Large-diameter deep anterior lamellar keratoplasty: A narrative review.

Deep anterior lamellar keratoplasty (DALK) involves the selective replacement of diseased corneal stroma while preserving healthy unaffected endothelium. While DALK has failed to gain widespread popularity, improved visual and refractive outcomes of large-diameter grafts, which patients directly perceive following suture removal, may represent a compelling reason to shift toward DALK. Since the unaffected host endothelium is retained, DALK offers the opportunity to use large-diameter grafts, which reliably achieves maximum visual potential without an increased risk of immune-mediated stromal rejection. In this narrative review, we evaluate the current evidence on large-diameter DALK including surgical technique and clinical outcomes.

Outcomes of large-diameter deep anterior lamellar keratoplasty and converted two-piece mushroom penetrating keratoplasty for herpetic corneal scars.

PURPOSE: To report the clinical outcomes of large diameter deep anterior lamellar keratoplasty (DALK) and converted two-piece microkeratome-assisted mushroom keratoplasty (MK) for herpetic corneal scars. METHODS: In this single-centre study, large diameter (9 mm) DALK was attempted in consecutive patients with herpetic corneal scars. In case of macroperforation or unsatisfactory clearance of the optical zone, the procedure was intraoperatively converted to two-piece microkeratome-assisted MK. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism, endothelial cell density (ECD), immunologic rejection, herpetic recurrence and graft failure rates in the two groups. RESULTS: DALK was successfully performed in 98 of 120 eyes, while the remaining 22 eyes required intraoperative conversion to MK. At 5 years, mean logMAR BSCVA was 0.10 ± 0.12 in the DALK group and 0.09 ± 0.15 in the MK group (P = 0.75). Refractive astigmatism at 5 years was 2.8 ± 1.4 D in the DALK group and 3.0 ± 1.7 D in the MK group (P = 0.67). ECD was higher in the DALK group than in the MK group at all time points (P < 0.001), with a mean annual cell loss of 10.9% after MK and 4.2% after DALK. The 5-year risk for immunologic rejection (DALK: 3%, MK: 5%, P = 0.38), herpetic recurrence (DALK: 6%, MK: 9%, P = 0.38), and graft failure (DALK: 4%, MK: 5%, P = 0.75) were comparable in both groups. CONCLUSION: Large diameter (9 mm) DALK yields excellent visual and clinical outcomes in eyes with herpetic corneal scars. In case of intraoperative complications, DALK can be converted to two-piece microkeratome-assisted MK to maximize the refractive benefit of a large diameter graft while minimizing the risk of endothelial failure.

Deep Anterior Lamellar Keratoplasty Using Dehydrated versus Standard Organ Culture-Stored Donor Corneas: Prospective Randomized Trial.

PURPOSE: To compare the outcomes of deep anterior lamellar keratoplasty (DALK) using dehydrated versus standard organ culture-stored donor corneas for eyes with keratoconus. DESIGN: Prospective, randomized, single-center trial conducted in Italy. PARTICIPANTS: Adult patients (age ≥ 18 years) with keratoconus scheduled for elective DALK. METHODS: Patients undergoing successful type 1 bubble pneumatic dissection using a standard DALK technique were randomized during surgery to receive either dehydrated (n = 30) or standard organ culture-stored (n = 30) donor corneas. MAIN OUTCOME MEASURES: The primary study outcome was best spectacle-corrected visual acuity (BSCVA) 12 months after surgery. Secondary outcomes were refractive astigmatism (RA), endothelial cell density (ECD), and complication rates. RESULTS: Postoperative BSCVA did not significantly differ between groups at both time points: mean difference at 6 months was 0.030 logarithm of the minimum angle of resolution (logMAR; 95% confidence interval [CI], -0.53 to 0.10 logMAR; P = 0.471) and at 12 months was -0.013 logMAR (95% CI, -0.10 to 0.08 logMAR; P = 0.764). No significant differences between groups were observed in terms of postoperative RA and ECD at all time points. In the first 3 days after DALK, an epithelial defect was present in 10 patients (33%) in the organ culture cornea group and in 29 patients (97%) in the dehydrated cornea group. Complete re-epithelialization was achieved by day 7 in all patients (100%) in both groups. CONCLUSIONS: The study provides evidence that the use of dehydrated corneas is noninferior to the use of standard organ culture donor corneas for DALK. Corneal tissue dehydration represents a viable solution that can allow long-term cornea preservation and avoid wastage of unused corneas. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Microsporidial Stromal Keratitis in Post-Keratoplasty Eyes.

PURPOSE: The purpose of this paper is to report the clinical manifestations, diagnostic evaluation, management and outcomes of microsporidial keratitis in post-keratoplasty eyes. METHODS: This is a retrospective review of three patients diagnosed with microsporidial stromal keratitis in post-keratoplasty eyes between January 2012 and December 2021 at a tertiary referral center (Ospedali Privati Forlì "Villa Igea", Forlì, Italy). RESULTS: All patients presented with fine multifocal granular infiltrates following keratoplasty for a presumed herpetic keratitis. No microorganisms were isolated from the corneal scrapings and no clinical response was observed with broad-spectrum antimicrobial therapy. In all cases, confocal microscopy demonstrated spore-like structures. The histopathologic examination of the excised corneal buttons confirmed the diagnosis of microsporidial stromal keratitis. Following therapeutic keratoplasty and treatment with an initial high dose and extended taper of topical fumagillin, clinical resolution was achieved in all eyes. The Snellen visual acuities at the final follow-up were 20/50, 20/63 and 20/32. CONCLUSIONS: Prior to definitive surgery, confocal microscopy can be employed for the in vivo detection of pathogenic microorganisms such as Microsporidium. In post-keratoplasty eyes, therapeutic keratoplasty and an initial high dose of topical fumagillin with extended taper can allow the resolution of microsporidial stromal keratitis with a satisfactory visual prognosis.

10-year experience with lamellar keratoplasty for the surgical Management of Paediatric Corneal Diseases.

PURPOSE: To evaluate the outcomes of various lamellar keratoplasty techniques performed at our Institution in children aged 14 years or younger over the last decade. METHODS: This single-centre study reviewed 72 eyes that underwent lamellar keratoplasty for various indications. Deep anterior lamellar keratoplasty (DALK) was performed in 19 eyes, mushroom penetrating keratoplasty (PK) in 27 eyes and Descemet stripping automated endothelial keratoplasty (DSAEK) in 25 eyes. The main outcome measures included best spectacle-corrected visual acuity (BSCVA), complications and rate of graft failure which was defined as any graft requiring repeat transplantation. RESULTS: Best spectacle-corrected visual acuity (BSCVA) significantly improved after DALK, mushroom PK and DSAEK (all p < 0.05), with 50%, 60% and 56% of eyes reaching ≥20/40, respectively. Stromal rejection was observed in 1 eye (5.3%) after DALK, whilst endothelial rejection occurred in 1 eye after mushroom PK (3.7%) and 1 eye after DSAEK (4.0%). Overall survival was 100% after DALK (mean follow-up: 23.0 months), 92.8% after mushroom PK (mean follow-up: 42.3 months) and 96.0% after DSAEK (mean follow-up: 33.6 months). CONCLUSION: Deep anterior lamellar keratoplasty (DALK), mushroom PK and DSAEK offer good visual outcomes for children with corneal pathology, with low rates of immunological rejection and graft failure.

Stromal peeling for deep anterior lamellar keratoplasty in post-penetrating keratoplasty eyes.

BACKGROUND/AIMS: To evaluate the clinical outcomes of deep anterior lamellar keratoplasty performed by stromal peeling in eyes that have previously undergone penetrating keratoplasty (PK) for keratoconus. METHODS: Standardised stromal exchange included (1) 9 mm trephination of the recipient bed outside the old PK wound, (2) creation of a partial anterior corneal flap through lamellar dissection across the PK wound, (3) opening the stromal component of the old PK wound using blunt-tipped Vannas scissors until a plane of separation is reached, (4) severing the attachment of the PK surgical scar from the recipient host, (5) peeling the stroma of the PK graft from the underlying tissue and (6) suturing the donor anterior corneal lamella prepared by microkeratome dissection (450 µm depth, 9 mm diameter). Main outcome measures were success rate, best spectacle-corrected visual acuity (BSCVA) and endothelial cell loss (ECL). RESULTS: Of 21 post-PK eyes, stromal exchange succeeded in all but three cases, which were converted to a two-piece mushroom PK. After complete suture removal, mean BSCVA significantly improved from 0.95±0.39 logMAR preoperatively to 0.23±0.17 logMAR (p<0.001). Mean ECL was 5.4±23.2%. Double anterior chamber formation occurred in eight cases (44%), which all resolved after a single re-bubbling. CONCLUSION: In post-PK eyes, stromal exchange can be performed by means of simple peeling without deep anterior lamellar dissection of the previous PK graft. Large-diameter (9 mm) repeat keratoplasty through stromal peeling yields excellent visual outcomes and minimal ECL. Double anterior chamber formation may complicate the postoperative course, but prompt intervention allows successful management.

Outcomes of cataract surgery with toric intraocular lens implantation after keratoplasty.

PURPOSE: To evaluate the efficacy and predictability of cataract extraction with toric intraocular lens (IOL) implantation after deep anterior lamellar keratoplasty (DALK) or mushroom penetrating keratoplasty (PK). SETTING: Villa Igea Hospital, Forlì, Italy. DESIGN: Prospective case series. METHODS: Toric IOL implantation was offered to patients with cataract, corneal astigmatism >1.5 diopters (D) and regular central corneal topography after complete suture removal. Phacoemulsification was performed through a 2.4 mm scleral tunnel and an enVista monofocal toric MX60T or Eyecryl monofocal toric IOL was inserted in the capsular bag. Main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, total prediction error, and IOL misalignment. RESULTS: 37 consecutive patients who had previously undergone either DALK (n = 27, 73%) or 2-piece mushroom PK (n = 10, 27%) were included. All patients completed the 6-month follow-up. The mean toric IOL power was 5.3 ± 1.1 D. Both UDVA and CDVA significantly improved (from 1.02 ± 0.27 to 0.46 ± 0.31 logMAR and from 0.65 ± 0.27 to 0.11 ± 0.12 logMAR, respectively; P < .001). 20 eyes (54%) reached UDVA ≥20/40, whereas 35 eyes (95%) reached a CDVA ≥20/40. Final refractive astigmatism was 0.93 ± 0.87 D, with 35 eyes (95%) within 2 D. Prediction error was ≤1 D in 18 eyes (49%). Absolute IOL misalignment was 3.3 ± 3.5 degrees. CONCLUSIONS: Toric IOL implantation in postkeratoplasty eyes allowed reduction of refractive astigmatism to predictably low levels with concomitant improved visual outcomes.

Corneal neovascularisation following deep anterior lamellar keratoplasty for corneal ectasia: incidence, timing and risk factors.

BACKGROUND: The purpose of this study was to evaluate the incidence, timing and risk factors of corneal neovascularisation (NV) after deep anterior lamellar keratoplasty (DALK) for corneal ectasia. METHODS: This study included 616 eyes who underwent DALK between 2012 and 2020 in two tertiary referral centres. In one centre topical corticosteroids were discontinued after complete suture removal 1 year after surgery, whereas in the other they were discontinued 3-4 months after surgery. The presence and severity of corneal NV was ascertained based on slit lamp photographs. Potential risk factors for corneal NV were evaluated using the Cox proportional hazards model. RESULTS: The cumulative incidence of corneal NV was 8.7% at 1 year after surgery and 13.2% at 5 years. Mean time interval from surgery to development of corneal NV was 12.8±16.2 months, with 68.9% of cases occurring before complete suture removal. Early discontinuation of topical steroids, older age and ocular allergy were associated with an increased risk of developing corneal NV (respectively, HR=2.625, HR=1.019, HR=3.726, all p<0.05). CONCLUSIONS: The risk of corneal NV is higher in the first year following DALK. Early discontinuation of topical steroids, ocular allergy and older age are significant predictors of corneal NV.

Deep Anterior Lamellar Keratoplasty: Current Status and Future Directions.

ABSTRACT: Deep anterior lamellar keratoplasty (DALK) involves selective replacement of diseased corneal stroma while preserving normal healthy endothelium. Despite several well-recognized advantages, the uptake of DALK has remained sluggish with an adoption rate that has plateaued over the past decade. Misconceptions such as the rarity of complications of penetrating keratoplasty, lack of standardization of the DALK technique, and limited substantial benefit in visual and refractive outcomes are frequently cited as arguments against performing DALK. This brief review discusses the recent findings that refute these perceived barriers; describes contemporary techniques, tools, and modifications in the surgical approach; and evaluates the evidence regarding the clinical outcomes of DALK.

Long-Term Outcomes of Two-Piece Mushroom Keratoplasty for Traumatic Corneal Scars.

PURPOSE: To report the outcomes of 2-piece microkeratome-assisted mushroom keratoplasty (MK) for eyes with full-thickness traumatic corneal scars and otherwise functional endothelium following corneal penetrating injury. DESIGN: This was an interventional case series. METHODS: In this single-center study, 41 consecutive eyes with traumatic corneal scars that underwent 2-piece microkeratome-assisted mushroom keratoplasty were evaluated. The 2-piece mushroom graft consisted of an anterior lamella 9 mm in diameter and a posterior lamella 6 mm in diameter. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, and postoperative complication rates. RESULTS: Of the 41 total cases, 38 eyes (93%) reached Snellen vision ≥20/100, 36 (88%) reached ≥20/60, 29 (71%) reached ≥20/40, and 13 (32%) reached ≥20/25 2 years following MK. Excluding eyes with vision-impairing comorbidities, baseline logMAR BSCVA (1.41 ± 0.73) significantly improved annually during the first 2 years (P < 0.001), reaching 0.16 ± 0.13 at year 2, which subsequently remained stable up to 10 years (P = .626). The RA exceeded 4.5 diopters in 2 cases (5%) after wound revision for high-degree astigmatism in 5 cases. Endothelial cell loss was 35.1% at 1 year, with an annual decline of 2.9% over 10 years. Elevation in IOP was observed postoperatively in 7 eyes, of which 6 had pre-existing glaucoma. The 10-year cumulative risk for graft rejection and failure was 8.5% and 10%, respectively. CONCLUSION: Two-piece microkeratome-assisted MK for traumatic corneal scars can allow excellent visual rehabilitation with relatively stable ECL and low rates of immunologic rejection and graft failure.

Culture of corneal endothelial cells obtained by descemetorhexis of corneas with Fuchs endothelial corneal dystrophy.

Currently, endothelial keratoplasty is the gold standard for the surgical treatment of Fuchs endothelial corneal dystrophy (FECD). Despite the remarkable success in terms of surgical outcomes, a shortage of corneal donor tissue poses a limitation to performing endothelial keratoplasty in many parts of the world. Cell therapy is a potential alternative strategy to keratoplasty and is currently under investigation. Considering that corneas with FECD may contain relatively healthy endothelial cells, samples obtained by descemetorhexis of eyes undergoing EK for FECD can be used for ex vivo expansion of endothelial cells as an autologous cell culture. In this study, we established corneal endothelial cell cultures derived from 40 patients that underwent endothelial keratoplasty for advanced FECD. Several parameters were evaluated including patient characteristics such as age, gender, and endothelial cell density as well as various processing and cell culture protocols based on different combinations of shipping temperatures, stabilization periods and treatment methods for corneal endothelial cell dissociation. FECD cultures were classified into three groups as: (i) no cells, (ii) cell cultures with endothelial-like morphology or (iii) cell cultures with fibroblast-like features. Our data seem to suggest that some factors can influence FECD cell culture characteristics including young age, high paracentral endothelial cell density, low shipping temperature and short stabilization period prior to cell isolation. Treatment with type 1 collagenase for cell isolation can delay endothelial-to-mesenchymal transition, but does not increase proliferative capacity. Although heterologous corneal endothelial cultures from healthy donors have shown encouraging outcomes, the feasibility of autologous cell therapy as a potential treatment for FECD remains challenging. Low initial cell concentration as well as endothelial to mesenchymal transition are the main obstacles to the application of FECD cultures in the clinical setting.

Ultrastructural Alterations of Grafted Corneal Buttons: The Anatomic Basis for Stromal Peeling Along a Natural Plane of Separation.

PURPOSE: To examine the ultrastructure of the natural plane of separation in grafted corneas and evaluate the outcomes of stromal peeling. DESIGN: Interventional case series. METHODS: In this multicenter study, stromal peeling was attempted in 96 consecutive eyes with unsatisfactory vision following penetrating keratoplasty (PK) for keratoconus (n = 79), herpetic keratitis (n = 11), and granular dystrophy (n = 6). Stromal exchange was performed by (1) 9 mm partial-thickness trephination; (2) creation of a corneal flap across the PK wound; (3) opening of the stromal component of the PK wound until a smooth, translucent natural plane was identified; (4) severing the attachment of the PK scar; (5) stromal peeling along the identified plane; and (6) suturing of donor lamella. Grafted corneas from cases that mandated conversion to PK were processed for transmission electron microscopy. RESULTS: The natural plane of separation was identified in all cases. Stromal exchange was successfully completed in 84 cases (87.5%). Snellen visual acuity ≥20/40 and ≥20/25 was reached in 93% and 72% of cases at 3 years (n = 49) and 86% and 62% at 4 years (n = 21) postoperatively. Mean endothelial cell loss at 1 year was 6.6% ± 9.5%. Stromal peeling occurred along a plane lined with a continuous layer of keratocytes separating pre-Descemet membrane (DM) stroma, DM, and endothelium from the anterior stroma. Pre-DM stroma was made of poorly organized lamellae containing widely spaced, randomly arranged collagen fibrils. CONCLUSIONS: Ultrastructural alterations in the stromal microarchitecture of grafted corneas provide evidence of a natural plane of separation identified intraoperatively. Stromal peeling can be successfully performed in post-PK eyes with various stromal pathology.

Interface Drainage and Antimicrobial Irrigation Avoid Repeat Keratoplasty for Post-DSAEK Cold Interface Abscess.

PURPOSE: To describe a surgical technique for the diagnosis and treatment of post-Descemet stripping automated endothelial keratoplasty (DSAEK) infectious interface keratitis presenting as a cold abscess. METHODS: This study included 2 eyes of 2 patients that developed delayed-onset interface infections after DSAEK. Through an anterior keratotomy, diagnostic samples for microbial culture and histopathology examination were collected, and empiric antibiotic therapy was delivered directly to the site of the infection at the graft-host interface. RESULTS: In both cases, microbiological examinations confirmed a fungal etiology consistent with Candida. Resolution of infection was achieved, and no signs of posterior segment involvement or recurrence of infection were observed. Both corneas remained clear with final visual acuity of 20/25 and 20/32. No case required additional surgical intervention or repeat keratoplasty after more than 15 months of follow-up. CONCLUSIONS: Interface drainage with antimicrobial irrigation may be considered for the management of post-DSAEK interface infections presenting as a peripheral cold abscess. By avoiding intraocular seeding of infectious pathogens, the anterior approach can achieve clinical resolution of infection, maintain visual function, and preserve the DSAEK graft, thereby obviating the need for a therapeutic keratoplasty.

Ten-year outcomes of microkeratome-assisted lamellar keratoplasty for keratoconus.

BACKGROUND/AIMS: To report the 10-year outcomes of modified microkeratome-assisted lamellar keratoplasty (LK) for keratoconus. METHODS: In this single-centre interventional case series, 151 consecutive eyes with keratoconus underwent modified microkeratome-assisted LK. Eyes with scars extending beyond the posterior half of the corneal stroma and preoperative thinnest-point pachymetry value of less than 300 µm were excluded. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, immunological rejection, ectasia recurrence and graft failure rates. RESULTS: Baseline BSCVA (0.89±0.31 logarithm of the minimum angle of resolution (logMAR)) significantly improved to 0.10±0.12 logMAR at year 3 (p<0.001), and remained stable up to 10 years. At 10 years, 94% of eyes saw ≥20/40, 61% saw ≥20/25 and 24% saw ≥20/20 Snellen BSCVA. At final follow-up, RA exceeding 4.5 dioptres was observed in 5 cases (4%). Endothelial cell loss was 25±17% at 1 year with an annual decline of 2% over 10 years. The 10-year cumulative risk for immunological rejection and graft failure was 8.5%, and 2.4%, respectively. No case developed recurrent ectasia at 10 years. CONCLUSION: Modified microkeratome-assisted LK results in stable visual and refractive outcomes with low rates of immunological rejection and graft failure in the absence of recurrence of ectasia for at least 10 years.

Pneumatic Dissection for Large-Diameter (9-mm) Deep Anterior Lamellar Keratoplasty in Eyes With Previous Anterior Lamellar Keratoplasty.

PURPOSE: To evaluate the surgical and 3-year clinical outcomes of modified big-bubble 9-mm deep anterior lamellar keratoplasty (DALK) in eyes with previous ALK (ALK). METHODS: In this interventional case series, 21 consecutive eyes with unsatisfactory vision after ALK (superficial ALK n = 9; laser-assisted ALK n = 7; and epikeratophakia n = 5) underwent large-diameter (9-mm) DALK. The surgery involved deep trephination based on the anterior segment optical coherence tomography pachymetry measurement at 9-mm diameter, pneumatic dissection from the base of the trephination and limited stromal clearance of the optical zone (6 mm). Main outcome measures were success rates of pneumatic dissection, best spectacle-corrected visual acuity, and complication rates. RESULTS: Pneumatic dissection with type 1 bubble formation succeeded in 19 (90%) eyes. In the 2 remaining cases, the 6-mm optical zone was cleared by manual dissection. Perforation occurred in one of the latter cases; no procedure was converted to penetrating keratoplasty. One month after complete suture removal, the preoperative mean best spectacle-corrected visual acuity (0.75 ± 0.23 logMAR) improved to 0.09 ± 0.10 logMAR (P < 0.001) and remained stable up to 3 years after surgery. At the final follow-up, refractive astigmatism was ≤4.5 and <6 D in 20 (95%) and 21 (100%) eyes, respectively. Stromal rejection was observed in 2 eyes (10%) and was treated successfully with steroids. CONCLUSIONS: Even in eyes with previous ALK, pneumatic dissection can be achieved through a modified DALK technique with a low risk of complications and excellent visual and refractive outcomes.

Five-year Outcomes of Converted Mushroom Keratoplasty from Intended Deep Anterior Lamellar Keratoplasty (DALK) Mandate 9-mm Diameter DALK as the Optimal Approach to Keratoconus.

PURPOSE: To compare the 5-year outcomes of 9-mm-deep anterior lamellar keratoplasty (DALK) for keratoconus with those of conversions to mushroom keratoplasty (MK). DESIGN: Retrospective cohort study. METHODS: The setting was the Ospedali Privati Villa Igea, Department of Ophthalmology, Forlì, Italy. The study population consisted of the medical records of all attempted DALK procedures (416 eyes) for the indication of keratoconus performed between January 2012 and January 2018; 68 eyes (16.4%) were converted to MK and analyzed as a separate cohort. The mean follow-up time was 33.8 ± 15.1 months. Procedure(s) consisted of 9-mm DALK and MK (9-mm anterior lamella with 6-mm posterior lamella). Outcome measurements were best-corrected visual acuity (BCVA), refractive astigmatism, and endothelial cell loss (ECL) at 5 years. RESULTS: Average BCVA at 5 years was 0.06 ± 0.07 in the DALK group and 0.09 ± 0.15 in the MK group (P = .88). Refractive astigmatism following suture removal (all visits later than 12 months) was slightly less in the DALK cohort (5-year DALK = 2.16 ± 1.40 diopter [D]; MK = 3.02 ± 0.89 D; P = .04; mean difference = 0.86 D [95% confidence interval [CI]: 0.71-1.01]). ECL was significantly higher in the MK group than in the DALK group at all follow-up intervals (5-year DALK = 19.36 ± 21.47%; MK = 56.61 ± 15.82%; P < .001). The total all-cause graft failure rate at 5 years was 0.58% for DALK (2 of 348) cases and 5.88% for MK (4 of 68) cases. CONCLUSIONS: Excellent 5-year visual and clinical outcomes associated with a 2-piece MK in cases converted from intended DALK mandate large-diameter DALK (9 mm) as the optimal surgical approach to keratoconus.

Three-Year Outcomes of Tri-Folded Endothelium-In Descemet Membrane Endothelial Keratoplasty With Pull-Through Technique.

PURPOSE: To assess the 3-year outcomes of tri-folded endothelium-in Descemet membrane endothelial keratoplasty (DMEK) using bimanual pull-through delivery technique. DESIGN: Interventional case series. METHODS: In this single-center study, we included 153 consecutive eyes that underwent DMEK for various indications (Fuchs endothelial corneal dystrophy [FECD]: n = 111; bullous keratopathy [BK]: n = 24; and failed graft: n = 18). DMEK grafts were loaded into a disposable cartridge in a tri-folded, endothelium-in configuration and delivered using bimanual pull-through technique. Main outcome measures were graft preparation and unfolding times, best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), and graft survival. RESULTS: Mean graft preparation time was 5.9 ± 1.1 minutes; and mean graft unfolding time was 2.9 ± 0.9 minutes. Excluding eyes with comorbidities, logarithm of minimum angle of resolution BSCVA improved significantly from baseline preoperative values of 0.92 ± 0.58 to 0.02 ± 0.07 at 1 year (P < .001) and remained stable up to 3 years. Mean postoperative ECD decreased significantly (P < .001) from eye bank values to 1,818 ± 362, 1,675 ± 372, and 1,580 ± 423 cells/mm2 at 1, 2, and 3 years, respectively. No significant differences in ECD were observed between eyes with FECD and BK, but ECD was significantly lower in eyes with previous failed graft (P < .05). Three-year cumulative graft survival rate was significantly (P < .001) lower for eyes with previous failed graft (71%) than for FECD (97%) and BK (92%). CONCLUSIONS: Tri-folded endothelium-in DMEK requires minimal time for graft unfolding, which is the surgical step considered most challenging by corneal surgeons. Visual outcomes and complication rates are not adversely affected by the modification of the surgical technique.

Initial High-Dose Prophylaxis and Extended Taper for Mushroom Keratoplasty in Vascularized Herpetic Scars.

PURPOSE: To report the outcomes of initial high-dose and extended taper of antiviral and steroid prophylaxis for the treatment of eyes with high-risk vascularized herpetic corneal scars that underwent 2-piece mushroom keratoplasty (MK). DESIGN: Prospective interventional case series. METHODS: In this single-center study, 52 consecutive eyes with vascularized (≥2 quadrants) herpetic corneal scars underwent 2-piece microkeratome-assisted MK. Initial high-dose and extended taper of combined oral and topical antiviral and steroid prophylaxis was administered. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, immunologic rejection, herpetic recurrence, and graft failure rates. RESULTS: Excluding patients with vision-impairing comorbidities, baseline BSCVA (1.73 ± 0.67 logMAR) significantly improved annually during the first 2 years (P < .001, P = .016), reaching 0.17 ± 0.18 logMAR at year 2, and remaining stable up to 10 years (P = .662). At 2 years, 86% of eyes saw ≥20/40, 55% saw ≥20/25, and 18% saw ≥20/20 Snellen BSCVA. RA exceeded 4.5 diopters in 7% of cases after wound revision for high-degree astigmatism in 7 cases. Endothelial cell loss was 40.9% at 1 year with an annual decline of 3.1% over 10 years. The 10-year cumulative risk for immunologic rejection, herpetic recurrence, and graft failure was 9.7%, 7.8%, and 7.6%, respectively. CONCLUSIONS: Initial high dose and extended taper of antiviral and steroid prophylaxis for MK in high-risk, vascularized herpetic corneal scars achieves clinical outcomes that remain stable for up to 10 years after surgery with minimal risk of immunologic rejection, herpetic recurrence and graft failure.