International Microsurgery Club Webinar Series-Bridging the Knowledge Gap during the COVID-19 Pandemic.

BACKGROUND: The impact of the coronavirus disease 2019 (COVID-19) outbreak shut down most conferences. To minimalize the influence, virtual meetings sprang up subsequently. International Microsurgery Club (IMC), as one of the largest professionals-only online microsurgery education groups worldwide, began to host regular weekend webinars during the pandemic to fill the knowledge gap. This study aims to discuss how webinars have fundamentally changed the way knowledge is delivered and exchanged. METHODS: From February 29, 2020 to March 14, 2021, 103 IMC webinars were reviewed and analyzed in detail to determine the use, benefit, and effect. A comparison between webinars hosted by the different societies was made as well. A questionnaire survey focusing on attendees' behavior, attitude, and using habit about webinars was also made. RESULTS: As for the 103 IMC webinar events, the peak participants were 112.3 people in average. The members requesting to join IMC abruptly increased during the pandemic, and the group activity increased dramatically. From the questionnaire (n = 68), the satisfaction level was high (8.88 ± 1.18/10). The respondents were most satisfied with the good quality of the speakers (73.5%). Not only hosts our webinar series but IMC also serves as the platform that welcomes webinars from other societies to share their information. In September 2020, International Microsurgery Webinar League was established via the significant webinar hosts, with more than 300 recorded webinar talks connected successfully. CONCLUSION: As the knowledge revolution driven by COVID-19 will continue, IMC will keep playing an essential role in exploring new and emerging opportunities to improve knowledge dissemination worldwide beyond the space-time boundary.

Prevention and Treatment of Posttraumatic Lymphedema by Soft Tissue Reconstruction With Lymphatic Vessels Free Flap: An Observational Study.

BACKGROUND: Extremities soft tissue damage may increase the risk of presenting posttraumatic lymphedema. This type of lymphedema is often ignored in trauma and reconstructive literature. We propose a microsurgical soft tissue reconstruction approach to prevent and/or treat posttraumatic lymphedema. PATIENTS AND METHODS: This is a multicentric retrospective observational study. Primary and secondary end points were to prevent and/or treat posttraumatic lymphedema and to achieve a stable soft tissue coverage, respectively. Patients with posttraumatic lymphedema and functional lymphatic channels in the indocyanine green lymphography, and patients with acute soft tissue trauma with lymphatic damage without lymphedema, either to treat and prevent lymphedema, respectively, were included as candidates for soft tissue reconstruction using a superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV). Patients with no pitting edema, fibrosis, or nonfunctional lymphatics channels were excluded. The inguinal lymphatic anatomy was studied with indocyanine green lymphography for designing and in-setting the flap. RESULTS: Eleven patients underwent to microsurgical reconstruction with SCIP-LV free flap; minimum follow-up was 12 months. There were no flap failures. In the posttraumatic lymphedema group, the mean reduction of excess volume was 63.01%. Quality of life improved 51.85%. No patients in the acute trauma group developed lymphedema after the preventive microsurgical approach. CONCLUSIONS: Soft tissue reconstruction with SCIP-LV free flap is an effective approach to prevent and treat posttraumatic lymphedema.

Smartphone Thermography for Lower Extremity Local Flap Perforator Mapping.

BACKGROUND: The versatile application of local perforator flaps for coverage throughout the lower extremity has already been well proven. Often a "free-style" approach has been used to design these flaps, as conventional imaging devices for perforator identification may be too expensive or unavailable. The recent adaptation of Smartphone thermal digital imaging may now prove to be a cheaper and more readily available means for identifying the requisite perforators that will sustain these local flaps. METHODS: Over the past year, a prospective study was undertaken of all patients having a local perforator flap for coverage of a lower extremity defect. Twenty-eight local perforator flaps involving all subtypes were utilized in 25 patients. Smartphone thermography was used in all patients preoperatively to identify preferable perforator or vascular network "hot spots" that allowed appropriate flap design. Intraoperative and postoperative monitoring was similarly done for all flaps to determine outcomes. RESULTS: All local perforator flaps were based on perforators identified using smartphone thermography. All flaps (23 or 82.1%) that the thermal digital image predicted 100% viability totally survived. Five flaps were predicted to have marginal viability, but two nevertheless survived completely while the others required only minor readjustments. Peninsular and keystone variety perforator flaps were those most commonly used.Thermography always facilitated making the correct decision as to whether a proximal- or distal-based peninsular flap would be superior. Subfascial elevation of cool spots in keystone flaps were found to be least likely to interfere with flap perfusion. CONCLUSION: Smartphone thermography is an inexpensive and expeditious means for identification of "hot spots" that is always used by us to ensure perfusion to lower extremity perforator local flaps. This is a complementary technique for their safer design, harvest, and subsequent monitoring in conjunction with more complex screening tools as indicated.

A New Planning Method to Easily Harvest the Superficial Circumflex Iliac Artery Perforator Flap.

BACKGROUND: The superficial circumflex iliac artery perforator flap (SCIP) is a thin, pliable, and versatile flap used mainly for extremities and head and neck reconstruction. Different planning methods have been described, but these are not yet standardized like in other flaps. The aim of this study is to present a fast, effective, and reliable method for SCIP flap planning using computed tomography angiography (CTA). PATIENTS AND METHODS: Between October 2017 and September 2018, CTA was performed on 40 patients. Preoperative planning of SCIP flaps based on the medial branch was performed analyzing CTA images. The perforating sites of the medial branch on the deep (point D) and superficial fascia (point S) were identified. Distances to those points, from the center of the umbilicus in the "y-axis" and the midline perpendicularly in the "x-axis," were measured. These measurements were transferred to the patient's skin as a guide for dissection. RESULTS: Eighty areas were studied identifying points D and S in CTA. Forty-three SCIP flaps were performed using this planning method. In 100% of the flaps, points D and S matched perfectly with handheld Doppler and surgical findings. CONCLUSION: Points D and S method for medial branch based SCIP planning with CTA is an easy to learn, efficient, fast, and reliable technique for preoperative planning, allowing a safe and predictable elevation of the flap.

Post-traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: A case report.

Post-traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision-making approach. We report a case of a 41-year-old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP-L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4-month follow-up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6-month follow-up. A successful treatment of post-traumatic lymphedema can be performed by using the SCIP-L free flap for soft tissue reconstruction of critical lymphatic drainage areas.

Reduced Anterolateral Thigh Flap Donor-Site Morbidity Using Incisional Negative Pressure Therapy.

BACKGROUND: Primary closure of the donor-site after harvest of a large anterolateral thigh flap (ALT) is associated with significant morbidity. Incisional negative pressure therapy (INPT) may decrease complications in high-risk incisions. This study assessed if the incidence of complications after primary closure of the ALT flap donor-site decreases with INPT. METHODS: Retrospective cohort study of a prospectively maintained database including patients who underwent upper and lower limb reconstruction, using an ALT free flap with primary closure of the donor-site. Two groups were defined: primary closure and INPT (study group) and primary closure with traditional dressings (control group). Nonparametric statistics were employed to identify prognostic factors, p < 0,05. RESULTS: Fifty-eight free ALT flaps in 58 patients (study group n = 28; control group n = 30) were included. Median flap width and length were 9 cm (range: 5-14) and 25 cm (range: 10-48), respectively. Median follow-up was 19 months (range: 3-78 months). No significant differences in age or flap size were identified in both groups (p > 0.05). The global complication rate was 7.14% (n = 2) in the INPT group, and 37% (n = 11) in the control group (p = 0.007). The study group had a lower dehiscence and skin necrosis rate (p < 0.05). Multivariate logistic regression analysis showed IPNT was associated with a significant reduction of donor-site complications (p = 0.006), especially in patients with defects > 8 cm (p = 0.003). CONCLUSION: In this cohort study the use of INPT significantly reduced the donor-site morbidity after ALT flap harvest.

Turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels: A case report.

Reconstruction of thigh defects is usually straightforward, but in cases of poor soft tissue quality, free flap reconstruction is not possible due to the absence of recipient vessels. The turbocharge technique may increase the viable, vascularized area of a flap. In this report we present a case of the use of a turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels. A 29-year-old woman who underwent neoadjuvant chemotherapy plus radiation therapy for a leiomyosarcoma on the left thigh. Six weeks later, complete tumor excision and a femoropopliteal bypass with contralateral saphenous vein was performed. In the following days the wound had dehiscence, infection, necrosis of the surrounding muscles and exposure of femoropopliteal bypass. No recipient vessels were available for free flap and critical limb ischemia due to bypass thrombosis was detected. The reconstruction of a large thigh defect (30 × 12 cm) and the coverage of a femoropopliteal bypass with a turbocharged bilateral pedicled DIEP flap was performed. A flap including the entire infraumbilical tissue was designed and the anastomosis of the proximal stump of the right inferior epigastric vessels with the distal ends of the inferior left epigastric vessels was performed to increase the viable area. The flap survived without any complications during the postoperative period. At 12-month follow up, coverage was stable with no tumor recurrence. Our result suggests that a turbocharged bilateral pedicled DIEP flap may be an option for reconstructing large tissue defects when no recipient vessels are available for free flap.

Cumulative Experience in Lymphovenous Anastomosis for Lymphedema Treatment: The Learning Curve Effect on the Overall Outcome.

BACKGROUND: The lymphovenous anastomosis (LVA) has become one of the treatment options for lymphedema. However, it is regarded as a difficult surgery that many young microsurgeons are reluctant to try. This report investigates the learning curve in regard to symptom improvement. METHODS: This is a retrospective analysis performed in 33 consecutive lymphedema patients (38 extremities) who underwent only LVAs from August 2010 to February 2016. Surgical outcomes in regard to surgeon's experience were evaluated. The surgeons experience was divided into three groups: early group with less than 2 years, moderate with 2 to 4 years, and mature group with more than 4 years of experience. RESULTS: A total of 31 limbs (8/8 in upper extremity and 23/30 in lower extremity) showed improvement. When we compare volume change and recurrence of cellulitis with regard to surgeon's experience, there were no statistically significant differences. However, the mean time per LVA was significantly decreased as the experience increased over time (p = 0.017). CONCLUSION: LVA is an effective treatment option to reduce the volume in the affected limb and to improve symptoms involved. Regardless of the number and experience of the surgeons, cellulitis improves significantly after LVA. The experience of the surgeon does not significantly impact the positive outcome while proficiency increases with experience.

Effects of Abdominoplasty on Intra-Abdominal Pressure and Pulmonary Function.

BACKGROUND: Abdominal wall weakness is a consequence of rectus abdominis diastasis and flaccidity of the myofascial component. A degree of plicature of the rectus abdominis generates an increase of intra-abdominal pressure (IAP), which may result in an increase of intrathoracic pressure, thus affecting thoracic hemodynamics and leading to inadequate ventilation. OBJECTIVES: To assess changes generated by plicature of the rectus abdominis on IAP and pulmonary function in patients undergoing abdominoplasty. METHODS: A total of 10 female patients with abdominal ptosis were included. Chronic smokers and patients with respiratory co-morbidities were excluded. The IAP was measured using a modified Kron's trans-bladder technique. Pulmonary function was assessed by pulmonary compliance (P-Comp) and was calculated with parameters provided by the mechanical ventilator. Both were calculated before and after plicature. RESULTS: The mean values for IAP before and after plicature were 6.6 and 9.3 mmHg respectively. Before plicature, the mean P-Comp value was 38.97 mL/cm of water, and after it was 36.54 mL/cm. Both differences were statistically significant. CONCLUSIONS: Based on the results obtained, it is possible to conclude that plicature of the rectus abdominis generates significant physiological changes, such as an increase in IAP and a decrease of P-Comp, which do not have a clinically relevant impact on healthy individuals. Measuring IAP with the modified technique and the assessment of pulmonary function using P-Comp are both reliable and provide a more accurate correlation with such physiologic changes. LEVEL OF EVIDENCE 3: Therapeutic.

A Comprehensive Approach to Posttraumatic Lymphedema Surgical Treatment.

Background Posttraumatic lymphedema (PTL) is sparsely described in the literature. The aim of this study is to propose a comprehensive approach for prevention and treatment of PTL using lymphovenous anastomosis (LVA) and lymphatic vessels free flap, reporting our experience in the management of early-stage lymphedema. Methods A retrospective observational study was performed between October 2017 and July 2022. Functional assessment with magnetic resonance lymphangiography and indocyanine green lymphography was performed. Patients with lymphedema and functional lymphatic channels were included. Cases with limited soft tissue damage were proposed for LVA, and those with acute or prior soft tissue damage needing skin reconstruction were proposed for superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV) to treat or prevent lymphedema. Primary and secondary outcomes were limb volume reduction and quality of life (QoL) improvement, respectively. Follow-up was at least 1 year. Results Twenty-eight patients were operated using this approach during the study period. LVA were performed in 12 patients; mean reduction of excess volume (REV) was 58.82% and the improvement in QoL was 49.25%. SCIP-LV was performed in seven patients with no flap failure; mean REV was 58.77% and the improvement QoL was 50.9%. Nine patients with acute injury in lymphatic critical areas were reconstructed with SCIP-LV as a preventive approach and no lymphedema was detected. Conclusion Our comprehensive approach provides an organized way to treat patients with PTL, or at risk of developing it, to have satisfactory results and improve their QoL.

Extremity reconstruction with superficial circumflex iliac artery perforator free flap: Refinements and innovations after 101 cases.

INTRODUCTION: The superficial circumflex iliac artery perforator flap is based on perforators originated on the superficial circumflex iliac artery. This flap is thin and pliable, of moderate size, and has a concealed donor site. The authors report their experience, innovations, and refinements in both planning and execution, and the outcomes obtained after 101 extremity reconstruction consecutive cases. PATIENTS AND METHODS: A total of 101 superficial circumflex iliac artery perforator flaps were prospectively reviewed and followed up for at least one year at Hospital del Trabajador. The flaps were used for both upper (n = 21) and lower limbs (n = 80), planned with computed tomography angiography/augmented reality, and raised above the superficial fascia using a standardized approach. Demographic data, anatomy of the flap, surgical technique, and the results were assessed. RESULTS: Average flap size was 90.5 cm2, ranging from 25 to 212 cm2. Total flap loss occurred in 6 flaps (5.9%). Four patients developed complications at the donor site. Debulking surgery was performed in 7 patients (6.9%). The average follow-up period was 850 days (range, 370-1405 days). CONCLUSIONS: The superficial circumflex iliac artery perforator flap is versatile, thin, and pliable, suitable for covering even large defects in either the upper or lower extremities, obtaining a shallow contour and optimal esthetics results. The elevation can be standardized, but requires training and proper planning. This is the largest series in a Western country reporting the experience, refinements, and innovation that allows for better results in limb reconstruction.

Interface Fluid Syndrome After Descemet Membrane Endothelial Keratoplasty in Patients With History of LASIK.

PURPOSE: The aim of this study was to evaluate the visual, pachymetric, tomographic, and biomicroscopic findings in a series of cases with laser in situ keratomileusis (LASIK) flap interface fluid syndrome (IFS) after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Six cases were included in this study; all patients had a history of LASIK and underwent DMEK for the treatment of bullous keratopathy. After uneventful surgery, all patients presented with corneal edema and IFS under the LASIK flap, which was demonstrated with anterior segment optical coherence tomography (AS-OCT). Visual acuity, clinical findings, pachymetry, endothelial cell count, and AS-OCT were documented during the management of these cases. RESULTS: IFS appears 2.33 days (±1.03) after DMEK. One case improved with conservative treatment. In 5 cases, the LASIK flap was lifted, the fluid was drained, and the flap was replaced. The mean best-corrected visual acuity after fluid drainage was 0.44 logMAR (range 0.18-1.0) and mean central corneal thickness was 538 µm ± 160. Total resolution of the IFS was achieved at 14.5 days (range 4-30) after DMEK. AS-OCT showed resolution of the flap interface in 5 of 6 cases, while 1 patient required second DMEK due to reaccumulation of the interface fluid. CONCLUSIONS: IFS can occur after DMEK in patients with previous LASIK. AS-OCT is a valuable tool for monitoring these cases preoperatively and postoperatively. Early surgical management is often needed to achieve resolution.

[Thoracic actinomycosis in the differential diagnosis of neoplasm: a propos of a case]. / Actinomicosis torácica como diagnóstico diferencial de neoplasia: a propósito de un caso.

Actinomycosis is an infrequent infection caused by bacteria from Actinomyces genus that manifests as a chronic, suppurative and progressive disease. It's more common in men. Thoracic actinomycosis occurs in 15% of the cases, and infection of the chest wall is less frequent. The clinical presentation mimics tuberculosis or neoplastic processes. In this article we present the case of a 63 year-old man with no comorbidity, with pulmonary actinomycosis involving the chest wall mimicking a neoplastic process, basing the diagnosis on histopathologic findings.

Pushing the Limits in Extremity Reconstruction Using Virtual Surgical Planning: A Case Series Study.

SUMMARY: Technology is advancing in benefit to solving complex problems. Preoperative planning is essential in any reconstructive process given the importance of achieving good results. New technologies facilitate the process to anticipate intraoperative findings. Virtual surgical planning has contributed in the evolution of craniomaxillofacial surgery. However, limited reports have been published regarding its usefulness in extremity reconstruction. The aim of this study was to push the limits and evaluate the use of virtual surgical planning with three-dimensional images for reconstruction of complex extremity defects using a free, open-source software. Patient candidates for upper or lower extremity microsurgical reconstruction with multiple defects or defects requiring reconstruction of various tissue components were included. Computed tomography angiography images were analyzed for virtual surgical planning using Horos software (Horos, Annapolis, Md.). Two upper and eight lower extremities were reconstructed with free flaps using virtual surgical planning; six cases had multiple defects, and four cases underwent different tissue components reconstruction. The postoperative period was uneventful, and there was no flap failure. A didactic video of the process and examples of some cases are presented. Virtual surgical planning is a powerful planning method, and the authors propose its use in complex extremity defects reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Femtosecond laser-assisted Bowman layer transplantation for advanced keratoconus.

BACKGROUND/AIMS: To assess the technical feasibility and outcomes of femtosecond laser-assisted Bowman layer transplantation (FLABOLT) in stabilizing progressive, advanced keratoconus, which is ineligible for corneal crosslinking. METHODS: This single-center retrospective study included 50 eyes of 49 patients with progressive advanced keratoconus, ineligible for corneal crosslinking, that underwent FLABOLT with both the donor graft and recipient mid-stromal pocket using a femtosecond laser. RESULTS: The mean follow-up was 13.2 ± 4.9 months (range 7-35 months). Donor graft preparation and accurate dissection of the recipient mid-stromal pocket were successful in 96% and 100% of cases, respectively. The mean maximum keratometry decreased by 1.93 D at 6 months after surgery and there was no change in the mean preoperative best contact lens-corrected visual acuity (BCLVA). Three eyes developed hydrops postoperatively and recovered after clinical treatment. One eye that achieved useful BCLVA postoperatively, worsened 2 years after the surgery due to progressive corneal scarring and required corneal transplantation for visual rehabilitation. Preoperative corneal scarring was a risk factor for BCLVA loss. All other eyes remained stable (92%), and no other procedure was required until the last follow-up. CONCLUSION: In this series, FLABOLT was successfully performed as an alternative to stabilize advanced progressive keratoconus. This technique is highly reproducible for graft preparation and recipient pocket dissection when assisted by femtosecond laser. Despite promising initial results, more studies with longer follow-up periods are needed to evaluate the effectiveness of FLABOLT in stabilizing advanced progressive keratoconus.

Pre-Descemet's endothelial keratoplasty: a simple, Descemet's membrane scoring technique for successful graft preparation.

PURPOSE: Pre-Descemet's endothelial keratoplasty (PDEK) donor tissue preparation involves the intrastromal injection of air to create a type 1 big bubble (BB) and avoidance of the creation of a type 2 BB. The purpose of this study was to design and test a technique to consistently creates a type 1 BB without risk of creating a type 2 BB. METHODS: A prospective matched study with 64 human donor sclerocorneal discs, which were not suitable for corneal transplantation, was conducted. The corneas were divided into two groups, of which 32 were subjected to the standard technique of preparing the PDEK donor tissue (group 1, control) and 32 new technique, where in the donor Descemet's membrane was scored with a Sinskey hook. Frequency of occurrence of different types of BB was compared and statistically analysed. RESULTS: With the standard technique (group 1), type 1 BB occurred in 53.1%, type 2 BB in 34.4% and mixed BB in 12.5% of samples. With the scoring technique (group 2), a type 1 BB occurred in 100% of the samples. No type 2 or mixed BB occurred in any case in group 2. The difference in creation of a type 1BB between the two groups was statistically significant (p=0.00). CONCLUSION: The scoring technique is a simple, inexpensive and reproducible option to consistently achieve a type 1 BB to prepare PDEK graft tissue. The next step would be to study the clinical outcomes of PDEK performed with tissue obtained by the scoring technique.

The Impact of the COVID-19 Pandemic on Corneal Transplantation in Brazil.

PURPOSE: The purpose of this study was to evaluate the impact of the coronavirus disease 2019 pandemic on corneal transplantation (CT) in Brazil. METHODS: Data from patients who underwent CT at the Hospital Oftalmológico de Sorocaba (HOS), Brazil, were analyzed. National and state numbers of keratoplasties, patients added to the CT waiting list, and total patients on the waiting list were also obtained. Baseline prepandemic (from January 1, 2019, to March 31, 2020) data were compared with 2 time frames of the coronavirus disease 2019 pandemic: elective CT suspension period (between April 1, 2020, and September 31, 2020) and after elective CT resumption (between October 1, 2020, and April 30, 2021). RESULTS: Despite elective CT resumption after the moratorium, the monthly CT rates did not return to baseline at HOS (-14.7%, P = 0.007), São Paulo state (-19.1%, P = 0.001), or Brazil (-30.1%, P < 0.001). The waiting list increased significantly regionally (P < 0.001) and nationally (P < 0.001). Among optical keratoplasties performed at HOS after resuming elective CTs, the proportion of endothelial keratoplasties declined from 38.2% to 30.0% (P < 0.001), whereas penetrating keratoplasties increased from 33.2% to 39.5% (P < 0.001) when comparing with prepandemic data. CONCLUSIONS: Keratoplasty numbers dropped significantly locally, regionally, and nationally. Hence, the CT waiting lists had a progressive increase, with significant long-term implications. An estimated increment on monthly CT rates of approximately 34% in São Paulo state, and 91% in Brazil, is required for the CT waiting list to get back to prepandemic numbers over the next 2 years.

Trends in Corneal Transplantation in a Tertiary Hospital in Brazil.

PURPOSE: The purpose of this study was to analyze the evolving trends of surgical techniques and indications of corneal transplantation (CT) at a tertiary hospital in Brazil. METHODS: The medical records of all patients who underwent CT at the Hospital Oftalmológico de Sorocaba (Sorocaba Eye Hospital) from the Banco de Olhos de Sorocaba (Sorocaba Eye Bank) group in Sorocaba, Brazil, from January 1, 2012, to December 31, 2019, were analyzed. Data regarding age, sex, transplant indication, and surgical technique were collected. RESULTS: A total of 16,250 CTs were performed. There was a statistically significant decreasing trend of keratoconus-related CT ( P < 0.0001), with rates dropping from 41.7% among all CTs in 2012 to 25.5% in 2019. Penetrating keratoplasty, anterior lamellar keratoplasty, and endothelial keratoplasty (EK) accounted for 59.3%, 27.1%, and 7.8% of the CTs performed in 2012 and 33.3%, 16.4%, and 39.9% in 2019, respectively. A statistically significant decreasing trend was observed for penetrating keratoplasty ( P < 0.0001) and anterior lamellar keratoplasty ( P < 0.0001), whereas EK showed a statistically significant increasing trend during the period ( P < 0.0001). Among EKs, Descemet membrane EK increased statistically significantly from 12.8% in 2012 to 74.4% in 2019 ( P < 0.0001). CONCLUSIONS: This study shows relevant evolving trends in indications and preferred CT techniques in a tertiary hospital in Brazil.

Partial-Thickness Intrastromal Lamellar Keratoplasty for Corneal Pellucid Marginal Degeneration.

PURPOSE: Pellucid marginal degeneration (PMD) is a bilateral corneal ectatic disorder, characterized by thinning of the inferior cornea. Numerous surgical procedures have been described in the literature, and there is a lack of consensus regarding the best available surgical management. Recently, full-thickness intrastromal lamellar keratoplasty (ILK) was described as an option for treating PMD and emerged as a promising technique. However, ILK results in an irregular surface, leading to a significant residual against-therule (ATR) astigmatism. METHODS: This study describes a variation of the ILK technique, using a partial-thickness graft to treat 2 cases of PMD. RESULTS: At the final follow-up, both patients improved visual acuity and had their mean simulated keratometry flattened, although a residual ATR astigmatism remained. CONCLUSIONS: The ILK technique modification might lead to a more regular thickness pattern, although it did not seem efficient in reducing the ATR astigmatism.