Surgical management of a posterior dislocated intraocular lens after descemet stripping automated endothelial keratoplasty.

PURPOSE: To describe the occurrence and management of a posterior chamber intraocular lens (IOL) dislocation into the vitreous cavity after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: We describe the clinical course of a pseudophakic patient with Fuchs endothelial dystrophy and previous Neodymium: Yttrium-Aluminum-Garnet (Nd:YAG) laser capsulotomy who underwent DSAEK. On postoperative day 10, the patient was examined and a detachment of the DSAEK graft was noted. After disc reattachment with use of an air bubble, the patient's vision did not clear because of persistent edema, but he appreciated a new large floater. A diagnosis of iatrogenic graft failure was made, and ultrasound examination confirmed dislocation of a plate-haptic silicone IOL into the vitreous cavity. The patient was treated with pars plana vitrectomy and concurrent penetrating keratoplasty. RESULTS: One year after penetrating keratoplasty, the patient had a visual acuity of 20/60 with mild neurotrophic keratopathy and irregular astigmatism. CONCLUSION: The use of intraocular air at the time of graft repositioning can induce posterior dislocation of an IOL in the setting of a YAG capsulotomy opening.

Comparison of the femtosecond laser (IntraLase) versus manual microkeratome (Moria ALTK) in dissection of the donor in endothelial keratoplasty: initial study in eye bank eyes.

PURPOSE: To determine the safety and efficacy of a femtosecond laser (IntraLase) and manual microkeratome (Moria ALTK) in creating precut endothelial keratoplasty donor tissue. METHODS: Sixteen corneoscleral buttons from 8 donors were evaluated within 2 days of the death of the donor. The mean donor age was 72 years, and mean death-to-preservation time was 11 hours. Eight eyes underwent deep lamellar keratectomy by using the femtosecond laser (IntraLase: firing rate, 30 kHz; lamellar cut energy, 7.4 microJ; side cut energy, 5.5 microJ; spot size, 10 microm; diameter, 9.0 mm; depth, 400 microm; spiral pattern), whereas the other 8 eyes were cut by using the Moria ALTK microkeratome (350-microm head). Ultrasonic pachymetry and endothelial cell density (ECD) were performed before and after keratectomy. The residual stromal bed was examined with electron microscopy to determine the smoothness of the surface. Cell viability was assessed by using a transferase dUTP nick end labeling (TUNEL) assay. RESULTS: The mean preoperative pachymetry was similar in the microkeratome group and femtosecond laser group (P = 0.239). The microkeratome group obtained a consistently deeper keratectomy of 446 +/- 25 versus 400 +/- 41 microm in the laser group (P = 0.023). Similarly, the residual stromal bed was thinner in the microkeratome group (115 +/- 28.5 vs. 177 +/- 42 microm; P = 0.005). There was no statistically significant difference in the ECD between the 2 groups preoperatively or at 48 hours after keratectomy. Compared with the preoperative state, there was a 1% and 4% reduction of ECD in the microkeratome and femtosecond laser groups, respectively. Scanning electron microscopy of the stromal surface consistently showed a smoother contour in the manual microkeratome group. TUNEL assays indicate no significant endothelial cell loss in either the microkeratome group or the femtosecond laser group. CONCLUSIONS: The femtosecond laser (30 kHz) and the manual microkeratome are equally effective in creating precut endothelial keratoplasty donor tissue, with no detrimental effect on endothelial cell density. The microkeratome creates a smoother stromal surface and thinner endothelial discs. The femtosecond laser lamellar dissection depth is less deep, and the stromal surface is less smooth. This particular feature of femtosecond laser keratectomy may improve disc adherence, which continues to be a problem in endothelial keratoplasty. A prospective, randomized study is needed to evaluate postoperative vision and disc adherence by using both technologies in endothelial keratoplasty.

New insights into the diagnosis and treatment of neurotrophic keratopathy.

Abnormalities of the ocular surface can be acquired or inherited disorders of the central nervous system. Loss of neural stimulation from the sensory division of the trigeminal nerve or from the autonomic nervous system can have devastating consequences on corneal epithelial wound healing and the precorneal tear film, leading to decreased vision. The pathogenesis of neurotrophic keratopathy is reviewed, and treatment modalities are recommended.