Capsular phimosis with intraocular lens tilt and decentration.

A 34-year-old woman with quiescent bilateral intermediate uveitis maintained on once-daily dexamethasone 0.1% eyedrops, complicated by left cataract and glaucoma controlled with a single antiglaucoma medication, presented for cataract surgery. Her left corrected distance visual acuity (CDVA) was 20/40 because of a posterior subcapsular lens opacity. The anterior chamber angles appeared closed in all 4 quadrants on gonioscopy. Ultrasound biomicroscopy (UBM) confirmed the gonioscopy findings and, in addition, revealed a crystalline lens thickness of 5.53 mm, normal ciliary body structure, and multiple localized chorioretinal scars with membranes over the pars plana region. She underwent left phacoemulsification, goniosynechiolysis, and in-the-bag implantation of a single-piece monofocal hydrophobic acrylic intraocular lens (IOL). On the first postoperative day, she achieved pinhole vision of 20/70 (-6 diopters [D] myopia to balance with the fellow eye). There was mild anterior chamber cellular activity and flare, consistent with postoperative inflammation. Her intraocular pressure (IOP) was 16 mm Hg without antiglaucoma therapy. She was advised to continue the prednisolone acetate 1% eyedrops 6 times daily and to reduce it to 4 times daily after a week for the next 4 weeks. At 1 month, she was refracted to 20/40 N5, and the eye was quiescent. Optical coherence tomography showed that the macular was normal. The topical steroids were gradually tapered to the preoperative level. However, a month later, she returned complaining of deteriorating vision while using twice-daily steroid eyedrops. Her CDVA was 20/60. Slitlamp examination revealed anterior capsule fibrosis and capsular phimosis, resulting in partial obstruction of the visual axis and mild decentration of the IOL superior temporally (Figure 1JOURNAL/jcrs/04.03/02158034-202310000-00013/figure1/v/2023-09-28T161738Z/r/image-tiff). The anterior segment was quiescent. The pupil could only be dilated to 4.5 mm despite the absence of posterior synechiae. Fundus examination revealed a normal-looking quiescent posterior segment. Her IOP was 16 mm Hg. UBM showed a thickened anterior capsule, intact zonular fibers, and a posteriorly bowed and decentered IOL within the capsular bag (Figure 2JOURNAL/jcrs/04.03/02158034-202310000-00013/figure2/v/2023-09-28T161738Z/r/image-tiff). She was referred for further management. Discuss how you would manage this problem, explaining your decisions. How would you be able to avoid the same problem when operating on her fellow eye?

Graft detachments in endothelial keratoplasty.

Graft detachment is the most common complication of endothelial keratoplasty. With the ongoing advancements in the field of endothelial keratoplasty, our understanding of risk factors of graft detachments and its management has been evolving. Various prevention measures have been described in literature including presoaking the donor graft, anterior chamber tamponade, venting incisions, sutures to prevent dislocation of graft. Management of a detached graft involves secondary interventions such as rebubbling, suturing and regrafts. In this review, we discuss graft detachment in different types of endothelial keratoplasty techniques including Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty; with emphasis on incidence, risk factors, preventive measures and their management.

Post-penetrating keratoplasty astigmatism.

Postoperative astigmatism is one of the common complications affecting visual outcomes after a penetrating keratoplasty. It can result from various factors related to host, donor and surgical technique, resulting in suboptimal visual outcome. While some of the measures taken during preoperative planning and during actual surgery can reduce the magnitude of postoperative astigmatism, postoperative correction of astigmatism is often required in cases with high degrees of astigmatism. When spectacles and contact lenses fail to provide optimal visual outcomes, various surgical techniques that include astigmatic keratotomy, compression sutures, toric intraocular lens placement, and laser refractive procedures can be considered. When none of these techniques are able to achieve a desired result with in the acceptable optical range, a repeat keratoplasty is considered a last option. We discuss the various causes and management of complication of postoperative astigmatism occurring after a full thickness corneal transplantation surgery.

Effect of virtual reality simulation training on real-life cataract surgery complications: systematic literature review.

Virtual reality simulation (VRS) has become progressively popular as a training tool in ophthalmology. However, debate continues as to whether VRS has resulted in better outcomes for patients after cataract surgery. Accordingly, a qualitative systematic literature review was conducted to identify whether VRS training results in a reduced complication rate after real-life cataract surgery. Included studies measured the effect of VRS on real-life patient outcomes after cataract surgery. Databases searched included MEDLINE (Ovid), The Cochrane Library, Web of Science, PubMed, and CINAHL. A total of 1917 studies were identified, of which 10 studies were included, spanning from 2011 to 2020. The studies comprised 471 ophthalmological residents, with their complication rates assessed after 30 462 cataract surgery procedures. This systematic literature review indicates that VRS seems to be most helpful in reducing the rate of posterior capsular rupture or errant curvilinear capsulorrhexis and had limited evidence in reducing the rate of other complications.

Corneal endothelial cell abnormalities in X-linked Alport syndrome.

Background: X-linked Alport syndrome results from the effect of COL4A5 mutations on basement membranes in the kidney, ear and eye. This study investigated individuals with X-linked Alport syndrome for corneal abnormalities.Patients and Methods: Six men and four women from 8 families with genetically-diagnosed X-linked Alport syndrome underwent ophthalmological examination including slit lamp examination and corneal endothelial specular microscopy. Results for corneal microscopy for men and women with X-linked disease were compared separately with the mean values for age- matched normals using the student's t test.Results: Five of the 6 men had end-stage kidney failure, all 6 had a hearing loss, three had lenticonus, and three had a central fleck retinopathy. Two men had a history of recurrent corneal erosions but no evidence of posterior polymorphous corneal dystrophy. None of the four women had kidney failure, but two had a hearing loss, and two had a central fleck retinopathy. One woman, whose son had recurrent corneal erosions, also had erosions, but no features of a posterior polymorphous corneal dystrophy.Corneal specular microscopy demonstrated abnormalities in affected men and women, with larger endothelial cells (p = .0001 in men, p = .004 in women) fewer 6-sided cells (p = .0001, p = .001 respectively) and reduced cell density (p = .03, p = .02 respectively) than normal.Conclusions: Recurrent corneal erosions are common in men and women with X-linked Alport syndrome, but posterior polymorphous corneal dystrophy is rare. The abnormal corneal endothelial cells in affected men and women are consistent with an abnormal Descemet membrane, and the reduced cell density resembles the reduced podocyte numbers found in the Alport glomerulus.

Five-Year Outcomes of Ultrathin Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To report 5-year outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) with a central graft thickness intended to be <100 µm. METHODS: This retrospective, consecutive, interventional case series included 354 eyes with endothelial decompensation due to various causes (Fuchs endothelial dystrophy, pseudophakic or aphakic bullous keratopathy, failed previous graft, herpetic endothelitis, or buphthalmos). Donor tissue was prepared using the microkeratome-assisted double-pass technique aiming at a graft thickness <100 µm. The Descemet membrane was stripped under air. The graft was delivered into the anterior chamber using the pull-through technique through a 3.2-mm clear corneal incision using a modified Busin glide. The best spectacle-corrected visual acuity (BSCVA), endothelial cell loss, graft survival rates, and immunologic rejection rates were evaluated. RESULTS: Follow-up data at 1, 2, 3, and 5 years after UT-DSAEK were collected from 214, 172, 147, and 105 eyes, respectively. After excluding eyes with comorbidities, BSCVA better than or equal to 20/20 was recorded in 36.3%, 37.4%, 46.4%, and 53.4% of eyes, respectively, whereas BSCVA better than or equal to 20/40 was documented in 95.5%, 95.3%, 96.0%, and 96.6% of eyes, respectively. The mean endothelial cell loss was 35.4%, 42.3%, 43.3%, and 52.3%; Kaplan-Meier graft survival probability was 99.1%, 96.2%, 94.2%, and 94.2%, and Kaplan-Meier cumulative probability of a rejection episode was 3.4%, 4.3%, 5%, and 6.9% at 1, 2, 3, and 5 years, respectively. CONCLUSIONS: UT-DSAEK grafts allow excellent 5-year outcomes, including BSCVA, endothelial cell density, and survival rates comparable with those recorded post-Descemet membrane endothelial keratoplasty, but with a higher immunologic rejection rate.

Single-piece femtosecond-assisted mushroom keratoplasty in children.

PURPOSE: To report outcomes of femtosecond-assisted single-piece mushroom keratoplasty for the treatment of full-thickness corneal disease in pediatric patients with healthy endothelium. METHODS: Femtosecond-assisted mushroom keratoplasty was performed in 8 eyes of 8 patients (age range, 8-17 years) with central full-thickness corneal opacity. The single-piece mushroom-shaped graft consisted of a large anterior portion (9 mm in diameter; 250 µm in thickness) and a small posterior portion (6-6.5 mm). Donor and recipient corneas were prepared using the WaveLight FS200 laser (Alcon Laboratories, Fort Worth, TX). The donor cornea was oversized by 0.2 mm. Outcome measures were best spectacle-corrected visual acuity, spectacle refraction, topographic astigmatism, endothelial cell density, graft rejection, and graft failure at 1, 3, 6, and 12 months. RESULTS: Mean best spectacle-corrected visual acuity at 1, 3, 6, and 12 months was 0.28, 0.16, 0.13, and 0.10 logMAR; all patients achieved logMAR of at least 0.4 at 1, 3, 6, and 12 months. The mean refractive cylinder was 2.6 D, and mean endothelial cell loss was 13.3% at 12 months postoperatively. Two eyes had immunologic rejection episodes that were reversed with topical steroids. All corneas remained clear at final follow-up. CONCLUSIONS: Femtosecond-assisted mushroom keratoplasty is a viable surgical option for eyes of older pediatric patients with full-thickness corneal stromal disease and healthy endothelium. Mushroom keratoplasty combines the refractive advantage of a large keratoplasty with the immunologic advantage of a small keratoplasty. Single-piece femtosecond-assisted mushroom keratoplasty may have a mechanical advantage over regular penetrating keratoplasty.

Descemet stripping automated endothelial keratoplasty in phakic eyes: incision modification reducing cataract formation.

AIM: To evaluate the efficacy of a technical modification to reduce the incidence of traumatic cataract induced by Descemet stripping automated endothelial keratoplasty (DSAEK) performed in phakic eyes. METHODS: A retrospective cohort study. The records of all patients with a clear crystalline lens and endothelial failure that underwent modified DSAEK at our insitution were reviewed. In this modification, in order to avoid inadvertent touch of the insertion forceps against the exposed crystalline lens while passing across the anterior chamber, the incision sites were shifted from the standard 9 and 3 o'clock positions, superiorly to the 10 and 2 o'clock position respectively. Formation of typically traumatic, anterior subcapsular cataract in these patients was compared to that observed in a cohort including all the patients with a clear crystalline lens and endothelial failure that underwent conventional DSAEK at our institution. RESULTS: The study group included 49 eyes following modified DSAEK and the control group included 35 eyes following DSAEK with conventional incision sites. Anterior subcapsular cataract occurring 4mo or less postoperatively was identified in 2 of 49 (4%) eyes in the study group and 7 of 35 (20%) eyes in the control group. The rates of traumatic cataract were significantly higher in the control group in comparison to the study group (P=0.03, RR=4.9, 95%CI 1.08-22.1). CONCLUSION: Traumatic cataract formation following phakic DSAEK may be avoided with a simple modification to the position of the incision sites.

Descemet's membrane detachments post cataract surgery: a management paradigm.

Descemet's membrane detachments (DMD) are relatively common after cataract surgery and most do not require any treatment. However, if large DMD are not treated appropriately, significant visual morbidity can ensue. We aim to develop a guideline for the management of DMD post cataract surgery based on a retrospective review of all cases encountered at the Royal Victorian Eye and Ear Hospital, Melbourne, Australia over a 4-year period from 2010 to 2014. We suggest conservative management if the visual axis is not involved; however, after 3mo surgical intervention may be warranted to prevent corneal sequelae. In cases where the visual axis is involved we suggest early intervention with air tamponade. The main risk factor for irreversible corneal oedema and subsequent endothelial transplant appears to be direct endothelial trauma rather than the DMD itself.

Brimonidine Induced Anterior Uveitis.

PURPOSE: To present the largest series reported so far of brimonidine induced granulomatous anterior uveitis. METHODS: Retrospective chart review of patients with chronic glaucoma on treatment with brimonidine presenting with anterior uveitis. RESULTS: 19 eyes of 12 patients with chronic glaucoma developed anterior uveitis with granulomatous keratic precipitates after being treated with brimonidine for periods of 7 days to 5 years (mean 19.7 months, +18.6 months). One patient had a gap of 1 year between onset in one eye and onset in the other. Ten eyes (52.6%) had concurrent granulomatous conjunctivitis; 16 eyes were pseudophakic. Stopping brimonidine led to complete, rapid resolution of uveitis in all patients, in most cases (11 eyes, 58%) without topical corticosteroids. No recurrences have occurred after withdrawal of brimonidine, over a follow-up period of 12-52 months (mean 27.9 months, +13.8 months). CONCLUSIONS: Ophthalmologists should be aware of this easily reversible uveitis syndrome that is induced by a common glaucoma medication. Familiarity with this entity is essential in making the correct diagnosis and avoiding unnecessary investigations and interventions.

Spontaneously resolving descemet's membrane detachment caused by an ophthalmic viscosurgical device during cataract surgery.

We present a case of a central Descemet's membrane detachment (DMD) induced by an Ophthalmic Viscosurgical Device during phacoemulsification surgery that resolved spontaneously, leaving a best spectacle corrected visual acuity of 20/20. The detachment was monitored with serial anterior segment optical coherence tomography images. Most cases of central DMD reported in the literature have been managed surgically to facilitate rapid visual recovery and minimize the risk of scarring. Our case adds to the literature in providing an alternative management strategy where surgical intervention may not be possible.

Surgical technique for graft exchange after big-bubble deep anterior lamellar keratoplasty.

PURPOSE: The aim of this study was to describe a surgical technique for repeat deep anterior lamellar keratoplasty (DALK) by baring Descemet membrane again in eyes affected by stromal opacity of the donor lamella. METHODS: Repeat DALK was performed in 5 eyes of 5 patients affected by central stromal opacity not involving the endothelium; indications for repeat surgery were postbacterial or postherpetic corneal scars (n = 3), postphotorefractive keratectomy haze (n = 1), and recurrence of granular dystrophy (n = 1). The surgical procedure consisted of the following: (1) superficial trephination, 250 µm in depth, on the original peripheral scar; (2) blunt detachment of the donor graft completed by means of corneal forceps; (3) apposition of the new lamella. Best spectacle-corrected visual acuity, topographic astigmatism, and endothelial cell density were evaluated preoperatively, as well as 3, 6, 9, 12, and 18 months after surgery. RESULTS: At the latest follow-up examination, with all sutures removed from all eyes, the best spectacle-corrected visual acuity was 20/30 or better in all cases with 3 eyes achieving 20/20. Postoperative refractive astigmatism averaged 3.0 ± 1.2 diopters (mean ± SD); endothelial cell density was not significantly affected by surgery. CONCLUSIONS: Repeat DALK is effective in removing diseased corneal stroma while keeping the recipient endothelium unaffected; the procedure is simple and does not require pneumatic dissection, thus eliminating the most challenging surgical step; postoperative visual recovery does not differ from that experienced after primary DALK.

Descemet stripping automated endothelial keratoplasty for endothelial decompensation in buphthalmos.

PURPOSE: To report the results of Descemet stripping automated endothelial keratoplasty (DSAEK) to treat endothelial failure in eyes with buphthalmos. DESIGN: Prospective interventional case series. METHODS: All buphthalmic eyes with endothelial failure undergoing DSAEK by the same surgeon (M.B.) between March 2007 and January 2012 were included. Outcome measures included best spectacle-corrected visual acuity (BSCVA), refraction, and endothelial cell loss (assessed 6, 12, 24, 36, and 48 months postoperatively). Standardized DSAEK was performed in all cases, with minor modifications in phakic and aphakic eyes. Other outcomes included comparisons to penetrating keratoplasty (PK) published results and comparisons to visual outcomes in DSAEK for other indications. RESULTS: There were 14 transplants performed in 12 eyes (11 patients). Mean age was 34.9 years (range 15-54 years). The average follow-up was 21.7 ± 13.8 months (range 6-48 months). At last follow-up examination, BSCVA had improved in 11 of 13 cases, with a logMAR average value ± standard deviation of 0.74 ± 0.66 from the preoperative value of 2.07 ± 0.80. Eleven eyes reached Snellen acuity of 20/200 or better, and 5 eyes reached 20/40 or better. Mean endothelial cell loss was 40.5% ± 8.9% (range 23.7%-53.1%). Complications included graft detachment (n = 2), glaucoma progression (n = 1), and late endothelial failure (n = 1). All complications were managed successfully either by repeat DSAEK (n = 2), rebubbling (n = 1), or cyclocryocoagulation (n = 1). CONCLUSIONS: DSAEK may be performed safely and effectively in buphthalmic eyes, with comparable results to outcomes after PK. Visual outcomes are not substantially different after DSAEK for this indication compared to DSAEK for other indications.

Ultrathin descemet's stripping automated endothelial keratoplasty with the microkeratome double-pass technique: two-year outcomes.

PURPOSE: To evaluate the outcomes and graft survival rates after ultrathin (UT) Descemet's stripping automated endothelial keratoplasty (DSAEK) using the microkeratome-assisted double-pass technique. DESIGN: Prospective, consecutive, interventional case series. PARTICIPANTS: Patients with endothelial decompensation of various causes (Fuchs endothelial dystrophy, pseudophakic or aphakic bullous keratopathy, failed previous graft, herpetic endotheliitis, or buphthalmus; n = 285 grafts). INTERVENTION: Donor preparation was performed using the microkeratome-assisted double-pass technique. Stripping of the Descemet's membrane was performed under air and the graft was delivered into the anterior chamber using the pull-through technique through a 3-mm clear-cornea incision using a modified Busin glide. MAIN OUTCOME MEASURES: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, endothelial cell density, and graft thickness (GT). RESULTS: Excluding all eyes with pre-existing ocular comorbidities, mean BSCVA at 3, 6, 12, and 24 months was 0.16, 0.11, 0.08, and 0.04 logarithm of the minimum angle of resolution units, respectively. The percentage of patients achieving BSCVA of 20/20 or better at 3, 6, 12, and 24 months was 12.3%, 26.3%, 39.5%, and 48.8%, respectively. A statistically significant (P < 0.0001) hyperopic shift of 0.78 ± 0.59 diopters (D; range, -0.75 to 1.75 D) was found at 1 year. The endothelial cell loss at 3, 6, 12, and 24 months was 29.8 ± 14.3%, 33 ± 15.5%, 35.6 ± 14.1%, and 36.6 ± 16.0%, respectively. The mean central GT recorded 3 months after surgery was 78.28 ± 28.89 µm. Complications included microkeratome failure to achieve perfect dissection in 21 donor tissues (7.2%), with 6 (2.1%) being discarded; total graft detachment in 11 cases (3.9%); primary failure in 4 cases (1.4%); and secondary failure in 4 additional cases (1.4%). Kaplan-Meier cumulative probability of a rejection episode at 3, 6, 12, and 24 months was 0%, 0.4%, 2.4%, and 3.3%, respectively. CONCLUSIONS: The visual outcomes of UT DSAEK are comparable with those published for Descemet's membrane endothelial keratoplasty and better than those reported after DSAEK in terms of both speed of visual recovery and percentage of patients with 20/20 final visual acuity. However, unlike with Descemet's membrane endothelial keratoplasty, preparation and delivery of donor tissue are neither difficult nor time consuming. Complications of UT DSAEK do not differ substantially from those recorded with standard DSAEK but are much less frequent than those reported after Descemet's membrane endothelial keratoplasty. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Recent advances in corneal transplantation for keratoconus.

From the rise of modern corneal graft surgery in the late 1950s until recently, corneal transplantation for keratoconus almost exclusively consisted of a full-thickness transplant, termed penetrating keratoplasty. This technique involved the removal of all of the layers of the patient's central cornea and replacement with a full-thickness graft. Over approximately the past 20 years, a quiet revolution has occurred with the development of several other types of corneal transplantation surgery for keratoconus. In addition to full thickness grafts, several different types of partial thickness, lamellar grafts, have been developed and are viable alternatives to a full-thickness graft in selected patients. The main aim of these lamellar grafts is to selectively replace the corneal stroma, leaving intact the patient's own Desçemet's membrane and endothelial cells, the main target of allograft transplant rejection. In this article, we review the current options with regard to corneal transplantation for keratoconus and review the evidence comparing newer and more established techniques.

Anterior segment optical coherence tomography-guided big-bubble technique.

PURPOSE: To evaluate the feasibility of intraoperative anterior segment (AS) optical coherence tomography (OCT) for quantification of the corneal depth reached with the dissecting cannula used for deep anterior lamellar keratoplasty, as well as its correlation with the success rate of big-bubble formation. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: One hundred consecutive keratoconus patients. INTERVENTION: Deep anterior lamellar keratoplasty was performed using the big-bubble technique. During surgery, the cannula used for pneumatic dissection was inserted into the peripheral stroma and advanced as deep and far toward the center as believed adequate by the surgeon. Then, after retracting the cannula, AS OCT was performed. The cannula was placed back in position and creation of the big bubble was attempted. MAIN OUTCOME MEASURES: Stromal depth reached with the cannula tip, success rate in achieving big-bubble formation, and complication rate. RESULTS: Bubble formation was obtained in 70 of 100 eyes (70%). In all remaining eyes, the procedure was completed by manual deep lamellar dissection. The average depth reached by the cannula tip was 104.3±34.1 µm from the internal corneal surface; the mean value recorded in cases of successful big-bubble formation (90.4±27.7 µm) was statistically lower than that measured in failed procedures (136.7±24.2 µm). In 1 case, corneal perforation occurred during the insertion of the cannula and required conversion to penetrating keratoplasty (PK). In 8 eyes, small microperforations occurred during stromal excision but could be managed conservatively, avoiding conversion to PK. In 2 advanced cones, an incomplete bubble formation was obtained, necessitating manual peripheral stromal removal. CONCLUSIONS: Successful big-bubble formation can be anticipated if pneumatic dissection is attempted at a sufficiently deep level. Although an ideal depth could not be defined, AS OCT allows objective evaluation of the depth reached by the cannula tip used for pneumatic dissection. The AS OCT findings may confirm the decision to proceed with air injection. It is possible that cannula repositioning based on the AS OCT depth may improve the success rate for big-bubble formation.

Combined Descemet-stripping automated endothelial keratoplasty and phacoemulsification with toric intraocular lens implantation for treatment of failed penetrating keratoplasty with high regular astigmatism.

We present the case of a 57-year-old woman who had combined Descemet-stripping automated endothelial keratoplasty (DSAEK) and phacoemulsification with implantation of a toric intraocular lens (IOL). Surgery was intended to treat a cataract developing in a post-penetrating keratoplasty (PKP) eye with high astigmatism and endothelial decompensation. Six months after uneventful surgery, the cornea was clear and the corrected distance visual acuity was 20/20 with a refraction of +0.25 -1.00 × 10 (from -3.00 -8.50 × 12 preoperatively). The internal topography map (OPD-Scan) showed an IOL rotation of 4 degrees. The endothelial cell loss was 15% of the eye-bank value. Descemet-stripping automated endothelial keratoplasty combined with phacoemulsification and toric IOL implantation is a relatively simple and very effective procedure for eyes with endothelial failure and high post-PKP astigmatism. The speed of visual rehabilitation and final visual acuity achieved with this approach was superior to that obtained with other surgical procedures.

Histopathological evaluation of anterior lamellar corneal tissue-on/-off storage conditions on DSAEK donor tissue after storage in organ culture.

PURPOSE: To compare the quality of corneal endothelium of precut Descemet-stripping automated endothelial keratoplasty (DSAEK) tissue when transported with and without the anterior lamellar corneal tissue (ALCT) when organ-culture corneal storage methods are used. METHODS: After microkeratome-assisted excision of anterior corneal lamella, five pairs of corneas (10 eyes) were stored either with the ALCT on the stroma (five eyes) or with ALCT off the stroma (five eyes) in organ-culture medium. Three pairs (six matched corneas) were left in the transport medium for 24 h prior to the microkeratome cut. Two pairs (four matched corneas) were left in the transport medium for 48 h prior to the microkeratome cut. All cuts were performed using a 300 (four eyes) or 350 (six eyes) microns head. A vital dye assay (alizarin red S and trypan blue) was used to identify devitalized and necrotic endothelial cells. RESULTS: In all matched cases, there was no difference between the endothelial cell appearance with or without the anterior corneal lamella. In all cases, there was no evidence for trypan blue stained cells beyond that normally seen on acceptable transplantable corneas and there was no evidence of loss of cells or any lifting of Descemet's membrane. CONCLUSIONS: There is no difference between the quality of the donor endothelial cell appearance with ALCT-on or -off when the donor cornea is stored using the organ-culture system of corneal storage. Organ-culture storage system is a safe and effective system in regard to preparation and transport of donor lenticules for DSAEK.

Descemet stripping automated endothelial keratoplasty in a case with a posteriorly fixated iris-claw intraocular lens.

PURPOSE: To report a successful case of Descemet stripping automated endothelial keratoplasty (DSAEK) performed on a vitrectomized eye with a potentially unstable posteriorly fixated iris-claw intraocular lens (IOL). METHOD: A standard DSAEK procedure was performed on a 42-year-old man referred to our institution because of corneal edema occurring after repeat surgery for rhegmatogenous retinal detachment. Preoperatively, the best-corrected visual acuity was 20/200, and slit-lamp examination revealed bullous keratopathy in the presence of a posteriorly fixated iris-claw IOL. RESULTS: Both surgery and the postoperative course were uneventful. On day 1, the graft was well centered and fully attached to the posterior corneal surface. The IOL was unchanged in its position. Subsequent follow-up showed progressive improvement in corneal clarity, with a best-corrected visual acuity (BCVA) of 20/50 at the last follow-up examination (4 months). CONCLUSIONS: This case demonstrates that DSAEK is an appropriate intervention for eyes with pseudophakic bullous keratopathy, even in the setting of eyes with posteriorly fixated iris-claw IOLs that are at risk of dislocation into the vitreous cavity.