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To report long-term clinical outcomes and estimated success rates after Bowman layer (BL) inlay transplantation in eyes treated for progressive keratoconus (KC).Thirty-five eyes (29 patients) with progressive KC underwent BL inlay transplantation. Best-corrected spectacle and contact lens visual acuity, Scheimpflug-based corneal tomography [simulated and maximum keratometry (Kmax)], central corneal thickness, thinnest point thickness, complications, and success rate were evaluated up to 8 years postoperatively for the total group and 2 subgroups [group 1: preoperative Kmax69 diopter (D) (n = 26); group 2: preoperative Kmax69D (n = 9)].Mean logarithm of the minimum angle of resolution best contact lens-corrected visual acuity for the total group and the 2 subgroups did not change from preoperative up to the last available follow-up (all P0.05), whereas best spectacle-corrected visual acuity improved for group 1 ( P = 0.03). Group 1 showed an average Kmax reduction of 7D in the first month ( P0.001) with no further changes up to 8 years postoperatively ( P0.05), whereas no significant changes were observed in group 2 (all P0.05). Postoperative KC progression occurred in 4 eyes (n = 3 group 1, n = 1 group 2) and 1 eye (group 2) underwent retransplantation for unsatisfactory visual performance. Kaplan-Meier analysis showed an estimated success rate of 85% at the 5 to 8 years follow-up in group 1 and of 75% at the 5 to 7 years follow-up for group 2.BL inlay transplantation stabilized KC in most eyes along with preservation of contact lens tolerance up to 8 years postoperatively and may be a successful treatment option, in particular for eyes with progressive advanced KC (Kmax69D).

Over the past twenty years, there have been many developments in the treatment of corneal diseases, especially in the field of corneal transplantation. By targeting treatments solely to the affected layers of the cornea, the procedures have become less invasive and the cornea recovers significantly faster. Despite the success of these new surgical techniques, new (cell) regenerative therapies are emerging.

For nearly a century, the definitive treatment of many corneal dystrophies and ectactic disorders was limited to penetrating keratoplasty, but over the past 2 decades, a surge of surgical innovation has propelled the treatment of many corneal diseases to more targeted approaches with significantly better visual outcomes. Anterior stromal diseases were first changed through endothelial-sparing techniques, such as deep anterior lamellar keratoplasty, but have more recently transitioned to stromal-sparing approaches. Ultraviolet corneal crosslinking strengthens the cornea and halts progression of keratoconus in >90% of cases. Intracorneal ring segment and corneal allogenic ring segment implantation offer methods to flatten ectatic corneas. However, Bowman layer transplantation – inlay and more recently onlay techniques – has shown promise for treating advanced keratoconus and preventing keratoplasty. The advent of endothelial keratoplasty radically changed the treatment of corneal endothelial dysfunction, and Descemet membrane endothelial keratoplasty specifically offers an average postoperative visual acuity of 20/25 (0.8) with only 8.8% of grafts requiring retransplantation in the first 5 years. Here, we review the rapid innovations for surgical treatment of corneal diseases, spanning from endothelial keratoplasty and endothelial regeneration to anterior lamellar keratoplasty and stromal augmentation, highlighting key steps which may be moving us closer to a “postkeratoplasty” world.

PURPOSE: To evaluate the 10-year graft survival and clinical outcomes of the first case series after Descemet membrane endothelial keratoplasty (DMEK).DESIGN: Retrospective, interventional case series.METHODS: After excluding the very first 25 DMEK eyes that constitute the technique learning curve, the following 100 consecutive primary DMEK eyes (88 patients) were included. Main outcome parameters (survival, best-corrected visual acuity [BCVA], central endothelial cell density [ECD], and central corneal thickness [CCT]) were evaluated up to 10 years postoperatively, and postoperative complications were documented.RESULTS: At 5 and 10 years after DMEK, 68 and 57 of 100 eyes, respectively, were still available for analysis. Of those eyes, 82% and 89% reached a BCVA of >= 20/25 (decimal VA >= 0.8) at 5- and 10 years postoperatively, respectively. Preoperative donor ECD decreased by 59% at 5 years and 68% at 10 years postoperatively. CCT averaged 668 +/- 74 mu m preoperatively and 540 +/- 33 mu m and 553 +/- 43 mu m at 5 and 10 years, respectively, after surgery. Within 10 years, 4% of eyes developed allograft rejection, no primary graft failures occurred, and 6% of the eyes developed secondary graft failure. Graft survival probability was 0.83 (95% confidence interval [CI], 0.75-0.92) and 0.79 (95% CI, 0.70-0.88) at 5 and 10 years postoperatively, respectively.CONCLUSIONS: Most eyes that underwent surgery in the pioneering phase of DMEK showed excellent and stable clinical outcomes with low postoperative complication rates and promising graft longevity over the first decade after surgery. This suggests that DMEK may be a safe long-term treatment option for corneal endothelial diseases. ((C) 2020 Elsevier Inc. All rights reserved.)

PURPOSE To describe the clinical outcome of a first patient undergoing Bowman layer (BL) transplantation with an onlay graft to reduce fluctuation in visual acuity and refractive error after previous radial keratotomy (RK) surgery. METHODS In 2018, a 66-year-old woman presented with complaints of long-standing diurnal fluctuation in best-spectacle corrected visual acuity (BSCVA) after RK in 1983. After the removal of host epithelium, a BL graft was positioned onto the host cornea. BSCVA, Scheimpflug-based corneal tomography, and anterior segment optical coherence tomography were evaluated up to 12 months postoperatively. RESULTS The surgery and postoperative course were uneventful. After surgery, the subjective complaints of visual fluctuation were reduced from 10 to 3 on a scale from 1 to 10. BSCVA (20/40; 0.5) did not change from preoperative to postoperative. Corneal tomography showed an overall central corneal steepening of 5.9 diopters. Biomicroscopy, Scheimpflug imaging, and anterior segment optical coherence tomography showed a completely epithelialized and well-integrated graft, with some minor epithelial remnants located in the preexisting keratotomy incisions. CONCLUSIONS BL onlay grafting may have the potential to manage patients with subjective complaints of diurnal fluctuation in visual acuity after previous RK.

Purpose: The aim of this study was to evaluate how Scheimpflug-derived parameters of eyes with Fuchs endothelial corneal dystrophy (FECD) are influenced by Descemet membrane endothelial keratoplasty (DMEK) depending on FECD severity and the presence of subclinical edema. Methods: A retrospective cohort study including 115 eyes (115 patients) that underwent DMEK for FECD and a control group of 27 eyes with nonpathological corneas was conducted. Preoperative and 6 months postoperative Scheimpflug imaging was used to analyze pachymetry, presence of tomographic features (loss of isopachs/displacement of the thinnest point/focal posterior depression), and corneal backscatter. FECD severity was based on the modified Krachmer scale and the absence/presence of subclinical edema. Results: Scheimpflug-derived pachymetry, tomographic, and corneal backscatter parameters were correlated with FECD severity, and all changed from preoperatively to postoperatively (all P < 0.05). Postoperative central corneal thickness, anterior and posterior corneal backscatter, and presence of focal posterior depression remained different from the control group (all P < 0.05). Of eyes without preoperative clinical edema (n = 75), 18.7% showed 0 or 1 tomographic feature (no edema group) and 82.4% had 2 or 3 features (subclinical edema group). Compared with the control group, postoperative best-corrected visual acuity for the “no edema” group did not differ (0.03 ± 0.12 vs. −0.02 ± 0.08 logarithm of the minimum angle of resolution, P = 0.150) but was worse for the subclinical edema group (0.06 ± 0.08 vs. −0.02 ± 0.08 logarithm of the minimum angle of resolution, P = 0.001). Conclusions: For eyes without preoperative edema, more parameters reversed back to ‘normal’ levels than for eyes with (sub)clinical edema. Although most analyzed parameters correlated with FECD severity, corneal tomography might be best suited for objective grading of disease severity to aid in surgical decision-making.

Purpose: To analyze if 6-month endothelial cell density (ECD) affects long-term ECD outcome and graft survival 5 years after Descemet membrane endothelial keratoplasty (DMEK) in eyes with Fuchs endothelial corneal dystrophy (FECD).Design: Retrospective cohort study.Participants: A total of 585 DMEK eyes were included. The study group was divided into 4 groups based on 6-month ECD quartiles: group 1 (n = 146) with 313 to 1245 cells/mm(2), group 2 (n = 148) with 1246 to 1610 cells/mm(2), group 3 (n = 145) with 1611 to 1938 cells/mm(2), and group 4 (n = 146) with 1939 to 2760 cells/mm(2). Group 1 was further split into subgroups 1a (n = 36) with 6-month ECD of

The aim of this study was to review the postoperative course and imaging features of 7 eyes that presented with corneal hydrops after Bowman layer (BL) transplantation was performed for advanced keratoconus to determine the potential mechanisms of hydrops formation.A retrospective analysis was performed of 7 eyes of 5 patients with advanced keratoconus that underwent midstromal BL transplantation at 2 tertiary referral centers and developed acute corneal hydrops on average 64 (±30) months (range 14-104 months) postoperatively. Corneal tomography and anterior segment optical coherence tomography (AS-OCT) images were reviewed to document the postoperative and posthydrops course.For all eyes, the post-BL transplantation course was uneventful until hydrops development. Despite stable postoperative topographies in 5 of 7 eyes, eyes developed hydrops with typical hypodense areas on AS-OCT that were limited to the stromal layers posterior to the BL graft. With AS-OCT (6/7 eyes), 2 eyes showed a break in Descemet membrane, whereas Descemet membrane was intact across the cornea in 2 eyes; in 2 eyes, the images were inconclusive. All patients admitted to continued eye rubbing, and all but 1 had a clinically significant allergy and/or atopic constitution. Most eyes (5/7) showed a relatively quick (visual) recovery within 1 to 4 months after hydrops.Hydrops formation in keratoconic corneas after midstromal BL transplantation may indicate that a break in Descemet membrane is secondary to hydrops development (and not vice versa). With a midstromal BL graft in situ limiting hydrops dimensions, resolution of the hydrops seemed relatively quick with recovery to prehydrops visual acuity in most eyes.

PURPOSE: The aim of this study was to describe a new type of medical device that allows for internet-enabled patient self-screening, without the aid of an ophthalmic professional, through biomicroscopy self-imaging and self-measurement of the best-corrected visual acuity (BCVA). METHODS: In this prospective nonrandomized comparative study, 56 patients were instructed to screen their own eyes using a custom-built e-Device containing miniaturized slitlamp optics and a visual acuity Snellen chart virtually projected at 20 ft. BCVA measurements were recorded, and biomicroscopic videos were scored for image quality of the anterior segment status on a scale from 1 to 5 (1 = poor and 5 = excellent) by a blinded observer. RESULTS: After a short instruction, all patients were able to self-image their eyes and perform a self-BCVA measurement using the e-Device. Patient self-image quality with the e-Device scored on average 3.3 (±0.8) for videos (n = 76) and 3.6 (±0.6) for photographs (n = 49). Self-BCVA measurement was within 1 Snellen line from routine BCVA levels in 66 of 72 eyes (92%). When compared with conventional biomicroscopy, patient self-biomicroscopy allowed for recognition of the relevant pathology (or absence thereof) in 26 of 35 eyes (74%);9 cases showed insufficient image quality attributed to device operating error (n = 6) and mild corneal edema and/or scarring (n = 3). Patient satisfaction with the device was 4.4 (±0.9). CONCLUSIONS: An e-Device for combined BCVA self-measurement and biomicroscopy self-imaging may have potential as an aid in remote ophthalmic examination in the absence of an ophthalmic professional and may be considered for patients who are unable to visit an ophthalmic clinic for routine follow-up.

The purpose of this study was to describe a case with recurrent corneal erosions who was treated with a Bowman layer (BL) onlay graft.BL onlay transplantation was performed.In a 79-year-old female patient who presented with bilateral map-dot-fingerprint dystrophy and a history of recurrent painful corneal erosions, BL onlay grafting was performed to restore the corneal surface. At 1 month postoperatively, the epithelium was smooth over the graft, and until 1.5 years postoperatively, the patients had no complaints and no recurrence of the epithelial corneal erosion.In the described case, the transplantation of an isolated BL graft as an onlay proved to be an effective treatment for painful chronic recurrent erosions in the context of map-dot-fingerprint dystrophy in a patient who had undergone numerous unsuccessful previous treatments.

Herein, we report the outcomes of intrastromal Descemet membrane (DM) transplantation in corneas with advanced keratoconus. Three eyes (three patients) showed advanced keratoconus. No eye underwent prior UV-cross-linking or any other ocular surgery. In all eyes, A donor DM was implanted into a mid-stromal pocket and clinical outcomes were evaluated up to 24 months after surgery. All procedures were uneventful. Up to 24 months postoperatively, the DM graft was well-positioned and barely visible within the recipient stroma; all corneas were clear. No eye showed signs of keratoconus progression throughout the follow-up. No changes were observed in uncorrected and best contact lens corrected visual acuity, central endothelial cell density, corneal thinnest point pachymetry, and maximum keratometry values. No early or late postoperative complications were observed. Intrastromal DM transplantation may be an alternative to intrastromal Bowman layer transplantation in advanced keratoconus, to postpone deep anterior lamellar or penetrating keratoplasty.

Purpose The aim of this study was to describe a new surgical technique for flattening the corneal curvature and to reduce progression in eyes with advanced progressive keratoconus (KC) by using Bowman layer (BL) onlay grafting and to report on the preliminary outcomes of this procedure. Methods In this prospective interventional case series, 5 patients with advanced progressive KC underwent BL onlay grafting. After removal of the epithelium, a BL graft was placed and "stretched" onto the stroma, and a bandage lens was placed to cover the BL graft. In 1 case, BL onlay grafting could be performed immediately after ultraviolet corneal crosslinking; all other eyes were ineligible for ultraviolet corneal crosslinking. Best spectacle- and/or best contact lens-corrected visual acuity, refraction, biomicroscopy, corneal tomography, anterior segment optical coherence tomography, and complications were recorded at 1 week and at 1, 3, 6, 9, and 12 to 15 months postoperatively. Results All 5 surgeries could be performed successfully. Average maximum keratometry went from 75 diopters (D) preoperatively to 70 D at 1 year postoperatively. All eyes showed a completely reepithelialized and a well-integrated graft. Best spectacle-corrected visual acuity improved at least 2 Snellen lines (or more) in 3 of 5 cases and best contact lens-corrected visual acuity remained stable, improving by 3 Snellen lines in case 1 at 15 months postoperatively. Satisfaction was high, and all eyes again had full contact lens tolerance. Conclusions BL onlay grafting may be a feasible surgical technique, providing up to -5 D of corneal flattening in eyes with advanced KC.

PURPOSE: To analyze the incidence of cataract extraction after Descemet membrane endothelial keratoplasty (DMEK) in phakic eyes and to evaluate the effect of phacoemulsification after DMEK on the donor endothelial cell density (ECD). METHODS: The clinical data of phakic patients with DMEK were examined. From this cohort, all patients who subsequently underwent phacoemulsification after DMEK were reviewed. Data from a prospectively collected dataset were analyzed, including demographic profile, ECD, corrected distance visual acuity (CDVA), central corneal thickness (CCT), and complications. RESULTS: From a series of 261 phakic patients with DMEK, 35 eyes (13.4%) required cataract surgery within the mean follow-up period of 54.2 ± 28 months. The mean time from DMEK to phacoemulsification was 18 ± 13 months (range: 3 to 69 months). The probability of cataract extraction after DMEK was 0.06 (95% CI: 0.03 to 0.09) at 1 year and 0.17 (95% CI: 0.12 to 0.22) at 10 years, respectively. ECD decreased from 1,314 ± 524 cells/mm 2 before phacoemulsification to 1,167 ± 443 cells/mm 2 (−11%) at 1 to 6 months postoperatively ( P = .333). CDVA improved from 0.27 ± 0.13 logMAR preoperatively to 0.07 ± 0.12 logMAR at 1 to 6 months postoperatively. CCT before phacoemulsification was 532 ± 46 µm and remained stable at 539 ± 56 µm at 1 to 6 months after phacoemulsification. Phacoemulsification did not elicit DMEK graft detachment in any of the eyes studied. CONCLUSIONS: The incidence and 10-year projection of cataract extraction in phakic eyes with DMEK was relatively low. Phacoemulsification after DMEK provided excellent CDVA outcomes, did not induce graft detachment, and was associated with an acceptable decrease in ECD. [ J Refract Surg . 2021;37(2):119–125.]

PURPOSE: To evaluate which parameters may affect endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK) by comparing eyes in the low vs high quartile of endothelial cell loss over a follow-up period of 4 years.DESIGN: Retrospective cohort study.METHODS: Donor endothelial cell density (ECD) decline was evaluated for 351 eyes of 275 patients up to 4 years after DMEK for Fuchs endothelial corneal dystrophy (FECD). Eyes with a postoperative endothelial cell loss in the lower quartile at all available follow-up moments were assigned to Group 1 (n = 51) and those in the upper quartile to Group 2 (n = 42). Multinomial regression was used to assess which covariates were related to greater ECD decline.RESULTS: Mean endothelial cell loss as compared to preoperative donor ECD for the entire study group was 33 (+/- 16)%, 36 (+/- 17)%, and 52 (+/- 18)% at 1, 6, and 48 months postoperatively. Endothelial cell loss of Group 1 was 12 (+/- 7)%, 13 (6)%, and 26 (+/- 8)% at, respectively, 1, 6, and 48 months postoperatively, and 59 (+/- 10)%, 64 (+/- 9)%, and 75 (+/- 5)% in Group 2. Partial graft detachment, donor death cause cardiovascular/stroke (vs cancer), postoperative complications other than graft detachment, and severity of preoperative FECD (all P

Purpose: To introduce the concept of using a Bowman layer (BL) onlay graft to manage superficial herpetic corneal scarring and to describe the clinical outcomes of the first 2 cases undergoing this procedure. Methods: Two patients with a quiescent superficial corneal scar after herpes (varicella zoster virus [n = 1] and herpes simplex virus [n = 1]) keratitis underwent BL onlay transplantation. After the removal of the host epithelium and limited superficial keratectomy, an isolated BL graft was placed onto the host corneal surface. The cornea was then covered with an amniotic membrane and a bandage contact lens. Best spectacle-corrected visual acuity (VA) and/or best contact lens-corrected VA (BCLVA), biomicroscopy, corneal tomography, and anterior segment optical coherence tomography were recorded at 1 week, 1 month, and 3, 6, 9, 12, and 18 months postoperatively. Results: In both cases, the surgical and postoperative courses were uneventful. An improvement of the corneal clarity was observed at biomicroscopy, and no varicella zoster virus/herpes simplex virus reactivation occurred throughout the follow-up period. Biomicroscopy, Scheimpflug imaging, and anterior segment optical coherence tomography showed a completely epithelialized and well-integrated graft postoperatively. In case 1, BCLVA with a scleral lens improved from 20/100 (0.1) preoperatively to 20/32 (0.6) postoperatively. For case 2, no preoperative BCLVA was available, but a BCLVA of 20/36 (0.55) was achieved after the procedure. Conclusions: A BL onlay graft may be a feasible surgical procedure, which may have the potential to reduce superficial corneal scarring and/or anterior corneal irregularities without resorting to deeper keratoplasty in these complex cases.

PURPOSE: To analyze 6-month results of 1000 consecutive Descemet membrane endothelial keratoplasty (DMEK) cases, and to evaluate if outcomes are influenced by surgical indication and preoperative lens status.DESIGN: Retrospective, interventional case series.METHODS: A series of 1000 eyes (738 patients) underwent DMEK mainly for Fuchs endothelial corneal dystrophy (FECD; 85.3%) or bullous keratopathy (BK; 10.5%). Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density, postoperative complications, and retransplantations.RESULTS: At 6 months after DMEK, there was no difference in BCVA outcome between FECD and BK eyes (P = .170), or between phakic and pseudophakic FECD eyes (P = .066) after correcting for patient age and preoperative BCVA. Endothelial cell loss at 6 months postoperatively was similar for phakic and pseudophakic FECD eyes (39%; P = .852), but higher for BK eyes than for FECD eyes (46% vs 39%, P = .001). Primary and secondary graft failure occurred in 3 (0.3%) and 2 eyes (0.2%), respectively, and 7 eyes developed allograft rejection (0.7%). Eighty-two eyes (8.2%) received rebubbling for graft detachment and retransplantation was performed in 20 eyes (2.0%). Rebubbling was more often required in eyes treated for BK vs FECD eyes (12.4% vs 7.4%, P = .022).CONCLUSION: DMEK consistently provides excellent short-term results, with similar high visual acuity levels for both FECD and BK eyes. As preoperative lens status did not influence DMEK outcomes, for phakic FECD eyes with a still relatively clear crystalline lens, lens preservation may be preferable in a selected group of younger patients, who may still benefit from their residual accommodative capacity. (C) 2019 Elsevier Inc. All rights reserved.

PURPOSE To study the influence of different intraoperative air tamponade times on graft adherence after Descemet membrane endothelial keratoplasty (DMEK). METHODS In this interventional case series, we evaluated 117 eyes with Fuchs endothelial corneal dystrophy (FECD) that underwent DMEK using intraoperative air tamponade times of 60 minutes (group I; n = 39), 45 minutes (group II; n = 39), or 30 minutes (group III; n = 39). At 1 and 6 months postoperatively, graft adherence status, endothelial cell density, central pachymetry, and postoperative complications were recorded. RESULTS At 1 month, 19 of the 117 eyes (16.2%) showed a clinically significant detachment (>1/3 of the graft surface area and affecting visual axis): 6 eyes in group I (15.4%), 5 eyes in group II (12.8%), and 8 eyes in group III (20.5%) (P = 0.82). A minor detachment (

Introduction: Deep and Superficial anterior lamellar keratoplasty (DALK and SALK, respectively) are rapidly replacing penetrating keratoplasty (PK) as the treatments of choice for anterior corneal disorders worldwide. Nevertheless, significant disagreements remain which encompass nearly every aspect of both operations and whether there are better alternatives.Areas covered: Here, we perform a comprehensive literature review of all articles published in the English language, indexed on Pubmed, and within the past 5 years on the subject of ‘anterior lamellar keratoplasty.’ From these articles, the most salient disputes are enumerated and presented.Expert commentary: Presently, there is no consensus in the areas of graft preparation, instrumentation, or operative technique for DALK/SALK. As new evidence emerges, these debates may be clarified, or – instead – merely forgotten, as alternative surgical techniques arise to supplant ALK entirely.

Penetrating and – to some extent, Deep anterior lamellar keratoplasty (PK and DALK, respectively) – represent the ‘old’ generation of treatments for keratoconus (KC). Increasingly, they are being replaced by newer, less invasive techniques, like ultra-violet corneal crosslinking (UV-CXL) and intracorneal ring segment (ICRS) implantation. Even more recently, Bowman layer (BL) transplantation has been introduced for patients with advanced KC; the operation is designed to stiffen, strengthen, and flatten the recipient cornea into a more normal, stable configuration and thereby prevent or delay the need for more invasive treatment. Here, we provide an overview and history of this new technique, and relay the operation’s mid-term surgical results.

Background To evaluate the efficacy of manual mid-stromal dissection in stabilizing progressive keratoconus. Methods Surgeries were performed in 16 eyes of 14 patients with progressive keratoconus. All eyes were examined before and at 1 day, 1 week, 1, 3, 6 and 12 months after surgery, and every 6 months thereafter. Pentacam (simK, Kmax and pachymetry), best corrected visual acuity (BCVA) and subjective refraction were recorded up to the latest follow-up visit (mean follow-up time 6.6 ± 2.4 years). Results All surgeries were uneventful, and no postoperative complications occurred. Keratometry values (n = 15) stabilized in 6/11 eyes (55%) with a preoperative Kmax 60 D showed continued progression. In 11/15 eyes (73%) pachymetry was unchanged. BCVA with spectacles remained stable in 7/12 eyes (58%) and improved ≥2 Snellen lines in 5/12 eyes (42%). BCVA with a contact lens remained stable in 4/9 eyes (44%), improved ≥2 Snellen lines in 3/9 eyes (33%) and deteriorated in 2/9 eyes (22%). Conclusions Manual mid-stromal dissection was effective in 50% of keratoconic corneas with Kmax values

Several treatment options corresponding to the grade of keratoconus have been established. These are ultra-violet corneal crosslinking and intracorneal ring segments for mild to moderate keratoconus, and penetrating keratoplasty or deep anterior lamellar keratoplasty for the more advanced cases of keratoconus. Bowman layer transplantation was developed as a procedure for patients with advanced, progressive keratoconus. The technique consists of transplanting an isolated donor Bowman layer into a mid-stromal pocket of a keratoconic cornea resulting in corneal flattening and stabilization against further ectasia. Thus, it aims at corneal stabilization in eyes with advanced keratoconus, and enabling continued contact lens wear for normal visual functionality. By being a sutureless procedure and using an acellular graft, it potentially avoids commonly known suture and graft-related complications of penetrating or deep anterior lamellar keratoplasty. The treatment seems to be a promising option in the management of advanced keratoconus in order to postpone or prevent a more invasive corneal surgery, while minimizing the risk of complications and allowing less stringent surveillance and less intensive medical therapy.

PURPOSE To report the mid-term outcomes of hemi-Descemet membrane endothelial keratoplasty (hemi-DMEK) performed for Fuchs endothelial corneal dystrophy (FECD). METHODS In this prospective, interventional case series, we evaluated clinical outcomes of 10 eyes from 10 patients who underwent hemi-DMEK for FECD. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), central pachymetry, and postoperative complications. RESULTS At 1 year postoperatively, 7/7 eyes (excluding 2 eyes with low visual potential) reached a BCVA of ≥20/40 (≥0.5), 6/7 (86%) ≥20/25 (≥0.8), 4/7 (57%) ≥20/20 (≥1.0), and 2/7 (29%) 20/17 (≥1.2). BCVA remained stable until 2 years postoperatively (P ≥ 0.05) and further improved thereafter (P < 0.05). Mean ECD decreased from 2740 (±180) cells/mm preoperatively to 850 (±300) cells/mm (n = 9) at 1 year (P ≤ 0.05) and showed an annual decrease of on average 6% to 7% thereafter (P ≥ 0.05 between consecutive follow-ups). Pachymetry decreased from preoperatively 745 (±153) μm to 533 (±63) μm (n = 9) and 527 (±35) μm (n = 8) at 1 and 3 years postoperatively, respectively. Within the first 6 postoperative months, 4/10 eyes underwent rebubbling for visually significant graft detachment. One eye received secondary circular DMEK for persistent graft detachment 1 month postoperatively; another eye developed secondary graft failure 2.5 years postoperatively, and 1 eye was suspected for an allograft reaction 1.5 years postoperatively. CONCLUSIONS Hemi-DMEK may render visual outcomes comparable to those achieved by conventional DMEK. Despite low ECD counts by 6 months, ECD levels remain fairly stable thereafter. Hence, hemi-DMEK may become a potential alternative technique for treatment of FECD while increasing the yield of the endothelial tissue pool.

PURPOSE To assess aqueous flare as a measure of subclinical inflammation after Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy. METHODS In this prospective cross-sectional and longitudinal case series at a tertiary referral center, 173 DMEK eyes of 169 patients and 19 age-matched healthy control eyes were included. Aqueous flare [photon count per millisecond (ph/ms)] was assessed by laser flare photometry at 1 day, 1 week, and 1 month after DMEK in group I (evaluation of postsurgical blood-aqueous barrier recovery; n = 25) and on average 28 (±19) months (range, 3-86 months) after DMEK in group II (evaluation of long-term inflammation; n = 148). RESULTS In group I, flare levels decreased from 1 day to 1 week [25.1 (±9.1) ph/ms vs. 13.4 (±4.8) ph/ms; P = 0.003] and remained stable up to 1 month after DMEK [12.1 (±3.2) ph/ms; P = 0.387]. However, average flare at 1 month was higher than that in healthy controls (P < 0.001). The long-term flare value after DMEK (group II) was 9.6 (±4.2) ph/ms and was higher in eyes associated with allograft rejection (n = 6) versus those without rejection [16.7 (±7.8) ph/ms vs. 9.3 (±3.8) ph/ms, respectively, P < 0.001]. All eyes associated with rejection had flare values above 10 ph/ms. CONCLUSIONS Aqueous flare after DMEK quickly decreased within the first postoperative month, indicating fast recovery of the blood-aqueous barrier. Long-term flare levels were higher in eyes associated with rejection, suggesting persistent subclinical inflammation. A flare level above 10 ph/ms may be used as a threshold for identifying eyes associated with or at risk of allograft rejection after DMEK.

Purpose To challenge the current consensus on the mechanism causing corneal hydrops in eyes with keratoconus (KC). Design Retrospective, interventional case series. Methods Sixteen eyes of 10 patients with comorbid KC and Fuchs endothelial corneal dystrophy (FECD) underwent uncomplicated Descemet membrane endothelial keratoplasty (DMEK), and 5 eyes of 5 patients with KC alone underwent Bowman layer (BL) transplantation complicated by inadvertent perforation of the posterior corneal stroma and Descemet membrane (DM). The presence or absence of hydrops was assessed by intra- and postoperative optical coherence tomography and by slit-lamp biomicroscopy. Results None of the 16 DMEK eyes manifested a hydrops at any time during or after surgery. By contrast, all 5 eyes undergoing BL transplantation complicated by posterior corneal perforation demonstrated a corneal hydrops, evident both intra- and postoperatively. Conclusions In eyes with KC, even the complete removal of DM did not produce a hydrops, whereas a combined defect in DM and the posterior corneal stroma seemed to consistently elicit a typical corneal hydrops.

Purpose To describe specific maneuvers and technical modifications to the standardized "no-touch" technique of Descemet membrane endothelial keratoplasty (DMEK) to successfully handle the presence of a glaucoma drainage device (GDD) tube in the anterior chamber of an eye with a failed primary penetrating keratoplasty (PK) graft. Methods A 42-year-old male patient underwent DMEK because of a failed primary PK graft in his phakic right eye. The patient was then evaluated at 3 and at 6 months after surgery. Results A modified no-touch DMEK technique proved a feasible treatment option for a decompensated primary PK graft in the presence of a long GDD tube. Conclusions With specific technical modifications DMEK can be successfully performed in eyes with decompensated primary PK grafts in the presence of a long GDD tube. The very thin DMEK graft allows positioning between the GDD tube and the failed PK graft, leaving the tube in place.

Purpose To describe the clinical outcome and complications of repeat Descemet membrane endothelial keratoplasty (re-DMEK). Design Retrospective case series study at a tertiary referral center. Participants From a series of 550 consecutive DMEK surgeries with ≥6 months follow-up, 17 eyes underwent re-DMEK for graft detachment after initial DMEK (n = 14) and/or endothelial graft failure (n = 3). The outcomes were compared with an age-matched control group of uncomplicated primary DMEK surgeries. Methods The re-DMEK eyes were evaluated for best-corrected visual acuity (BCVA), densitometry, endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications. Main Outcome Measures Feasibility and clinical outcome of re-DMEK. Results In all eyes, re-DMEK was uneventful. At 12 months, 12 of 14 eyes (86%) achieved a BCVA of ≥20/40 (≥0.5); 8 of 14 eyes (57%) achieved ≥20/25 (≥0.8), 3 of 14 eyes (21%) achieved ≥20/20 (≥1.0), and 1 eye (7%) achieved 20/17 (1.2); 5 eyes were fitted with a contact lens. Average donor ECD decreased from 2580±173 cells/mm 2 before to 1390±466 cells/mm 2 at 6 months after surgery, and pachymetry from 703±126 μm to 515±39 μm, respectively. No difference in densitometry could be detected between re-DMEK and control eyes ( P = 0.99). Complications after re-DMEK included primary graft failure (n = 1), secondary graft failure (n = 2), graft detachment requiring rebubbling (n = 1), secondary glaucoma (n = 2), cataract (n = 1), and corneal ulcer (n = 1). One eye received tertiary DMEK. Conclusions In the management of persistent graft detachment and graft failure after primary DMEK, re-DMEK proved a feasible procedure. Acceptable BCVA may be achieved, albeit lower than after DMEK in virgin eyes, and some cases may benefit from contact lens fitting. Complications after re-DMEK may be better anticipated than after primary DMEK because graft detachment and graft failure tended to recur, suggesting that intrinsic properties of the host eye play a role in graft adherence and graft failure.

Background/aimTo assess the clinical outcome of the first series of Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK), a potential hybrid technique between ‘descemetorhexis only’ and conventional, circular DMEK.MethodsProspective interventional case series at a tertiary referral centre. Twelve eyes of 12 patients with central Fuchs endothelial corneal dystrophy underwent Quarter-DMEK, that is, transplantation of one quadrant of a full-diameter DMEK graft, and were evaluated for best-corrected visual acuity (BCVA), endothelial cell density (ECD) and complications up to 6 months postoperatively.ResultsAt 6 months postoperatively, all eyes reached a BCVA of ≥20/40 (≥0.5), 11/12 (92%) of ≥20/25 (≥0.8) and 6/12 (50%) of ≥20/20 (≥1.0). Mean central ECD decreased from 2867 (±161) cells/mm2before to 1255 (±514) cells/mm2at 1 month, 1058 (±455) cells/mm2at 3 months and 968 (±427) cells/mm2at 6 months after surgery. Rebubbling was performed in 4/12 eyes (33%) within the first two months.ConclusionsQuarter-DMEK may be a feasible procedure that allows for visual outcomes similar to conventional, circular DMEK. The relatively large drop in ECD within the first month may have resulted from more extensive endothelial cell migration and/or measurement error (at the graft edges). If longer-term outcomes would resemble those of conventional DMEK, Quarter-DMEK may potentially quadruple the availability of endothelial grafts.

To evaluate changes in maximum keratometry (Kmax), corneal higher-order aberrations (HOAs), and densitometry (backscattered light) up to 1 year after UV cross-linking and their possible relation with changes in the visual outcome.Retrospective cohort study on 18 eyes of 16 patients, who underwent UV cross-linking after the Dresden protocol for progressive keratoconus or ectasia after laser-assisted in situ keratomileusis. Corrected distance visual acuity (CDVA), Scheimpflug-based corneal tomography, mean image brightness (corneal densitometry) from the anterior 120 μm of the midcornea, and posterior 60 μm of the central 6 mm of the cornea, and HOAs were evaluated.Kmax at 1 month (59.7 ± 6.0D) after UV cross-linking resembled preoperative Kmax (59.3 ± 6.4D, P = 0.368), decreased until 3 months postoperatively (58.3 ± 6.3D, P = 0.002), and stabilized thereafter (P0.227). All postoperative corneal densitometry values were higher than preoperative values in all measured depths (P0.05). One-month anterior and total corneal HOAs (4.28 ± 1.64 μm and 3.87 ± 1.62 μm, respectively) resembled preoperative values (4.10 ± 1.70 μm and 3.67 ± 1.62 μm, respectively; P0.221) and then decreased until 12 months postoperatively (3.86 ± 1.84 μm and 3.40 ± 1.80 μm, respectively; P0.005). Thinnest point thickness decreased from before (442 ± 25 μm) to 3 months postoperatively (427 ± 25 μm, P0.001), with no difference at 12 months postoperatively compared with preoperative values (437 ± 29 μm, P = 0.149). CDVA and endothelial cell density remained unchanged (P0.345 and P0.257, respectively). No relations were found between CDVA and the evaluated parameters (P0.05).One year after UV cross-linking, the observation of stable CDVA and thinnest point thickness, together with reduced Kmax suggests no ectasia progression within the study period in these cases. Although HOAs showed a trend toward improvement, corneal densitometry remained elevated.

To describe Descemet membrane endothelial keratoplasty (DMEK) complications and strategies for their prevention and management.Five hundred consecutive eyes with DMEK of 393 patients were reviewed in this retrospective study for intraoperative and postoperative complications up to 2 years and for corresponding management.Intraoperative challenges (difficult graft unfolding/positioning, high vitreous pressure, iris root hemorrhage, and Descemet membrane remnants) were encountered in 81 eyes (16.2%). Visually significant graft detachment was the main postoperative complication (34 eyes, 6.8%). Graft failure occurred in 8 eyes (1.6%). Other postoperative complications were an increase of intraocular pressure/decompensated glaucoma in 48 eyes (9.6%), significant cataract in 11 of 124 phakic eyes (8.9%), allograft rejection in 7 eyes (1.4%), cystoid macular edema in 5 eyes (1.0%), microbial keratitis in 2 eyes (0.4%), and retinal detachment in 1 eye (0.2%). Different strategies for prevention and management of these complications have been identified.DMEK shows acceptable rates of complications up to 2 years after surgery, which can be managed successfully. Anticipation of potential challenges and difficulties may aid in modifying intraoperative strategies for predisposed eyes. This knowledge may further minimize complications, in particular, when performing DMEK for an extended spectrum of corneal endothelial disorders.

PURPOSE The aim of this study is to evaluate contrast sensitivity, color vision, and subjective patient satisfaction after Descemet membrane endothelial keratoplasty (DMEK) in patients with bilateral Fuchs endothelial dystrophy (FED). METHODS From a group of 500 DMEK surgeries performed in our center, patients with a history of bilateral FED and unilateral DMEK were identified. A total of 29 patients were included in the study and divided into 2 groups: phakic (n = 12) and pseudophakic unilateral DMEK (n = 17) and their contralateral, untreated FED-affected eye. In addition, a control group of 10 healthy eyes of 10 patients was included. Pelli-Robson contrast sensitivity and Farnsworth-Munsell 100 hue color vision tests were performed. Subjective optical quality was graded with a questionnaire. RESULTS Compared with untreated FED-affected eyes, best spectacle-corrected visual acuity was higher after DMEK in phakic and pseudophakic eyes (P = 0.030 and P < 0.001, respectively); a similar result was obtained for contrast sensitivity (P < 0.001 and P < 0.001, respectively). Color vision did not differ between untreated FED-affected and DMEK-operated eyes in the phakic group (P = 0.802) and the pseudophakic group (P = 0.227). Subjective optical quality was better in DMEK-operated eyes than in untreated FED-affected eyes in the phakic group (P < 0.001) and in the pseudophakic group (P < 0.001). CONCLUSIONS In FED, DMEK may not only be effective for obtaining a higher visual acuity but particularly improving the contrast sensitivity may also lead to better subjective optical performance. Although frequently mentioned spontaneously by patients, an objective change in color vision could not be substantiated. Hence, quantifying contrast sensitivity before surgery may aid in the decision for surgery, and in the evaluation of surgical outcome.

To evaluate the incidence and causes of anterior corneal surface irregularities after successful Descemet membrane endothelial keratoplasty (DMEK) and the efficacy of contact lens fitting in these cases.Tertiary referral center.Retrospective study of prospectively collected data.Eyes with a subnormal visual outcome or monocular diplopia after successful DMEK were fitted with a contact lens. These cases were evaluated with Pentacam rotating Scheimpflug camera imaging preoperatively and 6 months postoperatively, and outcomes were compared with those in a randomly selected DMEK control group.In a series of 262 surgeries, 23 eyes (21 patients) were fitted with contact lenses; the control group comprised 23 eyes. Indications for contact lens fitting included (1) obvious corneal surface irregularities due to preexisting corneal scarring, (2) surface irregularities associated with longstanding preoperative stromal edema, and (3) undetectable optical imperfections. The postoperative corrected distance visual acuity (CDVA) with spectacles improved after contact lens correction (P.001). Preoperative and postoperative irregularity indices were significantly higher in the contact lens group than in the DMEK control group (P.05). Positive correlations were found between the duration of preoperative stromal edema and postoperative Scheimpflug camera indices (P.02).After successful DMEK, 23 of 262 eyes (9%) showed subnormal spectacle CDVA and/or monocular diplopia due to corneal scarring, surface irregularities, or undetectable optical imperfections that could be managed by contact lens fitting. Prolonged preoperative corneal edema for more than 12 months may be a risk factor for diffuse irregular astigmatism after DMEK.Dr. Melles is a consultant to DORC International BV/Dutch Ophthalmic USA. No author has a financial or proprietary interest in any material or method mentioned.

To describe and compare 2 preparation techniques for Bowman layer (BL) grafts for use in BL transplantation.A retrospective evaluation of the 2 methods for preparing BL grafts was performed, that is, BL graft preparation from donor globes not eligible for penetrating keratoplasty or endothelial keratoplasty (technique I, n = 36) and BL graft preparation from previously excised corneoscleral buttons (technique II, n = 36) that could not be used for PK or had been denuded of Descemet membrane and endothelium for Descemet membrane endothelial keratoplasty graft preparation. BL graft preparation difficulties were recorded, and the preparation failure rate was examined and compared between the techniques.Overall, BL graft preparation was successful in 51 cases (51/72; 70.8%), of which 25 preparations were successful using technique I, and 26 using technique II, representing a success rate of 69.4% (25/36) and 72.2% (26/36) for techniques I and II, respectively. Reasons for discarding a BL graft were tearing of the BL tissue during the preparation (n = 19) and stroma attached to the graft (n = 2).Isolated BL grafts can be prepared from both whole donor globes and corneoscleral rims with equivalent success. Preparation from corneoscleral rims may offer the advantage that, from one donor cornea, the posterior layers can be used for Descemet membrane endothelial keratoplasty graft preparation and the anterior part for BL graft preparation.

To monitor refractive changes after Descemet membrane endothelial keratoplasty (DMEK) and to determine what may influence these changes and the time point of stabilization.From 67 pseudophakic DMEK eyes operated on for Fuchs endothelial dystrophy at a tertiary referral center, biomicroscopy, visual acuity, subjective refraction, and Scheimpflug-based corneal tomography data were obtained before and up to 2 years postoperatively. Visual acuity and changes in spherical equivalent (SE), mean anterior and posterior simulated keratometry (Km), and central pachymetry were analyzed.At 3 months postoperatively, both hyperopic (28/67 eyes) and myopic (21/67 eyes) shifts were observed; 18/67 eyes showed no SE change. The mean change in SE at 3 months was +0.33 diopters (D) (95% confidence interval = [0.11, 0.54], P = 0.028), which stabilized thereafter (P0.466). Initial flattening of mean anterior Km by 0.66D (95% confidence interval = [-0.81, -0.51], P0.001) at 3 months was followed by a slow steepening, which became significant between 1 and 2 years postoperatively (P0.001). Posterior Km stabilized after 3 months (P0.252). Preoperative to 3 months postoperative absolute changes in anterior Km were positively related to preoperative backscattered light from the central anterior cornea (P = 0.035), and the presence of partial graft detachment postoperatively (P = 0.013).After DMEK, SE and posterior corneal curvature were on average stable at 3 months after surgery, whereas the mean anterior corneal curvature showed an ongoing gradual change. Changes in anterior corneal curvature may be related to preoperative anterior corneal densitometry or postoperative partial graft detachment.

Purpose To evaluate the midterm outcomes of Descemet membrane endothelial keratoplasty (DMEK) up to 4–7 years postoperatively. Design Retrospective, consecutive interventional case series. Methods A total of 250 consecutive eyes of 209 patients who underwent DMEK at our institute and had potentially at least 4 years of follow-up. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), central corneal thickness (CCT), graft survival rate, and postoperative complications. Results At 6 months postoperatively, 73% of the eyes reached a BCVA of ≥20/25 (0.8) and 44% ≥20/20 (1.0), and remained stable up to 7 years ( P = .7114). ECD dropped by 33.9% in the first 6 months, and then declined by a yearly rate of 9.0%. CCT did not show a significant change after 6 months up to 7 years ( P = .8447). The cumulative graft survival rate at 4 and 7 years was 0.96 (95% confidence interval [0.93, 0.99]). Rebubbling procedures were performed in 4.4% of eyes, all within the first 6 postoperative months. Repeat transplantations were performed in 15.2% of cases to manage greater than one third graft detachment (11.6%), primary graft failure (1.6%), or secondary graft failure (2.0%), with the majority (79%) of repeat transplantations performed within the first year. After 6 months, the main complications were allograft rejection (2.4%) and secondary graft failure (2.0%). Conclusions The visual acuity level achieved at 6 months after DMEK may remain stable up to at least 4–7 years; ECD shows a constant, slow decrease; and complications after the first 6 months occur in

Purpose To describe corneal clearance after reendothelialization of the recipient posterior stroma, by a "free-floating" donor Descemet roll in the recipient anterior chamber after Descemet membrane endothelial keratoplasty (DMEK), as a potential new approach in managing corneal endothelial disorders. Methods An 80-year-old woman underwent DMEK for Fuchs endothelial dystrophy. Within hours after the surgery, a "free-floating" Descemet roll was observed in the recipient anterior chamber. Because the operated eye had low visual potential, the patient requested to await the clinical outcome, which was monitored by biomicroscopy, and endothelial cell density (ECD) and pachymetric measurements were evaluated. Results Within the first few weeks after DMEK, the transplanted cornea showed diffuse corneal edema with a central pachymetry of more than 1000 μm. From 1 month onward, the transplanted cornea started to clear in the inferior quadrants. At 6 months, only remnant edema was present in the superior far periphery, pachymetry across the cornea had returned to normal, and ECD measured 830 cells per square millimeter. Conclusions The performance of a descemetorhexis followed by the implantation of a "free-floating" Descemet roll in the recipient anterior chamber, tentatively named Descemet membrane endothelial transfer, may have potential as a "no-keratoplasty" surgical concept in the management of corneal endothelial disorders.

Purpose To evaluate the learning curve in Descemet's membrane endothelial keratoplasty (DMEK) in the management of corneal endothelial disorders. Design Retrospective, nonrandomized, clinical study at a tertiary referral center. Participants We included 135 eyes of 118 patients with Fuchs' endothelial dystrophy. Methods In a first group of 135 consecutive eyes, a DMEK was performed. To determine the extent of a possible learning curve in DMEK surgery, the whole group was divided into 3 subgroups of 45 patients, to compare clinical outcomes at 1, 3, and 6 months. Main Outcome Measures Best-corrected visual acuity (BCVA), endothelial cell density (ECD), and intra- and postoperative complications. Results Among the 3 groups clinical outcomes were similar, with 73% of cases achieving a BCVA of ≥20/25 (≥0.8) and an average ECD of 1747±527 cells/mm 2 , at 6 months. Graft detachment was the main complication and correlated with intraoperative vitreous pressure ( P Conclusions The learning curve in DMEK did not correlate with clinical outcome (BCVA and ECD), but rather to the presence of a functional graft. However, the number of functional grafts (decline in graft detachment rate) increased with surgical experience. Financial Disclosure(s) Proprietary or commercial disclosures may be found after the references.

Traditionally, the mainstay of treatment for advanced keratoconus (KC) has been either penetrating or deep anterior lamellar keratoplasty (PK or DALK, respectively). The success of both operations, however, has been somewhat tempered by potential difficulties and complications, both intraoperatively and postoperatively. These include suture and wound-healing problems, progression of disease in the recipient rim, allograft reaction, and persistent irregular astigmatism. Taken together, these have been the inspiration for an ongoing search for less troublesome therapeutic alternatives. These include ultraviolet crosslinking and intracorneal ring segments, both of which were originally constrained in their indication exclusively to eyes with mild to moderate disease. More recently, Bowman layer transplantation has been introduced for reversing corneal ectasia in eyes with advanced KC, re-enabling comfortable contact lens wear and permitting PK and DALK to be postponed or avoided entirely. We offer a summary of the current and emerging treatment options for advanced KC, aiming to provide the corneal specialist useful information in selecting the optimal therapy for individual patients.

Objective To evaluate the clinical outcome of mid-stromal isolated Bowman layer transplantation, a new surgical technique to reduce and stabilize ectasia in eyes with advanced keratoconus, to postpone penetrating keratoplasty or deep anterior lamellar keratoplasty, and to enable continued daily contact lens wear. Design Prospective, nonrandomized cohort study at a tertiary referral center. Participants Twenty-two eyes of 19 patients with progressive, advanced keratoconus not eligible for ultraviolet cross-linking. Interventions The mid-stroma was manually dissected and an isolated donor Bowman layer was positioned within the stromal pocket. Main Outcome Measures Before and up to 36 months after surgery (mean follow-up, 21±7 months), best spectacle-corrected visual acuity (BSCVA), best contact lens–corrected visual acuity (BCLVA), Scheimpflug-based corneal tomography measurements, endothelial cell density, biomicroscopy, refraction, and intraoperative and postoperative complications were recorded. Results Two surgeries were complicated by an intraoperative perforation of Descemet membrane; no other intraoperative or postoperative complications were observed. Maximum keratometry decreased on average from 77.2±6.2 diopters (D) to 69.2±3.7 D ( P P ≥ 0.072). Mean BSCVA improved from 1.27±0.44 logarithm of the minimum angle of resolution units before surgery to 0.90±0.30 logarithm of the minimum angle of resolution units 12 months after surgery ( P P = 0.105). Mean thinnest-point pachymetry increased from 332±59 μm before surgery to 360±50 μm at the latest follow-up ( P = 0.012), and no change in endothelial cell density was found ( P = 0.355). Conclusions With isolated Bowman layer transplantation, reduction and stabilization of corneal ectasia was achieved in eyes with progressive, advanced keratoconus. Given the low risk for complications, the procedure may be performed to postpone penetrating or deep anterior lamellar keratoplasty.

To evaluate the clinical outcome of 500 consecutive cases after Descemet's membrane endothelial keratoplasty (DMEK) and the effect of technique standardization.Prospective, interventional case series at a tertiary referral center.A total of 500 eyes of 393 patients who underwent DMEK for Fuchs' endothelial corneal dystrophy, bullous keratopathy, or previous corneal transplant failure.Best-corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications were evaluated before and 1, 3, and 6 months after DMEK.Comparison between 2 groups (group I: cases 1-250, outcome of "early surgeries" during transition to technique standardization; group II: cases 251-500, outcome of "late surgeries" after technique standardization).At 6 months, 75% of eyes reached a BCVA of ≥20/25 (≥0.8), 41% of eyes achieved ≥20/20 (≥1.0), and 13% of eyes achieved ≥20/18 (≥1.2) (n=418) when excluding eyes with ocular comorbidities (n=57). When including all available eyes at 6 months (n=475), 66% of eyes reached a BCVA of ≥20/25 (≥0.8), and 36% of eyes achieved ≥20/20 (≥1.0). Mean ECD decreased by 37% (±18%) to 1600 (±490) cells/mm2 (n=447) at 6 months (P0.001). Postoperative pachymetry averaged 525 (±46) μm compared with 667 (±92) μm preoperatively (P0.001). None of these parameters differed among the 2 groups (P0.05). (Partial) graft detachment presented in 79 eyes (15.8%), and 26 eyes (5.2%) required a secondary surgery within the first 6 months (re-bubbling in 15, secondary keratoplasty in 11). With technique standardization, the postoperative complication rate decreased from 23.2% to 10% (P0.001) and the rate of secondary surgeries decreased from 6.8% to 3.6% (P=0.10).In comparison with earlier endothelial keratoplasty techniques, DMEK may consistently give higher visual outcomes and faster visual rehabilitation. When used for the extended spectrum of endothelial pathologies, DMEK proved feasible with a relatively low risk of complications. Technique standardization may have contributed to a lower graft detachment rate and a relatively low secondary intervention rate. As such, DMEK may become the first choice of treatment in corneal endothelial disease.

Purpose To determine the various causes of unexpected incomplete visual rehabilitation at 6 months postoperative after Descemet membrane endothelial keratoplasty (DMEK). Design Retrospective study of prospectively collected data at a tertiary referral center. Methods From a larger group of 400 consecutive DMEK surgeries, the last 200 consecutive eyes were reviewed for visual discomfort despite a best-corrected visual acuity (BCVA) of ≥20/25 (≥0.8) or unexpected subnormal BCVA (≤20/28; ≤0.7) at 6 months after DMEK. Biomicroscopy, funduscopy, Pentacam imaging, noncontact specular microscopy, anterior segment optical coherence tomography, and surgical videos were used to determine the causes of incomplete visual rehabilitation. Results A total of 69 eyes out of 178 eyes that were included in the analysis (38.8%) presented with incomplete visual rehabilitation after DMEK, further categorized as "primarily patient-related" in 40 of 178 (22.5%), "primarily graft-related" in 21 of 178 (11.8%), and a combination of "patient-/graft-related" in 8 of 178 cases (4.5%). Unrecognized pre-existing ocular pathology and/or posterior segment disease in 19 of 178 eyes (10.7%), clinically significant corneal irregularities and/or central corneal scarring often secondary to long-standing preoperative corneal edema in 14 of 178 eyes (7.9%), or (partial) graft detachment in 20 of 178 eyes (11.2%) were the main causes of unexpected incomplete visual rehabilitation. Transient or persistent monocular ghost images or diplopia occurred in 10 of 178 eyes (5.6%), sometimes requiring contact lens fitting. Conclusions In contrast to earlier endothelial keratoplasty techniques that may frequently be associated with undefined transplant-related subnormal visual outcomes, incomplete visual rehabilitation after DMEK may virtually always be explained by concomitant ocular pathology or evident graft failure.

Purpose: To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and to determine whether such eyes can be successfully ‘repaired’ with a secondary Descemet membrane endothelial keratoplasty (DMEK). Methods: Twelve eyes of 12 patients, who underwent secondary DMEK to manage poor visual outcome after initial DSEK/DSAEK, were evaluated with biomicroscopy, Pentacam imaging, and specular and confocal microscopy, before and at 1, 3 and 6 months after DMEK. Results: Four causes of reduced optical quality of the transplanted host cornea could be identified in DSEK/DSAEK: five eyes (42%) showed large host-Descemet remnants within the visual axis during surgery; six eyes (50%) irregular graft thickness; six eyes subtle ‘stromal waves’; and nine eyes (75%) high reflectivity at the donor-to-host interface. After DMEK graft replacement, all corneas cleared and achieved a best corrected visual acuity of ≥20/25 (≥0.8), except for one with a partial Descemet graft detachment. Pachymetry values decreased from 670 (±112) μm before to 517 (±57) μm after secondary DMEK. Higher-order aberrations (Coma and Trefoil) at the posterior surface tended to be lower (p = 0.07) in DMEK grafts than in DSEK/DSAEK grafts. Conclusion: Host-Descemet remnants at the donor-to-host interface, interface reflectivity, graft thickness irregularity and donor stromal contraction may contribute to poor visual outcome after DSEK/DSAEK, without causing permanent host corneal damage, as in most cases, complete visual recovery could be achieved by performing a secondary DMEK.