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.

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.

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.

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.

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.

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.

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.

Graft Survival, Graft Rejection, and Glaucoma in a Consecutive Series of Descemet Stripping Endothelial Keratoplasty.

PURPOSE: The goal of this study was to compare outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma and abnormal anatomy to eyes with Fuchs endothelial corneal dystrophy (FECD). METHODS: In a retrospective interventional series of all cases of DSEK between April 1, 2006, and November 30, 2015, recipient diagnosis, preoperative glaucoma status, concurrent surgical procedures, and graft outcomes were recorded. Graft survival, risk of rejection, and subsequent glaucoma surgery were estimated by using Kaplan-Meier analysis with risk factors determined by proportional hazard models. RESULTS: Of 703 DSEKs in 666 eyes (509 subjects), the main recipient diagnoses were FECD (n = 496), pseudophakic corneal edema (n = 112), and failed graft (n = 83). Glaucoma was present in 150 cases before DSEK. Overall graft survival was 85%, 75%, and 71% at 5, 10, and 12 years, respectively, and for FECD without glaucoma was 95%, 89%, and 87% at 5, 10, and 12 years, respectively. Independent risk factors for graft failure included recipient diagnoses of pseudophakic corneal edema (HR = 8.3, P < 0.001), failed graft (HR = 6.4, P < 0.001), and preoperative medical glaucoma (HR = 7.1, P < 0.001) or surgical glaucoma (HR = 12.3, P < 0.001). Preoperative glaucoma treated by previous surgery resulted in graft survival of 28% at 10 years. Preoperative glaucoma was associated with an increased risk of graft rejection (HR = 6.8, P < 0.001) and subsequent glaucoma surgery (HR > 17.4, P < 0.001). CONCLUSIONS: Preoperative glaucoma increases the risk of graft failure, graft rejection, and needing subsequent glaucoma surgery in the first decade after DSEK. With previous glaucoma surgery, DSEK graft survival was more favorable compared with published reports of Descemet membrane endothelial keratoplasty.

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.

Deep Learning Model for the Detection of Corneal Edema Before Descemet Membrane Endothelial Keratoplasty on Optical Coherence Tomography Images.

Purpose: Descemet membrane endothelial keratoplasty (DMEK) is the preferred method for treating corneal endothelial dysfunction, such as Fuchs endothelial corneal dystrophy (FECD). The surgical indication is based on the patients' symptoms and the presence of corneal edema. We developed an automated tool based on deep learning to detect edema in corneal optical coherence tomography images. This study aimed to evaluate this approach in edema detection before Descemet membrane endothelial keratoplasty surgery, for patients with or without FECD. Methods: We used our previously described model allowing to classify each pixel in the corneal optical coherence tomography images as "normal" or "edema." We included 1992 images of normal and preoperative edematous corneas. We calculated the edema fraction (EF), defined as the ratio between the number of pixels labeled as "edema," and those representing the cornea for each patient. Differential central corneal thickness (DCCT), defined as the difference in central corneal thickness before and 6 months after surgery, was used to quantify preoperative edema. AUC of EF for the edema detection was calculated for Several DCCT thresholds and a value of 20 µm was selected to define significant edema as it provided the highest area under the curve value. Results: The area under the curve of the receiver operating characteristic curve for EF for the detection of 20 µm of DCCT was 0.97 for all patients, 0.96 for Fuchs and normal only and 0.99 for non-FECD and normal patients. The optimal EF threshold was 0.143 for all patients and patients with FECD. Conclusions: Our model is capable of objectively detecting minimal corneal edema before Descemet membrane endothelial keratoplasty surgery. Translational Relevance: Deep learning can help to interpret optical coherence tomography scans and aid the surgeon in decision-making.

Case report of transient corneal edema after immunization with adenovirus-vectored COVID-19 vaccine.

RATIONALE: To report a case of bilateral transient corneal edema presumably associated with adenovirus-vectored coronavirus disease 2019 (COVID-19) vaccination that resolved with eye drops treatment. PATIENT CONCERNS: A 55-year-old Asian woman presented with sudden onset of bilateral visual disturbance developed 6 days after immunization with an adenovirus-vectored COVID-19 vaccine (AstraZeneca, London, United Kingdom). She underwent uneventful cataract surgery in right and left eyes 2 months ago and maintained good visual acuity bilaterally. Slit-lamp examination showed bilateral mild corneal edema that was confirmed with anterior segment optical coherent tomography. Anterior chamber and vitreous were clear bilaterally. Both fundi were normal. DIAGNOSES: The patient was diagnosed with corneal edema following adenovirus-vectored COVID-19 vaccination. INTERVENTIONS: She was prescribed with prednisolone acetate 1% eye drops bilaterally. OUTCOMES: Treatment with topical steroid for 2 weeks resulted in resolution of the corneal edema and improvement of the visual acuity bilaterally. LESSONS: This case suggests that transient corneal edema can develop following adenovirus-vectored COVID-19 vaccination. Prompt ophthalmologic evaluation and treatment may improve the corneal edema.

Risk Factors for Repeat Keratoplasty After Endothelial Keratoplasty-An IRIS Registry Analysis.

PURPOSE: To assess risk factors for repeat keratoplasty after endothelial keratoplasty (EK). DESIGN: Retrospective cohort study. METHODS: EK procedures performed between 2013 and 2018 in the IRIS Registry (Intelligent Research in Sight) were identified. STUDY POPULATION: Patients aged 18 years and older who underwent EK. MAIN OUTCOME MEASURES: (1) Risk factors for repeat keratoplasty and (2) complication rates after EK. A Kaplan-Meier survival analysis was used to determine the probability of repeat keratoplasty. A multivariable shared frailty survival model was used to assess risk factors. RESULTS: A total of 59 344 procedures were identified in the registry, of which 30 600 EK procedures met the inclusion criteria for the analysis. The probability of repeat keratoplasty was 17.4% (95% CI 16.7-18.0) at 5 years. Risk factors for repeat keratoplasty include postoperative rebubbling procedure (HR 2.24, 95% CI 2.05-2.45), prior failed graft (HR 2.07, 95% CI 1.84-2.32) or bullous keratopathy (HR 1.47, 95% CI 1.33-1.61) vs Fuchs dystrophy as surgical indication; subsequent routine cataract surgery (HR 1.61, 95% CI 1.45-1.79), as well as subsequent (HR 1.53, 95% CI 1.39-1.69) and prior/concurrent (HR 1.23, 95% CI 1.11-1.36) glaucoma surgery or history of glaucoma (HR 1.24, 95% CI 1.14-1.35). Medicaid (HR 1.47, 95% CI 1.13-1.92), military/government (HR 1.29, 95% CI 1.03-1.60), Medicare Fee-for-Service (HR 1.17, 95% CI 1.05-1.31) or Medicare Managed (HR 1.17, 95% CI 1.01-1.36) insurances vs private insurance, as well as Black vs White race (HR 1.25, 95% CI 1.11-1.40) and smoking (HR 1.16, 95% CI 1.05-1.27) were also associated with an increased risk of undergoing repeat keratoplasty. CONCLUSIONS: Black race, government-based insurance plans, and smoking were identified as independent factors associated with repeat keratoplasty in addition to history of glaucoma, glaucoma surgery, and prior graft failure or bullous keratopathy as surgical indication.

Management of acute corneal hydrops with compression sutures and air tamponade.

Background: Acute corneal hydrops is a vision threatening complication of corneal ectasia like keratoconus, keratoconus, keratoglobus, Pellucid marginal degeneration, Terrien's marginal degeneration and post refractive surgery keratectasia. The associated risk factors for development of corneal hydrops (CH) are early onset of keratoconus, microtrauma associated with contact lens use, eye rubbing, allergic conjunctivitis, atopy, and Down's syndrome. With the conservative approach of management of CH, it takes longer time (in months) for corneal oedema to get resolved and there is development of vascularization and scarring. This video presents the simple technique of using compression sutures along with pneumodescemetopexy by intracameral air injection for management of CH. It led to rapid resolution of corneal oedema. It is a simple technique, with no need of special gases like C3F8 or SF6 and can be easily performed at a very basic set up. Purpose: To highlight the efficacy of simple technique of applying compression sutures and air tamponade in management of CH and to demonstrate the efficacy of anterior segment OCT in diagnosis and to assess the prognosis of a case of CH. Synopsis: A 9-year-old boy presented with CH, with anterior segment OCT showing torn descemet's membrane and fluid pockets in corneal stroma. Four full-thickness compression sutures were applied and intracameral sterile air was used for pneumodescetopexy. The serial post operative clinical and OCT picture showed rapid resolution of corneal oedema. Highlights: This video highlights the use of OCT imaging in the diagnosis of CH and full-thickness compression sutures as the safe and effective technique in the management of acute CH. Video link: https://youtu.be/54C3hJB_WTM.