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Aim To analyze the changing trends in penetrating keratoplasty (PKP) indications. Methods This retrospective study included all patients with PKP between 2006 and 2017. Patients were classified using histological diagnoses. Our groups were as the following: pseudophakic or aphakic bullous keratopathy, regraft, acute necrotizing and ulcerative keratitis, keratoconus, Fuchs' dystrophy, corneal dystrophy other than Fuchs', corneal scar, other diagnoses and failed endothelial keratoplasty graft. Additionally, two different time-periods (2006-2012 and 2013-2017) were analysed. Results Totally 1721 histological analyses of 1214 patients were available for review. The diagnoses were pseudophakic or aphakic bullous keratopathy in 487 (28.3%), regraft in 443 (25.7%), acute necrotizing and ulcerative keratitis in 313 (18.2%), corneal scar in 153 (8.9%), keratoconus in 140 (8.1%). Fuchs' dystrophy in 61 (3.5%), corneal dystrophy other than Fuchs' in 46 (2.7%), other diagnoses in 44 (2.6%) and failed endothelial keratoplasty graft in 34 (2.0%) cases. From the first to the second analysed time-period, incidence of acute necrotizing and ulcerative keratitis, corneal scar, Fuchs' dystrophy increased (P≤0.032 for all) and incidence of keratoconus significantly decreased (P=0.015). Conclusion Pseudophakic or aphakic bullous keratopathy is the leading indication for PKP, followed by regraft and acute necrotizing and ulcerative keratitis.

AimTo describe the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with an anterior chamber intraocular lens (ACIOL) compared to secondary posterior chamber (PC) IOL.MethodsThis was a retrospective comparative cohort study. The clinical data of 82 eyes from 82 consecutive patients with pseudophakic (PBK) or aphakic bullous keratopathy (ABK) who either underwent DSAEK with retained or secondary ACIOL (n=23) or DSAEK with IOL exchange and/or secondary PCIOL (retropupillary iris-claw IOL, n=25; intrascleral-fixated IOL, n=29; or sulcus IOL, n=5) were analysed. The main outcome measures were graft survival and complications up to 5 years.ResultsThe graft survival in the secondary PCIOL group was superior than the ACIOL group over 5 years (year 1, 100.0% vs 100.0%; year 3, 94.7% vs 75.0%; year 5, 91.1% vs 60.6%, p=0.022). The presence of an ACIOL was a significant risk factor associated with graft failure (HR, 4.801; 95% CI, 1.406 to 16.396, p=0.012) compared to a secondary PCIOL. There was no significant difference in the rate of graft detachment and elevated intraocular pressure between the groups. There were five cases (9.3%) of IOL subluxation or dislocation in the retropupillary iris-claw and intrascleral-fixated IOL groups.ConclusionsEyes that underwent DSAEK with ACIOL in situ had poorer long-term graft survival compared with those with secondary PCIOL. Intraocular lens exchange was not associated with a higher complication rate. In ABK or PBK eyes with ACIOL, we recommend performing IOL exchange and/or secondary PCIOL implantation combined with endothelial keratoplasty.

Purpose: To present the results of a modified sutured transcleral or sutureless intrascleral three-piece foldable intraocular lens (IOL) implantation with Descemet membrane endothelial keratoplasty...

Background The purpose of this work was to study the evolving trends in techniques and indications for corneal transplantation in Poland. Methods This retrospective, descriptive analysis of corneal transplantations was performed at the Ophthalmology Department of Saint Barbara Hospital, Trauma Center, Sosnowiec, Poland, between 1988 and 2014. Structure of indications and surgery type rates over 26 years were tabulated by means of 5-year intervals. Results Between 1989 and 2014, 1762 corneal transplantations were performed, including 1375 (78%) cases of penetrating keratoplasty, 137 (8%) lamellar keratoplasty, 112 (6%) patch grafts, and 138 (8%) keratolimbal allografts. The major indications and their respective overall percentage were corneal leucoma (24%), pseudophakic/aphakic bullous keratopathy (22%), Fuchs dystrophy (13%), keratoconus (13%), re-graft (11%), keratitis (9%), and limbal stem cell deficiency (8%), with changes in relative frequency of the leading indications over the following time intervals. The number of corneal transplantations gradually increased during the years reviewed. The rates of lamellar, keratolimbal, and patch grafts have grown dynamically since 2010, reaching 20%, 17%, and 12%, respectively, of procedures performed during 2010 to 2014. Conclusions Over the past quarter of a century, there has been evolution in corneal transplantation service, from the first penetrating keratoplasty to the wide spectrum of procedures, including femtosecond laser–assisted keratoplasty. Although, since 2010, the rates of lamellar and keratolimbal allografts have grown rapidly, penetrating keratoplasty has remained the leading technique.

OBJECTIVES To determine whether indications for keratoplasty differ between academic centers and the Eye Bank Association of America (EBAA) annual statistics from 2002 to 2012. METHODS A retrospective review was performed for the indications for keratoplasty from 2002 to 2012 based on surgical specimens originating from three different academic centers. Data were compared with statistical reports obtained from the EBAA for the corresponding years. RESULTS From 2002 to 2007, at Washington University in St Louis (WU), the most common indication for keratoplasty was graft failure at 31.6%. At St Louis University, the most common indications for keratoplasty were pseudophakic and aphakic bullous keratopathy (PBK/ABK) at 34.6% followed closely by graft failure at 32.7%. Combining the 2002 to 2007 EBAA data, the most common indication for keratoplasty was PBK/ABK at 19.5%, whereas regrafts accounted for only 13.0% of keratoplasties. From 2008 to 2012, regrafts accounted for 41.9% of keratoplasties at WU and 33.1% of keratoplasties at University of California, Davis. In contrast, the EBAA data showed that only 11.4% of keratoplasties were regrafts. CONCLUSIONS Graft failure accounted for approximately 30% to 40% of indications for keratoplasties at three academic centers from 2002 to 2012, which was more than double and in some cases triple that of the EBAA data during this period. These higher frequencies of regrafting may represent a referral bias of patients with complicated cases to academic centers who then require multiple keratoplasties.

Objective: For nearly a century, penetrating keratoplasty has been the surgical technique of choice in the management of corneal changes. However, in recent years, several lamellar keratoplasty techniques have been developed, modified or improved, especially techniques for replacing the posterior portion, for the correction of bullous keratopathy. The aim of this study was to evaluate the effectiveness and safety of endothelial keratoplasty versus penetrating keratoplasty for pseudophakic and aphakic bullous keratopathy. Methods: A systematic review of the literature was carried out, and the main electronic databases were searched. The date of the most recent search was from the inception of the electronic databases to December 11, 2015. Two authors independently selected relevant clinical trials, assessed their methodological quality and extracted data. Results: The electronic search yielded a total of 893 published papers from the electronic databases. Forty-four full-text articles were retrieved for further consideration. Of these 44 full-text articles, 33 were excluded because they were all case series studies; therefore, ten studies (with one further publication) met the inclusion criteria: one randomized clinical trial with two publications; three controlled studies; and six cohort studies. The clinical and methodological diversity found in the included studies meant that it was not possible to combine studies in a metaanalysis. Conclusions: There is no robust evidence that endothelial keratoplasty is more effective and safe than penetrating keratoplasty for improving visual acuity and decreasing corneal rejection for pseudophakic and aphakic bullous keratopathy. There is a need for further randomized controlled trials. RESUMO Objetivo: Durante quase um século, a ceratoplastia penetrante tem sido a técnica cirúrgica de escolha no tratamento de doenças corneais. No entanto, nos últimos anos, têm sido desenvolvidas várias técnicas de transplante lamelar, especialmente modificadas ou aperfeiçoadas para substituir a porção posterior para a correção da ceratopatia bolhosa. O objetivo deste estudo foi avaliar a eficácia e segurança da ceratoplastia endotelial quando comparada a ceratoplastia penetrante para a ceratopatia bolhosa afácica ou pseudofácica. Métodos: Uma revisão sistemática da literatura foi realizada, e as principais bases de dados eletrônicas foram pesquisadas. A data das bases de dados da última pesquisa foi 11 de dezembro de 2015. Dois autores selecionaram independentemente os estudos relevantes, avaliaram sua qualidade metodológica e extraíram os dados. Resultados: A busca eletrônica resultou em um total de 893 artigos publicados a partir das bases de dados eletrônicas. Quarenta e quatro artigos de texto completos foram recuperados para uma análise mais aprofundada. Destes 44 artigos de texto completos, 33 foram excluídos por serem estudos de séries de casos, portanto, dez estudos (com uma publicação adicional) preencheram os critérios de inclusão: um ensaio clínico randomizado, três estudos controlados e seis estudos de corte. A diversidade clínica e metodológica encontrada nos estudos incluídos tornou impossível combinar os resultados em uma metaanálise. Conclusões: Não há evidencias robustas de que a ceratoplastia endotelial é mais eficaz e segura do que o transplante penetrante de córnea para melhorar a acuidade visual e diminuir a rejeição da córnea na ceratopatia bolhosa afácica ou pseudofácica. Há necessidade de mais estudos controlados, randomizados.

EK has become the standard of care for corneas with endothelial failure, most commonly Fuchs’, phakic or aphakic bullous keratopathy, failed PK, and the ICE syndromes [1–8]. EK now consists of two main procedures, DSAEK and DMEK (Figs. 3.1 and 3.2). Each procedure replaces the diseased endothelium without surface trephinations, avoiding all the pitfalls of PK. DSAEK donors are comprised of a layer of donor stroma (approximately 125 μm) as a carrier for the donor endothelium while DMEK is pure Descemet’s membrane and endothelium (15 μm). The difference in the donor’s thickness makes the two procedures surgically distinct, but the underlying principles between them are the same. The goal is donor adherence onto the host’s inner surface, thereby creating a new functioning endothelium. This is accomplished with an air bubble (or gas) to tamponade the donor into position.

The surgical indication for Descemet-stripping automated endothelial keratoplasty (DSAEK) is largely limited to phakic or pseudophakic cases of endothelial dysfunction with normal pupils, because the endothelial lenticule is generally attached to the recipient cornea by use of gas tamponade into the anterior chamber. Although it may be desirable for vitrectomized cases with aniridia and aphakic bullous keratopathy without capsule support to undergo DSAEK, one of the major problems is lenticule detachment during surgery or in the postoperative period. To perform DSAEK in such cases, special surgical techniques are needed in order to facilitate adhesion of the lenticule. Herein, we describe a suture technique for attaching the endothelial lenticule in DSAEK for aniridic and aphakic cases that have undergone vitrectomy for traumatic vitreoretinal disease.

Background/aims To review the indications and types of keratoplasty performed in the West of Scotland between 2001 and 2010. Methods A retrospective analysis of the histopathological diagnoses of all corneal buttons submitted to the regional Ocular Pathology Laboratory (Glasgow, UK) between January 2001 and December 2010 was performed. Results Between 2001 and 2010, a total of 921 keratoplasties were performed in the West of Scotland. These included 646 (70.1%) penetrating keratoplasties and 275 (29.9%) lamellar keratoplasties (LK). Keratoconus (n¼264, 28.7%) was the leading indication for keratoplasty, followed by graft failure (n¼177, 19.2%), Fuch’s endothelial dystrophy (n¼124, 13.5%), keratitis (n¼106, 11.5%), pseudophakic/aphakic bullous keratopathy (n¼88, 9.6%), endothelial failure (n¼67, 7.3%), non-Fuch’s corneal dystrophies (n¼21, 2.3%), trauma (n¼19, 2.0%), autoimmune/inflammatory diseases (n¼16, 1.7%) and others (n¼39, 4.2%). A significant increase in the proportion of LK over penetrating keratoplasty was observed during this 10year period: from 14.1% LK (2001e2005) to 40.4% LK (c 2 ¼71.78, p value

The indications for penetrating keratoplasty have changed over the past several years. One hundred and eighty cases of penetrating keratoplasty performed in the Department of Ophthalmology, Naestved Centralsygehus, Denmark, from January 1984 to December 1993, were analysed. Overall pseudophakic bullous keratopathy was the most common indication for penetrating keratoplasty (28.3%). This was followed by keratitis (13.9%), Fuchs' dystrophy (13.9%), regraft (11.1%), aphakic bullous keratopathy (10.0%) and keratoconus (6.7%). Pseudophakic bullous keratopathy was the most common indication for penetrating keratoplasty in 1989 and in each year from 1991 to 1993. Before 1989 the most common indications were keratitis (18.0%) and aphakic bullous keratopathy (14.8%). The emergence of pseudophakic bullous keratopathy, as the most common indication for penetrating keratoplasty, correlates well with the dramatic increase in the number of cataract extractions with intraocular lens implantation performed since the early 1980s. Especially semiflexible, closed-loop anterior chamber lenses used in our department in the early years of the period, have been the cause of subsequent corneal edema.

Purpose To compile a survey of complications during and after Descemet's stripping with automated endothelial keratoplasty (DSAEK) in 118 eyes conducted by cornea subspecialists at a single academic center. Design Retrospective case series. Participants One hundred eighteen eyes undergoing DSAEK in 99 patients. Methods Outcomes of DSAEK performed in 118 eyes by 10 surgeons were reviewed retrospectively. Sixty-four eyes had pseudophakic bullous keratopathy. Forty-one had Fuchs' endothelial dystrophy and cataract. Three had aphakic bullous keratopathy. In 10 eyes, previous DSAEK performed at the same institution failed. Complications of DSAEK were noted from the intraoperative and postoperative periods. Detached DSAEK grafts were repositioned, rebubbled, or both immediately after diagnosis of this complication. Main Outcome Measures Intraoperative and postoperative complications of DSAEK. Results Graft detachment was the most common type of complication encountered. In 27 (23%) of 118 eyes, graft detachments were observed. Twenty-five eyes with detached grafts successfully were repositioned or rebubbled after surgery, or both. In 1 eye, a previously detached graft reattached spontaneously. In 1 aphakic eye, the graft detached into the vitreous cavity. In 17 eyes, successful reattachment of the cornea occurred (68%). Twenty-one of the 118 eyes were considered to have failed DSAEK, meaning that persistent edema was present after DSAEK. Seven (6%) demonstrated graft rejection. In 5 eyes (4%), retinal detachment (RD) developed. In 6 (5%), cystoid macular edema developed. In 1 aphakic patient, an air bubble could not be maintained during surgery, and sulfur hexafluoride was injected into the anterior chamber. In 1 eye (1%), epithelial ingrowth developed. One eye (1%) demonstrated blood in the graft interface. In 1 eye (1%), a limited intraoperative suprachoroidal hemorrhage occurred. Two eyes (2%) had pupillary block after surgery that resolved with removal of the air bubble. Conclusions Descemet's stripping with automated endothelial keratoplasty has become a popular and effective treatment for corneal endothelial dysfunction, but complications resulting from DSAEK do occur. Graft detachment is the most common complication, but postoperative repositioning or rebubbling, or both, allow for graft reattachment in most cases. Other complications found in this series were graft failure, graft rejection, cystoid macular edema, RD, suprachoroidal hemorrhage, and pupillary block. Retained Descemet's membrane and epithelial ingrowth, are potential causes of dislocation. Financial Disclosure(s) The authors have no proprietary or commercial interest in any materials discussed in this article.

To evaluate the efficacy of combined procedure of Descemet's membrane endothelial keratoplasty (DMEK) and posterior iris-claw-fixated intra ocular lens (IOL) implantation in the management of aphakic bullous keratopathy (ABK). Sankara eye centre, a tertiary eye care centre. A prospective case series analysis. A prospective study comprised ten eyes of ten patients who underwent DMEK and posterior iris-claw-fixated IOL. Mean follow-up period was 12-36 months. Pre-operative and post-operative best corrected visual acuity (BCVA), endothelial cell density (ECD) and complications were noted. A total ten eyes of ten patients underwent DMEK. Out of ten patients BCVA improved from 1.00 to 1.60 LogMAR with mean and SD of 1.40 ± 0.20 to +0.20-0.40 LogMAR with mean and SD of 0.30 ± 0.07, with a significant p value of

Aim: To study the indications of penetrating keratoplasty in Southern India. Settings and Design: Retrospective study. Material and Methods: Retrospective evaluation of eye bank records from December, 2002 to December, 2012 with respect to indications for penetrating keratoplasty. Results: During the period considered for study, 102 penetrating keratoplasties were performed. The leading indications for penetrating keratoplasty were corneal scarring (60.7%), followed by regrafting (12.7%), spheroidal degeneration (9.8%), aphakic bullous keratopathy (5.88%), pseudophakic bullous keratopathy (2.94%), acute infectious keratitis (2.94%), corneal dystrophy and keratoconus (4.9%). Healed infectious keratitis (72.88%) was the most common subcategory among the eyes with corneal scarring followed by traumatic corneal scars (16.12%). Conclusion: Corneal scarring from healed infectious keratitis are the most common indication for keratoplasty in Southern India.

PURPOSE To determine the indications for penetrating keratoplasty (PK) in Iran. METHODS : All eye bank records of patients who had undergone PK between 1994 and 2004 at ophthalmic centers throughout the country were reviewed. RESULTS During this 11-year period, a total of 19,668 cases were operated on. The most common indication for PK was keratoconus (n = 6787, 34.51%), followed by corneal opacity and scar (n = 3674, 18.68%), pseudophakic bullous keratopathy (n = 1808, 9.19%), corneal dystrophies (n = 1272, 6.47%), aphakic bullous keratopathy (n = 1198, 6.09%), and regraft (n = 1038, 5.28%). There was an increasing trend in rates of keratoconus and pseudophakic bullous keratopathy and a decreasing trend in aphakic bullous keratopathy over this period (P < 0.001). No significant change of trend was noted in the corneal opacity and scar, regraft, and corneal dystrophy groups. CONCLUSIONS Keratoconus is the most common indication for PK in Iran.

Purpose: To identify the indications for penetrating keratoplasty in northern India. Methods: All the eye bank records of penetrating keratoplasties performed during the period from June 1997 to November 2003 at Rajendra Prasad Center for Ophthalmic Sciences were reviewed. Results: During this period, 2022 penetrating keratoplasties were performed. The leading indications for penetrating keratoplasty were corneal scarring (38.03%) followed by acute infectious keratitis (28.38%), regrafting (11.5%), aphakic bullous keratopathy (7.27%), pseudophakic bullous keratopathy (6.18%), and corneal dystrophy (3.85%). Healed infectious keratitis (19.83%) was the most common subcategory among the eyes with corneal scarring followed by traumatic corneal scars (16.71%). Healed (19.83%) and active keratitis (28.38%) together accounted for the majority of keratoplasties (48.21%). In cataract-related corneal edema (13.45%), aphakic bullous keratopathy (7.27%) was almost as frequent as compared with pseudophakic bullous keratopathy (6.18%). Conclusions: Corneal infections either active or healed are the most common indication for keratoplasty in northern India.

“All our words are but crumbs that fall down from the feast of the mind” -Khalil Gibran It is not rare to come across an eye, which on the first look appears irrecoverably lost. However, a step by step management after ensuring adequate retinal function, tackling one pathology at a time often produces some visual benefit, even in the most morbid looking eyes. We present a case report of a 82-year-old lady who presented to us with an Intercalary and Ciliary Staphyloma with Aphakic Bullous Keratopathy Right Eye. Her eagerness to get some vision in her eye encouraged us to undertake the stepped surgical intervention, resulting in a visually useful eye.

Marcus Ang1,2, Jodhbir S Mehta1–4, Arundhati Anshu1,2, Hon Kiat Wong5, Hla M Htoon2, Donald Tan1–31Singapore National Eye Centre, 2Singapore Eye Research Institute, 3Department of Ophthalmology, National University Health Systems, 4Department of Clinical Sciences, Duke-NUS Graduate Medical School, 5Department of Ophthalmology, Tan Tock Seng Hospital, SingaporeBackground: The purpose of this study was to compare endothelial cell counts after Descemet’s stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty in Asian eyes.Methods: This was a retrospective study of patients from our prospective Singapore Corneal Transplant Study cohort who received corneal transplantation in 2006–2008. We compared eyes that underwent DSAEK or penetrating keratoplasty for Fuchs’ endothelial dystrophy or pseudophakic and aphakic bullous keratopathy. Clinical data, and donor and recipient characteristics were recorded. Of 241 patients who met our inclusion criteria, 68 underwent DSAEK and 173 underwent penetrating keratoplasty. The main outcome measure was endothelial cell loss at 1 year. Secondary outcome measures were graft survival and visual outcomes at 1-year follow-up.Results: There were no significant differences in baseline characteristics of patients between the treatment groups. Percent endothelial cell loss at 1-year follow-up was greater in penetrating keratoplasty eyes (40.9% ± 2.9%) compared with DSAEK eyes (22.4% ± 2.3%; P < 0.001). DSAEK-treated eyes had significantly superior uncorrected visual acuity (mean difference = 0.42 ± 0.0059; P < 0.001) and best spectacle-corrected visual acuity (mean difference = 0.14 ± 0.032; P < 0.001) as compared with penetrating keratoplasty-treated eyes. Penetrating keratoplasty-treated eyes had worse astigmatism as compared with DSAEK-treated eyes (-3.0 ± 2.1 versus -1.7 ± 0.8; P < 0.001). Graft survival at 1 year was comparable in both groups, ie, 66/68 (97.0%) DSAEK-treated eyes versus 158/173 (92.0%) of penetrating keratoplasty-treated eyes had clear grafts (P = 0.479).Conclusion: We report lower percent endothelial cell loss comparing DSAEK and penetrating keratoplasty at 1-year follow-up in Asian eyes, with comparable graft survival rates in both groups.Keywords: Descemet’s stripping automated endothelial keratoplasty, endothelial cell count, penetrating keratoplasty

To report the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK).A retrospective case series was conducted on 51 patients who underwent DSAEK 5 years ago. DSAEK was performed for Fuchs corneal dystrophy, pseudophakic or aphakic bullous keratopathy, or failed penetrating keratoplasty (PKP). Best spectacle-corrected visual acuity (BSCVA), endothelial cell counts (ECC), and current graft status were ascertained for the eyes included in the study. Episodes of rejection and need for repeat transplantation were also analyzed.Forty-seven of 51 eyes had clear grafts at the most recent postoperative visit. There were 4 graft failures treated with repeat DSAEK, and regrafts are also clear to date. One eye had an episode of rejection that was successfully treated with topical steroids.Long-term results of DSAEK were excellent. Grafts were clear despite lower than normal endothelial cell counts. To our knowledge, this is the longest running study of DSAEK outcomes to date.

Objectives: To describe the surgical technique of penetrating keratoplasty (PKP) combined with scleral fixation of posterior chamber intraocular lens (PC-IOL). To determine the visual outcome and complications of PKP combined with scleral fixation of PC-IOL. Study Design: Prospective study. Setting: Department of Ophthalmology and Ophthalmic out-patient clinic, Nahariya Medical Center, Israel. Patients: 10 patients, aged 47–81 (mean 66.4 years), underwent PKP combined with scleral fixation of PC-IOL and were followed for periods of 20–34 months (mean 27.4 months). Seven of the patients had aphakic bullous keratopathy, one had Fuch's corneal dystrophy with cataract and two had corneal opacities and cataract. Main Outcome Measures: Periodic visual acuity, complete eye examination and fluorescein angiography, when indicated. Results: Visual acuity improved in all patients from light perception to counting fingers preoperatively, to 20/40 to 20/300 postoperatively. Pre-existing ocular pathologic findings were the main reason for only partial improvement of visual acuity in some of the patients. No significant complications were encountered in any of the patients. Conclusions: Scleral fixation of PC-IOL may be considered as an alternative surgical procedure to anterior chamber IOL implantation when combined with PKP and when capsular or zonular support is absent or unsafe.

We report a modified technique of direct scleral fixation of a posterior chamber intraocular lens (PC-IOL) using a specially designed intraocular needle-holder. The procedure was carried out in three eyes with posttraumatic subluxated cataracts; one with aphakic bullous keratopathy and with an accidental posterior capsular rent, and one with a superior zonulodialysis. The needle-holder greatly facilitated the procedure, enabling us to place the PC-IOL precisely in the ciliary sulcus with no subsequent decentration. This method avoids iris fixation and provides more secure scleral fixation of the PC-IOL.

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.

A 78-year-old female patient who had a third penetrating keratoplasty for aphakic bullous keratopathy and iris fixation of a posterior chamber intraocular lens using a single, 10-0 nylon running suture technique developed a suture track leak postoperatively. Attempts to ease the tension on the suture track reduced the astigmatism and stopped the leak temporarily. Eighteen months after the procedure, epithelial downgrowth was noted on the corneal graft on both sides of the leak site and intraocular pressure was elevated. A fourth penetrating keratoplasty combined with a trabeculectomy was performed. To our knowledge, this is the first report of epithelial downgrowth associated with suture adjustment following the single, continuous suture technique.

Objective: To evaluate the safety and efficacy of aphakic bullous keratopathy (ABK) management with combined PK, anterior vitrectomy, angle synechiolysis, and Artisan intraocular lens implantation. Methods: Fourteen eyes of 11 patients underwent the procedure. Mean follow-up was 12–36 months (mean 24) for visual acuity (Va), refractive error (RE), intraocular pressure (IOP), tonography, graft clarity, intraocular lens centration, and any complications. Results: The postoperative mean values were: Va improved from 20/400 to 20/50, spherical RE was –2.65 diopters, IOP was 17.5 mmHg, tonography improved by 55%, all grafts were clear; no IOL decentrations or serious complications were noted. Conclusions: This iris-fixated intraocular lens appears to offer simplicity in implantation and may be combined with PK, anterior vitrectomy, and angle synechiolysis. It may be a safe and effective alternative with PK in the management of ABK.

Background: An increase in intraocular pressure (IOP/glaucoma) any time after penetrating keratoplasty (PK) leads to a significant endothelial cell loss with dire consequences. The present study was conducted to know the incidence of increased IOP and factors associated with it following optical PK. Materials and Methods: A prospective study was conducted at Ophthalmology Department of PDU Medical College and Civil Hospital Rajkot, a secondary level center for 2 years from May 2010 to April 2012. A total of 50 patients admitted for optical PK during the study period were enrolled. Detailed history was elicited regarding ocular problem and any treatment taken for the same. Results: Nearly 30% of the patients reported an increase in IOP in the present study. Majority (58.0%) patients were above the age of 55 years. Based on preoperative diagnosis, increase in IOP was reported among patients with aphakic bullous keratopathy (100.0%), adherent leucoma (50.0%), graft failure (44.4%) and pseudophakic bullous keratopathy (25.0%). After 1 month of optical PK, 18.0% patients reported an increase in IOP, 28.0% after 2 months and 26.0% after 3 months. Out of 15 patients who reported an increase in IOP, 14 (93.3%) were given medical treatment and 1 (6.7%) patient required surgical treatment. Conclusion: Age above 55 years, preoperative diagnosis of adherent leucoma, aphakic eyes were major risk factors for the post-operative increase in IOP in the present study. Peak rise in IOP was reported following 2 months post keratoplasty. Post PK glaucoma in the majority of patients responded to medical treatment.

Objetivos: Avaliar as indicações mais freqüentes, bem como o resultado da acuidade visual final após a ceratoplastia penetrante, realizadas por residentes em treinamento. Métodos: Avaliaram-se retrospectivamente 159 casos de ceratoplastia penetrante realizadas no período de janeiro de 1991 a outubro de 1998, na Faculdade de Medicina de São José do Rio Preto - Hospital de Base, correlacionando-os em termos de indicação para ceratoplastia penetrante e acuidade visual final. O tempo mínimo de acompanhamento para obtenção da acuidade visual final foi de seis meses. Para comparação e análise estatística da acuidade visual final, os casos de ceratoplastia penetrante foram divididos em seis grupos de diagnóstico pré-operatório: ceratocone, ceratopatia bolhosa pseudofácica, ceratopatia bolhosa afácica, distrofia endotelial de Fuchs, ceratopatia em faixa e leucomas. Todas as cirurgias foram realizadas por residentes em treinamento, sob supervisão docente. Resultados: O ceratocone foi o grupo que atingiu um maior aumento médio de acuidade visual pós-operatória em linhas (7,55 ± 2,83) e a ceratopatia em faixa o menor (0,33 ± 3,20). Constatou-se significativa diferença entre as indicações encontradas nos países desenvolvidos, onde se observa predominância de ceratocone. De acordo com nosso estudo, as principais indicações para ceratoplastia penetrante foram, em ordem decrescente, leucoma, ceratopatia bolhosa pseudofácica, ceratocone, distrofia endotelial de Fuchs, ceratopatia bolhosa afácica e ceratopatia em faixa. Conclusão: O ceratocone apresentou diferença significativa (p < 0,05) em termos de melhora de acuidade visual final quando comparado com os outros 5 grupos de indicação para ceratoplastia penetrante. Purpose: This study was designed to evaluate the most frequent indications, as well as the results of final visual acuity (VA) after penetrating keratoplasty (PK), performed by residents. Methods: A consecutive series of 159 cases of PK was followed during the period from January 1991 to October 1998, at the Medical School of São Jose do Rio Preto - "Hospital de Base", in terms of indication for penetrating keratoplasty and final visual acuity. The minimum follow-up to assess the final visual acuity was 6 months. The cases of penetrating keratoplasty were divided into 6 groups of preoperative diagnosis for better comparison and statistical analysis of the final visual acuity. Such groups were: keratoconus, pseudophakic bullous keratopathy, aphakic bullous keratopathy, Fuchs' endothelial distrophy, band keratopathy and leukomas. All surgeries were performed by residents under supervision. Results: Keratoconus was the group that reached the highest average increase of postoperative lines of visual acuity (7.55 ± 2.83) and band keratopathy the smallest one (0.33 ± 3.20). A significant difference was observed among the indications for penetrating keratoplasty when compared to developed countries, where keratoconus is the most predominant indication. Our analysis revealed that the most important indications for penetrating keratoplasty in decreasing order were: leukoma, pseudophakic bullous keratopathy, keratoconus, Fuchs' endothelial distrophy, aphakic bullous keratopathy and band keratopathy. Conclusion: Keratoconus showed significant difference of final visual acuity levels (p value < 0,05) when compared to the other 5 groups of penetrating keratoplasty indications.

To evaluate the indications for and outcomes of repeat penetrating keratoplasty over a 7-year period and compare them to a similar study over the prior 6-year period at the same institution.Retrospective noncomparative case series.Two hundred twenty-three consecutive repeat corneal transplants performed by one of five corneal surgeons between 1989 and 1995 were studied.Reasons for primary and regraft failure, indications for the initial corneal graft, graft clarity, and best-corrected visual acuity were measured on each patient.Between 1989 and 1995, 16% (271 of 1689) of transplants performed by our cornea group were regrafts compared with 9% (165 of 1860) in the period from 1983 to 1988 (P0.01). The most common indications for penetrating keratoplasty before regraft were pseudophakic bullous keratopathy (27%, 61 of 223), failed graft (20%, 44 of 223), Fuchs' dystrophy (11%, 24 of 223), aphakic bullous keratopathy (9%, 21 of 223), keratoconus (8%, 17 of 223), and herpes simplex keratitis (6%, 14 of 223). Compared with the prior study period of 1983 to 1988, an increase was revealed in the incidence of failed graft (11% to 20%, P = 0.03), and a decrease was revealed in the incidence of aphakic bullous keratopathy (19% to 9%, P = 0.01). Of the 223 regrafts, 55 (25%) failed during the study period (range, 1 month to 7.5 years; mean 2.1 years). Eleven percent (6 of 55) of regraft failures occurred within 6 months, and 55% (30 of 55) failed within 18 months. Of the 150 regrafts with 2 years follow-up (mean, 3.9 years), 111 (74%) had clear grafts. A best-corrected visual acuity of 20/20 to 20/40 was achieved in 41% (46 of 111), 20/50 to 20/100 in 32% (36 of 111), 20/200 to 20/400 in 21% (23 of 111), and counting fingers to no light perception in 5% (6 of 111).Failed grafts are increasing as an indication for penetrating keratoplasty. Graft clarity and visual acuity results continue to be very good, supporting the use of repeat corneal transplantation.

Purpose To study the appearance of a fibrous retrocorneal membrane as seen by confocal microscopy. Methods A 67-year-old white woman with a history of multiple ocular surgeries, including repeated penetrating keratoplasties for aphakic bullous keratopathy, developed a retrocorneal membrane in the right eye. The membrane was first noticed 3 years after the last corneal transplant and remained stable subsequently. The patient was examined by in vivo white light tandem-scanning confocal microscopy. Results At the level of the retrocorneal membrane, confocal microscopy disclosed the presence of a hyperreflective fibrous-appearing layer. Normal endothelial cells could not be found. Anterior to the hyperreflective layer, activated keratocytes were identified. Conclusion Confocal microscopy may allow noninvasive diagnosis of fibrous retrocorneal membrane. Additionally, our data suggest that the posterior keratocytes might play a role in the production and deposition of fibrous tissue.

SUMMARY Concerns on anterior chamber intraocular lens (AC lOL) implantation are often raised due to the association of complications with the old-styled closed-loop AC lOL, especially those implanted in the mid-1980’s. Although those lenses are no longer marketed, there are still more than 200,000 patients with this type of lens in place in the United States. There are evidences that the new-style open-loop AC lOL may not be associated with the problems caused by closed-loop AC lOL. We report our experience in patients with pseudophakic bullous keratopathy (PBK) and aphakic bullous keratopathy (ABK) that underwent penetrating keratoplasty (PK) associated with AC lOL exchange (pseudophakic) or secondary implantation (aphakic). RESUMO Devido às complicações associadas às lentes intra-oculares de câmara anterior do tipo “alça fechada”, muito usada nos anos 80, o uso de lente de câmara anterior tem sofrido críticas, ora relacionadas à sua influência sobre a fisiologia do endotélio, ora relacionadas ao comprometimento do seio camerular, levando à progressiva formação de sinéquias anteriores. Essa preocupação se deve ao grande número de artigos publicados relacionando às lentes de “alça fechada”, a chamada “epidemia de ceratopatia bolhosa” durante o início dos anos 90. Encontramos porém evidências na literatura desassociando as modernas lentes de câmara anterior de “alça aberta” de tais complicações. Neste estudo reportamos nossa experiência com implante lentes de câmara anterior de “alça aberta” em pacientes portadores de ceratopatia bolhosa pseudofácica (explante com substituição) e afácica (implante secundário) em pacientes submetidos a concomitante transplante penetrante de córnea.

Purpose: To study the changing indications for penetrating keratoplasty in Singapore and compare local indications with developed countries with established corneal graft programs. Methods: A descriptive study of all penetrating keratoplasty cases performed in the Singapore National Eye Center over a 5 year period, from 1 January 1991 to 31 December 1995 using records of the Singapore Eye Bank registry. Results: A total of 327 penetrating keratoplasties were performed. Bullous keratopathy was the indication in more than a quarter of all cases (26.3%). Aphakic bullous keratopathy (11.6%) and pseudophakic bullous keratopathy (11.3%) accounted for the majority of the bullous keratopathy cases. The other leading indications were: regrafts (11.9%), corneal dystrophies (10.4%), traumatic scarring (10.1%) and keratoconus (9.8%). A higher proportion of aphakic and pseudophakic bullous keratopathy as well as regrafts was noted in this series, compared to a previous report on corneal transplantation in the 1980s. A rising indication rate of pseudophakic bullous keratopathy, in conjunction with a declining indication rate of herpetic keratitis was observed over the 5 year study period. Conclusions: The indications for penetrating keratoplasty in Singapore appear to follow the trend seen in developed Western countries over the past few decades.

To identify patient characteristics influencing treatment outcomes of allograft corneal rejection.Retrospective case file review.Files containing details of first episode of corneal allograft rejections in patients who underwent penetrating keratoplasty at the Royal Victorian Eye and Ear Hospital, Melbourne, Australia from 1991 to 2006 were reviewed. Cases were divided into 2 groups based on the response to treatment for graft rejection: treatment responders and failures. Main parameters evaluated were demographic characteristics, preoperative clinical profile, donor characteristics, surgical technique, presentation, and treatment of rejection episode.A total of 235 cases of graft rejection were identified, of which 195 cases (83%) were successfully treated and 40 (17%) failed to respond. Age (P = .08) and gender (P = .61) were comparable in both groups. On univariate analysis, primary diagnosis of keratoconus (P = .04) and phakic lens status at the time of surgery (P = .02) were more common in treatment responders whereas aphakic bullous keratopathy (P ≤ .01), history of glaucoma (P.01), aphakia (P.01), and previous grafts (P.01) were more common among treatment failures. Multivariate analysis revealed that preoperative corneal neovascularization (adjusted odds ratio [aOR] 3.6, 95% CI: 1.3-9.7, P = .01), a larger (9 mm) donor size (aOR 5.7, 95% CI: 1.3-24.9, P = .02), and corneal edema at presentation (aOR 4.7, 95% CI: 1.7-13.2, P.01), were independently associated with failure of treatment of graft rejection.Treatment failure in cases of corneal allograft rejection is more likely to occur among patients with corneal neovascularization, large donor graft buttons, and corneal edema at presentation.

PURPOSE To examine the leading indications for penetrating keratoplasty. METHODS We retrospectively performed a chart review of 904 cases of penetrating keratoplasty over a 10-year period (1986-1995). Where possible, the clinical indication was corroborated by the pathological report. RESULTS Leading indications included pseudophakic bullous keratopathy (PBK; 28.5%), regraft (22.4%), keratoconus (10.0%), Fuchs' dystrophy (7.6%), aphakic bullous keratopathy (ABK; 6.1%), herpetic keratopathy (4.2%), bacterial infection (4.2%), physical trauma (4%), interstitial keratitis (3.7%), and corneal scarring (2.8%). The most common type of intraocular lens found in patients with PBK was the anterior-chamber lens [AC IOL, 71.6%; posterior-chamber lens (PC IOL), 16%; iris-plane IOL (IP IOL; 12.5%]. In our series, we noted decreasing trends in the incidences of ABK (p < 0.001) and PBK (p < 0.04) and an increasing trend in the incidence of regraft (p < 0.0083). Our data do not show statistically significant changes in the incidences of Fuchs' dystrophy and keratoconus. Gender differences were present for Fuchs' dystrophy with female exceeding male patients by a 3:1 ratio (p < 0.001). Male exceeded female patients by 2:1 for keratoconus (p < 0.001). Male exceeded female patients by 3:1 for trauma (p < 0.001). CONCLUSIONS In this series, the leading indications for penetrating keratoplasty were found to be generally in agreement with the data reported in recent literature. Variations may reflect the wide variations in practice and referral patterns.

PURPOSE To evaluate the long-term graft survival and complications of flexible, open-loop anterior-chamber intraocular lenses in patients with penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy. METHODS We reviewed charts of all consecutive patients who underwent penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy combined with implantation of a flexible, open-loop, anterior-chamber intraocular lens at our institution between 1983 and 1988. One-hundred one eyes of 99 patients were evaluated. Graft-survival rates were calculated by using the Kaplan-Meier actuarial method. RESULTS Mean follow-up was 49.8 months (range, 1-144). The probability of graft survival at 1, 2, 4, 6, and 8 years was 93, 87, 78, 65, and 65%, respectively. A total of 25 (24.8%) grafts failed. Progressive corneal edema without signs of rejection was the most common finding in patients with failed grafts (10 eyes, 40%). The most frequent complication observed was newly diagnosed or worsening of preexisting glaucoma (46 eyes, 45.5%). CONCLUSIONS Our long-term results support flexible, open-loop anterior-chamber intraocular lenses as a reasonable option, at the time of penetrating keratoplasty, in patients with pseudophakic and aphakic bullous keratopathy.

Intraocular lens (IOL) insertion is now the standard method of aphakic correction in this country. Previous studies have shown that an IOL can activate the alternative complement system of normal human serum in vitro, thereby generating peptides capable of stimulating inflammation that can result in visual morbidity in pseudophakic eyes. The objective of the present study was to determine if human aqueous humor (AH) levels of total protein, total C3, and C3a cleavage products (activated C3) are influenced by an IOL in pseudophakic eyes as compared with phakic and aphakic eyes. AH from five diagnostic categories was examined: cataract, posterior capsulotomy-IOL, Fuchs' endothelial dystrophy with corneal edema, aphakic bullous keratopathy, and pseudophakic bullous keratopathy. The results of this study do not support the hypothesis that IOLs affect AH protein and complement levels. Statistically, there was no significant difference in AH protein levels when pseudophakic eyes were compared with phakic and aphakic eyes. No significant difference in C3a levels was demonstrated between pseudophakic and phakic eyes, whereas aphakic eyes had significant higher levels than those with pseudophakia. There were significantly greater levels of protein, C3, and C3a in eyes with edematous corneas versus those with clear corneas. Although these studies are difficult to interpret, AH levels of these substances appear to be more related to dysfunctional corneal endothelium and corneal edema than to the presence of an IOL.

• In previous experiments, we found that a high-water-content hydroxyethyl methacrylate (Permalens) hydrogel implant was not only well tolerated within the rabbit corneal stroma but also would successfully alter the anterior radius of curvature, and thus the refractive state, of the rabbit eye. The same lens material implanted in the cornea of a patient with aphakic bullous keratopathy was tolerated for six months and decreased epithelial edema but did not alter the refractive state. This cornea, containing the intrastromal lens, was obtained at subsequent penetrating keratoplasty and studied by light and transmission electron microscopy. Morphologically, the epithelium and anterior stroma were not edematous, whereas the stroma posterior to the lens remained edematous. Minimal fibroblastic activity was evident at the lens-stroma interface. There were no signs of inflammation, ulceration, or neovascularization.

We reviewed the preoperative clinical indications and associated surgical procedures for 2,299 penetrating keratoplasties performed at our institution from 1983 through 1988. Pseudophakic bullous keratopathy was the most common indication overall, accounting for 526 cases (23%). A marked increase was noted in the incidence of pseudophakic bullous keratopathy as an indication for penetrating keratoplasty beginning in 1985. The association of anterior chamber intraocular lenses in eyes with pseudophakic bullous keratopathy undergoing penetrating keratoplasty increased from 19 of 43 cases (44%) in 1983 to 79 of 108 cases (73%) in 1988. The incidence of intraocular lens exchange at the time of penetrating keratoplasty in cases of pseudophakic bullous keratopathy increased from six of 43 (14%) in 1983 to 63 of 108 (58%) in 1988. Other major indications for penetrating keratoplasty included Fuchs' dystrophy (375 cases, 16%), keratoconus (348 cases, 15%), aphakic bullous keratopathy (331 cases, 14%), and regraft (233 cases, 10%). Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 397 of 1,532 phakic eyes (26%). The incidence of triple procedure (penetrating keratoplasty, cataract extraction, and intraocular lens implantation) increased from 27 of 248 phakic eyes (11%) in 1983 to 68 of 258 phakic eyes (26%) in 1988.

Corneal edema developed in seven aphakic eyes of six patients (three men and three women ranging in age from 60 to 88 years) who used daily- or extended-wear hydrophilic and silicone contact lenses. This edema, which developed suddenly, persisted despite discontinuation of contact lens wear and treatment with topical corticosteroids. The onset of the edema occurred in two patterns. In three eyes, edema occurred soon (30 minutes to 30 days) after the contact lens was first worn and persisted during follow-up periods averaging 15 months. In the other four eyes, the edema developed late, after 20 to 66 months. In three of these eyes, edema resolved after follow-up periods averaging seven months. In the fourth eye, it was still present after 18 months. of the affected eyes in which peripheral endothelial cell densities could be measured, all but one had fewer than 800 cells/mm 2 . Central cell densities in the five uninvolved fellow eyes averaged 1,964 cells/mm 2 . Marked polymegathism and cornea guttata were present in all affected and fellow eyes. We believe this condition is a complication of aphakic contact lens wear, distinct from contact-lens-intolerance syndrome and aphakic bullous keratopathy.

Jones and Rice (I968) have demonstrated experimentally that the endothelium of the donor corneal disc may be subjected to considerable mechanical trauma during penetrating keratoplasty by the more commonly used techniques. From these experimental observations they have developed a method in which the corneal disc is sutured over a cushion of air, thus obviating much of the endothelial trauma inseparable from other techniques of penetrating keratoplasty. Their paper referred to keratoplasty in aphakic bullous keratopathy, but the protection of the endothelium is of equal importance in all types of penetrating keratoplasty in order to obtain a clear graft. One of the difficulties of using the technique is that of maintaining the bubble of air in the anterior chamber while direct sutures are being inserted into the host-graft junction. The description of the operation by Jones and Rice calls for the use of two overlay sutures to hold the graft in place while the direct sutures are being placed. It is often found that ifsuch overlay sutures are tightened sufficiently to provide a reasonable close host-donor contact, there is a considerable tendency for the host cornea to buckle with consequent difficulty in maintaining an air seal whilst inserting the continuous iO/O nylon suture. If the overlay sutures are only tightened enough to produce host-donor contact without buckling the host cornea, then such contact frequently does not seem to be sufficient to prevent loss of air whilst the continuous suture is being inserted. It is felt that the repeated loss of air from the anterior chamber, with recurrent contact of the lens or vitreous face with the donor endothelium, is likely to produce the very complication that the technique was designed to avoid, namely damage to the donor endothelium. Various modifications of the technique were designed to avoid this situation and provide a more air-tight seal while the continuous suture was being inserted, but the use of the splint to be described has been found to give uniformly satisfactory results.

• Various anterior segment problems can be approached through the pars plana and treated with instrumentation that has been developed for vitreous surgery. Two cases of aphakic bullous keratopathy due to vitreous touch and three cases of subluxated lenses were successfully treated. Of two cases of advanced, persistent hyperplastic primary vitreous, one showed a successful result.

SUMMARY Seventy-three eyes with limbus to limbus bullous keratopathy following cataract extraction were followed 24 months to determine the long-term visual prognosis following penetrating keratoplasty. All but one eye required anterior vitrectomy. A manual vitrectomy technique was utilized in all cases. Results obtained were equal to or better than other contemporary literature reports utilizing mechanical vitrectomy techniques.

We conducted a clinical and pathologic review of 1,057 recipient corneal buttons on file at the Wilmer Institute, to assess the incidence of corneal conditions treated with keratoplasty, and how these have changed (1941-1973). Regrafting was the most frequent indication for keratoplasty in the last ten years in this series. Some corneal diseases, such as inflammatory conditions, decreased in relative importance as an indication for keratoplasty, while others such as aphakic bullous keratopathy (including vitreous touch) and Fuchs' endothelial dystrophy increased.

In series of 39 corneal grafts, aphakic bullous keratopathy comprised 13 (33%) of the cases. By scanning and transmission electron microscopy, endothelial degeneration and posterior collagenous proliferation were consistent features. In all 13 cases, the patchy loss of endothelial cells occurred diffusely over the entire posterior corneal surface. The remaining endothelial cells had become extremely attenuated to increase their surface area. In nine cases, acellular proliferations of collagenous tissue were interposed between the endothelial cells and Descemet's membrane. These posterior collagenous layers were composed of collagen fibrils and basement membrane material, randomly arrayed in a feltwork of uniform thickness; they appeared ultrastructurally identical to those encountered in a variety of conditions involving endothelial distress.

• Thirty-four eyes with advanced aphakic bullous keratopathy were treated with the Cardona keratoprosthesis as a primary procedure. There were three extrusions (9%), two of which were associated with infections; two other conditions were worsened (6%) as a result of a late permanent vitreous hemorrhage or possibly an infection. Twenty-eight eyes (82%) showed a notable improvement during follow-up periods that ranged from 6 to 72 months. The advantages and limitations of this technique are compared to those of penetrating keratoplasty.