Advanced Corneal Imaging in Keratoconus: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the diagnostic capabilities of the newest generation of corneal imaging devices for the identification of keratoconus. METHODS: Corneal imaging devices studied included tomographic platforms (Scheimpflug photography, OCT) and functional biomechanical devices (imaging an air impulse on the cornea). A literature search in the PubMed database for English language studies was last conducted in February 2023. The search yielded 469 citations, which were reviewed in abstract form. Of these, 147 were relevant to the assessment objectives and underwent full-text review. Forty-five articles met the criteria for inclusion and were assigned a level of evidence rating by the panel methodologist. Twenty-six articles were rated level II, and 19 articles were rated level III. There were no level I evidence studies of corneal imaging for the diagnosis of keratoconus found in the literature. To provide a common cross-study outcome measure, diagnostic sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were extracted. (A perfect diagnostic test that identifies all cases properly has an AUC of 1.0.) RESULTS: For the detection of keratoconus, sensitivities for all devices and parameters (e.g., anterior or posterior corneal curvature, corneal thickness) ranged from 65% to 100%. The majority of studies and parameters had sensitivities greater than 90%. The AUCs ranged from 0.82 to 1.00, with the majority greater than 0.90. Combined indices that integrated multiple parameters had an AUC in the mid-0.90 range. Keratoconus suspect detection performance was lower with AUCs ranging from 0.66 to 0.99, but most devices and parameters had sensitivities less than 90%. CONCLUSIONS: Modern corneal imaging devices provide improved characterization of the cornea and are accurate in detecting keratoconus with high AUCs ranging from 0.82 to 1.00. The detection of keratoconus suspects is less accurate with AUCs ranging from 0.66 to 0.99. Parameters based on single anatomic locations had a wide range of AUCs. Studies with combined indices using more data and parameters consistently reported high AUCs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Safety and Efficacy of Epithelium-Off Corneal Collagen Cross-Linking for the Treatment of Corneal Ectasia: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the evidence on the safety and effectiveness of epithelium-off corneal collagen cross-linking (CXL) for the treatment of progressive corneal ectasia. METHODS: A literature search of the PubMed database was most recently conducted in March 2024 with no date restrictions and limited to studies published in English. The search identified 359 citations that were reviewed in abstract form, and 43 of these were reviewed in full text. High-quality randomized clinical trials comparing epithelium-off CXL with conservative treatment in patients who have keratoconus (KCN) and post-refractive surgery ectasia were included. The panel deemed 6 articles to be of sufficient relevance for inclusion, and these were assessed for quality by the panel methodologist; 5 were rated level I, and 1 was rated level II. There were no level III studies. RESULTS: This analysis includes 6 prospective, randomized controlled trials that evaluated the use of epithelium-off CXL to treat progressive KCN (5 studies) and post-laser refractive surgery ectasia (1 study), with a mean postoperative follow-up of 2.4 years (range, 1-5 years). All studies showed a decreased progression rate in treated patients compared with controls. Improvement in the maximum keratometry (Kmax) value, corrected distance visual acuity (CDVA), and uncorrected distance visual acuity (UDVA) was observed in the treatment groups compared with control groups. A decrease in corneal thickness was observed in both groups but was greater in the CXL group. Complications were rare. CONCLUSIONS: Epithelium-off CXL is effective in reducing the progression of KCN and post-laser refractive surgery ectasia in most treated patients with an acceptable safety profile. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Outcomes and Complications of Limbal Stem Cell Allograft Transplantation: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the safety and outcomes of keratolimbal allograft (KLAL) transplantation and living-related conjunctival limbal allograft (lr-CLAL) transplantation for bilateral severe/total limbal stem cell deficiency (LSCD). METHODS: Literature searches were last conducted in the PubMed database in February 2023 and were limited to the English language. They yielded 523 citations; 76 were reviewed in full text, and 21 met the inclusion criteria. Two studies were rated level II, and the remaining 19 studies were rated level III. There were no level I studies. RESULTS: After KLAL surgery, best-corrected visual acuity (BCVA) improved in 42% to 92% of eyes at final follow-up (range, 12-95 months). The BCVA was unchanged in 17% to 39% of eyes and decreased in 8% to 29% of eyes. Two of 14 studies that evaluated the results of KLAL reported a notable decline in visual acuity over time postoperatively. Survival of KLAL was variable, ranging from 21% to 90% at last follow-up (range, 12-95 months) and decreased over time. For patients undergoing lr-CLAL surgery, BCVA improved in 31% to 100% of eyes at final follow-up (range, 16-49 months). Of the 9 studies evaluating lr-CLAL, 4 reported BCVA unchanged in 30% to 39% of patients, and 3 reported a decline in BCVA in 8% to 10% of patients. The survival rate of lr-CLAL ranged from 50% to 100% at final follow-up (range, 16-49 months). The most common complications were postoperative elevation of intraocular pressure, persistent epithelial defects, and acute allograft immune rejections. CONCLUSIONS: Given limited options for patients with bilateral LSCD, both KLAL and lr-CLAL are viable choices that may provide improvement of vision and ocular surface findings. The studies trend toward a lower rejection rate and graft failure with lr-CLAL. However, the level and duration of immunosuppression vary widely between the studies and may impact allograft rejections and long-term graft survival. Complications related to immunosuppression are minimal. Repeat surgery may be needed to maintain a viable ocular surface. Reasonable long-term success can be achieved with both KLAL and lr-CLAL with appropriate systemic immunosuppression. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Management of endothelial disease without keratoplasty.

PURPOSE OF REVIEW: Currently, the most widely used treatment for endothelial disease is endothelial replacement via endothelial keratoplasty. Increasingly selective techniques have allowed for increased safety and faster visual recovery. However, alternative treatment options that are lower in cost, require less surgical expertise, and rely less on tissue availability are needed. This review discusses established and emerging therapies for endothelial disease without keratoplasty. RECENT FINDINGS: Regenerative therapies that have been successful include Descemet stripping only and Descemet membrane transplants. Rho-kinase inhibitors promote cell proliferation, adhesion, and migration and appear to have a role in these treatments and possibly in the prevention of endothelial disease. Cell-based therapies and the development of an artificial endothelial implant have also demonstrated promising results. SUMMARY: There are numerous emerging treatments for endothelial disease that have proven successful. Advances in our understanding of disease pathogenesis on a cellular level will continue to expand possibilities for therapeutics.

The S-stamp in Descemet Membrane Endothelial Keratoplasty Safely Eliminates Upside-down Graft Implantation.

PURPOSE: To present 6-month clinical outcomes from a series of 165 consecutive Descemet membrane endothelial keratoplasty (DMEK) procedures before and after the introduction of a novel stromal-sided S-stamp preparation technique that has decreased the incidence of iatrogenic primary graft failure by eliminating upside-down grafts. DESIGN: Retrospective nonrandomized comparative case series. PARTICIPANTS: We included 165 consecutive eyes that had undergone DMEK surgery for Fuchs' or pseudophakic bullous keratopathy. These cases were divided into 2 cohorts: the first cohort comprised 31 cases that used unstamped tissue before the S-stamp was introduced, and the second cohort comprised 133 cases after the S-stamp was incorporated into the standardized technique. A single unstamped DMEK case was performed after the introduction of the S-stamp for a total of 32 unstamped cases. METHODS: Donor materials were prepared at a single eye bank using a standardized technique, which subsequently incorporated the addition of a dry ink gentian violet S-stamp to the stromal side of Descemet membrane. All surgeries were performed at a single clinical site by 5 surgeons (2 attending surgeons and 3 fellows). Two of the 165 DMEK cases were performed for pseudophakic bullous keratopathy (2 cases, 1 in each cohort), and the remaining cases were for Fuchs' endothelial dystrophy. Primary outcome measures were assessed at 6 months and maintained in a prospective institutional review board-approved study. MAIN OUTCOME MEASURES: We analyzed the 6-month endothelial cell density, incidence of iatrogenic primary graft failure, upside-down graft implantation, and rebubble events. RESULTS: The S-stamp eliminated upside-down graft implantations (0/133 S-stamped vs 3/32 unstamped) and did not significantly alter 6-month endothelial cell loss (31±17% S-stamped vs 29±14% unstamped; P = 0.62) or frequency of rebubble (17/133 S-stamped vs 1/32 unstamped; P = 0.20). CONCLUSION: The incorporation of a stromal-sided S-stamp eliminates iatrogenic primary graft failure owing to upside-down implantation of DMEK grafts, without adversely affecting early postoperative complications or 6-month endothelial cell loss.

Achieving target refraction after cataract surgery.

PURPOSE: To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institution's Comprehensive Ophthalmology Service. DESIGN: Retrospective study. PARTICIPANTS: We examined 1275 eye surgeries for this study. METHODS: All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days. MAIN OUTCOME MEASURES: The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent. RESULTS: We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery. CONCLUSIONS: This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks.

Ocular blast injuries in mass-casualty incidents: the marathon bombing in Boston, Massachusetts, and the fertilizer plant explosion in West, Texas.

PURPOSE: To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas. DESIGN: Multicenter, cross-sectional, retrospective, comparative case series. PARTICIPANTS: Seventy-two eyes of 36 patients treated at 12 institutions were included in the study. METHODS: Ocular and systemic trauma data were collected from medical records. MAIN OUTCOME MEASURES: Types and severity of ocular and systemic trauma and associations with mechanisms of injury. RESULTS: In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P<0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified. CONCLUSIONS: Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

Evolving indications for Descemet's stripping automated endothelial keratoplasty.

PURPOSE OF REVIEW: Recent advances in the field of endothelial transplantation, including increasing acceptance of Descemet's membrane endothelial keratoplasty, may alter the indications for Descemet's stripping automated endothelial keratoplasty, to a procedure reserved for complex endothelial disorders. RECENT FINDINGS: Recent literature demonstrates that Descemet's membrane endothelial keratoplasty provides better and faster visual outcomes and decreased immunologic rejection compared to Descemet's stripping automated endothelial keratoplasty. However, Descemet's membrane endothelial keratoplasty may be more challenging in the management of a number of more complex endothelial disorders. While the literature on complex Descemet's membrane endothelial keratoplasty is limited, the utility of Descemet's stripping automated endothelial keratoplasty has been validated in the management of endothelial dysfunction in the setting of a number of comorbid conditions including prior penetrating keratoplasty, prior glaucoma surgery, iridocorneal endothelial syndrome, aniridia, aphakia, and anterior chamber intraocular lenses, among others. SUMMARY: The increasing adoption of Descemet's membrane endothelial keratoplast is changing the practice of endothelial keratoplasty. However, limitations of the Descemet's membrane endothelial keratoplasty procedure have also served to crystallize the essential role of Descemet's stripping automated endothelial keratoplasty in many complex endothelial keratoplasty scenarios. This article will review indications for endothelial keratoplasty, along with the current evidence for Descemet's stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty in their management.

Double-Scroll Formation by Fluid Column Manipulation in Preloaded DMEK Grafts Prepared From Younger and Older Donor Tissue.

PURPOSE: The purpose of this study was to determine whether manipulation of preloaded single-scroll Descemet membrane endothelial keratoplasty (DMEK) grafts within the fluid column of an injector can safely and reliably result in formation of double-scroll DMEK grafts and whether there are differential effects on younger versus older donor tissue. METHODS: Pairs of DMEK grafts prepared from older (65-80 years) and younger (48-64 years) donors were preloaded into a Straiko modified Jones tube. One member of the pair was manipulated within the fluid column to form a double-scroll graft, and the other remained unmanipulated. Outcomes measured include success rate for double-scroll formation, endothelial cell loss (ECL), and relative scroll width. RESULTS: Older donor grafts formed double scrolls with a 100% success rate. ECL of older donor manipulated grafts was statistically higher than that of unmanipulated mate grafts (17.4% ± 3.5% vs. 13.0% ± 4.2%, P = 0.03), but was still within the acceptable range for transplant. Younger donor grafts were successfully manipulated into double scrolls with a 67% success rate, and there was no difference in the ECL of manipulated and unmanipulated grafts (15.5% ± 4.4% vs. 13.0% ± 4.5%, P = 0.24). For all grafts and conformations, there was a significant relationship between relative scroll width and ECL ( P < 0.01). CONCLUSIONS: Fluid column manipulation can be used reliably to form double-scroll DMEK grafts. For younger donor grafts, manipulation yields a double scroll without increasing ECL. For older donor grafts, manipulation results in a minimal, acceptable increase in ECL. Surgeons should weigh the advantage of an easily opened graft against the risk of increased ECL when considering this technique.

Examination of a Modified Graft Preparation Technique to Induce Double-Scroll Formation and Promote the Use of Younger Descemet Membrane Endothelial Keratoplasty Donor Tissue.

PURPOSE: The purpose of this study was to determine whether controlled balanced salt solution (BSS) bursts during graft preparation can safely promote formation of a double-scrolled Descemet membrane endothelial keratoplasty (DMEK) graft in younger donor tissue. METHODS: DMEK grafts prepared from young donor tissue (average age, 55 years; range, 39-66 years) were floated in BSS to spontaneously form scrolls (N = 10 pairs). Controlled BSS bursts were used to promote double-scroll (DS) formation in 1 member of each pair. Grafts were stained, preloaded, and shipped before cell viability analysis. After appropriate training, a less experienced technician performed this technique on 10 additional corneas. Outcomes measured for both technicians include the success rate for obtaining a DS, scroll conformation after shipping, and endothelial cell loss (ECL). RESULTS: There was no difference in ECL between grafts subjected to additional manipulation compared with unmanipulated mate grafts (observer 1: 15.2% ± 3.3% vs. 15.2% ± 4.4%, P = 0.99; observer 2: 16.3% ± 2.9% vs. 15.9% ± 4.5%, P = 0.8). A technician experienced with this technique had a 90% success rate, whereas a less experienced technician had a 70% success rate. The mean ECL of the 10 grafts manipulated by the less experienced technician was not significantly different from results obtained from the experienced technician (observer 1: 18.5% ± 6.0% vs. 15.2% ± 3.3%, P = 0.15; observer 2: 18.1% ± 5.6% vs. 16.3% ± 2.9%, P = 0.34). Scrolls maintained their conformation during shipping events. CONCLUSIONS: Double-scroll graft formation using controlled BSS bursts is a reliable technique that can be performed without causing additional damage to DMEK grafts. This technique may make graft unscrolling easier and can promote the use of younger donor tissue for DMEK.

Reducing instruments in a vitrectomy surgical tray: cost savings and results from a major academic hospital.

BACKGROUND: Unused or rarely used instruments in standard surgical trays can unnecessarily increase costs. Prior studies have demonstrated the practicality and cost savings of reduced instrument tray sizes in various subspecialties. This study describes results and estimated cost savings from a reduced instrument tray used for vitrectomy surgery at a large, tertiary academic medical center. METHODS: Common usage patterns of vitrectomy instruments by one retina surgeon were reviewed and a reduced instrument vitrectomy tray was created and implemented in successive vitrectomy surgeries. Need for opening the previously utilized larger tray was recorded. Estimated cost savings of the new trays were calculated based upon per instrument sterilization, processing, and instrument replacement costs. RESULTS: New vitrectomy trays including just 7 instruments (89% reduction compared to original trays) were created and implemented in 189 successive cases. The original tray was never opened. Estimated cost savings from saved sterilization and processing resources is approximately $9588 per year. Assuming 5- and 10-year lifespan per instrument, annual cost avoidance is projected at $7886 and $15,772, respectively. Other indirect benefits relevant to healthcare quality were also noted. CONCLUSION: A reduced instrument tray can be successfully implemented for vitrectomy surgery and can result in significant indirect benefits as well as direct cost savings from reduced sterilization costs. Our study highlights the substantial impact made by evaluating the usage pattern and making appropriate instrument tray changes for just one retina surgeon. Applying these same methods to other surgeons and specialties can have significant implications on healthcare costs and quality.

Intraoperative S-Stamp Enabled Rescue of 3 Inverted Descemet Membrane Endothelial Keratoplasty Grafts.

PURPOSE: To report the clinical outcomes of 3 Descemet membrane endothelial keratoplasty (DMEK) grafts, in which an upside down DMEK graft orientation was discovered after SF6 gas insufflation of the anterior chamber and the orientation was then corrected intraoperatively. METHODS: A total of 371 consecutive DMEK cases using an S-stamp were analyzed and found to include 3 cases in which the DMEK graft was initially elevated with SF6 gas in an upside down orientation, as demonstrated intraoperatively by the S-stamp. In each case, the graft was immediately manipulated into the proper orientation and the rescued case completed using our standard technique. The postoperative complications of these cases were reported and the percentage of endothelial cell loss at 6 months was compared with that of cases in this series without this rare intraoperative complication. RESULTS: All 3 rescued grafts achieved successful recipient corneal clearance and improved vision for the patient. There was no graft failure, rebubble, or rejection in these 3 cases. The average 6-month endothelial cell loss in the 3 initially inverted grafts was 51%, 58.3%, and 67% compared with 31.6% (SD ± 17.4%) in the series at large. CONCLUSIONS: Incorporation of a stromal-sided S-stamp has been previously shown to reduce the risk of iatrogenic primary graft failure through the prevention of upside down graft implantation. In these 3 instances, although the stamp did not prevent initial upside down graft elevation, it did allow the surgeon to immediately recognize this rare problem, correct it intraoperatively, and prevent iatrogenic graft failure in each case.

Descemet Membrane Endothelial Keratoplasty After Failed Descemet Stripping Without Endothelial Keratoplasty.

PURPOSE: To describe the clinical course, surgical experience, and postoperative outcomes of 3 patients with Fuchs endothelial dystrophy who underwent Descemet membrane endothelial keratoplasty (DMEK) after failed Descemet stripping without endothelial keratoplasty. METHODS: Three patients who underwent DMEK for management of persistent corneal edema after deliberate Descemet stripping in the setting of Fuchs endothelial dystrophy were identified. Patients were examined at day 1, week 1, and months 1, 3, and 6 after DMEK. Visual acuity, central corneal thickness (CCT), and evaluation of central corneal endothelial cell counts were recorded. RESULTS: Two women and one man, aged 56, 72, and 68 years, were included. The time interval between primary Descemet stripping and DMEK ranged from 3.5 to 8 months. Preoperative visual acuities were 20/200, 20/300, and 20/80. Immediately before DMEK, no patients had countable central endothelial cells, and CCTs were 825, 1034, and 878 µm. After DMEK, all patients had improvement in visual acuity to 20/70, 20/20, and 20/20 with CCTs of 529, 504, and 528. The postoperative period in the first case was notable for the immediate development of a pigmented pupillary membrane with posterior synechiae, as well as cystoid macular edema, of uncertain chronicity, noted 1 month postoperatively. The second case also developed posterior synechiae. Two cases completed 6-month endothelial cell counts totaling 2200 and 3114 cells per square millimeter (endothelial cell loss of 13% and 5.3%). CONCLUSIONS: DMEK is a reliable procedure to facilitate corneal rehabilitation and visual recovery in the event of poor corneal clearance after Descemet stripping without endothelial keratoplasty.

Relationship Between Tissue Unscrolling Time and Endothelial Cell Loss.

PURPOSE: To assess the relationship between intraoperative unscrolling time of the donor Descemet membrane endothelial keratoplasty (DMEK) tissue and 6-month postoperative endothelial cell loss (ECL), and to determine whether donor age, scroll tightness, and the presence of an S stamp are related to unscrolling time. METHODS: Ninety-three consecutive uncomplicated DMEK surgeries performed on eyes with Fuchs endothelial dystrophy using our standardized technique (ie, prestripped tissue with or without a premarked S stamp from our eye bank, overstripping the recipient, Straiko glass injector, no-touch tap technique, and bubble of 20% SF6 gas) were evaluated. Intraoperative unscrolling times and 6-month endothelial cell densities were measured and analyzed. RESULTS: Sixty-nine cases comprised the study cohort. The median unscrolling time was 4 minutes (range: 0.8-17.5 minutes), and the median ECL was 26.9% (range: -4.3% to 80.0%). There was no relationship between unscrolling time and ECL at 6 months by the Pearson correlation coefficient (r = -0.02, P = 0.89). Younger donor age, tighter scrolls, and absence of an S stamp had no correlation with longer unscrolling times (all P > 0.05). Only 2 of 4 cases of iatrogenic primary graft failure had unscrolling times available for analysis; in this limited sample, there was no association between iatrogenic primary graft failure and unscrolling time. CONCLUSIONS: Once the DMEK tissue is safely in the anterior chamber, surgeons need not rush the "DMEK dance" because longer unscrolling times may not endanger the endothelium.

Stamping an S on DMEK Donor Tissue to Prevent Upside-Down Grafts: Laboratory Validation and Detailed Preparation Technique Description.

PURPOSE: To report endothelial cell loss (ECL) caused by a novel S-stamp preparation technique for Descemet membrane endothelial keratoplasty (DMEK). METHODS: Six cadaveric human corneas were prepared for DMEK transplantation using a single standardized technique, including the application of a dry ink gentian violet S-stamp to the stromal side of Descemet membrane. Endothelial cell death was evaluated and quantified using computerized analysis of vital dye staining. RESULTS: ECL caused by the S-stamp was 0.6% (range 0.1%-1.0%), which comprised less than one-tenth of the total ECL caused by our preparation of the DMEK graft from the start to finish, including recovery, prestripping, S-stamping, and trephination (13.7% total ECL, range 9.9%-17.6%). CONCLUSIONS: Our novel S-stamp donor tissue preparation technique is intuitive to learn and holds the promise of preventing iatrogenic primary graft failure due to upside-down grafts without causing unacceptable increases in ECL.

Standardized DMEK Technique: Reducing Complications Using Prestripped Tissue, Novel Glass Injector, and Sulfur Hexafluoride (SF6) Gas.

PURPOSE: To report low complication rates in Descemet membrane endothelial keratoplasty (DMEK) using sulfur hexafluoride (SF6) gas, a novel glass injector, and donor tissue prestripped by an eye bank technician. METHODS: A standardized technique of DMEK was performed in 80 consecutive Fuchs corneal dystrophy cases using technician-prestripped tissue, a novel glass injector, a modified Yoeruek tap technique, and an SF6 gas (20% concentration) bubble for prolonged tissue support. Twenty-five donors were premarked with an "S" stamp for intraoperative orientation. Surgery was performed by 2 experienced DMEK surgeons and 2 inexperienced cornea fellows. Complications were recorded, and the percent endothelial cell loss was calculated at 6 months postoperatively. RESULTS: There were 5 cases that received an air bubble injection postoperatively (6% rebubble rate). There were 6 grafts that immediately failed, 2 because of excessive surgical trauma, and 4 because of upside-down graft placement documented by optical coherence tomography. None of the 25 cases with an S stamp failed. Recipient corneas cleared quickly with no clinical evidence of toxicity from the SF6 gas bubble, and the grafts experienced a mean endothelial cell loss of 27% at 6 months. CONCLUSIONS: Tissue prestripped by an eye bank technician can be safely used for DMEK surgery. SF6 gas for prolonged tissue support may reduce the rebubble rate in DMEK, with no apparent acute toxic effect. An unrecognized upside-down graft was the primary cause of graft failure in this series. Upside-down grafts may be eliminated by the use of donor tissue premarked by the eye bank with an S orientation stamp.

Retinal detachment associated with traumatic chorioretinal rupture.

Traumatic chorioretinal rupture, also known as sclopetaria, is a full-thickness break of the choroid and retina caused by a high-velocity projectile striking or passing adjacent to, but not penetrating, the globe. Previous reports have emphasized that retinal detachment seldom occurs, and observation alone has been the recommended management strategy. However, the authors present herein a series of consecutive patients with retinal detachment associated with sclopetaria and provide a literature review of the topic. They recommend that patients with traumatic chorioretinal rupture be monitored closely for the development of retinal detachment during the first few weeks after the injury.