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PURPOSE To report the outcomes of two-piece microkeratome-assisted MK for eyes with full-thickness traumatic corneal scars and otherwise functional endothelium following corneal penetrating injury. DESIGN Interventional case series METHODS: : In this single-center study, 41 consecutive eyes with traumatic corneal scars that underwent two-piece microkeratome-assisted mushroom keratoplasty were evaluated. The two-piece mushroom graft consisted of an anterior lamella of 9-mm diameter and a posterior lamella of 6-mm diameter. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density and postoperative complication rates. RESULTS Of the 41 total cases, 38 eyes (93%) reached Snellen vision ≥20/100, 36 (88%) reached ≥20/60, 29 (71%) reached ≥20/40 and 13 (32%) reached ≥20/25 2 years following MK. Excluding eyes with vision-impairing comorbidities, baseline logMAR BSCVA (1.41±0.73) significantly improved annually during the first 2 years (p < 0.001) reaching 0.16±0.13 at year 2 which subsequently remained stable up to 10 years (p = 0.626). RA exceeded 4.5 diopters in 2 cases (5%) after wound revision for high-degree astigmatism in 5 cases. Endothelial cell loss was 35.1% at 1 year with an annual decline of 2.9% over 10 years. Elevation in IOP was observed postoperatively in 7 eyes of which 6 had pre-existing glaucoma. The 10-year cumulative risk for graft rejection and failure was 8.5% and 10% respectively. CONCLUSION Two-piece microkeratome-assisted MK for traumatic corneal scars can allow excellent visual rehabilitation with relatively stable ECL and low rates of immunologic rejection and graft failure.

Purpose: The purpose of this paper is to report the clinical manifestations, diagnostic evaluation, management and outcomes of microsporidial keratitis in post-keratoplasty eyes. Methods: This is a retrospective review of three patients diagnosed with microsporidial stromal keratitis in post-keratoplasty eyes between January 2012 and December 2021 at a tertiary referral center (Ospedali Privati Forlì “Villa Igea”, Forlì, Italy). Results: All patients presented with fine multifocal granular infiltrates following keratoplasty for a presumed herpetic keratitis. No microorganisms were isolated from the corneal scrapings and no clinical response was observed with broad-spectrum antimicrobial therapy. In all cases, confocal microscopy demonstrated spore-like structures. The histopathologic examination of the excised corneal buttons confirmed the diagnosis of microsporidial stromal keratitis. Following therapeutic keratoplasty and treatment with an initial high dose and extended taper of topical fumagillin, clinical resolution was achieved in all eyes. The Snellen visual acuities at the final follow-up were 20/50, 20/63 and 20/32. Conclusions: Prior to definitive surgery, confocal microscopy can be employed for the in vivo detection of pathogenic microorganisms such as Microsporidium. In post-keratoplasty eyes, therapeutic keratoplasty and an initial high dose of topical fumagillin with extended taper can allow the resolution of microsporidial stromal keratitis with a satisfactory visual prognosis.

Background/AimsTo report the 10-year outcomes of modified microkeratome-assisted lamellar keratoplasty (LK) for keratoconus.MethodsIn this single-centre interventional case series, 151 consecutive eyes with keratoconus underwent modified microkeratome-assisted LK. Eyes with scars extending beyond the posterior half of the corneal stroma and preoperative thinnest-point pachymetry value of less than 300 μm were excluded. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, immunological rejection, ectasia recurrence and graft failure rates.ResultsBaseline BSCVA (0.89±0.31 logarithm of the minimum angle of resolution (logMAR)) significantly improved to 0.10±0.12 logMAR at year 3 (pConclusionModified microkeratome-assisted LK results in stable visual and refractive outcomes with low rates of immunological rejection and graft failure in the absence of recurrence of ectasia for at least 10 years.

Background: Corneal neovascularization (CN) is a clue feature of different ocular pathological conditions and can lead to corneal edema and opacification with subsequent vision loss. Vascular endothelial growth factor (VEGF), which plays a key role in new vessels formation, proliferation and migration, was found to be up-regulated in these conditions. Nowadays, it is possible to downregulate the angiogenic process by using anti-VEGF agents administered by different routes. Objective: To evaluate the efficacy, safety and possible future directions of anti-VEGF agents used for the treatment of CNV owing to different aetiologies. Methods: A computerized search of articles dealing with the topic of anti-VEGF therapy in CN was conducted in PubMed, Scopus and Medline electronic databases. The following key phrases were used: anti-VEGF agents, corneal neovascularization, bevacizumab, ranibizumab, vascular endothelial growth factor, angiogenesis. Results: The use of anti-VEGF therapy in the treatment of CN reduced pathological vessel density without causing significant side effects. Various administration routes such as topical, subconjunctival and intrastromal ones are available, and the choice depends on patient and disease characteristics. Much more effectiveness is achieved in case of early administration before mature and wellestablished vessels take place. A combined approach between various drugs including anti-VEGF agents should be adopted in those cases at higher risk of neovascularization recurrence such as chronic long-standing diseases where ischemic and inflammatory stimuli are not definitively reversed. Conclusion: The efficacy and safety of anti-VEGF agents support their adoption into the daily clinical practice for the management of CN.

Deep anterior lamellar keratoplasty (DALK) involves selective replacement of diseased corneal stroma while preserving normal healthy endothelium. Despite several well-recognized advantages, the uptake of DALK has remained sluggish with an adoption rate that has plateaued over the past decade. Misconceptions such as the rarity of complications of penetrating keratoplasty, lack of standardization of the DALK technique, and limited substantial benefit in visual and refractive outcomes are frequently cited as arguments against performing DALK. This brief review discusses the recent findings that refute these perceived barriers; describes contemporary techniques, tools, and modifications in the surgical approach; and evaluates the evidence regarding the clinical outcomes of DALK.

PURPOSE The purpose of this study was to evaluate the efficacy and predictability of cataract extraction with toric intraocular lens (IOL) implantation following deep anterior lamellar keratoplasty (DALK) or mushroom penetrating keratoplasty (PK). SETTING "Villa Igea" Hospital, Forli, Italy. DESIGN Prospective case series. METHODS Toric IOL implantation was offered to patients with cataract, corneal astigmatism > 1.5D and regular central corneal topography after complete suture removal. Phacoemulsification was performed through a 2.4-mm scleral tunnel and an enVista monofocal toric MX60T (Bausch & Lomb, Rochester, NY) or Eyecryl monofocal toric IOL (Biotech Vision Care, Ahmedabad, India) was inserted in the capsular bag. Main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, total prediction error and IOL misalignment. RESULTS 37 consecutive patients that had previously undergone either DALK (n= 27, 73%) or two-piece mushroom PK (n = 10, 27%) were included. All patients completed the 6-months follow-up. The mean toric IOL power was 5.3±1.1 D. Both UDVA and CDVA significantly improved (respectively, from 1.02±0.27 to 0.46±0.31 logMAR, from 0.65±0.27 to 0.11±0.12 logMAR; p

Purpose To examine the ultrastructure of the natural plane of separation in grafted corneas and evaluate the outcomes of stromal peeling. Design Interventional case series. Methods In this multicenter study, stromal peeling was attempted in 96 consecutive eyes with unsatisfactory vision following penetrating keratoplasty (PK) for keratoconus (n = 79), herpetic keratitis (n = 11), and granular dystrophy (n = 6). Stromal exchange was performed by (1) 9 mm partial-thickness trephination; (2) creation of a corneal flap across the PK wound; (3) opening of the stromal component of the PK wound until a smooth, translucent natural plane was identified; (4) severing the attachment of the PK scar; (5) stromal peeling along the identified plane; and (6) suturing of donor lamella. Grafted corneas from cases that mandated conversion to PK were processed for transmission electron microscopy. Results The natural plane of separation was identified in all cases. Stromal exchange was successfully completed in 84 cases (87.5%). Snellen visual acuity ≥20/40 and ≥20/25 was reached in 93% and 72% of cases at 3 years (n = 49) and 86% and 62% at 4 years (n = 21) postoperatively. Mean endothelial cell loss at 1 year was 6.6% ± 9.5%. Stromal peeling occurred along a plane lined with a continuous layer of keratocytes separating pre-Descemet membrane (DM) stroma, DM, and endothelium from the anterior stroma. Pre-DM stroma was made of poorly organized lamellae containing widely spaced, randomly arranged collagen fibrils. Conclusions Ultrastructural alterations in the stromal microarchitecture of grafted corneas provide evidence of a natural plane of separation identified intraoperatively. Stromal peeling can be successfully performed in post-PK eyes with various stromal pathology.

BackgroundThe purpose of this study was to evaluate the incidence, timing and risk factors of corneal neovascularisation (NV) after deep anterior lamellar keratoplasty (DALK) for corneal ectasia.MethodsThis study included 616 eyes who underwent DALK between 2012 and 2020 in two tertiary referral centres. In one centre topical corticosteroids were discontinued after complete suture removal 1 year after surgery, whereas in the other they were discontinued 3–4 months after surgery. The presence and severity of corneal NV was ascertained based on slit lamp photographs. Potential risk factors for corneal NV were evaluated using the Cox proportional hazards model.ResultsThe cumulative incidence of corneal NV was 8.7% at 1 year after surgery and 13.2% at 5 years. Mean time interval from surgery to development of corneal NV was 12.8±16.2 months, with 68.9% of cases occurring before complete suture removal. Early discontinuation of topical steroids, older age and ocular allergy were associated with an increased risk of developing corneal NV (respectively, HR=2.625, HR=1.019, HR=3.726, all pConclusionsThe risk of corneal NV is higher in the first year following DALK. Early discontinuation of topical steroids, ocular allergy and older age are significant predictors of corneal NV.

Currently, endothelial keratoplasty is the gold standard for the surgical treatment of Fuchs endothelial corneal dystrophy (FECD). Despite the remarkable success in terms of surgical outcomes, a shortage of corneal donor tissue poses a limitation to performing endothelial keratoplasty in many parts of the world. Cell therapy is a potential alternative strategy to keratoplasty and is currently under investigation. Considering that corneas with FECD may contain relatively healthy endothelial cells, samples obtained by descemetorhexis of eyes undergoing EK for FECD can be used for ex vivo expansion of endothelial cells as an autologous cell culture. In this study, we established corneal endothelial cell cultures derived from 40 patients that underwent endothelial keratoplasty for advanced FECD. Several parameters were evaluated including patient characteristics such as age, gender, and endothelial cell density as well as various processing and cell culture protocols based on different combinations of shipping temperatures, stabilization periods and treatment methods for corneal endothelial cell dissociation. FECD cultures were classified into three groups as: (i) no cells, (ii) cell cultures with endothelial-like morphology or (iii) cell cultures with fibroblast-like features. Our data seem to suggest that some factors can influence FECD cell culture characteristics including young age, high paracentral endothelial cell density, low shipping temperature and short stabilization period prior to cell isolation. Treatment with type 1 collagenase for cell isolation can delay endothelial-to-mesenchymal transition, but does not increase proliferative capacity. Although heterologous corneal endothelial cultures from healthy donors have shown encouraging outcomes, the feasibility of autologous cell therapy as a potential treatment for FECD remains challenging. Low initial cell concentration as well as endothelial to mesenchymal transition are the main obstacles to the application of FECD cultures in the clinical setting.

PURPOSE To describe a surgical technique for the diagnosis and treatment of post-Descemet stripping automated endothelial keratoplasty (DSAEK) infectious interface keratitis presenting as a cold abscess. METHODS This study included 2 eyes of 2 patients that developed delayed-onset interface infections after DSAEK. Through an anterior keratotomy, diagnostic samples for microbial culture and histopathology examination were collected, and empiric antibiotic therapy was delivered directly to the site of the infection at the graft-host interface. RESULTS In both cases, microbiological examinations confirmed a fungal etiology consistent with Candida. Resolution of infection was achieved, and no signs of posterior segment involvement or recurrence of infection were observed. Both corneas remained clear with final visual acuity of 20/25 and 20/32. No case required additional surgical intervention or repeat keratoplasty after more than 15 months of follow-up. CONCLUSIONS Interface drainage with antimicrobial irrigation may be considered for the management of post-DSAEK interface infections presenting as a peripheral cold abscess. By avoiding intraocular seeding of infectious pathogens, the anterior approach can achieve clinical resolution of infection, maintain visual function, and preserve the DSAEK graft, thereby obviating the need for a therapeutic keratoplasty.

Background/aimsTo evaluate the clinical outcomes of deep anterior lamellar keratoplasty performed by stromal peeling in eyes that have previously undergone penetrating keratoplasty (PK) for keratoconus.MethodsStandardised stromal exchange included (1) 9 mm trephination of the recipient bed outside the old PK wound, (2) creation of a partial anterior corneal flap through lamellar dissection across the PK wound, (3) opening the stromal component of the old PK wound using blunt-tipped Vannas scissors until a plane of separation is reached, (4) severing the attachment of the PK surgical scar from the recipient host, (5) peeling the stroma of the PK graft from the underlying tissue and (6) suturing the donor anterior corneal lamella prepared by microkeratome dissection (450 µm depth, 9 mm diameter). Main outcome measures were success rate, best spectacle-corrected visual acuity (BSCVA) and endothelial cell loss (ECL).ResultsOf 21 post-PK eyes, stromal exchange succeeded in all but three cases, which were converted to a two-piece mushroom PK. After complete suture removal, mean BSCVA significantly improved from 0.95±0.39 logMAR preoperatively to 0.23±0.17 logMAR (pConclusionIn post-PK eyes, stromal exchange can be performed by means of simple peeling without deep anterior lamellar dissection of the previous PK graft. Large-diameter (9 mm) repeat keratoplasty through stromal peeling yields excellent visual outcomes and minimal ECL. Double anterior chamber formation may complicate the postoperative course, but prompt intervention allows successful management.

To compare the 5-year outcomes of 9-mm-deep anterior lamellar keratoplasty (DALK) for keratoconus with those of conversions to mushroom keratoplasty (MK).Retrospective cohort study.The setting was the Ospedali Privati Villa Igea, Department of Ophthalmology, Forlì, Italy. The study population consisted of the medical records of all attempted DALK procedures (416 eyes) for the indication of keratoconus performed between January 2012 and January 2018; 68 eyes (16.4%) were converted to MK and analyzed as a separate cohort. The mean follow-up time was 33.8 ± 15.1 months. Procedure(s) consisted of 9-mm DALK and MK (9-mm anterior lamella with 6-mm posterior lamella). Outcome measurements were best-corrected visual acuity (BCVA), refractive astigmatism, and endothelial cell loss (ECL) at 5 years.Average BCVA at 5 years was 0.06 ± 0.07 in the DALK group and 0.09 ± 0.15 in the MK group (P = .88). Refractive astigmatism following suture removal (all visits later than 12 months) was slightly less in the DALK cohort (5-year DALK = 2.16 ± 1.40 diopter [D]; MK = 3.02 ± 0.89 D; P = .04; mean difference = 0.86 D [95% confidence interval [CI]: 0.71-1.01]). ECL was significantly higher in the MK group than in the DALK group at all follow-up intervals (5-year DALK = 19.36 ± 21.47%; MK = 56.61 ± 15.82%; P.001). The total all-cause graft failure rate at 5 years was 0.58% for DALK (2 of 348) cases and 5.88% for MK (4 of 68) cases.Excellent 5-year visual and clinical outcomes associated with a 2-piece MK in cases converted from intended DALK mandate large-diameter DALK (9 mm) as the optimal surgical approach to keratoconus.

Background/aimsTo identify and evaluate risk factors associated with the need to convert intended deep anterior lamellar keratoplasty (DALK) to penetrating keratoplasty (PK).MethodsRetrospective institutional cohort study including all consecutive eyes undergoing intended DALK between May 2015 and October 2018 at ‘Villa Igea’ Hospital (Forli, Italy). The indications for surgery were categorised as (1) keratoconus without scarring; (2) keratoconus with scarring; (3) non-keratoconus without scarring; and (4) non-keratoconus with scarring. Multivariate binary logistic regression analysis was performed, introducing, as independent variables, those that reached a significance level of less than 0.05 in univariate analysis. The main outcome measure was whether or not conversion to a PK occurred.Results705 eyes were included, with conversion to PK occurring in 16.2% (n=114) of cases. The factors that remained significant in multivariate analysis were corneal scarring (OR=3.52, pConclusionOccurrence of a type 2 bubble, the need for manual dissection, the presence of scarring and surgeon inexperience are independent risk factors for the need to convert intended DALK to PK. Correct identification and management of the type of bubble achieved during pneumatic dissection is instrumental in minimising the rate of conversion to PK.

Purpose: To use an automated morphometric analysis system of in vivo confocal microscopy (IVCM) images for evaluating reinnervation occurring at the subbasal nerve plexus (SNP) after direct corneal neurotization (DCN) and to further report neurophysiological and histopathological findings. Methods: Prospective interventional case series including 3 eyes with neurotrophic keratitis that underwent DCN. Deep anterior lamellar keratoplasty was performed 18 months after DCN in patient 1. The following evaluations were performed before and at 3, 6, and 12 months after DCN: clinical evolution of keratitis; corneal sensitivity; IVCM images of the SNP analyzed with “ACCMetrics;” neurophysiological study of corneal reflex. Protein gene product 9.5 immunofluorescence staining assay and transmission electron microscopy were conducted on the neurotized button excised during deep anterior lamellar keratoplasty. Results: Complete healing was obtained in all patients by 3 months postoperatively. Corneal sensitivity was absent preoperatively in all eyes and improved after surgery, reaching an average value of 30 mm 1 year postoperatively. The corneal SNP was not visible at IVCM in any of the cases preoperatively and became visible by 3 months postoperatively, showing IVCM metrics comparable to normal contralateral eyes at 1 year. In all cases, neurophysiological evaluation showed a partial recovery of the electrical activity of the cornea. In patient 1, protein gene product (PGP) 9.5 staining of neurotized cornea showed nerve fascicles at the SNP, whereas transmission electron microscopy showed amyelinic nerve axons and nerve endings. Conclusions: The corneal SNP exhibited IVCM metrics comparable to the normal contralateral eye 1 year after DCN. Ex vivo histopathological assessment of neurotized corneas confirmed the presence of nerves with normal ultrastructure.

To assess the 3-year outcomes of tri-folded endothelium-in Descemet membrane endothelial keratoplasty (DMEK) using bimanual pull-through delivery technique.Interventional case series.In this single-center study, we included 153 consecutive eyes that underwent DMEK for various indications (Fuchs endothelial corneal dystrophy [FECD]: n = 111; bullous keratopathy [BK]: n = 24; and failed graft: n = 18). DMEK grafts were loaded into a disposable cartridge in a tri-folded, endothelium-in configuration and delivered using bimanual pull-through technique. Main outcome measures were graft preparation and unfolding times, best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), and graft survival.Mean graft preparation time was 5.9 ± 1.1 minutes; and mean graft unfolding time was 2.9 ± 0.9 minutes. Excluding eyes with comorbidities, logarithm of minimum angle of resolution BSCVA improved significantly from baseline preoperative values of 0.92 ± 0.58 to 0.02 ± 0.07 at 1 year (P.001) and remained stable up to 3 years. Mean postoperative ECD decreased significantly (P.001) from eye bank values to 1,818 ± 362, 1,675 ± 372, and 1,580 ± 423 cells/mmTri-folded endothelium-in DMEK requires minimal time for graft unfolding, which is the surgical step considered most challenging by corneal surgeons. Visual outcomes and complication rates are not adversely affected by the modification of the surgical technique.

To report the outcomes of initial high-dose and extended taper of antiviral and steroid prophylaxis for the treatment of eyes with high-risk vascularized herpetic corneal scars that underwent 2-piece mushroom keratoplasty (MK).Prospective interventional case series.In this single-center study, 52 consecutive eyes with vascularized (≥2 quadrants) herpetic corneal scars underwent 2-piece microkeratome-assisted MK. Initial high-dose and extended taper of combined oral and topical antiviral and steroid prophylaxis was administered. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, immunologic rejection, herpetic recurrence, and graft failure rates.Excluding patients with vision-impairing comorbidities, baseline BSCVA (1.73 ± 0.67 logMAR) significantly improved annually during the first 2 years (P.001, P = .016), reaching 0.17 ± 0.18 logMAR at year 2, and remaining stable up to 10 years (P = .662). At 2 years, 86% of eyes saw ≥20/40, 55% saw ≥20/25, and 18% saw ≥20/20 Snellen BSCVA. RA exceeded 4.5 diopters in 7% of cases after wound revision for high-degree astigmatism in 7 cases. Endothelial cell loss was 40.9% at 1 year with an annual decline of 3.1% over 10 years. The 10-year cumulative risk for immunologic rejection, herpetic recurrence, and graft failure was 9.7%, 7.8%, and 7.6%, respectively.Initial high dose and extended taper of antiviral and steroid prophylaxis for MK in high-risk, vascularized herpetic corneal scars achieves clinical outcomes that remain stable for up to 10 years after surgery with minimal risk of immunologic rejection, herpetic recurrence and graft failure.

PURPOSE: To identify predictors of bubble formation and type during big-bubble deep anterior lamellar keratoplasty (BB-DALK) performed in keratoconus at different stages of severity. DESIGN: Retrospective Cohort Study. METHODS: Setting: University Magna Græcia (Catanzaro, Italy); Study Population: Consecutive keratoconus patients undergoing BB-DALK from September 2014 to Feb- ruary 2019; Observation Procedure: Keratometric astigmatism, mean keratometry value (K-mean), highest keratometry value (K-max), thinnest point, anterior segment Optical Coherence Tomography (AS-OCT)-based stage of ectasia. Main Outcome Measures: Rate of bubble formation and type; number and fate of micro/macro-perforation; conver- sion to mushroom keratoplasty (MK); comparison of parameters in patients with bubble formation vs failure and in type 1 vs type 2 bubble; areas under the curves (AUC) of preoperative parameters for distinguishing between bubble types. RESULTS: Pneumatic dissection succeeded in 113/155 eyes (72.9%), with 100 type 1 bubbles (88.4%), 11 type 2 (9.8%) and 2 mixed-type (1.8%). Micro-perforations were managed conservatively in type-1 bubbles; macro-perforations occurring in both types of bubbles required conversion to MK. Preoperative K-mean and K-max values were significantly higher in eyes in which bubble formation succeeded (respectively, P=0.006 and P

Purpose To determine whether autologous Descemet stripping endothelial keratoplasty is technically feasible and whether it eliminates the risk of endothelial rejection in "only eyes" at high risk of immunological rejection. Methods This is a prospective observational interventional study from 2016 to 2018 with a 24-month follow-up in a tertiary-level corneal referral center, Forli, Italy. One 25-year-old woman with failed penetrating keratoplasty after endothelial rejection in the context of chronic panuveitis and a blind fellow eye due to retinal detachment underwent autologous Descemet stripping automated keratoplasty. An endothelial graft was harvested from the fellow eye by performing a hinged, microkeratome-assisted superficial stromal flap, with removal of the central posterior stromal bed. The posterior lamellar graft created was then transplanted into the other eye using a standardized Descemet stripping automated endothelial keratoplasty (DSAEK) technique. Main outcome measures were endothelial rejection, best spectacle-corrected visual acuity, and endothelial cell density. Results No endothelial rejection was seen during the 2-year follow-up duration. Stable improvement in best spectacle-corrected visual acuity from 0.2 to 0.4 (decimal Snellen) was observed. Endothelial cell density of 1465 (cells/mm) was recorded at the final follow-up. Conclusions The use of this repeatable technique to harvest and transplant an autologous DSAEK graft eliminates endothelial rejection in high-risk eyes.

PURPOSE To evaluate the possibility of using the intrastromal corneal ring segments (ICRSs) previously implanted as a depth reference for performing pneumatic dissection in deep anterior lamellar keratoplasty (DALK). METHODS The depth of placement of 2 symmetrical ICRSs placed in the superior and inferior midperipheral cornea of 4 eyes of 4 patients with keratoconus was measured by means of anterior segment optical coherence tomography. Because of irregular and/or high astigmatism, DALK using pneumatic dissection was performed in all eyes. The standardized procedure included the following: 1) Deep trephination of the recipient cornea outside the ICRSs (9 mm in diameter), aimed at facilitating the insertion and advancement of a dedicated cannula under the ICRS implant, just within its peripheral margin; 2) air injection for pneumatic dissection; 3) removal of about 80% of the anterior stroma; 4) perforation of the "big bubble" ceiling under viscoelastic protection and removal of its central 6 mm; and 5) suturing of a donor lamella of the anterior stroma obtained by microkeratome dissection using a 450-μm head and punched to a diameter of 9 mm. RESULTS In all cases, the site for air injection was selected where the thickness of the stroma underlying the superior ICRS did not exceed 150 μm. Pneumatic dissection succeeded uneventfully in all eyes; postoperative best spectacle-corrected visual acuity was 20/20 in 3 of 4 eyes, whereas refractive astigmatism was less than 3 diopters in all cases. CONCLUSIONS The presence of ICRSs facilitates gauging the depth of cannula insertion at the time of DALK, to succeed with pneumatic dissection.

Purpose To evaluate the relationship between surgical experience and the success rate of pneumatic dissection for deep anterior lamellar keratoplasty (DALK) using deep trephination. Methods A noncomparative case series evaluating the first 10 consecutive keratoconic eyes without deep stromal scarring, operated by 8 surgeons of 3 different experience levels, was conducted; there were a total of 80 patients. Standardized DALK was performed, including deep trephination 450 to 550 μm in depth and 9 mm in diameter, pneumatic dissection, removal of the stroma, and transplantation of a 9-mm partial-thickness anterior lamellar graft. The success rate of pneumatic dissection correlated with surgical experience. Results Pneumatic dissection succeeded in 7, 7, 8, and 9 cases of 10 cases in the first group of 4 inexperienced surgeons (under 10 previous keratoplasties of any kind); in 9 and 10 of 10 cases in the second group of 2 relatively experienced surgeons (under 100 keratoplasties); and in 10 and 8 of 10 cases in the third group of 2 very experienced surgeons (more than 1000 previous keratoplasties). No difference between the groups was found to be statistically significant with the χ test (P > 0.05). Conclusions The standardized DALK technique using a deep trephination allows high success rates of pneumatic dissection even for surgeons inexperienced in keratoplasty.

Purpose To report the outcomes of Descemet membrane endothelial keratoplasty (DMEK) with intensive antiviral therapy for corneal edema secondary to herpes simplex virus type 1 (HSV-1)-mediated endotheliitis. Methods All eyes with polymerase chain reaction positive for HSV-1 undergoing DMEK for endothelial decompensation between January 2014 and January 2018 were followed up prospectively at our tertiary referral center. All eyes had been free of active inflammation for a minimum of 9 months and were treated prophylactically with high-dose systemic and topical antivirals, which were continued for a prolonged period of time. Primary outcomes were the occurrence of immunological rejection and/or recurrence of endotheliitis, eventually resulting in graft failure. Secondary outcomes were best spectacle-corrected visual acuity and endothelial cell loss. Results Four consecutive eyes of 4 patients were included with a mean (±SD) patient age of 68.5 ± 15.1 years. The postoperative follow-up averaged 22 months. No eyes exhibited any signs of immunologic rejection, recurrence of endotheliitis, or graft failure. Mean (±SD) decimal best spectacle-corrected visual acuity improved from 0.2 ± 0.1 to 0.7 ± 0.2 (P = 0.007), whereas mean (±SD) endothelial cell loss was 56% ± 10.2% at the final postoperative follow-up. Conclusions DMEK is an effective option to treat corneal edema secondary to HSV-1-related endotheliitis. Intensive antiviral prophylaxis may reduce the risk of recurrence and subsequent graft failure.

PURPOSE To evaluate the orientation of keratometric astigmatism (KA) after deep anterior lamellar keratoplasty (DALK) for keratoconus and its correlation with preoperative peripheral KA. METHODS This is a retrospective, single-center observational study including keratoconic patients undergoing DALK between January 2016 and January 2017 with regular astigmatism postoperatively. The orientation of postoperative KA was classified as with-the-rule (WTR), against-the-rule, or oblique and was correlated with the corresponding preoperative peripheral KA, calculated by the sinusoidal fitting of points of the axial keratometric power map at 8 mm diameter. RESULTS Forty-one keratoconic eyes were included, with the most common orientation of KA post-DALK being WTR (65.9%), followed by against-the-rule (19.5%) and oblique (14.6%). A significant correlation was found between preoperative peripheral KA and post-DALK KA regarding axis (P < 0.001, r = 0.88) and power (P = 0.0128, r = 0.23). CONCLUSIONS The axis of post-DALK astigmatism and to a lesser extent its respective power in keratoconic eyes can be predicted using the preoperative peripheral KA, with "WTR" being the most common astigmatic orientation.

PURPOSE To evaluate the feasibility of regularizing the peripheral corneal thickness before deep trephination in highly irregular corneas undergoing deep anterior lamellar keratoplasty (DALK) by means of intrastromal hydration with saline. METHODS This is an interventional case series including all eyes with irregular peripheral corneal thickness undergoing DALK for any indication between January 1, 2016, and January 1, 2017, at a single tertiary center in Forli, Italy. Before trephination, 1 mL of normal saline was injected intrastromally into each clock hour of peripheral thinning (determined using preoperative pachymetry) using a 30-gauge needle. A deep trephination of 400 to 450 μm was then performed, and DALK was completed as per our previously described technique. Primary outcome measures were perforation during trephination and intraoperative complications, with secondary outcomes of best corrected visual acuity and refraction. RESULTS Peripheral intrastromal hydration was performed in 61 eyes of 61 patients. Intrastromal hydration ensured a safe trephination without perforation into the anterior chamber (AC) in 59 of 61 eyes. In the 2 cases in which perforation occurred, the perforation site was sutured with a full-thickness suture and the surgery was completed successfully. No cases required conversion to penetrating keratoplasty. Intrastromal injection of 1 mL of normal saline resulted in an increase in corneal thickness of 31%. After surgery, double AC was observed in 3 cases (4.9%), with all cases being managed successfully by air injection into the AC. CONCLUSIONS Zonal peripheral intrastromal hydration is a feasible technique to enable safe, deep trephination even in corneas of highly irregular thickness.

Background/AimsTo evaluate the 5-year outcomes of sutureless superficial anterior lamellar keratoplasty (SALK) in the treatment of surface ablation-related corneal haze recurring after phototherapeutic keratectomy (PTK).MethodsProspective interventional study at a tertiary referral centre in Forli, Italy. Ten consecutive eyes with corneal haze following photorefractive keratectomy, recurring after treatment with PTK with or without mitomycin C, undergoing sutureless SALK. Sutureless SALK was performed using a microkeratome in donor and recipient. Main outcome measures: best spectacle-corrected visual acuity (BSCVA), surgically induced astigmatism (SIA), rate of recurrence and complications.ResultsThere were no intraoperative complications and there was no recurrence of haze in any eye postoperatively. BSCVA showed significant improvement at all postoperative time points. Mean preoperative visual acuity improved from 0.46 logMAR units (SD=0.12) to 0.12 (SD=0.12, p=0.0001) at 5 years. At 6 months, SIA was 2.50±1.04 with no further significant change at 5 years (2.53±1.39, p=0.95). There was no significant change in mean spherical equivalent and no significant difference between preoperative and postoperative astigmatism vector values at 5 years.ConclusionsSutureless SALK provides a useful treatment option in patients with recurrent haze after excimer laser treatment. It can eliminate haze recurrence for at least a period of 5 years and can improve BSCVA, although there may be significant SIA.

PURPOSE To report the outcomes of a modified deep anterior lamellar keratoplasty (DALK) procedure for the treatment of scarred corneas in otherwise healthy pediatric eyes. METHODS All pediatric eyes undergoing DALK by the same surgeon (M.B.) between July 2013 and June 2017 were enrolled. The standard DALK procedure was modified by including a large (9 mm) and deep (150 μm from the thinnest pachymetric measurement) trephination, a minimal cannula advancement from the base of the trephination, and a clearing of a central 6 mm optical zone. The success rates of pneumatic dissection, visual and refractive outcomes, and complications were reported. A complete ophthalmologic examination was performed preoperatively and a few days after suture removal (6-months post-DALK) for all patients as well as 12, 24, and 36 months postoperatively for available patients. RESULTS Fourteen eyes of 13 patients with various indications were included in this study. The mean age at the time of surgery was 11.7 ± 2.5 years. Pneumatic dissection succeeded in all but one case (13/14 eyes = 92.8%), which was completed by hand dissection. All sutures were removed within 6 months of surgery. With a minimum postoperative follow-up of 6 months, best spectacle-corrected visual acuity improved from ≤20/50 to ≥20/40 in all but one eye, which was known to be amblyopic. CONCLUSIONS Despite impaired corneal transparency and increased tissue consistency, a modified DALK technique allows successful pneumatic dissection in an extremely high percentage of scarred pediatric eyes. Visual results compare favorably with those obtained in children after penetrating keratoplasty, while vision threatening complications are minimized.

Purpose To identify risk factors predictive of postoperative double anterior chamber formation after deep anterior lamellar keratoplasty (DALK). Design Retrospective institutional cohort study. Methods The study group included all consecutive eyes undergoing primary DALK between May 2015 and October 2018 at Villa Igea private hospital (Forli, Italy). The indications for surgery were categorized as (1) keratoconus without scarring; (2) keratoconus with scarring; (3) non-keratoconus without scarring; and (4) non-keratoconus with scarring. Multivariate binary logistic regression analysis was performed, introducing, as independent variables, those that reached a significance level of less than .05 in univariate analysis. The main outcome measure was whether or not postoperative double anterior chamber (AC) occurred. Results A total of 591 eyes of 591 patients were included. The main indication for DALK was keratoconus (67.2%, n = 397), and pneumatic dissection was achieved in 72.9% (n = 431) of patients. Postoperative double AC was observed in 8.1% (n = 48) of cases. Age, intraoperative central DM perforation, type 2 bubble formation, and presence of scar in keratoconic and nonkeratoconic corneas were all associated with an increased risk of postoperative double AC formation in the univariate analysis. Manual dissection was not associated with double AC formation. The factors that remained significant in multivariate analysis were keratoconus with scarring (odds ratio [OR] = 3.56, P = .02), non-keratoconus with scarring (OR = 5.09, P = .002), intraoperative central perforation (OR = 6.09, P = .03), and type 2 bubble formation (OR = 14.17, P Conclusions Scarred corneas of both normal and abnormal shape are independent risk factors for double AC formation following DALK, along with intraoperative perforation and the occurrence of a type 2 bubble.

Purpose To describe a new objective technique of digital image analysis for the quantification and the morphological characterization of corneal staining in the setting of dry eye disease (DED), and to apply it to distinguish Sjögren syndrome (SS) from ocular graft versus-host disease (oGVHD). Methods Slit-lamp photographs of corneal staining obtained from 40 patients with DED (20 with SS and 20 with oGVHD; mean age 60.7 ± 12.3 years) were evaluated. Images were subjectively graded using Oxford and National Eye Institute (NEI) scales, the staining pattern was classified as micropunctate, macropunctate, coalescent, or patch. The corneal staining index (CSI) was calculated automatically using the software ImageJ 1.51s. Particles analysis was used to calculate mean area, circularity, and roundness of staining spots. Results CSI was significantly correlated with Oxford and NEI scales (respectively Rs = 0.823 and Rs = 0.773; both P < 0.001), and showed a good interobserver reliability (intraclass correlation coefficient [ICC] = 0.988 [95% confidence interval [CI]: 0.978–0.994]). The mean area of staining spots calculated with particles analysis was significantly correlated with the subjective classification of the staining pattern (Rs = 0.550, P < 0.001). The circularity and roundness of staining spots were significantly higher in oGVHD patients compared with SS (respectively, 0.51 ± 0.11 vs. 0.44 ± 0.10, P = 0.040; 0.61 ± 0.03 vs. 0.59 ± 0.02, P = 0.004). Sensitivity and specificity to distinguish oGVHD from SS were respectively 65.0% and 60% for circularity and 80.0% and 70.0% for roundness. Conclusions The new algorithm showed good reliability and was well correlated with the traditional subjective grading scales. Particles analysis for the objective assessment of the staining pattern may help to differentiate patients with oGVHD from those with SS. Translational Relevance The digital image analysis technique may be a reliable alternative to evaluate corneal staining objectively in the clinic and in clinical trials.

Purpose To evaluate the rate and outcomes of immunologic stromal rejection occurring after large deep anterior lamellar keratoplasty (DALK) and the effect of the underlying disease on the cumulative probability of rejection. Methods This was a retrospective chart review of all eyes that underwent a 9-mm DALK at Ospedali Privati Forli (Forli, Italy). On the basis of preoperative diagnosis, eyes were assigned to group 1: keratoconus, group 2: stromal disease with a low risk for rejection, or group 3: stromal disease with a high risk for rejection. The cumulative probability of experiencing a rejection episode over time was assessed by Kaplan-Meier analysis and was compared among the 3 groups using the log-rank test. Values of corrected distance visual acuity, central corneal thickness, and endothelial cell density before and 6 months after rejection were compared. Results Twenty of 377 eyes (5.3%) experienced an episode of stromal rejection [17/265 (6.4%) in group 1, 2/71 (2.8%) in group 2, and 1/41 (2.4%) in group 3]. The mean time interval between DALK and the rejection onset was 11.8 months (range 1-24). The cumulative probability of rejection episodes did not differ significantly among the 3 groups. All episodes resolved within 6 months after the onset, with no significant differences between prerejection and 6-month postrejection values of corrected distance visual acuity, central corneal thickness, and endothelial cell density. Conclusions The rate of immunologic stromal rejection after large 9-mm DALK is within the range reported in the literature for conventional DALK, regardless of the indication for surgery.

Purpose To design and validate the efficacy of three-dimensional (3D) printed smart storage glide (SSG) which is capable of preserving and delivering posterior lenticules for Descemet stripping automated endothelial keratoplasty (DSAEK). Methods Laboratory investigation (A) was followed by clinical validation (B). Unsuitable corneas for transplantation (n=20) were used for study A. These tissues were cut using a standard microkeratome, punched and loaded into the SSG and preserved for 7 days in transport media. Endothelial cell density (ECD), Trypan blue and Alizarin red staining for endothelial morphology, thickness measurements and glucose uptake, cell apoptosis and immunostaining post preservation were analysed. For study B, clinical grade corneas (n=14) were preloaded in SSG and grafted in patients with indications of Fuchs’ dystrophy (n=8), pseudophakic bullous keratopathy (n=3), posterior polymorphous dystrophy (n=2), and previous DSAEK failure (n=1). Standard DSAEK included descemetorhexis under air and bimanual delivery of the tissue under infusion of buffered saline solution through an anterior chamber maintainer placed at the 12 o’clock position. Main outcome measures for study B were less surgical time, best spectacle-corrected visual acuity (BSCVA), speed of visual recovery, and ECD. Results For study A, an average ECD loss was 2.30±3.21%, thickness increased by 30.80±20.85% and one-third of glucose was utilised during the preservation phase. Alizarin red showed hexagonality of the cells. Cell apoptosis was not observed and expression of ZO-1 was noted on the preserved tissues. In study B, 25% ECD loss was observed after 6 months. BSCVA improved to 20/25 or better within 3 months after DSAEK. Mean surgical time recorded was 21 min. Conclusions This paper describes the development, design, laboratory and clinical validation of a 3D printed SSG which helps to store and deliver posterior lenticules, therefore allowing transportation of quality-controlled precut tissues.

● PURPOSE: To assess early and late micromorphological modifications of cross-linked corneas in vivo by means of Heidelberg Retinal Tomography (HRT) II confocal microscopy. ● DESIGN: Prospective nonrandomized open trial. ● METHODS: Micromorphological examination of 44 cross-linked keratoconic corneas was performed in vivo by HRT II confocal laser scanning microscopy. Riboflavin ultraviolet (UV)-A‐induced corneal collagen crosslinking (CXL) was performed according to the Siena protocol: pilocarpin 1% drops 30 minutes before, topical anesthesia with lidocaine 4% drops 15 minutes before irradiation, mechanical scraping of epithelium (9-mmdiameter area), preirradiation soaking for 10 minutes in riboflavin solution 0.1% (Ricrolin, Sooft, Italy) applied every 2.5 minutes for 30 minutes, 30 minutes exposure to solid-state UVA illuminator (Caporossi; Baiocchi; Mazzotta, X-linker, CSO, Italy), 8-mm-diameter irradiated area, energy delivered 3 mW/cm 2 . All patients were examined by confocal scans preoperatively and at the following times after treatment: one, three, and six months, and one, two, and three years. ● RESULTS: No damage to the limbal region was observed. Epithelial regrowth was complete after four days of soft contact lens bandage. The anatomy of the subepithelial plexus was restored one year after the operation with full corneal sensitivity. Increased density of extracellular matrix in late postoperative period indicated cross-linked collagen to a depth of 340 m expressed by a late demarcation line. ● CONCLUSION: In vivo confocal microscopy showed early and late modification of corneal microstructure after the treatment. The three-year stability of CXL recorded could be related to increased cross-links formation, synthesis of well-structured collagen and new lamellar interconnections. (Am J Ophthalmol