Challenges of DMEK Technique with Young Corneal Donors' Grafts: Surgical Keys for Success-A Pilot Study.

PURPOSE: To report on the surgical maneuvers recommended for a successful unfolding of very young donors in order to accomplish an uneventful Descemet Membrane Endothelial Keratoplasty (DMEK) surgery. METHODS: Five patients (three females and two males, mean age 71.2 ± 6.7 years) with Fuchs endothelial cell dystrophy who underwent DMEK with very young donors (between 20 and 30 years old) were included. The following demographic data were assessed: donor's age, donor's endothelial cell density (ECD), preservation time, recipient's age and sex and unfolding surgical time. Best-corrected visual acuity (BCVA; decimal system), ECD and corneal central thickness (CCT) were assessed preoperatively and at 6-month follow-up. RESULTS: Donors' mean age was 23.6 ± 3.6 years (range 21 to 30) and the mean ECD was 2748.6 ± 162.6 cells/mm2. All of them underwent an uneventful DMEK as a single procedure performed by one experienced surgeon (MAG) with a mean unfolding time of 7.2 ± 4.9 min (range 4 to 15). The essential steps, including patient preparation as well as DMEK graft implantation, orientation, unrolling and centering are detailed. At 6 months, BCVA was 0.6 ± 0.2, ECD was 1945.0 ± 455.5 cells/mm2 and CCT was 497.0 ± 19.7 microns. CONCLUSIONS: We hereby present the keys to overcome tightly scrolled grafts of very young donors, which prove perfectly suitable for DMEK surgery. The graft shape tends towards a double-roll and specific maneuvers are strongly recommended.

Outcomes of Corneal Transplant in Childhood Glaucoma.

PRCIS: Childhood glaucoma produces alterations in the postnatal development and function of various ocular structures, including the cornea. Childhood glaucoma patients present lower corneal transplant survival rates. Our series shows outcomes of corneal transplant in childhood glaucoma with survival rates of 29% at 2 years. OBJECTIVE: To investigate the surgical outcome of different types of keratoplasty in eyes with childhood glaucoma. PATIENTS AND METHODS: A retrospective review was made of the medical records from 17 eyes of 15 patients who were diagnosed with childhood glaucoma and received a corneal transplantation between January 2010 and July 2020. Patient demographics, intraocular pressure, previous ocular surgery, comorbidities, corneal transplant surgery, and follow-up outcome were collected. The primary efficacy endpoint was graft survival (in months) until failure, the latter being considered as irreversible loss of corneal transparency. Secondary efficacy points were the need for an increase in topical hypotensive therapy and the need for additional surgery. RESULTS: Seventeen eyes of 15 patients were included, 11 eyes (10 patients) with primary congenital glaucoma and 6 with other types of childhood glaucoma. Corneal transplantation was performed at the mean age of 23.76 ± 14.86 years. At the time of the transplantation, the number of topical medications was 1.35 ± 1.27, intraocular pressure was 15.00 ± 8.34 mm Hg, and patients had received up to 7 glaucoma surgeries. Descemet stripping automated endothelial keratoplasty was performed in 13 eyes (76%) and penetrating keratoplasty in 4 (24%). After surgery, 7 (41%) eyes required increased topical treatment and 2 (12%) glaucoma surgery. Twelve eyes (71%) developed graft failure at 24 months, the mean time of survival being 13.88 ± 8.25 months. CONCLUSIONS: Management of corneal decompensation in childhood glaucoma poses a challenge. In this series of childhood glaucoma with corneal transplantations, the survival rate was 29% at 24 months.

Face mask use and effects on the ocular surface health: A comprehensive review.

In the COVID-19 period, face masks increased exponentially. Several studies suggest that the rise in ocular discomfort symptoms during the pandemic is mostly part of dry eye disease and that these are due to the effect of face masks, resulting in the newly described term MADE, for "mask-associated dry eye". The most commonly proposed mechanism states that wearing a face mask creates an unnatural upward airflow towards the ocular surface during expiration, although the increased temperature, humidity and levels of carbon dioxide of the exhaled air, stress, increased use of video display terminals, as well as changes in the ocular microbiota may contribute. Evidence supports that the use of face masks causes an increase in dry eye disease symptoms, a decreased tear break-up time, corneal epithelial trauma, periocular temperature changes and inflammatory markers secretion. Given that the use of masks may be frequent in some settings in the near future, it is important to establish its effects and consequences on the ocular surface.

Effect of face mask on topographic corneal parameters in healthy individuals.

PURPOSE: To evaluate whether the use of masks has an effect on the measurement of corneal topographic parameters. METHODS: A study including healthy patients with no previous ocular diseases or surgeries was conducted. Corneal topography was evaluated with an elevation topography Pentacam Scheimpflug. Four measurements were taken: two measurements with face mask and another two measurements after 10 min without wearing the face mask. The following parameters were evaluated: anterior topographic flat meridian (K1), anterior topographic steepest meridian (K2), mean keratometry (Km) and maximum keratometric point (Kmax). RESULTS: Thirty-five eyes of thirty-five healthy individuals were included; with a mean age of 33.5 ± 13.8 years (range 24-66) and 26 (74%) being female. Mean time with face-mask was 3.8 ± 2.2 h (range 1-8). No differences in mean K1, K2, Km and Kmax with and without face-mask were noted (paired t-test, all, p > 0.05). Intraclass correlation coefficients (ICC) were excellent for all four analyzed parameters (ICC > 0.914), although they were lower when measurements with face-mask were considered. CONCLUSIONS: Although tear film alterations with the use of face-mask have been described in the literature, no significant differences can be noted in topographic variables.

Long-Term Results of Postoperative Rescuing of Inverted DMEK Grafts: Two Case Reports.

PURPOSE: The purpose of this study was to report the clinical outcomes of postoperative repositioning of 2 inverted Descemet membrane endothelial keratoplasty (DMEK) grafts in 2 patients with endothelial dysfunction. METHODS: Two patients underwent DMEK surgery in a tertiary referral corneal clinic. Initial surgery was performed by 2 different corneal surgeons, and a third surgeon repositioned both cases. In the early postoperative period, partial and subtotal detachments were observed at slitlamp and inverted graft orientation was confirmed by anterior segment optical coherence tomography. In both cases, uneventful reposition of the inverted graft was performed by an experienced DMEK surgeon on days 2 and 9 after initial DMEK surgery. RESULTS: Repositioning surgery was successful in both patients. The Moutsouris sign was used to confirm proper orientation. One patient had total graft adherence at day 1 postrepositioning. The second patient required a rebubbling procedure, despite the correct orientation confirmed by using anterior segment optical coherence tomography. Visual acuity and corneal thickness were stable in both cases (case 1: 20/30, 567 µm; case 2: 20/80, 543 µm). Both patients had clear corneas and functional cell counts 2 years after repositioning (451 cells/mm 2 and 1052 cells/mm 2 ). CONCLUSIONS: Postoperative repositioning of an inverted DMEK graft may be a viable procedure to delay or prevent regrafting.

Effect of Face Mask on Tear Film Stability in Eyes With Moderate-to-Severe Dry Eye Disease.

PURPOSE: The purpose of this study was to evaluate whether tear film stability worsens with the use of masks in patients with dry eye disease, objectively analyzing the tear film stability using noninvasive tear film breakup time (NITBUT) with and without a face mask. METHODS: A cross-sectional study including patients with moderate or severe dry eye disease was conducted. Tear stability was measured using an Oculus Keratograph 5M (Oculus, Wetzlar, Germany), which records NITBUT, both first and average NITBUT. Two measurements were taken: an initial measurement with a mask and a second measurement after 10 minutes without wearing the face mask. RESULTS: Thirty-one patients were included with a mean age of 57.6 ± 11.7 years (range 31-80) and 30 being female (97%). Mean first NITBUT with face mask was 6.2 ± 3.8 seconds (range 2.0-19.8), which increased to 7.8 ± 5.6 seconds (range 2.3-24.0) without the use of mask (P = 0.029), differences being -1.6 ± 0.7 seconds (CI 95% -3.1075 to -0.1770). Mean average NITBUT with a face mask was 12.3 ± 4.8 seconds (range 4.0-19.4) and increased to 13.8 ± 5 seconds (range 5.5-24.0) without the use of mask (P = 0.006), mean difference being -1.5 ± 0.5 seconds (CI 95% -2.5290 to -0.4458). CONCLUSIONS: Face mask use decreases tear film stability in patients with moderate-to-severe dry eye.