Clinical Utility of COVID-19 Real Time-Polymerase Chain Reaction Testing of Ocular Tissues of Non-COVID-19 Cornea Donors Deemed Suitable for Corneal Retrieval and Transplantation.

PURPOSE: The purpose of this study was to evaluate the prevalence of SARS-CoV-2 in human postmortem ocular tissues of asymptomatic donors and its implications on our eye banking protocols. METHODS: The expression of SARS-CoV-2 RNA was assessed by reverse transcription-polymerase chain reaction in corneal rims and conjunctival tissues from 100 donors who were found suitable for transplantation as per the donor screening guidelines of the Global Alliance of Eye Bank Associations. The donor's clinical history and cause of death were assessed for secondary analysis. RESULTS: Of 200 ocular tissues (100 corneal and 100 conjunctival) from the same 1 eye of 100 surgical-intended donors, between September 2020 and April 2021, the overall positivity rate for SARS-CoV-2 was ∼1% (2/200). Both the ocular samples that tested positive were conjunctival biopsies (2/100, 2%), whereas corneal samples were negative (0/100, 0%) in both donors. The causes of donor death were trauma in 51 donors, suicide in 33, cardiac arrest in 7, electric shock in 5, metabolic cause in 2, malignancy in 1, and snake bite in 1. None of the donors had a medical history suggestive of COVID infection or possible contact. None of the recipients from the donors were reported to have any systemic adverse event after keratoplasty until the follow-up of 6 weeks. CONCLUSIONS: The overall prevalence of SARS-CoV-2 was 1% (2% for conjunctival and 0% for corneal samples, P value = 0.5) in the donors who were found suitable for cornea recovery and transplantation. The findings of exceptionally low positive rates in our samples validate the criticality of history-based donor screening and do not support the necessity of postmortem PCR testing as a criterion for procurement and subsequent use for corneal transplantation.

Higher incidence of penetrating keratoplasty having effects on repeated keratoplasty in South Korea: A nationwide population-based study.

PURPOSE: To investigate the incidence of corneal transplantation and identify rates and risk factors of repeated corneal transplantation in South Korea. METHODS: This is a retrospective population-based cohort study using the Korean National Health Insurance System database. Among the entire South Korean population (N = 51,827,813), we included those who underwent corneal transplantation more than once between January 2006 and December 2016, and analyzed the annual incidence of keratoplasty. The person-year incidence of repeated keratoplasty after the first operation was calculated according to risk factors including age group, sex, income level, surgical method, surgical etiology, and presence of major systemic diseases. Cox regression analysis was employed to evaluate the hazard ratios of those risk factors on repeated keratoplasty. RESULTS: A total of 9,452 cases of corneal transplantation occurred from January 2006 to December 2016. The average annual incidence of corneal transplantations was 1.694 per 100,000. The proportion of penetrating keratoplasty steadily decreased from 92.22% in 2006 to 77.81% in 2016. The average incidence of repeated keratoplasty among those who underwent corneal transplantation at least once was 43.24 per 1,000 person-years. Males had a greater incidence of repeated keratoplasty compared to females (males: 47.66 per 1,000, females: 36.04 per 1,000). The age group from 20 to 39 years demonstrated the lowest incidence of repeated keratoplasty at 24.94 per 1,000. Keratoconus had the lowest incidence of repeated keratoplasty (22.82 per 1,000). CONCLUSION: This study may provide a better understanding of corneal diseases, help predict disease burden, and plan health care systems accordingly in South Korea.

Resuturing after penetrating keratoplasty without trauma: Indications and results.

PURPOSE: To determine the indications, frequency, influential factors and clinical outcomes of resuturing in an atraumatic setting after penetrating keratoplasty (PK). METHODS: Medical records of all patients who underwent resuturing in the absence of traumatic wound dehiscences after PK between January 1, 2007 and December 31, 2015 were reviewed. The cases were divided into 2 groups: patients with suture-related problems underwent mandatory resuturing (mandatory group), and patients with post-PK ectasia or a progressive increase in K values and surgically induced astigmatism underwent optional resuturing (Optional group). Patient demographics and surgical indications for PK, reasons for and frequency of resuturing, time between PK and resuturing, and clinical outcomes were evaluated. RESULTS: The frequency of resuturing was 9.03% (59 of 633), and the mean age was 39.15±17.80 years. The most common indication for PK was keratoconus (42.4%) and the interval between PK and resuturing ranged from 0.03 to 32 months. The underlying cause leading to resuturing was suture-related problems in 43 eyes (72.9%), development of ectasia or progressive steepening of the K values and surgically induced astigmatism in 16 eyes (27.1%). The mean visual acuity increased, the K value and astigmatism decreased significantly following resuturing in both the mandatory group and the Optional group (P≤0.2). The decrease in astigmatism and K values was more marked in the Optional group, as expected (P≤0.001). CONCLUSION: While resuturing is essential in order to obtain wound integrity in the setting of dehiscence, it is effective in terms of achieving higher visual acuities and lower astigmatism and K values in high astigmatism and post-PK ectasia cases.

Indications and Techniques of Pediatric Keratoplasty in Eastern China From 2008 to 2017.

PURPOSE: To explore the transition of indications and surgical techniques of pediatric keratoplasty in Eastern China in the past 10 years. METHODS: Medical charts of 1026 pediatric patients (1059 eyes) who underwent keratoplasties at the Eye, Ear, Nose and Throat Hospital of Fudan University from 2008 to 2017 were retrospectively reviewed. The indications for keratoplasty and the surgical techniques were collected and analyzed. RESULTS: A total of 634 infants (≤3 years) (661 eyes), 207 toddlers and older children (4-12 years) (211 eyes), and 185 adolescents (13-18 years) (187 eyes) were included. The median age at the time of surgery was 2 years. The surgical indications were composed of congenital abnormalities (74.6%), acquired nontraumatic diseases (16.5%), acquired traumatic diseases (3.6%), and regraft (5.3%). Only congenital abnormality had a significant growing trend during this decade (P = 0.023). Keratoconus (67.2%) exceeded infectious keratitis (14.9%) and was the most common acquired nontraumatic cause in our study. The annual number of pediatric keratoplasties increased significantly from 40 cases in 2008 to 190 cases in 2017 (P < 0.001). Although penetrating keratoplasty was performed in 414 eyes (39.1%), its application in the treatment of keratoconus decreased significantly during this decade (P = 0.04). By contrast, deep anterior lamellar keratoplasty showed an increasing trend because of its popularization in the treatment of keratoconus (P = 0.003). CONCLUSIONS: Congenital abnormalities have replaced infectious keratitis and have been the leading indications of pediatric keratoplasty in the past 10 years. Although the using of penetrating keratoplasty was still the predominant procedure to treat pediatric corneal pathologies, the adoption of deep anterior lamellar keratoplasty showed a significant increasing trend during the past decade.

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.

Wound dehiscence after penetrating keratoplasty.

BACKGROUND: The purpose of this study was to investigate factors affecting wound dehiscence due to blunt trauma following penetrating keratoplasty (PK) and the clinical outcomes. METHODS: The medical records of patients who experienced blunt traumatic wound dehiscence after PK between 1995 and 2015 were analyzed retrospectively. The incidence and etiology of the trauma, the time interval between PK and globe rupture, final graft clarity, best-corrected visual acuity, complications, secondary surgeries, and factors potentially affecting wound dehiscence size were recorded. RESULTS: This study included a total of 39 patients with a mean age of 42.66±16.66 years, of whom 23 patients were male and 16 patients were female. The incidence of wound dehiscence was 2.3%. The mean interval between the PK procedure and wound dehiscence was 25.91±47.24 months and the mean follow-up time was 34.43±51.02 months. The most common trauma mechanism was force with a blunt object (53.8%) and the most frequent site of wound dehiscence was the temporal quadrant (30.8%), the wound ranging from 30° to 270° in size. The patients were divided into 4 groups according to wound dehiscence size. As the size of the wound dehiscence size increased, the male ratio increased, wound dehiscence was more commonly located in the nasal and superior quadrants, lens injury and posterior segment complications were more frequent, and graft transparency was achieved at a lower rate. CONCLUSION: Traumatic wound dehiscence after PK is rare, but may lead to serious, lifelong consequences, including eye loss. Patients should be well informed about the risks and potential sequelae of wound dehiscence.

Ceratoplastias penetrantes realizadas em serviço oftalmológico de referência revisão dos resultados e complicações / Penetrating keratoplasty performed at ophthalmologic reference service review of results and complications

Resumo Objetivo: Descrever o perfil epidemiológico, avaliar as complicações e a melhora da acuidade visual em pacientes submetidos a ceratoplastia penetrante na Policlínica de Botafogo-RJ. Métodos: Estudo transversal e retrospectivo, realizado no período de janeiro/2014 a abril/2018, com revisão de 27 prontuários de pacientes submetidos a transplante. Resultado: Dos 27 pacientes avaliados, 15 (55,5%) do sexo masculino e 12 (44,5%) eram do sexo feminino. A média de idade foi 46,7 (Dp 20,2). As indicações para realização de transplante foram úlcera de córnea 6 (22,2%), ceratocone 5 (18,5%), ceratopatia bolhosa 5 (18,5%), ceratopatia em faixa 2 (7,4%), leucoma 2 (7,4%), rejeição, 2 (7,4%), falência primária 1 (3,7%), recidiva da infecção 1 (3,7%), ectasia corneana pós LASIK 1 (3,7%), descemetocele 1 (3,7%) e distrofia granular 1 (3,7%). As principais complicações 4 (26,6%) foram a ocorrência de glaucoma e catarata. Em relação a acuidade visual, no período pré transplante 22 (81.5%) dos pacientes apresentavam a melhor AV corrigida pior ou igual a 20/400. No pós-operatório apenas 9 (33.3%) se mantiveram com a melhor AV corrigida pior ou igual a 20/400. Conclusão: Estudos dessa natureza nos permite o aprimoramento cirúrgico, acompanhamento pós-operatório e cuidado com os pacientes.

Abstract Objective: To describe the epidemiological profile, complications and visual acuity improvement in patients submitted to penetrating keratoplasty in the Policlínica de Botafogo-RJ. Methods: Cross - sectional and retrospective study, carried out from January 2014 to April 2018, with review of 27 charts of patients submitted to transplantation. Results: Of the 27 patients evaluated, 15 (55.5%) were male and 12 (44.5%) were female. Mean age was 46.7 (DP 20.2). The indications for transplantation were corneal ulcer 6 (22.2%), keratoconus 5 (18.5%), bullous keratopathy 5 (18.5%), keratopathy in lane 2 (7.4%), leukoma 2 (7.4%), rejection, 2 (7.4%), primary failure 1 (3.7%), recurrence of infection 1 (3.7%), corneal ectasia after LASIK 1 (3.7%), descemetocele 1 (3.7%) and granular dystrophy 1 (3.7%). The main complications 4 (26.6%) were the occurrence of glaucoma and cataract. Regarding visual acuity, in the pre-transplant period 22 (81.5%) of the patients had the best corrected VA worse than or equal to 20/400. Conclusion: Studies of this nature allow us to improve surgical, postoperative follow-up and patient care.

Moderately Long-Term Safety and Efficacy of Repeat Penetrating Keratoplasty.

PURPOSE: To investigate the moderately long-term safety and efficacy of repeat penetrating keratoplasty (PK) for treatment of a failed PK graft. METHODS: Retrospective consecutive clinical case series. Of 992 consecutive cases that underwent PK at Baptist Eye Institute, Kyoto, Japan, between April 1998 and September 2013, 96 cases that underwent repeat PK with more than 3 years postoperatively follow-up were retrospectively reviewed. Surgical outcomes including donor graft survival rate, best spectacle-corrected visual acuity, endothelial cell density, and complications afeter repeat PK were assessed. RESULTS: At 1, 3, and 5 years after repeat PK, the donor graft survival rate was 91%, 75%, and 64%, respectively, and the mean endothelial cell density in those survived grafts was 1778, 1207, and 989 cells/mm, respectively. Best spectacle-corrected visual acuity over 20/200 and 20/40 was achieved in 71% and 27% of the patients, respectively, at 1 year postoperatively, in 59% and 31% of the patients, respectively, at 3 years postoperatively, and in 53% and 29% of the patients, respectively, at 5 years postoperatively. The most common complication for repeat PK was the need for additional glaucoma surgery [n = 11 patients (11.5%)]. Cox proportional hazard regression analyses revealed that previous glaucoma surgery and a rejection episode were high risk factors for graft failure in repeat PK [hazard ratio (HR) = 6.7; 95% confidence interval (CI), 2.1-21.2 and HR = 5.6; 95% CI, 1.8-18.0, respectively]. CONCLUSIONS: Repeat PK provided relatively safe and effective moderately long-term surgical outcomes.

Leap forward in the treatment of Pythium insidiosum keratitis.

BACKGROUND: Pythium insidiosum is a parafungus that causes keratitis resembling fungal keratitis. This study compares outcome in a large cohort of patients with P insidiosum keratitis treated with antifungal drugs, to a pilot group treated with antibacterial antibiotics. METHODS: Between January 2014 and December 2016, 114 patients with culture positive P insidiosum keratitis were included in the study. A subset of culture isolates was tested in vitro for response to nine antibacterial antibiotics by disc diffusion and E test. Patients were treated with topical natamycin in 2014, 2015 and up until mid 2016. Thereafter, the patients received a combination of topical linezolid and topical and oral azithromycin. Therapeutic penetrating keratoplasty (TPK) was done for patients not responding to medical therapy. RESULTS: In vitro disc diffusion assay showed linezolid to be most effective. The rate of TPK was significantly higher in 2015 compared with 2016 (43/45, 95.6% vs 22/32, 68.8%; p=0.002). Eighteen patients were treated with antibacterial and 14 were treated with antifungal antibiotic in 2016. One patient was lost to follow-up in each group. The rate of TPK was higher and proportion of healed ulcers was lower (p=0.21, Fisher's exact test) in the group on antifungal therapy (TPK-11/13, 84.6%; Healed-2/13, 15.3%) compared with the group on antibacterial therapy (TPK-11/17, 64.7%; Healed-6/17, 35.2%). CONCLUSIONS: We report favourable but not statistically significant response of P insidiosum keratitis to antibacterial agents in a pilot series of patients. Further evaluation of this strategy in larger number of patients is recommended.

Repeat Keratoplasty for Failed Deep Anterior Lamellar Keratoplasty in Keratoconus: Incidence, Indications, and Outcomes.

PURPOSE: To analyze the incidence, indications, and clinical outcomes of penetrating keratoplasty (PK) and repeat deep anterior lamellar keratoplasty (DALK) after failed DALK for keratoconus. METHODS: This retrospective interventional case series reviewed the medical records of patients with keratoconus who underwent DALK and were followed up for at least 1 year. Patients who underwent PK or repeat DALK for failed DALK were identified. The incidence, indications, and clinical outcomes after repeat keratoplasty were assessed. RESULTS: A total of 382 consecutive eyes with keratoconus underwent DALK over a 9-year period. Graft failure was observed in 14 eyes (3.7%). The reasons for the graft failure included nonhealing epithelial defects (n = 1), pseudoanterior chamber (n = 2), patient dissatisfaction with vision (n = 4), interface opacification (n = 4), high astigmatism (n = 1), and recurrence of keratoconus in the graft (n = 2). Of these 14 eyes with graft failure, 12 eyes underwent PK (n = 11) or repeat DALK (n = 1). At the most recent examination, which was performed 49.7 ± 25.2 months after the secondary graft, all regrafts were clear. There was no significant difference between eyes with clear first grafts and eyes that underwent PK or repeat DALK in visual outcomes at the final examination. Graft rejection was the most common complication, which was encountered in 75% of the regrafts. CONCLUSIONS: The prognosis for repeat keratoplasty was excellent, and the outcomes of secondary grafts were comparable to those of primary DALK grafts. However, the rate of rejection with secondary grafts was high, necessitating close follow-up after PK and repeat DALK performed for failed DALK.

Keratoplasty in the United States: A 10-Year Review from 2005 through 2014.

PURPOSE: To report evolving indications and preferred techniques of corneal transplantation in the United States. DESIGN: Retrospective review. METHODS: Annual reports from the Eye Bank Association of America on corneal graft distribution in the United States from 2005 through 2014 were reviewed. MAIN OUTCOME MEASURES: Number and percentage of corneal grafts distributed for various types of keratoplasty and their surgical indications in the United States. RESULTS: The total number of corneal transplants increased from 44 277 in 2005 to 46 513 in 2014. In the past decade, penetrating keratoplasty dramatically decreased (from 95% to 42%) and largely has been replaced by various lamellar keratoplasty (LK) techniques (from 5% to 58%). Descemet stripping (automated) endothelial keratoplasty was the most common (50%) type of corneal transplantation performed in the United Stated in 2014. The volume of Descemet membrane endothelial keratoplasty (DMEK) has been doubling every year since 2011 and accounted for 11% of total endothelial keratoplasties in 2014. There was a significant shift in indication for corneal transplantation, with Fuchs' endothelial dystrophy (22%) being the most common, followed by corneal edema occurring after cataract surgery (12%) in 2014. Eye banks supplied precut corneal grafts for 68% of LK techniques in 2014. CONCLUSIONS: In the United States, there has been a major shift in preferred keratoplasty techniques over the past decade, with a wide adoption of new LK techniques.

Limitations of Keratoplasty in China: A Survey Analysis.

PURPOSE: Each year, over 8,000 corneal transplantation surgeries are performed in China. Unlike developed countries, which have established standard requirements for operative experience for corneal specialists, little information exists on surgical training for keratoplasty in China. The aim of this study was to assess the keratoplasty experience of Chinese corneal specialists and to characterize their surgical patterns. METHODS: One hundred and twenty-one corneal specialists in 16 provinces (65 cities) in China were invited to complete an anonymous survey at the 2014 Chinese Corneal Society annual meeting, which consisted of questions with single or multiple-choice answers. Demographics, the number and type of keratoplasties performed, and the perceived limiting factors for performing keratoplasties were analyzed. RESULTS: An overwhelming 89% response rate was achieved. Of the 108 respondents, 76% worked in tertiary centers, and only 23% held a medical doctorate degree. Furthermore, 69% of the participants had received corneal fellowship training of less than one year. Only 71% were capable of keratoplasties. Among those doing keratoplasty, 68% performed less than 50 keratoplasties each year. Of the same group of keratoplasty surgeons, 88% of corneal specialists capable of keratoplasties had performed penetrating keratoplasties, 87% had performed lamellar keratoplasties, 12% had performed deep anterior lamellar keratoplasties, and 5% had performed Descemet's stripping endothelial keratoplasties. When questioned on the reasons for the low number of keratoplasties performed in China, the respondents deemed the following factors most important: lack of surgical training (71%), a shortage of donor supply (52%), and a lack of curricula (42%). A multivariate logistic regression analysis showed that corneal transplantation capabilities are significantly associated with responders' education levels and training time. CONCLUSION: Keratoplasty surgery experience is suboptimal for Chinese corneal specialists. Penetrating and lamellar keratoplasties are the preferred surgical patterns. Our findings raise concerns about the adequacy of keratoplasty training in China.

Transplant rejection following endothelial keratoplasty and penetrating keratoplasty in the United Kingdom: incidence and survival.

PURPOSE: To investigate the incidence and outcome of cornea transplant rejection following endothelial keratoplasty (EK) and penetrating keratoplasty (PK) for Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK). DESIGN: Multicenter cohort study. METHODS: Patients registered on the United Kingdom Transplant Registry (UKTR) who had an EK or PK for FED or PBK between April 1, 2005 and March 31, 2011 were included. Data were collected from UKTR forms at 1 and 2 years. Postoperative steroid use varies between surgeons and cannot be captured in this reporting system. Rejection events were identified as those recorded as endothelial rejection. RESULTS: A total of 3486 corneal transplants were undertaken: 1973 for FED, 1513 for PBK. For FED, 2-year rejection-free survival was 93% (95% confidence interval [CI] 90%-94%) for PK and 94% (95% CI 92%-96%) for EK (P = .3). In transplants that had a rejection episode, 50% of PKs (17) and 60% of EKs (15) subsequently failed. For PBK, 2-year rejection-free survival for PK was 88% (95% CI 86%-90%) and 90% (95% CI 86%-92%) for EK (P = .6). In transplants that had a rejection episode, 85% of PKs (41) and 76% of EKs (22) subsequently failed. Inflammation (ie, conjunctival injection, presence of keratic precipitates and intraocular signs) at the time of surgery for patients with FED was significant for developing rejection: 3.5 times greater compared with those with no inflammation (P = .02). CONCLUSIONS: There is no significant difference in rejection-free survival between EK and PK for FED or PBK. The presence of inflammation is an important risk factor, and attention to its control before and following surgery is important.

Does Corneal Collagen Cross-linking Reduce the Need for Keratoplasties in Patients With Keratoconus?

PURPOSE: To investigate whether the introduction of corneal collagen cross-linking (CXL) influences the frequency of keratoplasties in patients with keratoconus. METHODS: Data were obtained from a cohort of patients from our corneal transplant registry. Two different periods were compared, 2005 to 2006 (period 1) and 2013 to 2014 (period 2). Patients during period 1 had surgery before the introduction of CXL treatment, and patients in period 2 had surgery after this treatment was well established in our department. Age and gender were registered, and the Amsler-Krumeich classification system was applied to grade the degree of keratoconus. RESULTS: The total number of keratoplasties performed during period 1 was 137, and keratoconus was the cause of surgery in 55 eyes (55 patients). The corresponding numbers in period 2 were 231 and 26 eyes (26 patients), respectively. The difference in the number of keratoplasties for keratoconus in both periods was statistically significant (P = 0.003). There were no significant differences in the distributions of age and gender between both periods. In period 1, 63.6% of the eyes were graded as stage 4 in the Amsler-Krumeich classification, compared with 96.2% in period 2 (P = 0.001). CONCLUSIONS: The frequency of keratoplasty for keratoconus has been more than halved in our department over the last decade. There is reason to believe that this reduction is for a great part caused by the introduction of CXL treatment.

[Trends in indications of perforating keratoplasty at the Department of Ophthalmology, Faculty Hospital, Brno, Czech Republic, E.U., during the period 2008-2012]. / Trendy v indikáciách k perforujúcej keratoplastike na Ocnej klinike FN Brno v rokoch 2008-2012.

INTRODUCTION: The aim of the study is retrospective analysis of perforating keratoplasty (PKP) indications at the Department of Ophthalmology, Faculty Hospital, Masaryk University, Brno, Czech Republic, E.U., during the period of 5 years, from January 1st, 2008 to December 31st, 2012. MATERIAL AND METHODS: We performed the PKP indications retrospective analysis at the Department of Ophthalmology, Faculty Hospital, Masaryk University, Brno, Czech Republic, E.U., during the period of 5 years, from January 1st, 2008 to December 31st, 2012, with complex evaluation of demographic and clinical data. The clinical diagnoses indicating the perforating keratoplasty were divided into 6 groups (keratoconus, bulous keratopathy, keratitis, corneal dystrophies, injuries, corneal transplant failure, and others) according to Cunningham et al. 2011 (2) and Boimer et al. 2012(1) methods. RESULTS: Our results correspond to data in the literature published abroad, where the majority of recently published papers refer significant increase of corneal transplant failure in the last years of follow-up.Key words: perforating keratoplasty, indications.

Prevention and treatment of corneal graft rejection: current practice patterns of the Cornea Society (2011).

PURPOSE: To analyze current practice patterns in the prevention and treatment of corneal graft rejection for both penetrating keratoplasty (PK) and endothelial keratoplasty (EK) and to compare these patterns with previously reported practices. METHODS: In 2011, an electronic survey was sent to 670 members of the Cornea Society worldwide addressing the routine postoperative management of corneal transplants at different time points, treatment of various manifestations of corneal graft rejection, and preferred surgical techniques. RESULTS: A total of 204 of 670 surveys (30%) were returned and evaluated. All respondents used topical corticosteroids for routine postoperative management and treatment of endothelial graft rejection. Prednisolone was the topical steroid of choice in all clinical scenarios, similar to previous surveys from 1989 to 2004. Use of subconjunctival and systemic steroids increased for many scenarios of probable and definite graft rejection. Routine use of prednisolone decreased by approximately 10% from previous surveys, whereas difluprednate was used in 13% of high-risk eyes during the first 6 months. Dexamethasone, fluorometholone, and loteprednol use remained stable. Adjunctive topical cyclosporine use increased significantly for PK and EK. EK was the preferred technique for endothelial dysfunction, whereas PK and deep anterior lamellar keratoplasty were both used for keratoconus and anterior scars. Most respondents (75%) felt that graft rejection occurs more frequently after PK than after EK. CONCLUSIONS: Prednisolone remains the treatment of choice for management and treatment of graft rejection; however, since the introduction of difluprednate, its use has declined slightly since the introduction of difluprednate. Despite perceived differences in rejection rates, there were no differences in prophylactic steroid treatment for PK and EK.

Does lamellar surgery for keratoconus experience the popularity it deserves?

PURPOSE: To analyse developments in surgical treatment for keratoconus (KC) by assessing rates and types of corneal surgery from 2005 to 2010. METHODS: The Dutch Transplantation Foundation supplied data on all keratoplasty procedures for KC performed from 2005 to 2010 in the Netherlands. Registration was carried out by the eyebank at allocation and by the surgeon at the time of surgery. The type of surgery was categorized as either a penetrating or a lamellar procedure. RESULTS: Five hundred and seventy-five anonymized records were received, with excellent data completion (99%). Patients undergoing penetrating surgery had on average a lower visual acuity, higher k-readings and were slightly older compared with the lamellar group. A previous corneal hydrops was recorded for 19.1% of patients. Regular penetrating keratoplasty decreased in popularity from 79.7% in 2005 to 43.7% in 2010, due to the increased rate of lamellar surgery (42.5% in 2010) and 'mushroom' penetrating keratoplasty (13.8% in 2010). When hydrops cases were excluded, popularity became equal (47.6% penetrating versus 52.4% lamellar surgery, in 2010). CONCLUSION: Lamellar surgery is gaining in popularity, although regular penetrating keratoplasty is still the more commonly performed procedure. Only when hydrops cases are excluded do transplant rates become comparable.

[Characteristics of traumatic versus spontaneous wound dehiscence after penetrating keratoplasty]. / Merkmale von traumatischen und spontanen Wunddehiszenzen nach perforierender Keratoplastik.

BACKGROUND AND PURPOSE: After penetrating keratoplasty (PK) patients remain at risk for wound dehiscence at the graft-host junction even years after surgery. The aim of our study was, firstly, to assess the site-specific characteristics between traumatic and spontaneous wound dehiscence at the graft-host junction and, secondly, to determine the incidence of traumatic and spontaneous wound dehiscence. METHODS: The medical records of all 243 patients who underwent a penetrating keratoplasty from 1 March 1996 to 1 March 2012 were retrospectively reviewed. During a 16-year period 9 eyes showed signs of open wound dehiscence after blunt ocular trauma and 7 eyes spontaneously after suture removal. RESULTS: Over the 16-year period, the incidence of traumatic wound dehiscence was 3.7 % (9 of patients), whereas the incidence of spontaneous wound dehiscence after suture removal was 2.9 % (7 of 243 patients). In traumatic cases the graft dehiscence occurred in 88.9 % (8 of 9 patients) in the nasal part, predominantly in the inferior nasal part. In one case (11.1 %), only the temporal part was affected. The average extent of wound dehiscence for traumatic cases was 96° of the total wound circumference in the nasal part, and only 30° of the circumference in the temporal part. Spontaneous dehiscence after suture removal mainly occurred at temporal site in 71.4 % (5 of 7 eyes), mostly temporal inferior. Only in one case was the nasal part affected (14.3 %). The average extent of wound dehiscence in spontaneous cases was 54° of the total circumference in the temporal part and 21° in the nasal part. The total average extent of dehiscence was significantly larger in traumatic cases, 126° (one third) for traumatic and 75° (one fifth) of the wound circumference for spontaneous cases. All of the re-sutured grafts retained clarity, except for 3 eyes among the traumatic cases. CONCLUSION: The difference between both groups was significant regarding the localisation, the extent and the clarity of the re-sutured grafts. The nasal inferior part was the most affected area in traumatic cases probably as a result of indirect, contrecoup injuries, and the temporal part in spontaneous wound dehiscence probably due to direct minor forces.

Evaluation of central corneal thickness after cataract surgery, penetrating keratoplasty and long-term soft contact lens wear.

PURPOSE: The aim of this study was to compare central corneal thickness (CCT) between corneas of normal healthy eyes (cNHE), corneas of eyes that had undergone cataract surgery by clear corneal phacoemulsification with implantation of an intracapsular intraocular lens (cIOL), corneal grafts after penetrating keratoplasty (gPK) and corneas of long-term soft contact lens wearers (cCL). METHODS: The study design was a consecutive cross-sectional trial. CCT was measured using rotating Scheimpflug camera (Pentacam, software version 1.16r04) in 80 cNHE, 79 cIOL, 46 gPK and 78 cCL. Analysis of variance (one-way ANOVA) was performed to compare differences of mean values between these four groups. Pearson's or Spearman's correlation coefficient (r) was determined between CCT value and age, follow up time after penetrating keratoplasty (timePK) or contact lens wearing time (timeCL). RESULTS: Means of CCT measurements were comparable between cNHE (mean CCT±standard deviation, 554±36µm), cIOL (551±40µm) and gPK (534±52µm) as determined by one-way ANOVA. Mean CCT values in cCL (537±37µm) were statistically significantly lower in comparison to cNHE (p=0.026, 95% CI=1.43-31.44). There was no linear correlation between age and CCT values of cNHE and cIOL (p=0.841, r=-0.031 and p=0.931, r=0.011, respectively). No linear relationship was determined between CCT values of cCL and timeCL (p=0.315, r=-0.125). CCT values of gPK did not correlate with timePK (p=0.738, r=0.054). CONCLUSIONS: The data reported here indicate that in the same statistical model among CCT values of cNHE, cIOL and gPK only long-term soft contact lenses (CL) wearer have significantly lower CCT measurements.

Clinical outcome of repeat penetrating keratoplasty.

PURPOSE: To compare the clinical outcome of regrafts with first grafts. METHODS: Two-year outcome data were obtained from the Swedish Cornea Transplant Register for patients undergoing penetrating keratoplasty between 2001 and 2008. Only data from the 3 centers with follow-up return rates >75% were included. The survival and visual outcome of regrafts with the original diagnoses of keratoconus, Fuchs endothelial dystrophy (FED), or bullous keratopathy (BK) were compared with first grafts for the same diagnoses by univariate and logistic regression methods. RESULTS: For keratoconus, the failure rate increased 3-fold in regrafts compared with first grafts (ie, 17% vs. 6%; P = 0.002) and doubled in FED regrafts (33% vs. 15%; P = 0.001). In BK, the failure rate was already high in first grafts, and the increase in failure of regrafts was minimal (P = 0.9). Visual acuity was also worse in regrafts compared with first grafts, mainly in the keratoconus and FED patients. In the keratoconus group, visual acuity with preferred correction was ≥0.5 in 69% of first grafts compared with only 55% in regrafts (P = 001). In FED, 52% of first grafts but only 19% of regrafts achieved visual acuity ≥ 0.5 (P = 0.001). The visual outcome of regrafts in BK was poor but little different from first grafts where fewer than 20% achieved visual acuity ≥ 0.5. CONCLUSIONS: This analysis confirmed the poorer survival of regrafts where the original indication was keratoconus or FED. In addition, visual outcome was also worse than in the first grafts. However, the outcomes of regrafts in BK were similar to first grafts.