Corneal endothelial cell loss and intraocular pressure following phacoemulsification using a new viscous-cohesive ophthalmic viscosurgical device.

PURPOSE: To compare results of two ophthalmic viscosurgical devices (OVDs)-Viscoat (a dispersive OVD, Alcon) and FR-Pro (a viscous-cohesive OVD, Rayner), in phacoemulsification surgery. METHODS: A prospective randomized controlled study. Patients undergoing phacoemulsification were randomly assigned to receive one of the two OVDs. Exclusion criteria were age under 40, preoperative endothelial cell count (ECC) below 1,500 cells/mm2 and an eventful surgery. The primary outcome was change in ECC from baseline to postoperative month one and month three. Secondary outcomes were the difference between ECC at postoperative month one and month three, changes in IOP and occurrence of an IOP spike ≥ 30 mmHg after surgery. RESULTS: The study included 84 eyes-43 in the Viscoat group and 41 in the FR-Pro group. Mean cell density loss at month one and month three was 17.0 and 19.2%, respectively, for the Viscoat group and 18.4 and 18.8%, respectively, for the FR-Pro group, with no statistically significant difference between the groups (p = 0.772 and p = 0.671, respectively). The mean ECC difference between the month one and month three visits was 50.5 cells/mm2 and was not statistically significant (p = 0.285). One eye in each group had an IOP spike ≥ 30 mmHg, both normalized by postoperative week one. CONCLUSIONS: Viscoat and FR-Pro have comparable results following phacoemulsification surgery, suggesting that while FR-Pro is not a dispersive OVD, its endothelial cell protection may be comparable to one, perhaps due to the addition of sorbitol. Furthermore, a one-month follow-up of ECC seems sufficient in such trials.

New surgical maneuver to position the graft in a descemet stripping with automated endothelial keratoplasty surgery / Nova manobra cirúrgica para posicionar o enxerto em cirurgia de ceratoplastia endotelial com desnudamento automatizado da Descemet

ABSTRACT Objective: To describe a new surgical maneuver to position the graft in a Descemet Stripping with Automated Endothelial Keratoplasty (DSAEK) surgery. Methods: Case series. Results: This technique allows a correct repositioning of the graft in a minimally invasive way. Conclusion: This new surgical maneuver was successful in manipulating the graft in DSAEK surgery and therefore might be effective and safe.

RESUMO Objetivo: Descrever uma nova manobra cirúrgica para posicionar o enxerto em uma cirurgia de ceratoplastia endotelial automatizada com desnudamento da Descemet. Métodos: Série de casos. Resultados: A técnica permitiu o correto reposicionamento do enxerto de forma minimamente invasiva. Conclusão: Esta nova manobra cirúrgica foi bem-sucedida para manipular o enxerto na cirurgia ceratoplastia endotelial automatizada com desnudamento da Descemet e, portanto, pode ser eficaz e segura.

Factors influencing the reduction in corneal endothelial cells after Ex-Press® surgery.

PURPOSE: We investigated the factors that influence the reduction in corneal endothelial cells after Ex-Press® surgery. METHODS: This was a retrospective study. We included patients who had undergone Ex-Press surgery and were followed up for > 2. We analyzed the corneal endothelial cell density (ECD) before and after Ex-Press surgery. We investigated the insertion position (Ex-Press device was inserted into cornea or trabecular meshwork (TM)), Ex-Press-iris touch, cornea-iris touch, peripheral anterior synechiae, history of trabeculotomy, history of selective laser trabeculoplasty, type of glaucoma, and simultaneous cataract surgery as influencing factors. We used multivariate analysis to determine the factors influencing the reduction rate of ECD. RESULTS: We included 129 eyes. The mean of ECD had decreased 7.0% at 2 years. Ex-Press surgeries significantly decreased the ECD after 2 years (p = 0.0118). As a result of the multivariate analysis, the factor that led to a significantly faster reduction in ECD was the insertion position of the Ex-Press (p < 0.0001). The reduction rate of ECD after 2 years in cases of insertion into the cornea (27 eyes) was 15.1 ± 3.6%, and in cases of insertion into a TM (102 eyes), it was 5.2 ± 1.4%. CONCLUSIONS: Insertion into the cornea was a risk factor for rapid ECD loss. The Ex-Press should be inserted into a TM for long-term protection of the corneal endothelial cells.

A Deep Learning Approach in Rebubbling After Descemet's Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate the efficacy of deep learning in judging the need for rebubbling after Descemet's endothelial membrane keratoplasty (DMEK). METHODS: This retrospective study included eyes that underwent rebubbling after DMEK (rebubbling group: RB group) and the same number of eyes that did not require rebubbling (non-RB group), based on medical records. To classify the RB group, randomly selected images from anterior segment optical coherence tomography at postoperative day 5 were evaluated by corneal specialists. The criterion for rebubbling was the condition where graft detachment reached the central 4.0-mm pupil area. We trained nine types of deep neural network structures (VGG16, VGG19, ResNet50, InceptionV3, InceptionResNetV2, Xception, DenseNet121, DenseNet169, and DenseNet201) and built nine models. Using each model, we tested the validation data and evaluated the model. RESULTS: This study included 496 images (31 eyes from 24 patients) in the RB group and 496 images (31 eyes from 29 patients) in the non-RB group. Because 16 picture images were obtained from the same point of each eye, a total of 992 images were obtained. The VGG19 model was found to have the highest area under the receiver operating characteristic curve (AUC) of all models. The AUC, sensitivity, and specificity of the VGG19 model were 0.964, 0.967, and 0.915, respectively, whereas those of the best ensemble model were 0.956, 0.913, and 0.921, respectively. CONCLUSIONS: This automated system that enables the physician to be aware of the requirement of RB might be clinically useful.

Recent Surgical Trends in Pediatric Corneal Transplantation: A 13-Year Review.

PURPOSE: Corneal transplantation is the standard of care for pediatric corneal opacities, but little consensus exists on optimal surgical management. Our goal was to evaluate cross-sectional data of donor and recipient characteristics collected from eye banks providing tissue for pediatric corneal transplant cases to assess surgical trends in pediatric keratoplasty over the past 13 years. METHODS: We performed a retrospective review of recipient data, collected from 4 major eye banks, for pediatric patients (<18 years) who underwent corneal transplantation between January 2005 and December 2017. We analyzed trends in surgical indications, types of keratoplasty, and donor/recipient characteristics. RESULTS: Our database included 2620 total pediatric cases. Penetrating keratoplasty (PKP) remains the most common surgery performed (79.8%), but more partial-thickness transplant cases [eg, endothelial keratoplasty (EK)] have been performed since 2008. The most commonly reported transplant indication was ectasias/thinnings (34.1%) overall and congenital opacities (17.0%) in children less than 5 years. Average donor age was significantly lower for the youngest recipient age group of less than 5 years (P < 0.001); endothelial cell count was also higher, and death-to-surgery time was lower for PKP and EK cases versus other keratoplasties. CONCLUSIONS: Indications for transplant vary across age groups but are consistent with previous reports. Popularity of partial-thickness transplants has increased since 2008. Surgeons prefer younger donor tissue for younger patients and have higher thresholds for endothelial cell count for PKP and EK cases. Centralized tracking of pediatric keratoplasty cases is necessary for further investigation of long-term outcomes.

Perioperative Use of Rho-Kinase Inhibitors has Beneficial Effect on Corneal Endothelium after Phacoemulsification.

PURPOSE: Does perioperative use of Rho-Kinase (ROCK) inhibitors have beneficial effect on corneal endothelial cells after phacoemulsification? SETTING: This study was conducted at King Abdulaziz University Hospital in Riyadh. DESIGN: This was a prospective study assessing the effect of ROCK inhibitors on corneal endothelium after phacoemulsification. METHODOLOGY: Three patients have used ROCK inhibitor 1 day before and 1 week after phacoemulsification surgery, and specular microscopy and Pentacam were done preoperatively and 3 months postoperatively. RESULTS: Endothelial cell density decreased to 11.3%, 9.45%, and 4.09% in eyes with ROCK inhibitors and 23.9% in one eye without ROCK inhibitor. CONCLUSION: Perioperative ROCK inhibitor use has a possible protective effect on corneal endothelium.

New ex vivo model of corneal endothelial phacoemulsification injury and rescue therapy with mesenchymal stromal cell secretome.

PURPOSE: To develop a reproducible ex vivo model of corneal endothelial cell injury using phacoemulsification in porcine eyes and to evaluate the effects of mesenchymal stromal cell secretome in this injury model. SETTING: Department of Ophthalmology, University of Illinois at Chicago, Illinois, USA. DESIGN: Experimental study. METHODS: A corneal endothelial injury model was optimized using different powers and durations of ultrasound energy inside ex vivo porcine eyes. Conditioned media from corneal mesenchymal stem cells was collected under serum-free conditions from passages 4 to 6. Immediately after the phacoemulsification injury, the anterior chamber fluid was replaced with unconditioned media or conditioned media and incubated at 37°C for 4 hours. At the end, endothelial cell viability was evaluated using trypan blue staining and analyzed with ImageJ software. RESULTS: Using specific parameters (50% power for 30 seconds), phacoemulsification inside fresh porcine eyes led to a consistent level of endothelial cell injury. Incubation with corneal mesenchymal stromal cell-conditioned media after the injury significantly reduced endothelial cells loss compared with unconditioned media (mean 1.29% ± 0.91% [SD] and 5.33% ± 3.24%, respectively, P < .05). CONCLUSIONS: Phacoemulsification inside fresh porcine eyes provided a reproducible model to study endothelial cell injury. Treatment with corneal mesenchymal stromal cell secretome after injury appeared to significantly enhance the survival of corneal endothelial cells. This might provide a new strategy for preventing corneal endothelial cell loss after phacoemulsification or other endothelial injuries. Further in vivo studies are necessary to determine the therapeutic potential.

Comparing Outcomes of Phacoemulsification With Femtosecond Laser-Assisted Cataract Surgery in Patients With Fuchs Endothelial Dystrophy.

PURPOSE: To compare the outcome in patients with Fuchs endothelial dystrophy (FED) who underwent standard phacoemulsification vs femtosecond laser-assisted cataract surgery (FLACS) in the treatment of visually significant cataracts. DESIGN: Retrospective, comparative, interventional case series. METHODS: Patient or Study Population: Between April 2013 and December 2016, 140 FED eyes with cataracts of all densities were included. Seventy-two eyes underwent phacoemulsification and 68 eyes underwent FLACS. Intervention or Observation Procedures: Automated noncontact specular microscopy was performed at baseline and postoperatively over a mean of 17.91 ± 10.47 months. Parameters collected include visual acuity, slit-lamp examination findings, and intraoperative findings. MAIN OUTCOME MEASURES: Pachymetry, endothelial cell density (ECD), and coefficient of variance (COV) were compared. RESULTS: Phacoemulsification had significantly greater postoperative median loss of ECD of 229.0 cells/mm2 (14.2%) compared to FLACS ECD of 133.0 cells/mm2 (6.5%) (U = 1343.0, Z = -2.241, P = .025). Mean loss of ECD was 346.524 ± 420.472 cells/mm2 and 119.964 ± 434.882 cells/mm2 for phacoemulsification and FLACS, respectively (P = .005). Mean percentage loss of ECD was 15.3% ± 17.5% for phacoemulsification and 4.4% ± 25.0% for FLACS (P = .006). Eyes that underwent phacoemulsification had 10.7% ± 15.4% mean ECD loss in the mild cataract group, and in the moderate/hard cataract group 19.5% ± 18.0%, P = .045. Eyes that underwent FLACS had 0.9% ± 22.5% mean ECD loss in the mild cataract group, and 8.2% ± 26.3% in the moderate/hard cataract group, P = .291. Comparison between procedures of mean ECD loss for moderate/hard cataracts was significant (P = .043). CONCLUSIONS: FLACS is shown to be superior to phacoemulsification in reducing postoperative endothelial cell loss in FED patients, which translates to a lower risk of corneal decompensation, especially in patients with moderate/hard cataract densities.

Application of thermoreversible hydrogel (poloxamer 407) to protect the corneal endothelium during phacoemulsification in porcine and rabbit eyes.

PURPOSE: To evaluate the effectiveness of thermoreversible (poloxamer) hydrogels as a substitute for ophthalmic viscosurgical devices (OVDs) during phacoemulsification in porcine and rabbit eyes and compare their endothelial protective effect with that of hyaluronic acid-based OVDs. SETTING: Department of Ophthalmology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea. DESIGN: Experimental study. METHODS: Fluorescein-stained poloxamer hydrogels (20%, 22%, 24%, and 26% [weight/weight%]) and cohesive (sodium hyaluronate 1.0% [Provisc]) and dispersive (sodium hyaluronate 3.0%-chondroitin sulfate 4.0% [Viscoat]) OVDs were injected into the anterior chamber of porcine eyes incubated at 32°C. In the in vitro study, the retention time was measured in 3 groups of 45 porcine eyes during continuous phacoemulsification. In the in vivo study, the endothelial cell count (ECC) was measured before and 3 days after intermittent phacoemulsification in 12 rabbit eyes randomized to a poloxamer hydrogel or a dispersive OVD group. RESULTS: The optimum concentration of thermosensitive hydrogel was 26%, at which no gel-to-sol phase transition occurred in the anterior chamber, with a 21°C irrigation solution. In the in vitro study, the mean retention times were 5.53 seconds ± 1.77 (SD), 125.00 ± 29.34 seconds, and 221.53 ± 42.48 seconds in the cohesive OVD, dispersive OVD, and 26% poloxamer hydrogel groups, respectively (P < .001). Throughout the 5-minute intermittent phacoemulsification, the 26% poloxamer hydrogel remained in the anterior chamber as a semisolid gel. In the in vivo study, the mean decrease in ECC was significantly lower in the 26% poloxamer hydrogel group than in the dispersive OVD group (P = .029). CONCLUSION: Thermoreversible hydrogels might be suitable substitutes for hyaluronic acid-based OVDs for corneal endothelial protection during phacoemulsification.

The protective effect of simvastatin against ultraviolet B-induced corneal endothelial cell death.

Purpose: Excessive ultraviolet B (UVB) exposure causing corneal endothelium injury, including apoptosis, is a serious condition. Therefore, drugs that can inhibit apoptosis in corneal endothelial cells represent an effective strategy. Simvastatin is widely used as a specific inhibitor of 3-hydroxy-3-methyl-glutaryl-CoA reductase, can reduce levels of low density lipoprotein (LDL) cholesterol, and exerts anti-inflammatory effects. However, the protective effect of simvastatin on corneal endothelial cells remains unclear. Therefore, the aim of this study was to elucidate whether UVB promotes the initiation of apoptosis in corneal endothelial cells and injury reversible by simvastatin treatment. Methods: We detected the cell viability, subG1 population, and caspase-3 activity. Results: Results showed that simvastatin alleviates UVB-induced cell death, cell apoptosis, and caspase-3 activity. Conclusion: Our findings indicated that simvastatin alleviated UVB-induced corneal endothelial cell apoptosis via caspase-3 activity.

Modified Descemet's stripping automated endothelial keratoplasty for eyes with glaucoma drainage devices and shallow anterior chambers.

PURPOSE: To present a modified Descemet's stripping automated endothelial keratoplasty (DSAEK) technique to avoid risks of endothelial cell loss related to the presence of a glaucoma tube in cases with shallow anterior chamber. METHOD: A 72-year-old patient with an only eye and corneal decompensation secondary to a Baerveldt tube was referred for keratoplasty. He was pseudophakic and had shallow anterior chamber. His best-corrected visual acuity was counting fingers close to face. He underwent a combined procedure with withdrawal and shortening of tube followed by a modified DSAEK employing a 7.5-mm donor graft in which a peripheral notch was performed to overlay the silicon tube. RESULTS: No intraoperative or postoperative complications were noted. The endothelial cell count was 2000/mm2 after 15 months of the surgery. His best-corrected visual acuity remains 6/18 with a stable glaucoma. CONCLUSION: This modified technique of DSAEK offers the benefits of endothelial transplant, and it could represent an option to reduce risks of corneal decompensation due to the presence of tubes in cases with shallow anterior chambers.

Preoperative photocoagulation reduces corneal endothelial cell damage after vitrectomy in patients with proliferative diabetic retinopathy.

Proliferative diabetic retinopathy (PDR) is a severe complication of diabetes and is a leading cause of visual decline and irreversible blindness. So we designed this study to investigate retrospectively the effect of preoperative photocoagulation on corneal endothelial cells after vitrectomy in patients with PDR.The study included 52 eyes of 46 patients with PDR complicated with vitreous hemorrhage, who underwent vitrectomy. Patients were apportioned to a photocoagulation group (26 eyes/23 patients) or nonphotocoagulation group (26/23 patients), according to their history of preoperative photocoagulation. A specular microscope was used to assess the corneal endothelial cell density and percentage of hexagonal cells (PHC) before surgery, and at 1 week, 1 month, and 3 months after surgery.The cell density was lower 3 months after surgery in the photocoagulation group, but at 1 month in the nonphotocoagulation group, all cases were significantly different from the preoperative value (P < .05 or P < .01). One week after surgery, the mean cell densities between the photocoagulation and nonphotocoagulation groups were not statistically different (P > .05). However, the mean cell densities at 1 and 3 months after surgery in the photocoagulation group were significantly higher than those in the nonphotocoagulation group (P < .05). The PHC values in the photocoagulation group at 1 week and in the nonphotocoagulation group at 1 week, 1 month, and 3 months were much lower than their respective preoperative values (P < .05 or P < .01). More importantly, at 1 and 3 months, the PHC had recovered to preoperative values in the photocoagulation group, but not in the nonphotocoagulation group. As for cell density and PHC, they were both significantly higher 1 and 3 months after surgery in the photocoagulation group than in the nonphotocoagulation group (P < .05).Photocoagulation before vitrectomy reduces subsequent corneal endothelial cell damage in PDR patients.

Comparison of 5% Sulfur Hexafluoride Versus 100% Air Tamponade in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To compare the rebubbling rate and clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) with 5% sulfur hexafluoride (SF6) gas versus 100% air as a tamponade for graft attachment. METHODS: Retrospective, comparative, interventional case series including 368 consecutive pseudophakic eyes with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy that underwent DMEK in a tertiary referral center between October 2010 and August 2015 using either air (group 1, 191 eyes) or 5% SF6 (group 2, 177 eyes) as a tamponade. The rebubbling rate, complications, best-corrected distance visual acuity (BCVA), manifest refraction, and endothelial cell density were analyzed before and at 1 week, 1, 3, 6, 12, 24, and 36 months after surgery. RESULTS: The rebubbling rate was 20.4% (39/191, group 1) versus 6.8% (12/177, group 2; P < 0.001). Complications included cystoid macular edema (n = 5, group 1, and n = 10, group 2; P = 0.14) and 1 case of presumed allograft rejection (n = 1, group 2). The follow-up period was 12 ± 8 months for group 1 and 6 ± 4 months for group 2. BCVA (logarithm of the minimum angle of resolution) had improved after 12 months from 1.43 ± 0.63 to 0.18 ± 0.26 (group 1, P < 0.001) and from 1.8 ± 0.63 to 0.18 ± 0.17 (group 2, P < 0.001). The percentage of eyes with BCVA ≥0.2 logarithm of the minimum angle of resolution at 12 months was 70.9% (90/127, group 1) and 78.4% (40/51, group 2; P = 0.3). Endothelial cell loss at 12 months after DMEK was 44 ± 18% (group 1) versus 33 ± 15% (group 2, P = 0.07). CONCLUSIONS: The use of a tamponade with 5% SF6 yielded a significantly lower incidence of graft detachment requiring surgical reintervention with no detrimental effect on graft endothelial cells. Thus, routine use of 5% SF6 for a graft tamponade in DMEK is recommended.

Evaluation of Corneal Endothelial Cell Loss After Uncomplicated Phacoemulsification Cataract Surgery With Intracameral Phenylephrine.

PURPOSE: To study the effects of intracameral phenylephrine 1.5% on corneal endothelial cell loss and morphological changes in patients who had uneventful phacoemulsification surgery. DESIGN: A double-blind randomized controlled trial. METHODS: This study comprised 295 patients who were randomized into the intracameral (ICM) mydriatic group or topical mydriatic group. Central corneal endothelial cell density (ECD), coefficient of variation (CV), and percentage of hexagonal cells were measured preoperatively and postoperatively at 1 week, 6 weeks, and 3 months with specular microscope. RESULTS: There was no significant difference in endothelial cell density and endothelial cell loss between the topical and ICM mydriatic groups. At 3 months, the mean endothelial cell density in the ICM group was 2129.76 ± 423.53 cells/mm2 and 2100.54 ± 393.00 cells/mm2 in the topical group (P = 0.539). The endothelial cell loss was 18.60 ± 12.79% in the IC M group and 19.44 ± 11.24% in the topical group (P = 0.550). No significant difference was seen in the percentage of hexagonal cells and coefficient of variation of patients between the 2 groups. CONCLUSIONS: Intracameral phenylephrine was not associated with increased risk of postoperative endothelial cell loss or morphological changes. It can be safely injected into the anterior chamber for pupil dilatation before phacoemulsification cataract surgery.

Preoperative Mannitolization Can Decrease Corneal Endothelial Cell Damage After Cataract Surgery.

PURPOSE: To evaluate whether preoperative mannitolization can change ocular biometry and affect postoperative corneal endothelial cell density. METHODS: Bilateral sequential cataract surgery was performed in 38 patients. Preoperative mannitolization was done in one eye of each subject. We checked the change in preoperative ocular biometry before and after intravenous mannitolization. We compared the postoperative corneal endothelial cell density between eyes with mannitolization and without mannitolization at postoperative week 1, 2, 5, and 8. We evaluated the relationship between change in ocular biometry and change in postoperative corneal endothelial cells in eyes that underwent preoperative mannitolization. RESULTS: After mannitolization, eyes exhibited decreased intraocular pressure, axial length (AL), and vitreous chamber depth (VCD) and increased anterior chamber depth (ACD) and lens position (LP) compared to before mannitolization (p < 0.05). Preoperative mannitolization has a tendency to decrease the intraoperative use of phaco energy in eyes with moderate nucleosclerosis. Eyes with preoperative mannitolization showed less loss of postoperative corneal endothelial cells than eyes without preoperative mannitolization (p < 0.05). The ACD, LP, and AL changes by mannitolization were all negatively correlated with corneal endothelial cell loss (p < 0.05). CONCLUSION: Preoperative mannitolization can decrease postoperative loss of corneal endothelial cells. The protective effect of preoperative mannitolization on the corneal endothelium may be due to the decreased need for phaco energy and changes in ocular biometry such as ACD, AL, and LP.

Short-term and long-term effects of small incision lenticule extraction (SMILE) on corneal endothelial cells.

PURPOSE: Small incision lenticule extraction (SMILE) is being used increasingly as a novel approach to correct refractive errors with femtosecond laser. The study was aimed to investigate the corneal endothelial changes 1 day (short term) and 1 year (long term) after SMILE procedure. METHODS: In this prospective study, a total of 56 eyes of 30 patients with myopia ranging from -3.25 to -8.25 diopters (D) and cylinder up to -3.50D were treated by SMILE. Postoperative uncorrected distance visual acuity (UDVA) and complications were assessed. Endothelial cell density (ECD), the coefficient of variation (CV), and the percentage of hexagonal cells were measured using a noncontact specular microscope preoperatively and at 1 day and 1 year postoperatively. The estimated residual stromal thickness (RST) of each patient was recorded. RESULTS: The median UDVA improved significantly from 1.00logMAR preoperatively to -0.10logMAR both at 1 day and 1 year (p<0.001). No eyes developed corneal edema or other complications during the follow-up period. There were no significant changes in the ECD, CV or the percentage of hexagonal cells at any visit point (all p>0.05). The mean estimated RST was 355.1±32.2µm (range 290-429µm). Endothelial cell changes in terms of ECD, CV or the percentage of hexagonal cells were not correlated with the estimated RST (p>0.05). CONCLUSIONS: SMILE yielded improvement in visual acuity and no adverse effects to corneal endothelial cells were found. However, further studies with a lower preoperative ECD and deeper lenticule extraction are needed to conduct.

Advances in cataract surgery: preserving the corneal endothelium.

PURPOSE OF REVIEW: Cataract surgery is known to lead to some degree of corneal endothelial cell loss (ECL). The purpose of this review is to describe how recent technological advancements such as femtosecond laser-assisted cataract surgery (FLACS) affect corneal endothelium during cataract surgery. RECENT FINDINGS: It has been suggested that FLACS may reduce the amount of required ultrasound energy used in cataract surgery, a factor known to be directly related to ECL. Several recent studies demonstrate either no difference or less ECL with FLACS than with standard phacoemulsification 1-3 months after surgery. However, results at 6 months show comparable ECL between the two techniques. Other recent advancements in surgical technique, such as biaxial microincision surgery, result in similar ECL rates to that of standard phacoemulsification. The use of ultraviolet light in the newly developing light-adjustable intraocular lenses does not increase ECL. Studies show either similar results or less ECL with the use of the newer viscous-dispersives when compared with other viscoelastic devices. Other aspects such as the use of intracameral injections have no adverse effects on corneal endothelium. SUMMARY: Newly emerging cataract surgical techniques cause comparable ECL to that of conventional phacoemulsification. Femtosecond laser-assistance may reduce ECL, but likely only in the early postoperative period. Further studies are needed to better elucidate short and long-term effects of FLACS on the corneal endothelium. Viscous dispersives may offer equal or increased protection of the corneal endothelium during surgery compared with viscoelastic devices currently in wide use, but further studies are required to support these results.

Descemet membrane endothelial keratoplasty postoperative year 1 endothelial cell counts.

PURPOSE: To report endothelial cell counts (ECC) in patients 1 year after Descemet membrane endothelial keratoplasty (DMEK) and suggest surgical techniques that may minimize intraoperative endothelial cell loss. DESIGN: Retrospective, observational case series. METHODS: This is a retrospective case series of 125 consecutive cases with 1 year of postoperative follow-up. Eight-millimeter DMEK grafts were prepared at a single institution via the submerged cornea, using backgrounds away technique. Grafts were introduced through a 2.4-mm incision and a "no-touch" technique was used to position them. RESULTS: The mean preoperative donor ECC was 2740 ± 210 (cells/mm(2)). Mean postoperative year 1 ECC was 2210 ± 550 for an ECC loss of 19% ± 10%. Rebubbling was performed in 5% of cases. CONCLUSION: Postoperative year 1 endothelial cell counts in DMEK can equal and even surpass those of Descemet stripping automated endothelial cell keratoplasty (DSAEK) or even penetrating keratoplasty. Given reported decreased rejection rates in DMEK, these patients may have notably superior ECC 5 and 10 years out from surgery compared to if they had undergone DSAEK.

Effect of femtosecond laser-assisted cataract surgery on the corneal endothelium.

PURPOSE: To compare the effect on the corneal endothelium of femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery. SETTING: Private clinic, Tasmania, Australia. DESIGN: Prospective comparative cohort study. METHODS: Femtosecond laser-assisted cataract surgery (study group) or conventional phacoemulsification (control group) was performed. The central corneal thickness, central 3.0 mm corneal volume, volume stress index, and central endothelial cell density (ECD) were measured preoperatively and 1 day, 3 weeks, and 6 months postoperatively. RESULTS: The study group comprised 405 eyes and the control group, 215 eyes. Postoperative corneal edema was significantly less in the study group at 1 day and 3 weeks. However, the difference was negligible at 6 months. The study group had significant reductions in ECD loss compared with the control group [corrected] at 3 weeks but not at 6 months (6-month mean -150 cells/mm(2) ± 244 [SD] versus -149 cells/mm(2) ± 233). Eyes in the study group with laser-automated corneal incisions had greater endothelial cell loss at 6 months than eyes in the study group with manual corneal incisions and eyes in the control group (P<.0001). Eyes in the study group with zero effective phaco time and manually created corneal incisions had statistically significantly less endothelial cell loss at 6 months than the other groups (P<.0001). CONCLUSIONS: Femtosecond laser pretreatment for cataract surgery was associated with a significant reduction in early postoperative corneal edema and endothelial cell loss compared with conventional phacoemulsification; however, the difference diminished with time. Laser-automated corneal incisions seemed to adversely affect the corneal endothelial cells. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.