Main issues in deep anterior lamellar keratoplasty: A systematic narrative review.

Deep anterior lamellar keratoplasty (DALK) has emerged as a transformative approach in managing corneal pathologies, notably keratoconus (KC), providing a viable alternative to penetrating keratoplasty (PK). This systematic review explores the intricacies of DALK, comparing its preoperative, intraoperative, and postoperative considerations with PK. Extensive literature searches revealed a wealth of data regarding DALK's advantages and challenges, with an emphasis on graft survival, visual outcomes, and complications. In the preoperative phase, DALK showcases its versatility, catering to a wide spectrum of patients, including those with KC and ocular surface disorders. Intraoperatively, it offers innovative techniques to address emphysema, bubble formation, and Descemet's membrane perforation, all while maintaining a strong focus on patient-centered outcomes. Postoperatively, DALK's lower rejection rates and decreased complications underscore its potential superiority over PK, although unique challenges such as graft failure from nonimmunologic factors demand vigilant management. This comprehensive review not only serves as a valuable resource for ophthalmic surgeons but also sheds light on the evolving landscape of corneal transplantation, highlighting DALK's role as a transformative force in the field.

Biomechanical changes in keratoconus after customized stromal augmentation.

PURPOSE: To verify corneal biomechanical changes, poststromal augmentation using myopic small-incision lenticule extraction's (SMILEs) lenticules in advanced keratoconus (KCN) through Corvis ST (Oculus, Wetzlar, Germany). MATERIALS AND METHODS: A clinical trial enrolled 22 advanced KCN patients. We implanted lenticules exceeding 100 µ according to a nomogram and evaluated biomechanical factors through Corvis ST at 3-, 6-, and 24-month postimplantation. We examined parameters during the first applanation (A1), second applanation (A2), highest concavity (HC)/max concavity events, and Vinciguerra screening parameters, as recently established criteria derived from the ideal blend of diverse biomechanical and ocular factors and formulated through the application of logistic regression. Regression analyses explored relationships with age, mean keratometry value, thickness, sphere, cylinder, and best-corrected visual acuity. RESULTS: Patients were well matched for age, intraocular pressure, and central corneal thickness (CCT). The mean spherical equivalent decreased from -13.48 ± 2.86 Diopters (D) to -8.59 ± 2.17 D (P < 0.007), and mean keratometry decreased from 54.68 ± 2.77 D to 51.95 ± 2.21 D (P < 0.006). Significant increases were observed in HC time (HCT), Radius-central curvature radius at the HC state-, peak distance (PD) during HC state, CCT, first applanation time, and stiffness parameter (A1T and SP-A1), whereas HC deformation amplitude, maximum deformation amplitude ratio at 2 mm, Corvis Biomechanical Index (CBI), integrated radius (IR), second applanation deformation amplitude (A2DA), first applanation velocity and deflection amplitude (A1V and A1DeflA) significantly decreased postlenticule implantation. Multivariable regression revealed age positively correlated with SP-A1 (P = 0.003) and negatively with HC delta Arc length (P = 0.007). Mean K positively correlated with CCT (P = 0.05) and negatively with CBI (P = 0.032). Best-corrected visual acuity positively correlated with HCT (P = 0.044), and the cylinder positively correlated with PD (P = 0.05) and CCT (P = 0.05) whereas negatively with IR (P = 0.025). CONCLUSIONS: Stromal augmentation using myopic SMILE lenticules induces significant corneal biomechanical changes in KCN.

Main issues in penetrating keratoplasty.

This review explores contemporary challenges in penetrating keratoplasty (PK), focusing on technical intricacies, technological advancements, and strategies for preventing graft rejection. A systematic literature search from January 2018 to July 2023 was conducted across PubMed, Cochrane, Web of Science, Scopus, and EMBASE. The inclusion criteria comprised studies on PK and its comparison with other corneal pathologies, with emphasis on keratoconus (KC). Two independent reviewers screened studies, extracting relevant data. The review covers PK evolution, highlighting infra-red femtosecond lasers' impact on graft shapes, minimizing astigmatism, and enhancing wound healing. Graft rejection, a primary complication, is examined, detailing risk factors and preventive measures. Preoperative considerations, diagnostic techniques for rejection, and PK in KC are discussed. Postoperative care's significance, including intraocular pressure monitoring and steroid administration, is emphasized. The paper concludes with a comprehensive approach to prevent graft rejection, involving topical and systemic medications. An outlook on evolving monoclonal antibody research is presented. As the field progresses, personalized approaches and ongoing therapeutic exploration are expected to refine strategies, enhancing PK outcomes.

Clinical Evaluation of a New Spectral-Domain Optical Coherence Tomography-Based Biometer.

The VEMoS-AXL system is a new optical biometer based on spectral domain optical coherence tomography (SD-OCT) that has been tested in terms of intrasession repeatability and compared with a swept-source optical coherence tomography biometer (SS-OCT), which is recognized as the gold standard for the performance of an agreement analysis. A biometric analysis was performed three consecutive times in 120 healthy eyes of 120 patients aged between 18 and 40 years with the SD-OCT system, and afterwards, a single measurement was obtained with the SS-OCT system. Within-subject standard deviations were 0.004 mm, 4.394 µm, and 0.017 mm for axial length (AL), central corneal thickness (CCT), and anterior chamber depth (ACD) measures obtained with the SD-OCT biometer, respectively. The agreement between devices was good for AL (limits of agreement, LoA: -0.04 to 0.03 mm) and CCT (LoA: -4.36 to 14.38 µm), whereas differences between devices were clinically relevant for ACD (LoA: 0.03 to 0.21 mm). In conclusion, the VEMoS-AXL system provides consistent measures of anatomical parameters, being most of them interchangeable with those provided by the SS-OCT-based gold standard.

Chloroprocaine 3% Gel as a Novel Ocular Topical Anesthetic: Results from a Multicenter, Randomized Clinical Trial in Patients Undergoing Cataract Surgery.

Purpose: To compare the efficacy and safety of a novel ophthalmic anesthetic, chloroprocaine 3% gel to tetracaine 0.5% eye drops in patients undergoing cataract surgery with phacoemulsification. Methods: This was a prospective, randomized, multicenter, active-controlled, masked-observer, parallel group competitive equivalence study. The study comprised 338 patients having routine cataract extraction by clear corneal phacoemulsification, randomized to receive 3 drops of chloroprocaine gel (n = 166) or tetracaine eye drops (n = 172) before surgery. The primary objective of the study was to assess the equivalence of chloroprocaine gel to tetracaine eye drops as proportion of patients with successful ocular surface anesthesia, without any supplementation just before intraocular lens implantation. Safety measurements were pain, irritation, burning, stinging, photophobia, and foreign body sensation, graded by the patient and objective ocular signs. Results: Equivalence was demonstrated, with a somewhat higher success rate of chloroprocaine gel: 152/166 (92.0%) chloroprocaine versus 153/172 (90.5%) tetracaine patients achieved ocular surface anesthesia with no supplementation. Difference in proportions was 1.5% confidence interval [95% CI: (-3.6 to 6.6)] and 90% CI fell within (-10 to 10). Mean onset of anesthesia was 1.35 ± 0.87 min for chloroprocaine and 1.57 ± 1.85 for tetracaine (P = 0.083). Mean duration of anesthesia was 21.57 ± 12.26 min for chloroprocaine and 22.04 ± 12.58 for tetracaine (P = 0.574). No treatment emergent adverse events related to chloroprocaine were reported and no relevant findings related to local tolerance or vital signs were observed in both arms. Conclusions: Results obtained from the present cataract study demonstrated that chloroprocaine 3% ophthalmic gel is safe and effective, representing a valid alternative in ocular topical anesthesia. Clinical Trial Registration number: NCT04685538.

Criteria for patient selection and indication for intracorneal ring segments in keratoconus.

BACKGROUND: Keratoconus is an ectatic, progressive corneal disorder characterized by alterations in the morphology of the corneal tissue that leads to limitation of visual function of the patient. Intracorneal ring segments (ICRS) are small synthetic devices that are implanted in the corneal stromal in order to regularize the morphology of the tissue therefore improving the visual function and the quality of life of the patients. MAIN TEXT: The present narrative review summarizes the main scientific articles developed by the authors in relation to the clinical outcomes and long-term results of ICRS in the treatment of keratoconus. It was found that those patients that benefit the most from this surgical intervention are those that have the most severe form of keratoconus. Additionally, patients with good visual function, those with more than 0.9 in the decimal scale are at risk of losing visual acuity after ICRS implantation. In relation to long-term results, scientific investigations published by the authors demonstrate that ICRS is a stable procedure after long period of time in terms of vision, refraction, and topographic variables in those patients with stable keratoconus. However, in patients with keratoconus and signs of progression, ICRS may not have the capability of halting the progression of the disease. Using artificial intelligence to guide ICRS implantation provide better clinical outcomes and improvement in corneal higher-order aberrations in patients with keratoconus in comparison to those treated using the commercial nomogram of implantation. CONCLUSIONS: ICRS is a safe surgical procedure in the treatment of keratoconus. Patients that benefit most from the surgery are those with a significant visual impairment. ICRS should not be considered in patients with good visual function because of the risk of losing lines of vision. Long-term follow-up demonstrate stability of the clinical outcomes in patients with stable keratoconus although ICRS may not have the ability of halting the progression of the disease. New technologies based artificial intelligence improved the indications and the clinical outcomes of keratoconus patients treated with ICRS.

Long-term Prevalence of Opacification of a Hydrophylic Acrylic Rotationally Asymmetric Refractive Multifocal Intraocular Lens.

PURPOSE: To determine the prevalence of opacification of a hydrophylic intraocular lens (IOL) with hydrophobic coverage and the percentage of explantations required, determining possible risk factors associated with these opacifications. METHODS: This ambispective study enrolled 575 eyes of 296 patients (age 36 to 87 years) that underwent cataract surgery between 2010 and 2017 with implantation of different models of Lentis Mplus IOLs: LS-312-MF30, LS-313-MF15, LS-313-MF30, LU-313-MF30, and LU-313-MF30T (Oculentis GmbH). Visual, refractive, and slit-lamp biomicroscopic changes were evaluated in a long-term follow-up. The percentage of cases with IOL opacification and the percentage of cases in which IOL explantation was required due to such opacifications were calculated at each visit. Five of the explanted IOLs from this series could be analyzed by scanning electron microscopy (SEM-EDX). RESULTS: IOL opacification developed in 63 eyes (11.0%). With 95% confidence, the prevalence of IOL opacification was between 842 and 1,401 cases per 10,000 eyes. The time elapsed between surgery and the presence of IOL opacification ranged between 0 and 9.3 years (mean: 4.7 ± 2.2 years). No significant differences in terms of IOL opacification rate were found according to gender (P = .378). No significant differences were found in arterial hypertension, diabetes, hypothyroidism, or hyperthyroidism rates between eyes with or without IOL opacification (P ≥ .053). IOL explantation was needed in 9 eyes (1.57%). SEM-EDX analysis confirmed the presence of rough areas on the IOL surface containing different components, such as calcium, phosphorous, copper, or nitrogen. CONCLUSIONS: The prevalence of opacification with time in Lentis Mplus IOLs is high, with no systemic risk factors associated with this complication, suggesting that it may be attributable to the material and/or the manufacturing process. [J Refract Surg. 2024;40(2):e98-e107.].

Evaluation of 9 IOL power calculation formulas using a heteroscedastic statistical method and a new method of IOL constant optimization.

PURPOSE: To evaluate the prediction accuracy of 9 IOL power calculation formulas using a heteroscedastic statistical analysis and a novel method for IOL constant optimization. DESIGN: Retrospective case series. METHODS: The LenStar LS900 (Haag-Streit, Koeniz, Switzerland) was used for the preoperative biometry. The predicted SE refraction of the implanted IOL were calculated for: Barrett Universal II, EVO-2.0, Hill RBF-3.0, Hill-RBF 2.0, Kane, PEARL-DGS, SRK-T, Hoffer-Q and Holladay-1. IOL constants were optimized prior to the analysis. A heteroscedastic statistical method was used to compare the standard deviation (SD) of prediction errors (PE). RESULTS: Two hundred seventy-eight eyes of 278 patients were included. The SD of the Kane was 0.4214D and was the lowest in this database. The SD of the PE of the Kane and EVO 2.0 were significantly lower than the SRK-T, Holladay 1, and Hoffer-Q. The SD of the PE of the PEARL formula was significantly lower than the SRK-T and Hoffer-Q. The SD of the PE of the Hill-RBF 3.0 was not significantly different to the Hill-RBF 2.0, Kane, EVO 2.0, Barrett Universal II and PEARL. No significant difference was found between the SD of the PE of the new generation formulas analysed. CONCLUSIONS: the lowest SD of the prediction error was provided by Kane, followed by EVO 2.0 and PERL-DGS formulas. However, no statistically significant differences were found between the SD of the PE of new generation formulas. Further studies are necessary to evaluate the accuracy of these formulas in extreme eyes.

Immediately sequential bilateral cataract surgery.

PURPOSE OF REVIEW: This review aims to clarify the advantages and disadvantages of immediately sequential bilateral cataract surgery (ISBCS) based on recent studies, illustrate the safety of this approach, the cost-effectiveness, and present the importance of inclusion protocols for the best results. RECENT FINDINGS: In recent studies, the authors found no evidence of an increased risk of bilateral devastating complications such as endophthalmitis with ISBCS based on descriptive evidence compared to delayed sequential bilateral cataract surgery (DSBCS). Furthermore, recent studies on cost analyses showed that ISBCS resulted in fewer costs and significant cost savings to third-party payers, patients, and society compared to DSBCS. SUMMARY: The ISBCS surgical approach decreases hospital visits, reduces costs, and provides rapid visual rehabilitation and neuro adaptation. The risk of bilateral simultaneous complications is now recognized to be very rare with intracameral antibiotics and compliance with correct protocols. With new generations of optical biometry and lens calculation formulas, refractive surprises are occasional for normal eyes. However, refractive surprise is controversial, especially in the implantation of presbyopia correction intra-ocular lenses, which must be evaluated carefully in the ISBCS approach.

Study of the Influence of Boundary Conditions on Corneal Deformation Based on the Finite Element Method of a Corneal Biomechanics Model.

Implementing in silico corneal biomechanical models for surgery applications can be boosted by developing patient-specific finite element models adapted to clinical requirements and optimized to reduce computational times. This research proposes a novel corneal multizone-based finite element model with octants and circumferential zones of clinical interest for material definition. The proposed model was applied to four patient-specific physiological geometries of keratoconus-affected corneas. Free-stress geometries were calculated by two iterative methods, the displacements and prestress methods, and the influence of two boundary conditions: embedded and pivoting. The results showed that the displacements, stress and strain fields differed for the stress-free geometry but were similar and strongly depended on the boundary conditions for the estimated physiological geometry when considering both iterative methods. The comparison between the embedded and pivoting boundary conditions showed bigger differences in the posterior limbus zone, which remained closer in the central zone. The computational calculation times for the stress-free geometries were evaluated. The results revealed that the computational time was prolonged with disease severity, and the displacements method was faster in all the analyzed cases. Computational times can be reduced with multicore parallel calculation, which offers the possibility of applying patient-specific finite element models in clinical applications.

Perioperative intense pulsed light to prevent and improve symptoms of post-laser corneal refractive surgery dry eye. A randomized clinical trial.

PURPOSE: To evaluate the efficacy of perioperative IPL therapy in preventing postoperative ocular surface disorders in patients undergoing corneal laser refractive surgery. DESIGN: randomized, controlled, clinical trial with triple-blinding. METHODS: Setting: Vissum Miranza - Alicante; Study population: 61 patients randomized in two groups: 31 study patients (perioperative IPL + laser refractive surgery) and 30 control patients (perioperative placebo + laser refractive surgery). Follow-up was conducted over a 6-month period; Intervention: Each participants underwent three IPL sessions with a two-week interval between each session (pre-surgery, post-surgery week-one, and post-surgery week-three). For controls, placebo was administered following the same protocol. MAIN OUTCOMES MEASURES: visual outcomes and refraction, slit-lamp examination, corneal topography, visual analogue scale questionnaire and Oculus Keratograph 5 M including tear meniscus height, non-invasive tear break- up time, ocular redness, infrared meibography and Ocular Surface Disease Index (OSDI) questionnaire. RESULTS: 61 randomized eyes were included. No significant differences were observed in terms of uncorrected and corrected distance visual acuity (UDVA, CDVA), refractive error or corneal aberrations. A statistically significant improvement in OSDI score (change -8.47, p = 0.043), tear meniscus (change 0.05 mm, p = 0.004) and Meibography (change -0.42, p = 0.012) was observed at the third postoperative month in the study group. Additionally, at the sixth postoperative month, there were statistically significant improvements in tear meniscus (change 0.06 mm, p = 0.018), tear break-up-time (change 1.68 s, p = 0.039) and Meibography (change -0.37, p = 0.030). CONCLUSIONS: Results suggest that perioperative IPL therapy applied to laser corneal refractive surgery improves objective and subjective ocular surface parameters over non-IPL-treated control patients and early postoperative dry eye symptoms.

Comparative evaluation of methods for obtaining the stress-free geometry of keratoconus corneas with different levels of severity.

A biomechanical model that simulates the physiological pressure load on the cornea without considering the stresses in vivo will result in an overstress or underestimation of the stress field and incorrect deformation of the corneal structure. Therefore, it is essential to propose numerical models that consider the stress-free geometry of the cornea. In this study, the Displacement and Pre-stress methods were compared to obtain the stress-free geometry (S-FG) and the physiological estimated geometry (P-EG), based on the patient-specific geometric behavior and the computational time required to reach each geometry. The same shape and contour conditions were considered in the models obtained from both methods for each of the pathological scenarios analyzed. Both methods behaved differently to obtain the free geometry, and this difference increased with the severity grade of the disease. However, they behaved in a similar way to reach the physiological estimated geometry. The Displacement method required a lower computational cost to reach the free geometry, with both methods presenting a similar computational cost to obtain the physiological geometry. The stress-free geometries obtained by both methods allowed to characterize the existing biomechanical decompensation during the progression of the diseases. In conclusion, the calculation of the stress-free corneal geometry associated to the clinically measured intraocular pressure with the Displacement and Prestress Methods in keratoconus eyes allows the development of accurate and useable models in clinical practice in real time. This displacement method shows some benefits in terms of computational cost.

In vivo confocal microscopy evaluation of infiltrated immune cells in corneal stroma treated with cell therapy in advanced keratoconus.

PURPOSE: This study investigates immune cell (ICs) infiltration in advanced keratoconus patients undergoing autologous adipose-derived adult stem cell (ADASC) therapy with recellularized human donor corneal laminas (CL). METHODS: A prospective clinical trial included fourteen patients divided into three groups: G-1, ADASCs; G-2, decellularized CL (dCL); and G-3, dCL recellularized with ADASCs (ADASCs-rCL). Infiltrated ICs were assessed using in vivo confocal microscopy (IVCM) at 1,3,6, and12 months post-transplant. RESULTS: Infiltrated ICs, encompassing granulocytes and agranulocytes, were observed across all groups, categorized by luminosity, structure, and area. Stromal ICs infiltration ranged from 1.19% to 6.62%, with a consistent increase in group-related cell density (F = 10.68, P < .0001), independent of post-op time (F = 0.77, P = 0.511); the most substantial variations were observed in G-3 at 6 and 12 months (2.0 and 1.87-fold, respectively). Similarly, significant size increases were more group-dependent (F = 5.76, P < .005) rather than time-dependent (F = 2.84, P < .05); G-3 exhibited significant increases at 6 and 12 months (3.70-fold and 2.52-fold, respectively). A lamina-induced shift in IC size occurred (F = 110.23, P < .0001), primarily with 50-100 µm2 sizes and up to larger cells > 300µm2, presumably macrophages, notably in G-3, indicating a potential role in tissue repair and remodeling, explaining reductions in cells remnants < 50µm2. CONCLUSIONS: ADASCs-rCL therapy may lead to increased IC infiltration compared to ADASCs alone, impacting cell distribution and size due to the presence of the lamina. The findings reveal intricate immune patterns shaped by the corneal microenvironment and highlight the importance of understanding immune responses for the development of future therapeutic strategies.

Role of Anterior Segment Optical Coherence Tomography in Staging and Evaluation of Treatment Response in Infectious Keratitis.

PURPOSE: The aim of this study was to evaluate the role of anterior segment optical coherence tomography during follow-up of infectious keratitis and to assess response to treatment. METHODS: This was a prospective, consecutive, observational clinical series of cases. Twenty-three eyes of 23 patients with clinically proven fungal keratitis were included in the study. The patients received medical treatment according to clinical diagnosis, and follow-up was performed weekly. Slit-lamp examination and photography, and anterior segment optical coherence tomography were performed at initial and follow-up visits until corneal healing occurred. The main outcome measures included infiltrate depth, width, and density; central corneal thickness; minimal corneal thickness; corneal thickness at the site of the lesion; and stromal thickness at the center of the lesion. RESULTS: Twenty-three eyes of 23 patients (17 men and 6 women), mean age 42.5 ± 19 (8-66) years, were clinically diagnosed with fungal keratitis. Localization was central in 14 cases and paracentral/peripheral in 9 cases. Healing time was 6 to 12 weeks. Minimal corneal thickness, corneal thickness at the site of lesion, and stromal thickness at the center of lesion, and also infiltrate width and depth changed significantly from the first visit to the healing stage at the last follow-up (0.009, 0.001, 0.007, 0.001, and <0.001, respectively). CONCLUSIONS: In cases of fungal keratitis, anterior segment optical coherence tomography can provide the clinician with a quantitative assessment of a number of corneal parameters that can be used to determine effectiveness of therapy and confirm complete healing of the lesions that cannot be achieved by clinical evaluation. CLINICAL TRIAL REGISTRATION: The study was registered in Clinical Trials.gov with NCT04969640.

Refractive lens exchange: What are the red lines?

Practical advancements in phacoemulsification techniques and intraocular lenses and the wide availability of phacoemulsification machines have led refractive lens exchange (RLE) to increase in popularity. Ethical boundaries in RLE have subsequently been pushed to include patients at higher risk of complications. In this editorial, we consider RLE outcomes and complications per type of refractive error, together with preoperative, intraoperative and postoperative ethical obligations for refractive surgeons. In the conclusions section, we propose an algorithm for ethics-guided indications to RLE.

Causes of intraocular pseudophakic lens explantation in Spain.

PURPOSE: To report the causes of pseudophakic intraocular lens (IOL) explantation in Spain over a 20 year period. METHODS: Multicenter observational prospective study of a consecutive series of cases corresponding to pseudophakic intraocular lenses explantations performed in 22 Spanish clinical centres from 2002 to 2021, within a national clinical research network. The clinical data of all IOL explantation patients was evaluated, and the different causes for IOL explantation were systematically analyzed. RESULTS: From a total of 1013 pseudophakic explantations, 919 cases were included in this investigation. The mean age of the patients at the time of explantation was 66.3 years, and 142 (15.45%) were women. Over the 20 years of the study, the five main reasons for explanting lenses in the last 20 years in Spain according to the Iberia RETICS database were: dislocation / decentration / misalignment (43.08%), bullous keratopathy (16.79%), neuroadaptation failure (13.85%), IOL opacification (9.71%), refractive surprise (6.87%). Other causes, less frequent, were uveitis / endophthalmitis / infection with 39 cases (4.25%); IOL substitution for reasons other than multifocal IOL neuroadaptation failure 3 cases (0.33%); and other causes, 47 cases (5.13%). Hydrophobic lenses were the most frequently explanted with a ratio of 47.1%. CONCLUSIONS: Over the 20 years of the study, the five main reasons for explanting lenses in the last 20 years in Spain according to the Iberia RETICS database were: dislocation / decentration / misalignment, bullous keratopathy, neuroadaptation failure, IOL opacification, and refractive surprise.

Refractive surgical correction and treatment of keratoconus.

Keratoconus is an ectatic corneal disorder that causes severe vision loss. Surgical options allow us to correct, partially or totally, the induced refractive error. Intracorneal ring segments (ICRS) implantation represents a minimally invasive surgical option that improves visual acuity, with a high success rate and a low overall complication rate. Corneal allogenic ICRS consists of ring segments derived from allogenic eye bank-processed donor corneas. Selective topography-guided transepithelial photorefractive or phototherapeutic keratectomy combined with CXL is another way in selected cases to improve spectacles corrected distance visual acuity. The microphotoablative remodeling of the central corneal profile is generally planned by optimizing the optical zones and minimizing tissue consumption. Phakic intraocular lens (PIOL) implant is considered in patients with stable disease and acceptable anatomical requirements. The two types of pIOLs, depending on their implantation inside the eye, are anterior chamber-pIOLs, which fixate to the anterior surface of the iris by using a polymethomethacrolate claw at the two haptics, and posterior chamber-pIOLs. In patients with both cataracts and keratoconus, the correct IOL power is difficult to obtain due to the irregular corneal shape and K values. Toric IOL is recommended, but carefully judging the topography and the possible need of subsequent keratoplasties.

Simultaneous tectonic Descemet stripping endothelial keratoplasty and tectonic Bowman layer transplant for the management of corneal perforation.

AIM: To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty (t-DSEK) and tectonic Bowman layer transplant (t-BLT) as an alternative to tectonic penetrating keratoplasty (t-PKP). METHODS: Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included. The technique for DSEK was modified depending on individual requirements. The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture. Success was measured by the ability of this procedure to close a corneal perforation. RESULTS: All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period. Reinterventions were relatively common: 2 cases required amniotic membrane transplant for persistent epithelial defects. One case required DSEK rebubbling. One case developed angle closure glaucoma requiring surgical peripheral iridectomy. CONCLUSION: Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.