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.

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.

Clinical analysis of tear film after lamellar keratoplasty

AIM: To study the tear film stability after lamellar keratoplasty METHODS: Five female and eight male patients with lamellar keratoconus, aged from 18 to 32, were involved. After lamellar keratoplasty, Schirmer I test (S I t), tear break-up time (BUT) test, fluorescein staining test were used to judge the effect of the surgery at different time point. RESULTS: The S 1 t were greatly increased in 7 clays post operation (11.86+/-2.28 -25.14+/-1.97, 19.86+/-1.61) (P<0.05), there is no significant difference between 2nd month, 3rd month post-operative and pre-operation(11.86+/- 2.28 - 14.57+/-1.48, 8.14+/-0.86) (P >0.05). The mean break-up time decreased in 7 days post operation (5.00+/-1.31 -2.71+/- 0.18, 2.57+/- 0.20, 2.71+/- 0.36, 2.43+/- 0.20) (P <0.05). The mean scores of fluorescence increased post-operatively (0.14+/- 0.14 - 8.00+/- 0.00, 8.00+/- 0.00, 8.00+/- 0.00, 7.57+/- 0.20) (P<0.01). CONCLUSION: Lamellar keratoplaty influence the tear film stability, artificial tears and improving corneal epithelium cured medicine should be used after surgery.

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.

Comparison of long-term results after manual and femtosecond assisted corneal trephination in deep anterior lamellar keratoplasty for keratoconus

AIM: To compare long-term postoperative outcomes of manual and femtosecond assisted corneal trephination in deep anterior lamellar keratoplasty(FS-DALK) for keratoconus.METHODS: In the retrospective study, 17 consecutive eyes that underwent vertical side cut incision FS-DALK and 22 eyes that underwent trephine incision DALK were collected over a 2-year period. Main measurements included postoperative uncorrected-visual acuity(UCVA), corrected distance visual acuity(CDVA), refractive sphere and cylinder, manifest refraction spherical equivalent(MRSE), flat and steep corneal keratometry(K1 and K2), endothelial cell density(ECD), and time of epithelium healing and suture removal.RESULTS: Groups were comparable for diagnosis and preoperative visual acuity. Follow-up averaged 23 mo(range, 12-36 mo). At 12 mo, the mean UCVA was better in the manual-DALK group(P=0.039), and the refractive sphere was lower in the FS-DALK group(P=0.040). MRSE between groups differed at 1, 6, and 12 mo postoperatively(P=0.047, 0.025, 0.042, respectively). Mean CDVA, cylinder, K1, K2,corneal astigmatism, ECD, and time of epithelium healing were similar between groups. Stability of MRSE, ECD, and K1 returned sooner after FS-DALK. Initial loosened suture removal time was earlier in the manual-DALK group(P=0.042) while complete suture removal time was similar(P=0.122).CONCLUSION: Manual and femtosecond assisted corneal trephination in DALK are options for advanced keratoconus. FS-DALK do not result in improved visual acuity but it is more stable during the follow-up period. FSDALK in the present form show limited benefit, so surgical design and parameters still need to be optimized and explored.

Changes in endothelial cell density following penetrating keratoplasty and deep anterior lamellar keratoplasty

· AIM: To compare the corneal endothelial cell density (ECD) of clear grafts after penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK). · METHODS: The study included 44 and 54 patients treated with PK and DALK, respectively, between March 2006 and April 2010. Corneal ECD was examined using specular microscopy at postoperative 1, 3, 6, 12, and 18 months, and the values were compared. · RESULTS: Corneal ECD reduction in the PK group was 7.4%, 15.2%, 23.5%, and 28.9% at 3, 6, 12 and 18 months respectively after surgery, compared with 4.2 % in the first month (P <0.01). These figures were 3.0%, 6.7%, 7.2%, and 7.7% at 3, 6, 12 and 18 months respectively, compared with 2.2 % in the first month in the DALK group (P >0.05). · CONCLUSION: Compared with DALK,PK significantly reduced ECD of the clear grafts. These results suggest that survival of endothelial cells in grafts is better after DALK than after PK. ·

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

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.

Fresh Amniotic Membrane Transplantation Combined Lamellar Keratoplasty for Patients with Recurrent Mooren's Ulcer

Purpose: To investigate the possibility of amniotic membrane as an immunologicalinsulating band to reduce the recurrent frequency of Mooren's ulcer.Methods: Twelve cases(12 eyes)with recurrent Mooren's Ulcer were observed. Amongthem, 4 cases(4 eyes)were male and 8 cases(8 eyes) female, ranging in age between 26and 51 years[mean(41 ± 3)years]. Three eyes recurred once, 5 eyes twice, and 4 eyesthree before. Eleven of 12 cases (11/12 eyes)with frequently recurrent Mooren's ulcerunderwent lamellar keratoplasty combined amniotic membrane transplantation(AMT).One patient who had entire corneal ulceration accepted AMT alone.Results: Follow-up time is 12 to 29 months, [mean (23 ± 6) months]. Before AMT, therecurrent frequency of Mooren's Ulcer of all cases after corneal surgery was 1 ～ 7 months[mean(3 ± 2)months]. Nine of 12 eyes with lamellar keratoplasty combined AMT did notrecur within the observation period; 2 eyes recurred 11 months after the surgery. Threemonths postoperatively, neovascularization was observed, which made it nearly impossibleto decipher between amniotic membrane and its nearby conjunctiva, only at the junctionof the transplant can some trails be observed. One case with entire AMT alone showedgraft resolution and neovascularization in 1 month.Conclusion:AMT combined with lamellar keratoplasty and lesion excision may delayrecurrence of Mooren's Ulcer, reduce its recurrent frequency. Besides the effects ofdecreasing inflammation, it may have immunological insulating function as well. Thisconclusion should be proven by further clinical comparative study of much moresamples.

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.

The Treatment of Terrien Marginal Degeneration Using Lamellar Keratoplasty with Dried Corneosclera

Purpose: To treat the Terrien marginal degeneration using lamellar keratoplasty with dried corneosclera and evaluate the clinical effect of this operation.Methods: The study included 78 cases with Terrien marginal degeneration who underwent the lamellar keratoplasty with dried corneosclera. Among them, 48 cases in experiment Ⅰ group and 30 cases in experiment Ⅱ group underwent lamellar keratoplasty with glycerin-preserved corneosclera and anhydrous calcium chloride-storeded corneosclera respectively. All the patients were followed-up from 6 months to 10 years. The control group consisted of 38 cases with Terrien marginal degeneration electively undergoing lamellar keratoplasty with fresh corneosclera simultaneously.Results: The area of the corneal thinning was mended and the eyeball was saved. The corneal astigmatism of the patients was corrected obviously.The patient’s vision was improved significantly. No recurrence and rejection were observed after the operation.There is no significant difference between the experiment group (experiment Ⅰ group or experiment Ⅱ group) and control group. (P > 0.05), despite longer duration of postoperative corneal edema in experiment group.Conclusions: The lamellar keratoplasty with dried corneosclera for treatment of Terrien marginal degeneration is a safe and effective operation. It is an alternative to lamellar keratoplasty with fresh corneosclera for treatment of Terrien marginal degeneration. It is suitable to be popularized in the local hospital of our country.

Comparison of clinical outcomes of deep anterior lamellar keratoplasty and excimer laser assisted anterior lamellar keratoplasty in keratoconus

AIM: To compare and evaluate the clinical outcomes of deep anterior lamellar keratoplasty(DALK) and excimer laser assisted anterior lamellar keratoplasty(ELLK) in eyes with keratoconus.METHODS: In this study, 57 eyes of 56 patients operated between 2013 to 2017 were included. Thirty-one eyes underwent big-bubble DALK and twenty-six eyes underwent ELLK. Preoperative and at control visits complete ophthalmic examination was performed. RESULTS: The mean patient age at the time of DALK surgery was 27 y and mean follow-up period was 21±5.4 mo. The mean patient age at the time of ELLK surgery was 27 y and mean follow-up period was 40±18 mo. Mean best spectacle corrected visual acuity(BSCVA) at postoperative period was significantly higher for DALK group(0.66±0.11) versus ELLK group(0.4±0.2)(P<0.05). Descemet's membrane microperforation was occurred in 7 patients in DALK group versus in 1 patient in ELLK group. In 4 eyes, interface irregularity was developed in ELLK group. None of the patients in follow-up had graft rejection in both groups.CONCLUSION: In ELLK group, complication rate is lower, the surgical technique is simpler, faster and safer and also ELLK requires less experience with respect to DALK. Further, DALK can be performed unless satisfactory visual acuity is achieved after ELLK.

Phacoemulsification in eyes with corneal opacities after deep anterior lamellar keratoplasty

To evaluate the maneuverability and efficacy of phacoemulsification and intraocular lens(IOL) implantation in eyes with corneal opacities after deep anterior lamellar keratoplasty(DALK), twelve eyes of 12 patients with mild to moderate corneal opacities after DALK and coexisting cataracts were analyzed retrospectively. Phacoemulsification and IOL implantation assisted with anterior capsule staining, as well as non-invasive optical fiber illumination, were performed on all eyes. No intraoperative or postoperative complications were noted. Mean corrected distance visual acuity(logMAR) improved from 1.24±0.17 to 0.73±0.22. Post-phaco intraocular pressure was maintained between 13 to 20 mm Hg in all cases throughout the follow-up period. Mean endothelial cell density decreased from 2258.42±205.94 to 1906.25±174.23 cells/mm2. Phacoemulsification and IOL implantation are safe and valid in eyes with mild to moderate corneal opacities after DALK and coexisting cataracts when assisted with anterior capsule staining and non-invasive optical fiber illumination.

Lamellar keratoplasty with corneoscleral graft for limbal dermoids

To assess the postoperative outcomes of limbal dermoid excision with corneoscleral graft transplantation. The charts of 8 consecutive patients （mean age： 13.0y） who had undergone limbal dermoid excision with lamellar corneosclerai graft transplantation by a single surgeon were retrospectively reviewed. Mean dermoid size was 7.75 mm （6.0-12.0 mm）. Mean visual acuities （in IogMAR units） before and after surgery were 1.8 and 1.7, respectively （P=0.29）. Spherical equivalents were 1.3 diopter （D） before surgery and 0.7 D after surgery （P=0.40）. The mean astigmatism measurements before and after surgery were 2.4 D and 1.5 D, respectively （P=0.17）. Vector analysis revealed a mild change in astigmatism with a mean ＂d＂ of 3,2 （0,56-6.89）, No intra- or post-operative complications occurred. Lamellar keratoplasty for limbal dermoids is safe and offers good cosmesis and tectonic stability. A significant decrease in the amount of astigmatism is not expected following surgery.

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.

Complications of intrastromal bevacizumab injection in lamellar keratoplasty

Dear Editor,We would like to report complications of intrastromal bevacizumab injection for corneal neovascularization(CNV)after lamellar keratoplasty(LK)in two patients.CNV is a significant risk factor for graft rejection.CNV leads to graft failure by disturbing the immune function of the cornea after penetrating keratoplasty(PKP).Studies reported that more than fifty percent of graft failure occurs in this condition[1].

Recurrence of keratoconus after deep anterior lamellar keratoplasty following pregnancy

Keratoconus is a progressive, non-inflammatory disease of the cornea, which is characterized by marked cornealsteepening and thinningrll. It induces myopia and irregular astigmatism leading frequently to severe visual impairmentu. Although several aetiological factors have been implicated in its pathophysiology, the exact mechanisms underlying keratoconus are not fully elucidated yet. Corneal crosslinking is the treatment of choice in order to inhibit the progression of keratoconus, whereas advanced cases require penetrating or lamellar keratolalasty for visual restoration.

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.

Recurrent interface abscess secondary to Acanthamoeba keratitis treated by deep anterior lamellar keratoplasty

Dear Sir,I am Dr. Yan-Long Bi, from the Department of Ophthalmology of the Tongji Hospital affiliated to Tongji University School of Medicine, Shanghai, China. I write to present a case report of recurrent amoebic corneal abscess