Ochrobactrum anthropi infection following corneal transplantation -a case report and review of literature.

BACKGROUND: Ochrobactrum anthropi is widely distributed and primarily infects patients with compromised immune functions . Historically, O. anthropi has been considered to possess low toxicity and pathogenicity; however, recent studies suggest that it may in fact cause severe purulent infections. In this case study, we examine a case of O. anthropi infection following corneal transplantation, exploring the occurrence and outcomes of such post-operative infections. CASE PRESENTATION: A retrospective analysis of cases involved examinations, genetic testing for diagnosis, and subsequent treatment. In patients undergoing partial penetrating keratoplasty with a fungal corneal ulcer perforation, anterior chamber exudation and purulence were observed post-surgery. Despite antifungal treatment, genetic testing of the anterior chamber fluid and purulent material confirmed O. anthropi infection. The use of antimicrobial treatment specifically targeting O. anthropi was found to be effective in treating the infection. CONCLUSION: Inflammatory reactions following corneal transplantation should be should be monitored for the presence of other infections. Genetic testing has significant implications for clinical diagnosis and treatment.

Loose suture-related ocular surface inflammation and activation of conjunctiva-associated lymphoid tissue in patients after keratoplasty.

The purpose of this study is to evaluate loose suture-related inflammation and activation of conjunctiva-associated lymphoid tissue (CALT) in patients after keratoplasty. The patients who were treated with keratoplasty at the First Affiliated Hospital of Harbin Medical University between 2015 and 2022 were recruited into the study. We evaluated the time and location of loose suture development in patients after keratoplasty. In addition, in vivo confocal microscopy was used to evaluate the activation of CALT and the accumulation of inflammatory cells around loose sutures. Meso Scale Discovery assay detection kits were used to evaluate the inflammatory cytokines in the tears of patients before and after the loose suture was removed. In this study, we collected the information from 212 cases (212 eyes) who had PK (126 eyes) and DALK-treated (86 eyes) for corneal transplantation, including 124 males and 88 females, aged 14-84 years old. The average age was 50.65 ± 16.81 years old. Corneal sutures were more prone to loose at 3 months and 6 months after keratoplasty, and the frequent sites were at 5 and 6 o'clock. An increased number of inflammatory cells could be observed around the loose sutures than normal sutures (P < 0.001). In CALT, the density of diffuse lymphocytes (P < 0.001), follicles (P < 0.001), and parafollicular lymphocytes (P < 0.001) were higher and the central reflection of the follicles (P < 0.001) was stronger when suture loosening happened. The levels of inflammatory cytokines such as IL-1ß (P = 0.003), IL-8 (P = 0.012), and TNF-α (P < 0.001) were higher in the tears of the patients with loose sutures. The activation of CALT was partly settled after removing the loose sutures. In conclusion, loose sutures after corneal transplantation can lead to increased infiltration of inflammatory cells, activation of CALT, and increased secretion of inflammatory cytokines in the tears of patients. Regular follow-up to identify and solve the problem in time can avoid suture-related complications.

[Modern techniques and features of selective keratoplasty]. / Sovremennye tekhnologii i vozmozhnosti selektivnoi keratoplastiki.

Selective keratoplasty involves replacing the affected layers of the cornea with similar donor tissue. In case of pathological changes in the middle and posterior stroma, deep anterior lamellar keratoplasty (DALK) is performed. Chronic corneal edema caused by endothelial dysfunction is an indication for endothelial keratoplasty - Descemet membrane endothelial keratoplasty (DMEK) or Descemet Stripping Endothelial Keratoplasty (DSAEK). Compared to penetrating keratoplasty (PK), these operations are characterized by a low risk of damage to intraocular structures and a relatively short rehabilitation period. Complications of selective keratoplasty include the formation of a false chamber between the lamellar graft and the recipient's cornea, ocular hypertension during anterior chamber air tamponade. Persistent epithelial defect can be a sign of primary graft failure in DALK, DSAEK and DMEK. Selective keratoplasty is characterized by a lower incidence of immune rejection than PK. In some cases, DALK can be complicated by corneal changes related to suture fixation of the graft. Long-term postoperative use of topical glucocorticoids can cause ocular hypertension and cataracts.

Unveiling the landscape of post-keratoplasty keratitis: a comprehensive epidemiological analysis in a tertiary center.

PURPOSE: The present study aimed to epidemiologically evaluate patients with infectious keratitis following corneal transplantation. METHODS: This retrospective study analyzed medical records of patients who underwent keratoplasty from March 2014 to March 2022 at a tertiary center. A total of seventy-five patients were evaluated. The data were classified based on culture results, the type of microorganisms involved, treatment requirements, and the type of primary keratoplasty performed. RESULTS: Seventy-five patients were evaluated in this study, with a mean age of 45.9 years (22-95 years). The mean duration between the first surgery and the incidence of infectious keratitis was 1.43 years, and most cases occurred in the first year (56.2%). Bacterial and fungal keratitis in 2.17%, 1.39%, and 1.26% of cases undergoing penetrating keratoplasty (PK), endothelial keratoplasty (EK), and anterior lamellar keratoplasty (ALK) occurred, respectively. Streptococcus viridans (9.3%) and Staphylococcus aureus (6.6%) had the highest prevalence. Across various smear and culture results (gram-positive, gram-negative, fungal, and negative culture), no significant differences were found in endophthalmitis rates (P = 0.797) and the necessity for tectonic grafts (P = 0.790). Similarly, the choice of surgical method (PK, ALK, EK) showed no significant impact on the need for tectonic grafts (P = 0.45) or the rate of endophthalmitis (P = 0.55). CONCLUSIONS: The incidence of keratitis after a corneal graft was 1.7%, with Streptococcus viridans and Staphylococcus aureus the most common microorganisms. The rate of endophthalmitis associated with post-keratoplasty keratitis was 0.053%. There was no correlation between the necessity for a tectonic graft or the incidence of endophthalmitis and the type of microorganisms involved.

Deep anterior lamellar keratoplasty and penetrating keratoplasty in macular corneal dystrophy: comparison of visual and topographic outcomes and complications.

PURPOSES: This study aims to assess and compare the postoperative visual and topographic outcomes, complications, and graft survival rates following deep anterior lamellar keratoplasty and penetrating keratoplasty in patients with macular corneal dystrophy. METHODS: In this study we enrolled 59 patients (23 male; and 36 female) with macular corneal dystrophy comprising 81 eyes. Out of these, 64 eyes underwent penetrating keratoplasty, while 17 eyes underwent deep anterior lamellar keratoplasty. The two groups were analyzed and compared based on best-corrected visual acuity, corneal tomography parameters, pachymetry, complication rates, and graft survival rates. RESULTS: After 12 months, 70.6% of the patients who underwent deep anterior lamellar keratoplasty (DALK) and 75% of those who had penetrating keratoplasty (PK) achieved a best-corrected visual acuity of 20/40 or better (p=0.712). Following surgery, DALK group showed lower front Kmean (p=0.037), and Q values (p<0.01) compared to the PK group. Postoperative interface opacity was observed in seven eyes (41.2%) in the DALK group. Other topography values and other complications (graft rejection, graft failure, cataract, glaucoma, microbial keratitis, optic atrophy) did not show significant differences between the two groups. The need for regrafting was 9.4% and 11.8% in the PK and DALK groups, respectively (p=0.769). Graft survival rates were 87.5% and 88.2% for PK and DALK; respectively (p=0.88 by Log-rank test). CONCLUSION: Both PK and DALK are equally effective in treating macular corneal dystrophy, showing similar visual, topographic, and survival outcomes. Although interface opacity occurs more frequently after DALK the visual results were comparable in both groups. Therefore, DALK emerges as a viable surgical choice for patients with macular corneal dystrophy without Descemet membrane involvement is absent.

UV light-mediated corneal crosslinking as (lymph)angioregressive pretreatment to promote graft survival after subsequent high-risk corneal transplantation (CrossCornealVision): protocol for a multicenter, randomized controlled trial.

BACKGROUND: Good vision highly depends on the transparency of the cornea, which is the "windscreen" of the eye. In fact, corneal blindness due to transparency loss is the second most common cause of blindness worldwide, and corneal transplantation is the main cure. Importantly, the cornea is normally avascular but can secondarily be invaded by pathological (blood and lymphatic) vessels due to severe inflammation, and the survival prognosis of a corneal graft mainly depends on the preoperative vascular condition of the recipient's cornea. Whereas transplants placed into avascular recipient beds enjoy long-term survival rates of > 90%, survival rates significantly decrease in pathologically pre-vascularized, so-called high-risk recipients, which account for around 10% of all performed transplants in Germany and > 75% in lower and middle-income countries worldwide. METHODS: This parallel-grouped, open-randomized, multicenter, prospective controlled exploratory investigator-initiated trial (IIT) intends to improve graft survival by preconditioning pathologically vascularized recipient corneas by (lymph)angioregressive treatment before high-risk corneal transplantation. For this purpose, corneal crosslinking (CXL) will be used, which has been shown to potently regress corneal blood and lymphatic vessels. Prior to transplantation, patients will be randomized into 2 groups: (1) CXL (intervention) or (2) no pretreatment (control). CXL will be repeated once if insufficient reduction of corneal neovascularization should be observed. All patients (both groups) will then undergo corneal transplantation. In the intervention group, remaining blood vessels will be additionally regressed using fine needle diathermy (on the day of transplantation). Afterwards, the incidence of graft rejection episodes will be evaluated for 24 months (primary endpoint). Overall graft survival, as well as regression of corneal vessels and/or recurrence, among other factors, will be analyzed (secondary endpoints). DISCUSSION: Based on preclinical and early pilot clinical evidence, we want to test the novel concept of temporary (lymph)angioregressive pretreatment of high-risk eyes by CXL to promote subsequent corneal graft survival. So far, there is no evidence-based approach to reliably improve graft survival in the high-risk corneal transplantation setting available in clinical routine. If successful, this approach will be the first to promote graft survival in high-risk transplants. It will significantly improve vision and quality of life in patients suffering from corneal blindness. TRIAL REGISTRATION: ClinicalTrials.gov NCT05870566. Registered on 22 May 2023.

Management of acute corneal hydrops - Current perspectives.

Acute corneal hydrops (ACH) is a rare but sight-threatening complication of corneal ectasias. We aim to review the current literature on etiopathogenesis, histology, role of ancillary investigations, management, and outcomes of ACH by classifying the various management strategies based on their site of action and the underlying mechanism. A review of the literature was conducted by searching the following databases: PubMed (United States National Library of Medicine), Embase (Reed Elsevier Properties SA), Web of Science (Thomson Reuters), and Scopus (Elsevier BV) till April 2023. The literature search used various combinations of the following keywords: acute corneal hydrops, keratoconus, ectasia, management, keratoplasty. Nine hundred eighty-three articles were identified based on the above searches. Case reports which did not add any new modality of treatment to the existing literature, articles unrelated to management, those with no full text available, and foreign-language articles with no translation available were excluded. Eventually, 75 relevant articles that pertained to the management of ACH were shortlisted and reviewed. Recent studies have described newer surgical interventions like full-thickness or pre-Descemetic sutures, thermokeratoplasty, and plasma injection that aim to close the posterior stromal break. Posterior lamellar keratoplasties act by replacing the posterior torn Descemet's membrane (DM), and early deep anterior lamellar keratoplasty (DALK) has been attempted to combine the correction of the anatomical defect and visual rehabilitation in a single surgery. These surgical interventions may help by reducing the scarring and increasing the number of patients who can be visually rehabilitated with contact lenses rather than keratoplasty.

Infectious keratitis following corneal transplantation: A long-term cohort study.

BACKGROUND: To assess the long-term incidence and risk factors for post-keratoplasty infectious keratitis (IK), associated ocular pathogens, and antibiotic resistance profiles. METHODS: Cohort study including 2553 consecutive penetrating, endothelial, and anterior lamellar keratoplasties performed between 1992 and 2020. Medical and microbiological records of patients clinically diagnosed with IK were retrospectively reviewed. MAIN OUTCOME MEASURES: cumulative incidence of IK, infectious agent species, and antibiotics resistance profiles. RESULTS: The average follow-up time after transplantation was 112 ± 96 months. Eighty-nine IK episodes were recorded; microbiological tests were positive in 55/89 (62%). The cumulated incidence of postoperative IK was 5.50%/10.25% at 10/20 years. The occurrence of at least one episode of IK after transplantation was associated with lower graft survival in the long term (p < 0.0001). Rejection risk (adjusted Hazard Ratio, 2.29) and postoperative epithelial complications (HR, 3.44) were significantly and independently associated with a higher incidence of postoperative IK. Infectious agents included 41 bacteria, 10 HSV, 6 fungi, and 1 Acanthamoeba. The rate of antibiotic resistance was 0% for vancomycin, 13% for fluoroquinolones, 20% for rifamycin, 59% for aminoglycosides, and 73% for ticarcillin. In 41% of cases, patients were under prophylactic topical antibiotics before the infectious episode. Topical antibiotics were significantly associated with increased resistance to penicillin, carbapenems, and aminoglycosides. CONCLUSION: IK (mainly bacterial) is a frequent complication of corneal transplantation in the long term. Vancomycin and fluoroquinolones can be considered as first-line treatments. Prolonged postoperative antibiotic preventive treatment is not advisable as it may increase antibiotic resistance.

Anterior Chamber Snowflake After Keratoplasty.

A 62-year-old woman presented with painless vision reduction and eye redness in the right eye for a week. Nine months after keratoplasty, she presented with diffuse tiny nodules all over the iris and a dense opacity in the anterior vitreous body. What would you do next?

Infectious Keratitis After Keratoplasty in the United States: Analysis of a National Medicare Claims Data Set.

PURPOSE: The aim of this study was to assess the incidence, trends, and risk factors of infectious keratitis (IK) and subsequent repeat keratoplasty after penetrating keratoplasty (PK) and endothelial keratoplasty (EK). METHODS: Using a retrospective cohort study design, IK cases within 6 months of keratoplasty were identified using billing codes among 100% Medicare beneficiaries aged 65 years and older who underwent either PK or EK between 2011 and 2020. Multivariable logistic regression models were used to evaluate factors associated with postkeratoplasty IK. RESULTS: We identified 115,588 keratoplasties, of which 20.0% (n = 23,144) were PK and 80.0% (n = 92,444) were EK. IK developed within 6 months with a rate of 3.32% (n = 769) post-PK and 0.72% (n = 666) post-EK. Overall rates of IK decreased from 16.05 to 9.61 per 1000 keratoplasties between 2011 and 2020 ( P < 0.001). The median interval between keratoplasty and diagnosis of IK was 73 days (interquartile range: 29-114 days) for PK and 74 days (interquartile range: 38-116 days) for EK. After IK, 22.9% (n = 176) and 23.8% (n = 159) eyes underwent repeat keratoplasty within 1 year for PK and EK, respectively. The occurrence of IK after PK was associated with age 85 years and older [odds ratio (OR): 1.38; 95% confidence interval (CI): 1.13-1.68] relative to patients aged 65 to 74 years. The occurrence of IK after EK was also associated with age 85 years and older (OR: 1.44; 95% CI: 1.14-1.82) relative to patients aged 65 to 74 years. CONCLUSIONS: IK was 4 times more common after PK than EK and the complication was associated with older age. Our findings may help corneal surgeons in counseling patients at higher risk and guiding their postoperative care.

Suture-related complications after deep anterior lamellar keratoplasty for keratoconus.

PURPOSE: The purpose of this study is to determine the incidence of suture-related complications, their risk factors, and effects on the clinical outcomes after deep anterior lamellar keratoplasty (DALK) for keratoconus. METHODS: In this retrospective, comparative, interventional study, the records of consecutive patients with keratoconus who underwent DALK were reviewed for suture-related complications. Univariate analyses were used to identify risk factors for suture complications. We compared groups with and without suture-related complications to evaluate the effects of these complications on clinical outcomes after DALK. RESULTS: Of the 633 DALKs, 438 eyes (69.2%) developed suture complications including loose sutures (32.7%), spontaneous suture rupture (30%), sterile suture abscesses (22.8%), suture tract vascularization (16.4%), suture erosion (10.3%), and suture cheese wiring (6.8%). Vernal keratoconjunctivitis increased the incidence of sterile suture infiltration, premature suture loosening, and suture tract vascularization. Loose suture was observed more commonly in larger graft size, while spontaneous suture rupture was associated with late suture removal. There was no statistically significant difference in postoperative outcomes including visual acuity, refraction, graft rejection, and failure in eyes with and without suture complications. However, suture-related complications were directly associated with sight-threatening ocular morbidities, including graft rejection (39 eyes), ulcer (1 eye), and failure (2 eyes). CONCLUSION: Suture-related complications frequently occurred after DALK for keratoconus. Ocular surface inflammation, large grafts, and late suture removal increased the risk of suture-related complications. While these complications had no negative impact on clinical outcomes in the majority of cases, some of them led to sight-threatening morbidity, underlining the importance of early diagnosis and treatment.

A 7-year review of clinical characteristics, predisposing factors and outcomes of post-keratoplasty infectious keratitis: the Nottingham infectious keratitis study.

Background/objectives: Post-keratoplasty infectious keratitis (PKIK) is a unique sight-threatening clinical entity which often poses significant therapeutic challenges. This study aimed to examine the clinical presentation, risk factors, management, and clinical outcomes of PKIK. Methods: This was a retrospective study of all patients who presented to the Queen's Medical Centre, Nottingham, with PKIK between September 2015 and August 2022 (a 7-year period). Relevant data on types of keratoplasty, clinical presentations, causative microorganisms, management, and outcome were analyzed. Results: Forty-nine PKIK cases, including four cases of interface infectious keratitis, were identified during the study period. The most common graft indications for PKP, DALK and EK were failed grafts (9, 37.5%), keratoconus (6, 54.5%) and Fuchs endothelial corneal dystrophy (FECD; 8, 57.1%), respectively. Staphylococcus spp. were the most commonly identified organisms (15, 50.0%). Bullous keratopathy (18, 36.7%), ocular surface disease (18, 36.7%), and broken/loose sutures (15, 30.6%) were the most common risk factors. Concurrent use of topical steroids was identified in 25 (51.0%) cases. Of 31 functioning grafts at presentation, 12 (38.7%) grafts failed at final follow-up with 15 (48.4%) patients retaining a CDVA of ≥1.0 logMAR. The overall estimated 5-year survival rate post-PKIK was 55.9% (95% CI, 35.9%-75.9%), with DALK having the highest survival rate [63.6% (95% CI, 28.9%-98.3%)], followed by EK [57.1% (95% CI, 20.4%-93.8%)] and PKP [52.7% (95% CI, 25.1%-80.3%)], though no statistical difference was observed (p=0.48). Conclusions: PKIK represents an important cause of IK and graft failure. Bullous keratopathy, OSD and suture-related complications are the commonest risk factors, highlighting the potential benefit of prophylactic topical antibiotics (for unhealthy ocular surface) and early suture removal (where possible) in reducing the risk of PKIK. Graft survival may be higher in lamellar keratoplasty following PKIK but larger studies are required to elucidate this observation.

Preoperative surgeon evaluation of corneal endothelial status: the Viability Control of Human Endothelial Cells before Keratoplasty (V-CHECK) study protocol.

INTRODUCTION: The success of keratoplasty strongly depends on the health status of the transplanted endothelial cells. Donor corneal tissues are routinely screened for endothelial damage before shipment; however, surgical teams have currently no means of assessing the overall viability of corneal endothelium immediately prior to transplantation. The aim of this study is to validate a preoperative method of evaluating the endothelial health of donor corneal tissues, to assess the proportion of tissues deemed suitable for transplantation by the surgeons and to prospectively record the clinical outcomes of a cohort of patients undergoing keratoplasty in relation to preoperatively defined endothelial viability. METHODS AND ANALYSIS: In this multicentre cohort study, consecutive patients undergoing keratoplasty (perforating keratoplasty, Descemet stripping automated endothelial keratoplasty (DSAEK), ultra-thin DSAEK (UT-DSAEK) or Descemet membrane endothelial keratoplasty) will be enrolled and followed-up for 1 year. Before transplantation, the endothelial viability of the donor corneal tissue will be evaluated preoperatively through trypan blue staining and custom image analysis to estimate the overall percentage of trypan blue-positive areas (TBPAs), a proxy of endothelial damage. Functional and structural outcomes at the end of the follow-up will be correlated with preoperatively assessed TBPA values. ETHICS AND DISSEMINATION: The protocol will be reviewed by the ethical committees of participating centres, with the sponsor centre issuing the final definitive approval. The results will be disseminated on ClinicalTrials.gov, at national and international conferences, by partner patient groups and in open access, peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05847387.

[Surgical technique of keratoplasty with simultaneous implantation of a continuous ring or ring segment into the graft]. / Khirurgicheskaya tekhnika keratoplastiki s odnomomentnoi implantatsiei tsel'nogo ili razomknutogo kol'tsa v transplantat.

The article presents the surgical technique of penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) with femtosecond-laser assistance involving simultaneous implantation of an intracorneal continuous ring (ICCR) or an intracorneal ring segment (ICRS) into the graft. Surgical technique no. 1 - keratoplasty with simultaneous implantation of ICRS. Intrastromal circular tunnel is formed in the central zone of donor cornea using femtosecond laser. Then penetrating trepanation 8.1 mm in diameter is performed symmetrically to the formed tunnel. After preparing penetrating or lamellar recipient bed, suture fixation is placed in the corneal transplant, then the ICRS is implanted into the graft. Surgical technique no. 2 - keratoplasty with simultaneous implantation of ICCR. The donor cornea is dissected from periphery to center using femtosecond laser. Central zone remains untouched. A large diameter full-thickness trepanation is performed and the donor cornea is divided into the anterior and posterior layers. The ICCR is put on the donor cornea while holding the posterior layer with forceps. Penetrating or lamellar recipient bed is prepared, then the corneal graft is fixed with sutures. Transparent corneal graft acceptance does not guarantee high visual acuity due to post-keratoplasty astigmatism. Surgical correction of astigmatism is performed in the long term post-operatively and isn't effective enough. We proposed this new surgical technique of keratoplasty with simultaneous implantation of ICCR and ICRS into the graft as close as possible to the visual axis of the eye, which can help make the postoperative astigmatism minimal both immediately after surgery and in the long term. The study proposes a new approach to intraoperative prevention of post-keratoplasty astigmatism. The technique is simple, safe and effective. Analysis of long-term outcomes is required before recommending this method for widespread use in clinical practice.

Risk Factors for Fibrous Ingrowth in Eyes Requiring Primary Keratoplasty.

PURPOSE: The aim of this study was to define risks for corneal transplantation associated with fibrous ingrowth among first-time transplant recipients. METHODS: We performed a retrospective case-control study of patients with a histopathologic diagnosis of fibrous ingrowth between 2002 and 2019. Patients with fibrous ingrowth from a first corneal specimen were included. Those with incomplete records were excluded. A 1:2 case-control ratio was used. Controls were matched using surgical indication, surgery year, transplantation method, sex, and age. RESULTS: Seventy-eight eyes (76 patients) were included and matched with 160 control eyes. The incidence of fibrous ingrowth found on a first corneal transplant was 0.6% per year. The most common keratoplasty indications were pseudophakic corneal edema (n = 25, 32%) and aphakic corneal edema (n = 15, 19%). Cases were more likely to have a history of ocular trauma (odds ratio [OR], 2.94; 95% CI, 1.30-6.30; P = 0.007), uveitis (OR, 2.73; 95% CI, 1.12-6.63; P = 0.022), retinal detachment or previous retinal surgery (OR, 2.40; 95% CI, 1.34-4.30; P = 0.003), glaucoma tube-shunt surgery (OR, 2.70; 95% CI, 1.29-5.65; P = 0.007), aphakia (OR, 3.02; 95% CI, 1.61-5.67; P = 0.0004), or iris derangement (OR, 10.52; 95% CI, 5.45-20.30; P <0.0001). A multivariate logistic regression model using iris derangement, history of ocular trauma, history of uveitis, and history of cataract surgery demonstrated 81% sensitivity and 66% specificity in predicting presence of fibrous ingrowth. CONCLUSIONS: A history of ocular trauma, uveitis, retinal detachment or previous retinal surgery, glaucoma tube-shunt surgery, aphakia, and iris derangement are risks for detecting fibrous ingrowth among first-time keratoplasty recipients. Patients with these conditions should be monitored closely for corneal decompensation.

High Astigmatism Secondary to Peripheral Ectasia Recurrence in Postpenetrating Keratoplasty Eyes Managed With Miniscleral Contact Lenses.

OBJECTIVES: After penetrating keratoplasty (PK) for keratoconus, vision can be impaired by high-degree astigmatism, particularly in those patients with recurrent peripheral ectasia. Scleral contact lenses (CLs) have long been used in the management of keratoconus both in treatment-naive corneas and those postcorneal transplants. We report the use of miniscleral CLs and their related visual and clinical outcomes in a series of patients with post-PK peripheral rim ectasia. METHODS: In this retrospective case series, 5 patients (7 eyes) presented because of reduced visual acuity with their spectacles/CLs and/or reduced comfort with their existing rigid gas-permeable lenses. All patients in this series underwent PK more than two decades ago for keratoconus (mean 28.7 years±7.2). All patients demonstrated characteristic thinning at the graft-host junction, with anterior chamber deepening. Central corneas had remained clear in all patients inferring high visual potential. Contact lenses used were No 7 Comfort 15 miniscleral and the Onefit MED scleral with 14.5 mm and 15.6 mm diameters, respectively. RESULTS: All eyes achieved a best-corrected visual acuity of 6/9 or greater. One case had difficulty with insertion and removal and has since discontinued wearing lens at this time. All others are successfully wearing the lenses regularly. CONCLUSION: Despite advances in CL design, surgical management is still required in some patients. Miniscleral CLs are effective in the refractive management of peripheral ectasia in keratoconic post-PK eyes and should be considered in such eyes before proceeding with repeat surgical intervention.

Long-Term Endothelial Cell Viability After Deep Anterior Lamellar Versus Penetrating Keratoplasty for Keratoconus.

OBJECTIVES: We compared long-term endothelial cell survival after penetrating versus after deep anterior lamellar keratoplasty for keratoconus. MATERIALS AND METHODS: We retrospectively compared 64 eyes of 55 patients who had penetrating keratoplasty and 40 eyes of 37 patients who had deep anterior lamellar keratoplasty for keratoconus (October 2003-February 2021). Best-corrected visual acuity, Goldmann applanation tonometry, fundus examination with 90D lens, and specular microscopy with CEM-530 (Nidek) were performed preoperatively and every 6 months postoperatively. Main outcomes were endothelial cell density, central corneal thickness, and visual acuity. Secondary outcomes were coefficient of variation, hexagonality, graft rejection episodes, and graft clarity. RESULTS: We found no significant differences between the 2 treatment groups regarding patient age, donor age, preoperative vision, central corneal thickness, and recipient-donor trephine diameters. Mean follow-up was 92.5 months. In deep anterior lamellar keratoplasty, the endothelium was preserved significantly better for 10 years versus for penetrating keratoplasty. Mean endothelial density in penetrating versus deep anterior lamellar keratoplasty was 2006.7 versus 2354.7 cells/mm2 at 1 year (P = .010), 1170.5 versus 2048.2 at 5 years (P <.001), and 972.5 versus 1831.6 at 10 years (P < .001). Cumulative endothelial cell loss was 43% and 19.7% at 10 years for penetrating and anterior lamellar keratoplasty, respectively. Significantly more thickening of central cornea was shown in penetrating keratoplasty after 7 years. Corneal thickness was 583.0 µm in penetrating and 545.1 µm in deep anterior lamellar keratoplasty (P = .002) at 10 years. Vision gain and coefficient of variation were similar. Hexagonality decreased significantly in both groups at 10 years. Rates of rejection were 12.5% in penetrating and 7.5% in deep anterior lamellar keratoplasty. Graft survival rates were 97.5% and 96.9%, respectively. CONCLUSIONS: In keratoconus, endothelial vitality is better preserved with deep anterior lamellar keratoplasty than with penetrating keratoplasty over a 10-year follow-up.

Management and prevention of corneal graft rejection.

The management of an episode of corneal graft rejection (CGR) is primarily by corticosteroids. Immunomodulators are useful for long-term immunosuppression and in dealing with cases of high-risk (HR) corneal grafts. The classical signs of CGR following penetrating keratoplasty (PKP) include rejection line, anterior chamber (AC) reaction, and graft edema. However, these signs may be absent or subtle in cases of endothelial keratoplasty (EK). Prevention of an episode of graft rejection is of utmost importance as it can reduce the need for donor cornea significantly. In our previous article (IJO_2866_22), we had discussed about the immunopathogenesis of CGR. In this review article, we aim to discuss the various clinical aspects and management of CGR.

Herpes simplex virus dissemination with necrotizing hepatitis following Descemet membrane endothelial keratoplasty.

BACKGROUND: Corneal transplants are the most common type of transplant and increasing in frequency. Donor cornea tissues are a rare source of herpes simplex virus (HSV) transmission and not routinely tested for presence of HSV. Donor graft-to-recipient transmission typically causes graft failure and anterior uveitis, and extra-ocular HSV disease has not been previously reported. We present a case of HSV transmission from donor cornea tissue that nearly cost the corneal transplant recipient his life. CASE REPORT: An elderly immunocompetent man developed an acute illness 10 days after having donor corneal tissue implanted in a Descemet membrane endothelial keratoplasty (DMEK). He was found to have HSV necrotizing hepatitis per liver biopsy, trilineage cytopenia, rhabdomyolysis, acute kidney failure, altered mental status, early-stage hemophagocytic lymphohistiocytosis (HLH), and donor corneal tissue implant infection resulting in graft failure and anterior uveitis. HSV DNA was detected in cerebral spinal fluid, peripheral blood, explanted donor corneal tissue, and anterior chamber fluid (220 million HSV DNA copies per mL). HSV-1 seroconversion denoted a primary HSV infection, and the patient had no other risk factor for HSV acquisition. Early recognition of HSV dissemination prompting treatment with intravenous acyclovir, as well as a short course of HLH-directed therapy, resolved the systemic illness. Vision was restored to near normal by replacement of the infected corneal graft with new donor DMEK tissue in conjunction with intravitreal foscarnet treatment. CONCLUSION: Awareness of the potential risk of donor cornea tissue transmitting HSV and leading to life-threatening HSV disease is paramount to early diagnosis and treatment. The role of donor cornea tissue in HSV transmission and disease merits additional attention and investigation.