Cataract surgery in setting of ocular surface disease.

PURPOSE OF REVIEW: The purpose of this article is to review the available strategies to successfully identify and manage ocular surface disease (OSD) pre, intra and post-cataract surgery. RECENT FINDINGS: Cataract surgery and OSD have an intricate relationship: the surgical procedure can induce or exaggerate OSD symptoms, while OSD can negatively impact surgical refractive outcomes and increase the rate of postoperative complications. SUMMARY: Improving the health and stability ocular surface is the key to enhance post cataract surgery refractive outcomes and avoid complications. This is pivotal for patients affected by severe OSD, but is also important for patients with minimal signs or symptoms. A correct diagnosis and a stepwise approach are the keys to improve the quality of life of such patients.

Deep Anterior Lamellar Keratoplasty: Can All Ruptures Be Fixed?

PURPOSE: The aim of this study was to report our experience in managing different types of Descemet membrane (DM) ruptures during deep anterior lamellar keratoplasty (DALK). METHODS: This study was a retrospective, consecutive, interventional case series of 1573 DALK procedures conducted on 1244 patients, performed between 2002 and 2017. Inclusion criteria consisted of a minimum of 24-month follow-up. DM rupture incidence, location, and surgical approach for repair were recorded. Postoperative measures were investigated only in eyes that experienced DM ruptures and included best spectacle-corrected visual acuity, endothelial cell loss, double anterior chamber, pupillary block, need for rebubbling, graft clarity, and rejection episodes. RESULTS: One thousand four hundred forty-three eyes met the inclusion criteria. DM ruptures occurred in 119 eyes (8.25%). Seventy-eight percent of DM ruptures were microruptures (≤2 mm), and they occurred more frequently during manual DALK cases. Macroruptures were less frequent (22%), and they occurred more frequently during subtotal and total anterior lamellar keratoplasty (STALK-TALK) cases. In general, DM ruptures mainly occurred in the peripheral cornea (95% of cases). One hundred (84%) of the 119 ruptures resolved by the first postoperative day. Nineteen cases (16%) developed double anterior chamber; all resolved by using different strategies. No intraoperative penetrating keratoplasty conversion was recorded. Pupillary block occurred in 7 cases (5.9%), but no Urrets-Zavalia syndrome was observed. The average postoperative endothelial cell loss was 410 ± 39 cells/mm 2 (19%) at 1-year follow-up, and there was no significant difference between cases requiring a rebubbling and cases that did not ( P = 0.896). All grafts but one were clear at the last follow-up. Graft failure from endothelial decompensation occurred in this lone case (0.8%). CONCLUSIONS: It is worth trying to repair all DM ruptures in DALK, and immediate penetrating keratoplasty conversion should be avoided. Understanding the physiomechanical mechanisms in DALK allows to correctly choose a proper rescue strategy to successfully repair DM ruptures.

Dilation devices in cataract surgery.

PURPOSE OF REVIEW: Cataract surgery in the setting of small pupil represent a major challenge and it is associated with a higher risk of complications. When pharmacologic pupil dilation fails, mechanical pupil expansion devices are needed to obtain and maintain sufficient intraoperative mydriasis. The purpose of this review is to assess the pupil expansion devices currently available. RECENT FINDINGS: A variety of pupil expansion devices are offered on the market. They differ for design, material, shape, size, cost, and easiness of insertion/removal, nonetheless they all seem to be effective in improving the pupil size and easing the cataract surgery. SUMMARY: Mechanical pupil expansion can be effectively achieved with a variety of devices, which are well tolerated and can facilitate cataract surgery in the setting of poor mydriasis.

Rediscovering a valuable manual Deep Anterior Lamellar Keratoplasty (DALK) technique: Outcomes of 42 "Peeling-off" DALK.

PURPOSE: Residual bed thickness in DALK should be less than 80µm to provide optimal visual outcomes. "Peeling-off" is a manual DALK technique, which separates the anterior stroma by pulling the deep stromal lamellae following the plane of their lowest adhesion, which is usually very deep. The purpose of this study is to measure the residual bed thickness achievable with this technique. METHODS: Retrospective case series of "Peeling-off" DALK cases performed between January 2014 and January 2021 with at least 1 year of follow-up. Indications for DALK, intraoperative and postoperative complications, residual recipient bed thickness at 1 day and at 1 month after surgery, and postoperative best corrected visual acuity (BCVA) at 1 year of follow up were evaluated. RESULTS: 42 eyes (42 patients) underwent DALK performed with "Peeling-off" technique. Indications for surgery were keratoconus in 33 eyes and stromal scar in 9 eyes. "Peeling-off" technique was used as a rescue approach to perform a DALK after a failed Big-Bubble in all cases, and also failed Air-Visco-Bubble in some cases. No intraoperative and postoperative complications were recorded. Residual recipient bed thickness was deep and regular, measuring 42 microns at 1 day postoperative (range 21-65 microns) and 23 microns (range 17-26 microns) at 1 month postoperative. Mean postoperative BCVA at 1 year of follow up was 0.18 logMAR ± 0.09. CONCLUSION: "Peeling-off" DALK is a valuable manual technique that achieves a deep stromal plane with optimal visual outcomes.

Deep anterior lamellar keratoplasty for corneal penetrating wounds.

PURPOSE: To report our surgical experience of deep anterior lamellar keratoplasty (DALK) performed in eyes with scarring resulting from a corneal penetrating wound without tissue loss. METHODS: Case series of three eyes of three patients that underwent DALK for poor vision due to a scar resulting from a previous corneal penetrating wound. Surgery was performed at least 1 year after the initial injury. Manual dissection technique was used in all cases. Preoperative and postoperative best correct visual acuity (BCVA), postoperative residual bed thickness, and postoperative endothelial cell count (ECC) were evaluated. RESULTS: Preoperative BCVA ranged from 1.3 to 1.0 LogMAR. Two eyes were pseudophakic and one eye had a traumatic cataract. Manual DALK was successfully accomplished in all three cases. The mean residual recipient bed thickness was 103 µm (range 68-130 µm). The mean endothelial cell loss at the 6th month of follow-up was 6% (range 3%-11%) with a further 1% decrease at 4 years. One of the patients underwent cataract surgery and limbal relaxing incisions 1 year after DALK having a total endothelial cell loss of 4.8% at 2 years of follow-up. BCVA at 2 years of follow-up was 0.1 LogMAR (range 0.22-0.0 LogMAR). No episode of rejection was recorded, and all grafts remained clear at last follow-up (5 years, range 4-6 years). CONCLUSIONS: Manual DALK should be considered in cases of corneal scars in optical zone resulting from penetrating wound.

Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination.

PURPOSE: The aim of this study was to describe a surgical technique to perform deep anterior lamellar keratoplasty (DALK) despite inadvertent full thickness trephination in one quadrant. METHODS: Case report of a 19-year-old boy who underwent DALK for visually significant post-infectious stromal scar in his left eye. An unintentional full thickness trephination occurred in the upper-nasal quadrant at the beginning of the surgery. After suturing the perforated area, manual DALK was performed, and an air bubble was left in the anterior chamber. Evaluated outcomes included best spectacle corrected visual acuity (BSCVA), residual recipient bed thickness, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double anterior chamber. RESULTS: The surgery was completed without any further complications. No double anterior chamber or Urrets-Zavalia syndrome was observed on the first postoperative day. Mean residual recipient bed thickness was 72 µm and regular. ECC was 2446 cell/mm2. BSCVA at 18 months of follow-up was 0.9. There were no episodes of rejection, and the graft remained clear at the last follow-up (4 years). CONCLUSION: Inadvertent partial full thickness trephination of the recipient cornea is a largely preventable but possible complication during DALK. Penetrating keratoplasty conversion can be avoided by performing a manual dissection DALK.

Deep Anterior Lamellar Keratoplasty After Previous Anterior Lamellar Keratoplasty to Improve the Visual Outcomes.

PURPOSE: To describe a series of patients who underwent deep anterior lamellar keratoplasty (DALK) after previous anterior lamellar keratoplasty (ALK) to improve their visual outcomes. METHODS: This is a retrospective case series of 9 DALK eyes (9 patients) with a history of previous ALK and an unsatisfactory visual outcome. Surgery was performed in all cases at least 3 years after ALK. Cannula big bubble, air viscobubble, and manual dissection techniques were performed. Preoperative and postoperative best-corrected visual acuity, residual recipient bed thickness, and endothelial cell count were evaluated. Follow-up was at least 24 months for all eyes. RESULTS: Two subtotal anterior lamellar keratoplasties (through 1 type 1 big bubble and 1 air viscobubble) and 7 manual dissection DALKs were achieved. A small rupture of the residual recipient bed occurred during 1 case, and it was managed without penetrating keratoplasty conversion. Mean best-corrected visual acuity improved from 0.64 to 0.09 logMAR. Postoperative residual recipient central bed thickness was less than 80 µm in all cases. No postoperative complications were recorded at the last follow-up (24-36 months postoperatively). CONCLUSIONS: Different DALK techniques can be successfully used to improve visual acuity in previous ALK eyes with an unsatisfactory visual outcome.

Total or subtotal full thickness recipient bed cut to repair donor-recipient curvature disparity in cases of DM rupture with manual DALK.

PURPOSE: To report how to manage a specific type of Descemet's membrane (DM) rupture during manual DALK with a concurrent donor-recipient disparity of curvature. METHODS: Case report of two patients that had DM rupture during manual DALK with a concurrent donor-recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a "DSEK autograft," was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. RESULTS: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). CONCLUSION: The existence of a donor-recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor-recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

Cataract surgery in corneal transplantation.

PURPOSE OF REVIEW: Corneal diseases are often associated with lens opacity. The present article reviews the recent advances in the management of cataract and corneal transplant. RECENT FINDINGS: Thanks to the development of lamellar transplant techniques and the evolution of cataract surgery, we now have several strategies to address corneal diseases and cataract including 'lamellar triple procedure'. Numerous precautions have been identified to have a successful surgery with good visual recovery. SUMMARY: Corneal diseases associated with cataract can be successfully managed using separate or combined surgical procedures, as appropriate. In most cases the intraocular lens power can be calculated with a predictable outcome.

Surgical Corneal Anatomy in Deep Anterior Lamellar Keratoplasty: Suggestion of New Acronyms.

Deep anterior lamellar keratoplasty (DALK) is the ideal surgery for corneal stromal diseases with a healthy endothelium. This technique offers substantial advantages compared with penetrating keratoplasty, primarily the avoidance of endothelial rejection and longer graft survival. Several DALK techniques have been described and classified into 2 categories, descemetic DALK (dDALK) and predescemetic DALK (pdDALK) depending on whether Descemet membrane-endothelium was thought to be exposed or minimal residual stroma was left behind. This classification was crucial to identify the conditions to achieve good visual outcomes with pdDALK techniques. The recent description of Dua's layer, also known as the pre-Descemet layer, has demonstrated that a very thin layer of stroma exists in some instances where Descemet membrane was thought to be completely exposed. This concept has generated a discrepancy between the previous and current applications of the terms "dDALK" and "pdDALK." We offer a summary of the published literature and a proposal for a new and more appropriate DALK nomenclature. We suggest adding the terms subtotal anterior lamellar keratoplasty (STALK) and total anterior lamellar keratoplasty (TALK).

Cannula-Assisted Technique to Unfold Grafts in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To describe the use of irrigating single-port cannulas to unfold Descemet membrane endothelial keratoplasty (DMEK) grafts when traditional tapping techniques are challenging. METHODS: This study is a retrospective, comparative, nonrandomized, interventional case series that includes 143 DMEKs performed between February 2014 and November 2015. All eyes were divided into 2 groups: in one group, there were 48 cases that underwent DMEK using tap techniques only (Tapping DMEK group), and in another group, there were 30 cases in which irrigating cannulas were used to unfold the graft as a secondary approach (Cannula DMEK group). Intraocular manipulation time and total graft manipulation time were assessed. Uncorrected visual acuity, best spectacle-corrected visual acuity, and endothelial cell count were evaluated at 6 and 12 months postoperatively. We also reviewed DMEK procedures performed between December 2015 and January 2017 to evaluate the use of irrigating cannulas to unfold the graft. RESULTS: All grafts were clear. There was a statistically significant improvement in uncorrected visual acuity and best corrected visual acuity at 6 and 12 months postoperatively in both groups (P < 0.01). Endothelial cell loss was 32.10% and 32.11% at 12 months in the Cannula and Tapping DMEK groups, respectively (P > 0.05). Total graft manipulation time was 3 minutes 40 ± 22 seconds in the Cannula DMEK group and 3 minutes 07 ± 26 seconds in the Tapping DMEK group (P < 0.01). Irrigating cannulas were used as a secondary approach in a smaller percentage of cases between December 2015 and January 2017 (26.2%) compared with DMEK performed during this study (38.5%). CONCLUSIONS: When it is difficult to unscroll the endothelium-Descemet membrane graft using only tap techniques, the use of Sarnicola cannulas is useful and effective without negatively affecting the postoperative endothelial cell count.

Cannula DALK Versus Needle DALK for Keratoconus.

PURPOSE: To evaluate outcomes and possible advantages of 2 different techniques of deep anterior lamellar keratoplasty (DALK) in patients with keratoconus: cannula big-bubble DALK and needle big-bubble DALK (Anwar technique). METHODS: This is a retrospective, nonconsecutive, comparative study of 507 eyes affected by keratoconus that underwent DALK between 2002 and 2012. Needle DALK and cannula DALK techniques were performed in 266 eyes and 241 eyes, respectively. When big bubble (BB) failed, air viscobubble (AVB) was used as a rescue bubble technique. When AVB failed, manual dissection was performed. Main outcomes analyzed were the frequency of descemetic deep anterior lamellar keratoplasty (dDALK) and predescemetic deep anterior lamellar keratoplasty (pdDALK), BB and AVB formation, Descemet membrane rupture, and penetrating keratoplasty conversion. RESULTS: The rate of dDALK achieved was higher (P < 0.01) in the cannula DALK group (94%; 198 BB and 28 AVB) than in the needle group (78%; 161 BB and 46 AVB). The remainder of cases involved pdDALK: 59 cases (22%) and 15 cases (6%) of the needle DALK group and cannula DALK group, respectively. Microperforation occurred in 18 cases spread between both groups. Macroperforation occurred in 5 cases in the needle DALK group. A double chamber occurred in seven cases, between both groups. No penetrating keratoplasty conversion was needed. CONCLUSIONS: The use of a smooth cannula during the DALK procedure yields a statistically higher percentage of dDALK and makes the maneuver more manageable compared with air injection with a needle. When BB fails, AVB seems to be a good rescue technique to achieve dDALK.

Early Deep Anterior Lamellar Keratoplasty (DALK) for Acanthamoeba Keratitis Poorly Responsive to Medical Treatment.

PURPOSE: To evaluate the success (eradication of infection) or failure (recurrence of infection in the cornea or sclera, or endophthalmitis) of early therapeutic deep anterior lamellar keratoplasty (DALK) for active Acanthamoeba keratitis (AK) poorly responsive to medical treatment. METHODS: Retrospective, noncomparative case series of 11 patients (11 eyes) affected by active AK poorly responsive to medical treatment who underwent early therapeutic DALK. Surgery was performed in all cases within 30 to 60 days from the onset of symptoms. Corneal ulcer depth was less than 300 µm in all cases. A 3-drug combination (chlorhexidine gluconate, propamidine isethionate, and neomycin sulfate) was the antiamoebic protocol used preoperatively and postoperatively. Cannula big bubble and "layer-by-layer" manual dissection techniques were performed. Eradication of infection, episodes of rejection, postoperative endothelial cell density, and the best spectacle-corrected visual acuity were evaluated. Histologic examination of surgical margins was performed, and margin clearance was assessed. Mean follow-up was approximately 2 years. RESULTS: Four descemetic DALK and 7 predescemetic DALK were performed. One small Descemet membrane rupture occurred. Peripheral surgical margins were free of infection in all cases. Deep surgical margins not free from infection were found in 2 cases. However, no episode of infection recurrence was observed. The postoperative average best spectacle-corrected visual acuity was 0.8 (range, 0.6-1.0). No case of rejection was recorded. CONCLUSIONS: Early therapeutic DALK could be considered a new approach to eradicate active infection in AK cases poorly responsive to medical treatment, with significant ulcer in the optical zone. Further studies are needed to validate this new indication for DALK.

Amniotic membrane transplantation in failed trabeculectomy.

PURPOSE: To determine the efficacy and safety of amniotic membrane transplantation for trabeculectomy in patients with previous failed filtering blebs. METHODS: A consecutive series of 19 eyes from 18 patients with 1 or more failed trabeculectomies were enrolled in this retrospective study. Trabeculectomy, with amniotic membrane positioned as a "graft" under the scleral flap, was performed, and the intraocular pressure (IOP), number of antiglaucoma medications, appearance of the filtering bleb, and intraoperative and postoperative complication data were retrospectively analyzed for a period of 24 months. Success was defined as IOP<21 mm Hg at the end of the follow-up period. RESULTS: The median preoperative pressure was 29 mm Hg [interquartile range (IQR)=5 mm Hg], with an average of 2.8 glaucoma medications (range, 1 to 4). At 6 months postoperatively the median IOP was 18 mm Hg (IQR=1.75 mm Hg) with no further significant increases recorded, settling at 19 mm Hg (IQR=3.25 mm Hg) at the end of the 24-month follow-up. Success was achieved in all 19 cases (100%), and only 1 patient (5%) required postoperative antiglaucoma therapy to reach the target pressure. At 24 months after surgery, 18 of 19 (95%) amniotic membrane filtering blebs were functioning well without antiglaucoma therapy. No patients had severe intraoperative or postoperative complications. CONCLUSIONS: Amniotic membrane transplantation in trabeculectomy seems to be a safe and useful procedure for improving the surgical outcome and maintaining low postoperative IOP in patients with a high risk of surgical failure.

Suture pull-through insertion of graft donor in Descemet stripping automated endothelial keratoplasty: Results of 4-year follow-up.

PURPOSE: To report our clinical experience and 4-year follow-up results of Descemet stripping automated endothelial keratoplasty (DSAEK) with the suture pull-through insertion technique. METHODS: This is a retrospective study of 195 eyes in which a posterior lamellar keratoplasty was performed between 2007 and 2011. The insertion of a folded donor lenticule was performed with a double-armed 10-0 suture using a straight transchamber needle and half-circle needle. Endothelial cell density was measured annually up to 4 years after the surgery, and cell loss was calculated based on the median preoperative donor endothelial cell density. Postoperative complications, primary graft failure, pupillary block, and dislocation of the donor tissue were assessed. RESULTS: All patients underwent uncomplicated DSAEK. Data were available for 195 eyes (100%) at 1 year, 186 eyes (95.3%) at 2 years, 176 eyes (90.2%) at 3 years, and 160 eyes (82%) at 4 years. Median preop-erative donor endothelial cell density was 2688 cells/mm2 [interquartile range (IQR) 207.5 cells/mm2], which decreased by 27% at 1 year (1956 cells/mm2, IQR 264.8 cells/mm2), 31% at 2 years (1855 cells/mm2, IQR 320.5 cells/mm2), 35% at 3 years (1756.5 cells/mm2, IQR 306.5 cells/mm2), and 36% at 4 years (1709.5 cells/mm2, IQR 288,0 cells/mm2). Nine patients (4.6%) had a dislocation of donor tissue; all were successfully reattached with a second air injection. Only three eyes (1.5%) developed graft failure. Pupillary block was present in 15 eyes (7.7%). CONCLUSION: DSAEK with suture pull-through insertion of donor graft represents a simplified and safe technique that has endothelial cell loss comparable with other techniques and low rates of intraoperative and postoperative complications.

Long-term graft survival in deep anterior lamellar keratoplasty.

PURPOSE: To determine corneal graft survival rates up to 10 years in a large consecutive series of deep anterior lamellar keratoplasties (DALKs). METHODS: A retrospective, consecutive, noncomparative cases series of DALK procedures in a total of 806 eyes of 711 patients with stromal diseases and healthy endothelium performed between 2000 and 2009. Inclusion criterion was surgery performed by a single surgeon (660 eyes), with at least 6 months of follow-up. Graft survival was analyzed using the Kaplan-Meier method. Endothelial loss was analyzed with the Gaussian distribution and the χ methods. Follow-up time, and preoperative and postoperative endothelial cell density (ECD) were considered in the analyses. RESULTS: Six hundred sixty eyes of 502 patients met the entry criteria. Mean length of follow-up was 4.5 years (range, 0.5-10 years). We report an average graft survival rate of 99.3% (range, 98.5%-100%); 3 eyes (0.45%) experienced graft failure and 1 eye (0.15%) developed late endothelial failure because of an intraoperative complication. Predominant indications for DALK in this series were keratoconus (74%), postherpetic keratitis scarring (15%), and corneal stromal opacities of different etiology (11%). Endothelial loss from preoperative levels averaged 11% (range, 10%-13%) at 6 months through 10 years after DALK. ECD was unchanged between 6 months postoperatively and the last follow-up visits. CONCLUSIONS: DALK is a successful form of transplantation in stromal corneal disorders with healthy endothelium, with higher long-term graft survival rates and stable ECD 6 months postoperatively. DALK survival rates do not vary significantly over time.

Blunt cannula for descemetic deep anterior lamellar keratoplasty.

PURPOSE: To evaluate the success of using a cannula for descemetic deep anterior lamellar keratoplasty (dDALK) and the frequency of Descemet perforation using the new Sarnicola deep anterior lamellar keratoplasty (DALK) cannula and spatula. METHODS: Retrospective study of medical records of 28 eyes of 28 patients who underwent the DALK procedure between December 2008 and February 2009 using the blunt Sarnicola spatula and cannula. Main outcomes analyzed were the frequency of dDALK and pre-dDALK, the frequency of big-bubble and air-visco bubble formation, and the frequency of Descemet rupture during the procedure. RESULTS: In 26 cases (93%), we achieved dDALK dissection; 2 cases (7%) were pre-dDALK. Big-bubble formation occurred in 24 cases (86%); in 2 cases (7%), an air-visco bubble was formed. No perforations of Descemet membrane occurred during air injection in an attempt to form a big bubble. A rupture of Descemet membrane occurred in 1 case (3.5%) during peripheral stromal excision. CONCLUSIONS: The smooth Sarnicola DALK spatula and cannula facilitate a high percentage of dDALK and make the maneuver more manageable compared to air injection with a needle.

Recurrence rate using fibrin glue-assisted ipsilateral conjunctival autograft in pterygium surgery: 2-year follow-up.

AIMS: To determine the recurrence rate after pterygium excision with ipsilateral conjunctival autograft using fibrin glue. METHODS: One hundred eleven eyes of 92 patients operated for primary pterygium were retrospectively evaluated for recurrence rate and intraoperative and postoperative complications. Pterygia were preoperatively divided in atrophic/grade 1 (n = 2; 1.80%), intermediate/grade 2 (n = 85; 76.58%), or fleshy/grade 3 (n = 24; 21.62%) types. All patients were operated using an ipsilateral conjunctival autograft fixed with fibrin glue. Only patients with 2-year follow-up were included in this study. RESULTS: Two years after surgery, the mean recurrence rate was 4.50% (n = 5). No intraoperative complications were noted. Postsurgical complications were graft pseudoedema (n = 45; 40.54%), graft retraction (n = 3; 2.70%), and donor site granuloma (n = 1; 0.90%). CONCLUSION: Fibrin glue-assisted ipsilateral conjunctival autograft seems to be safe and efficacious and associated with a low rate of recurrence.