Optimizing outcomes for keratoplasty in ectatic corneal disease.

PURPOSE OF REVIEW: Advanced keratectasia often requires corneal transplantation for restoration of vision. This review discusses the surgical approach suitable for these cases including significant updates in the current literature. RECENT FINDINGS: With greater understanding of ectatic corneal disease and its associated operative challenges, several modifications in the surgical approach have been developed. Identified predictive factors for successful pneumatic dissection and intraoperative complications have informed surgical planning and decision-making. In the setting of failed pneumatic dissection, sequential use of alternative lamellar dissection techniques is a reasonable surgical strategy. Surgical refinements to optimize visual outcomes and postoperative interventions to correct residual refractive errors have improved visual rehabilitation after keratoplasty. SUMMARY: With evidence of its undisputed advantages, DALK has been widely recognized as the primary surgical option for ectatic corneal disease.

Outcomes of a Modified Technique for Successful Pneumatic Dissection in Pediatric Eyes With Corneal Scars.

PURPOSE: To report the outcomes of a modified deep anterior lamellar keratoplasty (DALK) procedure for the treatment of scarred corneas in otherwise healthy pediatric eyes. METHODS: All pediatric eyes undergoing DALK by the same surgeon (M.B.) between July 2013 and June 2017 were enrolled. The standard DALK procedure was modified by including a large (9 mm) and deep (150 µm from the thinnest pachymetric measurement) trephination, a minimal cannula advancement from the base of the trephination, and a clearing of a central 6 mm optical zone. The success rates of pneumatic dissection, visual and refractive outcomes, and complications were reported. A complete ophthalmologic examination was performed preoperatively and a few days after suture removal (6-months post-DALK) for all patients as well as 12, 24, and 36 months postoperatively for available patients. RESULTS: Fourteen eyes of 13 patients with various indications were included in this study. The mean age at the time of surgery was 11.7 ± 2.5 years. Pneumatic dissection succeeded in all but one case (13/14 eyes = 92.8%), which was completed by hand dissection. All sutures were removed within 6 months of surgery. With a minimum postoperative follow-up of 6 months, best spectacle-corrected visual acuity improved from ≤20/50 to ≥20/40 in all but one eye, which was known to be amblyopic. CONCLUSIONS: Despite impaired corneal transparency and increased tissue consistency, a modified DALK technique allows successful pneumatic dissection in an extremely high percentage of scarred pediatric eyes. Visual results compare favorably with those obtained in children after penetrating keratoplasty, while vision threatening complications are minimized.

Anterior Segment Optical Coherence Tomography of Post-Descemet Stripping Automated Endothelial Keratoplasty Eyes to Evaluate Graft Morphology and Its Association With Visual Outcome.

PURPOSE: To evaluate the relationship between graft thickness/regularity and visual outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Records of post-DSAEK patients who were examined by anterior segment optical coherence tomography at "Villa Igea" Private Hospital (Forlì, Italy) since April 2015 were reviewed. Pachymetric and elevation maps of both host cornea and graft were analyzed. Graft regularity was determined based on the root mean square error (RMSE) of the graft pachymetric measurements taken 3 and 6 mm from the center and the RMSE of the corneal elevation measurements at its posterior and interface surfaces. These parameters were correlated with best-spectacle-corrected visual acuity (BSCVA) (expressed in logarithm of the minimum angle of resolution) and compared between eyes with central graft thickness (CGT) ≥100 µm (group 1) and eyes with CGT <100 µm (group 2). RESULTS: Eighty-nine post-DSAEK eyes of 89 patients with Fuchs endothelial dystrophy or bullous keratopathy and no significant comorbidities were included. There were 40 eyes (CGT = 138.2 ± 31.7 µm) in group 1 and 49 eyes (CGT = 73.3 ± 15.5 µm) in group 2. The RMSEs of graft pachymetry and the RMSEs of the interface and posterior surface elevation maps at 3 and 6 mm differed significantly between both groups (P < 0.05). When only eyes with Fuchs endothelial dystrophy (n = 54) were considered in both groups, there was a statistically significant correlation (r = 0.44; P = 0.001) between BSCVA and CGT. CONCLUSIONS: DSAEK grafts thinner than 100 µm are more regular than thicker ones. In eyes with Fuchs endothelial dystrophy that are otherwise healthy, thinner grafts yield significantly better BSCVA.

Outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes with failure of primary Descemet membrane endothelial keratoplasty (DMEK).

AIM: To evaluate the outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes after failure of primary Descemet membrane endothelial keratoplasty (DMEK). METHODS: This was a retrospective, non-comparative interventional case series done in a tertiary care hospital. The study group included 21 eyes of patients which underwent UT-DSAEK following the failure of primary DMEK. Outcome measures included best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) both recorded 6 and 12 months postoperatively as well as central graft thickness (CGT) measured 6 months after UT-DSAEK. RESULTS: When considering only eyes without comorbidities (17 of 21), 12 months after UT-DSAEK, BSCVA was ≥20/25 in 12/13 (92%) eyes and ≥20/20 in 4/13 (30%) eyes. Mean ECD loss rate was 38.9% at 12 months postoperatively (range 8%-57%). Six months postoperatively, CGT averaged at 81±34 µm (range 34-131 µm). No intraoperative complications were recorded. Postoperatively, one patient (no. 8) had graft wrinkles that were fixed 2 days following UT-DSAEK. Four patients have developed intraocular lens (IOL) opacification, and two of them underwent IOL exchange. No other postoperative complications were recorded. CONCLUSIONS: UT-DSAEK is instrumental in the management of primary DMEK graft failure, allowing visual rehabilitation which is comparable with that of repeat DMEK.

Immunologic Stromal Rejection After Deep Anterior Lamellar Keratoplasty With Grafts of a Larger Size (9 mm) for Various Stromal Diseases.

PURPOSE: To evaluate the rate and outcomes of immunologic stromal rejection occurring after large deep anterior lamellar keratoplasty (DALK) and the effect of the underlying disease on the cumulative probability of rejection. METHODS: This was a retrospective chart review of all eyes that underwent a 9-mm DALK at Ospedali Privati Forlì (Forlì, Italy). On the basis of preoperative diagnosis, eyes were assigned to group 1: keratoconus, group 2: stromal disease with a low risk for rejection, or group 3: stromal disease with a high risk for rejection. The cumulative probability of experiencing a rejection episode over time was assessed by Kaplan-Meier analysis and was compared among the 3 groups using the log-rank test. Values of corrected distance visual acuity, central corneal thickness, and endothelial cell density before and 6 months after rejection were compared. RESULTS: Twenty of 377 eyes (5.3%) experienced an episode of stromal rejection [17/265 (6.4%) in group 1, 2/71 (2.8%) in group 2, and 1/41 (2.4%) in group 3]. The mean time interval between DALK and the rejection onset was 11.8 months (range 1-24). The cumulative probability of rejection episodes did not differ significantly among the 3 groups. All episodes resolved within 6 months after the onset, with no significant differences between prerejection and 6-month postrejection values of corrected distance visual acuity, central corneal thickness, and endothelial cell density. CONCLUSIONS: The rate of immunologic stromal rejection after large 9-mm DALK is within the range reported in the literature for conventional DALK, regardless of the indication for surgery.