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Corneal Transplantation: Recent Advances and Current Perspectives

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Ophthalmology".

Deadline for manuscript submissions: closed (15 April 2025) | Viewed by 15207

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Dr. Mohit Parekh

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Guest Editor

Schepens Eye Research Institute of Mass Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
Interests: ophthalmology; cornea transplantation; keratoplasty; eye banking

Dr. Vito Romano

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Guest Editor

1. Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Brescia, Italy
2. Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
Interests: cornea transplantation; keratoconus; endothelial dystrophy; imaging; cataract; refractive surgery; pterygium
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Special Issue Information

Dear Colleagues,

Corneal diseases are one of the leading causes of blindness globally. The standard treatment of care includes corneal transplantation. However, keratoplasties rely majorly on donor tissues, which unfortunately are in limited supply, restricting treatment options. Although the burden on the availability of the donor tissues has been minimized with recent advances in keratoplasty techniques, modern devices, and alternative options such as cultured cell transplantation, the requirement is still high to treat corneal diseases globally. Alternative options in advancing the field of corneal transplantation are underway. Hence, this Special Issue aims to look the future of corneal transplantation, and authors are encouraged to submit articles related to a) advanced corneal transplantation techniques; b) inclusion of artificial intelligence for diagnosis and outcome predictions; c) cultured cells or tissue engineering; d) artificial cornea; e) modern day devices; f) robotics in eye surgery; g) modern eye banking; f) imaging; and g) healthcare economics in keratoplasty.

Dr. Mohit Parekh
Dr. Vito Romano
Guest Editors

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Keywords

cornea transplantation
keratoconus
endothelial dystrophy
imaging
cataract
refractive surgery
artificial intelligence
devices
research
tissue engineering

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8 pages, 1656 KiB

Open AccessFeature PaperArticle

Descemet Membrane Endothelial Keratoplasty Graft Preparation Using the Liquid Bubble Technique with Subtrabecular Hydrodissection: A Retrospective Real-Life Study

by Emmanouil Blavakis, Mateusz Kecik, Georgios D. Panos, Gabriele Thumann and Horace Massa

J. Clin. Med. 2024, 13(20), 6048; https://doi.org/10.3390/jcm13206048 - 10 Oct 2024

Viewed by 1229

Abstract

Background: Techniques for the preparation of grafts for Descemet membrane endothelial keratoplasty (DMEK) can be classified into those that involve the manual dissection of the Descemet membrane (DM) and those that use an injection of a liquid or a gas to achieve a separation of the DM from the posterior corneal stroma. The purpose of this study was to evaluate the efficiency of the liquid bubble technique. Methods: The success rate of the technique was calculated retrospectively using the operating reports. Video files for each graft preparation were retrieved and the time, number of injections, and number of injections sites required for the hydrodissection were measured. The number of cases in which a manual dissection of the Descemet membrane was necessary was recorded. Information on donor age and graft preservation time were retrieved from the eye bank file. Results: In 58 cases, the success rate was 98.3%. In the 28 procedures where a video was available, the median time for hydrodissection was 4.4 min. The median number of injection sites was 2, with a median number of injections of 3.5. Manual dissection as a rescue technique was performed in 25% of cases, with one case resulting in graft tears. The mean graft diameter was 7.6 mm. The mean donor age was 66 years, and the mean graft storage time was 22 days. Conclusions: The liquid bubble technique can be a fast and valuable choice for DMEK graft preparation, especially in centers where the tissue is prepared in the operating theater. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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13 pages, 4118 KiB

Open AccessArticle

Pseudochamber-Protected Keratoplasty (PPK) with a New Inter-Corneal Surgical Device Implant Technique in High-Risk Cases

by José F. Alfonso, Carlos Lisa, Belén Alfonso-Bartolozzi, Rosa Alvarado-Villacorta, David Madrid-Costa and Luis Fernández-Vega-Cueto

J. Clin. Med. 2024, 13(19), 5715; https://doi.org/10.3390/jcm13195715 - 25 Sep 2024

Viewed by 915

Abstract

Background/Objectives: To describe the pseudochamber-protected keratoplasty (PPK) procedure with the new Endo-K Pro^® implant technique and report the clinical outcomes in patients at high risk for penetrating keratoplasty (PKP). Methods: This case series study included patients who required a PKP and had a high risk for corneal transplant failure. All cases underwent the PPK procedure with simultaneous Endo-K Pro^® implantation and had a minimum follow-up of 12 months. Graft survival was the primary outcome (defined as a clear graft with an endothelial cell density >500 cells/mm²). Central corneal thickness (CCT), corrected distance visual acuity (CDVA), intraocular pressure (IOP), and complication rate were the secondary outcomes. Results: Twenty-five eyes (twenty-five patients) were included. The mean follow-up was 23.64 ± 8.2 months (range: 12–36 months). Graft survival was achieved in 23 of the 25 cases (92%). One eye had to be re-transplanted due to persistent oedema secondary to uncontrolled IOP. In two cases (8%), the graft failed three months after surgery when an anterior pseudochamber collapsed due to direct contact of donor endothelium and host tissue. Six eyes experienced host tissue protrusion that was successfully managed using an Nd: YAG laser (two eyes) or injecting a cohesive viscoelastic into the pseudochamber (four eyes). CDVA increased significantly during the follow-up period. No significant changes were found in IOP. No intra- or postoperative complications were reported. Conclusions: PPK with the Endo-K Pro^® implant seems to be an effective and safe surgical approach as an alternative in high-risk patients for PKP, allowing full-thickness corneal transplantation without performing an open-sky procedure. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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12 pages, 2636 KiB

Open AccessArticle

Superficial Keratectomy Alone versus in Combination with Amniotic Membrane Transplantation in Aniridia-Associated Keratopathy and a Short-Term Clinical Outcome

by Bogumił Wowra, Marzena Wysocka-Kosmulska, Dariusz Dobrowolski and Edward Wylęgała

J. Clin. Med. 2024, 13(11), 3258; https://doi.org/10.3390/jcm13113258 - 31 May 2024

Viewed by 980

Abstract

Background/Objectives: Aniridia-associated keratopathy (AAK) is a potentially vision-threatening pathology in congenital aniridia, for which both the underlying etiopathogenesis and effective treatment remain unclear. Methods:This prospective study was conducted to assess and compare the short-term outcome after superficial keratectomy (SK) alone or in a combination with an amniotic membrane transplantation (AMT). Here, 76 eyes were enrolled in 76 patients with grade 4 AAK. In all eyes, in order to assess preoperatively the efficiency of the limbal epithelial stem cells (LESC), the presence of corneal epithelial cells in confocal microscopy was established. The analyses included: best corrected visual acuity (BCVA), the stage of AAK and the number of corneal quadrants involved in corneal neovascularization (CNV). Results: Six months after surgery, the mean BCVA was 0.05 and ranged from 0.002 up to 0.1 in both groups. Improvement in BCVA occurred in 94.29% patients when *SK alone* was performed, and in 92.68% when in combination with AMT. There were no statistically significant differences in the effect of therapy depending on the type of surgery, regarding BCVA, stage of AAK and the number of quadrants with CNV. Conclusions: SK alone is an effective procedure in short outcomes limited to six months for advanced AAK in association with LESC partial efficiency. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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10 pages, 5108 KiB

Open AccessArticle

Donor Characteristics in Graft Detachment after Posterior Lamellar Keratoplasty for Fuchs Endothelial Dystrophy and Bullous Keratopathy

by Nicola Cardascia, Flavio Cassano, Valentina Pastore, Maria Gabriella La Tegola, Alessandra Sborgia, Francesco Boscia and Giovanni Alessio

J. Clin. Med. 2024, 13(6), 1593; https://doi.org/10.3390/jcm13061593 - 11 Mar 2024

Cited by 1 | Viewed by 1247

Abstract

Background: Descemet Membrane Endothelial Keratoplasty (DMEK) has been widely adopted to treat Fuchs endothelial dystrophy (FED) and Bullous keratopathy (BK). Graft detachment (GD) is one of the common earliest post-operatory complications, and it is usually recovered by Air Rebubbling (ARB). Methods: Retrospectively, we investigated predictive factors related to GD between January 2016 and March 2020, a pre-COVID era, in 72 patients, 72 eyes, and their donors’ lamellar characteristics, focusing on donor’s cause of death. The patients were divided according to the posterior lamellar keratoplasty technique adopted. Results: GD and consequent ARB were most common but not significantly prevalent in DMEK (p = 0.11). It was more common in FED for both surgical approaches. Only in BK treated with DSAEK were host steeper mean astigmatism (p = 0.03) and donors with smaller graft pre-cut diameters (p = 0.02) less likely to be related to GD. Regarding donor’s cause of death, only cardiovascular accident could be related to GD in BK treated with DMEK (p = 0.04). Conclusions: Our study shows that the conventional match between pathology and corneal lenticule is not sufficient to prevent ARB. Donor’s cause of death can impair graft and host attachment. In particular, cardiovascular death may impair the efficiency of donors’ endothelial cells, inducing GD after DMEK in BK. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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12 pages, 1734 KiB

Open AccessArticle

Predicting Long-Term Endothelial Cell Loss after Preloaded Descemet Membrane Endothelial Keratoplasty in Fuchs’ Endothelial Corneal Dystrophy: A Mathematical Model

by Pietro Viola, Enrico Neri, Tommaso Occhipinti, Mohit Parekh, Roberto Cian, Diego Ponzin, Antonio Moramarco and Alfonso Iovieno

J. Clin. Med. 2024, 13(3), 877; https://doi.org/10.3390/jcm13030877 - 2 Feb 2024

Cited by 1 | Viewed by 1582

Abstract

(1) Background: This study offers a biexponential model to estimate corneal endothelial cell decay (ECD) following preloaded “endothelium-in” Descemet membrane endothelial keratoplasty (DMEK) in Fuchs’ endothelial corneal dystrophy (FECD) patients; (2) Methods: A total of 65 eyes undergoing DMEK alone or combined with cataract surgery were evaluated. The follow-up period was divided into an early phase (first 6 months) and a late phase (up to 36 months). Endothelial cell count (ECC) and endothelial cell loss (ECL) were analyzed; (3) Results: The half time of the ECD was 3.03 months for the early phase and 131.50 months for the late phase. The predicted time-lapse interval to reach 500 cells/mm² was 218 months (18.17 years), while the time-lapse interval to reach 250 cells/mm² was 349 months (29.08 years). There was no statistically significant difference between the ECL in DMEK combined with cataract extraction and DMEK alone at 24 months (p ≥ 0.20). At the late phase, long-term ECL prediction revealed a lower ECC half time in patients undergoing DMEK combined with cataract surgery (98.05 months) than DMEK alone (250.32 months); (4) Conclusions: Based on the mathematical modeling, a predicted average half-life of a DMEK graft could reach 18 years in FECD. Moreover, combining cataract extraction with DMEK could result in excessive ECL in the long term. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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14 pages, 1994 KiB

Open AccessArticle

Ocular Manifestations in Patients Affected by p63-Associated Disorders: Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC) and Ankyloblepharon-Ectodermal Defects-Cleft Lip Palate (AEC) Syndromes

by Enzo Di Iorio, Filippo Bonelli, Raluca Bievel-Radulescu, Nicolò Decastello, Stefano Ferrari, Vanessa Barbaro and Diego Ponzin

J. Clin. Med. 2023, 12(23), 7377; https://doi.org/10.3390/jcm12237377 - 28 Nov 2023

Cited by 1 | Viewed by 1660

Abstract

Background/Aims: The Ectrodactyly-Ectodermal dysplasia-Clefting (EEC) and Ankyloblepharon–ectodermal defect–cleft lip/palate (AEC) syndromes are rare autosomal dominant diseases caused by heterozygous mutations in the p63 gene. Patients are characterized by abnormalities of the skin, teeth, and hair and have limb defects, orofacial clefting and ectodermal dysplasia. In addition, they often show ocular surface alterations, leading to progressive corneal clouding and eventually blindness. Here, we present 8 cases describing patients affected by EEC (n = 6, with 5 sporadic and 1 familial cases) and AEC (n = 2, both sporadic cases) syndromes. We attempt to provide a description of the ocular disease progression over the years. Methods: Clinical examinations and monitoring of ocular parameters for the assessment of limbal stem cell deficiency were constantly performed on patients between 2009 and 2023. Quantitative data and comparison with existing cases described in the literature are reported. Results: The therapies supplied to patients were essential for the management of the symptoms, but unfortunately did not halt the progression of the pathology. Conclusions: A constant monitoring of the patients would help avoid the sudden worsening of symptoms. If the progression of the disease slows down, it would allow for the development of newer therapeutic strategies aimed at correcting the genetic defect. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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10 pages, 616 KiB

Open AccessArticle

Hemi-Ultrathin Descemet Stripping Automated Endothelial Keratoplasty (Hemi-UT-DSAEK) Using Pediatric Donor Corneas: A Case Series

by Pia Leon, Lorena Francescutti, Pietro Gentile, Federica Birattari, Diego Ponzin, Davide Camposampiero, Antonella Franch and Mohit Parekh

J. Clin. Med. 2023, 12(17), 5442; https://doi.org/10.3390/jcm12175442 - 22 Aug 2023

Cited by 1 | Viewed by 1044

Abstract

Objective: We sought to evaluate the clinical outcomes of hemi-UT-DSAEK grafts from the pediatric donor corneas of patients affected by Fuchs Endothelial Corneal Dystrophy (FECD). Methods: A prospective, interventional case series was conducted at the Ophthalmology Department of Venice Civil Hospital and the Veneto Eye Bank Foundation (Venice, Italy). Six eyes of six patients affected by FECD received large-diameter, semicircular hemi-UT-DSAEK grafts obtained from three pediatric donor corneas using the standard pull-through method. Endothelial cell density (ECD), central corneal thickness (CCT), best-corrected visual acuity (BCVA) and intraoperative and postoperative complications were recorded at different time intervals up to 12 months. Results: The average donor age was 64.6 ± 8.6 years, and the pre-operative ECD was 3266 ± 225 cells/mm². At 12 months postoperatively, the average ECD was 1376 ± 509 cells/mm² with a mean decrease of 56.8 ± 19.1% from the preoperative donor count. At 12 months, four out of six eyes had significantly improved and reached a BCVA of ≥20/25 (Snellen equivalent). The mean CCT significantly decreased from 788 ± 138 μm before surgery to 576 ± 30 μm at 12 months postoperatively (p < 0.01). Conclusions: Hemi-UT-DSAEK grafts using pediatric donor corneas are surgically feasible and can provide similar clinical outcomes compared to conventional UT-DSAEK. Transplanting pediatric donor tissues with high ECD into two patients could potentially increase the donor tissue pool to treat endothelial disease. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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12 pages, 1248 KiB

Open AccessArticle

Descemet Membrane Endothelial Keratoplasty (DMEK) Reduces the Corneal Epithelial Thickness in Fuchs’ Patients

by Jens Julian Storp, Larissa Lahme, Sami Al-Nawaiseh, Nicole Eter and Maged Alnawaiseh

J. Clin. Med. 2023, 12(10), 3573; https://doi.org/10.3390/jcm12103573 - 20 May 2023

Cited by 3 | Viewed by 1764

Abstract

Fuchs’ endothelial corneal dystrophy (FECD) is the occurrence of corneal edema due to endothelial cell dystrophy. Descemet membrane endothelial keratoplasty (DMEK) is considered to be the gold standard of treatment. The aim of this study was to investigate the changes in the corneal epithelial thickness of FECD patients before and after DMEK and to compare these results with a healthy control cohort. In this retrospective analysis, 38 eyes of patients with FECD that were treated with DMEK and 35 healthy control eyes received anterior segment optical coherence tomography (OCT; Optovue, XR-Avanti, Fremont, CA, USA). The corneal epithelial thicknesses in different locations were analyzed and compared between the preoperative, postoperative, and control cohorts. The median follow-up time was 9 months. There was a significant degression of the mean epithelial thickness after DMEK in the central, paracentral, and mid-peripheral zones (p < 0.01) of the cornea. The total corneal thickness and stromal thickness decreased significantly as well. No significant differences were observed between the postoperative and control cohorts. In conclusion, the FECD patients had an increased epithelial thickness compared to the healthy controls, which decreased significantly after DMEK and reached thickness levels comparable to those of healthy control eyes. This study emphasized the importance of distinguishing between the corneal layers in anterior segment pathologies and surgical procedures. Moreover, it accentuated the fact that the structural alterations in FECD extend beyond the corneal stroma. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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11 pages, 1231 KiB

Open AccessArticle

Assessing the Learning Curve for DMEK Using Post-Procedural Clinical Outcomes—Comparison of Four Different Surgeons during Two Different Periods

by Emilia Sophie Stuhlmacher, Shady Suffo, Cristian Munteanu, Berthold Seitz and Loay Daas

J. Clin. Med. 2023, 12(3), 811; https://doi.org/10.3390/jcm12030811 - 19 Jan 2023

Cited by 4 | Viewed by 1397

Abstract

Purpose: Evaluating the learning curve of individual surgeons for Descemet Membrane Endothelial Keratoplasty (DMEK) and Triple-DMEK and assessing outcome with experience. Methods: The first 41 and the last 41 surgeries of each of the four surgeons were retrospectively included. Surgery duration and graft preparation time were recorded. Corrected distance visual acuity (CDVA, logMAR) and central corneal thickness (CCT, µm) were collected preoperatively after 6 and 12 months, as well as postoperative complications, e.g., re-bubbling or repeat penetrating keratoplasty. Results: Surgical duration for Triple-DMEK and DMEK decreased significantly by 21 min and 14 min between the two periods (p < 0.001; p < 0.001). Graft preparation time decreased significantly from 13.3 ± 5.2 min (95%CI 12.8–14.3) in period 1 to 10.7 ± 4.8 min (95%CI 10.2–11.4) in period 2 (p = 0.002). The postoperative changes in CDVA and CCT over both periods were not significant (p = 0.900; p = 0.263). The re-bubbling rate decreased significantly from 51.2% in period 1 to 26.2% in period 2 (p < 0.001). The repeat penetrating keratoplasty (PKP) was 7.3% in period 1 and 3.7% in period 2 (p = 0.146). Re-DMEK was necessary in 6.1% in period 1 and 4.9% in period 2 (p = 0.535). Several parameters showed significant differences between the surgeons in both periods (surgical duration: period 1: p < 0.001, period 2 p < 0.001; graft preparation: period 1: p < 0.001, period 2 p < 0.001). Conclusion: Significant decrease in surgery duration, graft preparation time, and the re-bubbling rate can be attributed to gained individual experience. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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Open AccessReview

General Treatment and Ophthalmic Management of Peters’ Anomaly

by Bogumil Wowra, Dariusz Dobrowolski, Mohit Parekh and Edward Wylęgała

J. Clin. Med. 2024, 13(2), 532; https://doi.org/10.3390/jcm13020532 - 17 Jan 2024

Cited by 2 | Viewed by 2085

Abstract

Peters’ anomaly (PA) is a manifestation of complex disorders in the development of the anterior segment of the eye. The most recognizable feature of the disease is a doughnut-shaped central corneal opacity and adhesions between the opacity and underlying iris. Glaucoma is observed in 30–70% of patients, with up to 50% of the patients showing concomitant vision-threatening disorders. Up to 60% of patients have systemic abnormalities or developmental delays. Being a rare malformation, PA is one of the most common congenital indications for corneal transplantation in infants. Penetrating keratoplasty is used as the primary method of treatment in cases with corneal opacification of a degree that forbids visual development in both eyes. The heterogeneity of co-occurring ophthalmic and systemic malformations in the spectrum of PA determines the wide range of success, defined by various endpoints: graft clarity or visual acuity. Although surgical advancement has made corneal grafting possible in younger children, it has a higher graft failure rate and worse visual prognosis than adult keratoplasty. Optical sector iridectomy, pupil dilation, or cornea rotation can alternatively be performed. Satisfying results of pediatric keratoprosthesis in particular cases of PA have been described. Postoperative treatment of PA aims to maintain a clear optical pathway and prevent amblyopia. This article therefore aims at reporting the ophthalmic treatment and need for multidisciplinary management of PA, including pharmacological and surgical treatment. Full article

(This article belongs to the Special Issue Corneal Transplantation: Recent Advances and Current Perspectives)

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