Late corneal ectasia after penetrating and deep anterior lamellar keratoplasty for keratoconus

AIM:To investigate tomographic features of late corneal ectasia after keratoplasty for keratoconus and compare penetrating keratoplasty(PK)and deep anterior lamellar keratoplasty(DALK)in terms of incidence,time of onset and risk factors of corneal ectasia.METHODS:Sixty eyes with PK and 30 eyes with DALK operated between 1999 and 2021 were analyzed.Final Pentacam scans were evaluated together with vision and previous topographies.Main outcome measures were vision,K values,apparent thinning on graft-host cornea and the difference between opposing quadrants in the thinnest point measurements.Anterior segment optic coherence tomography was performed for further evaluation.RESULTS:Mean follow-up was 127.2mo(24–282mo)in PK,and 64.3mo(24–144mo)in DALK.K max was higher in DALK(60.6 vs 56.7 D,P=0.012).Inferior recipient was thinner(595.9μm)in PK than DALK(662.2μm,P=0.021),due to longer follow-up.Overall corneal ectasia rate was 20.0%within 24y.Ectasia rate was the same(6.7%)in DALK 2/30 and in PK 4/60 in 10y and 13.3%in 12y(4/30 and 8/60,respectively).It increased to 23.3%(14/60)in PK over 24y.While ectasia was not seen before 7y in PK,it could be seen in DALK starting from the 5^(th) year.The intervals between keratoplasty and ectasia were 144.5mo in PK and 99mo in DALK.Inferior recipient was significantly thinner in 18 eyes with ectasia(502.7μm)compared to 76 non-ectasia(649.1μm,P=0.000).Inferior graft was thinner(561.0 vs 620.4μm,P=0.006),K max(63.3 vs 56.5 D,P=0.000),and anterior elevation was higher in ectasia(89.1 vs 48.6μm,P=0.002).Accelerated crosslinking was performed on 5 eyes.CONCLUSION:Inferior-superior recipient and inferior graft thinning on tomography,with high K max and anterior elevation emerge as the most reliable criteria for the diagnosis of late ectasia.The incidence of corneal ectasia increases with the time.

Two-step strategy—conjunctival flap covering surgery combined with secondary deep anterior lamellar keratoplasty for the treatment of high-risk fungal keratitis

AIM:To investigate whether the two-step strategy[conjunctival flap covering surgery(CFCS)combined with secondary deep anterior lamellar keratoplasty(DALK)]is effective for patients with high-risk fungal keratitis(FK).METHODS:In this noncomparative,retrospective case series,10 subjects(6 males,4 females)with a mean age of 56.5±7.1(range 47-72)y with high-risk FK undergone the two-step strategy were included.Reported outcome measures were healing of the corneal ulcer,recurrence of FK,reject reaction,improvement in best corrected visual acuity(BCVA)and relevant complications.RESULTS:The average diameter of corneal infiltrates was 7.50±0.39 mm,ranging from 6.94 to 8.13 mm.The mean depth of corneal infiltrates was 422.4±77.1μm,ranging from 350 to 535μm.The mean corneal thickness was 597.4±117.3μm,ranging from 458 to 851μm.Hypopyon and endothelial plaques were presented in all patients.The period between the two steps was 3.65±0.9(ranging from 3 to 5)mo.The graft diameter was 7.75±0.39 mm.At the last follow-up(average 9.25±3.39,ranging from 5.5 to 17mo),no fungal recurrence or graft rejection appeared,and all patients showed improvement of BCVA.One patient suffered from liver function impairment due to oral voriconazole for 4wk and recovered spontaneously after 1wk of drug withdrawal.CONCLUSION:The two-step strategy is safe and effective in the treatment of high-risk FK by transforming intentional therapeutic penetrating keratoplasty during acute infection to later optical DALK.It is a practical strategy,especially in areas lacking fresh donor corneas and eye bank services.

Donor cornea quality used for penetrating keratoplasty vs deep anterior lamellar keratoplasty

Deep anterior lamellar keratoplasty(DALK) has recently been introduced as an alternative procedure to penetrating keratoplasty(PK) for corneal pathologies not affecting the corneal endothelium. DALK does not rely on donor endothelium and requires less rigid criteria for donor corneal tissue quality. Therefore, DALK makes it possible to use donor corneas deemed unsuitable for PK. Furthermore, lamellar keratoplasty allows acellular corneal tissue to be transplanted. As a result, long-term preservation techniques are being revisited to increase the availability of donor corneas and subsequently alleviate constraints of availability, cost, storage, and transportation in many countries. The recent alterations in corneal transplantation techniques and hence the type of donor cornea tissues used for each technique, may require corneal surgeons and eye banks to reevaluate their selection criteria. The purpose of this systematic review is to present an updated analysis on the type and quality of donor corneas used for PK and DALK, assess the influence of donor and eye bank factors on the quality of donor corneas, and determine whether any of these donor factors affect clinical outcomes, complications, and graft survivals.

Incorporation of Nano-Zinc Oxide in Lamellar Zirconium Phosphate: Synthesis and Characterization

In order to provide ultraviolet barrier, antifungal and antibacterial properties, nano-zinc oxide (ZnO) was added to lamellar zirconium phosphate (ZrP). The phosphate was synthesized via reaction of zirconium oxychloride octahydrate and phosphoric acid following its chemical modification with Jeffamine and nano-ZnO. Diffractometric, morphological, thermal, structural and relaxometric evaluations were conducted. Fourier transform infrared spectroscopy (FTIR) revealed increase of the area between 4000 - 3000 cm-1 due to the formation of ionic specie PO? +NH3-[C-(H)(CH3)-CH2-O-(C-(H)(CH3)-CH2-O)8-(CH2-CH2-O-CH3)] and nano-ZnO particles. Wide-angle X-ray diffraction indicated that intercalation of Jeffamine was successful. Thermogravimetry confirmed that nano-ZnO particle forced the expulsion of Jeffamine outside ZrP galleries. Scanning electron microscopy evidenced the Jeffamine intercalation and sample heterogeneity. Hydrogen molecular relaxation indicated the increase of molecular rigidity owing to the formation of ionic specie and the addition of nano-ZnO particles. It was postulated that a multifunctional and miscellaneous material constituted by as prepared ZrP, some delaminated ZrP platelets and nano-ZnO particles was achieved. The material has potential for usage as filler in polymeric composites.

High temperature deformation behavior and optimization of hot compression process parameters in TC11 titanium alloy with coarse lamellar original microstructure

The high temperature deformation behaviors of α＋β type titanium alloy TC11 （Ti-6.5Al-3.5Mo-1.5Zr-0.3Si） with coarse lamellar starting microstructure were investigated based on the hot compression tests in the temperature range of 950-1100 ℃ and the strain rate range of 0.001-10 s-1. The processing maps at different strains were then constructed based on the dynamic materials model, and the hot compression process parameters and deformation mechanism were optimized and analyzed, respectively. The results show that the processing maps exhibit two domains with a high efficiency of power dissipation and a flow instability domain with a less efficiency of power dissipation. The types of domains were characterized by convergence and divergence of the efficiency of power dissipation, respectively. The convergent domain in a＋fl phase field is at the temperature of 950-990 ℃ and the strain rate of 0.001-0.01 s^-1, which correspond to a better hot compression process window of α＋β phase field. The peak of efficiency of power dissipation in α＋β phase field is at 950 ℃ and 0.001 s 1, which correspond to the best hot compression process parameters of α＋β phase field. The convergent domain in β phase field is at the temperature of 1020-1080 ℃ and the strain rate of 0.001-0.1 s^-l, which correspond to a better hot compression process window of β phase field. The peak of efficiency of power dissipation in ℃ phase field occurs at 1050 ℃ over the strain rates from 0.001 s^-1 to 0.01 s^-1, which correspond to the best hot compression process parameters of ,8 phase field. The divergence domain occurs at the strain rates above 0.5 s^-1 and in all the tested temperature range, which correspond to flow instability that is manifested as flow localization and indicated by the flow softening phenomenon in stress-- strain curves. The deformation mechanisms of the optimized hot compression process windows in a＋β and β phase fields are identified to be spheroidizing and dynamic recrystallizing controlled by self-diffusion mechanism, respectively. The microstructure observation of the deformed specimens in different domains matches very well with the optimized results.

Dynamic spheroidization kinetics behavior of Ti-6.5Al-2Zr-1Mo-1V alloy with lamellar microstructure

Abstract： The dynamic spheroidization kinetics behavior of Ti-6.5Al-2Zr-1Mo-1V alloy with a lamellar initial microstructure was studied by isothermal hot compression tests in the temperature range of 750-950℃ and strain rates of 0.001-10 s^-1. The results show that the spheroidized fraction of alpha lamellae increases with the increase of temperature and the decrease of strain rate. The spheroidization kinetics curves predicted by JMAK equation agree well with experimental ones. The corresponding SEM and TEM observations indicate that the dynamic spheroidization process can be divided into two stages. The primary stage is boundary splitting formed by two competing mechanisms which are dynamic recrystallization and mechanical twin. In the second stage, the penetration of beta phase into the alpha/alpha grain boundaries is dominant, which is controlled in nature by diffusion of the chemical elements such as Al, Mo and V.

Femtosecond laser-assisted deep anterior lamellar keratoplasty for keratoconus and keratectasia

·AIM: To describe the initial outcomes and safety of femtosecond laser-assisted deep anterior lamellar keratoplasty(DALK) for keratoconus and post-LASIK keratectasia.·METHODS: In this non-comparative case series, 10 eyes of 9 patients underwent DALK procedures with a femtosecond laser(Carl Zeiss Meditec AG, Jena,Germany). Of the 9 patients, 7 had keratoconus and 2had post-LASIK keratectasia. A 500 kHz VisuMax femtosecond laser was used to perform corneal cuts on both donor and recipient corneas. The outcome measures were the uncorrected visual acuity(UCVA),best-corrected visual acuity(BCVA), corneal thickness,astigmatism, endothelial density count(EDC), and corneal power.·RESULTS: All eyes were successfully treated. Early postoperative evaluation showed a clear graft in all cases. Intraoperative complications included one case of a small Descemet’s membrane perforation.Postoperatively, there was one case of stromal rejection,one of loosened sutures, and one of wound dehiscence.A normal corneal pattern topography and transparency were restored, UCVA and BCVA improved significantly,and astigmatism improved slightly. There was no statistically significant decrease in EDC.· CONCLUSION: Our early results indicate that femtosecond laser-assisted deep anterior lamellar keratoplasty could improve UCVA and BCVA in patients with anterior corneal pathology. This approach shows promise as a safe and effective surgical choice in the treatment of keratoconus and post-LASIK keratectasia.

Anterior lamellar recession for management of upper eyelid cicatricial entropion and associated eyelid abnormalities

AIM：To evaluate the functional and aesthetic outcomes of upper eyelid cicatricial entropion（UCE） correction using anterior lamellar recession（ALR） with addressing the associated conditions including dermatochalasis,brow ptosis,blepharoptosis,and lid retraction.METHODS：Chart review of patients with upper lid cicatricial entropion who had undergone ALR from 2013 to 2016 was reviewed.Success was defi ned as the lack of any lash in contact with the globe,no need for a second procedure,and acceptable cosmesis at the fi nal follow up.RESULTS：Sixty eight patients（97 eyelids） were operated by ALR with simultaneous correction of associated lid problems in each case when necessary.The mean followup time was 17.8 mo（range,6.0-24.0 mo）.Concomitantly,levator tucking was performed in 19 eyelids（19.6%）,upper lid retractor recession in 18 eyelids（18.6%）,and internal browpexy in 31 eyelids（32.0%）.In 95.8% of patients（95%CI：0.85-0.96）,satisfactory functional and cosmetic outcome was achieved with a single surgical procedure.CONCLUSION：Based on the principles of lamellar recession and concurrently addressing the associated lid problems,this approach is an effective and safe treatment of UCE.

Influence of columnar grain boundary on fracture behavior of as-cast fully lamellar Ti-46Al-0.5W-0.5Si alloy

The fracture behavior of fully lamellar γ-TiAl alloys depends on the angle between the lamellar orientation and loading axis,but the role of the presentation of grain boundary cannot be ignored.To investigate the influence of the grain boundary on the initiation and propagation of cracks,the tensile test of the alloy was conducted at room temperature with loading axis parallel and perpendicular to the lamellar orientation,respectively.The cracks adjacent to the fracture zone of the tensile specimens have been investigated to analyze the fracture behavior.Results show that the grain boundary has dual influences on the fracture behavior.When the loading axis is parallel to the lamellar orientation,cracks are preferentially initiated at and propagate along the grain boundaries.When the loading axis is perpendicular to the lamellar orientation,the grain boundaries can prevent the propagation of cracks from running across.Additionally,serrated-shape grain boundaries have a better inhibiting effect on the propagation of cracks than planar boundaries.

Filaggrin mutations are associated with ichthyosis vulgaris in the Southern Chinese population

Filaggrin (FLG) plays an important role in the epidermal barrier function, which identified in patients with ichthyosis vulgaris(IV).To study the genetics of FLG mutations in Southern Chinese patients with IV. We evaluated the influence of five mutations (3321 delA, 441delA, 1249 insG, E1795X and S3296X) in a cohort of 65 IV Chinese patients and in 100 control individuals using the Sequenom? MassARRAY? system. The null allele frequency of 3321delA was 52.31%(34/65). FLG mutation 441delA was only found in one IV patients. FLG mutations 1249insG, E1795X and S3296X were not found in these patients. These findings show that the mutation 3321delA represent the most frequent genetic cause in Southern Chinese IV patients. Our findings confirm and extend the knowledge of the influence of FLG mutations in IV.

Femtosecond laser-assisted deep anterior lamellar keratoplasty in phototherapeutic keratectomy versus the big-bubble technique in keratoconus

AIM：To compare the functional and anatomic results of femtosecond laser（FSL）-assisted deep anterior lamellar keratoplasty（DALK） associated with phototherapeutic keratectomy（PTK） and FSL-assisted DALK performed using the big-bubble technique in keratoconus.METHODS：During the first phase of the study,an electron microscopy histopathology pilot study was conducted that included four unsuitable donor corneas divided into two groups：in FSL group,FSL lamellar cuts were performed on two corneas and in FSL＋PTK group,PTK was performed at the stromal beds of two corneas after FSL lamellar cuts were made.During the second phase of the study,a randomized clinical trial was conducted that included two treatment groups of patients with keratoconus：group 1（n=14 eyes） underwent FSL-assisted DALK associated with PTK and group 2（n=12 eyes） underwent FSL-assisted DALK associated with the bigbubble technique.The main outcome measures were the postoperative visual acuity（VA） and optical coherence tomography（OCT） measurements,confocal microscopic findings,and contrast sensitivity.RESULTS：In the pilot study,histopathology showed a more regular stromal bed in the FSL＋PTK group.In the clinical trial,group 1 had significantly worse best spectaclecorrected VA and contrast sensitivity（P〈0.05 for both comparisons）.The residual stromal bed measured by OCT was significantly（P〈0.05） thicker in group 1.Confocal microscopy detected opacities only at the donor-receptor interface in group 1.CONCLUSION：Patients with keratoconus treated with FSL-assisted DALK performed using the big-bubble technique fare better than treated with FSL-assisted DALK associated with PTK.

Comparison of visual and topographic outcomes of deep-anterior lamellar keratoplasty and penetrating keratoplasty in keratoconus

AIM：To compare visual,surgical and topographic outcomes of deep anterior lamellar keratoplasty（DALK）and penetrating keratoplasty（PK）for keratoconus（KC）.METHODS：In this multicenter,prospective,randomized clinical trial 76 eyes of 71 KC patients operated between January 2011 and July 2014 in 2 tertiary referral hospitals were included. Consecutive patients were alternately selected to receive one of the two surgical methods. Thirty eight eyes underwent DALK with the big-bubble technique and 38 eyes underwent PK.RESULTS：Mean best spectacle corrected visual acuity（BSCVA）at the first postoperative week（P=0.012）and the first postoperative month（P〈0.001）was statistically significantly higher in DALK group. The mean BSCVA at12 mo was not significantly different for DALK（0.30±1.99 log MAR）versus PK（0.40±0.33 log MAR）（P=0.104）. The76.3% of the eyes had a BSCVA over 0.5 in DALK and 47.4%in PK group（P=0.009）. The 7.9% of the eyes had a BSCVA of 1.0 in DALK and 5.3% in PK group（P=0.644）. Mean spherical equivalent was-2.94 D in DALK and-3.09 D in PK group.Mean topographic astigmatism was 4.62 D and 4.18 D respectively. Regular topographic patterns were observed in 31（81.6%）of DALK and 29（76.3%）of PK（P=0.574）. The most frequent topographic pattern was oblate asymmetric bow tie,seen in 39.5% in DALK and 23.7% in PK. CONCLUSION：Big bubble DALK provides an earlier visual improvement compare to PK. However,visual and topographic outcomes are similar to those in PK at 1y. Postoperative complications including rejection and intraocular pressure elevation are more frequent in PK. DALK is a safer alternative to PK for KC. However,intraoperativeperforation of the Descemet＇s membrane is a significant complication.

Influence of silicide on fracture behavior of a fully lamellar Ti-46Al-0.5W-0.5Si alloy

The fracture behavior of fully lamellar binary γ-TiAI alloys is extremely anisotropic with respect to the lamellar orientation. For the fully lamellar Ti-46Al-0.5W-0.5Si alloy, the existence of silicide clusters plays a critical role on the fracture behavior. In the present study, tensile test and three point bending test were performed at room temperature with the loading axis parallel and perpendicular to the lamellar orientation, respectively. To investigate the influence of silicide clusters on the initiation and propagation of cracks, the fracture surface and the cracks adjacent to the fracture zone of the specimens have been analyzed. Results show that the fracture process is related to the morphology and distribution of the silicide clusters. Crack preferentially initiates at and propagates along the interface of silicide and a2/7 lamellar with the loading axis perpendicular to the length direction of silicide. While the silicide can prevent the propagation of cracks from running across with the crack growth direction perpendicular to the length direction of silicide.

Indications for penetrating keratoplasty and anterior lamellar keratoplasty during 2010-2017

AIM: To review the indications of penetrating keratoplasty(PK) and anterior lamellar keratoplasty(ALK) at Qingdao Eye Hospital, Shandong Eye Institute, Qingdao, China, from 2010 to 2017. METHODS: The data of all patients undergoing PK or ALK from January 2010 to December 2017 was retrospectively reviewed, with the indications during 2010-2013 and 2014-2017 compared. RESULTS: A total of 1869 eyes were included, among which 1405 eyes(75.2%) had PK and 464 eyes(24.8%) had ALK. The leading indications were suppurative keratitis(36.8%), keratoconus(15.5%), herpes keratitis(13.1%), and regraft(10.5%). In eyes undergoing PK, the top four indications were suppurative keratitis(38.7%), herpes keratitis(15.3%), keratoconus(12.6%), and regraft(12.5%) during 2014-2017, with the proportion of suppurative keratitis and herpes keratitis decreased while regraft and keratoconus increased compared with 2010-2013. In eyes with ALK, suppurative keratitis(30.8%), keratoconus(24.1%), corneal dystrophies and degenerations(10.6%), and corneal dermoid tumor(9.7%) were the top four indications, and there was no significant difference for the proportion of each indication between 2010-2013 and 2014-2017. CONCLUSION: Suppurative keratitis is the most common indication for PK and ALK at Qingdao Eye Hospital during 2010-2017, followed by keratoconus, herpes keratitis, and regraft. In eyes treated with PK, the proportion of suppurative keratitis and herpes keratitis decrease while regraft and keratoconus increase during 2014-2017 compared with 2010-2013.

Microstructure evolution and mechanical properties of homogenizing treated fully lamellar Ti-46Al-0.5W-0.5Si alloy

The microstructure of as-cast Ti-46AI-0.5W-0.5Si alloy exhibits significant microinhomogenetity due to the non-equilibrium solidification and low atom diffusion rate. In order to reduce the adverse effect of this microsegregation on plasticity, the microstructure evolution of the Ti-46AI-0.5W-0.5Si alloy homogenized at different temperatures from 1,200 ℃ to 1,320 ℃was investigated, and the optimized process of homogenizing treatment, i.e., annealing treated at 1,280 ℃ and held for 8 h, was determined. Microstructures of both the as-cast and heat treated alloys were observed by means of optical microscope and scanning electron microscopes. Tensile tests at room temperature were conducted on the homogenizing treated fully lamellar Ti-46AI-0.5W-0.5Si alloy with loading axis parallel to the lamellar interface. Results show that, at higher heat treatment temperatures, the W element diffuses sufficiently, the microstructure tends to be more homogeneous, and the profile of the silicide clusters becomes smooth. Heat treating conducted in the a＋y two phase region can keep the columnar grains and the original lamellar orientation within them. The microstructure of the alloy after heat treated in a＋y two phase region exhibits the coexisting morphology of coarse lamellar and thin lamellar. The homogenization process at 1,280℃ for 8 h can significantly reduce the microsegregation, and the elongation at room temperature can increase from 0.48% （as-cast） to 1.34%.

Achieving High Strength-plasticity of Nanoscale Lamellar Grain Extracted from Gradient Lamellar Nickel

Traditional metallic materials usually face a dilemma between high strength and poor strain hardening capacity.However,heterogeneous structured metallic materials have been found to obviously overcome the trade-of.Herein,gradient lamellar structure was fabricated through ultrasound-aided deep rolling technique in pure Ni with high stacking fault energy after heat treatment.The gradient lamellar Ni was successively divided into the four regions.In-situ micropillar compression tests were conducted in diferent regions to reveal the corresponding microscopic mechanical properties.Microscopic characterization techniques were performed to explore underlying deformation mechanisms and the efects of microstructural parameters on deformation behaviors.This work demonstrates that the micropillar with near nanoscale lamellar thickness possesses excellent strength and plasticity.On one hand,the reason for high strength of near nanoscale micropillar is that the strength of micropillar increases with the decrease of lamellar thickness according to the Hall-Petch efect.On the other hand,numerous lamellar grain boundaries perpendicular to the loading direction is found to hinder the motion of slip bands,resulting in great strain hardening capacity in the near nanoscale lamellar micropillar.

Central corneal epithelium self-healing after ring-shaped glycerin-cryopreserved lamellar keratoplasty in Terrien marginal degeneration

Dear Sir, I am Dr Yan-Long Bi, from the Department of Ophthalmology, Tongji University Affiliated to Tongji University School of Medicine, Shanghai, China. I write to present a case report of total limbal stem cells deficiency after treatment with ring-shaped lamellar keratoplasty secondary to Terrien marginal degeneration. During 3 years

Evolution of lamellar structure in Ti-47Al-2Nb-2Cr-0.2W alloy sheet

The Ti-47Al-2Nb-2Cr-0.2W alloy sheets were obtained by hot pack rolling. The as-rolled sheet has an inhomogeneous duplex microstructure composed of elongated gamma grains and lamellar colonies. Heat treatments were conducted on the as-rolled sheets. The results show that the microstructures with different sizes and grain boundary morphologies were developed after different heat treatments. A coarse fully lamellar structure can be refined if the heating time, together with the cooling rate, is appropriately controlled. The grain growth exponent is found to be approximately 0.2, and the activation energy of grain boundary migration of the alloy is around 225 kJ/mol.

Cryopreserved limbal lamellar keratoplasty for peripheral corneal and limbal reconstruction

This study aimed to evaluate the outcomes and described the recovery process of cryopreserved limbal lamellar keratoplasty（CLLK） for peripheral corneal and limbal diseases. Thirteen eyes of 12 patients with a mean age of 41±23.9 y were included. The average follow-up was 12.1±5.6 mo. Stable ocular surface was achieved in all eyes at last follow-up. Epithelialization originated from both recipient and graft in 9 eyes. We conclude that CLLK compensates for the shortage of donor corneas and cryopreserved limbal grafts provide epithelialization sources in ocular surface reconstruction.

Etiology and failure analysis of anterior lamellar keratoplasty

AIM：To analyze indications and reasons for failure of anterior lamellar keratoplasty（ALK）.METHODS：The clinical records were retrospectively reviewed.Main outcome measures included indications for ALK and reasons for failure of ALK.RESULTS：A total of 434 patients（462 eyes） were treated with ALK at Qingdao Eye Hospital,Shandong Eye Institute from June 1,2009 to May 31,2016.The main indications were infectious keratitis（33.3%）,keratoconus（23.6%）,corneal dystrophy and degeneration（9.8%）,Mooren＇s ulcer（8.4%）,corneal neoplasm（7.8%）,viral keratitis（6.5%） and regrafting（3.7%）.Fungal keratitis accounted for 73.4% in the infectious keratitis cases.ALKs were failed in 36 patients,with the major causes being recurrence of primary diseases（63.9%）.The leading causes of graft failure was Mooren＇s ulcer（36.1%）,followed by infectious keratitis（30.6%）.Recurrence of fungal keratitis accounted for 81.8% in the failed cases after ALK for infectious keratitis cases.CONCLUSION：Infectious keratitis and keratoconus are the main indications for ALK,of which fungal keratitis was the major cause of corneal infections.Recurrence of primary disease is the main reason of graft failure after ALK,in which the main primary diseases associated with graft failure are Mooren＇s ulcer and fungal keratitis.