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

ABSTRACT 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.

Manually prepared lamellae for Descemet stripping endothelial keratoplasty (Pachy-DSEK): comparison of four dissection depths / Lamelas manualmente dissecadas para transplante endotelial de córnea (Pachy-DSEK): comparação entre quatro profundidades de dissecção

ABSTRACT Purpose: This study aimed to compare four depths of manual dissection for the preparation of Descemet stripping endothelial keratoplasty lamellae. Methods: Eye bank corneas were randomized into four groups according to dissection depths: Pachy-100 (incision depth = central corneal thickness-safety margin of 100 µm), Pachy-50 (safety margin of 50 µm), Pachy-0 (no safety margin), and Pachy+50 (incision depth = central corneal thickness + 50 µm). All endothelial lamellae were prepared using a standardized method of manual dissection (Pachy-DSEK). The central, paracentral (3.0-mm zone), and peripheral (6.0-mm zone) lamella thicknesses and incision depths were measured by optical coherence tomography. The 3.0-mm and 6.0-mm zone central-to-peripheral thickness ratios were calculated. Results: Endothelial perforation occurred only in the Pachy+50 group (n=3, 30%). Central lamella's thickness in Pachy-100, Pachy-50, Pachy-0, and Pachy+50 groups measured 185 ± 42 µm, 122 ± 29 µm, 114 ± 29 µm, and 58 ± 31 µm, respectively (p<0.001). The overall 3.0- and 6.0-mm C/P ratios were 0.97 ± 0.06 and 0.92 ± 0.14, respectively. Preoperative donor characteristics were not correlated with most thickness outcomes. The planned incision depth correlated significantly with most lamella's thickness parameters (p<0.001). The overall thickness of the lamella negatively correlated with the planned incision depth (p<0.001, r=-0.580). The best outcome was found in the Pachy-0 group, as 75% of the lamellae measured <130 µm and there was no endothelial perforation. Conclusions: By using a standardized method of dissection, most manually prepared lamellae presented a planar shape. Setting the incision depth to the central corneal thickness did not result in endothelial perforation and a high percentage of ultrathin lamellae was achieved.

RESUMO Objetivo: Comparar quatro profundidades de dissecção manual usadas no preparo de lamelas para transplante endotelial. Métodos: Córneas humanas de treinamento disponibilizadas foram randomizadas em quatro grupos: Pachy-100 (profundidade de incisão = espessura corneana central - margem de segurança de 100 µm), Pachy-50 (margem de segurança de 50 µm), Pachy-0 (sem margem de segurança) e Pachy+50 (profundidade de incisão = espessura corneana central + 50 µm). Todas as lamelas foram dissecadas através um método padronizado e já publicado (Pachy-DSEK). As espessuras das lamelas (centro, zona de 3,0mm e zona de 6,0mm) foram medidas com tomografia de coerência óptica. A razão de espessura centro-periferia foi calculada aos 3,0 e 6,0 mm de diâmetro. Resultados: Perfuração endotelial ocorreu apenas no grupo Pachy+50 (n=3, 30%). A espessura central da lamela nos grupos Pachy-100, Pachy-50, Pachy-0 e Pachy+50 foi de 185 ± 42 µm, 122 ± 29 µm, 114 ± 29 µm, e 58 ± 31 µm, respectivamente (p<0,001). As razões C/P aos 3,0 e 6,0 mm foram de 0,97 ± 0,06 e 0,92 ± 0,14, respectivamente. Os parâmetros de características do doador não se correlacionaram com os resultados de espessura de lamela. A profundidade planejada de incisão se correlacionou com a maioria dos parâmetros de espessura de lamela (p<0,001). A espessura de lamela se correlacionou negativamente com a profundidade planejada da incisão (p<0.001, r=-0,580). O melhor resultado foi observado no grupo Pachy-0, em que 75% das lamelas mediram abaixo de 130 µm e não houve perfuração endotelial. Conclusão: Através de um método padronizado de dissecção, a maioria das lamelas endoteliais apresentou uma configuração planar. O planejamento de profundidade de incisão igual à espessura corneana central resultou em alta porcentagem de lamelas ultrafinas sem ocorrência de perfuração.

Descemet's membrane endothelial keratoplasty for primary graft failure after penetrating keratoplasty / Transplante endotelial de membrana de Descemet para falência primária após transplante penetrante

ABSTRACT Primary graft failure (PGF) is a known complication following penetrating keratoplasty (PKP). The usual approach to treat this complication is to repeat a penetrating keratoplasty. Here, we report a case of Descemet's membrane endothelial keratoplasty (DMEK) for the treatment of PGF after PKP. A patient that underwent PKP, developed PGF with persistent graft edema and very poor visual acuity despite aggressive steroid use and a proof anti-viral treatment. Three months after the initial surgery, a DMEK was performed under the PKP graft. There was progressive early corneal clearing and, by the end of the first month, the patient already had no corneal edema. Uncorrected visual acuity (UCVA) improved to 20/40 and best corrected visual acuity (BCVA) to 20/20. DMEK may be an alternative to a second PKP for the treatment of PGF. This technique is a less invasive option when compared to the standard PKP procedure.

RESUMO A falência primária do enxerto é uma complicação conhecida que pode ocorrer após o transplante penetrante de córnea. O tratamento usual dessa complicação é com um novo transplante penetrante. Apresentamos um caso em que foi usado o transplante endotelial de membrana de Descemet (DMEK - do inglês Descemet membrane endo-thelial keratoplasty) para o tratamento da falência primária após o transplante penetrante. Uma paciente submetida a transplante penetrante evoluiu com falência primária do enxerto a despeito do uso intenso de corticoide tópico e uma prova terapêutica de antivirais. Três meses após a cirurgia inicial, foi optado pela realização do transplante endotelial de membrana de Descemet sob o transplante penetrante. Houve um clareamento precoce e progressivo do enxerto com melhora importante da visão. Após um mês, a visão sem correção era de 20/40 melhorando para 20/20 com refração. O transplante endotelial de membrana de Descemet pode ser uma alternativa a um novo transplante penetrante como tratamento da falência primária.

Wet bio-amniotic membrane plugging combined with transplantation in the treatment of small corneal perforations

ABSTRACT Purpose: Wet bio-amniotic membrane plugging combined with transplantation is a novel option that combined amniotic membrane plugging with amniotic membrane transplantation for the treatment of small corneal perforations. This study aimed to evaluate the efficacy of wet bio-amniotic membrane plugging in the treatment of small corneal perforations and compared it with that of the penetrating keratoplasty procedure. Methods: Forty patients (41 eyes) with small corneal perforations <3 mm in diameter treated at our hospital between July 2018 and January 2021 were retrospectively included. Among them, 21 eyes were treated with wet bio-amniotic membrane plugging (wet bio-amniotic membrane plugging group), and 20 eyes were treated with penetrating keratoplasty procedure (penetrating keratoplasty procedure group). The best-corrected visual acuity, anterior chamber formation, corneal thickness, primary disease control, postoperative complications, and graft survival rate were assessed. Results: No significant difference in baseline characteristics was found between the wet bio-amniotic membrane plugging and penetrating keratoplasty procedure groups (p>0.05). The postoperative control rates of primary diseases in the wet bio-amniotic membrane plugging and penetrating keratoplasty procedure groups were 95.2% and 90.0%, respectively (p=0.481). Visual acuity was improved 6 months after the operation in the wet bio-amniotic membrane plugging group and was improved at postoperative 1 month in the penetrating keratoplasty procedure group. The formation time of the anterior chamber in the wet bio-amniotic membrane plugging group was significantly shorter than that in the penetrating keratoplasty procedure group (p=0.023). The corneal thickness of the two groups significantly increased 12 months after the operation; however, the degree of thickening in the penetrating keratoplasty procedure group was higher than that in the wet bio-amniotic membrane plugging group (p<0.001). During the follow-up, postoperative complications were not different between the two groups (p>0.999). Conclusion: The results suggest that wet bio-amniotic membrane plugging is effective and safe in the treatment of small corneal perforations. Thus, it can be used as an emergency treatment alternative to penetrating keratoplasty procedure for small corneal perforations.

Deep anterior lamellar keratoplasty and penetrating keratoplasty in macular corneal dystrophy: comparison of visual and topographic outcomes and complications

ABSTRACT Purposes: This study aims to assess and compare the postoperative visual and topographic outcomes, complications, and graft survival rates following deep anterior lamellar keratoplasty and penetrating keratoplasty in patients with macular corneal dystrophy. Methods: In this study we enrolled 59 patients (23 male; and 36 female) with macular corneal dystrophy comprising 81 eyes. Out of these, 64 eyes underwent penetrating keratoplasty, while 17 eyes underwent deep anterior lamellar keratoplasty. The two groups were analyzed and compared based on best-corrected visual acuity, corneal tomography parameters, pachymetry, complication rates, and graft survival rates. Results: After 12 months, 70.6% of the patients who underwent deep anterior lamellar keratoplasty (DALK) and 75% of those who had penetrating keratoplasty (PK) achieved a best-corrected visual acuity of 20/40 or better (p=0.712). Following surgery, DALK group showed lower front Kmean (p=0.037), and Q values (p<0.01) compared to the PK group. Postoperative interface opacity was observed in seven eyes (41.2%) in the DALK group. Other topography values and other complications (graft rejection, graft failure, cataract, glaucoma, microbial keratitis, optic atrophy) did not show significant differences between the two groups. The need for regrafting was 9.4% and 11.8% in the PK and DALK groups, respectively (p=0.769). Graft survival rates were 87.5% and 88.2% for PK and DALK; respectively (p=0.88 by Log-rank test). Conclusion: Both PK and DALK are equally effective in treating macular corneal dystrophy, showing similar visual, topographic, and survival outcomes. Although interface opacity occurs more frequently after DALK the visual results were comparable in both groups. Therefore, DALK emerges as a viable surgical choice for patients with macular corneal dystrophy without Descemet membrane involvement is absent.

Review on corneal perforation among mentally disabled patients in a tertiary center in Melaka, Malaysia

Corneal perforation is an ocular emergency arising from various causes of infectious and non-infectious disease. Its management could range from temporising measures to various surgical intervention. This study was done to evaluate the causes and management of corneal perforation among mentally disabled patients in Melaka. Retrospective review was done using the ward admission records from 2019 to 2022. Data gathered from cases with corneal perforation was reviewed. There were total of 15 patients with 8 (53.4%) males and 7 (46.6%) females. Out of these, 10 (66.6%) patients are mentally disabled. Majority of the patients (73%) were more than 50 years old. The visual acuity at presentation was poorer than 3/60 in 12 (80%) patients, out of which 10 (83%) patients are mentally disabled. There was a high proportion of perforation, 12 (80%) caused by infective keratitis which is also the main cause of perforation among disabled patients. Among the mentally disabled patients, 5 patients (50%) underwent evisceration, 4 patients (40%) underwent conjunctival flap and 1 patient (10%) was managed conservatively. Comparing with the patients without disability, 2 (40%) patients underwent tectonic keratoplasty, 2 (40%) patients underwent evisceration and 1 (20%) patient underwent conjunctival flap. People with disabilities experience worse health and poorer access to health care compared to people without disability. The presenting visual acuity in the disabled group is poorer. The main cause of corneal perforation among mentally disabled was infection and the options of treatments mainly were conjunctival flaps and evisceration.

An approach to reduce Descemet抯 membrane scrolling: Relevance to Descemet抯 membrane endothelial keratoplasty (DMEK)

Purpose: We aimed to determine whether Descemet抯 membrane (DM) scrolling occurs primarily along the vertical or horizontal axis and establish whether oval trephination along the axis of least scrolling can reduce the grade of the scroll. Methods: The longest limbus?to?limbus axis on 28 sclerocorneal discs was taken as the horizontal axis. The horizontal (n = 7) or (right angles to it) vertical (n = 6) axis was marked on DM before peeling it off. The direction and grade of scrolling was observed. Narrow strips (3�mm wide) were then cut along the two axes (n = 4 each) and the scrolling pattern was observed. Ellipses (7 � 9 mm) of DM were punched along the two axes (n = 6 each) and the scrolls graded. Immunofluorescent staining for elastin on horizontal and vertical tissue sections from three DM samples was performed. The intensity and thickness of elastin staining were measured. Results: Twenty?four (85.72%) DM samples showed scrolling along the horizontal axis, none showed scrolling along the vertical axis, and four (14.28%) samples showed a spiral scroll, regardless of which axis was marked (grade 3.7 and 3.6). Vertically oval discs showed significantly reduced scrolling (grade 1.2) compared to horizontally oval discs (grade 3.5). Narrow strips of DM showed a similar scrolling pattern. Immunohistology showed no difference in any of the parameters examined along the two axes or from the center to the periphery. Conclusion: DM scrolls primarily along the horizontal axis. Vertically oval DM samples show minimal scrolling, which can be an advantage in DMEK. Differential scrolling is not determined by the distribution of elastin.

Long-term outcomes of therapeutic corneal transplants performed in a tertiary eye care hospital in South India

Purpose: This study aimed to review the demographics, clinical characteristics, and long?term outcomes of therapeutic penetrating keratoplasty (TPK) performed in a tertiary eye care hospital. Methods: Case records of 149 therapeutic transplants (135 patients) that were performed during the calendar year 2016 were retrospectively analyzed, and outcomes were measured until 3 years of follow?up. Information on demographics, presentation characteristics, keratoplasty indications, offending microbe, and secondary surgical interventions was studied. The final outcome was classified in terms of therapeutic, anatomical, and functional outcomes. Results: The median age of the recipients was 55 years with 61% men. The most common indications for TPK were perforated infectious ulcer (45.9%), nonhealing ulcers (29.9%), and graft infections (17.4%). Fungal etiology was noted in 61.2% and bacterial etiology in 17.4% of the eyes. Therapeutic success was achieved in 130 eyes (89%) at the end of 1 month. Anatomical success was achieved in 130 (98.5%) and 88 patients (86.3%) at the end of 1 and 6 months, respectively. At the 6?month time point, 78 patients (76.5%) attained functional success with vision better than light perception. Three?year follow?up data were available for 23.7% of recipients, of which only 12 patients (37.5%) retained a clear graft either after a primary therapeutic or secondary optical keratoplasty. Conclusion: Therapeutic keratoplasty is highly effective in eradicating infection and providing anatomical integrity. However, timely intervention can aid in achieving the best functional outcome.

Cataract surgery following penetrating keratoplasty in children

Background: Following penetrating keratoplasty, cataract surgery warrants certain modifications to ensure maximum survival of the graft. Purpose: To emphasize the intraoperative challenges and surgical manipulations to be followed. Synopsis: The surgeon makes a superior sclerocorneal tunnel avoiding the graft host junction. Dispersive viscoelastic is used. Continuous curvilinear capsulorhexis is done. Cataractous lens aspirated with a low flow rate. The intraocular lens is placed in the bag. Superior peripheral iridectomy and primary posterior capsulorhexis are done. The wound closed with two interrupted 10�nylon sutures. Graft host junction integrity is maintained. Highlights: Ensure 1. Good intraoperative corneal visibility, 2. Avoid graft host junction for main port incision 3. Generous dispersive viscoelastic use/soft shell technique to protect the corneal endothelium, 4. Avoid phaco energy in case of soft cataracts/low phaco energy and flow rates, 5. Phaco probe to be meticulously oriented away from corneal endothelium, 6. Primary posterior capsulorhexis to be done as in any pediatric cataract surgery, 7. Make sure of the graft host junction integrity at the end of the surgery, 8. Restrict to a single port whenever possible.

Indications and types of keratoplasties: Trends in the past 10 years (2011-2020) in Eastern India

Purpose: To observe the trends of various types of keratoplasties in different etiologies over a period of 10 years (2011?2020) in a tertiary eye care center of eastern India. Methods: A retrospective review of patients undergoing keratoplasties from 2011 to 2020 was performed in a tertiary eye care hospital situated in eastern part of India. Apart from demographic data, primary indication for each surgery and type of procedure carried out was recorded. For comparison, data were divided into two time periods: Group I: Jan 2011 to Dec 2015 and Group II: Jan 2016 to Dec 2020. Results: Over a period of 10 years, a total of 2365 (Group I: 902, Group II: 1463) keratoplasties were performed. The average age of patients was 45.8 � 19.9 and 46.9 � 20.9 years in Group I and Group II, respectively. Among all the corneal grafts, 1747 (74%) surgeries were full?thickness. Although optical penetrating keratoplasty (OPK) was most the common indication for full?thickness keratoplasties, Descemet抯 stripping endothelial keratoplasty (DSEK) remained most performed lamellar keratoplasty. Keratitis, corneal scars, and bullous keratopathies remain to be most common indications in both groups. Number of lamellar keratoplasties increased significantly from Group I to Group II for corneal scars (P = 0.02), bullous keratopathies (P = 0.01), and endothelial dystrophies (P = 0.00). Conclusion: With change in time, the indication and technique of keratoplasty has witnessed a changing trend from full?thickness keratoplasty to lamellar keratoplasty. There is rise in trend of lamellar keratoplasties over the period

Phacoemulsification, pinhole pupilloplasty, and pre-Descemet抯 endothelial keratoplasty for keratoconus with Fuchs� endothelial dystrophy

The comorbidity of keratoconus with Fuchs� endothelial dystrophy with cataract is a rare clinical combination. We present an amalgamation of surgical techniques to manage the above clinical conditions and its complications in single setting. The modified triple procedure, namely, the phacoemulsification, pinhole pupilloplasty, and pre-Descemet抯 endothelial keratoplasty (PDEK) in the order of description is followed in single sitting. Lens removal by phacoemulsification, correction of irregular astigmatism by pinhole pupilloplasty (pinhole optics), and exchanging the endothelial layer for PDEK forms the main segments of the triple procedure. This combination of techniques may decrease the risk of multiple surgeries and its related complications. Moreover, it will allow the patient for faster visual rehabilitation by improving the uncorrected visual acuity and visual quality.

Anti-fungal efficacy of combination of amphotericin B with colistin and gentamicin in McCarey-Kaufman corneal preservation medium

Purpose: To curtail the potential of donor corneal tissue disseminating fungi to the recipient抯 eye, we evaluated the addition of amphotericin B to McCarey?Kaufman (M?K)梒orneal storage medium supplemented with colistin. Methods: Amphotericin B was examined for its ability to inhibit the growth of Candida albicans and Aspergillus flavus using a microbroth dilution test and checkerboard assay in combination with only gentamicin and a combination of colistin, gentamicin, and amphotericin B. The safety on epithelium and endothelium was evaluated by 3?(4,5?dimethylthiazol?2?yl)?2, 5?diphenyltetrazolium bromide (MTT) assay. Results: The minimal inhibitory concentration of gentamicin was found to be >256 ?g/ml against both C. albicans and A. flavus, whereas that of amphotericin B was found to be in a range of 0.25�5 and 1�?g/ml for C. albicans and A. flavus, respectively. According to the checkerboard assay, 80% (4/5) of C. albicans isolates and 100% (5/5) of A. flavus isolates responded synergistically to the combination of amphotericin B and gentamicin, but only 20% (1/5) of C. albicans isolates showed an additive effect. None of the tested isolates displayed antagonism. The combined effect of the three drugs also did not display any antagonistic effect. Additionally, the MTT assay reveals no toxic effect of the antimicrobials used on corneal epithelial and endothelial cells. Conclusion: In vitro experiments demonstrate that amphotericin B is not toxic to either epithelium or endothelium and is a promising additive to the M?K medium supplemented with colistin.

Comparison of penetrating keratoplasty versus lamellar keratoplasty for macular corneal dystrophy: a retrospective study of a single-center experience

Background: Although penetrating keratoplasty (PK) still remains the dominant form of transplantation for macular corneal dystrophy (MCD) patients, many studies evaluating these new forms of selective lamellar keratoplasty (LK) now suggest equivalent or better visual outcomes. This study aimed to explore the difference in outcomes and complications that follows each type of these operations. Methods: A retrospective, single-center study was performed at King Abdulaziz medical city in 2022. The study included patients with a histological diagnosis of MCD who undergone either PK or LK. Data was collected from health records using a form that consisted of patient characteristic, type of operation and post-operative outcomes, including visual acuity, survival rate and complications. Results: The study included a total of 54 eyes of patients who have MCD. A best corrected visual acuity (BCVA) of 0.5 or better was achieved in 82.5% of eyes of PK group and 42.9% of eyes of LK group. Graft survival rate was 90% (36 eyes) and 85.7% (12 eyes) in PK and LK groups respectively. Regarding complications, four PK eyes (10%) and one LK eye (7.1%) had high intraocular pressure, three PK eyes (7.5%) and one LK eye (7.1%) developed rejection, one PK eye (2.5%) developed recurrent epithelial erosion, and another one PK eye (2.5%) developed Traumatic epithelial laceration. Conclusions: PK operations resulted in a better post-operative visual acuity compared to LK group. The graft survival rate was slightly better for the PK group. PK was associated with higher incidence of complications than LK group.

A long-term clinical outcome of Hoffmann pocket four-point scleral fixated intraocular lens implantation combined with penetrating keratoplasty – A single corneal surgeon’s report

Purpose: To analyze retrospectively the outcomes of Hoffmann pocket scleral fixated intraocular lens implantation combined with penetrating keratoplasty at a tertiary institute by a single corneal surgeon. Methods: Forty?two eyes of 42 patients, aged between 11 and 84 years, had a mean follow?up of 2 ± 2.216 years. Overall, five (11.9%) had congenital and 37 had acquired pathology, 15 were pseudophakic, 23 were aphakic, and four were phakic. The commonest indication was trauma in 19 (45.2%), and 21 had previous multiple surgeries including five retinal procedures. Results: The grafts were clear in 20 (47.6%), they failed in 20, three had acute rejection, three were ectatic, two had infection, one had persistent edema, and one had endophthalmitis. The mean log of minimum angle of resolution (logMAR) best corrected visual acuity was 1.902 pre?op, 1.802 at the final follow?up, and 0.52 after excluding preexisting retinal pathologies. At the last follow?up, the vision improved in 18 (42.9%), maintained in 6, and worsened in 18, and three needed more than ?5.00 D and seven needed more than ?3.00 D cylinder correction. Five had glaucoma preoperatively, 10 developed the condition postoperatively, six needed cyclodestructive procedure, and three had valve surgery. Conclusion: Advantages of this surgery are avoidance of additional sections to insert the lens, direct positioning of the lens in the posterior chamber, rotational stability of the lens from four?point fixation, and untouched conjunctiva over the scleral pockets. The fact that 20 had clear grafts and 18 visually improved, though two needed lens removal and one developed retinal detachment postsurgery is encouraging. More cases with longer follow?ups will help understand the technique better

Intra-operative optical coherence tomography in corneal lamellar graft reinforcement for Boston type I keratoprosthesis corneal melt

Corneal melt is a sight-threatening complication of Boston type 1 keratoprosthesis (KPro). Severe corneal melt may result in hypotony, choroidal hemorrhage, and even spontaneous extrusion of the KPro, which may lead to a poor visual prognosis. Lamellar keratoplasty is one surgical option for the management of mild corneal melt, especially when a new KPro is not available. Herein, we present a new surgical technique application, intra-operative optical coherence tomography (iOCT) for the management of cornea graft melt after Boston type 1 KPro implantation. The visual acuity and the intra-ocular maintained stable at 6 months post-operatively, and the KPro remained in place without corneal melting, epithelial ingrowth, or infection. iOCT may prove to be a real-time, non-invasive, and accurate treatment for corneal lamellar dissection and suturing beneath the anterior plate of the KPro, which can effectively help the surgeon to make surgical decisions and reduce post-operative complications.

Deep anterior lamellar keratoplasty versus penetrating keratoplasty: comparison of clinical outcomes in contralateral eyes / Ceratoplastia lamelar anterior profunda versus ceratoplastia penetrante: comparação dos resultados clínicos em olhos contralaterais

ABSTRACT Purpose: This study aimed to compare the clinical outcomes following deep anterior lamellar keratoplasty and penetrating keratoplasty in contralateral eyes of the same patients. Methods: In this retrospective, comparative case series, clinical outcome data included best-corrected visual acuity, refractive spherical equivalent, refractive astigmatism, endothelial cell density, endothelial cell loss, central corneal thickness, and intraocular pressure, which were evaluated at 6, 12, 24, and 36 months after deep anterior lamellar keratoplasty and penetrating keratoplasty. Additionally, complications were assessed. Results: Fifty-two eyes (26 patients) were included, of which 19 patients had keratoconus, 6 had stromal dystrophy, and 1 had post-laser-assisted in situ keratomileusis ectasia. The mean follow-up was 44.1 ± 10.5 months in the deep anterior lamellar keratoplasty Group and 47.9 ± 11.9 months in the penetrating keratoplasty Group. No significant differences were observed in the mean best-corrected visual acuity, refractive spherical equivalent, refractive astigmatism, and central corneal thickness between the deep anterior lamellar keratoplasty and penetrating keratoplasty Groups during follow-up. The endothelial cell density was significantly higher in the deep anterior lamellar keratoplasty Group than in the penetrating keratoplasty Group at 24 and 36 months postoperatively (p=0.022 and 0.013, respectively). Endothelial cell loss was significantly lower in the deep anterior lamellar keratoplasty Group than in the penetrating keratoplasty Group at 24 and 36 months postoperatively (p=0.025 and 0.001, respectively). Intraocular pressure was significantly lower in the deep anterior lamellar keratoplasty Group than in the penetrating keratoplasty Grroup at 6 months postoperatively (p=0.015). Microperforation occurred in 4 eyes (15%) during deep anterior lamellar keratoplasty surgery; however, penetrating keratoplasty was not required. No endothelial rejection occurred in the penetrating keratoplasty Group during follow-up. Conclusions: Over the 3-year follow-up, endothelial cell loss and intraocular pressure in the deep anterior lamellar keratoplasty Group were significantly lower than those in the penetrating keratoplasty Group, while visual and refractive results were similar.

RESUMO Objetivo: Este estudo teve como objetivo comparar os resultados clínicos após ceratoplastia lamelar anterior profunda e ceratoplastia penetrante nos olhos contralaterais dos mesmos pacientes. Métodos: Nesta série de casos comparativa e retrospectiva, avaliaram-se os seguintes dados de resultados clínicos: melhor acuidade visual corrigida, equivalente esférico refrativo, astigmatismo refrativo, densidade de células endoteliais, perda de células endoteliais, espessura central da córnea e pressão intraocular. Esses dados foram avaliados aos 6, 12, 24 e 36 meses após ceratoplastia lamelar anterior profunda e ceratoplastia penetrante. Também foram avaliadas as complicações. Resultados: Foram incluídos 52 olhos (26 pacientes), sendo que 19 pacientes apresentavam ceratocone, 6 apresentavam distrofia estromal e 1 apresentava ectasia após ceratomileuse in situ assistida por laser. O tempo médio de acompanhamento foi de 44,1 ± 10,5 meses no grupo da ceratoplastia lamelar anterior profunda e 47,9 ± 11,9 meses no grupo da ceratoplastia penetrante. Nenhuma diferença significativa foi observada nas médias da melhor acuidade visual corrigida, equivalente esférico refrativo, astigmatismo refrativo e espessura central da córnea entre os grupos da ceratoplastia lamelar anterior profunda e da ceratoplastia penetrante durante o acompanhamento. A densidade de células endoteliais foi significativamente maior no grupo da ceratoplastia lamelar anterior profunda que no grupo da ceratoplastia penetrante aos 24 e 36 meses de pós-operatório (p=0,022 e 0,013, respectivamente). A perda de células endoteliais foi significativamente menor no grupo da ceratoplastia lamelar anterior profunda que no grupo da ceratoplastia penetrante aos 24 e 36 meses de pós-operatório (p=0,025 e 0,001, respectivamente). A pressão intraocular foi significativamente menor no grupo da ceratoplastia lamelar anterior profunda que no grupo da ceratoplastia penetrante aos 6 meses de pós-operatório (p=0,015). Ocorreu microperfuração em 4 olhos (15%) durante a cirurgia de ceratoplastia lamelar anterior profunda; entretanto, a ceratoplastia penetrante não foi necessária. Não ocorreu nenhuma rejeição endotelial no grupo da ceratoplastia penetrante durante o período de acompanhamento. Conclusões: Durante o acompanhamento de 3 anos, a perda de células endoteliais e a pressão intraocular foram significativamente menores no grupo da ceratoplastia lamelar anterior profunda que no grupo da ceratoplastia penetrante, mas os resultados visuais e refrativos foram semelhantes.

Repeat deep anterior lamellar keratoplasty (DALK) for failed primary DALK

Purpose: To evaluate the effectiveness of repeat deep anterior lamellar keratoplasty (DALK) in patients of previous failed DALK. Methods: A retrospective analysis of records of seven patients who had undergone repeat DALK following the failure of the primary DALK was done. The indications for repeat surgery, time elapsed since the first surgery, and pre? & postoperative best?corrected visual acuity (BCVA) were noted for all the patients. Results: The follow?up period ranged between one? to four?year post repeat DALK. The indication of primary DALK was keratoconus with vernal keratoconjunctivitis (VKC) (n = 3), corneal amyloidosis (n = 2), Salzman nodular keratopathy (n = 1), and healed keratitis (n = 1). The need for repeat surgery arose when the BSCVA dropped to less than 20/200. The time interval elapsed since the first surgery ranged from two months to four years. Postoperatively, the BSCVA improved from 20/120 to 20/30 at the end of one?year post repeat DALK in all except one patient. All regrafts were clear at the most recent examination, performed after a mean period of 18 months after the secondary graft. No complication was encountered during the resurgery. The dissection of the host bed was easier in the second surgery owing to weaker adhesions. Conclusion: The prognosis for repeat DALK for failed DALK is excellent, and the outcomes of secondary grafts were comparable to those of primary DALK grafts. Re DALK offers the advantage of an easier dissection and lower chances of graft rejection compared to penetrating keratoplasty.

Decision-making in Herpes Simplex viral keratitis grafts

Background: Keratoplasty after healed herpes simplex viral keratitis is a challenge due to problems arising preoperatively, intraoperatively, and postoperatively. Purpose: In this video, we describe the necessary challenges and the steps, which can be taken to prevent and manage those cases of healed herpes simplex virus (HSV) keratitis that would require a keratoplasty.Synopsis: The video talks about both the typical and atypical features of HSV keratitis, clinical examination, the scenarios which would require a keratoplasty, problems arising intraoperatively and how to manage them, and finally how to approach these high?risk grafts postoperatively. Highlights: Our video highlights the diagnosis of HSV keratitis, which cases are ready for surgery, and preoperative, intraoperative, and postoperative considerations before corneal transplantation in healed HSV keratitis. Decision?making before corneal transplant in HSV grafts can become more structured if these points are followed.

Complications of Descemet stripping endothelial keratoplasty – A retrospective interventional study at a tertiary eye care center in Southern India

Purpose: To analyze the visual outcome and complications of Descemet stripping endothelial keratoplasty (DSEK) with their management in 256 eyes at a tertiary eye care center in southern India. Methods: This is a retrospective interventional study of 62 months duration conducted at a tertiary eye care center in southern India. Two hundred and fifty?six eyes of 205 patients were included in the study after obtaining written informed consent from the patients. All cases of DSEK were performed by a single experienced surgeon. In all cases, donor dissection was performed manually. A Sheet’s glide was inserted through the temporal corneal incision and donor button was placed on the Sheet’s glide with the endothelial side down. The lenticule was separated and inserted into the anterior chamber by pushing the lenticule into the anterior chamber using Sinskey’s hook. Any complication, either intraoperative or postoperative, was recorded and managed either medically or by appropriate surgical means. Results: The mean best corrected visual acuity (BCVA) before surgery was CF?1 m, which improved to 6/18 after surgery. Intraoperative donor graft perforation during dissection was seen in 12 cases, thin lenticule in three eyes, and repeated artificial Anterior Chamber (AC) collapse in three eyes. Dislocation of lenticule was the most common complication seen in 21 eyes, which was managed by graft repositioning and rebubbling. Eleven cases had minimal separation of the graft and seven cases had interface haze. Pupillary block glaucoma was seen in two cases that resolved with partial release of bubble. Surface infiltrate was seen in two cases, which was managed with topical antimicrobial agents. Primary graft failure was seen in two cases. Conclusion: DSEK is a promising alternative to penetrating keratoplasty for corneal endothelial decompensation, but it also has its own merits and limitations, and most often, merits overweigh limitations.

Lost-to-follow-up: A study on corneal transplantation from Eastern India

Purpose: This study aims to analyze the pattern of follow?ups and the reasons for follow?up loss in keratoplasty cases in a tertiary eye care center. Methods: This is a single?center retrospective cross?sectional study. During the study period, 165 eyes underwent corneal transplantation. The data on the demographic features of the recipients and the indications of keratoplasty, including visual acuity before and after surgery, duration of follow?up, and the condition of the graft at the last follow?up, were collected. The primary outcome was to determine the factors causing lost?to?follow?up (LTFU) among graft recipients. LTFU was defined when a patient failed to adhere to any of the following seven follow?up visits since the surgery: 4 ± 2 weeks, 3 ± 1 months, 6 ± 1 months, 12 ± 2 months, 18 ± 2 months, 24 ± 3 months, and 36 ± 6 months. The secondary outcome was to analyze the best?corrected visual acuity (BCVA) among patients available for the final follow?up. Results: The recipient follow?up rates at 6, 12, 18, 24, and 36 months were 68.5%, 57.6%, 47.9%, 42.4%, and 35.2%, respectively. Old age and distance to the center were significant factors for lost?to?follow?up. A failed graft as an indication for transplantation and those undergoing penetrating keratoplasty for optical purposes were significant factors for completing follow?up. Conclusion: The inability to follow?up after corneal transplantation is a common challenge. Elderly patients and those living in remote areas must be prioritized for follow?ups.