Outcomes of difluprednate treatment for corneal graft rejection.

OBJECTIVE: To evaluate outcomes of difluprednate treatment in penetrating keratoplasty (PK) graft rejection DESIGN: Retrospective, interventional case series. PARTICIPANTS: Patients treated with difluprednate for acute endothelial rejection after PK. METHODS: Data were collected on resolution of rejection, treatment regimen used, best spectacle-corrected visual acuity (BSCVA), intraocular pressure (IOP), and side effects. MAIN OUTCOME MEASURE: rate of rejection resolution. SECONDARY OUTCOME MEASURES: BSCVA change and side-effect rates. RESULTS: Thirty-three eyes of 33 patients aged 56.7 ± 17.9 years were included. Twenty-four grafts (72.7%) were high-risk grafts. Complete treatment success was achieved in 19 of 33 grafts (57.6%) over 1.8 ± 1.4 months. Non-high-risk grafts had 100% treatment success rate (9 of 9 grafts). All treatment failures occurred in high-risk grafts, which had a significantly lower treatment success rate of 41.7% (10 of 24 grafts) compared with non-high-risk grafts (p = 0.004). Mean BSCVA in the treatment-success group improved from 1.07 ± 0.74 logMAR at the time of rejection to 0.44 ± 0.33 logMAR after treatment (p = 0.003). High-dose difluprednate (every 1-3 hours while awake) was used in 93.9% of eyes. IOP elevation and toxic epitheliopathy were each seen in 21.2% of patients. IOP elevation was managed successfully with topical medication and/or difluprednate discontinuation. Epitheliopathy resolved in all cases after completion of difluprednate treatment, except for one case complicated by an infected ulcer. CONCLUSIONS: High-dose difluprednate was effective in treating PK graft rejection, especially in non-high-risk grafts. Adjunct treatment may be required in high-risk grafts. Monitoring for IOP elevation and for toxic epitheliopathy is recommended.

Stepwise Combination of Femtosecond Astigmatic Keratotomy With Phacoemulsification and Toric Intraocular Lens Implantation in Treatment of Very High Postkeratoplasty Astigmatism.

PURPOSE: To report the outcomes of stepwise combined femtosecond astigmatic keratotomy (FSAK) and phacoemulsification with toric intraocular lens (IOL) implantation in the treatment of very high astigmatism after either penetrating keratoplasty or deep anterior lamellar keratoplasty. METHODS: This is a retrospective, interventional case series including 8 eyes of 6 patients with very high astigmatism [≥8.00 diopter (D)] after either penetrating keratoplasty or deep anterior lamellar keratoplasty who underwent FSAK, followed by phacoemulsification and toric IOL implantation. Outcome measures were corneal and manifest astigmatism and uncorrected and best spectacle-corrected visual acuity (UCVA, BSCVA). RESULTS: The average age was 58.9 ± 5.1 years. The average follow-up time was 40.9 ± 43.8 months. Outcome measure changes after both FSAK and toric IOL implantation were: corneal astigmatism improved from 13.56 ± 4.81 D to 4.48 ± 2.83 D (P < 0.001), manifest astigmatism improved from 9.15 ± 3.86 to 1.46 ± 0.88 D (P = 0.011), UCVA improved from 1.69 ± 0.45 LogMAR (Snellen equivalent ∼20/980) to 0.23 ± 0.11 LogMAR (Snellen equivalent ∼20/33, P < 0.001), and BSCVA improved from 1.01 ± 0.71 LogMAR (Snellen equivalent ∼20/200) to 0.19 ± 0.11 LogMAR (Snellen equivalent ∼20/30, P = 0.015). BSCVA and UCVA at the last follow-up were 20/40 or better in all patients. All procedures were uneventful. Two eyes underwent photorefractive keratectomy after FSAK to regularize and further reduce astigmatism before toric IOL implantation. One patient underwent temporary compression suturing because of FSAK overcorrection. CONCLUSIONS: Combined stepwise use of FSAK and phacoemulsification with toric IOL implantation was an effective and apparently safe approach in patients with very high postkeratoplasty astigmatism. Additional treatment using photorefractive keratectomy may be beneficial in some cases.

Outcomes of femtosecond laser-assisted Descemet membrane endothelial keratoplasty for failed penetrating keratoplasty.

OBJECTIVE: To analyze the outcomes of femtosecond laser-enabled Descemet membrane endothelial keratoplasty (FE-DMEK) in treatment of failed penetrating keratoplasty (PK) grafts. STUDY DESIGN: Retrospective, interventional case series. PARTICIPANTS: Patients with a failed PK graft who underwent FE-DMEK at Toronto Western Hospital, Canada, between 2014 and 2016. METHODS: Outcome measures were best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), rates of graft detachment, rebubbling, rejection, and failure. RESULTS: Eight eyes of 8 patients were included. Mean age was 64.7 ± 14.5 years. Average follow-up time was 27.5 ± 8.6 months (range 15-36 months). There were no intraoperative complications and no issues with the creation of the descemetorhexis-all descemetorhexis cuts were complete. There were no significant graft detachments and no need for rebubbling. There were no primary or secondary graft failures and all grafts were viable at the final follow-up. BSCVA worsened from 0.41 ± 0.33 logMAR (Snellen equivalent ∼20/50) to 1.37 ± 0.91 logMAR (Snellen equivalent ∼20/460) after PK failure (p = 0.012), and improved significantly after FE-DMEK to 0.34 ± 0.14 logMAR (Snellen equivalent ∼20/45), 0.42 ± 0.12 logMAR (Snellen equivalent ∼20/50), 0.27 ± 0.14 logMAR (Snellen equivalent ∼20/35), and 0.25 ± 0.16 logMAR (Snellen equivalent ∼20/35) at 6 months, 12 months, 24 months, and at final follow-up, respectively (p = 0.013, p = 0.027, p = 0.022, and p = 0.008, respectively). ECD decreased from 2837 ± 229 cells/mm2 preoperatively to 1069 ± 413 cells/mm2 (61.4% cell-loss rate) and 974 ± 344 cells/mm2 (64.8% cell-loss rate) at 12 months and 24 months, respectively (p < 0.001). Cell loss was higher than in historical controls. CONCLUSIONS: FE-DMEK was effective in the management of PK graft failure, showing very low detachment and rebubble rates.

Three-Year Outcome Comparison Between Femtosecond Laser-Assisted and Manual Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate 3-year outcomes of femtosecond laser-assisted Descemet membrane endothelial keratoplasty (F-DMEK) compared with manual Descemet membrane endothelial keratoplasty (M-DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS: A retrospective, interventional study, including eyes with FECD and cataract that underwent either F-DMEK or M-DMEK combined with cataract extraction at either the Toronto Western Hospital or Kensington Eye Institute, and that had at least 18 months' follow-up was conducted. EXCLUSION CRITERIA: complicated anterior segments, previous vitrectomy, previous keratoplasty, corneal opacity, or any other visually significant ocular comorbidity. RESULTS: Included were 16 eyes of 15 patients in the F-DMEK group (average follow-up 33.0 ± 9.0 months) and 45 eyes of 40 patients in the M-DMEK group (average follow-up 32.0 ± 7.0 months). There were no issues with the creation of femtosecond descemetorhexis (in the F-DMEK group)-all descemetorhexis cuts were complete. Best spectacle-corrected visual acuity improvement did not differ significantly between the groups at 1, 2, and 3 years (P = 0.849, P = 0.465 and P = 0.936, respectively). Rates of significant detachment in F-DMEK and M-DMEK were 1 of 16 eyes (6.25%) and 16 of 45 eyes (35.6%) (P = 0.027). Rebubbling rates were 1 of 16 eyes (6.25%) and 15 of 45 eyes (33.3%) (P = 0.047). Cell-loss rates following F-DMEK and M-DMEK were 26.8% and 36.5% at 1 year (P = 0.042), 30.5% and 42.3% at 2 years (P = 0.008), 37% and 47.5% at 3 years (P = 0.057), respectively. Graft failure rate was 0% in F-DMEK and 8.9% in M-DMEK (all were primary failures; P = 0.565). CONCLUSIONS: F-DMEK showed good efficacy with reduced detachment, rebubble, and cell-loss rates, compared with M-DMEK.