Cataract surgery in setting of ocular surface disease.

PURPOSE OF REVIEW: The purpose of this article is to review the available strategies to successfully identify and manage ocular surface disease (OSD) pre, intra and post-cataract surgery. RECENT FINDINGS: Cataract surgery and OSD have an intricate relationship: the surgical procedure can induce or exaggerate OSD symptoms, while OSD can negatively impact surgical refractive outcomes and increase the rate of postoperative complications. SUMMARY: Improving the health and stability ocular surface is the key to enhance post cataract surgery refractive outcomes and avoid complications. This is pivotal for patients affected by severe OSD, but is also important for patients with minimal signs or symptoms. A correct diagnosis and a stepwise approach are the keys to improve the quality of life of such patients.

Allogeneic Ocular Surface Stem Cell Transplantation Outcomes With Decreased or No Systemic Immunosuppression in the Elderly.

PURPOSE: The aim of this study was to report outcomes after allogeneic ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency in the setting of decreased or no systemic immunosuppression (SI) in the elderly. METHODS: A retrospective chart review was performed of all eyes that underwent OSST for limbal stem cell deficiency between 2005 and 2020 at CVP Physicians. Inclusion criteria included patients who were (1) at least 70 years at the time of (2) allogeneic OSST. Postoperative SI regimens were assessed. Outcome measures included improvement in visual acuity, ocular surface stability, and adverse effects. RESULTS: There were 14 eyes of 14 patients that met the inclusion criteria with mean follow-up of 3.0 (range 0.4-7.0) years. SI was run at a lower level for 6 patients, and 8 patients did not receive any SI. Nine eyes underwent keratolimbal allograft, 1 had a living-related conjunctival limbal allograft, and 4 had combined OSST. Most eyes (85.7%) attained improvement in visual acuity during their follow-up. At the last follow-up, 57.1% maintained a stable ocular surface. Six eyes developed acute rejection or late failure. Minimal adverse events were noted. CONCLUSIONS: Elderly patients administered less or no SI exhibit overall favorable outcomes after allogeneic OSST. Although not significantly different, surface stability and duration of improved vision was greater with low SI. No SI may be an option that still achieves improved vision in a high proportion for at least part of their follow-up. Decreasing SI after OSST in this population can improve quality of life while minimizing adverse effects.

Dilation devices in cataract surgery.

PURPOSE OF REVIEW: Cataract surgery in the setting of small pupil represent a major challenge and it is associated with a higher risk of complications. When pharmacologic pupil dilation fails, mechanical pupil expansion devices are needed to obtain and maintain sufficient intraoperative mydriasis. The purpose of this review is to assess the pupil expansion devices currently available. RECENT FINDINGS: A variety of pupil expansion devices are offered on the market. They differ for design, material, shape, size, cost, and easiness of insertion/removal, nonetheless they all seem to be effective in improving the pupil size and easing the cataract surgery. SUMMARY: Mechanical pupil expansion can be effectively achieved with a variety of devices, which are well tolerated and can facilitate cataract surgery in the setting of poor mydriasis.

Deep Anterior Lamellar Keratoplasty: Can All Ruptures Be Fixed?

PURPOSE: The aim of this study was to report our experience in managing different types of Descemet membrane (DM) ruptures during deep anterior lamellar keratoplasty (DALK). METHODS: This study was a retrospective, consecutive, interventional case series of 1573 DALK procedures conducted on 1244 patients, performed between 2002 and 2017. Inclusion criteria consisted of a minimum of 24-month follow-up. DM rupture incidence, location, and surgical approach for repair were recorded. Postoperative measures were investigated only in eyes that experienced DM ruptures and included best spectacle-corrected visual acuity, endothelial cell loss, double anterior chamber, pupillary block, need for rebubbling, graft clarity, and rejection episodes. RESULTS: One thousand four hundred forty-three eyes met the inclusion criteria. DM ruptures occurred in 119 eyes (8.25%). Seventy-eight percent of DM ruptures were microruptures (≤2 mm), and they occurred more frequently during manual DALK cases. Macroruptures were less frequent (22%), and they occurred more frequently during subtotal and total anterior lamellar keratoplasty (STALK-TALK) cases. In general, DM ruptures mainly occurred in the peripheral cornea (95% of cases). One hundred (84%) of the 119 ruptures resolved by the first postoperative day. Nineteen cases (16%) developed double anterior chamber; all resolved by using different strategies. No intraoperative penetrating keratoplasty conversion was recorded. Pupillary block occurred in 7 cases (5.9%), but no Urrets-Zavalia syndrome was observed. The average postoperative endothelial cell loss was 410 ± 39 cells/mm 2 (19%) at 1-year follow-up, and there was no significant difference between cases requiring a rebubbling and cases that did not ( P = 0.896). All grafts but one were clear at the last follow-up. Graft failure from endothelial decompensation occurred in this lone case (0.8%). CONCLUSIONS: It is worth trying to repair all DM ruptures in DALK, and immediate penetrating keratoplasty conversion should be avoided. Understanding the physiomechanical mechanisms in DALK allows to correctly choose a proper rescue strategy to successfully repair DM ruptures.

Rediscovering a valuable manual Deep Anterior Lamellar Keratoplasty (DALK) technique: Outcomes of 42 "Peeling-off" DALK.

PURPOSE: Residual bed thickness in DALK should be less than 80µm to provide optimal visual outcomes. "Peeling-off" is a manual DALK technique, which separates the anterior stroma by pulling the deep stromal lamellae following the plane of their lowest adhesion, which is usually very deep. The purpose of this study is to measure the residual bed thickness achievable with this technique. METHODS: Retrospective case series of "Peeling-off" DALK cases performed between January 2014 and January 2021 with at least 1 year of follow-up. Indications for DALK, intraoperative and postoperative complications, residual recipient bed thickness at 1 day and at 1 month after surgery, and postoperative best corrected visual acuity (BCVA) at 1 year of follow up were evaluated. RESULTS: 42 eyes (42 patients) underwent DALK performed with "Peeling-off" technique. Indications for surgery were keratoconus in 33 eyes and stromal scar in 9 eyes. "Peeling-off" technique was used as a rescue approach to perform a DALK after a failed Big-Bubble in all cases, and also failed Air-Visco-Bubble in some cases. No intraoperative and postoperative complications were recorded. Residual recipient bed thickness was deep and regular, measuring 42 microns at 1 day postoperative (range 21-65 microns) and 23 microns (range 17-26 microns) at 1 month postoperative. Mean postoperative BCVA at 1 year of follow up was 0.18 logMAR ± 0.09. CONCLUSION: "Peeling-off" DALK is a valuable manual technique that achieves a deep stromal plane with optimal visual outcomes.

Bilateral Effect of OC-01 (Varenicline Solution) Nasal Spray for Treatment of Signs and Symptoms in Individuals with Mild, Moderate, and Severe Dry Eye Disease.

PURPOSE: This study compares outcomes of therapy with OC-01 (varenicline solution) for dry eye disease in study eyes and nonstudy fellow eyes of participants in 2 pivotal clinical trials. METHODS: All 891 patients randomized to receive OC-01 (varenicline solution) 0.03 mg, OC-01 (varenicline solution) 0.06 mg, or vehicle control (VC) in each nostril twice daily for 28 days in the Phase IIb ONSET-1 (Evaluation of the Efficacy of OC-01 Nasal Spray on Signs and Symptoms of Dry Eye Disease) and Phase III ONSET-2 trials were included in this post hoc analysis. One eye was designated as the study eye. The mean change from baseline in anesthetized Schirmer test score (STS) and the percentage of eyes achieving a ≥10-mm STS improvement were compared between treatments in study and fellow eyes overall and by baseline Eye Dryness Score. FINDINGS: In the study eyes, the mean STS improvement from baseline to day 28 was 10.4 mm, 10.5 mm, and 4.9 mm in the 0.03 mg, 0.06 mg, and VC groups, respectively; comparable values in nonstudy fellow eyes were 8.7 mm, 8.8 mm, and 2.7 mm, respectively. The percentages of study eyes achieving a ≥10-mm STS improvement were 48.1%, 48.4%, and 25.9%, respectively, whereas the comparable values in nonstudy eyes were 42.9%, 43.9%, and 19.7%, respectively. No significant treatment-subgroup interactions were observed in study or fellow eye STS outcomes by baseline Eye Dryness Scores <40 and ≥40 (p > 0.05 for all). IMPLICATIONS: OC-01 (varenicline solution) nasal spray had significant tear film production improvements compared with VC in both study and fellow eyes. These findings suggest efficacy across a broad spectrum of presenting disease severity.

Deep anterior lamellar keratoplasty for corneal penetrating wounds.

PURPOSE: To report our surgical experience of deep anterior lamellar keratoplasty (DALK) performed in eyes with scarring resulting from a corneal penetrating wound without tissue loss. METHODS: Case series of three eyes of three patients that underwent DALK for poor vision due to a scar resulting from a previous corneal penetrating wound. Surgery was performed at least 1 year after the initial injury. Manual dissection technique was used in all cases. Preoperative and postoperative best correct visual acuity (BCVA), postoperative residual bed thickness, and postoperative endothelial cell count (ECC) were evaluated. RESULTS: Preoperative BCVA ranged from 1.3 to 1.0 LogMAR. Two eyes were pseudophakic and one eye had a traumatic cataract. Manual DALK was successfully accomplished in all three cases. The mean residual recipient bed thickness was 103 µm (range 68-130 µm). The mean endothelial cell loss at the 6th month of follow-up was 6% (range 3%-11%) with a further 1% decrease at 4 years. One of the patients underwent cataract surgery and limbal relaxing incisions 1 year after DALK having a total endothelial cell loss of 4.8% at 2 years of follow-up. BCVA at 2 years of follow-up was 0.1 LogMAR (range 0.22-0.0 LogMAR). No episode of rejection was recorded, and all grafts remained clear at last follow-up (5 years, range 4-6 years). CONCLUSIONS: Manual DALK should be considered in cases of corneal scars in optical zone resulting from penetrating wound.

Limbal Stem Cell Deficiency: Demographics and Clinical Characteristics of a Large Retrospective Series at a Single Tertiary Referral Center.

PURPOSE: The aim of this study was to characterize a large cohort of patients presenting to a single referral center for limbal stem cell deficiency (LSCD). METHODS: A retrospective chart review of all patients with a clinical diagnosis of LSCD from 2002 to 2015 was performed. Demographics, etiology, previous ocular surgeries, visual acuity, and treatment were assessed. RESULTS: Seven hundred thirty-eight eyes of 434 patients (51.4% male subjects) were diagnosed with LSCD. The mean presenting age was 42.9 years, 70% presented with bilateral disease, and overall vision was poor. The most common etiologies were congenital aniridia (30.9%), chemical or thermal injuries (20.6%), contact lens (16.8%), Stevens-Johnson syndrome (SJS, 10.4%), and iatrogenic (7.3%). Congenital aniridia had a significantly increased association with glaucoma or ocular hypertension (P < 0.0001). Chemical or thermal injuries (P = 0.0007), SJS (P < 0.0001), and mucous membrane pemphigoid (P < 0.0001) had a significantly increased association with eyelid pathology. The mean logMAR best corrected visual acuity (analysis excluded eyes with light perception and no light perception) at presentation was 1.145 (∼20/280). Keratoplasty performed (before presentation at our center) without first addressing the LSCD was seen in 80 eyes; all keratoplasties failed due to recurrence of the LSCD. CONCLUSIONS: Patients presenting with LSCD were on average middle aged without sex predominance. LSCD was most commonly bilateral, comprised a wide range of etiologies, and decreased vision substantially. Ocular comorbidities may need to be treated before treating the LSCD surgically. Finally, not addressing the LSCD (primary issue) first can result in keratoplasty failure.

Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination.

PURPOSE: The aim of this study was to describe a surgical technique to perform deep anterior lamellar keratoplasty (DALK) despite inadvertent full thickness trephination in one quadrant. METHODS: Case report of a 19-year-old boy who underwent DALK for visually significant post-infectious stromal scar in his left eye. An unintentional full thickness trephination occurred in the upper-nasal quadrant at the beginning of the surgery. After suturing the perforated area, manual DALK was performed, and an air bubble was left in the anterior chamber. Evaluated outcomes included best spectacle corrected visual acuity (BSCVA), residual recipient bed thickness, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double anterior chamber. RESULTS: The surgery was completed without any further complications. No double anterior chamber or Urrets-Zavalia syndrome was observed on the first postoperative day. Mean residual recipient bed thickness was 72 µm and regular. ECC was 2446 cell/mm2. BSCVA at 18 months of follow-up was 0.9. There were no episodes of rejection, and the graft remained clear at the last follow-up (4 years). CONCLUSION: Inadvertent partial full thickness trephination of the recipient cornea is a largely preventable but possible complication during DALK. Penetrating keratoplasty conversion can be avoided by performing a manual dissection DALK.

Clinical Outcomes of Allogeneic Ocular Surface Stem Cell Transplantation in Pediatric Patients.

PURPOSE: To describe the outcomes of allograft ocular surface stem cell transplantation (OSST) and the complication profile of systemic immunosuppression (SI) in pediatric patients with limbal stem cell deficiency. METHODS: This was a retrospective interventional case series from a single tertiary referral institution of 20 eyes from 13 patients who 1) underwent allograft OSST surgery, 2) were 18 years or less at time of OSST, and 3) received SI with 4) a minimum of 12-months follow-up. The main outcome measures were ocular surface stability, visual acuity, and SI adverse events. RESULTS: The mean age of patients was 15.1 ± 3.2 years (range 9-18 years). The mean follow-up was 5.6 ± 5.0 years after OSST. At the last follow-up, 15 eyes (75%) had a stable ocular surface, 1 eye (5%) developed partial failure, and 4 eyes (20%) developed total surface failure. Preoperative mean logarithm of the minimum angle of resolution visual acuity 1.5 improved to 1.1 at the last follow-up (P = 0.1); when 4 eyes of 3 nonadherent patients were excluded, the results were more pronounced and statistically significant (1.5 improved to 1.0, P = 0.002). SI was tolerated well by all patients with minimal adverse events. CONCLUSIONS: OSST provides a stable ocular surface and is a successful treatment option for pediatric patients with limbal stem cell deficiency. SI is well-tolerated with a minimal complication profile.

Deep Anterior Lamellar Keratoplasty After Previous Anterior Lamellar Keratoplasty to Improve the Visual Outcomes.

PURPOSE: To describe a series of patients who underwent deep anterior lamellar keratoplasty (DALK) after previous anterior lamellar keratoplasty (ALK) to improve their visual outcomes. METHODS: This is a retrospective case series of 9 DALK eyes (9 patients) with a history of previous ALK and an unsatisfactory visual outcome. Surgery was performed in all cases at least 3 years after ALK. Cannula big bubble, air viscobubble, and manual dissection techniques were performed. Preoperative and postoperative best-corrected visual acuity, residual recipient bed thickness, and endothelial cell count were evaluated. Follow-up was at least 24 months for all eyes. RESULTS: Two subtotal anterior lamellar keratoplasties (through 1 type 1 big bubble and 1 air viscobubble) and 7 manual dissection DALKs were achieved. A small rupture of the residual recipient bed occurred during 1 case, and it was managed without penetrating keratoplasty conversion. Mean best-corrected visual acuity improved from 0.64 to 0.09 logMAR. Postoperative residual recipient central bed thickness was less than 80 µm in all cases. No postoperative complications were recorded at the last follow-up (24-36 months postoperatively). CONCLUSIONS: Different DALK techniques can be successfully used to improve visual acuity in previous ALK eyes with an unsatisfactory visual outcome.

Use of Panel-Reactive Antibody Testing in the Planning and Management of Ocular Surface Stem Cell Transplantation.

PURPOSE: Panel-reactive antibody (PRA) testing has been widely adopted in solid organ transplantation for risk assessment in potential allograft recipients but has not been studied in the context of ophthalmic transplantation. The purpose of this study is to evaluate outcomes in patients undergoing ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency (LSCD) relative to preoperative PRA level. METHODS: This is retrospective chart review of all eyes with documented PRA level that underwent OSST for LSCD between May 2000 and March 2019 at a single institution. Eyes with stable ocular surface but <1 year of follow-up and eyes without updated PRA before repeat OSST were excluded. Eyes were grouped by PRA <80% and ≥80%. The primary outcome was ocular surface failure, whereas the secondary outcome was clinical allograft rejection. RESULTS: Sixty-nine surgeries met inclusion criteria, consisting of 54 living-related conjunctival limbal allografts, 5 keratolimbal allografts, and 10 combined living-related conjunctival limbal allografts/keratolimbal allografts (Cincinnati procedure). The most common etiologies for LSCD were aniridia (33%), chemical/thermal injury (28%), and contact lens associated (14%). Surface failure occurred in 5 of 12 eyes (58%) with PRA ≥80% versus 12 of 57 eyes (21%) with PRA <80% (P = 0.01). The relative risk for surface failure with PRA ≥80% was 2.8 [confidence interval (CI), 1.38-5.55]. There was no significant difference in acute rejection (P = 1). CONCLUSIONS: Pretransplant PRA level is an important prognostic factor for ocular surface stability in eyes undergoing OSST for LSCD, with implications for donor selection, perioperative management, and systemic immunosuppression.

Total or subtotal full thickness recipient bed cut to repair donor-recipient curvature disparity in cases of DM rupture with manual DALK.

PURPOSE: To report how to manage a specific type of Descemet's membrane (DM) rupture during manual DALK with a concurrent donor-recipient disparity of curvature. METHODS: Case report of two patients that had DM rupture during manual DALK with a concurrent donor-recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a "DSEK autograft," was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. RESULTS: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). CONCLUSION: The existence of a donor-recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor-recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

Long-term Outcomes of Living-Related Conjunctival Limbal Allograft Compared With Keratolimbal Allograft in Patients With Limbal Stem Cell Deficiency.

PURPOSE: To compare the long-term outcomes of living-related conjunctival limbal allograft (lr-CLAL) with keratolimbal allograft (KLAL) in patients with limbal stem cell deficiency. METHODS: A retrospective, comparative, interventional cohort of patients with bilateral total limbal stem cell deficiency who underwent surgical treatment with a KLAL or lr-CLAL procedure alone (not combined with any other ocular surface stem cell transplantation procedures) with a minimum follow-up of 1 year and who received systemic immunosuppression. Ocular surface stability, best-corrected visual acuity (BCVA), and postoperative complications at the last follow-up were the main outcome measures. RESULTS: There were 224 eyes that underwent KLAL alone and 63 eyes that underwent lr-CLAL alone, with a mean follow-up time for all eyes of 7.2 years (range 1.0-16.0 years). For lr-CLAL eyes, 82.5% maintained a stable ocular surface compared with 64.7% of KLAL eyes at the last follow-up. Only 6.3% of lr-CLAL eyes demonstrated a failed ocular surface compared with 15.6% of KLAL eyes. The mean BCVA was 20/158 for KLAL eyes compared with 20/100 for lr-CLAL eyes at the last follow-up. A smaller proportion of lr-CLAL eyes (30.2% compared with 43.3%) developed an episode of acute rejection, and a higher proportion of these episodes resolved with treatment in the lr-CLAL group (79.0% compared with 53.6%). CONCLUSIONS: lr-CLAL demonstrates lower rejection rates, improved graft survival, and better BCVA compared with KLAL. Both careful preoperative donor selection and triple-agent systemic immunosuppression (including tapered systemic corticosteroids) are critical to optimizing the ocular surface stem cell transplantation outcomes.

Cataract surgery in corneal transplantation.

PURPOSE OF REVIEW: Corneal diseases are often associated with lens opacity. The present article reviews the recent advances in the management of cataract and corneal transplant. RECENT FINDINGS: Thanks to the development of lamellar transplant techniques and the evolution of cataract surgery, we now have several strategies to address corneal diseases and cataract including 'lamellar triple procedure'. Numerous precautions have been identified to have a successful surgery with good visual recovery. SUMMARY: Corneal diseases associated with cataract can be successfully managed using separate or combined surgical procedures, as appropriate. In most cases the intraocular lens power can be calculated with a predictable outcome.

Long-term outcomes of conjunctival limbal autograft in patients with unilateral total limbal stem cell deficiency.

PURPOSE: To investigate the long-term clinical outcomes of conjunctival limbal autograft (CLAU) in patients with unilateral total limbal stem cell deficiency (LSCD). METHODS: In this retrospective interventional case series, the medical charts of patients with unilateral total LSCD were reviewed. Patients who underwent CLAU and no other allograft ocular stem cell transplantation with a minimum follow-up of 1 year were included. Main outcome measures were ocular surface stability, best-corrected visual acuity (BCVA), and postoperative complications. RESULTS: 27 eyes fulfilled the inclusion criteria with a mean follow-up period of 49.8 ±â€¯36.6 months (4.15 years; range 12-186.72 months; 1-15.56 years). Ocular surface stability was achieved in 77.8% (n = 21) of eyes at last follow-up, while 22.2% (n = 6) developed partial surface failure. Optical penetrating or deep lamellar anterior keratoplasty was performed in 44.45% (n = 12). BCVA improved from 1.42 ±â€¯0.95 mean LogMAR (equivalent to 20/400) preoperatively to 0.53 ±â€¯0.47 mean LogMAR (equivalent to 20/70) at last follow-up (p < 0.001). BCVA ≥20/40 was achieved in 44.45% (n = 12) at last follow-up. Microbial keratitis occurred in 14.81% (n = 4). Ocular hypertension secondary to corticosteroid use developed in 25.9% (7/27) eyes. There were no other complications in the donor or recipient eyes. CONCLUSIONS: CLAU can provide long-term ocular surface stability and successful visual outcomes in patients with unilateral LSCD.

Surgical Corneal Anatomy in Deep Anterior Lamellar Keratoplasty: Suggestion of New Acronyms.

Deep anterior lamellar keratoplasty (DALK) is the ideal surgery for corneal stromal diseases with a healthy endothelium. This technique offers substantial advantages compared with penetrating keratoplasty, primarily the avoidance of endothelial rejection and longer graft survival. Several DALK techniques have been described and classified into 2 categories, descemetic DALK (dDALK) and predescemetic DALK (pdDALK) depending on whether Descemet membrane-endothelium was thought to be exposed or minimal residual stroma was left behind. This classification was crucial to identify the conditions to achieve good visual outcomes with pdDALK techniques. The recent description of Dua's layer, also known as the pre-Descemet layer, has demonstrated that a very thin layer of stroma exists in some instances where Descemet membrane was thought to be completely exposed. This concept has generated a discrepancy between the previous and current applications of the terms "dDALK" and "pdDALK." We offer a summary of the published literature and a proposal for a new and more appropriate DALK nomenclature. We suggest adding the terms subtotal anterior lamellar keratoplasty (STALK) and total anterior lamellar keratoplasty (TALK).

Ocular Surface Stem Cell Transplantation for Treatment of Keratitis-Ichthyosis-Deafness Syndrome.

PURPOSE: To report our surgical experience with ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency (LSCD) in the setting of keratitis-ichthyosis-deafness (KID) syndrome. METHODS: Retrospective interventional case series. RESULTS: We present 5 eyes of 3 patients with KID syndrome that developed LSCD and underwent OSST. Mean follow-up after OSST was 8.3 ± 4.3 years (range 3.4-11.4 years). Two eyes underwent living-related conjunctival limbal allograft (lr-CLAL), and 3 eyes were treated with keratolimbal allograft (KLAL). Four of the 5 eyes underwent subsequent keratoplasty. Both lr-CLAL eyes maintained a stable ocular surface at final follow-up. Conversely, all KLAL eyes developed a failed surface requiring repeat KLAL surgery. Because of multiple failed KLALs, 1 eye underwent placement of a keratoprosthesis. CONCLUSIONS: KID syndrome is a rare cause of LSCD. Although OSST can stabilize the surface, long-term treatment of KID syndrome can be challenging. An lr-CLAL may offer further benefit over a KLAL in these eyes because it is HLA- and ABO-matched tissue; it also helps to treat keratoconjunctivitis sicca, often a prominent feature of KID syndrome.

Cannula-Assisted Technique to Unfold Grafts in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To describe the use of irrigating single-port cannulas to unfold Descemet membrane endothelial keratoplasty (DMEK) grafts when traditional tapping techniques are challenging. METHODS: This study is a retrospective, comparative, nonrandomized, interventional case series that includes 143 DMEKs performed between February 2014 and November 2015. All eyes were divided into 2 groups: in one group, there were 48 cases that underwent DMEK using tap techniques only (Tapping DMEK group), and in another group, there were 30 cases in which irrigating cannulas were used to unfold the graft as a secondary approach (Cannula DMEK group). Intraocular manipulation time and total graft manipulation time were assessed. Uncorrected visual acuity, best spectacle-corrected visual acuity, and endothelial cell count were evaluated at 6 and 12 months postoperatively. We also reviewed DMEK procedures performed between December 2015 and January 2017 to evaluate the use of irrigating cannulas to unfold the graft. RESULTS: All grafts were clear. There was a statistically significant improvement in uncorrected visual acuity and best corrected visual acuity at 6 and 12 months postoperatively in both groups (P < 0.01). Endothelial cell loss was 32.10% and 32.11% at 12 months in the Cannula and Tapping DMEK groups, respectively (P > 0.05). Total graft manipulation time was 3 minutes 40 ± 22 seconds in the Cannula DMEK group and 3 minutes 07 ± 26 seconds in the Tapping DMEK group (P < 0.01). Irrigating cannulas were used as a secondary approach in a smaller percentage of cases between December 2015 and January 2017 (26.2%) compared with DMEK performed during this study (38.5%). CONCLUSIONS: When it is difficult to unscroll the endothelium-Descemet membrane graft using only tap techniques, the use of Sarnicola cannulas is useful and effective without negatively affecting the postoperative endothelial cell count.