Descemet's Membrane Endothelial Keratoplasty for Corneal Endothelial Failure Secondary to Three Types of Phakic Intraocular Lens - Retrospective Study.

Purpose: To analyze the outcomes of Descemet's membrane endothelial keratoplasty (DMEK) for corneal endothelial failure secondary to phakic intraocular lens implantation (PIOL) at a reference center for corneal transplantation in Spain. Design: Retrospective, single-surgeon case series. Methods: Single-center analysis of patients who underwent DMEK for PIOL-related corneal decompensation between July 2011 and July 2020 with at least 6 months of follow-up postoperatively. Primary outcome was final best-corrected visual acuity (BCVA, logMAR) compared to pre-DMEK BCVA. Secondary outcomes analyzed included post-DMEK refractive spherical equivalent, endothelial cell loss (%ECL), and graft failure. Results: Sixteen eyes (14 patients) underwent DMEK for PIOL-related corneal decompensation. Mean (SD) time to PIOL explantation was 9.3 (5.0) years, and median (P25-P75) time between PIOL explantation and DMEK surgery was 3 (2-4) months. Median pre-DMEK BCVA was 0.80 (1.08-0.60) logMAR. A statistically significant improvement in BCVA was observed 1 month after DMEK (p = 0.001), and median final BCVA was 0.15 (0.0-0.35) logMAR (p = 0.002). Mean %ECL was 55.6 (18.7) % at 2-year follow-up and 61.7 (11.7) % in eyes with over 4 years of follow-up. Two eyes required re-bubbling (12.5%), one of which ended in primary graft failure (6.2%) and one eye had late endothelial graft failure (LEGF) at 4-year follow-up (1/15 grafts, 6.7%). Conclusion: In patients with PIOL-related corneal decompensation, DMEK leads to good and clinically significant refractive and visual outcomes in the medium-long term, with a good safety profile. Prospective studies are encouraged to ascertain whether these cases are at increased risk of accelerated endothelial cell loss and LEGF.

Outcomes of cystoid macular edema following Descemet's membrane endothelial keratoplasty in a referral center for keratoplasty in Spain: retrospective study.

The aim of this study was to analyze the outcomes of eyes with visually significant cystoid macular œdema (vs-CMO) after Descemet membrane endothelial keratoplasty (DMEK) in a referral center for keratoplasty in Spain. We conducted a retrospective, single-surgeon case series of eyes that developed post-DMEK vs-CMO performed between January 2011 and December 2020. Data collected included: indication for DMEK; biometric data; ocular comorbidities; past medical history; time to detection of vs-CMO after DMEK (T, weeks); best-corrected visual acuity (BCVA, logMAR) and central retinal thickness (CRT, µm) at diagnosis of vs-CMO, after resolution of CMO, and at last follow-up; and management strategy. Main outcomes analyzed were incidence of vs-CMO, improvement in BCVA and CRT after treatment of vs-CMO. Of 291 consecutive DMEK surgeries, 14 eyes of 13 patients (4.8%) developed vs-CMO. Five patients (38.5%) had history of CMO, and 28.6% of eyes had ophthalmic comorbidities. Median (P25-P75) T was 4 (3-10) weeks. Treatment success was observed in 12/13 eyes (92.3%), two of which required second-line treatment. In successful cases (median time-to-resolution 3.0 (2.0-3.5) months), median BCVA improved from 0.60 (0.40-0.80) logMAR to 0.30 (0.15-0.40) logMAR (p = 0.002) after treatment, and median CRT improved from 582.5 (400.0-655.0) µm to 278.0 (258.0-294.0) µm (p = 0.005). In our study, we found a 4.8% rate of post-DMEK vs-CMO, with most cases occurring in the first 3 months after surgery. Good functional and anatomical outcomes are expected in most eyes, without treatment-related complications or implications in graft outcomes. Additional studies are encouraged to determine a standardized protocol for post-DMEK vs-CMO.

Ten-year outcomes of pseudophakic mini-monovision correction of hyperopic presbyopia.

PURPOSE: To evaluate long-term efficacy, safety, and spectacle independence after the treatment of hyperopic presbyopia with pseudophakic mini-monovision using standard monofocal intraocular lenses (IOLs) after bilateral cataract surgery. SETTING: Private practice in Barcelona, Spain. DESIGN: Retrospective, noncomparative case series. METHODS: Patients with hyperopic presbyopia underwent bilateral cataract surgery with pseudophakic mini-monovision using standard monofocal IOLs between 2008 and 2018. Main outcomes analyzed were uncorrected distance visual acuity (UDVA), uncorrected near distance visual acuity (UNVA), and rates of spectacle independence at postoperative day 1 (POD1), months 1, 6 and 12, and at 5 and 10 years (Y10) postoperatively. RESULTS: The study enrolled 463 patients. Both UDVA and UNVA significantly improved postoperatively ( P < .05). The mean binocular UDVA improved from 0.47 ± 0.3 logMAR preoperatively to 0.096 ± 0.14 at POD1 to 0.16 ± 0.2 at Y10 ( P = .0033). The binocular UNVA was 0.05 logMAR at Y10, whereas in preoperative visits, all patients needed spectacles. The mean UDVA for the dominant eye ≤0.20 logMAR was achieved in 84.29% at the Y10. Self-reported and measured complete spectacle independence for near vision was achieved in 79.61% of patients at POD1 and 71.92% at Y10 postoperatively. For distance, respectively, in 86.29% of patients at POD1 and 78.43% at Y10. The achieved results were stable. No serious events were reported, as well as no photic phenomena. CONCLUSIONS: Pseudophakic mini-monovision in hyperopic presbyopes is a safe, effective, and low-cost approach for the long-term correction of presbyopia. It significantly reduces spectacle dependence and fulfils patients' expectations after bilateral cataract surgery.

Photorefractive keratectomy after DMEK for corneal decompensation by phakic IOL.

PURPOSE: To provide the first description of photorefractive keratectomy (PRK) for the correction of mild residual refractive error after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Case report. RESULTS: A 45 year-old woman presenting with phakic intraocular lens (PIOL)-related corneal decompensation underwent staged DMEK surgery following PIOL explantation and cataract surgery. Eighteen months after DMEK, uncorrected distance visual acuity (UDVA) was 20/60 and best-corrected visual acuity (BCVA) was 20/22, with a stable refraction. The patient requested refractive surgery to decrease spectacle dependance, and wavefront-optimized PRK was performed. At last follow-up observation thirty-three months after PRK (54 months after DMEK surgery), UDVA was 20/20, the cornea remained clear without signs of rejection or endothelial failure, and the endothelial cell loss rate was not accelerated after PRK. CONCLUSION: Since long-term visual and refractive stability can be expected after DMEK, PRK may be a particular safe and effective approach for the correction of mild residual refractive errors after DMEK. However, we consider that surgeons must exercise caution when considering keratorefractive surgery in these eyes due to postoperative changes in corneal curvature and thickness, and further studies are encouraged.

Long-term efficacy and safety profiles of iris-fixated foldable anterior chamber phakic intraocular lens implantation in eyes with more than 10 years of follow-up.

PURPOSE: To evaluate the long-term efficacy, safety, predictability, and stability of a foldable anterior chamber phakic intraocular lens (pIOL) (Artiflex) implantation in eyes with more than 10 years of follow-up. SETTING: Instituto de Microcirugía Ocular, Barcelona, Spain. DESIGN: Retrospective study. METHODS: Patients who underwent Artiflex pIOL implantation during 2008 to 2011 and with more than 10 years of follow-up were included. Variables analyzed were as follows: uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, spherical equivalent (SE), endothelial cell count (ECC), and intraocular pressure (IOP) preoperatively and at 1 month, 1 year, 5 years, and the final follow-up. Descriptive statistics were performed and results reported following the Standard for Reporting Refractive Surgery Outcomes. RESULTS: 76 eyes (40 patients) were analyzed, and the mean follow-up was 10.67 ± 0.64 years. The mean preoperative SE was -8.26 ± 2.47 diopters (D), and the mean preoperative cylinder was -0.95 ± 0.86 D. At the final follow-up, efficacy and safety indices were 0.82 and 1.11, respectively. In total, 58 eyes (76%) achieved a UDVA of ≥20/40. 30 eyes (39%) gained ≥1 line of CDVA, and no eye lost ≥2 lines of CDVA. At the final follow-up, 46 (61%) and 58 (76%) eyes were within ±0.50 D and ±1.00 D of attempted SE correction, respectively. 72 eyes (95%) had ≤1.00 D of postoperative astigmatism, and 46 eyes (61%) were within ±15 degrees from the intended correction axis. At the last visit, a statistically significant myopic progression of -0.56 ± 0.83 D was observed ( P = .01). The mean ECC loss at the final follow-up was 12.2 ± 12.5%. IOP remained stable. Two eyes (2.63%) developed cataract after 10.3 years. CONCLUSIONS: Long-term results demonstrated that Artiflex pIOL implantation was effective, predictable, stable, and safe.

Secondary Endothelial Keratoplasty-A Narrative Review of the Outcomes of Secondary Corneal Endothelial Allografts.

BACKGROUND: We review the literature on the efficacy and safety outcomes of secondary Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK). METHODS: Literature search of English-written publications up to September 27, 2020 in PubMed database, using the terms "endothelial keratoplasty" in combination with keywords "secondary" or "repeat." In addition, we manually searched the references of the primary articles. RESULTS: Twenty-seven studies (n = 651 eyes) were retained and reviewed, including 10 studies on repeat DSEK, 8 studies on repeat DMEK, 6 studies of DMEK following DSEK, and 3 studies of DSEK after failed DMEK. All studies reported significant improvement in visual acuity after secondary endothelial keratoplasty (EK). Twelve studies compared visual outcomes between primary and secondary EK, reporting conflicting findings. Sixteen studies reported endothelial cell loss rates after secondary EK, and only 1 study reported significantly increased endothelial cell loss rates compared with primary EK. Allograft rejection episodes occurred in 1.8% of eyes (range, 0%-50%). Six studies compared complication rates between primary and secondary EK eyes, and only 1 study found a higher median number of complications. However, 2 studies reported higher regraft failure rates compared with primary EK eyes. CONCLUSIONS: Secondary EK is surgically feasible and renders significant visual improvement after failed primary EK, although it is not clear whether visual outcomes and allograft survival are comparable with primary EK, raising the question of whether secondary EK eyes are "low risk" as primary EK eyes. Further larger, prospective studies are encouraged to obtain additional quality data on secondary corneal endothelial allotransplantation.

Repeat Descemet Membrane Endothelial Keratoplasty for Failed Primary Descemet Membrane Endothelial Keratoplasty at a Referral Center for Keratoplasty in Spain: DIMOEK Study.

PURPOSE: To analyze the clinical results of repeat Descemet membrane endothelial keratoplasty (re-DMEK) for failed primary DMEK graft at a referral center for keratoplasty in Spain. DESIGN: Retrospective, interventional, comparative case series. METHODS: From a single-center, single-surgeon series of 189 consecutive DMEK surgeries, 14 (7.41%) were re-DMEK eyes. The primary outcome was best-corrected visual acuity change (ΔBCVA, logarithm of minimal angle of resolution [logMAR]) from baseline (before first DMEK) to last follow-up. Secondary outcomes were ΔBCVA from baseline at 3, 6, and 12 months postoperatively, endothelial cell loss (%ECL), rebubbling rate, and re-DMEK graft failure. Outcomes were compared with an age-matched control group of 18 successful primary DMEK eyes. RESULTS: After re-DMEK (median follow-up time 14.5 [42.5] months), mean BCVA improved from 0.55 (0.42) logMAR (Snellen 20/71 [20/53]) at baseline to 0.09 (0.26) logMAR (Snellen 20/25 [20/36]; P = .037). ΔBCVA from baseline was statistically significant at months 3 (P = .028), 6 (P = .023), and 12 (P = .012), and ΔBCVA was significant observed between months 6 and 12 (P = .028). BCVA differences between patient groups were statistically nonsignificant at 3 (P = .397), 6 (P = .468), and 12 months (P = .647). Mean %ECL in re-DMEK eyes with follow-up ≥12 months was 48.2 (15.1%), and the rebubbling rate was 28.6%; differences between groups were statistically nonsignificant for both variables (P = .580 and P = .669, respectively). Three re-DMEK eyes developed graft failure, all achieving final BCVA ≤0.30 logMAR (Snellen ≥20/40) after tertiary keratoplasty. CONCLUSIONS: Repeat DMEK produces significant, continuous visual improvement after failed primary DMEK. Although visual outcomes and %ECL were comparable to primary DMEK, there was a relatively high rate of graft failure after re-DMEK.

Transitional conic toric intraocular lens for the management of corneal astigmatism in cataract surgery.

SYNOPSIS: Transitional toric intraocular lens (IOL) was developed to improve refractive outcomes in cataract surgery. We report refractive, vectorial outcomes, and stability of spherical equivalent over 12 months after implantation of this IOL. PURPOSE: To evaluate visual and refractive outcomes of a transitional conic toric intraocular lens (IOL) (Precizon®) for the correction of corneal astigmatism in patients undergoing cataract surgery. SETTING: The Ocular Microsurgery Institute (IMO), a private practice in Barcelona, Spain. DESIGN: This is a retrospective, non-randomized study. METHODS: Retrospective chart review of 156 patients with preoperative regular corneal astigmatism >0.75 diopters (D) who underwent consecutive phacoemulsification and Precizon toric IOL implantation between January 2014 and December 2015 was performed. Two groups were divided according to attempted residual refraction: group 1 with emmetropia and group 2 with mild myopia for monovision. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest refraction were analyzed preoperatively and 3, 6, and 12 months postoperatively. RESULTS: Precizon toric IOL was implanted in 97 eyes of 61 patients. Six months postoperatively, none of the eyes lost any line of CDVA. In all, 98% of the eyes were within ±1.00 D of attempted spherical correction. The mean preoperative keratometric cylinder was 1.92 ± 1.04 D (range 0.75-6.78), and the mean postoperative refractive cylinder was 0.77 ± 0.50 D (range 0-2.25), with 81% of the eyes with ≤1.00 D of residual cylinder. Two IOLs required realignment due to intra-operative positioning error. Eleven eyes required enhancement with corneal refractive surgery. CONCLUSION: Preexisting regular corneal astigmatism was effectively and safely corrected by the implantation of the transitional conic toric IOL in patients undergoing cataract surgery.

Unilateral Iris-Claw Intraocular Lens Implantation for Aphakia: A Paired-Eye Comparison.

PURPOSE: To perform a paired-eye comparison of secondary iris-claw intraocular lens (IOL) implantation for aphakia. METHODS: Retrospective, comparative, nonrandomized interventional case series of aphakic eyes, which underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation for aphakia in one eye and no surgery (group 1) or cataract surgery (group 2) in the fellow eye. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent, central endothelial cell count (cECC), and complications were evaluated before surgery, and at yearly intervals up to 5 years. RESULTS: Thirty aphakic eyes implanted with the Artisan were included, and the fellow eyes served as controls. In group 1, postoperative logMAR UDVA and CDVA was significantly higher in the Artisan-implanted eyes (P < 0.01). In group 2, no differences were found in postoperative UDVA and postoperative CDVA between the Artisan-implanted eyes and the eyes that underwent cataract surgery throughout the follow-up (P ≥ 0.05). No statistically significant differences were found in postoperative spherical equivalent between the Artisan-implanted eyes and unoperated eyes or eyes that underwent cataract surgery (P ≥ 0.05). In group 1, cECC was significantly lower in the Artisan-implanted eyes [1973 ± 822 vs. 2616 ± 481 cells per square millimeter at 2 years (P < 0.01)] throughout the follow-up (P < 0.01). In group 2, cECC was not significantly lower in the Artisan-implanted eyes (P ≥ 0.05) [1934 ± 689 vs. 2058 ± 818 cells per square millimeter at 2 years (P = 0.67)]. CONCLUSIONS: Visual rehabilitation with secondary iris-claw IOL implantation in aphakic eyes without capsular support seems to be an effective and safe procedure. As expected, uncomplicated cataract surgery with posterior chamber IOL implantation showed lower endothelial cell count loss. Close monitoring of the corneal endothelium is mandatory.

Paired-eye comparison of corneal endothelial cell counts after unilateral iris-claw phakic intraocular lens implantation.

PURPOSE: To compare the corneal endothelial cell density (ECD) after unilateral iris-claw phakic intraocular lens (pIOL) implantation. SETTING: Instituto de Microcirugia Ocular, Barcelona, Spain. DESIGN: Retrospective interventional nonrandomized paired-eye comparison. METHODS: Patients who had pIOL implantation in 1 eye and corneal refractive surgery (Group 1) or no surgery in the fellow eye (Group 2) between 1998 and 2010 were included. The main outcome measures were central corneal ECD and the percentage of corneal endothelial cell loss. Secondary outcome measures were uncorrected distance visual acuity, corrected distance visual acuity, manifest refraction, and complications. Outcome measures were analyzed 1, 5, and 10 years postoperatively. RESULTS: Both groups comprised 29 patients. Ten years after surgery, the mean endothelial cell loss was 6.41% ± 8.02% (SD) (Group 1, iris-claw pIOLs), 5.59% ± 5.98% (Group 1, corneal refractive surgery), 7.84% ± 6.83% (Group 2, iris-claw pIOLs), and 6.74% ± 3.97% (Group 2, no surgery). No significant endothelial cell loss was observed after pIOL implantation or corneal refractive surgery at any timepoint (P > .05). No significant differences were observed in the percentage of endothelial cell loss between the groups (P > .05). CONCLUSIONS: Iris-claw pIOL implantation did not produce significant corneal endothelial cell loss up to 10 years after surgery compared with corneal refractive surgery and unoperated eyes when strict inclusion criteria were met. FINANCIAL DISCLOSURE: Dr. Güell is a consultant to Ophtec BV and Carl Zeiss Meditec AG. No other author has a financial or proprietary interest in any material or method mentioned.

SMILE Procedures With Four Different Cap Thicknesses for the Correction of Myopia and Myopic Astigmatism.

PURPOSE: To study the feasibility of performing myopic femtosecond small incision lenticule extraction (SMILE) with four different cap thicknesses (130, 140, 150, and 160 µm). METHODS: In this retrospective, comparative, non-randomized clinical trial, a refractive lenticule of intrastromal corneal tissue was cut with the VisuMax femtosecond laser system (Carl Zeiss Meditec AG, Jena, Germany) using different depths of the non-refractive lenticule cut. Manifest refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and Objective Scattering Index (OSI) were evaluated. Minimum follow-up time was 1 year. RESULTS: Ninety-four eyes of 47 patients with myopia with (14 patients) and without (33 patients) astigmatism were treated. One year after the surgery, mean log-MAR UDVA, logMAR CDVA, SE, and OSI were 0.07 ± 0.12, 0.01 ± 0.37, 0.07 ± 0.57, and 0.88 ± 0.17, respectively (P < .05). There were no significant statistical differences in logMAR UDVA, logMAR CDVA, SE, or OSI (P > .05) variables when the different groups were compared for the same periods of time. CONCLUSIONS: No differences in visual acuity, refractive outcomes in optical visual quality, or complications were observed when using SMILE at four different depths.

Comparison of Sulfur Hexafluoride 20% versus Air Tamponade in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To compare clinical outcomes using 20% sulfur hexafluoride (SF6) versus 100% air as a tamponade for graft attachment in Descemet membrane endothelial keratoplasty (DMEK). DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS: Pseudophakic patients with Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy that underwent DMEK using either 20% SF6 (group 1; 42 eyes) or 100% air (group 2; 39 eyes) tamponade between April 2010 and August 2011. METHODS: A bimanual infusion technique was used to introduce and position the donor endothelium-Descemet membrane graft tissue. Outcome measures were analyzed at the following time points: before surgery, 3 and 6 months after surgery, and at yearly intervals up to at least 3 years. MAIN OUTCOME MEASURES: Corrected distance visual acuity (CDVA), manifest refraction, pachymetry, central endothelial cell count (cECC), complications, and rebubbling rates. RESULTS: Three years after surgery, mean CDVA improved from 0.48±0.45 logarithm of the minimum angle of resolution (logMAR) to 0.04±0.23 in group 1 (P < 0.001) and from 0.67±0.45 logMAR to 0.09±0.13 logMAR in group 2 (P < 0.001). The percentage of eyes with CDVA of 20/25 or more was 85.71% (36/42 eyes) in group 1 and 82.05% (32/39 eyes) in group 2 (P = 0.43). Mean preoperative cECCs and at last follow-up were: group 1, 2525±338 cells/mm(2) and 1758 ± 398 cells/mm(2) (mean cell loss, 30±11%; P = 0.008); and group 2, 2492±204 cells/mm(2) and 1678±373 cells/mm(2) (mean cell loss, 32±13%; P = 0.008). Endothelial cell loss was similar in both groups (P = 0.65). Intracameral air reinjection was needed in 1 patient in group 1 (2.38%) and in 5 patients in group 2 (12.8%). The rebubbling rate was significantly higher in group 2 (P = 0.004). No episodes of immunologic graft rejection were documented. CONCLUSIONS: Although clinical outcomes and corneal endothelial cell loss were similar in both groups, tamponade with 20% SF6 yielded a significantly lower incidence of graft detachments that may warrant its routine use in DMEK. Longer-term, randomized studies are needed to recommend this approach fully.

Corneal impairment in a patient with type 2 distal arthrogryposis.

OBJECTIVE: Case report of a 7-year-old male patient, diagnosed with idiopathic progressive corneal alteration developed within a period of 6 months. METHODS: Description of type 2 distal arthrogryposis affecting hands and feet, a bilateral, congenital hearing loss, alterations such as keloid-like scarring, congenital heart disease, and cryptorchidism with no relevant family history. RESULTS: Corrected visual acuity in the right eye (RE) was 0.5 and in the left eye was 1 and, in addition to that, a bilateral corneal subepithelial fibrosis that was denser in the RE without neovessels and no signs of inflammatory activity. CONCLUSION: This is the first publication relating arthrogryposis with corneal affectation, probably because of a collagen anomaly characteristic in these patients.

Epithelial ingrowth after LASIK: visual and refractive results after cleaning the interface and suturing the lenticule.

PURPOSE: The aim was to study the visual and refractive results in patients with epithelization in the corneal interface after laser in situ keratomileusis (LASIK) who were treated by cleaning the corneal interface (epithelial cyst extraction) and suturing the corneal flap. METHODS: This is a retrospective, noncomparative interventional case series. The main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive cylinder (CYL), spherical equivalent (SE), recurrence of epithelial ingrowth, and complications. RESULTS: From a total of 7520 LASIK refractive eyes, 13 eyes with epithelial ingrowth were treated. The mean age was 46.9 years. The mean preoperative logMAR UDVA was 0.34 (SD, 0.19). At 2 months, the mean postoperative logMAR UDVA was 0.18 (SD, 0.17) and at 1 year was 0.12 (SD, 0.18) (P = 0.01). The mean logMAR CDVA before surgery was 0.16 (SD, 0.16). Two months and 1 year postoperatively, the mean logMAR CDVA was 0.05 (SD, 0.08) and 0.03 (SD, 0.06), respectively (P = 0.03). The mean SE before surgery was 0.30 D (SD, 1.09). The mean SE 2 months and 1 year after surgery was -0.07 (SD, 0.53) and -0.004 (SD, 0.18), respectively (P = 0.04). The mean CYL before surgery was -0.92 D (SD, 1.09); and the mean CYL 2 months and 1 year after surgery was -0.60 (SD, 0.84) and -0.18 (SD, 0.75), respectively (P = 0.26). No epithelial ingrowth recurrence was observed up to 1 year after epithelial removal. CONCLUSIONS: Cleaning the corneal interface and suturing the corneal flap was effective and appeared safe in treating epithelial ingrowth after LASIK, with an extremely low rate of regrowth. However, further prospective controlled studies with a longer follow-up are needed.

Historical Review and Update of Surgical Treatment for Corneal Endothelial Diseases.

The cornea remains in a state of deturgescence, maintained by endothelial cell Na+/K+ ATPase and by tight junctions between endothelial cells that limit entrance of fluid into the stroma. Fuchs' endothelial corneal dystrophy (FECD) was initially described by Fuchs in 1910 as a combination of epithelial and stromal edema in older patients. It manifests as bilateral, albeit asymmetric, central corneal guttae, corneal edema, and reduced vision. When edema is severe, the corneal epithelium can detach from its basement membrane, creating painful bullae on the anterior surface of the cornea. The course of this dystrophy can be further accelerated after intraocular surgery, specifically cataract extraction. Pseudophakic bullous keratopathy (PBK) is endothelial cell loss caused by surgery in the anterior chamber. If the corneal endothelium is damaged during surgery, the same spectrum of symptoms as found in FECD can develop. In the nineteenth century, penetrating keratoplasty was the only surgical procedure available for isolated endothelial disease. In the 1960s, Dr. José Barraquer described a method of endothelial keratoplasty using an anterior approach via laser-assisted in situ keratomileusis (LASIK) flap. In 1999, Melles and colleague described their technique of posterior lamellar keratoplasty. Later, Melles et al. started to change host dissection using simple "descemetorhexis" in a procedure known as Descemet's stripping endothelial keratoplasty. Following the widespread adoption of Descemet's stripping automated endothelial keratoplasty, the Melles group revisited selective Descemet's membrane transplantation and reported the results of a new procedure, Descemet's membrane endothelial keratoplasty (DMEK). Recently, some eye banks have experimented with the preparation of DMEK/Descemet's membrane automated endothelial keratoplasty donor tissue that may help the surgeon avoid the risk of tissue loss during the stromal separation step. Recently, the authors described a new bimanual technique for insertion and positioning of endothelium-Descemet membrane grafts in DMEK.

Late onset of a persistent, deep stromal scarring after PRK and corneal cross-linking in a patient with forme fruste keratoconus.

PURPOSE: To present a case of a late, deep stromal scar in a 22-year-old patient with forme fruste keratoconus who underwent combined corneal cross-linking and photorefractive keratectomy (PRK). METHODS: Topography-guided corneal cross-linking combined with corneal PRK (without complications) was performed in both eyes with a delay of 2 weeks between each eye. RESULTS: At the 5-month postoperative examination of the right eye, a localized corneal haze was circumscribed to the posterior deep stroma, signifying a decrease of visual acuity. However, this improved partially and temporarily when treated with topical corticoids during 2 years of follow-up and then reoccurred, affecting the corrected distance visual acuity. CONCLUSIONS: To the authors' knowledge, this is the first documented, clinical case presenting a deep stromal affectation without endothelial decompensation and visual acuity affectation as a postoperative complication following topography-guided PRK and corneal cross-linking.

Combined intracorneal ring segments and iris-fixated phakic intraocular lens for keratoconus refractive and visual improvement.

PURPOSE: To evaluate the efficacy and safety of keratoconus refractive and visual improvement by combined intracorneal ring segments (ICRS; Intacs/Intacs SK, Addition Technology Inc., Des Moines, IL) and phakic intraocular lens (PIOL; Artisan/Artiflex Toric IOL, Ophtec BV, Groningen, Holland) implantation. METHODS: This study comprised patients who had ICRS implantation followed by PIOL implantation 6 or more months later for the correction of keratoconus. Over a 12-month follow-up after PIOL implantation, the main outcome measures were uncorrected and corrected distance visual acuity (UDVA and CDVA), spherical equivalent refraction, and central endothelial cell density. Efficacy and safety indexes were calculated. RESULTS: The study included 21 eyes of 16 patients. The mean UDVA 12 months after ICRS and PIOL implantation increased from 2.0 ± 0 to 0.25 ± 0.22 logMAR (Snellen 20/2000 to 20/35) (P < .001). The mean CDVA increased from 0.31 ± 0.13 to 0.13 ± 0.13 log-MAR (Snellen 20/40 to 20/25) (P = .039). Predictability of refractive results was good, with spherical equivalent refraction within ±0.50 diopter of the attempted correction in 13 eyes (61.9%) and within ±1.00 diopter in 19 eyes (90.5%). Mean central endothelial cell density decreased from 2,513 ± 245 cells/mm(2) preoperatively to 2,312 ± 263 cells/mm(2) (P = .402). The efficacy index was 1.06 and the safety index was 1.40. CONCLUSIONS: Keratoconus visual and refractive improvement by the sequential implantation of Intacs ICRS and Artisan/Artiflex Toric IOL is a safe and predictable procedure.

Secondary iris-claw anterior chamber lens implantation in patients with aphakia without capsular support.

BACKGROUND/AIMS: To evaluate the efficacy, predictability, safety and complications of secondary iris-claw intraocular lens (IOL) implantation in aphakic eyes without capsular support. METHODS: Retrospective, non-comparative, interventional case series of 128 aphakic eyes, which consecutively underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation, were included. Manifest refraction, uncorrected visual acuity, best-spectacle corrected visual acuity, biomicroscopy, tonometry, funduscopy and central endothelial cell count (cECC) were evaluated before surgery, and at yearly intervals up to 5 years. Minimum follow-up time was 1 year. RESULTS: One hundred twenty-eight eyes were treated. Mean age was 54.55 years (range, 1-98 years). Mean follow-up was 41.8 months (SD 23.63). Mean preoperative logarithm of the minimum angle of resolution BSCVA and spherical equivalent (SE) were 0.67 ((SD) 0.53) and 9.63 D (SD 5.50), respectively. One year postoperatively, mean logarithm of the minimum angle of resolution best-spectacle corrected visual acuity improved to 0.52 (SD 0.46) (p<0.05), and remained stable up to 5 years. One year postoperatively, mean SE was -0.52 (SD 2.21) (p<0.05). Mean SE progressively decreased during the 1st year, and remained stable thereafter (p<0.05). Mean preoperative cECC was 2237.47 (SD 793.33) cells/mm(2). cECC showed a slight, though statistically significant, decrease over the years (p=0.05). Main complications were: 2 pupillary block; 3 transient increase in intraocular pressure; 1 IOL replacement; 2 penetrating keratoplasty and 4 cystoid macular oedema. CONCLUSIONS: Iris-claw IOL implantation in aphakic eyes is an effective, predictable and safe procedure in the first 5 years of follow-up. However, a longer follow-up is required to demonstrate its long-term safety.