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Aims: To compare best-corrected visual acuity (BCVA), contrast sensitivity and endothelial cell density (ECD) after ultrathin Descemet's stripping automated endothelial keratoplasty (UT-DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK)., Methods: A randomised, single-blinded, single-centre design was used. 72 patients with Fuchs' endothelial dystrophy and cataract were randomised to UT-DSAEK or DMEK combined with phacoemulsification and lens implantation. 27 patients with cataract were included in a control group and treated with phacoemulsification and lens implantation. The primary outcome was BCVA at 12 months., Results: Compared with UT-DSAEK, DMEK resulted in better BCVA with mean differences of 6.1 early treatment diabetic retinopathy study (ETDRS) (p=0.001) after 3 months, 7.4 ETDRS (p<0.001) after 6 months and 5.7 ETDRS (p<0.001) after 12 months. The control group obtained significantly better BCVA with a mean difference of 5.2 ETDRS (p<0.001) compared with DMEK 12 months postoperatively. Compared with UT-DSAEK, contrast sensitivity was significantly better 3 months after DMEK with a mean difference of 0.10 LogCS (p=0.03). However, our study found no effect after 12 months (p=0.08). ECD was significantly lower after UT-DSAEK compared with DMEK with mean differences of 332 cells/mm 2 (p<0.01) after 3 months, 296 cells/mm 2 (p<0.01) after 6 months and 227 cells/mm 2 (p=0.03) after 12 months., Conclusions: Compared with UT-DSAEK, DMEK resulted in better BCVA 3, 6 and 12 months postoperatively. Twelve months postoperatively, DMEK had a higher ECD than UT-DSAEK; however, no difference in contrast sensitivity was found., Trial Registration Number: NCT04417959., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To evaluate the outcomes and complications of hybrid Descemet membrane endothelial keratoplasty (H-DMEK) using a Descemet stripping automated endothelial keratoplasty (DSAEK) pull-through donor inserter and donor stroma as carrier., Methods: This was a retrospective interventional case series of eyes with bullous keratopathy (BK) and Fuchs endothelial corneal dystrophy (FECD), which underwent H-DMEK, performed using a bimanual pull-through technique using DSAEK-prepared donor stroma as carrier and the EndoGlide Ultrathin DSAEK donor insertion device. Complex cases with tube shunts, trabeculectomy, aphakia, aniridia, previous vitrectomy, keratoplasty or combined with intraocular lens exchange, were also included. The outcome measures were intraoperative and postoperative complications, best corrected visual acuity (BCVA) and endothelial cell loss after surgery., Results: Of the 85 eyes from 79 patients, 43.5% (n=37) had BK, 28.2% (n=24) had FECD while 24.7% (n=21) had failed grafts. DMEK was performed in 37 complex eyes (43.5%). Four eyes (4.7%) required rebubbling for graft detachment and two cases of graft failure were observed. A BCVA of 20/25 or better was attained in 44.7% and 57.1% of eyes without pre-existing ocular pathology at 6 and 12 months, respectively. The overall endothelial cell loss was 32.2%±20.5% at 6 months, which improved from 37.2%±20.9% to 24.2%±17.5%, comparing the first 40 and last 45 cases (p=0.012)., Conclusion: Hybrid DMEK offers a controlled 'pull-through' technique of donor insertion in the 'endothelium-in' configuration, which may be useful especially in complicated eyes. More studies are needed to confirm the long-term endothelial cell loss and graft survival associated with this technique., Competing Interests: Competing interests: DT: Patent of EndoGlide (royalties to Network Medical), (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To assess the influence of graft thickness and regularity on visual recovery and postoperative wavefront aberrations after endothelial keratoplasty (EK)., Methods: 150 EKs performed in eyes with corneal endothelial disorders and no other ocular comorbidities, preoperative and postoperative assessment with spectral domain optical coherence tomography and postoperative assessment with whole eye wavefront aberrometry were retrospectively analysed. Eyes were classified into five groups: Descemet Membrane Endothelial Keratoplasty (DMEK), nanothin Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) (15-49 µm), ultrathin DSAEK (50-99 µm), thin DSAEK (100-149 µm) and conventional DSAEK (150-250 µm)., Results: The preoperative diagnosis was Fuchs dystrophy in 139 eyes (92.7%). The graft thickness measured after graft deswelling was in average 74 µm with a mean coefficient of variation of 17%. The average follow-up time was 32 months. The mean spectacle-corrected logarithm of minimum angle of resolution visual acuity improved from 0.76 (20/116) before surgery to 0.14 (20/27) at last follow-up visit. No significant differences in final visual acuity were found between the five groups. The time to reach 20/40 vision was significantly shorter in the DMEK and nanothin DSAEK groups compared with the remaining three DSAEK groups. No significant differences in postoperative aberrometry measurements were found between the five groups. Shorter time to reach 20/40 visual acuity was associated with better preoperative visual acuity and thinner graft. Higher final vision improvement was associated with poorer preoperative visual acuity. Higher postoperative high-order aberrations were associated with poorer preoperative visual acuity., Conclusion: The main advantage of DMEK and nanothin DSAEK over thicker DSAEKs was the rapidity of visual recovery. Final quality of vision was not influenced by graft thickness and regularity., Competing Interests: Competing interests: VB, Chiesi (Parma, Italy; consulting), Dompe (Milan, Italy; consulting), Optovue (Fremont, California, USA; consulting)., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To determine whether clinical performance is negatively affected by prestripping Descemet membrane endothelial keratoplasty (DMEK) grafts from organ-cultured corneas., Methods: We reviewed clinical records of all patients who underwent DMEK surgery for Fuchs endothelial dystrophy between 28 October 2014 and 11 August 2015. Grafts had been prepared from organ-cultured corneoscleral buttons 24 hours prior to surgery or during surgery. We included only patients for which at least one follow-up examination was available at a minimum of 2 months postoperatively., Main Outcome Measures: best-corrected visual acuity (BCVA), central corneal thickness, endothelial cell count and rebubbling rates., Results: Data given are mean±SD. No statistically significant differences were recorded at baseline between the partially stripped group (n=65) and the control group (n=72) with regard to donor age (70±9 vs 69±8 years; p=0.49), donor cornea endothelial cell density (2586±604 vs 2522±186 cells/mm 2 ; p=0.6), BCVA (before DMEK: 0.77±0.5 vs 0.63±0.3 logMAR; p=0.27; before triple-DMEK: 0.56±0.2 vs 0.52±0.2 logMAR; p=0.33) or central corneal thickness (621±72 vs 607±53 μm; p=0.49). Mean follow-up was 149±83 versus 148±77 days; p=0.79. No statistically significant differences were observed between the two groups postoperatively with regard to BCVA (after DMEK: 0.25±0.2 vs 0.21±0.2 logMAR; p=0.59; after triple-DMEK: 0.22±0.2 vs 0.2±0.1 logMAR; p=0.98), central corneal thickness (502±42 vs 508±41 μm; p=0.47), endothelial cell count (1537±245 vs 1551±287 cells/mm 2 ; p=0.65) and number of graft detachments requiring rebubbling (4.6% vs 9.7%; p=0.33)., Conclusions: We found no evidence that the use of prestripped DMEK grafts is inferior to same-day preparation in organ-cultured corneas within the given follow-up., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Purpose: To describe improvements in visual acuity and contrast sensitivity following Descemet stripping automated endothelial keratoplasty (DSAEK)., Methods: We analysed 128 consecutive patients (128 eyes) with Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK) who underwent DSAEK at a single tertiary referral centre from January 2006 to September 2009. Our main outcome measures were best-corrected visual acuity (BCVA) and contrast sensitivity over 24 months follow-up., Results: Median age was 67 (60-73) years with 55% women (n=70) and majority Chinese (74%, n=94) in our Asian population. There were no significant differences between demographics between the FED (48%, 61 eyes) and BK (52%, 67 eyes) groups. Forward multivariate linear regression adjusted for age, gender, donor graft thickness and diagnosis (FED vs BK) revealed that preoperative visual acuity was the most significant factor associated with visual acuity at 1 year (B=0.032, p=0.03, R(2)=0.122). Visual recovery was longer in eyes with BK, with a significantly better visual acuity in the FED group at 12 months (mean logarithm of the minimum angle of resolution BCVA BK: 0.27±0.1 vs FED: 0.22±0.9; p=0.001), but not significant at 24 months (p=0.154). Contrast sensitivity significantly improved more in the first 6 months in the FED when compared with the BK group (at 3.0, 6.0 and 12.0 cycles per degree, p<0.01)., Conclusions: Our study suggests that while there was significant improvement in contrast sensitivity and visual acuity after DSAEK, poor preoperative visual acuity was associated with an inferior visual outcome and the time to recovery was longer in eyes with BK., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: To design and validate the efficacy of three-dimensional (3D) printed smart storage glide (SSG) which is capable of preserving and delivering posterior lenticules for Descemet stripping automated endothelial keratoplasty (DSAEK)., Methods: Laboratory investigation (A) was followed by clinical validation (B). Unsuitable corneas for transplantation (n=20) were used for study A. These tissues were cut using a standard microkeratome, punched and loaded into the SSG and preserved for 7 days in transport media. Endothelial cell density (ECD), Trypan blue and Alizarin red staining for endothelial morphology, thickness measurements and glucose uptake, cell apoptosis and immunostaining post preservation were analysed. For study B, clinical grade corneas (n=14) were preloaded in SSG and grafted in patients with indications of Fuchs' dystrophy (n=8), pseudophakic bullous keratopathy (n=3), posterior polymorphous dystrophy (n=2), and previous DSAEK failure (n=1). Standard DSAEK included descemetorhexis under air and bimanual delivery of the tissue under infusion of buffered saline solution through an anterior chamber maintainer placed at the 12 o'clock position. Main outcome measures for study B were less surgical time, best spectacle-corrected visual acuity (BSCVA), speed of visual recovery, and ECD., Results: For study A, an average ECD loss was 2.30±3.21%, thickness increased by 30.80±20.85% and one-third of glucose was utilised during the preservation phase. Alizarin red showed hexagonality of the cells. Cell apoptosis was not observed and expression of ZO-1 was noted on the preserved tissues. In study B, 25% ECD loss was observed after 6 months. BSCVA improved to 20/25 or better within 3 months after DSAEK. Mean surgical time recorded was 21 min., Conclusions: This paper describes the development, design, laboratory and clinical validation of a 3D printed SSG which helps to store and deliver posterior lenticules, therefore allowing transportation of quality-controlled precut tissues., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Aim: To evaluate the clinical outcomes of Descemet's membrane endothelial keratoplasty (DMEK) in the treatment of patients with Fuchs' endothelial dystrophy., Methods: This prospective study involved 16 consecutive patients who had DMEK done and who were evaluated over a year. Measurements included best corrected visual acuity (BCVA), endothelial cell count, and central corneal thickness., Results: Two patients had failed grafts. Of the remaining 14 patients with successful grafts, after 12 months, 79% had BCVA of 6/6 or better, and all patients had a BCVA of 6/9 or better. Median endothelial cell count was 1567 cells per mm(2) (range=900-2359) representing a 40% reduction compared with preoperative counts. Median central corneal thickness was 498 µm (range 445-567 µm) compared with a median of 649 µm (range 548-740 µm) preoperatively. All patients attained total visual rehabilitation without further surgical intervention., Conclusions: In our experience, DMEK has the potential to become the primary procedure for treating Fuchs' endothelial dystrophy and endothelial disease as it produces rapid total visual rehabilitation with few complications, and an easy follow-up and management regimen. Donor preparation and graft insertion, however, remain important challenges., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Aims: To examine the effect of rounding of visual acuity data on estimates of surgical performance., Method: In this observational study, the distribution of 1-year Snellen visual acuity data from 606 endothelial keratoplasties from the NHSBT UK transplant database was analysed. A curve was fitted to the data and used to estimate the frequencies of partly read Snellen lines. The estimates were used to create a virtual database of grafts with Snellen acuities that included individual letter scores. The virtual database was then sampled to produce datasets for 10 virtual surgeons. Various acuity analysis methods were then applied to simulate possible effects of surgeons rounding their data., Results: Rounding of acuity data was found to have a notable effect on estimates of surgeons' success rates. When a criterion of 6/12 or better was applied, the success rates ranged from 62% to 80% using a conservative method of estimation but ranged from 80% to 94% using a less conservative method., Conclusions: Rounding of visual acuity scores is an important potential bias in outcome data and should be avoided. If rounding is required we recommend that it is carried out conservatively, giving credit only for lines read completely., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: To report the surgical outcomes of Descemet's stripping endothelial keratoplasty (DSEK) in cases of congenital hereditary endothelial dystrophy (CHED) cohort and compare it with penetrating keratoplasty (PK) in a paired-eye setting., Methods: Ours is a retrospective, comparative, consecutive and interventional clinical case series. All patients less than 14 years of age who underwent PK in one eye and DSEK in the contralateral eye at a single centre from January 2006 and February 2011 were analysed. Main outcome measures were graft clarity, visual outcome and complications., Results: The mean age of the patients was 6.6±2.19 years at the time of presentation. The outcomes of two surgeries were compared with 1 year of follow-up at the corresponding follow time. At 1 year, all grafts were clear. There was no significant difference in the spherical component of the refraction; the astigmatism was significantly lower after EK. The refraction stabilised in patients with EK as early as 3 months, while it continued to change up to 1 year after PK. Complications included graft dislocation in two cases of DSEK, which were managed by rebubbling, and a graft dehiscence in one case of PK, which was managed by resuturing. The final visual acuity improved in all the patients., Conclusions: Endothelial keratoplasty is a viable option to conventional PK in cases of CHED. It offers an advantage of early visual stabilisation compared with PK.

Aim: To evaluate the efficacy of a secondary Descemet stripping endothelial keratoplasty (DSEK) as a back-up procedure for managing graft failure after primary Descemet membrane endothelial keratoplasty (DMEK)., Design: Non-randomised prospective clinical study., Methods: A first group of 50 cases with Fuchs endothelial dystrophy underwent DMEK. Two to five weeks after the DMEK, 10 cases showed no corneal clearance, so a secondary DSEK was performed. To evaluate the eyes of these 10 cases, best corrected visual acuity (BCVA) and endothelial cell density at 6 and 12 months were used as outcome parameters., Results: At 6 months after secondary DSEK, 87% of the cases had a BCVA of > or = 20/40 (> or = 0.5) and one eye reached 20/25 (> or = 0.8). Donor DSEK grafts endothelial cell densities averaged 2617+/-152 cells/mm2 before surgery, 1510+/-799 cells/mm2 at 6 months and 1602+/-892 cells/mm2 at 12 months after surgery., Conclusion: In the event of a DMEK graft failure, a secondary DSEK may be an effective back-up procedure, as it may give a clinical outcome similar to that after a primary DSEK. Particularly during the surgeon's learning curve, patient information may be provided not only on visual outcomes after DMEK, but also after DSEK., Trial Registration Number: NCT00521898.

Background/aim: To compare intraocular pressure (IOP) measurements taken by the Goldmann applanation tonometer, the Tono-Pen and the ocular blood flow pneumotonometer in eyes with varying central corneal thickness (CCT) due to penetrating keratoplasty (PK), keratoconus (KC), and Fuchs' endothelial dystrophy (FED)., Methods: IOP was measured with the Goldmann applanation tonometer, Tono-Pen XL, and OBF pneumotonometer in 127 eyes with the following corneal abnormalities. There were 56 eyes that had undergone PK, 37 eyes with KC, and 34 eyes with FED. CCT was measured using an ultrasound pachymeter after IOP determinations had been made., Results: Mean IOP measurements in all three patient groups were significantly higher when measured by OBF pneumotonometer. Linear regression analysis showed that patients with FED had a significant increase in IOP with increasing CCT of 0.18 mm Hg/10 microm using the Goldmann tonometer, 0.15 mm Hg/10 microm with the Tono-Pen, and 0.26 mm Hg/10 microm with the OBF pneumotonometer. In patients with KC and after PK, linear regression analysis did not show a significant effect of CCT on IOP. A multivariate linear regression model controlling for age, sex, graft size, and patient group, showed that the effect of CCT on IOP for Tono-Pen (0.13 mm Hg/10 microm CCT) and Goldmann (0.14 mm Hg/10 microm CCT) were significantly lower than for the OBF pneumotonometer (0.26 mm Hg/10 microm CCT)., Conclusions: This study found that mean IOP measurements using the OBF pneumotonometer were significantly higher than those made using the Goldmann applanation tonometer or Tono-Pen in eyes with a variety of cornel pathologies. The OBF pneumotonometer was found to be most affected by variation in CCT. For all three instruments, the relation between IOP and CCT depended on the corneal pathology and was greatest for FED.

Aim: To compare a cohort of corneal graft patients in east Jerusalem with one in Sweden, concerning diagnosis, sex, patient age, preoperative visual acuity in both eyes, and type of operation., Methods: Standard forms developed for the Swedish Corneal Transplant Register were used for data collection at the time of operation., Results: In east Jerusalem, keratoconus accounted for 51% of the grafts compared with only 27% in Sweden and the male:female ratio was reversed. There were very few patients with endothelial disease. The Palestinian patients had overall worse visual acuity both in the eye to be operated and the fellow eye compared with patients in Sweden., Conclusion: Significant differences were found between the Palestinian and Swedish cohorts in the distribution of indications for transplantation and preoperative visual acuity.