PURPOSE:To evaluate the outcomes of Descemet membrane endothelial keratoplasty (DMEK) in aphakic and aniridic eyes.
METHODS:A retrospective chart review of either aphakic or aniridic patients who ...underwent DMEK at Toronto Western Hospital, Canada, between 2015 and 2019 was performed. Demographic characteristics, intraoperative and postoperative complications, and best corrected visual acuity (BCVA) were analyzed.
RESULTS:Nine eyes of 9 patients, aged 51.0 ± 8.6 years, were included (3 aniridic, 5 aphakic, and 1 combined). The average follow-up was 15.7 ± 12.7 months. The best corrected visual acuities before surgery and 3 and 6 months after surgery were 1.28 ± 0.47, 1.33 ± 0.98, and 1.03 ± 0.56 LogMAR, respectively. Six eyes (67%) had graft detachment, with 3 of them larger than 30% of the graft area. One eye (11%) developed hyphema. The overall failure rate was 88% (8 of 9 eyes), meaning only one was viable at the last follow-up. Primary graft failure was seen in 4 eyes (44%) after detachment (n = 3) and intraoperative hyphema (n = 1). Secondary failure occurred in 4 eyes (44%) at 7, 12, 15, and 36 months. The secondary failure at 36 months was after rejection. Failures were managed with penetrating keratoplasty (n = 2), repeat DMEK (n = 3), Descemet stripping automated endothelial keratoplasty (n = 1), and observation because of poor vision potential (n = 2). Cumulative graft survival probabilities at 12 and 24 months were 44% and 17%, respectively.
CONCLUSIONS:Aniridic and aphakic patients experienced unacceptably high detachment and failure rates after DMEK. Before performing DMEK, the risks and benefits should be carefully weighed and perhaps other keratoplasty techniques should be used.
PURPOSE OF REVIEWTo discuss the development of presbyopia-correcting intraocular lenses (IOLs), what we have learned since their introduction a few decades ago, what are the options currently on the ...market, and where the technology is heading in the future.
RECENT FINDINGSMultifocal and accommodating IOLs have gone through several modifications to improve distance, intermediate and near vision compared to their predecessors. These modifications have also targeted unwanted side-effects such as glare and halos in the multifocal lenses and inconsistent near-vision results in the accommodating IOLs and although the results have improved, they are far from perfect. Therefore, careful patient selection for each of these technologies is crucial for success and patient satisfaction.
SUMMARYPresbyopia correction remains a great challenge in cataract and refractive surgery. In this article, we review the development of presbyopia-correcting IOLs, starting from the simple, two-zone, multifocal, refractive models introduced 2 decades ago, the current Food and Drug Administration (FDA) approved multifocal and accommodating lenses as well as those undergoing FDA trials and take a look into developing technologies that may be available to us in the future.
PURPOSE:To compare the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with Descemet membrane endothelial keratoplasty (DMEK) for the treatment of failed penetrating ...keratoplasty (PKP).
METHODS:This is a retrospective chart review of patients with failed PKP who underwent DMEK or DSAEK. The median follow-up time for both groups was 28 months (range 6–116 months). Data collection included demographic characteristics, number of previous corneal transplants, previous glaucoma surgeries, best-corrected visual acuity, endothelial cell density, graft detachment and rebubble rate, rejection episodes, and graft failure.
RESULTS:Twenty-eight eyes in the DMEK group and 24 eyes in the DSAEK group were included in the analysis. Forty-three percent of eyes in the DMEK group and 50% of eyes in the DSAEK group had to be regrafted because of failure (P = 0.80). The most common reason for failure was persistent graft detachment (58%) in the DMEK group and secondary failure (58%) in the DSAEK group; hence, the time between endothelial keratoplasty and graft failure differed significantly between the groups (P = 0.02). Six eyes (21%) in the DMEK group and 7 eyes (29%) in the DSAEK group developed graft rejection (P = 0.39). Rejection was the cause of failure in 67% and 71% in the DMEK and DSAEK groups, respectively. The best-corrected visual acuity 6 months after surgery was better in the DMEK group compared with the DSAEK group (P = 0.051).
CONCLUSIONS:Both DSAEK and DMEK have a role in treating PKP failure. Primary failure due to persistent graft detachment was significantly higher in the DMEK group, although the overall failure rate in the medium term was similar.
Purpose To compare the visual outcomes following deep anterior lamellar keratoplasty (DALK), penetrating keratoplasty (PK), and manual top-hat PK (TH-PK) in subjects undergoing corneal ...transplantation for keratoconus (KC). Design A retrospective comparative case series. Methods settings: Cornea clinic at the Toronto Western Hospital. study population: Fifty patients who underwent corneal transplantation for KC: 17 eyes underwent DALK, 20 eyes underwent traditional PK, and 13 had TH-PK. main outcome measures: Preoperative and postoperative uncorrected and best spectacle-corrected visual acuity (UCVA, BSCVA), high-order aberrations (HOA), complication rate, and endothelial cell counts. Results The median BSCVA at 12 months follow-up was 20/40 in the DALK eyes and 20/30 in the traditional PK and TH-PK eyes. The mean final spherical equivalent power in the three groups was less than −1 diopter (D). The median astigmatism was less than 3.5 D in the three groups. Complication rates were similar for three groups, although the DALK group tended toward more complications. Although DALK and TH-PK procedure results in significantly shorter time to suture removal ( P < .01), they caused increased levels of HOAs ( P = .02). Endothelial cell counts at 12 months were significantly higher in DALK and TH-PK eyes when compared to the traditional PK eyes ( P < .001). Conclusions DALK, PK, and TH-PK provide comparable visual outcomes in keratoconus patients. Although DALK and TH-PK induce more HOA, they speed up the time to suture removal and provide higher endothelial cell density at one year of follow-up.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To compare 4-year survival outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet-stripping automated endothelial keratoplasty (DSAEK) in eyes with previous glaucoma surgery.
This ...is a retrospective, comparative case series, including patients with previous trabeculectomy or glaucoma drainage device implantation, who later underwent either DMEK (n = 48) or DSAEK (n = 41). Follow-up was limited to 12 to 60 months to prevent bias. Primary outcomes were graft survival and rejection. Secondary outcomes were best spectacle-corrected visual acuity (BSCVA), detachment/rebubble, endothelial cell loss, and intraocular pressure elevations.
Baseline characteristics, follow-up duration, and preexisting glaucoma parameters did not differ significantly between the groups. Graft survival probability after DMEK and DSAEK was 75% and 75% at 1 year, 63% and 50% at 2 years, 49% and 44% at 3 years, 28% and 33% at 4 years, and 28% and 29% at 5 years, respectively (P = 0.899 between the groups). Graft rejection rates were 20.8% and 19.5%, respectively (P = 1.000). Primary failure, rebubbling, endothelial cell loss, and intraocular pressure elevation did not differ significantly between the groups. Preoperative BSCVA did not differ between the groups (P = 0.821). Postoperative BSCVA was significantly better in the DMEK group at 6, 12, and 24 months (P < 0.001, P = 0.022, and P = 0.047, respectively). In a multivariable model (R2 = 0.576), the type of surgery was the only significant factor affecting postoperative BSCVA, in favor of DMEK (coefficient value -0.518, P = 0.002).
In eyes with previous glaucoma surgery, DMEK and DSAEK had comparably low survival and comparably high rejection rates. Postoperative visual acuity might be better after DMEK in this setting.
Purpose:
The scrolling properties of the Descemet membrane endothelial keratoplasty (DMEK) graft are essential for surgical success. Currently, there is limited knowledge on what dictates the ...tightness of the DMEK scroll. The purpose of this study was to determine the impact of temperature and protein digestion on DMEK graft scroll tightness.
Methods:
For the temperature experiment, a total of 28 eyes were used for this study. Scrolls in the cold group were kept at 4°C while scrolls in the hot group were kept at 37°C. Scroll width was recorded at the 5-, 15-, and 30-minute mark. For the protein digestion experiment, a total of 18 eyes were exposed to collagenase A (10 CDU/mL) in Optisol solution. Scroll width was recorded at the time points of 1, 3, 5, 10, and 20 minutes.
Results:
The results of the temperature experiment did not yield any statistically significant changes in the mean scroll width of the DMEK scrolls across both temperature ranges and observation times. For the protein digestion experiment, the mean scroll width grew from 1.85 mm to 2.13 mm from the beginning of the experiment until the final observation at 20 minutes. This is a 14.7% change over 20 minutes with a
P
value (<0.001), exemplifying a statistically significant change in scroll width.
Conclusions:
Temperature did not have any significant effect over scroll tightness, but scroll tightness decreased with collagenase exposure.
PURPOSE:To evaluate Descemet membrane endothelial keratoplasty (DMEK) in the setting of failed penetrating keratoplasty (PKP) and to identify factors associated with DMEK success and failure after ...PKP.
METHODS:A retrospective chart review of patients who underwent DMEK for failed PKP at Toronto Western Hospital, Canada, between 2014 and 2017 was performed. Demographic characteristics, number of previous transplants, intraoperative and postoperative complications, best spectacle-corrected visual acuity (BSCVA), and endothelial cell density were analyzed.
RESULTS:Twenty-eight eyes were included in the study. Rebubbling intervention was performed in 12 eyes (43%) within the first postoperative weeks. Five eyes (18%) developed graft rejection episodes. Twelve eyes (43%) had to be regrafted after DMEK surgery and were deemed failures (because of persistent Descemet membrane detachment, rejection episode that led to secondary failure, and infection). BSCVA before DMEK was significantly worse in the eyes that failed than those that did not 1.97 ± 0.85 and 1.2 ± 0.56 logMAR, respectively, (P = 0.01). Rebubbling was required in 75% of eyes in the failure group compared with 19% in the success group (P = 0.002). Six of the 16 eyes (37.5%) in the success group underwent femtosecond laser-enabled DMEK, whereas this technique was not used in any of the eyes in the failure group (P = 0.017).
CONCLUSIONS:DMEK is a viable option for cases of failed PKP. DMEK failure after PKP might be associated with lower visual acuity before DMEK surgery, higher number of rebubble interventions, and manual descemetorhexis rather than femtosecond laser-enabled DMEK.
To evaluate factors associated with improvement in vision following femtosecond astigmatic keratotomy (FSAK) in patients with keratoconus post-keratoplasty.
Retrospective, interventional case series.
...The study took place in an institutional setting. This was a retrospective study that included patients with keratoconus who underwent FSAK for astigmatism following penetrating (PKP) or deep anterior lamellar keratoplasty (DALK). Success was defined as improvement in 3 Early Treatment Diabetic Retinopathy Study lines (doubling of the visual angle) of uncorrected distance visual acuity (UDVA) or best spectacle-corrected visual acuity (BSCVA).
A total of 56 eyes in 56 patients with keratoconus were included. Following FSAK, there was a significant improvement in UDVA (1.30 ± 0.49 to 0.87 ± 0.58 logarithm of minimal angle of resolution logMAR; P < .001), BSCVA (0.40 ± 0.26 to 0.27 ± 0.29 logMAR; P <.001), and corneal astigmatism (8.69 ± 2.72 to 3.92 ± 2.13 diopter D; P < .001). Success was achieved in 60.7% (34/56) of cases, and this group had a higher proportion of previous PKP (73.5% vs 45.5%; P = .03), worse preoperative UDVA (1.42 ± 0.47 vs 1.11 ± 0.47 logMAR; P = .03), and a greater preoperative manifest cylinder (7.56 ± 2.26 vs 5.72 ± 2.12 D; P = .01). In multiple regression analysis, PKP (vs DALK) (odds ratio OR: 8.52; P = .009), worse preoperative UDVA (OR: 9.08, P = .02), and greater preoperative cylinder (OR: 1.51; P = .04) were independently associated with success, and, when combined, led to a sensitivity and specificity of 84.6% and 93.8%, respectively, in predicting success. The optimal cutoff predicting success with a preoperative cylinder was a cylinder >6.75 D.
Approximately 60% of patients with keratoconus post-keratoplasty experience doubling of the visual angle following FSAK. Patients with previous PKP and a greater cylinder are more likely to benefit from this procedure. Separate nomograms for DALK and PKP patients may be warranted.
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Purpose To compare two insertion methods in Descemet stripping automated endothelial keratoplasty (DSAEK): Busin guide-assisted vs Forceps-assisted insertion of the corneal lenticule graft. Design ...Prospective, consecutive, comparative, nonrandomized study. Methods setting: Cornea clinic at the Toronto Western Hospital. study population: Sixty-three eyes of 63 consecutive patients were included. All patients underwent DSAEK for Fuchs endothelial dystrophy, pseudophakic bullous keratopathy, aphakic bullous keratopathy, failed graft, or iridocorneo endothelial syndrome. Twenty-six consecutive donor discs were inserted with the Busin guide and 37 consecutive eyes underwent forceps assisted insertion of the donor. main outcome measures: Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, corneal endothelial cell loss, and postoperative complications. Results Busin guide-assisted DSAEK group had significantly worse UCVA and lower donor endothelial cell counts preoperatively. No significant differences were noted in the intraoperative or postoperative complications. Six months following surgery, BCVA was not significantly different between groups: 20/37 in the Busin guide-assisted DASEK group vs 20/42 in the Forceps-assisted group ( P = .39). Mean spherical equivalent was −0.02 diopters (D) and 0.82 D ( P = .06), and mean refractive cylinder was 2.2 D and 1.31 D ( P = .0006), respectively. Endothelial cell loss was significantly lower in the Busin guide-assisted DASEK group: 25% loss vs 34.3% loss in the Forceps-assisted DSAEK group. ( P = .04). Conclusions Although visual outcomes were not different between the groups studied, Busin guide-assisted DSAEK resulted in lower percentage of endothelial cell loss compared with forceps insertion, six months following surgery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
