Clinical and microbiological analysis of fungal keratitis in Toronto, Canada: A 20-year study.

Fungal keratitis is a devastating and difficult-to-treat ocular infection with high morbidity. Understanding geographic microbiological and clinical trends helps to guide rapid and effective treatment. We therefore report the characteristics and outcomes of fungal keratitis in Toronto,ON Canada, over a 20-year period. An electronic search of microbiology records at University Health Network, Toronto, ON, Canada identified all patients with positive corneal fungal culture over a 20-year period seen at our tertiary referral cornea practice. Review of corresponding patient charts identified demographic and microbiological details, clinical course, treatment regimen, and final outcomes associated with each episode of culture-positive fungal keratitis. A total of 46 patients with 51 discrete fungal keratitis episodes were included. Five patients experienced recurrent fungal keratitis. Candida species accounted for 60.8% of positive fungal cultures, followed by Filamentous species at 35.3%. Preferred initial anti-fungal treatment was topical amphotericin at 36.7% followed by topical voriconazole at 32.6%. Surgical intervention was required in 48.9% with therapeutic penetrating keratoplasty being the most common procedure (22.4%). Final visual acuity (VA) of <20/200 was attributed to 58% of patients in this study. Risk factors for poor outcomes included poor VA, topical steroid use at presentation, Candida involvement, history of ocular surface disease, organic ocular trauma, or prior corneal transplantation. Candida is the most frequent keratomycotic pathogen in Toronto. Risk factors for poor visual outcome include prior corneal transplantation, ocular surface disease/trauma, or pre-existing topical steroid use. Early suspicion, diagnosis and treatment are paramount for best clinical outcomes. LAY SUMMARY: Fungal keratitis can cause severe vision loss without effective treatment. In Toronto, Candida had been the most common species over a 20-year period. Poor clinical outcome was associated with low presenting visual acuity, previous corneal transplant, topical steroid use, trauma, and Candida involvement.

Prosthetic Replacement of the Ocular Surface Ecosystem for Limbal Stem Cell Deficiency: A Case Series.

OBJECTIVES: To assess outcomes of limbal stem cell deficiency (LSCD) in patients treated with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE). METHODS: Retrospective case series. Patients with LSCD who received PROSE treatment were included. Data including best-corrected visual acuity (BCVA) and LSCD staging before and after PROSE dispensing were collected to characterize each case. RESULTS: Five eyes of four patients were included. All patients were female, with an age range of 21 to 80 years. Each patient received a PROSE device with diameters ranging from 16 to 18.5 mm. Follow-up ranged from 11 to 29 months. Tolerated wear times ranged from 3.5 to 10 hr daily. Four eyes showed improved BCVA and unchanged LSCD staging as per the global consensus after PROSE treatment. Three of these eyes had stage 3 and one had stage 1C LSCD at diagnosis. The fifth eye had worse BCVA and recurrence of stage 3 LSCD post-living-related conjunctival limbal allograft transplant despite PROSE treatment. CONCLUSIONS: Prosthetic Replacement of the Ocular Surface Ecosystem may be a viable treatment for LSCD, including severe cases, because it can provide symptom relief and improve vision. Its customizability, as demonstrated in this study, is beneficial for troubleshooting issues with fitting. Future studies are needed to further assess PROSE as treatment for LSCD.

Prosthetic Replacement of the Ocular Surface Ecosystem for Terrien Marginal Degeneration: A Case Series.

OBJECTIVES: To assess outcomes of the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in patients with advanced Terrien marginal degeneration (TMD). METHODS: This is a retrospective case series of patients with advanced TMD who were assessed and fit with customized PROSE lenses. Data were collected on PROSE fitting details including visual acuity (VA) before and after PROSE, slit-lamp findings, and corneal tomography scans. RESULTS: Six eyes in four patients were included. All patients attempted at least one other contact lens (CL) modality before PROSE. Some patients had corneal comorbidities such as pseudopterygium and pseudobleb that contributed to intolerance to previous lenses and warranted extra considerations in the fitting process. With PROSE, VA improved in all six eyes. Patients with structural corneal comorbidities achieved improved vision, comfort, and lens tolerance with PROSE. Two eyes had noncorneal ocular comorbidities that limited PROSE efficacy. Another eye discontinued PROSE wear because of limbal stem-cell disease progression necessitating a limbal stem-cell transplant. CONCLUSIONS: PROSE treatment can be an effective option to improve vision and comfort for patients with advanced TMD who are intolerant to first-line therapeutic CL modalities, even in the presence of other corneal comorbidities.

Surgical Management of the Ocular Surface in Neurotrophic Keratopathy: Amniotic Membrane, Conjunctival Grafts, Lid Surgery, and Neurotization.

PURPOSE: To review the surgical modalities available to treat Mackie stage 2 and stage 3 neurotrophic keratopathy. METHODS: Literature review and technique descriptions. RESULTS: The following procedures are described in detail with accompanying videos: temporary, permanent, and botox-assisted tarsorrhaphy; amniotic membrane transplant; keratoplasty with amniotic membrane and tarsorrhaphy augmentation; Gunderson and conjunctival pedicle flaps; buccal graft transplantation; and neurotization. CONCLUSION: A variety of surgical options exist to manage neurotrophic keratopathy when medical treatments alone fail to resolve epitheliopathy. Ongoing protection and optimization of the ocular surface health remains crucial to prevent recurrent epithelial breakdown.

Diagnoses and Outcomes of Prosthetic Replacement of the Ocular Surface Ecosystem Treatment-A Canadian Experience.

OBJECTIVES: To investigate underlying diagnoses and outcomes of patients undergoing Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment at the first Canadian PROSE center. METHODS: A retrospective chart review was conducted on patients referred for PROSE treatment and fitted with PROSE devices from 2018 to 2020. Data were collected on diagnoses, presenting symptoms, previous lens modalities attempted, best-corrected visual acuities (BCVAs) pre-PROSE and post-PROSE, daily wear time, and failure rates. Best-corrected visual acuities pre-PROSE and post-PROSE were compared to evaluate visual improvement. RESULTS: In total, 78 patients (126 eyes) were analyzed. The most common diagnoses were keratoconus (n=39 eyes) and postcorneal graft (n=15) in the distorted cornea group, and limbal stem cell deficiency (n=17) and graft versus host disease (n=15) in the ocular surface disease (OSD) group. Most frequent symptoms included blur, photophobia, and pain. Most common lens modalities attempted pre-PROSE were conventional scleral lenses and glasses. The overall mean BCVA improvement was 0.40 logarithm of the minimal angle of resolution (logMAR) (4-lines Snellen) (P<0.0001). Best-corrected visual acuities improvement in the distorted cornea group (0.52 logMAR, 5-lines) was significantly greater than in the OSD group (0.29 logMAR, 3-lines) (P=0.004). CONCLUSIONS: Prosthetic replacement of the ocular surface ecosystem treatment can provide significant visual improvement for patients with distorted corneal surfaces and OSDs who failed other lens modalities.

Ocular Findings in Alemtuzumab (Campath-1H)-induced Thyroid Eye Disease.

Alemtuzumab (Campath-1H) is a humanized anti-CD52 monoclonal antibody used in the treatment of multiple sclerosis (MS). Studies demonstrate significant reduction in relapse risk and the risk of accumulating sustained disability. Adverse events include infusion-associated reactions, infections, and secondary autoimmunity. Systemic thyroid disease is the most common secondary autoimmune event and affects up to approximately 30% of treated patients. This is the first description of the ocular findings and management in a case of thyroid eye disease (Graves' Ophthalmopathy [GO]) following alemtuzumab therapy. The ocular disease was managed conservatively while the systemic Graves' was managed with thyroidectomy.

In vivo confocal microscopy findings after Descemet stripping only with and without topical ripasudil supplementation in Fuchs endothelial dystrophy.

OBJECTIVE: To report corneal epithelial and corneal endothelial cell (CEC) changes following Descemet stripping only (DSO) with and without topical ripasudil using in vivo confocal microscopy (IVCM). METHODS: Prospective interventional case series of patients who underwent DSO for Fuchs endothelial dystrophy with or without postoperative topical ripasudil (4%, 6 times per day). Patients underwent IVCM (ConfoScan 3; NIDEK Technologies, Padova, Italy) at baseline, monthly until corneal clearance, and then every 6 months. En face images were obtained of the epithelium, anterior and posterior corneal stroma, and endothelium of the central and superior cornea. The epithelial and endothelial layer images were evaluated qualitatively. RESULTS: IVCM imaging was obtained from 34 patients, 26 (76%) of whom were supplemented with ripasudil and 8 (24%) of whom were not. Two eyes (6%) did not clear and required a keratoplasty. IVCM confirmed epithelial and endothelial cell morphology changes and reestablishment of a CEC mosaic. Hyperreflective nuclei, pleomorphism, multinucleated cells, and pseudoguttae were identified within the descemetorhexis. In patients on ripasudil, epithelial cells demonstrated transition from stratified squamous to spindle cell shape in regions of ripasudil-induced honeycomb edema. Migrating cells adopted an amoeboid shape and cytoplasm elongation when crossing to central stroma. Transient epithelial cell morphology changes and endothelial cell amoeboid shape changes appear to be uniquely associated with ripasudil. Rarely, figures were noted in both ripasudil-treated and non-ripasudil-treated corneas that resembled mitotic bodies. CONCLUSIONS: CECs display a range of adaptive mechanisms during healing to re-form the endothelial mosaic following DSO. Ripasudil administration appears to induce unique epithelial and endothelial cell changes.

Trends and Clinical Outcomes of Fungal Keratitis in Canada: A 20-year Retrospective Multicentre Study.

PURPOSE: An increase in fungal and particularly filamentous keratitis has been observed in many geographic areas, mostly in contact lens wearers. This study seeks to characterize long-term trends in fungal keratitis in a continental climate area to provide guidance for diagnosis and treatment. DESIGN: Retrospective multicentric case series. METHODS: Cases of microbiology-confirmed fungal keratitis from 2003 to 2022 presenting to tertiary care centers across Canada were included. Charts were reviewed for patient demographics, risk factors, visual acuity, and treatments undertaken. RESULTS: A total of 138 patients were identified: 75 had yeast keratitis while 63 had filamentous keratitis. Patients with yeast keratitis had more ocular surface disease (79% vs 28%) while patients with filamentous keratitis wore more refractive contact lenses (78% vs 19%). Candida species accounted for 96% of all yeast identified, while Aspergillus (32%) and Fusarium (26%) were the most common filamentous fungi species. The mean duration of treatment was 81 ± 96 days. Patients with yeast keratitis did not have significantly improved visual acuity with medical treatment (1.8 ± 1 LogMAR to 1.9 ± 1.5 LogMAR, P = .9980), in contrast to patients with filamentous keratitis (1.4 ± 1.2 LogMAR to 1.1 ± 1.3 LogMAR, P = .0093). CONCLUSIONS: Fungal keratitis is increasing in incidence, with contact lenses emerging as one of the leading risk factors. Significant differences in the risk factors and visual outcomes exist between yeast keratitis and filamentous keratitis which may guide diagnosis and treatment.

Case Series of Rare Fungal Keratitides: Experiences from a Quaternary Eye Hospital in Sydney, Australia.

The present article reports on the management of six different and rare cases of fungal keratitides, two of which have never been documented in previous literature. This is a case series of six patients with rare fungal keratitides managed at a quaternary eye referral unit, Sydney Eye Hospital, Australia over a period of 7 months (May to December, 2022). The order of occurrence of fungi isolated was Scedosporium apiospermum, Lomenstospora prolificans, Cladosporium spp., Paecilomyces, Syncephalastrum racemosum and Quambalaria spp. A combination of medical and surgical interventions was employed, including topical and systemic anti-fungal therapy, with one requiring therapeutic penetrating keratoplasty and another eventuating in evisceration. Two patients were successfully treated with corneal debridement and two others required pars plana vitrectomy with anterior chamber washout. It is important to remain vigilant with monitoring patient symptoms and correlating with clinical signs to guide antifungal therapy even in the context of confirmed culture and sensitivity results.

Economic appraisal of prosthetic replacement of ocular surface ecosystem in Canada.

OBJECTIVE: To perform an economic appraisal of the Prosthetic Replacement of Ocular Surface Ecosystem (PROSE; BostonSight, Needham Heights, Mass.) lens in patients with a distorted corneal surface or ocular surface disease in Canada. DESIGN: Retrospective observational cohort study with cost, cost-utility, and benefit-cost analyses. PARTICIPANTS: Patients who received PROSE from the only PROSE clinic in Canada from 2018 to 2020. METHODS: Visual acuity (VA) outcomes of the participants were assessed. Benefits were defined as VA improvements that were converted into utilities and then quality-adjusted life years. Economic values were derived via government statements, clinic financial statements, and published literature. RESULTS: Average best-corrected VA (BCVA) improvement was -0.42 ± 0.41 logMAR (p = 2.68 × 10-13) or Snellen 20/53 for the overall cohort, -0.51 ± 0.48 (p = 5.42 × 10-8) or Snellen 20/65 for distorted corneal surface patients, and -0.31 ± 0.30 (p = 1.30 × 10-7) or Snellen 20/41 for ocular surface disease patients. This corresponded to discounted quality-adjusted life year gains of 0.51, 0.65, and 0.42, respectively, over an estimated 5-year PROSE device lifespan. Average cost to fit a patient with PROSE was USD$5 469.85 (CAD$7 087.28), of which USD$4 971.38 (CAD$6 441.42) was clinic cost and USD$498.47 (CAD$645.87) was patient cost. Cost-utility was USD$10 256.47 (CAD$13 289.31) for the overall cohort, USD$8 439.79 (CAD$10 935.44) for distorted corneal surface patients, and US$13 069.90 (CAD$16 934.67) for ocular surface disease patients. The benefit-cost ratio was 34.4 for all, 43.8 for distorted corneal surface patients, and 28.3 for ocular surface disease patients. CONCLUSIONS: Our economic appraisal demonstrated that PROSE treatment provides a significant, cost-effective benefit to Canadian patients with distorted corneal surfaces and ocular surface diseases. This indicates that PROSE clinics are an efficient investment.

Phototherapeutic keratectomy versus epithelial debridement combined with anterior stromal puncture or diamond burr for recurrent corneal erosions.

OBJECTIVE: To compare outcomes of phototherapeutic keratectomy (PTK) versus epithelial debridement combined with anterior stromal puncture (ASP) or diamond burr for the treatment of recurrent corneal erosions (RCES) in a large tertiary centre. METHODS: Patients with a diagnosis of RCES secondary to trauma or epithelial basement membrane dystrophy who underwent a surgical procedure between 2009 and 2019 were included in the study. The following data were collected: demographics, ocular history, prior medical treatment, ocular surgeries, intervention, complete epithelialization at postoperative week 1, recurrences, and complications. Recurrence was defined as either an objective finding of a corneal epithelial defect or symptoms suggestive of recurrent epithelial erosion on history. Recurrence rate and time to epithelialization were compared between groups. RESULTS: A total of 97 eyes (73 patients) were included in the study. Mean patient age was 51 ± 16.1 years, and mean follow-up was 474 days. RCES was secondary to epithelial basement membrane dystrophy in 80% (n = 78 of 97), trauma (15%, n = 15 of 97), or idiopathic (4%, n = 4 of 97). Epithelial debridement with ASP was performed in 34 eyes (35%), diamond burr in 33 eyes (33%), and PTK in 30 eyes (31%). Compared with epithelial debridement with ASP (recurrence 29.4%), the recurrence rate was significantly lower for both the diamond burr (9.1%, p = 0.031) and PTK groups (10%, p = 0.048). The diamond burr and PTK groups also had a significantly higher rate of complete epithelialization at 1 week (p < 0.05). CONCLUSION: Compared with epithelial debridement with ASP, diamond burr and PTK have significantly lower rates of recurrence and time to epithelialization and may be considered first for surgical management of RCES.

Investigating the role of inflammation in keratoconus: A retrospective analysis of 551 eyes.

PURPOSE: Keratoconus (KCN), classically defined as a noninflammatory corneal ectasia, was recently associated with chronic inflammation. This study aimed to further evaluate the association between inflammation and KCN severity by assessing patient tear films. METHODS: Retrospective chart review of consecutive patients (July 2016-February 2020) referred to a tertiary KCN centre. Using tomography Kmax values, the worst-eyes of patients with a diagnosis of KCN and tear film test results were included. Eyes were stratified as matrix metalloproteinase-9 (MMP9) positive or negative and analyzed using independent t and Pearson chi-squared tests. A p-value ≤ 0.05 was considered significant. RESULTS: 551 (51.40%) unilateral eyes were included. Mean age was 30.1 years and 70.1% were male. 55.5% of the eyes were MMP9 positive. Mean corrected distance visual acuity was 20/30<συπ>-3 Snellen and Kmax was 60.1 Diopters. MMP9 positive eyes had a higher Kmax (p = 0.048), and were more likely from patients who were male (p < 0.001), had a paediatric history of asthma (p = 0.042), and used glasses (p = 0.041). MMP9 negative eyes more likely corresponded to soft contact lens users (p = 0.012). No other significant differences were found in risk factors, topography, tomography, and tear film osmolarity. CONCLUSION: MMP9 positive keratoconic eyes had significantly higher Kmax readings which may correlate with increased disease severity, supporting an association between keratoconus and inflammation. Further research is warranted to evaluate the role of targeted therapy and contact lens use on MMP9 levels in keratoconic eyes and whether disease progression is affected.

Comparative evaluation of four Descemet membrane endothelial keratoplasty graft preparation techniques.

OBJECTIVE: To compare subjective and objective outcomes of 4 different Descemet membrane endothelial keratoplasty (DMEK) peeling techniques performed by novice surgeons at different stages in their surgical career. DESIGN: An ex vivo prospective study. METHODS: In the first round, 2 DMEK peeling techniques were pitched against each other: the peripheral scoring and Sinskey dissection technique with the peripheral scoring and microhoe dissection and the peripheral blunt microhoe dissection against the scleral spurectomy and microhoe dissection. Three surgeons with different operative experience performed the peeling. Outcome measures included graft peeling time, surgeon's peeling difficulty grading (on a scale of 1-10, 1 being the easiest and 10 the hardest), number of radial and circumferential tears before and after trephination, and tissue loss. The 2 techniques that performed the best from the first round proceeded to the final round to identify the best overall technique. RESULTS: In total, 90 tissues (45 pairs) were peeled by 3 surgeons. Following the first-round results, the peripheral scoring and Sinskey dissection and peripheral blunt microhoe dissection proceeded to the final round. There were no significant differences between the groups in terms of peeling times, subjective feeling of difficulty, post-trephination tears, and peeling success rates (P > 0.05 for all). However, the peripheral scoring and Sinskey dissection technique had significantly fewer pretrephination radial tears (1.3 ± 1.3 vs 6.1 ± 5.2, P = 0.007) and circumferential tears (0.6 ± 0.9 vs 1.8 ± 2.1, P = 0.02). CONCLUSIONS: This study demonstrates that the learning curve can be overcome quickly with appropriate DMEK peeling techniques. The peripheral scoring and Sinskey dissection peeling technique allows efficient peeling with fewer related tears.

Long-Term Stability of Femtosecond Astigmatic Keratotomy After Treatment of High Postkeratoplasty Astigmatism.

PURPOSE: The purpose of this study was to assess long-term stability and outcomes of femtosecond astigmatic keratotomy (FSAK) after treatment of high postkeratoplasty astigmatism. METHODS: This retrospective study included patients who underwent FSAK for high astigmatism (≥4 D) after penetrating keratoplasty or deep anterior lamellar keratoplasty. Main outcome measures were corneal astigmatism, uncorrected visual acuity, and best-corrected visual acuity (BCVA) at 1 month and 1, 5, and 10 years. RESULTS: Overall, 61 eyes of 61 patients (mean age 56 ± 19 years, 54.1% male) were included in this study. Preoperative corneal astigmatism ranged from 4 to 25 D. One month after FSAK, mean corneal astigmatism was significantly reduced from 9.02 ± 3.97 D to 4.86 ± 3.10 D ( P < 0.001). Thereafter, corneal astigmatism remained stable at all visits up to 10 years ( P < 0.05 for all compared with baseline). After FSAK, there was a significant improvement in logMAR uncorrected visual acuity from 1.21 ± 0.48 to 0.87 ±0.54 ( P < 0.001) and logMAR BCVA from 1.03 ± 0.55 to 0.49 ± 0.45 ( P < 0.001) which remained stable up to 10 years. A mild reduction in BCVA improvement was seen between 1 month and 1 year. CONCLUSIONS: Femtosecond astigmatic keratotomy was effective and stable at reducing very high magnitudes of postkeratoplasty astigmatism over the long term. The procedure also had a stable effect on visual acuity, albeit some reduction in the degree of BCVA improvement was seen over the early postoperative period.

Case Report: Use of Amniotic Membrane for Tectonic Repair of Peripheral Ulcerative Keratitis With Corneal Perforation.

Purpose: To provide a perspective and surgical video demonstration of peripheral corneal ulceration and perforation managed with multilayered amniotic membrane transplantation. Case Reports: Case 1 describes a 48-year-old female with progressive redness and pain, and an inferonasal corneal thinning and perforation in the left eye from peripheral ulcerative keratitis. She underwent conjunctival recession with amniotic membrane inlay and onlay (Sandwich technique) transplantation. The amniotic membrane integrated well, and her Snellen visual acuity improved from 6/21 preoperatively to 6/9 at 3 months post op. Case 2 describes a 78-year-old male with redness and pain with temporal corneal thinning bilaterally and perforation in the right eye from peripheral ulcerative keratitis. Both eyes underwent similar surgical intervention with smooth integration of the amniotic membrane in the cornea and improvement in the visual acuity. Both patients were also started on systemic immunosuppression in collaboration with the rheumatology team. Conclusion: We report successful use of multilayered amniotic membrane transplantation for the treatment of corneal ulceration and perforation. The authors believe the simplicity of the surgical technique, easier access to amniotic membrane tissue, and lower induced post-operative astigmatism all provide advantages over alternative treatment modalities.

Medium-Term Failure of Descemet's Stripping Only and Fuchs' Dystrophy With Pancorneal Guttae.

PURPOSE: The purpose of this study was to report the medium-term outcome of our index case of Descemet stripping only (DSO) in the clinical setting of Fuchs endothelial corneal dystrophy with pancorneal guttae. METHODS: This was a retrospective case report. RESULTS: A 44-year-old woman with bilateral Fuchs endothelial corneal dystrophy was referred for consideration of DSO. At initial slit-lamp examination, widespread guttae were observed with no clear zone visible. Confocal microscopic examination also failed to isolate a population of undisturbed endothelial cells. DSO with supplemental ripasudil was performed with corneal clearance achieved at 2.5 months. A stable result was obtained for 18 months with a subsequent slow decline in vision and return of diurnal fluctuation. At 3.5 years after DSO, DMEK was performed with resolution of symptoms. CONCLUSIONS: Medium-term failure in this clinical setting is further evidence that DSO is likely best offered to patients with central guttae but a clear corneal periphery, indicative of a healthy cell reservoir.

Outcomes of femtosecond laser-assisted cataract and refractive lens surgery in patients with prior radial keratotomy.

PURPOSE: To investigate outcomes of femtosecond laser (FL)-assisted cataract surgery (FLACS) and refractive lens exchange (RLE) in patients with prior radial keratotomy (RK). SETTING: Single clinical practice. DESIGN: Retrospective observational case series. METHODS: All patients with prior RK undergoing FLACS- or FL-assisted RLE surgeries over a 6-year period were reviewed. Inclusion criteria were diurnal stability and stable manifest refraction. Exclusion criteria were any other incisional corneal surgery, macular or glaucomatous pathology, or vision loss due to any other cause. Data collected included demographics, visual acuity, laser settings, and complications. Main outcome measures were intraoperative and postoperative complications and visual outcomes. Safety and efficacy indices were evaluated. RESULTS: 16 eyes of 9 patients were included. Mean age and follow-up time were 59.9 ± 9.9 years (range 44 to 75 years) and 3.3 ± 2.5 months, respectively. The mean number of RK cuts was 11.8 ± 5.3 (range 8 to 20). Mean preoperative uncorrected (UDVA) and corrected distance visual acuity (CDVA) were 0.9 ± 0.4 logMAR (Snellen 20/160) and 0.2 ± 0.3 logMAR (Snellen 20/30), respectively. 2 intraoperative anterior capsule tears were identified. 1 postoperative intraocular lens dislocation occurred. Postoperatively, the mean UDVA and CDVA were 0.2 ± 0.2 logMAR (20/30) and 0.1 ± 0.1 logMAR (20/25), respectively. The safety index was 1.6, and the efficacy index was 1.2. CONCLUSIONS: FLACS- or FL-assisted RLE surgery in RK patients has a high risk for anterior capsule tear and should be avoided. Thickened incisional scars are potential sources of incomplete laser penetrance. Toric lens implantation in RK eyes provide unpredictable astigmatic correction and should also be avoided.

Surgical Management of Fuchs Endothelial Corneal Dystrophy: A Treatment Algorithm and Individual Patient Meta-Analysis of Descemet Stripping Only.

PURPOSE: This study aims to determine predictive factors for success of Descemet stripping only (DSO) in Fuchs corneal endothelial dystrophy and propose a DSO treatment algorithm. METHODS: Ovid MEDLINE, Embase, and Cochrane CENTRAL databases were searched to evaluate DSO case series, including combined phacoemulsification and DSO, and the use of Rho-kinase inhibitors (ROC-i). Our primary outcome was success of corneal clearance. Secondary outcomes included the time to corneal clearance, the postoperative endothelial cell count (ECC), and the impact of ROC-i. RESULTS: Sixty-eight cases were evaluated with a mean follow-up of 12.4 months. DSO corneal clearance was achieved in 85% (n = 58) with a mean time of 4.9 weeks for the ROC-i group compared with 10.1 weeks in the observation group (P < 0.0001). The mean central ECC postoperatively was higher in the ROC-i group compared with the observation group 1151 ± 245 versus 765 ± 169 cells/mm2, respectively (P < 0.018). The postoperative best-corrected visual acuity (BCVA) improved in 61 eyes (90%), with mean final BCVA of 0.17 (0.26) logMAR (P = 0.001), which was statistically significant compared with preoperative BCVA. Factors influencing success were 4-mm descemetorhexis size, a clear peripheral ECC with no clinical sequelae of decompensation or guttae, and a low central corneal thickness. No intraoperative complications were noted. The commonest postoperative complication was deep corneal stromal scars noted at the descemetorhexis edge (n = 9). CONCLUSIONS: DSO has a role in the treatment of a subset of patients with Fuchs corneal endothelial dystrophy and that adjuvant treatment with ROC-i may lead to faster corneal clearance.

Central versus paracentral cone location and outcomes of accelerated cross-linking in keratoconus patients.

PURPOSE: To compare outcomes 1 year after accelerated cross-linking (CXL) between keratoconus eyes with central cones to those with paracentral cones. METHODS: In this post hoc analysis of data from a prospective multicentre study, consecutive progressive keratoconus eyes treated with accelerated CXL were included. Preoperative and 1 year post CXL manifest refraction, corneal cylinder, maximal keratometry (Kmax), central corneal thickness and coma were assessed. Central and paracentral cones were defined as cones within the central 3 mm and those between 3 and 5 mm, respectively. Eyes with apical scarring and peripheral cones (>5 mm) were excluded. The primary outcome measures were changes in best spectacle-corrected visual acuity (BSCVA) and Kmax. RESULTS: Overall, 314 eyes (n = 314) with a mean age of 27.5 ± 7.7 years were included. At baseline, the central cone group was younger (p < 0.001), had lower corneal astigmatism (p = 0.03) and coma (p = 0.02). At 1 year post CXL, after adjusting for baseline characteristics (age, BSCVA, corneal astigmatism, Kmax and coma), the central cone group showed a greater reduction in myopia (mean difference 1.27 ± 0.60D, p = 0.04) and more improvement in BSCVA (mean difference 0.08 ± 0.02 logMAR, p < 0.001) compared to the paracentral group. There was no significant difference in progression rates between the central and paracentral groups (ΔKmax > 2D, 6.7% vs. 6.5%, respectively, p = 0.83). CONCLUSIONS: This large-scale study of keratoconus eyes 1 year after accelerated CXL indicates that compared to those with paracentral cones, central cones have on average almost one additional line improvement in BCSVA and 1.27 D more reduction in myopia.

Risk Factors for Repeat Descemet Membrane Endothelial Keratoplasty Graft Failure.

PURPOSE: To evaluate repeat Descemet membrane endothelial keratoplasty (re-DMEK) success rates and to identify risk factors for re-DMEK failure. DESIGN: Retrospective case series. METHODS: Settings: Institutional. PATIENTS AND INTERVENTIONS: A chart review was performed, including all eyes with primary DMEK failure that underwent re-DMEK between 2013 and 2019 at the Toronto Western Hospital and the Kensington Eye Institute (Toronto, Ontario, Canada) and had at least 6 months of follow-up. MAIN OUTCOME MEASURE: Predicting factors for re-DMEK outcome. RESULTS: Of 590 consecutive DMEK surgeries, 40 eyes (6.7%) were identified for having a secondary DMEK surgery after primary DMEK failure. Etiologies for primary DMEK were Fuchs endothelial corneal dystrophy (32.5%), pseudophakic bullous keratopathy (35%), previous failed graft (27.5%), and other indications (5%). Fifty-five percent of the cohort were categorized as having a complicated anterior segment including 11 eyes with previous glaucoma surgery, 7 eyes post-penetrating keratoplasty, 4 eyes post-Descemet stripping automated endothelial keratoplasty, 3 eyes peripheral anterior synechia, 3 eyes previous pars plana vitrectomy, 2 eyes aphakia, and 1 eye each with aniridia, anterior chamber intraocular lens, and iris-fixated intraocular lens. Re-DMEK failure was documented in 12 eyes (30%) of the entire cohort. The risk factor for re-DMEK failure was the presence of a complicated anterior segment (P = .01, odds ratio = 17.0 [95% confidence interval: 1.92-150.85]), with 50% re-DMEK failure rate in this subgroup. CONCLUSION: Re-DMEK is a viable option for cases of primary DMEK failure, especially for eyes with Fuchs endothelial corneal dystrophy as the indication for primary DMEK without other ocular morbidities; however, eyes categorized with a complicated anterior segment had high re-DMEK failure rates..