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Nuno Moura-Coelho,1– 4 João Paulo Cunha,4,5 Arnaldo Dias-Santos,2,6 Marco Dutra-Medeiros,2,6 Renato Papa-Vettorazzi,1 Felicidad Manero,1 José Güell1,3,7 1Cornea and Refractive Surgery Unit, Instituto Microcirugía Ocular (IMO) Barcelona, Barcelona, Spain; 2Ophthalmology, Faculdade de Ciências Médicas – Universidade Nova de Lisboa (NMS|FCM-UNL), Lisbon, Portugal; 3Anterior Segment, European School for Advanced Studies in Ophthalmology (ESASO), Lugano, Switzerland; 4Ophthalmology, Escola Superior de Tecnologias da Saúde de Lisboa (ESTeSL) – Instituto Politécnico de Lisboa, Lisbon, Portugal; 5Ophthalmology, Hospital CUF Cascais, Cascais, Portugal; 6Ophthalmology, Centro Hospitalar Universitário Lisboa Central (CHULC), Lisbon, Portugal; 7Ophthalmology, Universidad Autónoma de Barcelona (UAB), Barcelona, SpainCorrespondence: Nuno Moura-Coelho, Email nunomouracoelho.oft@gmail.comPurpose: To analyze the outcomes of Descemet’s membrane endothelial keratoplasty (DMEK) for corneal endothelial failure secondary to phakic intraocular lens implantation (PIOL) at a reference center for corneal transplantation in Spain.Design: Retrospective, single-surgeon case series.Methods: Single-center analysis of patients who underwent DMEK for PIOL-related corneal decompensation between July 2011 and July 2020 with at least 6 months of follow-up postoperatively. Primary outcome was final best-corrected visual acuity (BCVA, logMAR) compared to pre-DMEK BCVA. Secondary outcomes analyzed included post-DMEK refractive spherical equivalent, endothelial cell loss (%ECL), and graft failure.Results: Sixteen eyes (14 patients) underwent DMEK for PIOL-related corneal decompensation. Mean (SD) time to PIOL explantation was 9.3 (5.0) years, and median (P25-P75) time between PIOL explantation and DMEK surgery was 3 (2– 4) months. Median pre-DMEK BCVA was 0.80 (1.08– 0.60) logMAR. A statistically significant improvement in BCVA was observed 1 month after DMEK (p = 0.001), and median final BCVA was 0.15 (0.0– 0.35) logMAR (p = 0.002). Mean %ECL was 55.6 (18.7) % at 2-year follow-up and 61.7 (11.7) % in eyes with over 4 years of follow-up. Two eyes required re-bubbling (12.5%), one of which ended in primary graft failure (6.2%) and one eye had late endothelial graft failure (LEGF) at 4-year follow-up (1/15 grafts, 6.7%).Conclusion: In patients with PIOL-related corneal decompensation, DMEK leads to good and clinically significant refractive and visual outcomes in the medium-long term, with a good safety profile. Prospective studies are encouraged to ascertain whether these cases are at increased risk of accelerated endothelial cell loss and LEGF.Keywords: descemet membrane endothelial keratoplasty, endothelial keratoplasty, phakic intraocular lens, corneal endothelial failure

Varintorn Chuckpaiwong, Sasin Muakkul, Prae Phimpho, Kaevalin Lekhanont, Passara Jongkhajornpong Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Passara JongkhajornpongDepartment of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Ramathibodi Hospital, 270 Thanon Rama VI, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, ThailandTel +662-2012729Email passaraj@yahoo.comObjective: To evaluate the incidence of corneal endothelial failure (CEF) and determine the risk factors of developing CEF after phacoemulsification in patients with Fuchs endothelial corneal dystrophy (FECD).Methods: A retrospective chart review of 2873 patients who underwent phacoemulsification with intraocular lens (IOL) implantation was conducted at Ramathibodi Hospital, Bangkok, Thailand from January 2007 to December 2019. Patient baseline characteristics, underlying diseases, levels of nuclear cataract, pre-operative specular microscopic parameters, intraoperative information (cumulative dissipated energy [CDE], mode of phacoemulsification, and complications), and occurrence of CEF were collected. Data were analyzed using Kaplan–Meier (KM) method and Cox proportional hazard model.Results: Ninety-four patients diagnosed with FECD at follow-up time of more than 6 months were included for analysis. Mean age was 70.3 ± 7.7 years with female predominance (81.91%). Median follow-up time was 3.2 years. Nine (9.57%) patients developed CEF during follow-up period. The overall incidence rate of CEF after phacoemulsification was 26 per 1000 person years (95% confidence interval [CI]; 14 to 49 per 1000 person years). Only intraoperative complications showed significant association with CEF at hazard ratio (HR) of 6.03 (95% CI 1.50 to 26.50). No significant association was found among age, gender, underlying diseases, level of nuclear sclerosis and pre-operative specular microscopic parameters.Conclusion: Intraoperative complications should be considered as an important risk factor for developing post-operative CEF in FECD patients. Apart from assessing pre-operative parameters, surgeons should also consider the possibility of and try to avoid any intra-operative complications, which could potentially result in CEF after phacoemulsification for each individual patient.Keywords: corneal endothelial failure; CEF, phacoemulsification, Fuchs endothelial corneal dystrophy; FECD

Purpose: To conduct a systematic review and meta-analysis on the outcomes of Descemetorhexis without endothelial keratoplasty (DWEK), associated or not with phacoemulsification (PKE) and Rho Kinase Inhibitor (RHOKI) in Fuchs Endothelial Corneal Dystrophy (FECD). Clinical Relevance: DWEK is an emergent corneal intervention that could be effective for patients with FECD.Method: PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and Science Direct databases were used to search for studies on DWEK surgery in patients with FECD, without language restriction, till 29th November 2020. We computed random-effect meta-analysis stratified by type of intervention and type of descemetorhexis size, and meta-regressions to compare between interventions and examine the influence of sociodemographic factors. PRISMA guidelines were followed and our search protocol was registered in PROSPERO (registration number CRD42020167566).Results: 11 articles were included in our systematic review, representing 127 eyes of 118 patients. DWEK globally improved visual acuity (effect size = -1.11, 95CI -1.70 to -0.52, P < 0.001) and pachymetry (-1.25, -1.92 to -0.57, P < 0.001), without significant effects on endothelial cell count (-0.59, -2.00 to 0.83, P = 0.419). The three types of interventions (i.e. DWEK±RHOKI, DWEK±PKE, and DWEK±PKE±RHOKI) improved visual acuity and pachymetry in early and mild stages of FECD. Descemetorhexis size ≤ 4 mm improved visual acuity (-0.72, -1.29 to -0.14, P < 0.001) and pachymetry (-0.68, -0.98 to -0.38, P < 0.001), whereas > 4 mm did not. Meta-regressions did not demonstrate significant results.Conclusion: DWEK, with or without PKE and/or RHOKI, improved visual acuity and pachymetry in early and mild stages of FECD, without efficacy on cell count. A descemetorhexis size ≤ 4 mm improved visual acuity and pachymetry.; Contexte : La DWEK est une technique chirurgicale émergente qui pourrait être efficace dans la prise en charge des patients atteints de dystrophie de Fuchs.Objectif : Réaliser une revue systématique de la littérature et une méta-analyse à propos de l’efficacité du descemetorhexis sans kératoplastie endothéliale (DWEK), associé ou non à la phakoémulsification (PKE) et aux inhibiteurs de rho kinase (RHOKI) dans la dystrophie cornéenne endothéliale de Fuchs (FECD).Méthode : Les bases de données PubMed, Cochrane Library, Embase, ClinicalTrials.gov, et Science Direct ont été utilisées pour rechercher des études sur la DWEK chez des patients atteints de FECD, sans restriction de langue, jusqu’au 29 novembre 2020. Nous avons procédé à une méta-analyse stratifiée par type d’intervention et par taille de descemetorhexis, et à des méta-régressions pour comparer les interventions entre elles et déterminer l’influence des facteurs sociodémographiques. Les guidelines PRISMA ont été suivies et notre protocole de recherché a été enregistré dans PROSPERO (n° d’enregistrement CRD42020167566).Résultats : 11 articles ont été inclus dans notre méta-analyse, représentant 127 yeux de 118 patients. La DWEK améliorait globalement l’acuité visuelle (taille d’effet = -1.11, IC95 -1.70 à -0.52, P < 0.001) et la pachymétrie (-1.25, -1.92 à -0.57, P < 0.001), sans effet significatif sur la densité cellulaire endothéliale (-0.59, -2.00 à 0.83, P = 0.419). Les trois types d’intervention (DWEK±RHOKI, DWEK±PKE, and DWEK±PKE±RHOKI) amélioraient l’acuité visuelle et la pachymétrie dans les stades précoces et légers de FECD. Une taille de descemetorhexis ≤ 4 mm augmentait l’acuité visuelle (-0.72, -1.29 à -0.14, P < 0.001) et la pachymétrie (-0.68, -0.98 à -0.38, P < 0.001), ce n’était pas le cas s’il était > 4 mm. Les méta-régressions ne montraient pas de résultats significatifs.Conclusion : La DWEK, avec ou sans PKE et/ou RHOKI, améliorait l’acuité visuelle et la pachymétrie dans les stades précoces de FECD, sans efficacité retrouvée sur la densité cellulaire. Une taille de descemetorhexis ≤ 4 mm améliorait l’acuité visuelle et la pachymétrie.

Purpose To report the outcomes of DSAEK surgery performed in pediatric patients. Design Noncomparative interventional case series. Subjects and methods All pediatric patients (age up to 16years) undergoing Descemet automated stripping endothelial keratoplasty (DSAEK) at our Institution since January 2008 have been enrolled in a prospective study. A standard DSAEK, involving delivery of an 8.5–9.5mm graft by Busin glide, was performed under general anesthesia in 19 eyes of 11 pediatric patients (congenital hereditary endothelial dystrophy n =13; congenital glaucoma n =2; posterior polymorphous dystrophy n =2, and failed penetrating keratoplasty n =2). Slit-lamp examination, refraction and visual acuity as well as endothelial cell density were evaluated preoperatively as well as 1, 3, 6, 12, and 18months postoperatively. Results All surgical procedures were uneventful. Graft detachment occurred in 4 cases and was managed successfully with repeat air injection. All corneas cleared within a week from surgery. Follow-up was 3–18months. At last follow-up examination, best-corrected visual acuity (BCVA) was better than 20/40 in 8 of the 13 cases of patients old enough to assess vision. A graft rejection episode was seen in 1 case within 3months from surgery but was reverted with steroidal treatment. No graft failures were observed. Conclusions DSAEK is an appropriate surgical intervention for children with corneal endothelial failure. In contrast to penetrating keratoplasty (PK), DSAEK is performed under "closed system" conditions, thus minimizing intraoperative risks. Finally, healing is much faster than with PK and all sutures can be removed within 2–4weeks from surgery, thus allowing fast visual recovery and prompt starting of amblyopia treatment.