema group, n=19; penetrating keratoplasty c subgroup, n=12; deep anterior lamellar keratoplasty d group, n=7) who received penetrating keratoplasty or deep anterior lamellar keratoplasty from 2000 to 2022 were retrospectively studied. At 1, 6, and 12 months after surgery, the best-corrected visual acuity, astigmatism, spherical equivalent, corneal endothelial cell density, and complications were analyzed. RESULTS: The best-corrected visual acuity and average corneal endothelial cell loss rate were not significantly different between the scar and edema groups (p>0.05). At 6 and 12 months after surgery, the astigmatism and spherical equivalent in the scar group were significantly lower than those in the edema group (p<0.05). The spherical equivalent of the deep anterior lamellar keratoplasty b subgroup was lower than that of the penetrating keratoplasty a subgroup in the scar group 6 months after surgery (p<0.05). In the edema group, there was no significant difference in spherical equivalent between subgroups (p>0.05). There were no significant differences in best-corrected visual acuity and astigmatism between subgroups within the two groups (p>0.05). In comparison to the scar group, the edema group experienced more complications. According to a survival analysis, there was no statistically significant difference between the scar group and the edema group regarding the progression of vision. CONCLUSIONS: In terms of the outcomes and prognosis for vision after keratoplasty with edema stage and scar stage, deep anterior lamellar keratoplasty may be as effective as penetrating keratoplasty.

Corset suture: A novel technique of overlay appositional continuous sutures with air tamponade for management of large acute corneal hydrops.

Management of large acute corneal hydrops (ACH) has always been a challenge. Various medical and surgical management options have been used, such as topical steroids, cycloplegics, antiglaucoma medications, antibiotics, Descemet's membrane reposition, and pre-Descematic sutures, for the management of acute hydrops, but have shown limited benefit. We hereby describe a novel technique of appositional continuous overlay sutures along with air tamponade for surgical management of corneal edema following large ACH. In this technique, the epithelium is scraped to visualize the stromal cleft, and then corneal marking is done to locate the suture placement site. Next, a continuous overlay, 10-0 nylon suture is passed in a crisscross fashion, just like the laces of a corset. A small paracentesis is made to lower the intraocular pressure. Stromal fluid is milked out using two iris spatulas, simultaneous suture tension adjustment is done, and the knot is secured. Appropriate anterior chamber tamponade is achieved using air, paracentesis is hydrated, and a bandage contact lens is applied. We noted complete resolution of corneal edema within 2 weeks of the procedure, with significant improvement in visual acuity.

Double trouble in DMEK surgery: Learning experience and review of the literature.

PURPOSE: To report a challenging Descemet Membrane Endothelial Keratoplasty (DMEK) case, complicated by intraoperative aqueous misdirection and spontaneous anterior chamber fibrin reaction. METHODS: A 70-year-old female affected by corneal edema due to Fuchs endothelial dystrophy underwent a triple procedure (cataract extraction - IOL implantation - DMEK surgery) in her left eye. This report illustrates the management of the intraoperative complications of aqueous misdirection syndrome and anterior chamber fibrin reaction. RESULTS: Despite the optimal management of the posterior pressure and the thorough removal of the fibrinous reaction during the case, the DMEK graft was not completely unfolded and centred at the end of the surgical procedure. Nonetheless, the patient showed good long-term anatomical and functional recovery: at the last follow-up (2 years after surgery), central corneal thickness was 526 µm with a best corrected visual acuity of 20/25 and an endothelial cell density of 1112 cell/mm2. CONCLUSION: Early recognition and prompt management of intraoperative aqueous misdirection syndrome and anterior chamber fibrin reaction during DMEK surgery is essential to ensure good functional and anatomical outcomes.

Re-descemet membrane endothelial keratoplasty (DMEK) with preservation of the original graft after free roll in anterior chamber: A case report.

INTRODUCTION: Lamellar keratoplasties have had a great impact in the management of corneal edema due to endothelial dysfunction. Minimally invasive transplant techniques such as Descemet Membrane Endothelial Keratoplasty (DMEK) have helped to reduce the morbidity involved in performing penetrating keratoplasty in this type of patient. Even so, these are complex techniques that are not free of complications and require a long line of surgical learning and an even more demanding experience in postoperative management. CLINICAL CASE: An 89-year-old woman suffering from Fuchs endothelial dystrophy and undergoing combined cataract and DMEK surgery presented stromal edema predominantly inferior and sectoral detachment of the graft 24 h after the intervention. After re-bubbling in consultations and 4 days later, the graft was observed rolled and free in the anterior chamber. She underwent re-DMEK with preservation of the original graft after 24 h, with de-epithelialization to optimize visualization. The graft was stained with trypan blue and the posterior stroma was protected with air. The graft was reimplanted under intraocular maneuvers and with an air bubble. 24 h after surgery, the adhered graft was observed, with a great decrease in stromal edema. One month later, the patient had a clear cornea, persistent complete graft adhesion, and visual acuity of 0.9. CONCLUSION: The discovery of free roll in the anterior chamber after DMEK surgery constitutes the most complex form of graft detachment. Corneal edema as well as the arrangement of the different intraocular structures are conditions to be considered for the surgical resolution of this complication. In many cases, surgical repositioning of the graft is feasible, which means saving costs without the need to use new donor corneal tissues.

[Intraoperative optical coherence tomography guided precise corneal suture in the treatment of acute keratoconus].

Objective: This study aimed to observe the clinical efficacy of precise suturing of posterior elastic layer fissures guided by intraoperative optical coherence tomography (OCT) in conjunction with anterior chamber puncture and drainage, and corneal thermokeratoplasty for the treatment of severe acute edematous keratoconus. Methods: Non-randomized controlled trial. Data were collected for a study involving 31 cases of acute edematous keratoconus patients who underwent surgical treatment at the Shandong Eye Hospital between June 2017 and July 2021. Among them, there were 30 male and 1 female patients, with an age range of 11 to 32 years and a mean age of (19.80±5.80) years. Eighteen patients in the study group underwent precise suturing of posterior elastic layer fissures guided by intraoperative OCT, in combination with anterior chamber puncture and drainage, and corneal thermokeratoplasty. Thirteen patients in the control group did not undergo suturing. Preoperative visual acuity, corneal edema diameter, corneal thickness, and posterior elastic layer fissure length were collected. Evaluation was performed using slit lamp microscopy, anterior segment OCT, and other methods to assess the time of initial postoperative corneal edema resolution and closure of the posterior elastic layer fissure. Deep lamellar keratoplasty was performed 2 to 4 weeks after edema resolution, and the corneal bed scar repair and visual acuity of the two groups were compared. Results: In the suturing group, the corneas of all 18 patients were accurately sutured to the deep stromal layer near the posterior elastic layer. The time for corneal edema resolution was 2.50 (1.00, 6.25) days in the suturing group and 7.00 (6.00, 10.50) days in the control group. The fissure healing time was 7.50 (7.00, 12.00) days in the suturing group and 14.00 (9.00, 14.00) days in the control group. The differences were statistically significant (all P<0.05). After 2 weeks, the central corneal thickness decreased to (529.80±174.50) µm in the suturing group and (612.00±205.12) µm in the control group. The suturing group showed accurate corneal suturing to the deep stromal layer near the posterior elastic layer, resulting in central corneal flattening, closure of voids in the stroma, and a significant decrease in corneal thickness. All 18 patients in the suturing group successfully completed deep lamellar keratoplasty, with 6 cases (6/18) experiencing mild graft bed leakage during surgery but without affecting the deep lamellar keratoplasty. One year postoperatively, the visual acuity (logarithm of the minimum resolution angle) was 0.23±0.12 in the suturing group and 0.33±0.11 in the control group, with a statistically significant difference (P<0.05). Conclusions: In the treatment of severe acute edematous keratoconus, precise suturing of posterior elastic layer fissures guided by intraoperative OCT, in conjunction with anterior chamber puncture and drainage, and corneal thermokeratoplasty, can rapidly alleviate corneal edema and promote the healing of posterior elastic layer fissures. This approach achieves better visual outcomes for subsequent lamellar keratoplasty surgeries. The use of intraoperative OCT guidance allows accurate positioning of the posterior elastic layer fissure in terms of location, direction, and depth of corneal stromal voids, thereby assisting surgeons in precise suturing.

Trends in keratoplasty from central and Northern India. Part I: Indications for keratoplasty.

PURPOSE: To report the indications for keratoplasty and analyze trends in two decades in India. METHODS: This was a retrospective review of eye bank registries of six tertiary eye care centers located in central and northern India from 2005 to 2021. The patterns of corneal pathology and changes in trends were analyzed. RESULTS: Between 2005 and 2021, 13223 corneal grafts were performed in the six collaborating tertiary eye care centers. The most common indication for keratoplasty in both decades was corneal ulcer (41.1%), followed by corneal scar (25.5%), failed graft (12.0%), post-cataract surgery corneal edema (11.7%), corneal dystrophies (3.1%), corneal ectasia (1.8%), corneal trauma (0.3%), congenital corneal opacity (0.3%), and others (4.1%). An increasing trend was seen in corneal ulcers, failed grafts, and keratoconus. A reducing trend was seen in corneal scar and aphakic bullous keratopathy. There was no change in pseudophakic bullous keratopathy and Fuchs endothelial corneal dystrophy. CONCLUSION: Corneal ulcers, corneal scars, failed grafts, and post-cataract surgery corneal edema remained the foremost indications for keratoplasty in two decades in India. An increasing trend was seen in corneal ulcers and failed grafts which are of concern as these indications carry a poorer outcome. Capacity building in lamellar keratoplasty techniques is the need of the hour as pseudophakic bullous keratopathy was an important indication, and an increasing trend was noticed in keratoconus.

Case Report: Role of Anterior Segment Optical Coherence Tomography for Managing Failed Endothelial Keratoplasty Graft.

SIGNIFICANCE: Some patients show poor visual outcomes after Descemet stripping automated endothelial keratoplasty. In such cases, secondary Descemet membrane endothelial keratoplasty can be performed to achieve complete visual recovery. Anterior segment optical coherence tomography (AS-OCT) is a valuable tool for the follow-up of posterior lamellar keratoplasty outcomes and complications. PURPOSE: This study aimed to report the clinical outcome of secondary Descemet membrane endothelial keratoplasty for managing poor visual results in a patient with graft failure after a previous Descemet stripping automated endothelial keratoplasty, highlighting the importance of AS-OCT in the follow-up of endothelial keratoplasty. CASE REPORT: A 38-year-old woman with high myopia underwent Descemet stripping automated endothelial keratoplasty for bullous keratopathy after explantation of an angle-supported phakic intraocular lens. Two years after keratoplasty, the patient experienced poor visual acuity (counting fingers), and significant corneal edema was observed on clinical examination hindering visualization of the anterior chamber structures. Anterior segment optical coherence tomography showed a failed and thickened graft adhering well to the recipient cornea in an anterior chamber without other comorbidities. Therefore, the graft was removed and replaced with a Descemet membrane endothelial keratoplasty graft without any complications. One year later, the clinical outcome was evaluated by comparing the pre-operative and post-operative best-corrected visual acuity, biomicroscopy findings, endothelial cell density, and corneal central thickness. CONCLUSIONS: Anterior segment optical coherence tomography is an important tool when deciding on the surgical technique to be applied and for the post-surgical monitoring of endothelial corneal grafts. This case demonstrates the successful management of Descemet stripping automated endothelial keratoplasty graft failure with Descemet membrane endothelial keratoplasty graft, highlighting the importance of AS-OCT in detecting complications such as graft dislocation and primary graft failure. In addition, corneal thickness measured using AS-OCT serves as a critical predictor of graft failure, as observed in this case.

Manual schism and intracameral air injection for impacted Descemet's membrane detachment.

A woman in her 60s was referred to us for management of poor vision following cataract surgery in the right eye. She had undergone manual small incision cataract surgery 12 weeks earlier. Slit-lamp biomicroscopy revealed corneal oedema, a horizontal line at the upper border and the adhered inferior border of detached Descemet's membrane (DM). Clinical diagnosis of impacted Descemet's membrane detachment (DMD) was considered.Surgical intervention with manual schisis and intracameral injection of air was planned. Using the 'push technique,' we tried to place the tip of the 27 gauge cannula between the back of the cornea and detached DM. The tip of the 27 gauge cannula was behind the impacted DM, and air injection was unsuccessful. Using the back-up the 'pull technique,' bent tip of the 27 gauge cannula was used to pull the impacted DMD. This manoeuvre, disimpacted the inferior border and the air bubble, was injected using the 27 gauge cannula. The air bubble unfolded and reattached the DM successfully.

Risk Factors for Fibrous Ingrowth in Eyes Requiring Primary Keratoplasty.

PURPOSE: The aim of this study was to define risks for corneal transplantation associated with fibrous ingrowth among first-time transplant recipients. METHODS: We performed a retrospective case-control study of patients with a histopathologic diagnosis of fibrous ingrowth between 2002 and 2019. Patients with fibrous ingrowth from a first corneal specimen were included. Those with incomplete records were excluded. A 1:2 case-control ratio was used. Controls were matched using surgical indication, surgery year, transplantation method, sex, and age. RESULTS: Seventy-eight eyes (76 patients) were included and matched with 160 control eyes. The incidence of fibrous ingrowth found on a first corneal transplant was 0.6% per year. The most common keratoplasty indications were pseudophakic corneal edema (n = 25, 32%) and aphakic corneal edema (n = 15, 19%). Cases were more likely to have a history of ocular trauma (odds ratio [OR], 2.94; 95% CI, 1.30-6.30; P = 0.007), uveitis (OR, 2.73; 95% CI, 1.12-6.63; P = 0.022), retinal detachment or previous retinal surgery (OR, 2.40; 95% CI, 1.34-4.30; P = 0.003), glaucoma tube-shunt surgery (OR, 2.70; 95% CI, 1.29-5.65; P = 0.007), aphakia (OR, 3.02; 95% CI, 1.61-5.67; P = 0.0004), or iris derangement (OR, 10.52; 95% CI, 5.45-20.30; P <0.0001). A multivariate logistic regression model using iris derangement, history of ocular trauma, history of uveitis, and history of cataract surgery demonstrated 81% sensitivity and 66% specificity in predicting presence of fibrous ingrowth. CONCLUSIONS: A history of ocular trauma, uveitis, retinal detachment or previous retinal surgery, glaucoma tube-shunt surgery, aphakia, and iris derangement are risks for detecting fibrous ingrowth among first-time keratoplasty recipients. Patients with these conditions should be monitored closely for corneal decompensation.

Long-Term Results of Combined Trabeculotomy Trabeculectomy in Primary Congenital Glaucoma.

PRCIS: Primary congenital glaucoma (PCG) in Tunisian children seems to be characterized by a high prevalence of inherited and advanced forms of the disease. Primary combined trabeculotomy trabeculectomy (CTT) allowed satisfactory long-term intraocular pressure (IOP) control and reasonable visual outcome. PURPOSE: To report the long-term outcome of CTT as the initial glaucoma surgery in children with PCG. METHODS: Retrospective analysis of children who underwent primary CTT for PCG between January 2010 and December 2019. The main outcome measures were IOP reduction, corneal clarity, complications, refractive errors, and visual acuity (VA). Success was defined as IOP <16 mm Hg without (complete) or with (qualified) antiglaucoma medication. The WHO criteria of vision loss were used to categorize visual impairment (VI). RESULTS: Of 62 patients, 98 eyes were enrolled. At the last follow-up, the mean IOP was reduced from 22.7 ± 4.0 mm Hg to 9.7 ± 3.9 mm Hg ( P < 0.0001). The complete success rate was 91.6%, 88.4%, 84.7%, 71.6%, 59.7%, and 54.3%, at the first, second, fourth, sixth, eighth, and tenth year, respectively. Follow-up averaged 42.1 ± 28.4 months. Preoperatively, 72 eyes (73.5%) had significant corneal edema versus 11 eyes (11.2%) at the end of the follow-up ( P < 0.0001). Endophthalmitis was encountered in one eye. Myopia was the most common refractive error (80.6%). Data on Snellen VA were available for 53.2% of the patients; 33.3% achieved a VA ≥6/12, 21.2% had mild VI, 9.1% had moderate VI, 21.2% had severe VI, and 15.2% were blind. The failure rate was statistically correlated to the early disease onset (<3 mo) and to preoperative corneal edema ( P = 0.022 and P = 0.037, respectively). CONCLUSION: Primary CTT seems to be a good procedure in a population with advanced PCG at presentation, problematic follow-up visits, and limited resources.

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

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

Different patterns in the corneal endothelial cell loss after pars plana and pars limbal insertion of the Baerveldt glaucoma implant.

PURPOSE: To assess corneal endothelial cell (CE) loss after pars plana (PP) and pars limbal (PL) insertion of a Baerveldt glaucoma implant (BGI). DESIGN: Retrospective multicenter interventional comparative study. METHODS: We studied central CE loss for 5 years after BGI surgery in 192 eyes. RESULTS: The prevalence of bullous keratopathy (BK) was greater in the PL cohort than in the PP cohort (P = .003). The CE loss after simultaneous PP vitrectomy and tube insertion into the vitreous cavity was 11.9% in the first year, which was greater than that of 2.9% in eyes where the tube was inserted simply into the vitreous cavity after a prior vitrectomy (P = .046). The annual percentage CE loss after the first year decreased unidirectionally in both of those groups and was 1.3% and 1.0% in the fifth year, respectively (P < .001). For limbal insertion, the CE loss in the simple PL cohort was biphasic, decreasing from 10.5% in the first year to 7.0% in the fifth year. Simultaneous cataract and BGI surgery enhanced the CE loss slightly in the first year in the PP and PL cohorts to 13.0% and 14.0%, respectively. However, these increases were not significant (P = .816 and .358, respectively). Low preoperative CE density (P < .001) and insertion site (P = .020) were significant risk factors for the development of BK. CONCLUSIONS: CE loss in the PL and PP cohorts was biphasic and unidirectional, respectively. The difference in annual CE loss became evident over time. PP tube implantation may be advantageous when the preoperative CE density is low.

Retrospective study of postoperative intraocular pressure and complications in phacoemulsification combined with endoscopic cyclophotocoagulation and phacoemulsification alone in dogs.

BACKGROUND: Long-term comparative data of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco-ECP) versus phacoemulsification (phaco) alone in dogs are rare. OBJECTIVES: To investigate the effects of ECP on postoperative intraocular pressure (IOP) and complications after phaco in dogs with normal IOP. METHODS: Medical records of IOP, conjunctival hyperemia, corneal edema, aqueous flare, posterior synechia, intraocular fibrin, and posterior capsule opacification (PCO) formation in 15 canine eyes that underwent phaco-ECP and 36 eyes that underwent phaco alone were evaluated retrospectively. ECP was applied when either the iridocorneal angle or the ciliary cleft was narrow or closed. RESULTS: The IOP of the phaco-ECP group persisted within the normal range postoperatively. The phaco-ECP group had a shorter period of dorzolamide use than did the phaco group. PCO was formed earlier in the phaco-ECP group than in the phaco group. The phaco-ECP group showed more severe corneal edema than the phaco group at every follow-up visit. Posterior synechia was more severe in the phaco-ECP group than in the phaco group from two weeks until the last follow-up. CONCLUSIONS: Although ECP might cause more postoperative complications such as corneal edema and posterior synechia, it could effectively reduce the incidence of IOP increase after phaco in dogs with a high risk of postoperative glaucoma.

Posterior Segment Air Injection-Assisted Descemet Membrane Endothelial Keratoplasty in Pseudophakic and Vitrectomized Eyes.

PURPOSE: This study aimed to present a novel technique for Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic and vitrectomized eyes. METHODS: The sterile air was injected into the posterior eye segment (anterior vitreous cavity) as a barrier to prevent the fluid of the vitreous cavity flowing into the anterior chamber, levitating the iris-lens diaphragm to flatten the anterior chamber during the surgery. This approach assists in the unfolding of the donor endothelial graft, helping to perform DMEK surgery on patients with a posterior intraocular lens (IOL) and vitrectomy. RESULTS: Four cases presented with corneal endothelial decompensation (pseudophakic bullous keratopathy) with previous IOL implantation and vitrectomy underwent DMEK with this technique. The Descemet endothelial graft unfolding time after air injection was 68.75 ± 8.96 seconds. No graft displacement occurred during the surgery. The uncorrected and corrected distance visual acuities were improved in 3 of 4 patients. The corneas were transparent, and there was no graft detachment observed postoperatively in all 4 patients. CONCLUSIONS: The posterior eye segment air injection can reduce the difficulty of unfolding the DMEK graft in patients after IOL implantation and vitrectomy and the potential intraoperative and postoperative complications, allowing for easy performance of DMEK surgery on pseudophakic and vitrectomized eyes for corneal endothelial dysfunction.

Interface Fluid Syndrome After Descemet Membrane Endothelial Keratoplasty in Patients With History of LASIK.

PURPOSE: The aim of this study was to evaluate the visual, pachymetric, tomographic, and biomicroscopic findings in a series of cases with laser in situ keratomileusis (LASIK) flap interface fluid syndrome (IFS) after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Six cases were included in this study; all patients had a history of LASIK and underwent DMEK for the treatment of bullous keratopathy. After uneventful surgery, all patients presented with corneal edema and IFS under the LASIK flap, which was demonstrated with anterior segment optical coherence tomography (AS-OCT). Visual acuity, clinical findings, pachymetry, endothelial cell count, and AS-OCT were documented during the management of these cases. RESULTS: IFS appears 2.33 days (±1.03) after DMEK. One case improved with conservative treatment. In 5 cases, the LASIK flap was lifted, the fluid was drained, and the flap was replaced. The mean best-corrected visual acuity after fluid drainage was 0.44 logMAR (range 0.18-1.0) and mean central corneal thickness was 538 µm ± 160. Total resolution of the IFS was achieved at 14.5 days (range 4-30) after DMEK. AS-OCT showed resolution of the flap interface in 5 of 6 cases, while 1 patient required second DMEK due to reaccumulation of the interface fluid. CONCLUSIONS: IFS can occur after DMEK in patients with previous LASIK. AS-OCT is a valuable tool for monitoring these cases preoperatively and postoperatively. Early surgical management is often needed to achieve resolution.

Partial-thickness compression sutures without descemetopexy for management of acute hydrops in keratoconus: A novel surgical technique.

This article reports a novel surgical technique of partial-thickness compression sutures without descemetopexy with air or gas for the management of acute hydrops in keratoconus. Two patients presented with localized corneal edema with a Descemet membrane (DM) tear in the left eye. Tomography of the right eye revealed localized steepening with increased maximum keratometry and decreased central pachymetry. They were diagnosed with keratoconus in the right eye and acute corneal hydrops (ACH) in the left eye. Compression sutures were passed through the stroma without touching the DM. The anterior chamber was not entered at all at any point during the surgery. Resolution of edema was noted intraoperatively itself. Further resolution of edema was noted from the first postoperative day which markedly reduced within the first week. A corneal scar with no edema was seen at six weeks. In both the patients, vision at presentation was counting fingers close to face which improved to 20/60 and 20/50, respectively, at the last visit.

Recent and Evolving Therapies in the Management of Endothelial Diseases.

Corneal endothelium is the innermost layer of the cornea which has both barrier and pump function and very important to maintain cornea clarity. Unlike epithelium, endothelium does not have regenerative potential; hence, endothelial damage or dysfunction could lead to corneal edema and visual impairment. Advanced corneal transplantation which involves selective replacement of dysfunctional endothelium has led to improved and faster visual rehabilitation. But in recent times, alternative therapies in the management of corneal edema and endothelial diseases have been reported. In this review, we aim to give a comprehensive review of various strategies for the management of corneal endothelial dysfunction in order to give treatment which is precisely tailored for each individual patient. A review of all peer-reviewed publications on novel strategies for the management of endothelial dysfunction was performed. The various approaches to the management of endothelial dysfunction are compared and discussed. Shortage of human donor corneas globally is fuelling the search for keratoplasty alternatives. Corneal endothelial dysfunction can be caused following surgery, laser or corneal endothelial dystrophies which could be amenable to treatment with pharmacological, biological intervention and reverse the endothelial dysfunction in the early stages of endothelial failure. Pharmacological and surgical intervention are helpful in cases of good peripheral endothelial cell reserve, and advanced cases of endothelial cell dysfunction can be targeted with cell culture therapies, gene therapy and artificial implant. Treatment strategies which target endothelial dysfunction, especially FECD in its early stages, and gene therapy are rapidly evolving. Therapies which delay endothelial keratoplasty also are evolving like DSO and need more studies of long-term follow-up and patient selection criteria.

Novel Proposed Algorithm in Congenital Hereditary Endothelial Dystrophy.

PURPOSE: Congenital hereditary endothelial dystrophy (CHED) is a rare, autosomal recessive, monogenic corneal condition with variable expressivity. Often presents in bilateral symmetrical progressive corneal cloudiness that starts in the early infancy. It is characterized by increased corneal thickness, profound corneal edema, and thickening of the Descemet membrane due to endothelial dysfunction. The published literature lacks uniform guidelines for grading corneal cloudiness and management algorithm for CHED cases. This article focuses on applying newer investigational modalities to fine-tune surgical outcomes and more recent CHED management strategies. METHODS: This comprehensive literature review was performed based on a search on the PubMed database of relevant CHED articles focusing on those published in the last 7 years. A total of around 70 articles were reviewed, and 17 of them were included in this review. These include systemic reviews, randomized controlled clinical trials, cohort studies, case-controlled studies, and case series. RESULTS: Corneal cloudiness grading in CHED using subjective and objective methods using Anterior Segment Optical Coherence Tomography (AS-OCT) and densitometry using Scheimpflug imaging can help select appropriate management plan for CHED cases. DSAEK outscores penetrating keratoplasty with much fewer complications and expedites visual recovery, which helps mitigate amblyopia. CONCLUSION: Managing cases of CHED has been a challenge due to the dilemma in timing and appropriate surgical method selection and lack of definitive medical or other conservative approaches. Currently, DSAEK has shown favorable results in cases of CHED. However, appropriate staging of CHED and selecting the appropriate management approach appears to play a critical role in managing such cases. Besides these, novel treatment modalities such as nonsteroidal anti-inflammatory agents (NSAIDS) that target restoring water-flux activity in subtype of CHED and gene editing using CRISPR-Cas9 are promising paradigm treatment modalities.

Detecting Subclinical Corneal Edema Using Corneal Thickness Mapping in Patients Presenting Fuchs Endothelial Corneal Dystrophy.

PURPOSE: To determine whether local corneal thickness changes observed with optical coherence tomography (OCT) can detect subclinical corneal edema in Fuchs endothelial corneal dystrophy (FECD). SETTING: Retrospective cohort study. METHODS: A series of patients presenting FECD who underwent cataract surgery alone (45 eyes) or with concomitant Descemet membrane endothelial keratoplasty (triple procedure; 117 eyes). The study reviewed medical records, collected the preoperative corneal thickness map and calculated the differences and ratio of corneal thickness measured at 5, 7, and 9 mm from the central corneal thickness. Area under the receiver operating characteristic curves (AUCs) were calculated and thresholds were selected to obtain a specificity of 90%. RESULTS: The median difference between 5- and 2-mm corneal thickness in the supra-nasal quadrant (∆5-2mmSN) was 38 µm (interquartile range 34-46) in the cataract group and 17 µm (2-38) in the triple procedure group (P < .001). The corneal thickness ratios of supra-nasal 5- to 2-mm (R5/2mmSN) and 7- to 2-mm (R7/2mmSN) were 1.07 (1.06-1.08) and 1.15 (1.13-1.17)] in the cataract group and 1.03 (1.00-1.06) and 1.09 (1.06-1.14) in the triple procedure group (P < .001). The probability of corneal edema was increased 7-fold with ∆5-2mm SN < 27 µm (AUC = 0.76) and 9.4- and 7.4-fold with R5/2mmSN and R7/2mmSN < 1.045 (AUC = 0.77) and 1.118 (AUC = 0.76), respectively. CONCLUSIONS: Local changes in corneal thickness may be useful in detecting preclinical corneal edema, especially in patients with FECD undergoing cataract surgery.

Systematic Review and Meta-analysis: Outcomes After Descemet Membrane Endothelial Keratoplasty Versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To compare the efficacy and safety of ultrathin Descemet stripping (automated) endothelial keratoplasty (UT-DS(A)EK) versus Descemet membrane endothelial keratoplasty (DMEK) for the treatment of Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK). DESIGN: Systematic review and meta-analysis. METHODS: Literature containing DMEK and UT-DSAEK were searched in the Cochrane Database of Systematic Reviews, PubMed, EMBASE, LILACS, and through manual reference searching. Studies were included that measured the outcome of interventions-including best corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications, especially graft detachment with the need of re-bubbling, graft rejection, graft failure, and postoperative elevated intraocular pressure (IOP)-in patients with FED and BK. Included outcomes were pooled as standardized mean differences (SMD) or risk ratios (RR) using random effects models. Inter-study heterogeneity was assessed using the Q-test and I2 statistic. RESULTS: Seven (of 163) studies met all the inclusion and exclusion criteria. Meta-analysis showed a significantly better BCVA 12 months postoperatively, but an increased re-bubbling rate in eyes after DMEK compared with eyes after UT-DS(A)EK (BCVA: SMD = 0.50 [95% CI 0.27-0.74] and re-bubbling rate: RR = 0.33 [95% CI 0.16-0.67]). All other parameters did not differ significantly between both interventions, although estimates were imprecise (graft failure: RR = 0.65 [95% CI 0.18-2.30], graft rejection: RR = 1.40 [95% CI 0.27-7.30], and postoperative intraocular pressure elevation: RR = 1.14 [95% CI 0.60-2.18]). Postoperative SMDs of ECD could not be evaluated due to significant heterogeneity between studies. CONCLUSIONS: Although the improvement in BCVA was higher after UT-DS(A)EK than after conventional DS(A)EK, the BCVA after DMEK was still superior. The complication rates were comparable for both procedures, except for the higher rate of re-bubbling after DMEK.