Myo-Glandular Flap Breast Reduction: Preventing the Bottoming out Deformity-A Novel Technique.

Large, heavy breasts are a common complaint among women causing various functional and aesthetic concerns. The plastic surgery community has offered a variety of surgical techniques to address this condition. Most of these operations developed during the 1970s-1980s cemented their place in history as fundamentals of breast reduction surgery and are still widely taught today. Despite ongoing plastic surgery advances, long-term complications surrounding breast reduction surgery remain a concern, even to experienced surgeons. Its apparent trends have shifted focus over time; from the basics of developing a patient-safe and easily replicable technique, toward developing more refined maneuvers allowing surgeons to reach desired and long-lasting outcomes while preventing known complications. The bottoming out phenomena, lack of nipple areola complex sensitivity, upper pole emptiness with low setting breasts and high revision rates still plague the breast reduction landscape. We present a novel technique involving a pectoralis major-based myo-glandular flap with breast parenchymal suspension to the upper chest wall to combat bottoming out and upper pole emptiness. These procedural elements allow the breasts to attain not only acceptable results, with smaller, round and well-projected breasts, but also to create an active opposing vector to resist the gravitational forces which otherwise pull breast tissue inferiorly creating the bottoming out deformity.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Correction of a Posttraumatic Orbital Deformity Using Three-Dimensional Modeling, Virtual Surgical Planning with Computer-Assisted Design, and Three-Dimensional Printing of Custom Implants.

We describe a case of complex, posttraumatic skull and orbital deformities that were evaluated and treated with advanced computer technology, including virtual surgical planning, three-dimensional (3D) modeling, and printed patient custom implants (PCI) fabricated by 3D printing. A 50-year-old man presented to our craniofacial referral center 1 year after failed reduction of complex left orbital, zygomatic, and frontal bone fractures due to a motorcycle collision. The patient's chief complaint was debilitating diplopia in all fields of gaze. On examination, he had left enophthalmos, left canthal displacement, lower eyelid ectropion, vertical orbital dystopia, and a laterally and inferiorly displaced, comminuted zygoma with orbital rim and frontal bone defects. The normal orbit was mirrored to precisely guide repositioning of the globe, orbital reconstruction, and cranioplasty. Preinjury appearance with normal globe position was restored with complete resolution of diplopia. Modern 3D technology allows the surgeon to better analyze complex orbital deformities and precisely plan surgical correction with the option of printing a PCI. These techniques were successfully applied to resolve a case of debilitating diplopia and aesthetic deficits after facial trauma. Further application of advanced 3D computer technology can potentially improve the results of severe orbital and craniofacial trauma reconstruction.

Experienced DSAEK Surgeon's Transition to DMEK: Outcomes Comparing the Last 100 DSAEK Surgeries With the First 100 DMEK Surgeries Exclusively Using Previously Published Techniques.

PURPOSE: To compare outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) when an experienced DSAEK surgeon transitions to DMEK while following 2 published endothelial keratoplasty surgical techniques. METHODS: This is a retrospective review of 200 eyes of 132 patients with Fuchs corneal dystrophy that underwent endothelial keratoplasty performed by one surgeon. Published, standardized techniques were followed for both DSAEK and DMEK. Postoperative complications were recorded. Best spectacle-corrected visual acuity (BSCVA), intraocular pressure, and central endothelial cell loss (ECL) were evaluated at 6 months postoperatively. RESULTS: There were no intraoperative complications. One DSAEK and 5 DMEK grafts developed graft detachment requiring rebubbling (P = 0.097). No iatrogenic primary graft failures occurred in the DSAEK group compared with one in the DMEK group. No pupil block episodes occurred in the DSAEK group compared with one in the DMEK group. Posterior synechiae formation occurred 15 times in the DMEK group and did not occur in the DSAEK group (P < 0.001). At 6 months, BSCVA was better in the DMEK group than in the DSAEK group (20/24; logMAR = 0.0844-20/32; logMAR = 0.2063) (P < 0.001). More eyes reached 20/20 or better BSCVA in the DMEK group compared with DSAEK (54.5%-13%) (P < 0.011). At 6 months, ECL was higher in the DMEK group than in the DSAEK group (31.9%-19.9%) (P < 0.001). CONCLUSIONS: Complications can be minimized and excellent outcomes can be achieved, without a steep learning curve, when an experienced DSAEK surgeon transitions to DMEK following a standardized technique. Six-month vision outcomes are better in the DMEK group; however, the rate of a newly described complication, posterior synechiae formation, and 6-month ECL are higher in the DMEK group than in the DSAEK group.

Preoperative graft thickness measurements do not influence final BSCVA or speed of vision recovery after descemet stripping automated endothelial keratoplasty.

PURPOSE: To evaluate the influence of preoperative graft thickness (GT) on final visual acuity and speed of vision recovery after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: The best spectacle-corrected acuity (BSCVA) was measured after DSAEK was performed at 1, 3, 6, 12, and 24 months. A regression analysis was performed to determine whether GT predicted the BSCVA across each time gate. The time to achieve the "1-year maximum BSCVA" was determined to assess the "speed" of recovery for all eyes that had data at 1, 3, 6, and 12 months. Additionally, the final BSCVA was compared between 2 distinct groups of "thin" (<125-µm) versus "thick" (>165-µm) tissue. RESULTS: There were 144 eyes evaluated. No significant correlations were found between the GT and the BSCVA at any of the time gates: 1, 3, 6, 12, or 24 months. Speed of vision recovery was not affected by the GT. The average GT values of the eyes that achieved BSCVA by 1, 3, 6 months and 1 year were not significantly different and were 154.7, 141.3, 149, and 150.1 µm, respectively. No difference was found between the BSCVA of "thick" versus "thin" tissues at any of the time gates: 1, 3, 6, or 12 months. CONCLUSIONS: Preoperative GT measurements were not correlated with the BSCVA after the DSAEK was performed at 1, 6, 12, or 24 months postoperatively and do not determine the speed of vision recovery. Additionally, no difference was found in postoperative vision outcomes when directly comparing tissues at either end of the GT spectrum of this study.

Posterior sloping angle as a predictor of contralateral slip in slipped capital femoral epiphysis.

BACKGROUND: Slipped capital femoral epiphysis is a condition with potentially severe complications. Controversy remains as to when to undertake prophylactic pinning. We aimed to assess the utility of the posterior sloping angle as a predictor for contralateral slip in a large, multi-ethnic cohort including Polynesian children with a high incidence of slipped capital femoral epiphysis. METHODS: All patients presenting to our hospital between 2000 and 2009 were identified and records were reviewed to determine demographic data and determine whether they subsequently developed a contralateral slip. The presenting radiographs were reviewed and the posterior sloping angle was measured. Patients with bilateral slips at presentation and those without initial radiographs were excluded. RESULTS: Records and radiographs of 132 patients were analyzed for the posterior sloping angle in the unaffected hip. Forty-two patients who had subsequently developed a contralateral slip had a mean posterior sloping angle (and standard deviation) of 17.2° ± 5.6°, which was significantly higher (p < 0.001) than that of 10.8° ± 4.2° for the ninety patients who had had a unilateral slip. Children who had developed a subsequent contralateral slip were significantly younger (11.1 years) than those who had developed a unilateral slip (12.2 years) (p < 0.001). If a posterior sloping angle of 14° were used as an indication for prophylactic fixation in this population, thirty-five (83.3%) of forty-two contralateral slips would have been prevented, and nineteen (21.1%) of ninety hips would have been pinned unnecessarily. The number needed to treat to prevent one subsequent contralateral slip is 1.79. CONCLUSIONS: To our knowledge, this is the largest study to date that confirms that the posterior sloping angle is a reliable predictor of contralateral slip and can be used to guide prophylactic pinning. The posterior sloping angle is applicable in the high-risk Polynesian population and could be useful in preventing future slips in populations that are difficult to follow up.

"Ultrathin" DSAEK tissue prepared with a low-pulse energy, high-frequency femtosecond laser.

PURPOSE: To evaluate the endothelial cell survival and stromal bed quality when creating deep stromal cuts with a low-pulse energy, high-frequency femtosecond laser to produce "ultrathin" tissue for Descemet stripping automated endothelial keratoplasty. METHODS: Seventeen corneas were used for this study. Five corneas were cut with the laser at a depth of 420 to 500 µm to produce a tissue thickness of approximately ≤70 µm. Five corneas served as an uncut comparison group. Vital dye staining and computer digitized planimetry analysis were performed on these corneas. The 7 remaining corneas were cut for scanning electron microscopy evaluation. RESULTS: The mean central posterior stromal thickness of cut corneas was 60.6 µm (range, 43-72 µm). Endothelial cell damage in cut and comparison corneas was 3.92% ± 2.22% (range, 1.71%-6.51%) and 4.15% ± 2.64% (range, 1.21%-7.01%), respectively (P = 0.887). Low-magnification (×12) scanning electron microscopy revealed a somewhat irregular-appearing surface with concentric rings peripherally. Qualitative grading of higher magnification (×50) central images resulted in an average score of 2.56 (between smooth and rough). CONCLUSIONS: Ultrathin tissue for Descemet stripping automated endothelial keratoplasty can be safely prepared with minimal endothelial cell damage using a low-pulse energy, high-frequency femtosecond laser; however, the resulting stromal surface quality may not be optimal with this technique.

Symptomatic delayed trans-dural herniation and strangulation of cauda equinae following resection of Myxopapillary ependymoma.

Pseudomeningocoele is a recognised complication of spinal surgery. It could be either asymptomatic or symptomatic. We present a 63-year-old male who developed a delayed pseudomeningocoele and symptomatic transdural herniation and strangulation of the cauda equinae following resection of a Myxopapillary ependymoma. He underwent successful operative re-exploration, un-tethering of the cauda equinae and re-closure of the dural defect with resolution of his symptoms. We discuss the clinical features, operative technical factors involved and the essential importance of neuroimaging with critical analysis of the imaging findings and correlation of the clinical symptoms, when such a diagnosis is being considered.

Descemet stripping endothelial keratoplasty: six-month results of the first 100 consecutive surgeries performed solo by a surgeon using 1 technique with 100% follow-up.

PURPOSE: To determine the outcomes and complication rates achieved by a novice cornea surgeon when performing Descemet stripping automated endothelial keratoplasty (DSAEK) while precisely following a previously described forceps insertion technique. METHODS: Prospective, noncomparative interventional case series including 100 eyes of 74 patients with endothelial decompensation. An institutional review board approved, prospective, DSAEK series was initiated. Cases included all initial patients with endothelial failure operated on by a single surgeon after his cornea fellowship training. The surgeon strictly adhered to a previously published 5-mm incision, folded forceps graft insertion technique. Patients were followed at 1 day, 1 week, and 1, 3, and 6 months. Postoperative complications (including graft dislocation, primary graft failure, and pupillary block), best spectacle-corrected visual acuity (BSCVA) and specular microscopy of central endothelial cell density at 6 months postoperatively were the main outcome measures. RESULTS: One hundred consecutive eyes were enrolled in the study, and 100% follow-up at 6 months was achieved. Postoperative complications included 2 graft dislocations (2%), and both grafts were attached successfully and cleared; 2 episodes of cystoid macular edema (2%) occurred, and 1 eye (1%) developed areas of anterior iris synechiae to the graft. There were no pupillary block episodes or primary graft failures. In eyes without comorbidity (n=57), the mean BSCVA improved from 20/48 preoperation to 20/29 at 6 months after operation (P<0.001). No eyes lost vision. Mean central endothelial cell density decreased from 2769 cells per square millimeter preoperatively to 2308 cells per square millimeter postoperatively at 6 months. This represented a mean cell loss of 16%. CONCLUSIONS: This study demonstrates that with meticulous attention to a standardized forceps insertion technique, excellent outcomes with low rates of complications, improved BSCVA, and low endothelial cell loss can be achieved with DSAEK surgery.

Textures in polygonal arrangements of square nanoparticles in nematic liquid crystal matrices.

A systematic analysis of defect textures in faceted nanoparticles with polygonal configurations embedded in a nematic matrix is performed using the Landau-de Gennes model, homeotropic strong anchoring in a square domain with uniform alignment in the outer boundaries. Defect and textures are analyzed as functions of temperature T, polygon size R, and polygon number N. For nematic nanocomposites, the texture satisfies a defect charge balance equation between bulk and surface (particle corner) charges. Upon decreasing the temperature, the central bulk defects split and together with other -1/2 bulk defects are absorbed by the nanoparticle's corners. Increasing the lattice size decreases confinement and eliminates bulk defects. Increasing the polygon number increases the central defect charge at high temperature and the number of surface defects at lower temperatures. The excess energy per particle is lower in even than in odd polygons, and it is minimized for a square particle arrangement. These discrete modeling results show for first time that, even under strong anchoring, defects are attached to particles as corner defects, leaving behind a low energy homogeneous orientation field that favors nanoparticle ordering in nematic matrices. These new insights are consistent with recent thermodynamic approaches to nematic nanocomposites that predict the existence of novel nematic/crystal phases and can be used to design nanocomposites with orientational and positional order.

A novel approach to processing descemet stripping automated endothelial keratoplasty specimens for histopathologic analysis.

PURPOSE: To describe a new technique for handling Descemet stripping automated endothelial keratoplasty (DSAEK) specimens intraoperatively and during processing. METHODS: The processing method begins by adding a drop of eosin to the specimen intraoperatively, followed by submersion in 10% formalin solution. The specimen appears reddish, allowing for easy identification and is floated onto an immersed slide to maintain an unfolded flattened specimen. After bisection, one half is stained with hematoxylin and eosin and covered with a cover slip, whereas the other half is transferred to filter paper and a cassette and is submitted for paraffin embedding on the cut edge. RESULTS: The technique reduces the chances of a specimen not surviving processing. The new method also allows for 2 views of DSAEK specimens, both topographical and cross-sectional, thus permitting analysis of endothelial cell density, spatial distribution of cells and guttae, endothelial cell count, and thickness measurements. CONCLUSIONS: A novel technique for handling DSAEK specimens to prevent loss and folding, while also allowing for cross-sectional and topographical viewing is reported.

Endothelial cell damage in descemet stripping automated endothelial keratoplasty with the underfold technique: 6- and 12-month results.

PURPOSE: To evaluate the endothelial cell loss at 6 and 12 months after Descemet stripping automated endothelial keratoplasty (DSAEK) using a modified 40/60 underfolding technique and to compare this to the literature on other commonly used implantation techniques, such as the conventional 60/40-fold, gliding, and hitch suture techniques. METHODS: Endothelial cell density was measured prospectively, and cell loss was calculated at 6 and 12 months after endothelial keratoplasty using a recently described underfolding implantation technique. RESULTS: In this study, 305 eyes undergoing DSAEK were evaluated. Average endothelial cell loss was 26% at 6 months and 27% at 12 months, all statistically significant reductions from preoperative values (P < 0.01). The decrease in cell count from 6 months to 12 months was not statistically significant. CONCLUSIONS: This study demonstrates reduction in endothelial cell loss after DSAEK using the underfold technique when compared with previous reports on conventional folding techniques and similarity to previous reports on glide techniques at 6 and 12 months postoperatively (26% vs. 34% vs. 23% at 6 months). This offers an easy modification to a commonly used existing technique and improves endothelial cell survival after DSAEK.

Descemet stripping automated endothelial keratoplasty in eyes with previous trabeculectomy and tube shunt procedures: intraoperative and early postoperative complications.

PURPOSE: To evaluate the intraoperative and early postoperative outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with previous glaucoma filtering surgeries. METHODS: A retrospective review of all DSAEK surgeries performed at one center comparing complications of DSAEK in eyes with previous glaucoma filtering procedures (study eyes) with a time-matched group of all other DSAEK cases (control eyes). RESULTS: There were 28 study eyes, 19 with previous trabeculectomies and 9 with previous glaucoma drainage devices (GDDs) and 431 control eyes. Study group intraoperative complications included 1 compromised bleb and 1 loss of donor tissue because of traumatic manipulation. One intraoperative complication, a perforation of the donor tissue, occurred in the control group. Venting stab incisions were used more often in study eyes (n = 5; 18%) than in control eyes (n = 12; 4.4%) (P = 0.002). GDD tubes were trimmed in 2 eyes (22%). No intraoperative manipulations were used to occlude the glaucoma filters or tubes. Postoperative complications in the study group included 1 dislocation (3.6%) and 1 decentered graft (3.6%) and 1 eye with loss of pressure control (3.6%), whereas in the control group, there were 10 dislocations (2.3%) and 1 decentered graft (0.2%) (P = 0.267 for dislocations and P = 0.118 for decentered grafts). One episode of pupillary block (0.2%) occurred in the control group, and none occurred in the study group. No primary graft failures occurred in either group. CONCLUSIONS: DSAEK surgeries in eyes with previous glaucoma filtering procedures were performed without primary graft failure and with reasonably low dislocation (3.6%) and graft decentration (3.6%) rates. Although the intraoperative complication rate for the study group (7.1%) was higher than the rate for the control group (0.23%), excellent early postoperative outcomes can be achieved when DSAEK is performed in eyes with previous trabeculectomies and GDDs.

Complications and clinical outcomes of descemet stripping automated endothelial keratoplasty with intraocular lens exchange.

PURPOSE: To evaluate complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with intraocular lens (IOL) exchange compared with DSAEK alone. DESIGN: Retrospective, interventional case series. METHODS: DSAEK was performed in 19 eyes in which the anterior chamber IOL was exchanged for a posterior chamber IOL (study group) and in 188 eyes in which the posterior chamber IOL was left in place (comparison group). The complications of graft dislocations, primary graft failure episodes, and pupillary block were recorded for all eyes. Six-month best spectacle-corrected visual acuity and mean central endothelial cell density were measured prospectively and then compared with preoperative values for all eyes. RESULTS: Dislocations occurred in 0 (0%) of 19 eyes in the study group and in 5 (3%) of 188 eyes in the comparison group (P = .47), with 0 primary graft failures and 0 pupillary block episodes in either group. Preoperative mean best spectacle-corrected visual acuity for those eyes without any underlying ocular comorbidities was 20/205 and 20/100 in the study and comparison groups, respectively (P = .18). Mean best spectacle-corrected visual acuity at 6 months improved to 20/48 in the study group and to 20/34 in the comparison group, a statistically significant difference (P = .01). Mean donor cell loss at 6 months was 33% in the study group and 26% in the comparison group (P = .18). CONCLUSIONS: Concurrent IOL exchange with DSAEK surgery does not increase the dislocation, primary graft failure, or pupillary block rates in the immediate postoperative period. Donor endothelial cell loss in DSAEK was not increased significantly by IOL exchange. Visual acuity was slightly worse after combined surgery than after DSAEK alone.

Descemet's stripping automated endothelial keratoplasty (DSAEK) using corneal donor tissue not acceptable for use in penetrating keratoplasty as a result of anterior stromal scars, pterygia, and previous corneal refractive surgical procedures.

PURPOSE: The purpose of this study was to evaluate outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using anterior stromal flawed (ASF) donor corneas that were unsuitable for use in full-thickness penetrating keratoplasty as a result of stromal scars, pterygia, or previous corneal refractive surgery and to compare results with DSAEK using standard tissue. METHODS: We conducted a review of our initial 42 (19 with 6-month follow up) consecutive DSAEK surgeries using ASF tissue compared with 357 (199 with 6-month follow up) time-matched controls using standard tissue. Intraoperative and perioperative complications, including dislocations and primary graft failures, were compared. Six-month best spectacle-corrected vision, incidence of rejection episodes, postoperative refractive astigmatism, keratometric values, pre- and postoperative topography-derived surface asymmetry index, and surface regularity index were compared. RESULTS: One surgeon-cut ASF tissue was perforated before surgery and was discarded. No surgeon-cut standard tissue was perforated. No intraoperative complications and no episodes of primary graft failure or pupillary block glaucoma occurred in either group. One (2.4%) postoperative graft dislocation and one (5.2%) graft rejection episode occurred in the study group. There were 10 (2.8%) dislocations and 8 (2.2%) graft rejection in the controls. A statistically similar significant improvement in best spectacle-corrected vision occurred in both groups. Corneal topography, pachymetry, and manifest astigmatism were not significantly different between groups. CONCLUSION: Postoperative results of DSAEK using donor tissue excluded from use in penetrating keratoplasty as a result of stromal flaws are equivalent to results using standard donor tissue. Central corneal thickness measurements should be performed before cutting to avoid tissue perforation. The use of ASF tissue for DSAEK will expand the cornea donor pool.

Retention of host embryonic descemet membrane in endothelial keratoplasty.

OBJECTIVE: To describe a case of retained host embryonic Descemet membrane (DM) after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Review of clinical findings in a case of DSAEK with retention of host embryonic DM. RESULTS: A geographic and patchy haze in the interface involving the visual axis was noted postoperatively as soon as 1 week after DSAEK surgery. This was noted on clinical exam and thought to be retained embryonic DM. Review of pathology on the explanted DM confirmed delamination of DM with absence of the anterior embryonic layer and only patchy areas of full-thickness DM. The haze was followed over time and did not regress over the first 6 months after surgery. It did not seem to affect vision significantly, and the patient achieved best spectacle-corrected vision of 20/30 by 6 months. CONCLUSIONS: Endothelial keratoplasty is a relatively new technique for posterior corneal transplantation. Variations in operative technique continue to be described. Delamination of DM during stripping can occur; however, retention of host embryonic DM in DSAEK surgery seems to be compatible with good vision.

Endothelial keratoplasty: vision, endothelial survival, and complications in a comparative case series of fellows vs attending surgeons.

PURPOSE: To compare a 6-month postoperative vision, endothelial cell loss, and immediate postoperative complications in Descemet stripping automated endothelial keratoplasty (DSAEK) cases performed by an experienced corneal surgeon and his inexperienced fellows using an established technique. DESIGN: Retrospective analysis of prospectively gathered data in 327 consecutive DSAEK cases. METHODS: DSAEK cases performed by fellows vs attending surgeons during a concurrent period were compared for 6-month postoperative best spectacle-corrected visual acuity (BSCVA), endothelial cell loss, and immediate postoperative complications. This series represents the initial consecutive cases performed by 3 cornea fellows using a technique identical to that used by the attending. RESULTS: After DSAEK, average BSCVA improved from 20/80 to 20/37 in the attending cases and 20/74 to 20/36 in the fellow cases. There was no statistical difference in endothelial cell loss between groups (32% vs 35%). The dislocation rate was 2% in the attending group and 1% in the fellow group. There were no primary graft failures or cases of pupillary block in either group. CONCLUSIONS: This study demonstrates no difference in vision or endothelial cell loss after DSAEK when performed by an experienced corneal surgeon or inexperienced fellows. Postoperative complications also were similar. Results and complications of DSAEK performed by supervised novice fellows can equal those of an experienced DSAEK surgeon.

Endothelial keratoplasty for Fuchs' dystrophy with cataract: complications and clinical results with the new triple procedure.

PURPOSE: To report the immediate postoperative complications and the 6- and 12-month clinical results in a large series of cases undergoing the new triple-procedure Descemet's stripping automated endothelial keratoplasty (DSAEK) and concurrent cataract surgery. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Three hundred fifteen eyes of 233 patients with Fuchs' corneal dystrophy were evaluated for the complications of dislocation and iatrogenic primary graft failure (IPGF). Two hundred three eyes of 149 patients had 6-month postoperative data available for other outcome analysis. METHODS: A standardized technique of DSAEK with extensive use of cohesive viscoelastic was performed in all 315 eyes with Fuchs' dystrophy, and 225 of those eyes had cataract surgery concurrently. Of the 203 eyes with 6-month data, concurrent phacoemulsification with intraocular lens placement (triple procedure) was performed in 149 of those eyes. MAIN OUTCOME MEASURES: The complications of graft dislocation and IPGF were recorded for all eyes. Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive spherical equivalent (SE), and central donor endothelial cell density (ECD) were measured prospectively and then compared with preoperative values for the triple-procedure eyes. RESULTS: There were 4 dislocations (4%) among the 90 straight DSAEK cases and 4 dislocations (1.8%) among the 225 triple-procedure cases (P = 0.327). There was not a single case of IPGF in any of the 315 DSAEK cases. After the triple procedure, the BSCVA in eyes without comorbidity (n = 122) improved with 93% at 20/40 or better at 6 months and 97% at 20/40 or better at 12 months. Refractive SE at 6 months averaged 0.11+/-1.08 diopters (D), with 73% of eyes within 1 D of emmetropia and 95% within 2 D of emmetropia. The postoperative mean ECD was 1955 cells/mm(2) at 6 months (n = 125) and 1979 cells/mm(2) at 12 months (n = 89) and represented a 32% cell loss from that before surgery (P<0.001) for both postoperative time points. CONCLUSIONS: The new triple-procedure DSAEK combined with cataract surgery provides rapid visual recovery and allows selection of an appropriate intraocular lens. Dislocations are rare (1.8%) and primary graft failure did not occur.