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Abstract: Floppy or irregular irides may be seen during endothelial keratoplasty in complex cases or in eyes with damaged irides and may cause uneven air fill, retro-pupillary air escape, anterior bowing of iris, forward movement of lens-iris diaphragm, shallowing of anterior chamber (AC), bellowing and floppiness of iris, uneven AC depth, difficulty in inserting and opening graft, iris trauma, intraoperative bleeding, and iridodialysis. We present a technique of iridodiathermy for tautening and flattening such irides. With continuous irrigation using AC maintainer, the bipolar endodiathermy probe tip is applied in localized spots to midperipheral iris in the affected area with power and duration adjusted to induce mild localized shrinkage and tightening of iris stroma. Such iris tautening decreases its floppiness and prevents anterior bowing, excessive mobility, irido-corneal touch, and peripheral anterior synechiae formation. It provides a stable AC with regular depth and improved, uniform, and nonmigratory air fill, thus decreasing intraoperative challenges., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report outcomes of keratopigmentation (KP) with commercial black ink in the treatment of dysphotopsia secondary to laser peripheral iridotomies (LPI) using manual anterior stromal puncture (ASP) and manual lamellar pocket (LP)., Methods: This is a retrospective case series of eyes that underwent KP for treatment of dysphotopsia secondary to LPI. Patients' postoperative symptoms were categorized as resolved, improved, no change, or worse. Any intraoperative and postoperative complications were noted, as well as the need for further treatments., Results: Five eyes in 4 patients underwent ASP, and 14 eyes in 13 patients underwent LP. Only 1 patient had improvement in symptoms in the AK group. Four patients had a complete resolution of symptoms after LP, whereas 7 had symptomatic improvement and 3 did not notice any change. Fifty-five percent of patients in the LP group experienced late-onset depigmentation between 3 and 5 years postoperatively. One patient who underwent 2 LP re-treatments experienced irregular corneal steepening with nonprogressive corneal thinning. Overall, there were no serious adverse reactions to the pigment used., Conclusions: ASP was not suitable for the treatment of dysphotopsia secondary to LPI. In the short term, LP had good outcomes, but commercial black ink was prone to depigmentation at 3 to 5 years postoperatively. We therefore do not recommend the use of such pigment for long-term management of dysphotopsia secondary to LPI.

Purpose: To describe a simple preoperative ink test as a novel adjunct to intrastromal keratopigmentation for post-laser peripheral iridotomy (LPI) dysphotopsias., Methods: A surgical marking pen is applied to the area over a peripheral iridotomy before intrastromal keratopigmentation. The patient can then assess whether there is any improvement in their symptoms of dysphotopsias. Manual intrastromal keratopigmentation can then be performed using a crescent blade into the clear cornea at 50% depth and tunneled centrally to create a pocket ensuring that the peripheral iridotomy is fully occluded. The crescent blade is coated with an alcohol-based commercially available black tattoo pigment, and the pocket is filled., Results: We have used the preoperative ink marker test on 5 eyes in patients with post-LPI (4 temporal and 1 superior) dysphotopsias before performing intrastromal keratopigmentation, with good patient satisfaction. Patients report immediate symptomatic relief after the procedure. This ink marking technique can also be extended to help identify which iris defect is symptomatic in patients with multiple iris defects., Conclusions: The preoperative ink test before intrastromal keratopigmentation is a novel adjunct to the treatment of post-LPI dysphotopsias.

Purpose: To study the outcomes and tolerance of micronized mineral pigments for corneal tattooing, using a superficial automated keratopigmentation (SAK) technique in an experimental animal model and a new puncture device to inject the pigments into the corneal stroma., Methods: Forty eyes of 40 New Zealand rabbits were included in this study. The animals were divided into groups A and B. Both groups underwent SAK using a new automated keratopigmentation device. Micronized mineral pigments were injected through the epithelium into the corneal stroma to replicate the iris color in 25 eyes (group A), and black color was used to replicate the pupil in 15 eyes (group B). Slit-lamp examination was performed to evaluate the outcome. Histopathological examination was also performed to ascertain the presence of pigment dispersion, inflammation, and/or neovascularization., Results: All 40 eyes showed good cosmetic appearance after keratopigmentation. No intraoperative complications were detected. At the first week, mild or moderated conjunctival injection was observed in 13 eyes and transitory corneal epithelial defects were also detected in 27 eyes. Examination was unremarkable 2, 4, and 6 months after surgery. No neovascularization was detected in any case in the histopathology study., Conclusions: SAK using a new automated puncture device and micronized mineral pigments achieved good cosmetic outcomes for iris and pupil simulation. This method could be a valid alternative to treat serious cosmetic eye problems that affect the superficial cornea or functional problems, such as photophobia or diplopia secondary to iris defects or trauma.

Purpose: To report the case of an anterior chamber epithelial cyst after uncomplicated deep anterior lamellar keratoplasty (DALK) treated with a tissue-sparing surgical technique., Methods: A 35-year-old female patient underwent DALK in her OS because of stage IV keratoconus. The surgery was uneventful, and 3 months postoperatively, best-corrected visual acuity (BCVA) was 20/25. By the sixth postoperative month, a cystic iris lesion was noticed. The lesion grew progressively larger, and BCVA dropped to 20/63 in OS. Cyst excision was performed., Results: No complications possibly related to the surgery were observed. Two years later, BCVA was 20/25 in OS, and there were no signs of cyst recurrence. Histopathological examination of the lesion showed an epithelial implantation cyst., Conclusions: An anterior chamber epithelial cyst is a sight-threatening condition that may occur after DALK. In selected cases, a conservative surgical approach is an effective treatment option, conveying excellent functional and anatomical outcomes.

Purpose: To analyze the anatomical features of peripheral staphyloma and evaluate the clinical effects of double lamellar keratoplasty on this eye disease., Methods: Four cases of peripheral staphyloma were treated by double lamellar keratoplasty. One third of the degenerative iris was excised, and the iris was returned into the anterior chamber. Perforation was repaired using a very thin layer of lamellar graft, 1 mm larger than the perforation, after which the anterior chamber was filled with buffered salt solution to check if there was any leak from the graft edge. If there was, the graft was resutured and reexamined. When there was no leak, one more lamellar graft was transplanted to treat the ulcer., Results: All patients presented a funnel-shaped corneal ulcer with a perforation at the bottom. The iris bulged out from the perforation like a balloon, becoming large with the elevated intraocular pressure. Postoperatively, the anterior chamber returned to its normal structure without anterior synechia. Useful vision was protected, and 3 patients had improved visual acuity., Conclusions: Peripheral staphyloma has similar morphological and anatomical structures with hernia. Double lamellar keratoplasty, which involves returning the iris into the anterior chamber, repairing the perforation, and transplanting a second lamellar graft, seems to be effective in the treatment of peripheral corneal staphyloma.

Purpose: To determine if treatment directed at the epithelial basement membrane abnormalities in eyes with endothelial disorder can improve visual acuity and surface irregularity., Methods: Retrospective interventional case series of 4 eyes of 3 patients with epithelial basement membrane abnormalities and endothelial disorder coincident with Fuchs endothelial corneal dystrophy or iridocorneal endothelial syndrome that had initial treatment directed only at the epithelial basement membrane disorder., Results: In 2 of the 4 eyes undergoing epithelial basement membrane debridement, visual acuity improved by 3 Snellen lines. In the other 2 eyes, the intervention improved visual acuity by 2 lines in 1 eye and no lines in the other, but the procedure allowed for accurate keratometry readings to be obtained for intraocular lens calculations before cataract surgery., Conclusions: Epithelial basement membrane abnormalities can occur in eyes with endothelial disorder. Treatment of the epithelial basement membrane disorder in these eyes can sometimes improve the regularity of the ocular surface and visual acuity.

Purpose: Epithelial downgrowth, a rare but devastating complication of intraocular surgery and penetrating ocular trauma, remains a therapeutic dilemma in ophthalmology. We present an interventional case report of an instance successfully treated with diode laser photocoagulation by using a purely endoscopic approach., Methods: Case report and literature review., Results: An 81-year-old woman initially presented with worsening visual acuity, diffuse corneal edema, band keratopathy, peripheral anterior synechiae, and an atypical iris cyst with angle involvement. Histopathologic examination of the iris cyst revealed nonkeratinized stratified squamous epithelium consistent with epithelial downgrowth. After thorough treatment of the epithelial downgrowth by an endoscopic technique, penetrating keratoplasty and cryoablation of the remaining corneal tissue were performed for visual rehabilitation. One year after treatment, no signs of recurrence were present., Conclusions: Diode photocoagulation by using an endoscopic approach potentially offers an effective, safe, and minimally invasive surgical approach for the management of epithelial downgrowth in patients with corneal opacity.

Purpose: To describe use of Descemet stripping with endothelial keratoplasty (DSEK) to treat corneal edema associated with iridocorneal endothelial (ICE) syndrome., Methods: In this retrospective, consecutive, interventional case series, the corneal endothelium was selectively replaced by the DSEK technique in eyes with ICE syndrome. Three eyes were treated at 1 center between June 2005 and July 2006. Descemet membrane and endothelium were stripped from the recipient and an 8- or 8.5-mm-diameter donor button consisting of posterior stroma and healthy endothelium was folded and implanted through a 5-mm incision. An air bubble was used to press the donor tissue against the recipient cornea, allowing it to attach without sutures. In 1 case with extensive peripheral anterior synechiae (PAS), after the PAS were broken, the anterior chamber was shallow, so a temporary anchor suture was placed in the peripheral edge of the donor tissue to help ensure that it would unfold in the correct orientation., Results: DSEK successfully resolved corneal edema in 3 male patients with unilateral ICE syndrome who were 47 to 67 years of age. Follow-up ranged from 1 to 14 months. Best spectacle-corrected visual acuity at the most recent visit was 20/20 to 20/30, with a mean refractive cylinder of 1.2 D., Conclusions: Selective replacement of dysfunctional endothelium with DSEK can successfully treat corneal edema and associated visual loss and pain caused by ICE syndrome. Visual recovery is rapid and refractive changes are minimal compared with replacement of the full corneal thickness with a traditional penetrating keratoplasty.

Purpose: To report a case of localized bullous keratopathy and total corneal decompensation secondary to iridocorneal touch in iridoschisis., Design: Single interventional case report with pathologic correlation., Methods: An 80-year-old man with bilateral iridoschisis presented with loss of vision in the left eye (OS). Examination of the OS showed shallow anterior chamber (AC), cortical cataract, and free-floating iris fibers causing iridocorneal touch, leading to localized bullous keratopathy and total corneal decompensation. Ultrasound biomicroscopy (UBM) confirmed the area of iridocorneal contact., Results: Penetrating keratoplasty combined with cataract extraction and posterior chamber lens implantation was performed in the OS. Histopathology of the corneal button showed features of corneal edema and endothelial cell loss with evidence of iridocorneal contact., Conclusions: Iridoschisis is an uncommon cause of bullous keratopathy and corneal decompensation. Patients with iridoschisis may need specular microscopy to determine the status of the corneal endothelium.

Purpose: To report a case of bilateral corneal graft dehiscence caused by blunt trauma., Methods: Case report of bilateral simultaneous corneal graft dehiscence with expulsion of the lens and iris as a result of airbag-induced trauma., Results: Both corneal buttons were resutured, the prolapsed iris tissue was repositioned in the right eye, and anterior vitrectomy was performed bilaterally. Topical and systemic antibiotics, topical steroids, cycloplegic agents, and antiglaucoma drugs were initiated. Repeated B-scan ultrasound examinations demonstrated an attached retina in both eyes. Three weeks after admission, the right eye was reoperated for removal of remnant lens material and additional anterior vitrectomy. The patient was fitted with polycarbonate spectacles with an optical correction of +8 in both eyes. Visual acuity improved to 20/200 and 0.5/60 in the right and left eyes, respectively. The right corneal graft regained transparency, but the left one remained hazy., Conclusion: Airbag deployment during motor vehicle collisions is a significant cause of ocular morbidity. The reported risk of airbag-related eye injury is 2.5% for any eye injury and 0.4% for severe eye injury. Patients undergoing corneal surgery should be counseled about the weakness of the donor-recipient interface and should consider wearing protective glasses.

Purpose: To report the management of a patient with the longest reported interval between intraocular surgery and the development of epithelial downgrowth., Methods: A 53-year-old man who underwent right eye penetrating keratoplasty in 1970 for keratoconus and removal of an iris cyst in 1977 developed epithelial downgrowth 25 years after cyst removal., Results: The area of epithelial downgrowth was initially treated with cryotherapy. Two weeks postoperatively, the patient had no resolution of epithelial downgrowth and developed diffuse corneal edema. Penetrating keratoplasty was performed along with extracapsular cataract extraction. At 6 months of follow-up, the patient's graft was clear, without evidence of recurrence of epithelial downgrowth, and he had 20/50 visual acuity., Conclusion: Epithelial downgrowth is an uncommon yet serious complication of intraocular surgery, making early detection of this condition important. This case illustrates that epithelial downgrowth can occur several decades after intraocular surgery.

Purpose: To report a case of epithelial ingrowth (downgrowth) occurring in a phakic corneal transplant patient after traumatic wound dehiscence with iris prolapse that was successfully eradicated with early surgical intervention., Methods: Interventional case report of a 70-year-old monocular, phakic patient who developed epithelial ingrowth within 1 week of repair of a traumatic penetrating keratoplasty wound dehiscence, with reposition of the iris that had been prolapsed for 36 hours. A gradually expanding membrane developed from the surface of the reposited iris, across the anterior lens capsule. Argon laser photocoagulation applied to the surface of the iris confirmed the diagnosis and outlined the extent of the epithelial tissue on the iris., Results: Intraoperative peeling of the epithelial membrane from the surface of the lens and excision of the involved iris were performed combined with extracapsular cataract extraction and insertion of a posterior chamber intraocular lens via an open-sky technique through a repeat penetrating keratoplasty opening in the cornea. This resulted in complete resolution of the intraocular epithelialization. Histopathologic examination of the excised tissue confirmed the diagnosis of epithelial ingrowth., Conclusions: Reposition of traumatically prolapsed iris tissue can result in epithelial ingrowth. Early aggressive surgical intervention can successfully remove all the epithelial tissue from within the anterior segment.

Purpose: To report a case of presumed epithelial inclusion cyst of the iris 7 years after radial keratotomy (RK) that was treated with double-frequency Nd:YAG laser (532 nm)., Methods: A young adult woman underwent bilateral RK for the correction of myopia of -4.50 Diopters 7 years prior to the development of a white mass in the anterior chamber of her left eye. There was no evidence of any other surgery or trauma to the eye during this period. An epithelial inclusion cyst of the iris was diagnosed, and double-frequency Nd:YAG laser (532 nm) was used to coagulate the cyst under topical anesthesia., Results: The size of the cyst reduced significantly immediately following laser treatment, and the prelaser visual acuity of 6/12 was maintained at 6 months' follow-up without any recurrence., Conclusions: In the absence of evidence of any other surgery or trauma, the most likely cause of the epithelial inclusion cyst of the iris following RK is epithelial seeding from the original surgery, which is amenable to coagulation with double-frequency Nd:YAG laser.

Purpose: To evaluate the clinical outcome of penetrating keratoplasty (PK) in iridocorneal endothelial (ICE) syndrome., Methods: Clinical charts of patients who underwent penetrating keratoplasty for ICE syndrome between 1985 and 1999 were reviewed retrospectively. Glaucoma control, best corrected visual acuity pre- and post-PK, graft clarity, graft rejection episodes, improvement in pain, and additional procedures were analyzed., Results: Fourteen cases were reviewed with an average follow-up of 58 months after PK. Initial grafts failed in seven patients (50%), in six cases because of rejection, and one owing to endothelial failure without signs of rejection. Repeat PKs were performed in six patients. At final follow-up, 12 grafts were clear. Glaucoma was controlled pre- and post-PK (average intraocular pressure, 16 mmHg for both eyes). Pre-PK, eight patients were using glaucoma medicines and nine had had glaucoma surgery. At the end of the follow-up, seven patients were using glaucoma medicines; six patients required glaucoma surgery after their initial PK. At the final follow-up visit, visual acuity in three patients (21%) was 20/40 or better, it ranged from 20/50 to 20/100 in four patients (29%) and 20/200 to 20/400 in five patients (36%), and in two patients with failed grafts (14%) it was counting fingers or worse., Conclusion: Clear grafts were achieved in 12 cases, although six patients (43%) underwent repeat PKs. All patients had glaucoma, which was controlled before and after PK by medical treatment and surgical procedures. Favorable outcomes can be achieved in patients with ICE syndrome but may require multiple corneal and glaucoma procedures.

Purpose: Defects in the iris are associated with clinically significant optical anomalies, such as glare and peripheral light scatter; however, current artificial-iris technology remains inadequate. The purpose of this study was to explore the practicality of a lamellar intrastromal tattoo technique as a treatment modality to correct optical and cosmetic defects resulting from simulated iris abnormalities in eye-bank eyes., Methods: Simulated iris defects (abnormally large pupil, sector iridectomy, iridodialysis, and aniridia) were produced in a series of eye-bank eyes. Depending on the simulated iris defect, one or two lamellar channel(s) were created at 50% depth of the cornea via a peripheral incision (1.8 mm) with specialized proprietary instruments (KeraVision, Inc., Fremont, CA, U.S.A.). Commercially available tattoo pigment was inserted through the lamellar channel(s) and blended into the defective region of the iris., Results: The tattoo treatment was relatively simple to perform. Tattoo pigment was inserted uniformly through the small incision, and adequate color blending to match the recipient iris was achieved. The intrastromal tattoo effectively obscured light., Conclusion: The lamellar intrastromal tattoo technique appeared to be efficacious for treating different types of iris defects in eye-bank eyes. Further investigation of this technique in nonsighted patient eyes is warranted.

The clinical results of penetrating keratoplasty for iridocorneal endothelial (ICE) syndrome are presented. Nine cases of penetrating keratoplasty for ICE syndrome were reviewed retrospectively. All grafts remain clear, with posterior corneal changes occurring in only one case, after a mean follow-up of 43 months. Penetrating keratoplasty produced visual improvement in 7 of the 9 cases, relief of pain in 6 of 6 cases, and prevention of further corneal infection in 1 case. We believe that penetrating keratoplasty has a place in the treatment regimen of this disease, not only to achieve improvement in vision, but also for relief of pain, and avoidance of recurrent corneal infections, and to allow a clear media for careful monitoring of optic disc and field changes in the associated glaucoma.