Search Results (28)

Background: Mushroom penetrating keratoplasty (MPK) is an alternative to traditional penetrating keratoplasty (PK) that offers improved graft survival and reduced immunological rejection. However, MPK grafts may still experience endothelial failure over time. This study evaluates the outcomes of non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK) as a surgical approach for endothelial decompensation following MPK. Methods: A monocentric, retrospective study was conducted at the Ophthalmology Department of Sant’Orsola-Malpighi Hospital, including patients who underwent nDSAEK for endothelial failure after MPK between 2022 and 2024. Pre- and postoperative best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell density (ECD) were assessed. Results: Eighteen eyes from 18 patients (mean age: 39.94 years) were included. Primary MPK indications were post-keratitis leucoma (77.7%), traumatic scarring (16.7%), and keratoconus (5.6%). At one year, mean BCVA improved significantly from 1.40 ± 0.42 logMAR to 0.46 ± 0.19 logMAR (p < 0.05), and mean CCT decreased from 721 ± 70.12 µm to 616 ± 52.80 µm (p < 0.05). The mean postoperative ECD was 1748 ± 100 cells/mm², with lower eye values requiring re-bubbling. No immunological rejection or graft failures were reported. Conclusions: nDSAEK is a promising treatment for MPK endothelial failure, demonstrating good visual and anatomical outcomes. Full article

This study investigates the pathophysiological process of healed perforated corneal ulcers (HPCUs) in humans. All subjects underwent keratoplasty due to opacities or leakage from HPCUs. Half of each specimen was fixed with 4% glutaraldehyde for transmission electron microscope (TEM) examination. The other half was fixed in 10% formaldehyde for immunofluorescence (IF) examination. TEM identified layered structures with two cell types (polygonal and elongated) connected by gap or adherent junctions during early stage of healing. Both apoptotic and mitotic changes were found in both types of cells. There were no endothelial cells or Descemet’s membrane (DM) present in early stage of healing. During the intermediate stage, the healed area comprised three layers: epithelium, Bowman’s layer, and stroma, with an increase in stromal collagen. Later, adjacent endothelial cells crept in, forming DM and completing the cornea’s 5-layer structure. IF examinations revealed that vimentin⁺ and α-smooth muscle actin (αSMA)⁺ myofibroblasts gathered around the damaged site. Proliferating cell nuclear antigen⁺ cells, which indicated cell proliferation, were found in both cells. Anti-phospho-histone H2AX antibodies were found in some epithelial cells. CK14-positive cells were only found in superficial polygonal cells. Corneal wound healing is a complex process that includes apoptosis, cell migration, mitosis, differentiation, and extracellular matrix remodeling. Full article

Background/Objectives: The Visual Function and Corneal Health Status (V-FUCHS) questionnaire assesses vision-related quality of life in patients affected by Fuchs endothelial corneal dystrophy (FECD) through 15 items, which are divided into the “visual acuity (VA) Factor” and “glare Factor” domains. The purpose of this study was to translate and validate the Italian version of the V-FUCHS instrument. Methods: The original V-FUCHS questionnaire was translated into Italian using certified forward and backward translation methods and administered to patients with FECD undergoing a unilateral or bilateral Descemet membrane endothelial keratoplasty (DMEK) for FECD and healthy controls. Its test–retest reliability was assessed by administering the questionnaire twice, four weeks apart. Modified Krachmer grade, best-corrected visual acuity (BCVA) and central corneal thickness (CCT) were also measured. Results: A total of 74 participants, aged 45 to 83 years, were prospectively enrolled and divided into five subgroups: mild-to-moderate FECD (n = 18), advanced FECD (n = 15), unilateral DMEK (n = 9), bilateral DMEK (n = 12), and healthy controls (n = 20). Retest reliability confirmed the consistency and agreement of their responses (intraclass correlation coefficient > 0.90 for both factors). The Italian V-FUCHS effectively discriminated between different stages of FECD severity, with significant differences in VA and glare factor scores across all subgroups (p < 0.001). While both BCVA and CCT showed correlations with V-FUCHS scores, only the association between the VA factor and BCVA was statistically significant (p < 0.05), indicating that the VA factor meaningfully reflects patients’ measured VA. Conclusions: The proposed Italian version of the V-FUCHS questionnaire is a valid and reliable tool for assessing visual disability in patients with FECD before and after DMEK. This instrument may aid in optimizing endothelial keratoplasty timings and evaluating postoperative symptomatic improvements in FECD patients. Full article

Objectives: Microbial keratitis is a precursor to corneal scarring, the fifth-leading cause of blindness and visual impairment worldwide. Despite its significance, there is a paucity of data quantifying the recurrence rates of keratitis and the subsequent corneal damage. This study aims to address this gap by providing a comprehensive analysis of the frequency and origin of keratitis recurrences and its impact on visual deterioration. Methods: We retrospectively analyzed a cohort of 1303 patients diagnosed with microbial keratitis at the Independent Public University Eye Hospital in Warsaw, Poland, between January 2018 and December 2023. All adult patients with at least one documented episode of infectious keratitis were included in the study. Patients were divided into two cohorts: Group 1: patients with recurrent keratitis (n = 233) and Group 2: patients with the first episode of keratitis (n = 1070). Results: The recurrence rate of keratitis was 17.88% (233 of 1303 patients), regardless of etiology. Visual acuity on admission did not differ significantly between the recurrent and naïve groups. However, among patients with at least three episodes, visual acuity was worse (median logMAR for 1 vs. 2 vs. 3 recurrences were the following: 0.30 (0.08–0.67) vs. 0.60 (0.12–1.30) vs. 0.44 (0.20–0.92), accordingly, p = 0.049). Univariate logistic regression identified contact lens usage as a significant risk factor for recurrence (OR 2.37, 95% CI: 1.84–3.08, p < 0.001), also including its inappropriate use (OR 2.25, 95% CI: 1.42–3.66, p = 0.001). In terms of etiology, bacteria were the most common identified cause of keratitis in both the recurrent and naïve groups, accounting for 38.36% (90 cases) in Group 1 and 47% (503 cases) in Group 2. Viruses were the second most prevalent etiology, representing 31.33% (73 cases) in Group 1 and 19.91% (213 cases) in Group 2. Furthermore, a multivariate logistic regression model indicated that advanced age, delayed treatment, fungal etiology, and post-corneal transplant status were strongly associated with worse visual outcomes. Conclusions: Although each recurrence contributes to cumulative vision loss, the majority of patients with recurrent keratitis present with a useful visual acuity (0.3 to 0.60 logMAR). Our study identified older age, fungal etiology, delayed treatment, and post-keratoplasty keratitis as the most significant risk factors for visual deterioration. These findings underscore the need for targeted interventions in populations at higher risk of adverse visual outcomes. Full article

Glaucoma is known to impair the function of corneal endothelial cells for various reasons, which increases the likelihood of patients with glaucoma requiring endothelial keratoplasty. Among the techniques available, Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) each present unique challenges, particularly for those with a history of glaucoma surgery. We conducted a literature review to evaluate the outcomes of DMEK and DSAEK in glaucoma patients, focusing on factors such as visual prognosis, graft survival, glaucoma exacerbations, and any necessary surgical modifications. The findings indicate that DMEK tends to provide better visual outcomes compared to DSAEK, with a lower rate of steroid responders due to a shorter postoperative steroid regimen. While DMEK has shown a higher incidence of graft detachment and a lower rate of graft rejection, compared to DSAEK, in the general population, the specific data regarding these outcomes in glaucoma patients remain scarce in the existing literature. Overall, the survival rates of both grafting techniques do not show significant differences within the glaucoma patient population. To draw more definitive conclusions about graft survival between the two methods, a greater number of comparative studies with longer follow-up periods is needed. Full article

Purpose: To determine the incidence, risk factors (including systemic immunosuppression), and outcomes of microbial keratitis in corneal transplants over a 16-year observation period at a tertiary referral hospital in Poland. Methods: This retrospective cohort study included 125 episodes of infectious keratitis in 117 patients who underwent corneal transplantation between 2008 and 2023 at the Department of Ophthalmology, Medical University of Warsaw, Poland. The data collected included demographics, indications for transplantation, infection rates, risk factors, best-corrected visual acuity (BCVA) at presentation and discharge, changes in visual acuity, and treatments received prior to hospital admission. Clinical signs, symptoms, diagnostic tests, and management strategies were also reviewed. Additionally, the outcomes of surgical interventions, such as therapeutic corneal transplantation and evisceration, were examined. Results: Among the 2869 corneal transplants performed over the 16-year period, the incidence of post-keratoplasty microbial keratitis (PKMK) was 4.35%. The most common indication for transplantation in affected patients was an active infection unresponsive to medical therapy (n = 62, 52%). One-third of PKMK cases occurred in patients with repeat transplants. Median visual acuity prior to infection was 1.6 logMAR, worsening to 2.3 logMAR at presentation. Following treatment, visual acuity improved to a median of 1.9 logMAR at discharge, with no significant improvement by the one-year follow-up. At that time, 75.1% of patients remained legally blind (BCVA ≤ 20/200); 21% recovered to pre-infection visual levels, while 46% experienced additional visual loss due to PKMK. Multivariate regression identified corneal perforation and systemic immunosuppression as independent predictors of poorer visual outcomes (p < 0.001 and p = 0.03, respectively. Conclusions: Microbial keratitis in corneal grafts is associated with poor long-term visual outcomes. At one year post-infection, the median BCVA was 1.9 logMAR, with 75.1% of patients remaining legally blind. Nearly half of the cohort experienced additional visual loss compared to their pre-infection status, underscoring the severity of PKMK and the need for vigilant postoperative care. Full article

Objectives: To provide an overview of the preoperative indications for endothelial graft in patients with Fuchs endothelial corneal dystrophy (FECD). Methods: A comprehensive database search without date restrictions was performed in PubMed. Keywords included Descemet membrane endothelial keratoplasty (DMEK), Descemet stripping automated endothelial keratoplasty (DSAEK), corneal keratoplasty, preoperative visual acuity, preoperative central corneal thickness, and densitometry. Articles aiming to describe or evaluate preoperative indications for endothelial keratoplasty were considered eligible and were included in this review. Results: The indications for surgery in FECD are disparate between the different studies. The tendency is to operate on patients earlier to obtain a better postoperative visual acuity at 1 year. The surgical decision is based on a number of arguments (visual acuity, CCT, densitometry). A preoperative visual acuity worse than 20/40 is generally considered a surgical indication for DMEK, based on current literature. Conclusions: Surgical decisions for Fuchs’ dystrophy should be individualized, guided by preoperative visual acuity, corneal OCT, and advanced imaging, with future risk scores potentially refining the timing of intervention to optimize outcomes. Full article

While full-thickness penetrating keratoplasty (PK) has seen a decline in favor of partial-thickness techniques like endothelial keratoplasty (EK) and anterior lamellar keratoplasty (ALK), PK remains indicated for corneal disease involving the entire corneal thickness. Mushroom keratoplasty (MK) is a noteworthy modification of PK, designed to combine the refractive benefits of a large-diameter anterior lamellar graft with the graft survival advantage of limited replacement of the corneal endothelium. Leveraging the use of a microkeratome, the MK donor graft can be prepared by microkeratome dissection, thereby achieving a central interface compatible with 20/20 Snellen vision. This review explores the various surgical techniques, visual outcomes, graft survival rates, and complication rates associated with MK for various indications. Full article

Background/Objectives: Clinically inactive corneal scars have repeatedly been shown to exhibit histological inflammation. This study aimed to evaluate the degree of histological inflammation in clinically inactive corneal scars of different origins and its correlation with graft rejection and failure following penetrating keratoplasty. Methods: The study included 205 primary corneal explants with clinically inactive central scars resulting from herpes simplex virus keratitis (HSV, n = 55), keratoconus (n = 39), mechanical trauma (n = 27), scrophulosa (n = 22) or other/unknown causes (n = 62). Central histological sections were categorized by the degree of inflammation, and an overall inflammation score (IS) was calculated. Results: HSV-associated scars exhibited a trend towards more graft rejection with higher IS (p = 0.074). Keratoconus-associated scars showed no IS-dependent differences in graft rejection or failure. The rejection rate in this group was 13/39. Scars resulting from mechanical trauma, such as perforating injuries, demonstrated a trend towards higher graft rejection (p = 0.15) and failure rates (p = 0.089) with increasing IS. The rejection rate in this group was 11/27. Scrophulosa-associated scars had significantly higher graft rejection rates (p = 0.041) at a lower cut-off of 0.06 compared to the cut-off of 0.36 for the other groups. Scars of other or unknown causes showed no IS-dependent differences in graft rejection or failure. Conclusions: Histological inflammation in HSV scars and scars resulting from mechanical trauma appeared to contribute to graft rejection. Despite low IS, the rejection rate in keratoconus scars and scars following mechanical trauma was unexpectedly high, indicating the presence of other influencing factors. While some correlations did not reach statistical significance due to small sample sizes in the subgroups, the observed trends should be considered clinically relevant. The study may have been “underpowered”, as histopathologically inflamed specimens with clinically inactive corneal scars are relatively rare. Full article

Purpose: To assess the long-term outcomes of combined penetrating keratoplasty (PKP) and pars plana vitrectomy (PPV). Methods: A retrospective review of eyes that underwent combined surgery followed for 12 months or longer. Demographic data, indications for surgery, and pre-/post-surgical eye examinations were retrieved. Results: Thirteen consecutive eyes (13 patients) were enrolled. The mean age was 51.5 ± 20.5 years, and the mean follow-up time was 67 ± 36.9 months. All cases had severe corneal opacity. Indications for surgery included retinal detachment (76.9%), dropped lens (7.7%), dropped intraocular lens (7.7%), and endophthalmitis with corneal abscess (7.7%). Visual acuity improved in 46.1% of the cases, though in most cases visual acuity remained low, and decreased in 23% of the cases. In 23% of the cases (3 eyes), ambulatory vision was achieved for more than 12 months and in 15.4% for three years. Silicone oil tamponade was used in all cases of retinal detachment (10 eyes). Of these eyes, at the final follow-up, four eyes were attached, two eyes were partially attached, and corneal opacity prevented retinal visualization in three eyes. One eye was eviscerated and one eye developed phthisis. Postoperatively, 61.5% of the cases underwent repeated PKP for graft decompensation. At the final visit, graft failure was observed in 75% of the cases. Conclusions: The long-term follow-up of eyes that underwent combined PKP and PPV supports this technique in complex cases for eye and vision preservation. The main problem after combined surgery is the long-term survival of the corneal graft which may require repeated PKP surgeries. With this approach, in 23% of the cases, ambulatory vision was maintained for more than 12 months. Full article

We describe retrospectively the indications and outcomes of nine patients who present with varying degrees of deep posterior stromal scarring or endothelial failure following deep anterior lamellar keratoplasty (DALK). These patients underwent a surgical strategy coined Intraoperative Optical Coherence Tomography Guided Femtosecond Laser-Assisted Descemet Membrane Endothelial Keratoplasty (iFAD). This strategy can be used to address suboptimal visual outcomes following primary DALK. Patients undergoing iFAD first had femtosecond laser-assisted trephination of the underlying posterior lamella using the liquid keratoplasty system on the Femto LDV Z8 platform (Zeimer Ophthalmic Systems AG, Port, Switzerland). A Descemet Membrane Endothelial Keratoplasty (DMEK) graft was subsequently transplanted in place of the removed lamella. Out of nine cases, major indications for seven included post-infective, blepharokeratoconjunctivitis (BKC) and deep stromal scarring related to stromal dystrophy. The remaining two had endothelial failure following primary DALK. The main benefits of this surgical approach are (1) Utilization of integrated real-time iOCT on the femtosecond laser platform allows for precise calibration of a wide range of vertical posterior trephination depths (96–329 microns) from the endothelial surface. (2) Femtosecond laser trephination utilizing a non-applanation liquid interface preserves trephination geometries and maximises precision-based surgical outcomes. (3) iFAD is a viable and straightforward technique for surgeons addressing patients who might otherwise require complex surgery to address residual deep stromal scars post-DALK. Full article

Partial-thickness corneal transplants using a deep anterior lamellar keratoplasty (DALK) approach has demonstrated better patient outcomes than a full-thickness cornea transplant. However, despite better clinical outcomes from the DALK procedure, adoption of the technique has been limited because the accurate insertion of the needle into the deep stroma remains technically challenging. In this work, we present a novel hands-free eye mountable robot for automatic needle placement in the cornea, AutoDALK, that has the potential to simplify this critical step in the DALK procedure. The system integrates dual light-weight linear piezo motors, an OCT A-scan distance sensor, and a vacuum trephine-inspired design to enable the safe, consistent, and controllable insertion of a needle into the cornea for the pneumodissection of the anterior cornea from the deep posterior cornea and Descemet’s membrane. AutoDALK was designed with feedback from expert corneal surgeons and performance was evaluated by finite element analysis simulation, benchtop testing, and ex vivo experiments to demonstrate the feasibility of the system for clinical applications. The mean open-loop positional deviation was 9.39 µm, while the system repeatability and accuracy were 39.48 µm and 43.18 µm, respectively. The maximum combined thrust of the system was found to be 1.72 N, which exceeds the clinical penetration force of the cornea. In a head-to-head ex vivo comparison against an expert surgeon using a freehand approach, AutoDALK achieved more consistent needle depth, which resulted in fewer perforations of Descemet’s membrane and significantly deeper pneumodissection of the stromal tissue. The results of this study indicate that robotic needle insertion has the potential to simplify the most challenging task of the DALK procedure, enable more consistent surgical outcomes for patients, and standardize partial-thickness corneal transplants as the gold standard of care if demonstrated to be more safe and more effective than penetrating keratoplasty. Full article

Backgrond: Intracorneal ring segments (ICRSs) are utilized to correct refractive changes impacting visual acuity, commonly implanted via femtosecond laser but can also inserted manually. Corneal deposits alongside the ICRS channels are seen commonly. Methods: This study explores the histological characteristics of corneal deposits following manual ICRS implantation, comparing them to previously published articles describing femtosecond laser-assisted cases. Results: This is a retrospective analysis of three cases involving manual ICRS implantation, accumulation of whitish deposits and later explanation of the corneas due to penetrating keratoplasty (PKP). Patient demographics, ocular history, and surgical details were collected. Histological analysis employed Hematoxylin and Eosin (H&E) and Masson’s trichrome staining. Whitish deposits along ICRS tracts were observed in all cases, with minimal fibroblastic transformation of keratocytes adjacent to the segments. Comparing these cases of manual to femtosecond laser-assisted ICRS implantation, in most cases, similar deposits were identified, indicating the deposits’ association with the stromal tissue reaction to the ring segment and not to the surgical technique. Conclusions: This study contributes insights into the histopathology of manually implanted ICRS, emphasizing the shared nature of deposits in both insertion methods. The findings highlight the link between deposits and the stromal tissue reaction to the ring segment, irrespective of the insertion technique. Full article

The purpose of this article is to evaluate the course of paraproteinemic keratopathy (PPK) in patients undergoing systemic therapy for the underlying hematological disease. Baseline and follow-up examinations included hematological work-up, best-corrected visual acuity, slit-lamp biomicroscopy, and in vivo confocal laser scanning microscopy (IVCM). We included 22 patients with bilateral PPK (aged 68 ± 10.4 years, 11 males). Ten patients with multiple myeloma (MM) underwent on-label systemic therapy. During follow-up, we observed a regression of corneal opacities in three patients under slit-lamp examination and under IVCM, while PPK remained unchanged in seven patients. In three patients with monoclonal gammopathy of ocular significance (MGOS), systemic therapy was initiated off-label to reduce the serum paraprotein load before penetrating keratoplasty (PKP). These patients showed no signs of PPK recurrence for up to 24 months after PKP. In one patient without systemic therapy, a recurrence in corneal grafts occurred within 12 months of PKP. In eight patients without systemic therapy, PPK remained stable. In conclusion, systemic therapy for MM patients reduced corneal opacity in 30% of treated patients. Furthermore, systemic therapy performed before PKP in patients without conventional systemic therapy indication (MGOS) likely postpones PPK recurrence in the corneal graft. Full article

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