[Uveitis and tattoos]. / Uvéites et tatouages.

The complications of tattoos are multiple and known for many years. However, their success explains their exponential multiplication in all countries. This confirmed the development of two new complications: a localized or remote skin sarcoidosis reaction, as well as the development of clinical and histological uveitis. This is in the context of a delayed hypersensitivity reaction, or a granulomatous reaction. Their prevention remains rather poorly known. It requires that each tattoo-carrying subject perform a systemic sarcoidosis check-up as well as an ophthalmological investigation in search of possible uveitis. If confirmed, preventive and therapeutic measures will be carried out in emergencies to avoid blindness. These new complications confirm the extreme severity of the use of uncontrolled inks, real toxic and sensitizing mixtures, especially apparently during extensive colorful tattoos. These particularly aggressive colored inks release multiple substances and nanoparticles into the body, not all of which are measured in the medium and long term.

[Keratoconus]. / Kératocône.

Keratoconus is a slowly progressive, non-inflammatory disorder of the eye characterized by thinning and protrusion of the cornea. Typically diagnosed in the patient's adolescent years, keratoconus may lead to substantial distortion of vision primarily from irregular astigmatism and myopia, and secondarily from corneal scarring. The classic histopathologic features include breaks in Bowman's layer and thinning of the corneal stroma. The etiology of keratoconus remains unclear. Form fruste keratoconus shows little progression, and has become known due to videotopographic analysis; it is very important to rule out in refractive surgery candidates. Treatment begins first and foremost with contact lenses, progressing to surgery as contact lens intolerance develops, with the goal of stabilization, including: cross-linking, intrastromal corneal ring segments and corneal transplantation.

[Intravitreal bevacizumab pretreatment in vitrectomy for severe diabetic retinopathy: a series of six cases]. / Utilisation du bévacizumab (Avastin(®)) en injection intravitréenne avant vitrectomie pour rétinopathie diabétique sévère, à propos de six cas.

INTRODUCTION: Bevacizumab (Avastin(®), Roche) is a full-length humanized monoclonal antibody applicable to all subtypes of vascular endothelial growth factor (VEGF). The purpose of this study was to report the results of its use as a surgical additive in severe cases of proliferative diabetic retinopathy (PDR). PATIENTS AND METHOD: This retrospective study focused on six eyes of six patients with complicated diabetic retinopathy. A vitrectomy was performed within 13.6 days after an intravitreal bevacizumab injection of 0.1 mL (2.5mg), with dissection of the fibrovascular proliferation using a mono- or bimanual delamination technique. RESULTS: The mean follow-up after intravitreal injection was 13.3 months. The mean surgery time was 64 minutes. The bimanual technique was not necessary. Only one iatrogenic retinal tear was repaired. The intraoperative bleeding was negligible. No adverse events resulting from the drug nor recurrence were observed throughout the follow-up period. CONCLUSION: Intravitreal bevacizumab is useful as a surgical additive in severe cases of PDR, significantly improving surgical conditions. Nevertheless, its use beyond approved indications should be reserved for complex surgical cases.

[Sutureless transconjunctival 20-gauge vitrectomy]. / Évaluation de la vitrectomie transconjonctivale 20-gauge sans suture.

PURPOSE: To evaluate the safety and efficacy of 20-gauge transconjunctival sutureless vitrectomy for a variety of vitreoretinal conditions. PATIENTS AND METHODS: This study was a retrospective clinical case series examining 29 eyes of 29 patients treated with 20-gauge transconjunctival sutureless vitrectomy. The main outcome measures included intraocular pressure, visual acuity, surgical time, and intraoperative and postoperative complications. RESULTS: The mean follow-up duration was 5.7 months. There were only two cases of postoperative ocular hypotony (6.9%) and one suspect case of endophthalmitis. Mean overall acuity improved from 0.495 logMar at baseline to 0.29 logMar (p=0.002) and mean total operative time was 19 min. We observed no cases of retinal detachment. CONCLUSION: Twenty-gauge transconjunctival sutureless vitrectomy is an effective surgical technique, but other studies are needed to confirm its safety and its value in other indications.

[Predictive factors for successful Ferrara intracorneal ring segment implantation in keratoconus]. / Facteurs prédictifs de succès des anneaux intracornéens de Ferrara dans le kératocône.

OBJECTIVE: To define predictive factors after manual implantation of intrastromal corneal ring segments (Ferrara ring) for the management of keratoconus. PATIENTS AND METHODS: Twenty-five eyes of 25 patients with keratoconus were implanted with Ferrara intracorneal ring segments using a mechanical procedure. We measured corneal ring implantation depth, best spectacle-corrected visual acuity (BSCVA), as well as refractive and keratometric outcomes. Patients were separated into two groups according to the gain of at least two lines of BSCVA ("good response") or the gain of only one line of BSCVA, no change, or the loss of lines of BSCVA ("poor response"). RESULTS: After a 6-month follow-up, 41% patients experienced a gain of at least two lines of BSCVA, 31.8% a gain of only one line, 13.6% no change, and 13.6% a loss of BSCVA. The sphere reduced from 4.39 to 2.34D (p<0.01), the cylinder from 4.19 to 2.77D (p<0.01), and the mean keratometry from 51.44 to 48.74D (p<0.02). As successful predictive factors, we found the asymmetry of keratoconus (p<0.01) in relation to the steepest meridian and patients implanted with a single ring (p<0.02). CONCLUSION: Defining preoperative successful predictive factors for Ferrara intracorneal ring segments is essential to enhance postoperative outcomes.

[Survey of complications in Descemet stripping automated endothelial keratoplasty in 32 eyes]. / Complications après Descemet stripping automated endothelial keratoplasty : étude monocentrique sur 32 yeux.

OBJECTIVE: To report complications during and after Descemet stripping automated endothelial keratoplasty (DSAEK) in 32 eyes at a single academic center with two techniques for delivering the endothelial corneal graft. PATIENTS AND METHODS: Outcomes from a single center of 32 consecutives cases of DSAEK were analyzed prospectively. In the first 23 patients, the endothelial graft underwent single-fold delivery with forceps, and in the remaining nine patients, the graft was delivered with the Busin glide-based technique. The complications of DSAEK were noted from the intra- and postoperative periods. RESULTS: Graft detachment was the most common type of complication encountered. In seven of 32 eyes (22%), graft detachments were observed. Three of the 32 eyes (9.5%) were considered to have failed DSAEK, meaning that persistent edema was present after DSAEK. One of the 32 eyes had a late corneal decompensation. Three eyes (9.5%) demonstrated graft rejection. Four eyes with detached grafts were successfully rebubbled after surgery. Two of the 32 eyes (6.2%) underwent repeat DSAEK and three eyes (9.5%) underwent penetrating keratoplasty. CONCLUSIONS: DSAEK is becoming the preferred method for treating endothelial dysfunction because it maintains the structural integrity of the eye and provides rapid visual recovery with minimal refractive change. However, we experienced some complications. Graft detachment is the most common complication, but postoperative rebubbling allows for graft reattachment in most cases. Other common complications found in this series were graft failure and graft rejection.

[Corneal allograft rejection after Descemet stripping automated endothelial keratoplasty (DSAEK): report of three cases]. / Rejet d'allogreffe de cornée après Descemet stripping automated endothelial keratoplasty (DSAEK) : à propos de trois cas.

INTRODUCTION: Descemet stripping automated endothelial keratoplasty (DSAEK) is an exciting alternative to standard full-thickness penetrating keratoplasty (PK) for the treatment of patients suffering from endothelial failure of the cornea. Corneal transplant rejection is the leading cause of endothelial failure after PK. While DSAEK may reduce the risk of corneal allograft rejection, endothelial rejection can still occur. CASE REPORTS: We report three cases of endothelial rejection after DSAEK. Subacute endothelial rejection occurred in all three cases after the topical steroid treatment regimen had been stopped. CONCLUSION: A lower rejection rate in comparison with PK cannot be assumed and comparative studies are necessary. Extended topical steroid may be used. Subacute endothelial graft rejection implies that the patient needs to be fully informed of the functional signs and the need to seek medical advice immediately.

[Corneal collagen cross-linking with ultraviolet-A light and riboflavin for the treatment of progressive keratoconus]. / Cross-linking du collagène cornéen induit par ultraviolet-A et riboflavine dans le traitement du kératocône évolutif.

INTRODUCTION: The aim of the present study was to evaluate the clinical usefulness of riboflavin- and ultraviolet-A (UV-A)-induced collagen cross-linking (CXL) on progressive keratoconus. PATIENTS AND METHODS: Twenty eyes of 20 patients with progressive keratoconus were included in a prospective, nonrandomized pilot study. The preoperative progression of keratoconus was documented by an increase in maximum keratometry (Kmax) on serial corneal topographies. Preoperative corneal thickness was at least 400 microm. The postoperative progression of keratoconus was evaluated from corneal topography, best-corrected visual acuity (BCVA) testing, and corneal biomechanical properties assessed with the Ocular Response Analyzer (ORA). The follow-up time was between 3 and 18 months. RESULTS: The steepening decreased significantly by 1.68+/-2.18 diopters (D) in the first year (p<0.05). The Kmax value decreased in 66% of eyes and remained stable in 17% (within+/-0.50 D). The mean preoperative BCVA was 0.49+/-0.22. Six months after the CXL treatment, the mean BCVA was 0.63+/-0.23 (p<0.05) and improved at least one line in 56.25% of eyes. The ORA values remained stable over the entire follow-up period. DISCUSSION: Extensive experimental study showed a significant increase in corneal rigidity after riboflavin/UV-A-induced CXL. CONCLUSION: Preliminary results on the clinical effects of riboflavin/UV-A-induced CXL are encouraging in reducing the progression of keratoconus. Long-term results are necessary to evaluate the duration of the stiffening effect.

[Juvenile xanthogranuloma of the corneoscleral limbus]. / Xanthogranulome juvénile de localisation cornéo-sclérale limbique.

An 18-year-old patient presented with a solitary limbal tumor on his left eye that had appeared and increased in size for 3 weeks. This mass did not display any extension into the anterior chamber on gonioscopy. Excisional biopsy by lamellar sclerokeratectomy was carried out and the lesion was sent for histologic examination. The pathologic diagnosis showed the characteristic picture of juvenile xanthogranuloma with numerous Touton giant cells. There was no recurrence after a 9-month follow-up. The diagnosis of isolated ocular juvenile xanthogranuloma may be difficult and histologic examination of ocular lesions is often necessary. When juvenile xanthogranuloma affects the uvea, treatment is medical. When it appears as a limbal mass, treatment is surgical. Juvenile xanthogranuloma should always be considered a differential diagnosis of a limbal mass, especially in children.

[Severe bacterial keratitis. A clinical, epidemiologic, and microbiologic study]. / Kératites bactériennes sévères. Etude épidémiologique, clinique et microbiologique.

INTRODUCTION: The aim of this study was to report the epidemiologic and microbiologic features and to define the risk factors of hospitalized cases of bacterial keratitis in the Toulouse University Hospital Center of Ophthalmology (France). METHODS: This was a retrospective study including all cases of serious bacterial keratitis hospitalized between January 2006 and November 2007. Epidemiologic, microbiologic, and clinical factors such as age, reasons for hospitalization, visual loss, and risk factors were described. RESULTS: Sixty-seven patients were hospitalized during this period, with a mean age of 46 years. The two most frequent clinical features for hospitalization were the area of stromal infiltrate (63%) and central corneal localization (61%). A local risk factor was identified in 92.5% of cases in decreasing order: contact lens wear (49%), keratopathy (16%), corneal injury (12%), and corneal surgery (7%). Sixteen percent had immunodeficiency from the most part because of diabetes and Gougerot-Sjögen's syndrome. Bacterial samples were positive in 57% of cases. Gram-negative bacteria were often isolated (45%) among contact lens wearers. After 3 months, the final visual acuity improved in 85% of the eyes studied. DISCUSSION: Contact lens wear, even if it was the leading risk factor of serious bacterial keratitis requiring hospitalization, was not a negative prognosis factor in our study. CONCLUSION: Factors such as a low preoperative visual acuity, age, and the size of the initial infiltrate have a poor prognosis and immunodeficiency is the predisposing factor associated with the worst final visual acuity.

[Deep lamellar anterior keratoplasty]. / Les kératoplasties lamellaires antérieures.

Penetrating keratoplasty is the most common method of corneal graft no matter which pathology is present. The surgical procedure is easy but unnecessary substitution of healthy recipient endothelium in diseases affecting only the anterior layers exposes the patient to the risk of immunologic rejection. Lamellar keratoplasty was the first procedure described. It has become less popular because it is technically difficult to perform and often has poor visual results due to imperfect lamellar dissection. Recent advances in surgical techniques enable us to manage these difficulties and lamellar keratoplasty may well become the first choice of treatment for most stromal diseases.

[Botulinum injection in infantile strabismus. Results and incidence on secondary surgery in a long-term survey of 74 cases treated before 36 months of age]. / Injection de toxine botulique dans les strabismes précoces. Efficacité et incidence sur les indications chirurgicales ultérieures. A propos de 74 cas traités avant l'âge de 36 mois.

PURPOSE: To evaluate the long-term results of early treatment of infantile strabismus with botulinum toxin A injection and its incidence on secondary oculomotor surgery. PATIENTS AND METHODS: A cohort of 74 cases of children presenting infantile strabismus, aged 7-36 months (mean, 18 months), received no more than two injections of 5 IU of botulinum in both medial recti. Secondary surgery was performed when horizontal and/or vertical deviation persisted. RESULTS: The patients were examined 2-7 years after the last injection (mean, 3.5 years). Forty cases needed only one injection. We found 46 (62%) cases of microtropia (from -4 to +4 PD), 17 cases of esotropia less than 20 PD, eight cases of esotropia greater than 20 PD, and three cases of exotropia. Horizontal deviation was improved in 82.4% of the cases. The only predictive factor of failure was the presence of high adduction (p<0.05). DVD was found at the same frequency in all groups (50%). Twenty-seven cases (35%) had secondary surgery, 19 of which were associated with vertical surgery. The relaxant role of botulinum seems to be clearly proven given that we only found 22% of esodeviation persisting under general anesthesia with myoresolution during secondary surgery (approximately 70% in untreated cases). CONCLUSIONS: Early treatment of infantile strabismus with botulinum seems effective and safe, improving 82.4% of our cases. Medical treatment is, however, still mandatory. Only 35% of our cases needed secondary surgery versus 70% of patients in spontaneous progression. The amount of horizontal surgery seems reduced after botulinum treatment. Vertical factors, found in 70% of operated cases, seem a major factor of instability of the results.

[Fungal keratitis caused by Scedosporium apiospermum]. / Kératite fongique à Scedosporium apiospermum.

INTRODUCTION: We report a case of posttraumatic keratomycosis caused by Scedosporium apiospermum that was treated with oral and topical voriconazole and penetrating keratoplasty. CASE REPORT: A patient was admitted to the hospital with a corneal abscess of his right eye due to trauma while gardening. No improvement was noted with topical fortified antibiotics (vancomycin, gentamicin, and cefazolin) and antimycotic (amphotericin B 1%) and oral itraconazole (200 mg/day). Fungal cultures of corneal scrapings revealed growth of Scedosporium apiospermum, a strain for which the main antifungals showed high minimal inhibitory concentrations (MICs), whereas the MIC of voriconazole was 0.125 microg/mL. Despite some improvement with topical 1% voriconazole and oral voriconazole (200 mg/day) treatment, a therapeutic penetrating keratoplasty was performed because of the high risk of corneal perforation. The graft remained clear without fungal recurrence with topical 2% cyclosporine A, dexamethasone, and voriconazole treatment. CONCLUSION: Scedosporium apiospermum is an uncommon cause of mycotic keratitis in humans. Prognosis is generally poor because of delayed diagnosis and resistance to conventional antifungals. Voriconazole is a triazole broad-spectrum antifungal agent. In conjunction with its oral administration, topical application of voriconazole extends the current armamentarium of antifungal agents for keratomycosis.

[Unilateral congenital cataracts removed early: long-term refractive changes]. / Cataractes congénitales unilatérales opérées précocement: devenir réfractif à long terme.

PURPOSE: Predict long-term refractive changes after primary lens implantation for unilateral congenital cataract in order to know the intraocular lens power to use to obtain best functional results. METHODS: This retrospective study analyzed 53 children with unilateral congenital cataract operated on with primary intraocular lens implantation, with a mean follow-up of 6.8 years. The mean age at surgery was 2.98 years. RESULTS: The mean myopic shift per year was -0.83 D/year. Children operated on before the age of 2 years had a mean myopic shift of -9.15 D, and others presented -2.13 D. The variability of myopic shift decreased with age. The mean visual acuity was +0.25 logMAR. Four intraocular lenses were changed because of substantial anisometropia. CONCLUSION: Early surgery with primary implantation and intensive amblyopia treatment provide good long-term visual results. Long-term refractive changes of very young children operated on for unilateral congenital cataract is extremely variable. Changing the intraocular lens is conceivable when substantial anisometropia slows down amblyopia rehabilitation.

[Refractive efficacy and tolerance of the foldable phakic iris-supported Artiflex lens in the surgical correction of moderately high myopia: a 2-year follow-up]. / Efficacité réfractive et tolérance de l'implant phaque myopique souple à fixation irienne Artiflex dans la correction chirurgicale de la myopie forte: résultats à deux ans.

INTRODUCTION: A new foldable version of an anterior chamber phakic lens designed to surgically correct high myopia was evaluated. PATIENTS AND METHODS: A prospective study on the efficacy and tolerance of a foldable phakic intraocular iris-supported lens, designed to correct moderately high myopia, is presented in this article. Twenty-five eyes of 25 patients were implanted uneventfully using this lens, newly designed and called the Artiflex lens. This phakic intraocular lens is an upgraded foldable version of the Artisan (or Verisyse) lens. The follow-up was complete (24 months) for all Artiflex-treated eyes and the targeted postoperative refraction was emmetropia. Inclusion criteria were moderately high myopia ranging from -8 to -14 D, unchanged refraction for 2 years, total contact lenses wearing intolerance, refractive cylinder power no greater than 1.5 D, anterior chamber depth greater than 3 mm, and endothelial cell count greater than 2,200 cells/mm2. RESULTS: The preoperative spherical equivalent was -9.70+/-2.37 D. The spherical equivalent was -1.07+/-0.84 D at 2 years postoperatively. The surgically induced astigmatism was 0.42 D x 67.4-degree axis. The percentage of eyes with an uncorrected visual acuity greater than or equal to 0.5 and 0.8 was 66.6% and 33.3%, respectively. Neither intra- nor postoperative complications were noted during the entire follow-up period. The mean endothelial cell count value was 2267+/-352 at 2 years postoperatively. The objective and subjective quality of vision was acceptable, associated with a high level of patient satisfaction. DISCUSSION: The refractive results and tolerance of the Artiflex lens are satisfactory and seem to be as good as other phakic intraocular lens outcomes. CONCLUSION: To correct moderately high myopia, the Artiflex lens seems to provide a suitable refractive efficacy and a quick visual recovery, secondary to a lowering of induced astigmatism. Furthermore, this phakic intraocular lens is associated with satisfactory safety and quality of vision at each milestone of the entire follow-up period.

[Evulsion of the optic nerve, a diagnosis to be recognised!]. / L'avulsion du nerf optique, un diagnostic à connaître!

INTRODUCTION: Evulsion of the optic nerve is a rare but serious injury. It occurs generally after an ocular contusion and may cause blindness. CASE: We report the case of a 53-year-old woman who presented with a blunt ocular trauma after having been punched by her husband. Initial examination of the left eye was impossible due to a major palpebral oedema. A CT scan of the orbit revealed a thickened optic nerve. No improvement was noted. DISCUSSION: Optic nerve avulsion is often caused by sudden and forceful rotation of the eye with tearing of the optic nerve as its globe entry level. The diagnosis can be confirmed by examination of the ocular fundus or by medical imaging such as CT scan of the orbital cavity as in our case report. The prognosis is usually poor.

[Orbital tumors in children: CT and MR imaging features]. / Tumeurs orbitaires chez l'enfant: revue iconographique en TDM et IRM.

The purpose of the article is to review the CT and MR imaging features of orbital tumors in children. Tumors in children are usually different than those in adults. Clinical symptoms are usually non-specific. Clinical examination combined with US may be sufficient for diagnosis and follow-up of benign and superficial lesions. CT and/or MRI are needed for deep or malignant lesions. CT is valuable for osseous and/or calcified lesions. MR is advantageous because of its superior spatial resolution and non-ionizing nature. Malignant tumors correspond to about 20% of lesions and include primary tumors (retinoblastoma, rhabdomyosarcoma) and metastases. Benign pathology is more frequent (80%) with dermoid cyst corresponding to about 50% of orbital masses.

[A murine model of transitory optic neuropathy based on small interference RNA-induced OPA1 silencing in vivo (gene mutation associated with Kjer's disease)]. / Modèle murin de neuropathie optique transitoire par inhibition in vivo de l'expression d'OPA1 (gène impliqué dans la maladie de Kjer).

PURPOSE: Developing a murine model of OPA1 linked optic neuropathy. METHODS: Intravitreal injections (in adult C57BL/6J mice) of small interference RNA (siRNA) specific to OPA1 were performed in the left eye. The right eye served as control, injected with nonspecific siRNA (siRNA scramble). Visual evoked potentials and flash electroretinograms were performed 5 and 12 days after injection. Three months after injection, microscopy of optic nerve sections was performed. RESULTS: The electrophysiological tests showed a significant reduction in the VEP when the siRNA OPA1-injected eye was stimulated, compared with the control eye injected with siRNA scramble. The electroretinogram was normal in both eyes: no significant difference between the right and the left eye was found. Three months after injection, no measurable axonal degeneration was found in either eye. CONCLUSION: The reduced expression of OPA1 based on RNA silencing in adult mice could induce reversible dysfunction of retinal ganglion cells.

[Automobile driving and visual aptitude in 100 patients over 60 years of age]. / Conduite automobile et aptitude visuelle chez 100 patients âgés de plus de 60 ans.

OBJECTIVE: To evaluate visual capacity and automobile driving in a sample of individuals over 60 years of age based on the visual function criteria as defined in the 29 May 1997 French Journal Officiel. MATERIAL AND METHODS: Drivers over 60 years of age were included in a prospective monocentric epidemiological study between January and March 2005. Binocular visual acuity and monocular visual acuity were measured in subjects with their optical corrections. Binocular or monocular visual field was tested depending on visual acuity results. Etiologies of visual acuity loss and visual field impairment of each eye were recorded in patients who did not meet the required criteria. RESULTS: One hundred patients were included (mean age, 70.7 years +/- 7.12 years). Twenty-nine patients did not meet the required criteria (29%; 95% confidence interval=[20.1;37.9]). On these 29 patients, 20 (69%; 95% CI=[52.2;85.8]) were unfit for driving an automobile with potential reversibility, whereas nine (31%; 95% CI=[14.2;47.8]) were permanently unfit from a visual point of view. CONCLUSION: The frequency with which patients ignore their poor distance visual acuity and the possibility of reversing the problem make it clear that the ophthalmologist has a role to play in detecting and informing patients.

[Deep anterior lamellar keratoplasty in the surgical treatment of keratoconus. A 1-year follow-up]. / Kératoplastie lamellaire antérieure profonde dans le traitement chirurgical du kératocône. Recul de plus d'un an.

OBJECTIVE: To evaluate the results of deep anterior lamellar keratoplasty (DALK) using dissection with air or with a viscoelastic substance in the surgical treatment of keratoconus as an alternative to penetrating keratoplasty. MATERIAL AND METHODS: This prospective monocentric noncomparative study involved patients with contact lens-intolerant keratoconus operated on between February 2001 and September 2002. Deep lamellar dissection was performed either by air injection into the cornea to create a white emphysema of the stroma or by viscoelastic injection. This allows the surgeon to separate Descemet's membrane from the posterior stroma using the air-to-endothelium interface. Previously, aqueous humor was replaced by air in the anterior chamber to visualize the posterior corneal surface. A full-thickness allogenic corneal button was sutured into the recipient bed, after stripping its Descemet's membrane. RESULTS: Fifteen eyes of 15 patients (mean age, 41.2 years) underwent DALK. The mean preoperative visual acuity was 0.11+/-0.06. At 1 year, the mean best corrected visual acuity was 0.47+/-0.16 (p<0.001). Mean keratometric astigmatism was reduced from 6.97+/-3.3 D to 2.77+/-1.76 D at 1 year (p<0.001). Specular microscopy 3 months postoperatively revealed average endothelial cell counts of 2018+/-662/mm2, while 1 month preoperatively this value was 2604+/-235/mm2 (cell loss, 22.5%; p>0.05). Perforation of Descemet's membrane during surgery occurred in five eyes (33.3%). Two cases were converted to penetrating keratoplasty. There was no endothelial rejection. CONCLUSION: In this series, DALK appears to be a promising procedure for treatment of keratoconus with encouraging refractive outcome, no progressive primary graft failure, and no allogenic endothelial graft rejection. DALK is an interesting alternative for penetrating keratoplasty even if it is technically more difficult.