Corneal Complications Related to Dupilumab Use.

OBJECTIVES: The aim of this report is to describe atypical corneal complications associated with dupilumab use. METHODS: This is a series of four cases of adult patients with infiltrative or ulcerative keratitis secondary to dupilumab use. RESULTS: All four patients in this series were prescribed dupilumab for the treatment of atopic dermatitis and developed infiltrative or ulcerative corneal lesions. In all cases, corneal disease was successfully managed with immediate discontinuation of dupilumab and topical steroid treatment. In two cases, the patient also received antibiotic eye drops for infection precautions. CONCLUSIONS: Although dupilumab is most commonly associated with conjunctivitis, physicians should be aware of potential severe corneal complications for early identification and intervention.

Impact of Donor, Recipient, and Graft Characteristics on Corneal Transplantation Outcomes.

Purpose: Although several donor, recipient, and graft characteristics have been studied in relation to corneal transplantation outcomes, no study to our knowledge has assessed the impact of donor cooling times on postoperative outcomes longitudinally. With only one corneal graft available for every 70 needed worldwide, this study seeks to identify any factors that could alleviate this shortage. Methods: Patients undergoing corneal transplantation at the Manhattan Eye, Ear & Throat Hospital over a 2-year period were retrospectively studied. Study metrics included age, diabetic history, hypertensive history, endothelial cell density, death-to-preservation time (DTP), death-to-cooling time (DTC), and time-in-preservation (TIP). Postoperative transplantation outcomes, including best corrected visual acuity (BCVA) at 6- and 12-month follow-up visits, need for re-bubbling, and need for re-grafting, were assessed. Unadjusted univariate and adjusted multivariate binary logistic regressions were performed to determine the association of cooling and preservation parameters with corneal transplantation outcomes. Results: Among 111 transplants, our adjusted model found that DTC ≥4 hours was associated with significantly worse BCVA, but only at 6-month postoperative follow-up (odds ratio [OR]: 0.234; 95% confidence interval [CI]: 0.073-0.747; p = 0.014). By 12-month follow-up, DTC >4 hours was no longer associated with BCVA in a statistically significant manner (OR: 0.472; 95% CI: 0.135-1.653; p = 0.240). A similar trend was found at a DTC cutoff of ≥3 hours. None of the other studied parameters, including DTP, TIP, donor age, or medical history were significantly correlated with transplantation outcomes. Conclusion: Longer DTC or DTP did not have a statistically significant effect on corneal graft outcomes after one year, though short-term outcomes were improved in donor tissues with DTC below four hours. None of the other studied variables correlated with transplantation outcomes. Given the global shortage of corneal tissue, these findings should be considered when determining suitability for transplantation.

Acute Corneal Transplant Rejection After Severe Acute Respiratory Syndrome Coronavirus 2 mRNA-1273 Vaccination.

PURPOSE: The purpose of this article was to report a case of full-thickness corneal transplant rejection 3 days after immunization with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Moderna mRNA-1273 vaccine. METHODS: Case Report. RESULTS: A 51-year-old man with a history of keratoconus and penetrating keratoplasty underwent repeat penetrating keratoplasty for graft failure. The patient had an uncomplicated intraoperative and postoperative course with improved vision and a healthy graft. The patient received the SARS-CoV-2 Moderna vaccine on postoperative week 3, and within 3 days, the patient began developing eye pain, photophobia, and blurred vision. The patient was found to have graft rejection with corneal edema and endothelial keratic precipitates. The rejection did not improve despite a trial of increased topical steroids and ultimately evolved into graft failure. CONCLUSIONS: To the best of our knowledge, this case of full-thickness graft rejection after the Moderna SARS-CoV-2 mRNA vaccination is the first to be reported worldwide. The temporal relationship between vaccination and subsequent rejection is highly suggestive of causation due to the short interval (3 days) between vaccination and rejection and the lack of other inciting factors in an otherwise healthy graft. Patients with corneal transplants who plan to take the COVID-19 vaccinations should be counseled on symptoms and closely monitored, and an individualized plan should be made in discussion with the ophthalmologist.

Clinical Outcomes of Descemet Stripping Endothelial Keratoplasty in Eyes With Glaucoma Drainage Devices.

PRECIS: In this retrospective case series of 85 eyes, 31.8% developed graft failure and graft survival was 50% at 3 years. The presence of an aqueous shunt has a significantly adverse effect on long-term graft survival. PURPOSE: To report visual outcomes and complications of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma drainage devices (GDD). MATERIALS AND METHODS: A retrospective chart review was conducted of 122 procedures of 85 eyes of 83 patients who underwent DSEK and had prior or concurrent GDD implantation. Mean follow-up was 36.5±31.4 months. Patients with postoperative follow-up of <3 months were excluded from analysis. Outcome measures examined included visual acuity, donor dislocation rate, intraocular pressure (IOP), and graft survival. RESULTS: The mean logMAR vision improved to 1.07 postoperatively from 1.43 preoperatively, with 61% of eyes experiencing improved visual acuity. Graft dislocation occurred in 27 (31.8%) eyes and required repeat injection of air in the anterior chamber. Primary graft failure occurred in 2 (2.4%) eyes, whereas secondary graft failure occurred in 27 (31.8%) of eyes, with an average time of 24.3 months for development. Estimated survival rates at 1, 2, and 3 years were 89%, 78%, and 50%, respectively. Escalation of IOP occurred in 21 (24.7%) eyes postoperatively, where 14 eyes underwent medical therapy and 7 eyes required surgical intervention/laser for IOP control. CONCLUSIONS: DSEK after GDD is a viable alternative to treat endothelial dysfunction, with the majority of patients achieving visual improvement. However, aqueous shunt implantation has a significantly adverse effect on long-term graft survival and close follow-up is warranted.

Clinical Outcomes and Intraocular Pressure Control After Scleral-glued Intraocular Lens Insertion in Eyes With Pseudoexfoliation.

PURPOSE: To analyze clinical outcomes and intraocular pressure control following scleral-glued intraocular lens (IOL) fixation in eyes with pseudoexfoliation (PXF). METHODS: A retrospective chart review and outcome analysis was performed on a series of eyes undergoing glue-assisted, scleral-fixated (scleral-glued) IOL insertion in the setting of PXF and poor or absent capsular support. RESULTS: In total, 28 eyes were included in the study. The indications for scleral-glued IOL fixation included late endocapsular IOL dislocation (21/28, 75%), exchange for iris-fixated IOL due to complication (4/28, 14%), subluxed crystalline lens (2/28, 7%), and aphakia after complicated cataract surgery (1/28, 4%). In total, 15/28 (54%) eyes had diagnosed preexisting glaucoma at the time of scleral-glued surgery. The most common postoperative complication was ocular hypertension requiring escalation of medical management, which occurred in 8/28 (29%) eyes. At final follow-up, corrected distance visual acuity was equivalent to or improved from preoperative measurements in 25/28 (89%) eyes. CONCLUSIONS: The scleral-glued surgery is a good option for fixating an IOL in eyes with PXF and poor zonular integrity or absent capsular support. Special attention should be placed on intraocular pressure control following surgery, which can be less predictable in PXF eyes with or without preexisting glaucoma.

Descemet Stripping Endothelial Keratoplasty in Eyes With Previous Glaucoma Surgery.

PURPOSE: To evaluate visual outcomes and complications after Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with previous glaucoma surgery. METHODS: A retrospective chart review was conducted of 129 procedures in 102 eyes of 96 patients who underwent DSAEK and previous glaucoma surgery at New York Eye and Ear Infirmary of Mt Sinai. The mean length of follow-up was 29.1 ± 25.5 months. Patients with postoperative follow-up duration of less than 3 months were excluded from analysis. Intraoperative and postoperative complications, postoperative course, and visual outcomes were analyzed. RESULTS: Graft dislocation occurred in 46 eyes (35.7%) and 38 eyes required repeat injection of air in the anterior chamber. Primary graft failure occurred in 3 eyes (2.3%), early graft failure in 20 eyes (15.5%), and secondary graft failure developed in 29 eyes (22.5%). There was a statistically significant increase in secondary graft failure in patients with previous aqueous shunt implantation compared with eyes with previous trabeculectomy (P = 0.03). Escalation of glaucoma therapy was needed medically in 25 eyes (24.5%), and 8 eyes (7.8%) required additional surgical intervention. CONCLUSIONS: There is a significant incidence of graft dislocation and graft failure after DSAEK in eyes with previous glaucoma surgery. In particular, aqueous shunt surgery compared with trabeculectomy may decrease long-term graft survival, and close follow-up is warranted.

Untoward events associated with aberrant fluid infusion during cataract surgery: Laboratory study with corroborative clinical observations.

PURPOSE: To determine the relationship between untoward events noted during phacoemulsification surgery associated with aberrant infusion misdirection and their causal relationship to current infusion sleeve design. SETTING: The New York Eye & Ear Infirmary of Mt. Sinai, New York, New York, USA. DESIGN: Retrospective case reports and experimental study. METHODS: Observations of live cataract surgery were documented with high-definition videography using 3 commercial phacoemulsification platforms. Laboratory studies using a Photron MC2 high-speed camera and the Kitaro cataract surgical system were used to simulate surgical maneuvers and assess flow patterns and visualize the dynamics of fluid movement in the anterior chamber. Color-flow Doppler ultrasound studies were used to demonstrate the effect of infusion fluid on the iris during surgery. RESULTS: Misdirected infusion and floppy-iris leaflets were determined to be secondary to a fulcrum effect at the corneal wound that constrained movement of the standard silicone sleeves. The phacoemulsification needles could therefore decenter independently of the infusion sleeve, attenuating infusion volume down 1 side of the sleeve and, as a result, obstructing fluid exiting the ipsilateral port. CONCLUSIONS: Untoward events associated with aberrant fluid infusion during phacoemulsification surgery were secondary to a fulcrum effect at the corneal wound. Complications included misdirected infusion that facilitated the transport of retained nuclear fragments to the vitreous, inconsistent lens followability during phacoemulsification, and exaggerated movements of the iris particularly consistent with intraoperative floppy-iris syndrome and pseudoexfoliation. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Facilitating cortical aspiration after insertion of a capsular tension ring.

UNLABELLED: We describe a simple, effective technique to prevent the cortical entrapment that can occur after a capsular tension ring (CTR) is implanted during phacoemulsification. Before the epinucleus has been removed, the blunt tip of an ophthalmic viscosurgical device (OVD) cannula is burrowed centrally in the cortical/epinuclear plate and OVD is injected as the cannula is advanced. The cannula is turned superiorly and dissection continued to the lens equator. The cleavage plane is extended for approximately 2 clock hours in the direction of the intended CTR insertion. The CTR is then inserted below the cortical/epinuclear plate. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Outcomes of glued foldable intraocular lens implantation in eyes with preexisting complications and combined surgical procedures.

PURPOSE: To evaluate the visual outcomes and complications of glued foldable intraocular lens (IOL) implantation in patients with a wide range of ocular pathologies and/or having combined surgical procedures. SETTING: New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA. DESIGN: Retrospective case series. METHODS: A chart review was conducted of all glued foldable IOL procedures performed in eyes with absent or insufficient capsule support. Patients with a postoperative follow-up less than 3 months were excluded from analysis. Intraoperative and postoperative complications, the postoperative course, and visual and refractive outcomes were analyzed. RESULTS: Sixty-five eyes (64 patients) were evaluated over a mean follow-up of 9.1 months ± 6.2 (SD). Ocular comorbidities were present in 98.5% of eyes, and 95.4% had additional concurrent surgical procedures. There was a statistically significant improvement in corrected distance visual acuity (P = .046), with 89.2% of eyes achieving better or equal vision postoperatively. Intraoperative complications included ocular hemorrhage (10.8%), haptic deformation (10.8%), and haptic breakage (1.5%). Postoperative complications included elevated intraocular pressure (13.8%), optic capture (12.3%), persistent anterior chamber inflammation (6.2%), IOL tilt (4.6%), cystoid macular edema (3.1%), recurrent ocular hemorrhage (3.1%), and retinal detachment (1.5%). CONCLUSION: The glued foldable IOL technique resulted in favorable visual outcomes but with a moderate risk for IOL-related and other postoperative complications in eyes with complex ocular comorbidities having combined surgical procedures. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Microbiological spectrum and antibiotic sensitivity in endophthalmitis: a 25-year review.

PURPOSE: To identify the spectrum and susceptibility pattern of pathogens responsible for culture-positive endophthalmitis referred to a single institution and investigate possible trends in both pathogens and antibiotic sensitivities over the past 25 years. DESIGN: A retrospective, laboratory-based study of consecutive microbiological isolates. PARTICIPANTS: A total of 988 consecutive culture-positive endophthalmitis isolates from 911 eyes. METHODS: All culture-positive endophthalmitis isolates collected from 1987 to 2011 were identified. Susceptibility rates to a variety of antibiotics were calculated. Chi-square test for trend was used to detect changes in spectrum or susceptibility over time. MAIN OUTCOME MEASURES: Microbial spectrum and susceptibility pattern over time. RESULTS: A total of 988 isolates were identified from 911 eyes. The average patient age was 67 ± 18 years, and 55% of the patients were female. The most prevalent pathogens were coagulase-negative staphylococcus (39.4%), followed by Streptococcus viridans species (12.1%) and Staphylococcus aureus (11.1%). Gram-negative organisms and fungi accounted for 10.3% and 4.6% of all isolates, respectively. With the exception of 2 isolates, Enterococcus faecium and Nocardia exalbida, all the other 725 (99.7%) gram-positive bacteria tested were susceptible to vancomycin. Of the 94 gram-negative organisms tested against ceftazidime, 2 were of intermediate sensitivity and 6 were resistant. For 8 antibiotics, increasing microbial resistance over time was observed: cefazolin (P = 0.02), cefotetan (P = 0.006), cephalothin (P<0.0001), clindamycin (P = 0.04), erythromycin (P<0.0001), methicillin/oxacillin (P<0.0001), ampicillin (P = 0.01), and ceftriaxone (P = 0.006). For 3 antibiotics, increasing microbial susceptibility was observed: gentamicin (P<0.0001), tobramycin (P = 0.005), and imipenem (P<0.0001). CONCLUSIONS: Coagulase-negative staphylococcus remains the most frequently identified cause of endophthalmitis. Vancomycin and ceftazidime seem to be excellent empiric antibiotics for treating endophthalmitis. Although a statistically significant trend toward increasing microbial resistance against a variety of antibiotics, including cephalosporins and methicillin, was observed, a significant trend toward decreasing microbial resistance against aminoglycosides and imipenem also was detected.

Clinical characteristics of Acanthamoeba keratitis infections in 28 states, 2008 to 2011.

PURPOSE: The aim was to describe a geographically and clinically diverse sample of cases of Acanthamoeba keratitis (AK) and establish the risk factors for poor outcomes among patients with this disease. METHODS: We conducted a retrospective, population-based case series of 116 patients with AK identified through a national surveillance network. Data were collected via a medical record review by diagnosing ophthalmologists and by phone interviews with patients. Exact logistic regression modeling was used to determine risk factors for poor visual outcomes. RESULTS: Among patients with data available on contact lens use, it was found that 93.3% wore contact lenses. The median time from symptom onset to care seeking was 2 days, whereas the median time from symptom onset to diagnosis was 27 days. Keratoplasty was performed in 27 of 81 patients with available outcome data and was more likely in patients >40 years old [odds ratio (OR) 5.25, 95% confidence interval (CI) 1.49-21.92]. When adjusted for age, the risk factors for keratoplasty included the presence of a ring infiltrate (OR 40.00, 95% CI 3.58-447.0) or any sign of stromal invasion (OR 10.48, 95% CI 2.56-55.09). One-third of patients with available data on best-corrected visual acuity had a best-corrected visual acuity <20/200, with the presence of a ring infiltrate as the only significant predictor of this outcome when adjusted for age (aOR 3.45, 95% CI 1.01-12.31). CONCLUSIONS: AK remains challenging to diagnose. Consequently, patients with advanced disease are more likely to have poor outcomes, particularly if they are older. The increasing awareness of AK among general eye care providers may shorten referral times and potentially improve outcomes.

Detection of herpes simplex virus type 1 in failed descemet stripping automated endothelial keratoplasty grafts.

PURPOSE: To determine the prevalence of herpes simplex virus type 1 (HSV-1) DNA in failed Descemet membrane stripping automated endothelial keratoplasty (DSAEK) grafts. METHODS: A retrospective interventional case series of patients with DSAEK graft failure treated at the New York Eye and Ear Infirmary between January 2009 and July 2012 was performed. Repeat DSAEK, penetrating keratoplasty, or keratoprosthesis procedure was subsequently performed on eyes with failed grafts. All failed grafts were examined immunohistochemically and with qualitative real-time polymerase chain reaction for HSV-1 DNA. In HSV-1-positive cases, corneoscleral donor rims from the original DSAEK procedures were also examined immunohistochemically and with polymerase chain reaction. RESULTS: Fifty-one failed DSAEK grafts from 50 eyes of 49 patients were identified. Indications for DSAEK were pseudophakic bullous keratopathy (28/51, 55%), Fuchs corneal endothelial dystrophy (12/51, 23%), failed penetrating keratoplasty (7/51, 14%), corneal decompensation from glaucoma (2/51, 4%), herpetic endotheliitis (1/51, 2%), and failed DSAEK (1/51, 2%). Forty-three grafts (83%) were primary DSAEK graft failure. HSV-1 DNA was isolated from 2 of 51 failed DSAEK grafts (4.0%). The corresponding corneoscleral donor rims did not demonstrate the presence of HSV-1. CONCLUSIONS: Based on our results, HSV-1 infection plays a minor role in DSAEK graft failure. The data suggest that recipient reactivation, rather than donor transmission, plays a role in HSV infection.

Descemet stripping automated endothelial keratoplasty after failed penetrating keratoplasty.

PURPOSE: To report the rate of graft dislocation, surgical anatomic success, and postsurgical complications associated with Descemet stripping automated endothelial keratoplasty (DSAEK) after previous primary failed penetrating keratoplasty (PK). METHODS: Institutional review board-approved, single-center, retrospective chart review study of 30 eyes of 30 patients with prior failed PK who underwent DSAEK with a minimum of 3 months follow-up. Primary outcomes measured included rates of anatomic success and failure, postoperative complications, lenticle size, visual acuity, intraocular pressure change, and a report of external factors that may affect success. RESULTS: Thirty eyes of 30 patients were identified. The primary dislocation rate was 16.7%. Five primary DSAEKs detached; 1 was successfully rebubbled in the office, 2 had repeat successful DSAEKs, and 2 failed on a second attempt and had a subsequent PK. Despite successful anatomic attachment, 1 eye had primary graft failure, 3 that cleared initially failed within 6 months, and 1 that successfully cleared had subsequent graft rejection resulting in failure at 6 months. The 2 eyes requiring PK were excluded from the visual outcomes analysis, leaving 28 eyes with successfully attached lenticles. At 3 months postoperatively, of the 28 eyes, 19 showed an improvement in visual acuity, 6 had no change in vision from preoperative data, and 1 had worsening of vision (anatomic attachment but endothelial failure). Two of the 28 eyes had no data at that time point. CONCLUSIONS: DSAEK eyes after failed PK demonstrated improved vision with a low complication rate in a majority of patients. The graft dislocation rate and postoperative complications rates are comparable with the primary DSAEK dislocation rates in our own published series and in the literature.

Graft rejection following descemet stripping automated endothelial keratoplasty: features, risk factors, and outcomes.

PURPOSE: To investigate the clinical features, risk factors, and treatment outcomes following immunologic graft rejection in eyes that have undergone Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Retrospective case review. METHODS: The charts for 353 DSAEK procedures performed at a single clinical practice at the New York Eye and Ear Infirmary from August 2006 to November 2010 were reviewed. Cases with at least 3 months follow-up were included. Outcome measures included rates of graft rejection, clinical findings, treatment outcomes, and risk factor analysis. RESULTS: Thirty of 353 DSAEKs developed graft rejection (8.5%). Kaplan-Meier rate of rejection was 6.0% at 1 year (n = 175), 14.0% at 2 years (n = 79), and 22.0% at 3 years (n = 39). Rejection episodes occurred between 0.8 and 34 months. Clinical findings included anterior chamber cells, keratic precipitates, endothelial rejection line, and host-donor interface vascularization. Risk factors for development of graft rejection were cessation of postoperative steroid (hazard ratio 5.49, P < .0001) and black race (hazard ratio 2.71, P = .02). Recipient age, sex, surgical indication, glaucoma, postoperative steroid response, corneal neovascularization or peripheral anterior synechiae, graft size, prior keratoplasty in fellow eye, and concurrent or subsequent procedures were not associated with graft rejection. Twenty-two out of 30 rejection episodes (73.3%) resolved with steroid treatment. CONCLUSIONS: Graft rejection is an important complication following DSAEK. In contrast to penetrating keratoplasty, rejection following DSAEK is almost exclusively endothelial. Among risk factors traditionally associated with graft rejection, cessation of topical steroids was most significant. Prompt recognition and treatment of DSAEK rejection can lead to favorable outcomes.

Removal of epithelial ingrowth via central perforating wound tract 6 years post LASIK.

BACKGROUND: The purpose was to report a case of a novel approach for the removal of central interface epithelial ingrowth caused by a perforating corneal injury 6 years after laser-assisted in situ keratomileusis (LASIK). METHODS: Access to a large central area of epithelial ingrowth under a LASIK flap was achieved through the wound tract from a perforating corneal injury. Suturing of the central LASIK flap in a similar manner commonly carried out peripherally was then performed to prevent recurrent epithelial ingrowth. RESULTS: The offending epithelial ingrowth was removed with no recurrence over a 1-year follow-up. CONCLUSIONS: This is, to our knowledge, the first reported case of central epithelial ingrowth removal from a LASIK interface by a perforating injury wound tract.

Progressive growth in epibulbar complex choristomas: report of 2 cases and review of literature.

PURPOSE: To report 2 patients with progressive complex choristomas and to review the literature on this subject. DESIGN: Interventional case reports. METHODS: Clinical and pathologic correlation was performed on 2 patients with progressive epibulbar choristomas. PubMed database was searched to identify all the previously reported cases of progressive epibulbar choristomas (using key words choristoma, dermoid, growth, progression, and evolution). RESULTS: Growth of the epibulbar choristomas was noted in infancy in 1 patient with oculoectodermal syndrome and in puberty in another otherwise healthy patient. Both lesions were identified histopathologically as complex choristomas. In addition to the characteristic choristomatous tissues, both lesions demonstrated increased vascularity, inflammatory infiltrate, and fibroblast proliferation within myxomatous stroma. Review of the literature identified 4 patients with progressive complex choristomas, 1 of whom demonstrated histopathologic findings similar to those of the 2 cases reported here. CONCLUSIONS: Epibulbar choristomas rarely enlarge, likely secondary to reactive changes within the tissue manifested by increased vascularity, inflammatory cell infiltration, and fibroblast proliferation with deposition of myxomatous stroma.

Spontaneous reattachment of Descemet stripping automated endothelial keratoplasty lenticles: a case series of 12 patients.

PURPOSE: To review 12 cases of postoperative detachment and spontaneous reattachment of Descemet stripping automated endothelial keratoplasty (DSAEK) lenticles. DESIGN: Retrospective, observational case series. METHODS: This was a review of patients undergoing DSAEK at 7 institutions. Patients who had a significant detachment of their DSAEK lenticle during the postoperative period were identified and divided into 2 groups. Significant detachment was defined as either complete central interface fluid with bare peripheral attachment (group 1) or a free-floating lenticle in the anterior chamber (group 2). Patients who subsequently had a spontaneous reattachment of the lenticle were identified, with data regarding surgical technique and intraoperative and postoperative complications collected for analysis. RESULTS: Our cohort consisted of 12 eyes of 12 patients who met the definition of significant postoperative detachment with subsequent spontaneous reattachment. Four patients had complete central detachment with peripheral attachment (group 1), whereas 8 patients had a free-floating lenticle (group 2). Ten of the 12 patients had a successful outcome as defined as an attached and clear DSAEK lenticle. In our study, reattachment was seen as early as 5 days and as late as 7 months after surgery, with reattachment in 9 of 12 patients by day 25. CONCLUSIONS: Spontaneous reattachment of detached DSAEK lenticles may occur during the postoperative period. The decision of when to bring the patient back for a rebubble ultimately must be made on a case-by-case basis.