Search

Purpose To describe the intraoperative and early postoperative complications using preloaded Descemet membrane endothelial keratoplasty (DMEK) grafts with intraocular injection of the graft in Optisol-GS and omission of trypan blue restaining. Methods This is a retrospective case series of 132 consecutive eyes with Fuchs endothelial dystrophy or endothelial failure who underwent DMEK using preloaded donor tissue prepared as previously described. The graft was not restained with trypan blue by the surgeon, and Optisol-GS was injected with the graft into the eye instead of being rinsed from the injector. Early postoperative complications (0-8 wk) including intraoperative fibrin formation, intraocular inflammation, elevated intraocular pressure, partial graft detachment requiring rebubble, and early graft failure were recorded. Results No eyes developed intraoperative fibrin formation or postoperative inflammation (such as toxic anterior segment syndrome) or elevated intraocular pressure. For eyes with Fuchs corneal dystrophy, our rebubble rate was 21% (22/106 eyes). Early graft failure was noted in 2% (3/132 eyes), which is similar to previous reports. Conclusions Our results suggest that injection of Optisol-GS into the anterior chamber during DMEK graft injection does not lead to increases in intraoperative or early postoperative complications. Trypan blue restaining is not necessary for intraoperative visualization. This simplification can reduce graft manipulation and save time and resources for this procedure.

PURPOSE To examine the corneal transplant failure rates and associations with uveitic eye disease. METHODS The retrospective chart review identified 70 eyes from 42 patients with uveitis that underwent 40 primary transplants and 30 repeat transplants at 2 major academic centers over a 9-year period. The graft failure rate was calculated. Variables hypothesized to be associated with graft failure were analyzed as covariates using a Cox proportional hazards analysis clustered by the patients to determine their association with failure rates. RESULTS Of the 70 grafts, the mean duration of follow-up for patients was 40.6 months (range 4-90 months) and the median survival time was 24.1 months (interquartile range of 9-290 months). Twenty-two patients (52%) had graft failure. There was a higher rate of graft failure in patients with infectious uveitis as compared to those with noninfectious uveitis (hazard ratio 2.46, P = 0.031). Patients with successful grafts had their inflammation controlled for a longer period of time before transplantation as compared to those with failed grafts (38.6 vs. 13.6 months, P = 0.004). Worse preoperative visual acuities were significantly associated with graft failure (P < 0.001). CONCLUSIONS There is limited knowledge of corneal transplant outcomes in uveitic patients in the current literature. In our study, over half of the grafts failed. Infectious uveitis (especially viral) was a strong predictor of graft failure. A shorter period of inflammation control before transplantation, previously failed grafts, and worse preoperative visual acuity were also associated with graft failure.

Purpose To compare corneal higher-order aberrations (HOA) after ultrathin Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). Design Patient- and outcome-masked randomized controlled clinical trial. Participants Patients with damaged or diseased endothelium from Fuchs endothelial dystrophy or pseudophakic bullous keratopathy who were good candidates for DMEK or ultrathin DSAEK. Methods Corneal anterior and posterior surface HOA were measured with Scheimpflug imaging before surgery and at 3, 6, and 12 months after surgery. HOA after ultrathin DSAEK and DMEK were compared; correlation was performed between best spectacle-corrected visual acuity (BSCVA) and HOA at each time point. Main Outcome Measures Higher-order aberrations of the anterior and posterior cornea, expressed as the root mean square deviation from a best fit sphere reference surface. Results At 3, 6, and 12 months after surgery, the posterior corneal surface had significantly less coma (P ≤ 0.003) and total HOA (P ≤ 0.001) in DMEK compared with ultrathin DSAEK (4.0- and 6.0-mm OZ). Posterior trefoil (P ≤ 0.034), secondary astigmatism (P ≤ 0.042), and tetrafoil (P ≤ 0.045) were lower in DMEK than ultrathin DSAEK at 3, 6, or 12 months (either 4.0- or 6.0-mm OZ). There were no significant differences in anterior surface HOA between DMEK and ultrathin DSAEK at any post-surgical time. Compared with baseline, total posterior HOA was increased (P ≤ 0.036) in ultrathin DSAEK at 3, 6, and 12 months, in contrast to DMEK, where it was decreased (P ≤ 0.044) at 6 and 12 months (4.0- or 6.0-mm OZ, or both). At 6 and 12 months, posterior corneal total HOA correlated with BSCVA (ρ ≤ 0.635, P ≤ 0.001; 4.0- and 6.0-mm OZ). There were no moderate or strong correlations between anterior or combined corneal surface HOA at any time point after surgery. Conclusions Descemet membrane endothelial keratoplasty results in less posterior corneal HOA compared with ultrathin DSAEK. Descemet membrane endothelial keratoplasty decreases and ultrathin DSAEK increases posterior corneal HOA compared with presurgical values. Total posterior corneal HOA correlates with 6- and 12-month postoperative visual acuity and may account for the better visual acuity observed after DMEK.

Purpose of review A survey of the recent literature of deep anterior lamellar keratoplasty using femtosecond laser technology. Recent findings There are several recent reports in the literature assessing technique and outcomes of deep anterior lamellar keratoplasty done with a femtosecond laser trephination. Most of these reports are laboratory studies and small case series with short-term outcomes. The laser technology is expensive and may not produce better results than conventional manual techniques. However, there are several theoretical advantages to femtosecond laser incisions in deep anterior lamellar keratoplasty that should be explored, including possible increased success of Descemet's membrane separation from stroma during surgery as well as postsurgical astigmatism benefits, earlier suture removal, and increased wound strength and healing. Summary Femtosecond laser trephination in the setting of DALK may improve the technique by decreasing the number of descemet's membrane ruptures and improving short-term and long-term outcomes as compared with manual techniques. However, there is no consensus on a standardized approach for wound design or postoperative management. The literature would benefit from a prospective randomized controlled trial.

Purpose To compare clinical outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) in the treatment of corneal endothelial dysfunction. Design Patient and outcome-masked, randomized controlled clinical trial. Participants Patients with damaged or diseased endothelium from Fuchs endothelial dystrophy or pseudophakic bullous keratopathy who were considered good candidates for DMEK or UT-DSAEK. Methods Study eyes were randomized by the eye bank to UT-DSAEK or DMEK 1 to 2 days before surgery. Main Outcome Measures The primary outcome of the trial was best spectacle-corrected visual acuity (BSCVA) at 6 months. Secondary outcomes included 3- and 12-month BSCVA; 3-, 6-, and 12-month endothelial cell counts; intraoperative and postoperative complications; and change in pachymetry. Results A total of 216 patients with endothelial dysfunction were screened, and 50 eyes of 38 patients were enrolled by 2 surgeons at Casey Eye Institute at Oregon Health & Science University in Portland, Oregon, and at Byers Eye Institute at Stanford University in Palo Alto, California. Overall, we found DMEK to have better visual acuity outcomes compared with UT-DSAEK after correcting for baseline visual acuity: compared with UT-DSAEK, those randomized to DMEK had 1.5 lines better BSCVA at 3 months (95% confidence interval [CI], 2.5–0.6 lines better; P = 0.002), 1.8 lines better BSCVA at 6 months (95% CI, 2.8–1.0 lines better; P Conclusions Descemet membrane endothelial keratoplasty had superior visual acuity results compared with UT-DSAEK at 3, 6, and 12 months in patients with isolated endothelial dysfunction with similar complication rates.

Purpose: To report 3 cases of corneal protein deposition occurring in association with systemic disease, with one case demonstrating a novel technique for clearing corneal deposits. Observations: Three patients presented with corneal deposits associated with systemic disease. Corneal involvement was noted prior to diagnosis of systemic disease in two patients, leading to subsequent diagnosis of multiple myeloma or monoclonal gammopathy of undetermined significance. OCT revealed protein deposition at various corneal levels, including at different stromal depths in the two cases of multiple myeloma. A novel technique of posterior endothelial scraping was performed in one case with deep stromal deposits, leading to significant corneal clearing. Conclusions and Importance: This case series demonstrates that recognition of corneal deposits may precede the diagnosis of systemic disease. It incorporates the use of anterior segment OCT to characterize corneal deposits, and demonstrates a novel surgical technique for clearing certain types corneal deposits. Keywords: Crystalline keratopathy, Deposition keratopathy, Paraproteinemia, Corneal pathology, Anterior segment optical coherence tomography, Multiple myeloma

Purpose The purpose of this study was to report a case of acute corneal epithelial rejection of living-related conjunctival limbal allograft (LR-CLAL) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. Observations A 27-year-old woman developed acute epithelial rejection of LR-CLAL 2 weeks after receiving the SARS-CoV-2 vaccine. She received the LR-CLAL transplant 4 years and 7 months previously and had a stable clinical course with no history of rejection. She had an ABO blood group and human leukocyte antigen compatible donor, no systemic comorbidities, and no rejection risk factors. Conclusions The novel SARS-CoV-2 vaccine upregulates the immune system to produce an adaptive immune response. The SARS-CoV-2 vaccine may potentially be associated with increased risk of rejection in those with ocular surface transplants.

Deep anterior lamellar keratoplasty is a partial-thickness corneal graft technique void of endothelium. DALK technique offers several advantages over penetrating keratoplasty such as it being an extraocular procedure, never entering into the anterior chamber. Additionally, there is no risk of endothelial rejection and reduced need for immunosuppressive medications. DALK has shown similar VA outcomes when compared to PKP. Femtosecond laser-assisted DALK offers a more accurately prepared and matched transplant incision. Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

PURPOSE To determine which baseline characteristics are associated with vision-related quality of life (QOL) after endothelial keratoplasty. METHODS A patient- and outcome-masked randomized clinical trial. Consecutive patients presenting with isolated endothelial disease requiring endothelial keratoplasty at Oregon Health Sciences University and Stanford University. Study eyes randomized to one of the 2 types of endothelial keratoplasty were given the national eye institute vision function questionnaire 25 at baseline and 12 months. In this prespecified secondary outcome, we assessed the role of recipient and donor characteristics as predictors of the 12-month national eye institute vision function questionnaire 25 change score. RESULTS The mean vision function questionnaire (VFQ) score was 74 (SD 14) at baseline and increased to 82 (SD 12) at 3 months and 87 (SD 10) at 12 months. We were unable to find a difference in vision-related QOL in study participants who underwent Descemet membrane endothelial keratoplasty compared with ultrathin Descemet stripping endothelial keratoplasty [coef -0.98, 95% confidence interval (CI) -9.27 to 7.31; P = 0.82]. In multivariable analysis, patients who underwent endothelial keratoplasty in 2 eyes had approximately 8 points higher VFQ at 12 months after the second eye than those who had only one eye enrolled (95% CI 0.10-15.72; P = 0.047). Posterior densitometry produced an approximately 1-point increase each in the VFQ change score for each 1 grayscale unit increase at baseline (95% CI 0.26-1.81; P = 0.009). Although the sample size was small, a diagnosis of pseudophakic bullous keratopathy had approximately 19-points more improvement on average compared with Fuchs (95% CI 7.68-30.00; P = 0.001). CONCLUSIONS Bilateral endothelial keratoplasty resulted in higher vision-related QOL compared with unilateral. Baseline densitometry, objective measure of corneal haze that predicts vision-related QOL, may play a role in monitoring disease progression.

PURPOSE: To compare the degree of corneal light scatter as measured by densitometry in ultrathin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK) and Descemet Membrane Endothelial Keratoplasty (DMEK) in the Descemet endothelial thickness comparison trial. METHODS: This was a prespecified secondary analysis of the Descemet endothelial thickness comparison trial, which was a prospective, randomized controlled trial. Subjects with isolated endothelial dysfunction were enrolled and were randomized to either UT-DSAEK or DMEK. Corneal opacity was quantitatively measured by Pentacam densitometry (OCULUS) at 3, 6, and 12 months. RESULTS: Fifty eyes of 38 patients were enrolled at the Casey Eye Institute at Oregon Health & Science University and the Byers Eye Institute at Stanford University. Corneal densitometry for the anterior and posterior layers improved in both UT-DSAEK and DMEK after surgery. The decrease was more pronounced in the posterior layer for both groups. However, there was no difference in the degree of corneal light scatter between UT-DSAEK and DMEK at postoperative month 12, and no difference in change in densitometry was observed between the 2 arms from baseline to month 12. CONCLUSIONS: Both UT-DSAEK and DMEK experience an improvement in the degree of corneal light scatter after surgery. However, there was no difference in densitometry between the 2 groups at month 12. Therefore, other factors such as higher order aberrations in the posterior cornea rather than stromal–stromal interface haze mediate the superior visual outcomes in DMEK compared with UT-DSAEK.

Purpose To detect keratoconus using optical coherence tomography (OCT) corneal map parameters and patterns. Setting Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA DESIGN:: Cross-sectional observational study. Methods A spectral-domain OCT was used to acquire corneal and epithelial thickness maps in normal, manifest keratoconic, subclinical keratoconic, and forme fruste keratoconic (FFK) eyes. A two-step decision tree was designed. An eye will be classified as keratoconus if both decision tree conditions are met: First, at least one of the four quantitative corneal thickness (minimum, minimum-maximum, superonasal-inferotemporal) and epithelial thickness (standard deviation) map parameters exceed cutoff values. Second, presence of both concentric thinning pattern on the epithelial thickness map and coincident thinning patterns on corneal and epithelial thickness maps by visual inspection. Results The study was compromised of 54 eyes from 29 normal participants, 91 manifest keratoconic eyes from 65 patients, 12 subclinical keratoconic eyes from 11 patients, and 19 FFK eyes from 19 patients. The decision tree correctly classified all normal eyes (100% specificity), and had good sensitivities for detecting manifest keratoconus (97.8%), subclinical keratoconus (100.0%), and FFK (73.7%). Conclusions The two-step decision tree provided a useful tool to detect keratoconus including cases at early disease stages (subclinical keratoconus and FFK). OCT corneal and epithelial thickness map parameters and patterns can be used in conjunction with topography to improve keratoconus screening.

Purpose A consecutive case series of patients with dupilumab-associated ocular surface disease (DAOSD) that describes common ocular symptoms and signs, proposes a symptom disease severity grading system, and describes treatment strategies of DAOSD patients was evaluated. Methods A retrospective chart review of patients with concomitant dupilumab-treated atopic dermatitis and DAOSD with ophthalmic evaluation between January 2014 and May 2019 was conducted. Results Twenty-nine patients (mean age 46 years, M/F: 12/17) with 57 ophthalmic exams were identified. The most common ocular symptoms included irritation/pain (n = 28, 97%), redness (n = 24, 83%), pruritus (n = 18, 62%), discharge (n = 18, 62%), and light sensitivity (n = 6, 21%). The most frequent signs included conjunctival injection (n = 18, 62%), superficial punctate keratitis (n = 16, 55%), and papillary reaction (n = 8, 28%). Topical corticosteroids (TCS) (n = 23, 79%), tacrolimus (n = 6, 21%), and artificial tears (n = 7, 24%) were the most commonly used therapies. Of those with follow-up documentation (n = 21), 20 were noted to have partial or complete response with TCS based on symptoms and reduction of signs. Using our proposed symptom-based grading scale, scaled 1 to 5 based on the presence of common symptoms listed above, 66% (n = 19) requiring topical immunomodulating therapy were found in the 'severe' group (≥3 symptoms) and 17% (n = 5) were found in the 'mild' group (≤2 symptoms). Conclusions This study provides insight into the commonly presenting ocular signs and symptoms associated with DAOSD and highlights the efficacy of TCS and other immunomodulators in improving symptoms associated with DAOSD. Based on our findings, we propose a symptom-based grading system that can guide nonophthalmic physicians regarding ophthalmology consult.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Purpose:To map and measure the depths of corneal neovascularization (NV) using 3-dimensional optical coherence tomography angiography (OCTA) at 2 different wavelengths.Methods:Corneal NV of varying severity, distribution, and underlying etiology was examined. Average NV depth and vessel density were measured using 840-nm spectral-domain OCTA and 1050-nm swept-source OCTA. The OCTA results were compared with clinical slit-lamp estimation of NV depth.Results:Twelve eyes with corneal NV from 12 patients were imaged with OCTA. Clinically "superficial," "midstromal," and "deep" cases had an average vessel depth of 23%, 39%, and 66% on 1050-nm OCTA, respectively. Average vessel depth on OCTA followed a statistically significant ordinal trend according to the clinical classification of vessel depth (Jonckheere-Terpstra test, P < 0.001). In 8 cases where both 840-nm OCTA and 1050-nm OCTA were acquired, there was excellent agreement in the mean vessel depth between the 2 systems (concordance correlation coefficient = 0.94, P < 0.001). The average vessel density measured by 840-nm OCTA was higher (average 1.6-fold) than that measured by 1050-nm OCTA.Conclusions:Corneal OCTA was able to map corneal NV in 3 dimensions and measure vessel depth and density. The depth of corneal NV varied between different pathologies in a manner consistent with previous pathologic studies. The measured vessel density appeared to be affected by the interscan time, which affects blood flow velocity sensitivity, and the wavelength, which affects the ability to penetrate through opacity. These findings suggest possible clinical applications of OCTA for the diagnosis of corneal pathology and quantitative monitoring of therapeutic response in patients with corneal NV.

To report on a new application of intraoperative optical coherence tomography (OCT) as a real-time imaging tool to help guide corneal biopsy.Single case report. After the negative result of a corneal biopsy, we used intraoperative OCT during repeat biopsy to assist in depth and acquisition of an anterior stromal opacity suspected to be immunoglobulin deposits.The use of intraoperative OCT is a novel tool, which assisted in successful identification and conservative biopsy of corneal immunoglobulin deposits.Intraoperative OCT is a novel tool that assists in the identification and location of corneal pathology for biopsy.

To analyze transepithelial phototherapeutic keratectomy (PTK) results using optical coherence tomography (OCT) and develop a model to guide the laser dioptric and depth settings.Casey Eye Institute, Portland, Oregon, USA.Prospective nonrandomized case series.Patients with superficial corneal opacities and irregularities had transepithelial PTK with a flying-spot excimer laser by combining wide-zone myopic and hyperopic astigmatic ablations. Optical coherence tomography was used to calculate corneal epithelial lenticular masking effects, guide refractive laser settings, and measure opacity removal. The laser ablation efficiency and the refractive outcome were investigated using multivariate linear regression models.Twenty-six eyes of 20 patients received PTK to remove opacities and irregular astigmatism due to scar, dystrophy, radial keratotomy, or previous corneal surgeries. The uncorrected distance visual acuity and corrected distance visual acuity were significantly improved (P .01) by 3.7 Snellen lines and 2.0 Snellen lines, respectively, to a mean of 20/41.2 and 20/22.0, respectively. Achieved laser ablation depths were 31.3% (myopic ablation) and 63.0% (hyperopic ablation) deeper than the manufacturer's nomogram. The spherical equivalent of the corneal epithelial lenticular masking effect was 0.73 diopter ± 0.61 (SD). The refractive outcome highly correlated to the laser settings and epithelial lenticular masking effect (Pearson R = 0.96, P .01). The ablation rate of granular dystrophy opacities appeared to be slower. Smoothing ablation under masking fluid was needed to prevent focal steep islands in these cases.The OCT-measured ablation depth efficiency could guide opacity removal. The corneal epithelial lenticular masking effect could refine the spherical refractive nomogram to achieve a better refractive outcome after transepithelial ablation.

Purpose To distinguish between corneal ectasia and contact lens–related warpage by characteristic patterns on corneal topography and optical coherence tomography (OCT) epithelial thickness maps. Setting Casey Eye Institute, Portland, Oregon, USA. Design Prospective and retrospective case series. Methods Axial and mean power maps were obtained on corneal topography systems. Epithelial thickness maps were generated using RTVue OCT. A sector divider was applied to all maps. The locations of the minimum epithelial thickness, maximum epithelial thickness, maximum axial power, and maximum mean power were determined based on sector averages. Agreement was defined as the extremums occurring in the same or adjacent sectors. Results Twenty-one eyes with keratoconus, 6 eyes with forme fruste keratoconus (better eye of asymmetric keratoconus), and 15 eyes with contact lens–related warpage were identified. The keratoconus and forme fruste keratoconus eyes had coincident topographic steepening with epithelial thinning. The locations of minimum epithelial thickness and maximum axial power agreed in 90% of the keratoconic eyes, while the minimum epithelial thickness and maximum mean power agreed in 95% of them. Conversely, the warpage eyes had coincident topographic steepening with epithelial thickening and normal pachymetry maps. The locations of maximum epithelial thickness and maximum axial power agreed in 93% of the warpage eyes, while the maximum epithelial thickness and maximum mean power agreed in all warpage eyes. Conclusion Results show that epithelial thickness maps and corneal topographic maps are powerful synergistic tools in evaluating eyes with abnormal topography and can help differentiate between keratoconus and nonectatic conditions.

Purpose Fuchs endothelial corneal dystrophy (FECD) might be managed by drug treatment before becoming severe enough to require surgery. For a clinical trial of such a drug, we hypothesize that selecting an adequate number of patients with FECD with only moderately compromised cell densities will be challenging. Thus, the purpose of the present study was to measure the prevalence of patients with FECD exhibiting moderately decreased corneal cell densities. Methods A retrospective data mining study (cross-sectional study) was performed on patient charts presenting at a large US northwestern academic health center by searching for diagnosis ICD-9 code 371.57 and Fuchs corneal dystrophies, including those with prior cataract surgeries and/or existing glaucoma. Patients with prior corneal transplants were excluded. Noncontact specular photomicroscopic data (Topcon 2000) were obtained from the central region whenever possible, and individual eyes were grouped according to cell density (cells/mm2): severe (1,500). Results The values for 98 eyes from 61 patients with FECD were as follows (mean ± SD): corneal thickness 573 ± 59 μm, cell size 627 ± 336 μm2/cell, coefficient of variation 23 ± 7, and density 1,883 ± 703 cells/mm2. The moderate subgroup with cell density values averaging 1,184 ± 212 (26) comprised 27% of the total FECD patient pool. Conclusions Only approximately 1 out of 4 patients with FECD will show moderately compromised corneal cell densities. A moderate level of damage may be optimal for clinical trials for testing topical drugs on endothelial cell viability. Thus, investigators will need to initially screen a fourfold excess of all patients with FECD.

PURPOSE The goals of this laboratory study were to evaluate the interface quality in laser-assisted lamellar anterior keratoplasty (LALAK) with microkeratome-cut grafts and achieve good graft-host apposition. METHODS Simulated LALAK surgeries were performed on 6 pairs of eye-bank corneoscleral discs. Anterior lamellar grafts were precut with microkeratomes. Deep femtosecond (FS) laser cuts were performed on host corneas followed by excimer laser smoothing. Different parameters of FS laser cuts and excimer laser smoothing were tested. Optical coherence tomography was used to measure corneal pachymetry and evaluate graft-host apposition. The interface quality was quantified in a masked fashion using a 5-point scale based on scanning electron microscopy images. RESULTS Deep FS laser cuts at 226 to 380 μm resulted in visible ridges on the host bed. Excimer laser smoothing with a central ablation depth of 29 μm and saline as a smoothing agent did not adequately reduce ridges (score = 4.0). Deeper excimer laser ablation of 58 μm and Optisol-GS as a smoothing agent smoothed ridges to an acceptable level (score = 2.1). Same sizing of the graft and host cut diameters with an approximately 50-μm deeper host side cut relative to the central graft thickness provided the best graft-host fit. CONCLUSIONS Deep excimer laser ablation with a viscous smoothing agent was needed to remove ridges after deep FS lamellar cuts. The host side cut should be deep enough to accommodate thicker graft peripheral thickness compared with the center. This LALAK design provides smooth lamellar interfaces, moderately thick grafts, and good graft-host fits.

Purpose To screen for subclinical keratoconus by analyzing corneal, epithelial, and stromal thickness map patterns with Fourier-domain optical coherence tomography (OCT). Setting Four centers in the United States. Design Cross-sectional observational study. Methods Eyes of normal subjects, subclinical keratoconus eyes, and the topographically normal eye of a unilateral keratoconus patient were studied. Corneas were scanned using a 26 000 Hz Fourier-domain OCT system (RTVue). Normal subjects were divided into training and evaluation groups. Corneal, epithelial, and stromal thickness maps and derived diagnostic indices, including pattern standard deviation (PSD) variables and pachymetric map–based keratoconus risk scores, were calculated from the OCT data. Area under the receiver operating characteristic curve (AUC) analysis was used to evaluate the diagnostic accuracy of the indices. Results The study comprised 150 eyes of 83 normal subjects, 50 subclinical keratoconus eyes of 32 patients, and 1 topographically normal eye of a unilateral keratoconus patient. Subclinical keratoconus was characterized by inferotemporal thinning of the cornea, epithelium, and stroma. The PSD values for corneal ( P P P = .049) thickness maps were all significantly higher in subclinical keratoconic eyes than in the normal group. The diagnostic accuracy was significantly higher for PSD variables (pachymetric PSD, AUC = 0.941; epithelial PSD, AUC = 0.985; stromal PSD, AUC = 0.924) than for the pachymetric map–based keratoconus risk score (AUC = 0.735). Conclusions High-resolution Fourier-domain OCT could map corneal, epithelial, and stromal thicknesses. Corneal and sublayer thickness changes in subclinical keratoconus could be detected with high accuracy using PSD variables. These new diagnostic variables might be useful in the detection of early keratoconus. Financial Disclosures Oregon Health and Science University (OHSU) and Drs. Li, Tan, and Huang have a significant financial interest in Optovue, Inc. These potential conflicts have been reviewed and managed by OHSU. Dr. Brass receives research grants from Optovue, Inc. Drs. Chamberlain and Weiss have no financial or proprietary interest in any material or method mentioned.

Importance Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics. Objective To examine ophthalmologist time requirements for EHR use. Design, Setting, and Participants A single-center cohort study was conducted between September 1, 2013, and December 31, 2016, among 27 stable departmental ophthalmologists (defined as attending ophthalmologists who worked at the study institution for ≥6 months before and after the study period). Ophthalmologists who did not have a standard clinical practice or who did not use the EHR were excluded. Exposures Time stamps from the medical record and EHR audit log were analyzed to measure the length of time required by ophthalmologists for EHR use. Ophthalmologists underwent manual time-motion observation to measure the length of time spent directly with patients on the following 3 activities: EHR use, conversation, and examination. Main Outcomes and Measures The study outcomes were time spent by ophthalmologists directly with patients on EHR use, conversation, and examination as well as total time required by ophthalmologists for EHR use. Results Among the 27 ophthalmologists in this study (10 women and 17 men; mean [SD] age, 47.3 [10.7] years [median, 44; range, 34-73 years]) the mean (SD) total ophthalmologist examination time was 11.2 (6.3) minutes per patient, of which 3.0 (1.8) minutes (27% of the examination time) were spent on EHR use, 4.7 (4.2) minutes (42%) on conversation, and 3.5 (2.3) minutes (31%) on examination. Mean (SD) total ophthalmologist time spent using the EHR was 10.8 (5.0) minutes per encounter (range, 5.8-28.6 minutes). The typical ophthalmologist spent 3.7 hours using the EHR for a full day of clinic: 2.1 hours during examinations and 1.6 hours outside the clinic session. Linear mixed effects models showed a positive association between EHR use and billing level and a negative association between EHR use per encounter and clinic volume. Each additional encounter per clinic was associated with a decrease of 1.7 minutes (95% CI, -4.3 to 1.0) of EHR use time per encounter for ophthalmologists with high mean billing levels (adjustedR2 = 0.42;P = .01). Conclusions and Relevance Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.

PURPOSE To report a case of local transmission of invasive lobular carcinoma from a donor to a recipient in a keratolimbal allograft after cessation of systemic immunosuppressive therapy. METHODS This is a case report including the clinicopathologic findings. Sections of the donor breast tumor and recipient conjunctival lesions were stained with hematoxylin and eosin. Immunohistochemical studies were performed using pancytokeratin, CK7, CK20, CAM 5.2, CD138, TTF1, estrogen receptor, progesterone receptor, GATA-3, GCDFP-15, and mammaglobin. Polymerase chain reaction-based DNA profiling of tumor cells was performed. RESULTS Histopathologic examination revealed an infiltrate of atypical cells with large hyperchromatic nuclei consistent with carcinoma. Immunohistochemical analysis showed pancytokeratin, CK7, CAM 5.2, GATA-3, and estrogen receptor positivity and progesterone receptor absence, consistent with the previously determined phenotype of the donor's breast carcinoma. Results of polymerase chain reaction analysis were also consistent with the donor's tumor. After reduced dosing of tacrolimus and mycophenolate mofetil, 2 limbal tumors occurred in the recipient. The immunosuppressive treatment had been stopped completely before the appearance of the third lesion. The recipient had no history of malignancy, and she had routine screenings for breast cancer. CONCLUSIONS We report a case of donor-derived breast carcinoma in a keratolimbal allograft recipient. The grafted tissue harbored donor-derived tumor cells for more than 4 years after surgery even after systemic immunosuppression was discontinued. Although no similar reports of tumor transfer could be found in the literature, this case suggests the need for increased stringency in donor selection and heightened surveillance for such tumor transmission.

Deep anterior lamellar keratoplasty is a partial thickness corneal graft technique void of endothelium. DALK technique offers several advantages over penetrating keratoplasty such as it being an extraocular procedure, never entering into the anterior chamber. Additionally, there is no risk of endothelial rejection, and no need for immunosuppressive medications. DALK has shown similar VA outcomes when compared to PKP. IntraLase-enabled DALK offers a more accurately prepared and matched transplant. Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

To improve accuracy and efficiency in quantifying the endothelial cell loss (ECL) in eye bank preparation of corneal endothelial grafts.Eight cadaveric corneas were subjected to Descemet Membrane Endothelial Keratoplasty (DMEK) preparation. The endothelial surfaces were stained with a viability stain, calcein AM dye (CAM) and then captured by a digital camera. The ECL rates were quantified in these images by three separate readers using trainable segmentation, a plug-in feature from the imaging software, Fiji. Images were also analyzed by Adobe Photoshop for comparison. Mean times required to process the images were measured between the two modalities.The mean ECL (with standard deviation) as analyzed by Fiji was 22.5% (6.5%) and Adobe was 18.7% (7.0%; p = 0.04). The mean time required to process the images through the two different imaging methods was 19.9 min (7.5) for Fiji and 23.4 min (12.9) for Adobe (p = 0.17).Establishing an accurate, efficient and reproducible means of quantifying ECL in graft preparation and surgical techniques can provide insight to the safety, long-term potential of the graft tissues as well as provide a quality control measure for eye banks and surgeons. Trainable segmentation in Fiji software using CAM is a novel approach to measuring ECL that captured a statistically significantly higher percentage of ECL comparable to Adobe and was more accurate in standardized testing. Interestingly, ECL as determined using both methods in eye bank-prepared DMEK grafts exceeded 18% on average.

PURPOSE To report on a patient with a welding flash burn with subsequent scarring and edema who twice underwent femtosecond laser-assisted keratoplasty (FLAK). Both grafts failed due to endothelial decompensation. He subsequently underwent successful Descemet stripping automated endothelial keratoplasty (DSAEK) under the second FLAK graft to decrease rejection risk and prevent further full-thickness keratoplasty. METHODS A 51-year-old man with a history of 2 FLAK procedures with subsequent graft failures likely from noncompliance with postoperative medications had diffuse microcystic edema with a visual acuity of counting fingers at 5 feet. The patient underwent DSAEK procedure 4 months after the second FLAK procedure. RESULTS No dehiscence occurred during second laser trephination of cornea. Sections of mild misalignment between the first and second FLAK graft trephinations were noted on optical coherence tomography. Post-DSAEK, the patient had a rapidly clearing, well-attached graft with mild temporal overlap of the graft-host interface. All sutures were removed from the overlying FLAK graft by 3 months after DSAEK (7 months after repeat FLAK). At 9 months post-DSAEK, the patient's uncorrected visual acuity was 20/40 and best spectacle-corrected visual acuity was 20/30. CONCLUSIONS Early secondary femtosecond laser trephination after first FLAK is possible even if the second graft is misaligned. A crescent remnant of the original graft was well-healed into the host cornea 7.5 months after the original surgery. The 3-month-old second FLAK graft was able to support a DSAEK surgery and rapid postoperative visual recovery. All sutures were removed from the cornea by 7 months after the second FLAK surgery.

IMPORTANCE: Vision-related quality of life can be a valuable outcome for some interventions in ophthalmology. In the primary Descemet Endothelial Thickness Comparison Trial (DETECT), Descemet membrane endothelial keratoplasty (DMEK) had superior postoperative visual acuity compared with ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). It is of interest to determine whether this trend extends to quality of life. OBJECTIVE: To determine the effect of UT-DSAEK and DMEK on vision-related quality of life. DESIGN, SETTING, AND PARTICIPANTS: A prespecified secondary analysis of a 2-surgeon patient- and outcome-masked randomized clinical trial was conducted at the Casey Eye Institute in Portland, Oregon, and Byers Eye Institute in Palo Alto, California. The study was conducted between January 20, 2015, and April 26, 2017. DETECT enrolled 38 individuals and included 50 eyes with isolated endothelial dysfunction; for this analysis, the second eye from a single participant was excluded along with any questionnaires in the first eye after second eye surgery for evaluation of 38 eyes at baseline and 3 months and 26 eyes at 12 months. Mean (SD) baseline visual acuity was 0.35 (0.31) logMAR in the DMEK arm and 0.28 (0.22) logMAR in the UT-DSAEK arm. Each arm consisted of 19 participants: 18 individuals with Fuchs dystrophy and 1 participant with pseudophakic bullous keratopathy. INTERVENTIONS: Study eyes were randomized to receive either UT-DSAEK or DMEK. MAIN OUTCOMES AND MEASURES: Responses to the National Eye Institute (NEI) Visual Function Questionnaire-39 (VFQ-39) administered at baseline and 3 and 12 months postoperatively were analyzed using the NEI-defined traditional subscales and composite score on a 100-point scale and with a Rasch-refined analysis. RESULTS: There were more women in both arms of the study (UT-DSAEK, 12 [63%]; DMEK, 11 [58%]); mean (SD) age was 68 (11) years in the UT-DSAEK arm and 68 (4) years in the DMEK arm. Overall, study participants experienced a 9.1-point improvement in NEI VFQ-39 composite score at 3 months compared with baseline (N = 38; 95% CI, 4.9-13.3; P

Purpose: To compare outcomes after Descemet Membrane Endothelial Keratoplasty (DMEK) and traditional Descemet Stripping Endothelial Keratoplasty (DSEK) during the surgeon’s DMEK learning curve in a prospective, non-randomized, consecutive, interventional case series. Methods: Consecutive patients presenting to the university eye clinics and undergoing endothelial keratoplasty were included. Data including patient demographics, visual acuity, endothelial cell counts and complications were recorded at baseline, as well as 3 and 6 months post-operatively. The primary outcome for this study was BSCVA at 6 months. Pre-specified secondary outcomes included endothelial cell counts and complication rates. Results: A total of 60 eyes of 42 consecutive patients met inclusion criteria, underwent endothelial keratoplasty, and were included in this analysis. Of these, 18 eyes of 14 patients had DSEK while 42 eyes of 28 patients had DMEK. After controlling for baseline visual acuity, study participants undergoing DMEK had a statistically significant approximately half-line improvement in visual acuity compared with DSEK at 3 months (P=0.05) but not at 6 months (P=0.22). DMEK patients experienced an average of 43% endothelial cell loss compared with 25% in DSEK. There were 5 primary graft failures after DMEK compared with 0 after DSEK and but this was not a statistically significant difference (P=0.09). Conclusion: During the surgeon’s DMEK learning curve there was some evidence of improved visual acuity outcomes in DMEK. We observed worse 6-month endothelial cell loss among DMEK patients; however this may improve with surgeon experience.

Objective: To survey cornea specialists’ opinions on different endothelial keratoplasty techniques and to gauge the perceived need for and utility of a randomized controlled trial (RCT) comparing them. Methods: A short survey was distributed to a group of cornea specialists at the Endothelial Keratoplasty Group meeting at the American Academy of Ophthalmology meeting in November 2015. Results: Thirty-three of 80 practicing surgeons present at the EKG meeting participated in the survey, yielding a response rate of 41%. Ninety-seven percent (n=32) of our respondents reported performing Descemet’s Stripping Endothelial Keratoplasty (DSEK) regularly, and 70% reported having performed Descemet’s Membrane Endothelial Keratoplasty (DMEK) at least once (n=23). While most respondents (n=26, 79%) thought there was at least some evidence that DMEK is superior to DSEK in terms of visual acuity, there was less certainty about comparing ultrathin-DSEK (UT-DSEK) to DMEK with 48% (n=16) thinking there was at least some evidence of DMEK’s superiority, 6% (n=2) thinking there was at least some evidence of UT-DSEK’s superiority, and 30% (n=10) unsure. Seventy-two percent (n=23) of respondents thought an RCT comparing visual acuity outcomes in UT-DSEK versus DMEK would be at least moderately beneficial, and 82% (n=27) reported they were at least moderately likely to change their EK technique based on the results of said RCT. Conclusion: There is substantial interest in an RCT comparing visual acuity outcomes in UT-DSEK versus DMEK.

Purpose To demonstrate feasibility and present postoperative outcomes for femtosecond laser-assisted keratoplasty (FLAK) in the setting of previous failed conventional penetrating keratoplasty (PK) and previous open-globe trauma with corneal laceration. Methods In this retrospective case series, data were collected for 12 consecutive patients at the Casey Eye Institute (Oregon Health and Science University, Portland, OR) with the primary diagnosis of either failed PK or open-globe trauma with corneal laceration that underwent zigzag incision FLAK. Outcome measures included topographic astigmatism, best spectacle-corrected visual acuity, uncorrected visual acuity, pinhole visual acuity, intraocular pressure, and timing of selective suture removal (or adjustment) over various follow-up intervals up to 18 months postoperatively. Results Mean follow-up was 10.42 months. Mean postoperative topographic astigmatism ranged between 3.56 and 6.81 diopters (D). Mean best spectacle-corrected visual acuity (BSCVA) in logarithm of minimal angle of resolution (logMAR) equivalents ranged between 0.18 and 0.61 as compared with 1.28 for preoperative BSCVA (P = 0.0064). Thirty-three percent (4 of 12) of patients had significantly increased intraocular pressure develop during the first year of follow-up that required glaucoma therapy. No adverse events or complications occurred as a result of either the femtosecond laser procedure itself or during the transportation of the patient from the laser suite to the operating room. Conclusions FLAK is a feasible transplantation technique in the setting of previous failed PK and open-globe trauma with corneal laceration. Significant globe pressure associated with laser applanation did not cause rupture of old corneal wounds among our case series. Postoperative astigmatism is within previous reported limits in the literature under varying suturing techniques. Development of ocular hypertension within 1 year of follow-up was comparable with historically reported rates for PK in the setting of previous trauma and failed grafts.

Both topical ocular and topical intranasal immunizations have been reported to stimulate the ocular mucosal immune system (OMIS) and the systemic immune system. Nasolacrimal ducts (NLDs) are the connecting bridges between the OMIS and nasal cavity-associated lymphoid tissue (NALT). These ducts drain topical ocularly administrated solutions into the inferior meatus of the nose to reach the NALT. Inversely, NLDs also drain intranasally administrated solutions to the mucosal surface of the eye and thus the OMIS. This unique anatomical connection between the OMIS and NALT systems provoked us to test whether the OMIS and NALT are immunologically interdependent. In this report, we show that both topical ocular administration and topical intranasal administration of a mixture of immunodominant CD4+T-cell epitope peptides from herpes simplex virus type 1 (HSV-1) glycoprotein D (gD) emulsified with the CpG2007mucosal adjuvant are capable of inducing local (in conjunctiva) as well as systemic (in spleen) HSV-peptide-specific CD4+T-cell responses. Interestingly, surgical closure of NLDs did not significantly alter local ocular mucosal CD4+T-cell responses induced following topical ocular immunization but did significantly enhance systemic CD4+T-cell responses (as measured by both T-cell proliferation and gamma interferon (IFN-γ) production;P< 0.005). In contrast, NLD closure significantly decreased ocular mucosal, but not systemic, CD4+T-cell responses following intranasal administration of the same vaccine solution (P< 0.001). The study suggests that NALT and the OMIS are immunologically interconnected.

Purpose To evaluate the association between office-hour central corneal thickness (CCT) and 24-hour intraocular pressure (IOP) fluctuation in patients with glaucoma. Design Observational case-control study. Methods Measurements of IOP were obtained every 2 hours during a 24-hour period from 52 untreated glaucoma patients and 29 age-matched normal control subjects housed in a sleep laboratory. Habitual IOP measurements were obtained using a pneumatonometer in the sitting positions during the diurnal/wake period (7 AM to 11 PM) and in the supine position during the nocturnal/sleep period (11 PM to 7 AM). CCT was measured in all subjects using ultrasound pachymetry once during office hours. The association between IOP fluctuation (peak IOP-trough IOP) during the 24-hour period and the office-hour CCT was assessed in both glaucoma patients and healthy age-matched controls using Spearman rank order correlation. Results There was no statistically significant correlation between IOP fluctuation and CCT in glaucomatous (P=0.405) and normal subjects (P=0.456). Conclusions Twenty-four-hour IOP fluctuations were not correlated with single CCT measurements taken during office hours in glaucoma patients.

Purpose To evaluate endothelial cell damage after eye bank preparation and passage through 1 of 2 different injectors for Descemet membrane endothelial keratoplasty grafts. Methods Eighteen Descemet membrane endothelial keratoplasty grafts were prepared by Lions VisionGift with the standard partial prepeel technique and placement of an S-stamp for orientation. The grafts were randomly assigned to injection with either a glass-modified Jones tube injector (Gunther Weiss Scientific Glass) or a closed-system intraocular lens injector (Viscoject 2.2; Medicel). After injection, the grafts were stained with the vital fluorescent dye Calcein AM and digitally imaged. The percentage of cell loss was calculated by measuring the area of nonfluorescent pixels and dividing it by the total graft area pixels. Results Grafts injected using the modified Jones tube injector had an overall cell loss of 27% ± 5% [95% confidence interval, 21%-35%]. Grafts injected using the closed-system intraocular lens injector had a cell loss of 32% ± 8% (95% confidence interval, 21%-45%). This difference was not statistically significant (P = 0.3). Several damage patterns including damage due to S-stamp placement were observed, but they did not correlate with injector type. Conclusions In this in vitro study, there was no difference in the cell loss associated with the injector method. Grafts in both groups sustained significant cell loss and displayed evidence of graft preparation and S-stamp placement. Improvement in graft preparation and injection methods may improve cell retention.

Purpose To evaluate the stromal interface quality after femtosecond laser full lamellar cuts in gamma-irradiated corneas (VisionGraft sterile cornea) and to determine the limits of the cut depth using the VisionGraft as donor corneas for laser-assisted lamellar anterior keratoplasty. Methods Fourteen VisionGraft corneas underwent full lamellar cuts using the femtosecond laser. The percent cut depth was 17% to 21% (100 μm, n = 2), 31% to 35% (n = 3), 38% to 40% (n = 3), 45% to 48% (n = 3), and 50% (n = 3) of the total stromal thickness (not including the epithelium). The cap and stromal bed surfaces were imaged with a scanning electron microscope. The quality of cut surfaces was graded by 2 masked observers based on two indices: ridge and roughness. Ridge grading indicated macroscopic irregularity. Roughness grading indicated microscopic irregularity. The grading was done on a subjective integer scale of 1 to 5 (1 = best and 5 = worst), which was used in a previous study of cut quality in fresh corneas. Results The ridge grading ranged from 1.5 for the shallowest cut to 2.2 for the deepest cut and weakly (r = 0.279) but significantly (P = 0.037) correlated with the percent cut depth. The roughness grading ranged from 2.63 to 2.56 and showed no trend with the percent cut depth (r = 0.006, P = 0.968). Conclusions Compared with previously published results of fresh corneas, in which ridge grading exceeded 3 for cuts deeper than 31%, cut quality was better for the VisionGraft. Even at depths up to 48% of the total stromal thickness, ridge grading was not worse than shallow cuts. Thus, gamma-irradiated corneas could provide a smoother interface than do fresh eye bank corneas for laser-assisted lamellar anterior keratoplasty.

The aim of this study was to investigate the use of a femtosecond laser (FL) in the eye bank preparation of corneas for Descemet membrane (DM) automated endothelial keratoplasty (fDMAEK) and to compare endothelial cell death in graft preparations between fDMAEK, Descemet stripping endothelial keratoplasty (DSEK), and DM endothelial keratoplasty (DMEK).Twenty cadaveric tissues were used to test the fDMAEK method. A 9.0-mm-diameter lamellar incision was made using the FL with a 6.0-mm perpendicular anterior ring cut that enabled a stromal rim by acting as a venting incision for bubble expansion. DM was pneumodissected off the central 6.0 mm of the tissue. The fDMAEK grafts were trephined and stained with a viability dye, calcein AM. The entire stained endothelial surface was digitally captured and the endothelial cell loss (ECL) was calculated using trainable segmentation software. For comparison, a series of 6 DSEK grafts and 8 DMEK grafts were created and analyzed.Six of 20 tissues (30%) were lost during fDMAEK preparation. In the 14 successful tissues, the average ECL was 30.4% [95% confidence interval (CI), 25.3-35.6] compared with 21.1% (95% CI, 13.2-28.9, P = 0.09) in the 6 DSEK grafts and 22.5% (95% CI, 18.0-27.0, P = 0.04) in the 8 DMEK grafts.FLs are useful in preparing DMAEK tissue at the eye bank and may promote predictable and precise big bubbles and stromal rims. The fDMAEK preparation success improved with experience and laser adjustments. In fDMAEK, the ECL is higher than was previously reported in DMEK and DSEK, likely due to greater tissue manipulation, although not significantly higher than DSEK controls.

Purpose To evaluate wound strength for patient safety during transport and endothelial viability when partial and complete femtosecond laser-assisted keratoplasty (FLAK) incisions are made in cadaveric corneas. Methods 19 human corneoscleral rims were divided into six groups, mounted on an anterior chamber maintainer and cut with a femtosecond laser programmed to the following patterns: ‘zigzag’ (A), ‘mushroom’ (B) and ‘top hat’ (C) in both full (1) and partial (2) thicknesses. The pressure required to produce leakage from the corneal incision was then measured. Eight additional corneas were cut with the ‘zigzag’ pattern: four full and four partial thickness, prepared and transported per standard eye bank protocol, and analysed for endothelial cell loss with trypan blue staining and digital image analysis. Results Mean leakage pressure in mm Hg for group A1 was 110 (SD 94); group A2, 1180 (SD 468); group B1, 978 (SD 445); group B2, 987 (SD 576); group C1, 710 (SD 474); group C2, 1290 (SD 231). There was a significant difference in leakage pressure between groups A1 and A2 (p=0.05), groups A1 and B1 (p=0.05), and groups A1 and C1 (p=0.05). Mean percentage endothelial damage after full-thickness cuts was 8.40 (SD 2.34) and 5.30 (SD 1.33) in partial-thickness cuts (p=0.11). Conclusions Partial thickness zigzag, top hat and mushroom-style partial FLAK incisions left an intact tissue wall with high resistance to rupture, whereas full-thickness cuts were more variable. Laser trephination and eye bank handling protocol for donor FLAK buttons leads to moderate peripheral endothelial cell loss in tissue with both complete and partial cuts.

Author(s): Tang, Maolong; Li, Yan; Chamberlain, Winston; Louie, Derek J; Schallhorn, Julie M; Huang, David | Abstract: PurposeTo differentiate between keratoconus and contact lens-related corneal warpage by combining focal change patterns in anterior corneal topography, pachymetry, and epithelial thickness maps.MethodsPachymetry and epithelial thickness maps of normal, keratoconus, and warpage, and forme fruste keratoconus (FFK) eyes were obtained from a Fourier-domain optical coherence tomography (OCT). Epithelial pattern standard deviation (PSD) was calculated and combined with two novel indices, the Warpage Index and the Anterior Ectasia Index, to differentiate between normal, keratoconus, and warpage eyes. The values of the three parameters were compared between groups.ResultsThe study included 22 normal, 31 keratoconic, 11 warpage, and 8 FFK eyes. The epithelial PSD was normal (l 0.041) for 100% normal eyes and abnormal (g 0.041) for 100% of keratoconic eyes, 81.8% of warpage eyes, and 87.5% of FFK eyes. The Anterior Ectasia Index of normal eyes (1.66 ± 0.74) was significantly lower than that for the keratoconus eyes (17.5 ± 7.17), the warpage eyes (2.98 ± 1.69), and the FFK eyes (6.95 ± 5.86). The Warpage Index was positive in all warpage eyes and negative for all keratoconic and FFK eyes except three wearing rigid gas-permeable contact lens.ConclusionsThe epithelial PSD can distinguish normal from keratoconus or warpage, but does not distinguish between these two conditions. The Anterior Ectasia Index is abnormal in keratoconus but not warpage. The Warpage Index is positive for warpage and negative for keratoconus, except in cases where keratoconus and warpage coexist. Together, the three parameters are strong tripartite discriminators of normal, keratoconus, and warpage.

Purpose To compare postoperative outcomes for femtosecond laser-assisted keratoplasty (FLAK) with conventional penetrating keratoplasty (PK). Design Retrospective, comparative surgical series. Participants Fifty consecutive patients who underwent FLAK and 50 case-controlled patients that had PK at the Casey Eye Institute (Oregon Health & Science University, Portland, OR). Methods Data was collected for 50 consecutive cases that underwent zigzag incision FLAK and was compared with 50 subjects that had conventional blade trephine incision PK with similar age, diagnosis and concurrent ocular morbidities over a 2-year follow-up period. Main Outcome Measures Topographic astigmatism, best spectacle-corrected visual acuity, uncorrected visual acuity, pinhole visual acuity, and the timing of selective suture removal (or adjustment) over various follow-up intervals up to 2 years postoperatively. Results Significantly lower topographic astigmatism was achieved in the FLAK group over the PK group in the 4- to 6-month follow-up period ( P = 0.0324), which correlated well with significant earlier selective suture removal that occurred in that same group over both the 2- to 3-month ( P = 0.0025) and 4- to 6-month ( P = 0.0236) follow-up periods. This difference in astigmatism was no longer present at any other follow-up period up to 24 months postoperatively. The subset analysis of patients with keratoconus or post-LASIK ectasia did not show any difference in either astigmatism or visual acuity at any time. Conclusions Compared with PKP, FLAK had significant improvement in astigmatism before but not after the 6 month postoperative follow-up period. Earlier suture removal was noted in the FLAK group. No significant improvement in best spectacle-corrected visual acuity was noted at any time point. There were no complications or difficulties with trephination in the FLAK procedure across a wide range of corneal pathologies. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Purpose To evaluate visual outcomes and astigmatism in patients who underwent penetrating keratoplasty (PK) with 2 different incision techniques. Design Retrospective comparison of a consecutive surgical series. Participants Fifty-seven consecutive patients who underwent PK at the University of California, Irvine, academic referral practice. Methods A comparison of 49 eyes of 43 patients that underwent femtosecond laser zig-zag incision pattern PK versus 17 eyes of 14 patients that underwent conventional Barron suction trephination PK performed contemporaneously. All PKs were closed with an identical, 24-bite running nylon suture technique. Main Outcome Measures Topographically determined astigmatism, best spectacle-corrected visual acuity (BSCVA), and recovery of full visual potential. Results The postoperative follow-up ranged from 1 to 12 months. There was a significant difference in average astigmatism between the groups at postoperative month 1 ( P = 0.013) and 3 ( P = 0.018). By month 3, the average astigmatism was 3 diopters (D) in the zig-zag group and 4.46 D in the conventional group. Of the patients with normal macular and optic nerve function ( n ZZ = 32; n con = 14), a significant difference in BSCVA was seen at month 1 ( P = 0.0003) and month 3 ( P = 0.006) with 81% of the zig-zag group versus 45% of the conventional group achieving BSCVA of ≥20/40 by month 3 ( P = 0.03). Conclusions The femtosecond laser generated zig-zag–shaped incision results in a more rapid recovery of BSCVA and induces less astigmatism compared with conventional blade trephination PK. Financial Disclosure(s) Proprietary commercial disclosure may be found after the references.

Purpose To evaluate and compare corneal higher-order aberrations (HOAs) after Descemet stripping automated endothelial keratoplasty (DSAEK), femtosecond laser-assisted penetrating keratoplasty (FLAK), and conventional penetrating keratoplasty (PKP). Methods A retrospective comparison of consecutive surgical series of 67 eyes of 59 patients between 1.5 and 19 months after corneal transplant surgery (22, 34, and 11 corneas underwent DSAEK, FLAK, and PKP, respectively, by a single surgeon). The main outcome measures were anterior and posterior corneal surface HOAs (Zernike polynomials, third to eighth order) determined with Scheimpflug photography at 4.0- and 6.0-mm optical zones and best spectacle-corrected visual acuity (BSCVA) (logarithm of the minimum angle of resolution equivalents). Results DSAEK had fewer total anterior HOAs compared with FLAK [P = 5.27 × 10(-5) (4.0 mm) and P = 1.02 × 10(-5) (6.0 mm)] and PKP [P = 1.82 × 10(-4) (4.0 mm) and P = 1.56 × 10(-4) (6.0 mm)] but greater total posterior HOAs than FLAK [P = 0.001 (4.0 mm) and P = 0.007 (6.0 mm)] and PKP [at 4.0-mm optical zone (P = 0.047)]. FLAK had fewer total anterior and posterior HOAs than PKP, but differences were not statistically significant. DSAEK grafts exhibited statistically significantly greater posterior HOAs than either type of PKP. The magnitude of anterior and posterior HOAs weakly correlated with BSCVA. Conclusions DSAEK induces fewer anterior surface HOAs but greater posterior surface HOAs than FLAK or PKP. Differences between FLAK and PKP are not statistically significant. Anterior and posterior HOAs correlate weakly with poorer visual outcome and likely contribute to decreased BSCVA after keratoplasty.