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PURPOSE: To describe 2-year results of deep intrastromal arcuate keratotomy with in situ keratomileusis (DIAKIK) for the treatment of high astigmatism after keratoplasty. METHODS: This prospective study included 20 eyes from 20 patients presenting with high astigmatism after keratoplasty. All were treated by two-step femtosecond laser surgery, with two intrastromal arcuate keratotomies and a corneal flap, followed a few months later by excimer photoablation after reopening of the flap. RESULTS: At 24 months, both uncorrected (UDVA) and corrected (CDVA) distance visual acuity had improved from 1.12 ± 0.42 logMAR (20/200 Snellen) before surgery to 0.58 ± 0.23 logMAR (20/80 Snellen) ( P < .001) and from 0.31 ± 0.26 logMAR (20/40 Snellen) to 0.20 ± 0.20 logMAR (20/32 Snellen) ( P = .04), respectively. The mean spherical equivalent improved from −5.01 ± 4.35 to −1.54 ± 2.42 diopters. The mean efficacy index was 0.63. The mean correction index was 0.93 ± 0.32. The mean flattening index was 1.09 ± 0.75 and the mean safety index was 1.39. No graft rejection or epithelial ingrowth was observed. CONCLUSIONS: This two-step procedure was an effective treatment for high astigmatism after keratoplasty. The use of both femtosecond and excimer lasers helped to avoid some complications that would have jeopardized the grafts. Refractive and topographic stability was good 2 years after surgery. [ J Refract Surg . 2019;35(4):239–246.]

PURPOSE: To assess epithelial corneal remodeling by anterior segment optical coherence tomography (AS-OCT) after intracorneal ring segments (ICRS) implantation in keratoconic eyes. METHODS: This prospective observational study included patients with keratoconus receiving ICRS of different arc lengths according to their tomographic pattern. AS-OCT and corneal topography (Scheimpflug camera) were performed before and 1, 3, and 6 months after surgery. Corneal pachymetry mapping was performed and total corneal and epithelial thicknesses (3-mm central and 16 points on 6-mm zone) were measured over the pupil center using AS-OCT. Topographic parameters were also assessed. RESULTS: A total of 68 keratoconic eyes were analyzed (Amsler-Krumeich stages 1 to 4) in four groups of 17 eyes: 210° ICRS, 320° ICRS, double 160° ICRS, and single 160° ICRS. Corneal pachymetry mapping revealed that epithelial thickness increased significantly in the internal zones juxtaposed to the ICRS without smoothing during the postoperative period ( P < .05). Mean maximum epithelial thickness increased from 67 ± 6 to 79 ± 7 µm for 210° ICRS, 66 ± 9 to 82 ± 4 µm for 320° ICRS, 63 ± 6 to 78 ± 7 µm for double 160° ICRS, and 62 ± 5 to 77 ± 5 µm for single 160° ICRS ( P < .0001). Significant epithelial thickening at the apex of the cone was observed in all groups ( P < .05). CONCLUSIONS: Significant epithelial thickening occurs after ICRS implantation adjacent to the ICRS to compensate for the ridge created with a thickening of epithelium over the cone due to regularization of the stromal surface. [ J Refract Surg . 2021;37(6):404–413.]

PURPOSE: To study corneal remodeling during the first 6 months after myopic small incision lenticule extraction (SMILE) with a 10% overcorrection nomogram, by spectral-domain optical coherence tomography (SD-OCT) and in vivo confocal microscopy (IVCM). METHODS: This prospective non-randomized observational study included 60 eyes from 30 patients treated by SMILE for low to moderate myopia. A 10% overcorrection nomogram was applied for all eyes. Epithelial and corneal thickness maps were obtained within the central 6 mm, by SD-OCT, at each visit. Lenticule thickness was calculated by subtracting the postoperative central stromal thickness from the preoperative central stromal thickness. IVCM was performed at each visit. RESULTS: The mean surgical refractive correction was −3.99 ± 1.50 diopters (D) before and −0.09 ± 0.37 D after surgery. Central epithelial thickness increased from 53.7 ± 4.0 to 57.1 ± 4.1 µm at 6 months after SMILE ( P < .001). The measured lenticule thickness was 16 ± 6.1 µm less than the programmed lenticule thickness ( P < .001). Both central epithelial hyperplasia and the mismatch between measured and programmed lenticule thickness were positively correlated to the degree of myopia ( r 2 = 0.60, P < .001 and r 2 = 0.47, P < .001, respectively). Fibrosis at the interface was not correlated with epithelial thickening ( r 2 = 0.06, P = .29) or lenticule thickness error ( r 2 = 0.07, P = .22). CONCLUSIONS: Both epithelial thickening and the mismatch between the targeted and achieved lenticule thickness resulted in a slight undercorrection with a 10% overcorrection nomogram in low and moderate myopia. Fibrosis at the interface was not responsible for lenticule thickness error. Additional overcorrection is required to increase accuracy. [ J Refract Surg . 2020;36(9):597–605.]

New direct oral anticoagulants (DOAC) have been approved for treatment and prevention of some thromboembolic diseases: acute and chronic phase of thromboembolic disease, deep venous thrombosis prophylaxis in orthopedic surgery and prevention of stroke in patients with atrial fibrillation. These molecules are an alternative to heparins and vitamin K antagonists. Among these, rivaroxaban (Xarelto®, Bayer Schering Pharma) is a direct factor Xa inhibitor, and dabigatran etexilate (Pradaxa®, Boehringer Ingelheim) is a direct free thrombin inhibitor. These molecules are almost the ideal anticoagulant: oral administration, few drug and food interactions, wide therapeutic target, and especially no lab monitoring. However, their use remains associated with hemorrhagic complications such as gastrointestinal, intracranial or urinary hemorrhages. We describe two clinical cases of spontaneous choroidal hemorrhage in patients treated with direct oral anticoagulants (rivaroxaban and dabigatran etexilate) for atrial fibrillation. These cases show that an ocular hemorrhagic risk exists with these drugs. Patients treated with DOAC should have the therapeutic dose adjusted based on creatinine clearance. Special monitoring should be performed in patients with age-related macular degeneration or with hypertension even though meta-analysis shows that the risk of intraocular bleeding is reduced by 22% compared with warfarin.

PURPOSE: To evaluate and compare epithelial remodeling after standard corneal cross-linking (S-CXL) and iontophoresis-assisted CXL (I-CXL) in eyes with keratoconus by anterior segment optical coherence tomography (AS-OCT). METHODS: In this prospective, observational study, AS-OCT and corneal topography were performed before and 1, 3, and 6 months after surgery. Corneal pachymetry was performed and epithelial and stromal thicknesses (central and 16 points on the 6-mm central zone) and the maximum simulated keratometry value (Kmax) were measured. RESULTS: Two groups of 30 patients (60 eyes total) with progressive keratoconus underwent S-CXL or I-CXL. Before surgery, both groups of patients presented with an irregular epithelial thickness profile. At 6 months postoperatively, localized corneal epithelial thinning was observed in the superior ( P = .026), inferior ( P = .034), inferonasal ( P = .024), and nasal ( P = .035) areas at 3 mm and in the superior ( P = .039), nasal ( P = .043), and inferior ( P = .01) areas at 6 mm in the SCXL group. Localized corneal epithelial thinning was observed at 3 ( P = .04) and 6 ( P = .01) mm in the inferior area in the I-CXL group. No significant stromal changes were observed for either group. Kmax was stable in both groups at 6 months. CONCLUSIONS: Significant epithelial remodeling occurs after S-CXL, resulting in a thinner, more regular thickness profile than after I-CXL. Epithelial thickness profile measurements after I-CXL could be used as an adjunctive follow-up tool for monitoring the efficacy of CXL in progressive keratoconus. [ J Refract Surg. 2018;34(8):551–558.]

Infectious keratitis are a frequent cause of ocular morbidity. Today, new treatments are necessary to combat the emergence of antibiotic resistant germs. Corneal collagen cross-linking has been suggested to treat corneal infectious (PACK-CXL). Its action would be both antimicrobial and protective for the cornea, increasing its biochemical resistence to proteolytic enzymes. In vivo, PACK-CXL might demonstrate good efficacy against bacterial keratitis, contrary to herpetic keratitis for which it is contraindicated. For fungal or amoebic keratitis, results are uncertain regarding its safety and efficacy. The purpose of this paper is to clarify the use of corneal collagen cross-linking to treat infectious keratitis.

To compare the pupil dynamics of an intracameral combination of 2 mydriatics and 1 anesthetic (Mydrane) to a standard topical regimen for cataract surgery.Sixty-two centers in Europe and 6 centers in Algeria.Prospective case series.Pupil size measurements were performed in 2 randomized studies (phase 2 and phase 3) under masked conditions (recorded videography, masked reading center). The outcomes in the phase 2 study supported evaluation of the timeframe to obtain pupil dilation and the phase 3 study provided results on mydriasis stability.Phase 2 and phase 3 comprised 139 patients and 591 patients, respectively. After intracameral combination administration, 95% of the pupil dilation was achieved within a mean of 28.6 seconds ± 4.6 (SD). At the beginning of capsulorhexis creation, the mean pupil diameter was larger than 7.0 mm in both groups. The intraoperative pupil diameter remained stable in the intracameral combination group and decreased in the topical group. The mean change in pupil size just before capsulorhexis to the end of surgery (just before cefuroxime injection) was -0.22 ± 0.72 mm and -1.67 ± 0.98 mm, respectively. No clinically significant change in pupil diameter (change1.0 mm) occurred in the majority of the intracameral combination group (89.3%) compared with the topical group (26.8%).Intracameral combination of 2 mydriatics and 1 anesthetic is an alternative to topical mydriatics for cataract surgery. The prompt onset of pupil dilation and the stable mydriasis induced by this drug combination improved the intraoperative conditions during crucial steps, such as intraocular lens implantation.

Unilateral corneal ectasia developed after small-incision lenticule extraction for mild myopia in a 43-year-old man with preoperative asymmetric astigmatism. The ectasia was diagnosed 4 years postoperatively. Preoperative data showed asymmetric astigmatism with no signs of forme fruste keratoconus. Inferior anterior curvature steepening exceeded 2.00 diopters without bulging of the posterior curvature, and pachymetric thickness exceeded 515 μm. Corneal ectasia can occur after small-incision lenticule extraction in patients older than 40 years with preoperative asymmetric astigmatism.

Purpose We describe the first case of minimally invasive corneal neurotization with the great auricular nerve (GAN) to treat unilateral neurotrophic keratopathy. We assessed corneal sensation and reinnervation by esthesiometry and confocal microscopy over 12 months of follow-up, and we provide a detailed description of the surgical technique. Methods Corneal neurotization was successfully achieved with the ipsilateral GAN in a 58-year-old woman. Cochet-Bonnet esthesiometry and in vivo confocal microscopy were performed before and after corneal neurotization, to monitor the recovery of corneal sensation and corneal reinnervation by subbasal nerve fibers. Results Neurotrophic keratopathy was a complication of the surgical treatment of meningioma. Before surgery, the patient had no corneal sensation or corneal innervation. Six months after surgery, confocal microscopy confirmed regrowth of a large number of nerve fibers in the subepithelial space of the cornea. Nine months after surgery, a central esthesiometry score of 10-mm was attained. Conclusions Corneal neurotization leads to reinnervation of the cornea and recovery of ocular sensation in adults. The GAN is suitable for use in corneal neurotization because of its anatomical proximity and the low level of associated morbidity. Confocal microscopy demonstrated the occurrence of corneal reinnervation, which preceded the recovery of corneal sensation.

Purpose To provide quantitative parameters for assessment of human donor corneal stroma by imaging stromal features of diseased and normal human corneas with full-field optical coherence microscopy (FFOCM), using confocal microscopy (CM) and histology as reference techniques. Methods Bowman's layer (BL) thickness and keratocyte density were assessed ex vivo in 23 human donor corneas and 27 human pathological corneas (keratoconus and other corneal disorders) with FFOCM, CM and histology. Stromal backscattering was assessed with FFOCM. Additionally, 10 normal human corneas were assessed in vivo with CM. Results In FFOCM, the logarithm of the normalized stromal reflectivity was a linear function of stromal depth (R2 = 0.95) in human donor corneas. Compared with keratoconus corneas, human donor corneas featured higher BL thickness (p = 0.0014) with lower coefficient of variation (BL-COV; p = 0.0002), and linear logarithmic stromal reflectivity with depth (higher R2, p = 0.0001). Compared with other corneal disorders, human donor corneas featured lower BL-COV (p = 0.012) and higher R2 (p = 0.0001). Using the 95% confidence limits of the human donor cornea group, BL thickness 18.6% (79%; 100%) and R2

Background To evaluate quantitative and qualitative changes in subbasal corneal nerves (SBN) via in vivo confocal microscopy (IVCM) in patients with Sjogren syndrome dry eye (SSDE) treated with topical cyclosporine A (CsA). Design Prospective, observational, non-randomized study. Participants Thirty eyes of 30 patients with SSDE refractory to conventional treatment treated with CsA 0.05% twice daily for six months. Fifteen eyes of 15 healthy, age and gender matched, volunteers constituted the control group at baseline. Methods A clinical evaluation of dry eye (DE), corneal sensation using Cochet-Bonnet esthesiometry and IVCM analysis of the central cornea were performed prospectively at baseline for all patients, and after six months of treatment with CsA. Main outcome measures Density, number, reflectivity and tortuosity of SBN, dendritic cell (DC) density, esthesiometry, and DE signs and symptoms. Results Topical CsA 0.05% improved clinical signs and symptoms, and increased corneal sensitivity. Following treatment, SBN density was significantly increased (P

To analyze refractive results after hyperopic presbyopia surgery by Q-factor modulation without additive monovision.Quinze-Vingts National Ophthalmology Hospital, Paris, France.Prospective nonrandomized study.Forty-five hyperopic presbyopic patients not tolerating monovision were included. The target for the dominant eye was emmetropia, whereas that for the nondominant eye was emmetropia associated with a target Q factor of -0.8. The postoperative follow-up included assessments of spherical equivalent (SE) refraction, monocular and binocular corrected and uncorrected (UDVA) distance visual acuities, and binocular corrected and uncorrected (UNVA) near visual acuities. Corneal pachymetry, topography, aberrometry and an analysis of patient satisfaction were performed at the 12-month examination.The study comprised 90 eyes of 45 consecutive patients. The mean age at surgery was 53.8 years ± 4.99 (SD). The mean preoperative SE was +2.33 ± 1.16 diopters (D) in the dominant eyes and +2.26 ± 1.17 D in the nondominant eyes. At 12 months postoperatively, 42 patients (93%) had a binocular UDVA of Snellen 20/20 and 37 patients (82%) had a binocular UNVA of Jaeger 2 (Parinaud 3). The mean SE at 12 months was -0.22 ± 0.35 D in the dominant eyes (P .0001) and -0.83 ± 0.50 D in the nondominant eyes (P .0001). Two eyes required retreatment. Overall, 39 patients (87%) said that they were satisfied and would recommend the intervention.The Q-factor modulation without additive monovision aims to compensate for presbyopia by changing the Q factor of the nondominant eye to generate a greater depth of field in hyperopic presbyopic patients who are unable to tolerate monovision. The visual outcomes and quality of vision were satisfactory, and only a few patients required additional correction.

Summary Standard corneal collagen crosslinking (S-CXL) is a safe, approved procedure, but it may result in severe pain, early vision loss and possible complications, such as infectious or sterile keratitis , in some cases. We describe four cases of sterile infiltrates after uneventful S-CXL for keratoconus , from diagnosis to medical management with six months of follow-up, reporting their pathophysiological features, and comparing our findings with published reports. We discuss various possibilities for diagnosing sterile infiltration more rapidly. In terms of the pathophysiology of sterile infiltrate formation, we separated our patients into two types, one with sterile infiltrate from an antigen reaction and the other with sterile infiltrate due to excessive scarring. Early local steroid treatment resulted in a good visual outcome in our cases.

PURPOSE To determine the anatomic criteria for diagnosing keratoconus progression by corneal optical coherence tomography (OCT). SETTING Quinze-Vingts National Ophthalmology Hospital, Paris, France. DESIGN Prospective case series. METHODS Scanning-slit corneal topography (Orbscan II) and Fourier-domain corneal OCT (RTVue) were performed in eyes with mild to moderate keratoconus (progressive or nonprogressive [stable] ectasia) at each examination to assess the keratoconus. Disease progression was defined as an increase of at least 1.0 diopter (D) in the steepest keratometry (K) measurement over 6 months. RESULTS Of the 134 eyes of 134 patients with mild to moderate keratoconus, 98 had had progressive ectasia and 36 nonprogressive ectasia. The mean maximum K increased significantly in the progressive group (2.1 D ± 1.2 [SD], P

We report the clinical features and management of a patient with severe bilateral infectious keratitis developing after simultaneous bilateral small-incision lenticule extraction. A 39-year-old man was referred to our emergency department 2 days after a small-incision lenticule extraction procedure for moderate myopia. He reported decreased vision, photophobia, and pain bilaterally. Visual acuity was counting fingers in the right eye and hand motion in the left eye. Slitlamp examination showed multiple white corneal infiltrates at the corneal cap–stromal bed interface. The interface was first rinsed with povidone–iodine 10.0% and then with vancomycin (50 mg/mL). Fortified antibiotics eyedrops administration was initiated. Cultures showed Streptococcus pneumonia. Anterior segment spectral-domain optical coherence tomography scans were performed daily. Once the infection was controlled 4 days later, corticosteroids eyedrops were begun. Three months postoperatively, the patient had a corrected distance visual acuity of 20/32 in the right eye and 20/25 in the left eye. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Cyclosporine A (CsA) is a cyclic undecapeptide, which is an immunosuppressive drug in the calcineurin inhibitor class. CsA was initially used as a systemic immunosuppressant to minimize rejection of solid organ transplants. In ophthalmology, topically applied CsA was first used to inhibit corneal allograft rejection in the 1980s and later in various inflammatory ocular surface disorders (OSD). Currently, topical ophthalmic CsA is available as a licensed commercial emulsion or is prepared by hospital pharmacies with concentration ranging from 0.05 to 2%. Many of its pharmacological effects on the ocular surface are direct consequences of its ability to inhibit T ciclosporine activation and apoptosis. Topical CsA differs from topical steroids in its favourable local and systemic tolerability at the concentrations used. Most clinical studies have evaluated topical CsA in moderate to severe dry eye disease (DED) and demonstrated its efficacy for improvement of signs and symptoms, thus providing the sole indication for market approval and treatment protocols. For the other indications - corneal graft rejection, blepharitis, allergic or viral keratitis, and ocular surface disease due to graft versus host disease or post-operative DED - evidence-based medicine remains unclear due to the lack of major randomized controlled trials. Despite the lack of standardized protocols or market approval for these conditions, numerous studies suggest clinical efficacy.

The KAMRA small-aperture corneal inlay can compensate for presbyopia. A small number of complications have been reported, including glare, halos, decentration, iron deposition, compromised distance and night vision, infectious keratitis and reversal corneal haze. We describe a case of corneal fibrosis after small-aperture corneal inlay implantation and its persistence after late explantation. The postoperative period was uneventful, with good uncorrected near and distance visual acuities. Six years after implantation, the patient reported vision loss in the left eye. A slitlamp evaluation and optical coherence tomography showed stromal opacity and a stromal hyperreflective signal at the level of the small-aperture corneal inlay. The corneal inlay was removed, but persistent decreased visual acuity and fibrosis were observed even 8 months after explantation and did not respond to steroids. Long-term monitoring with multimodal imaging methods is important to detect late adverse events after small-aperture corneal inlay implantation.

Purpose To define the optical coherence tomography (OCT) corneal changes predisposing to acute corneal hydrops among patients with advanced keratoconus. Design Retrospective cohort study. Participants A total of 191 advanced keratoconic eyes from 191 patients with advanced keratoconus cases were studied. Methods Data collected from patients with advanced keratoconus cases were studied during a minimum period of 24 months of follow-up. High-resolution Fourier-domain corneal OCT (5 μm of axial resolution) and corneal topography were performed every 4 months during the follow-up. Several anatomic features at the keratoconus cone were analyzed with OCT, including epithelial and stromal thicknesses, the aspect of Bowman's layer, the presence of Vogt's striae, and stromal opacities. A comparative analysis between anatomic corneal features in eyes that developed corneal hydrops and those that did not develop this complication during the follow-up was performed. Main Outcome Measures Evaluation of anatomic corneal changes at risk of developing a corneal hydrops on the basis of OCT findings. Results Eleven cases of corneal hydrops (5.8%) occurred in our series during a mean follow-up of 30 months (24–36 months). All of these patients were male and younger (23.7±5.9 years) than patients with no acute keratoconus (32.7±11.3 years). Increased epithelial thickening with stromal thinning at the conus and the presence of anterior hyperreflectives at the Bowman's layer level were significantly associated with corneal hydrops, whereas the presence of corneal scarring was a preventive factor. At the healing stage, a pan-stromal scar occurs, with a significant stromal thickening and cornea flattening. Conclusions Increased epithelial thickening, stromal thinning at the keratoconus cone, anterior hyperreflectives at the Bowman's layer level, and the absence of stromal scarring are associated with a high risk of developing corneal hydrops. These aspects should be taken into account by the clinician in the evaluation of keratoconus eyes and in the planning of corneal keratoplasty.

Corneal collagen crosslinking (CXL) is, at present, the only treatment that can slow or even stop the progression of keratoconus. It uses riboflavin and ultraviolet A (UVA) to create covalent bonds ("crosslinks") between collagen fibrils thus increasing corneal rigidity. Although to date there has been no direct evidence of intrastromal corneal crosslinking, several studies have reported the safety and efficacy of the conventional CXL protocol. This protocol is indicated for progressive keratoconus with a minimal corneal thickness (without the epithelium) of at least 400 μm. It should be performed as early as possible in patients under 18 years with keratoconus or with post-LASIK ectasia. Because of the epithelial debridement, it may rarely induce complications such as infectious keratitis or stromal scars. A variety of new protocols is under investigation and may reduce the rate of these complications. In addition, combination of CXL with other surgical treatments (intracorneal ring segments or photorefractive keratectomy) may improve visual outcomes in patients with keratoconus. Finally, the antimicrobial and anti-edematous properties of CXL have been shown, suggesting new therapeutic indications of this procedure such as infectious keratitis or stromal edema in the future.

To compare the efficacy, safety, and microstructural corneal changes during 2 years after conventional corneal collagen cross-linking (C-CXL) and transepithelial corneal CXL by iontophoresis (I-CXL) for keratoconus.Eighty eyes of 80 patients with progressive keratoconus were treated by C-CXL (n = 40) or I-CXL (n = 40). Patients were investigated before surgery and 1, 3, 6, 12, and 24 months after treatment. We measured central corneal thickness and maximal simulated keratometry values (Kmax) and performed specular microscopy and in vivo confocal microscopy at each time point. The demarcation line was assessed 1 month after treatment.Kmax remained stable after I-CXL during the entire study period (P = 0.56), whereas the average keratometry increased by 0.2 diopter (50.9 ± 5.6-51.1 ± 5.2). Kmax significantly decreased 1 (P = 0.02) to 2 years (P0.01) after C-CXL, with an average decrease of 1.1 diopters (49.9 ± 4.5-48.8 ± 4.2). The failure rate of I-CXL was 20% and that of C-CXL 7.5%. The demarcation line was superficially visible in 35% of cases after I-CXL compared with 95% of cases after C-CXL. Endothelial cell density and central corneal thickness remained stable during the entire study period. The change in Kmax 2 years after C-CXL and I-CXL and the preoperative Kmax were negatively correlated (r = 0.14, P = 0.013, and r = 0.17, P = 0.007, respectively).I-CXL halted progression of keratoconus less efficiently than did C-CXL after 2 years of follow-up. Longer prospective studies are still needed to ensure I-CXL efficacy.

Topography-guided transepithelial photoablation using the Wavelight Allegretto excimer laser was performed in a patient whose corrected distance visual acuity (CDVA) was severely impaired by superficial fibrosis and major irregular corneal astigmatism. One month postoperatively, the CDVA had improved from 20/400 to 20/50 with spectacle correction and 20/25 with a rigid gas-permeable contact lens. Postoperative corneal topography showed a substantial reduction in the irregular component of the astigmatism. Optical coherence tomography analysis revealed a major decrease in the central fibrotic scarring around the corneal visual axis. No complication occurred, and the patient was very satisfied. Topography-guided custom ablation seems to be a safe and efficient technique for reduction of the irregular component of corneal astigmatism in a scarred cornea. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Keratoplasty may induce major spherical refractive error related to abnormal corneal radius of curvature (CRC).Two hundred and thirty-eight consecutive eyes of 238 patients with clear graft and at least one postoperative Orbscan examination performed after suture removal (average follow-up time, 86 months) were retrospectively analyzed. Anterior lamellar keratoplasties (ALK group, n = 119) and penetrating keratoplasties (PK group, n = 119) were matched for preoperative diagnosis and lens status.The average postoperative, suture-out, Orbscan 3-mm CRC was 7.17 mm with a wide 95 % confidence interval [6.26 mm; 8.37 mm]. It was 7.05 mm in the ALK group and 7.31 mm in the PK group (p 0.01). In the ALK group, this figure was 7.00 mm for oversized grafts and 7.67 mm for non-oversized grafts (p 0.001). CRC values were significantly lower for eyes with keratoconus (7.00 mm) or stromal scar after infectious keratitis (7.06 mm) compared with stromal scar after trauma (7.74 mm) or stromal dystrophies (8.17 mm). Values were significantly lower for big-bubble ALKs (6.92 mm) and manual dissection-ALKs (7.14 mm) compared with PKs (7.31 mm) and microkeratome-assisted ALKs (7.45 mm). The average Orbscan 3-mm SimK cylinder, irregularity, and refractive power symmetry index were, respectively, 4.7 D/4.8 D/1.9 D for ALKs and 5.2 D/4.8 D/1.8 D for PKs (p = 0.99).The CRC is lower after ALK compared with PK, and features important variability. In eyes with ALK, non-oversized grafts result in postoperative CRC close to normal values and corneal diseases associated with stromal thinning and DALK result in lower postoperative CRC.

Objective To study corneal morphologic changes in a large keratoconic population and to establish a structural optical coherence tomography (OCT) classification. Design Cross-sectional, observational study. Participants A total of 218 keratoconic eyes from 218 patients and 34 eyes from 34 normal subjects. Methods A Fourier-domain OCT system with 5-μm axial resolution was used. For each patient, 3 high-resolution scans were made across the keratoconus cone. All scans were analyzed by keratoconus specialists who were not given access to patients' clinical and topographic data, and who established an OCT classification. The reproducibility of the classification and its correlation with clinical and paraclinical characteristics of patients with keratoconus were evaluated. The OCT examinations were performed every 4 months to follow up structural corneal changes. Main Outcome Measures Evaluation of the structural corneal changes occurring in keratoconus cases with various stages of severity based on OCT findings. Results Fourier-domain OCT classification containing 5 distinct keratoconus stages is proposed. Stage 1 demonstrates thinning of apparently normal epithelial and stromal layers at the conus. Stage 2 demonstrates hyperreflective anomalies occurring at the Bowman's layer level with epithelial thickening at the conus. Stage 3 demonstrates posterior displacement of the hyperreflective structures occurring at the Bowman's layer level with increased epithelial thickening and stromal thinning. Stage 4 demonstrates pan-stromal scar. Stage 5 demonstrates hydrops; 5a, acute onset: Descemet's membrane rupture and dilaceration of collagen lamellae with large fluid-filled intrastromal cysts; 5b, healing stage: pan-stromal scarring with a remaining aspect of Descemet's membrane rupture. The reproducibility of the classification was very high between the corneal specialist observers. Clinical and paraclinical characteristics of keratoconus, including visual acuity, corneal epithelium and stromal thickness changes, corneal topography, biomechanical corneal characteristics, and microstructural changes observed on confocal microscopy, were concordant with our OCT grading. Conclusions Optical coherence tomography provides an accurate assessment of structural changes occurring in keratoconus eyes. These changes were correlated with clinical and paraclinical characteristics of patients. The established classification not only allows structural follow-up of patients with keratoconus but also provides insight into the pathogenesis of keratoconus and treatment strategies for future research. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Background To evaluate the incidence, evolution, clinical characteristics, possible risk factors or preventive factors, and visual outcomes of epiretinal membrane (ERM) recurrence. Methods Retrospective study of 440 consecutive patients (440 eyes) who underwent pars plana vitrectomy for ERM. The internal limiting membrane (ILM) was peeled in 266 cases, with the help of indocyanine green in 27 cases and brilliant blue in 45 cases. Cases of symptomatic ERM recurrence were reoperated. Results The incidence of ERM recurrence was 5% (22/440), and 2% of the patients were reoperated (9/440). Epiretinal membrane recurrence was symptomatic in 9 cases (41%) and asymptomatic in 13 cases (59%). ILM peeling was the only factor preventing ERM recurrence (adjusted odds ratio = 0.33, P = 0.026). The use of staining dyes did not prevent recurrence (adjusted odds ratio = 0.35, P = 0.338). In the case of ERM reproliferation, the absence of ILM peeling, the existence of ERM on the fellow eye, and poor visual acuity before surgery seemed to be associated with a high risk of symptomatic recurrence and reoperation. The mean duration for follow-up was 3.5 ± 1.7 years. Conclusion ILM peeling not only reduces the likelihood of reproliferation of ERM but also seems to improve the visual prognosis of recurrent ERMs. The use of dyes did not reduce the rate of recurrence compared with when ILM was peeled without dyes.

A 48-year-old woman with no significant past history underwent bilateral simultaneous laser in situ keratomileusis for correction of her myopia. On the tenth postoperative day, the patient complained of visual decrease and photophobia. Slit lamp exam showed corneal epithelial irregularities. Confocal microscopy was performed and revealed a characteristic appearance of epithelial basement membrane dystrophy (EBMD). The patient was successfully treated with artificial tears and autologous serum eyedrops. EBMD may be missed before LASIK surgery, even after a careful pre-operative examination. Exacerbation of EBMD after LASIK surgery is rare. It should be considered when unexplained corneal epithelial defects or irregularities occur following LASIK. Confocal microscopy is very useful to confirm the diagnosis.

PURPOSE To assess the influence of donor characteristics on the outcome of anterior lamellar keratoplasty (ALK) and to evaluate whether corneal donor tissue considered unsuitable for penetrating or posterior lamellar keratoplasty due to poor endothelial condition may be safely used for ALK. METHODS Institutional setting. One hundred sixty-six consecutive ALK (166 patients) performed for optical indication in eyes with corneal diseases not involving the corneal endothelium. The main outcome measures were graft survival, early (0-12 months postoperatively) and late (after 12 months) annual endothelial cell loss, and postoperative logarithm of the minimum angle of resolution visual acuity. RESULTS The average and extreme values of donor tissue characteristics were: donor age, 70.6 years (range, 28-88 years); organ culture time, 20.9 days (range, 12-35 days); graft endothelial cell density before transplantation, 2047 cells per millimeters (range, 100-3300 cells/mm2); and deswelling time, 2.0 days (range, 1-4 days). The average follow-up time of patients was 48.1 ± 24.8 months (mean ± SD). None of the donor characteristics significantly influenced graft survival or postoperative endothelial cell loss (early and late phase). Donor age >80 years was associated with lower postoperative visual acuity at all postoperative points in time (P < 0.05). At 3 years, the mean logarithm of the minimum angle of resolution visual acuity was 0.44 (20/55) for grafts from donors older than 80 years and 0.25 (20/35) for younger donors. This result was shown to be significant both in univariate and in multivariate analysis. CONCLUSIONS Grafts from elderly donors should be discarded before ALK. Conversely, donor tissue with poor endothelial cell density (

The objective of this study was to assess the factors associated with anatomical and visual outcomes in patients presenting with Acanthamoeba keratitis (AK).This is a retrospective noncomparative interventional case series study comprising 44 eyes from 42 patients presenting with AK, treated with topical hexamidine diisethionate and topical polyhexamethylene biguanide, monitored between 2004 and 2008. AK was confirmed by polymerase chain reaction or direct microscopic examination. Correlation between clinical presentation and prognosis was assessed. Anatomical outcome was assessed according to the percentage of eyes requiring at least 1 surgical procedure in addition to topical treatment. Visual outcome was assessed by the best-corrected visual acuity at the end of follow-up.Polymerase chain reaction results were positive for Acanthamoeba in 40 of the 44 eyes (91%) and in 16 of the 44 eyes (36%) by direct microscopic examination. Confocal microscopy suggested the presence of Acanthamoeba in 12 of 19 eyes (63%). Amniotic membrane transplantation was performed in 8 eyes, penetrating keratoplasty in 4 eyes, and evisceration in 2 eyes. The average follow-up time was 10 months. Surgical treatment was significantly associated (P0.05) with time from symptom onset to diagnosis of30 days, an initial visual acuity of ≤20/200, an infiltrate size of3 mm, preperforating infiltrates, and corneal neovascularization. The average final visual acuity was 20/48 in eyes that did not require surgical treatment (n = 34) and 20/1702 in eyes that required at least 1 surgical procedure (n = 10; P0.0001).Late diagnosis, low initial visual acuity, corneal neovascularization, large infiltrates, and preperforated infiltrates were associated with surgical treatment in patients presenting with AK. Surgical intervention was associated with worse visual outcome.

Purpose: To target the use of two biologic tests in the diagnostic of viral Herpesviridae anterior uveitis (AC) by the consideration of clinical behavior and delay of intraocular sampling.Methods: Aqueous humor samples were collected from 42 patients suspected of having AU of infectious origin at presentation. The diagnosis of infectious uveitis was confirmed by quantification of antibodies with the Goldmann-Witmer coefficient (GWC) and/or detection of Herpesviridae genomes with PCR. The data were compared with data of 16 uveitis control samples used to calculate the specificity of the tests.Results: Sixteen out of 42 eyes (38%) had a final diagnosis of anterior segment infectious uveitis of viral origin (Herpesviridae) confirmed by PCR positive result (5/14 eyes; 14 of the 16 eyes were tested by PCR) and/or specific intraocular antibody synthesis (14/16 eyes).Conclusions: While the GWC is progressively less often performed, these findings suggest that it still has a role in AU suspected of herpesvirus et...

To evaluate the incidence, clinical and microbiological characteristics and risk factors of infectious keratitis in patients with limbal stem cell deficiency (LSCD).Retrospective comparative case series of 35 patients with severe LSCD.The mean follow-up time was 46 months. Infectious keratitis were mainly caused by Gram positive bacteria (94%). Only 7 infections (37%) healed under fortified adapted antibiotics. In 8 cases (42%), amniotic membrane transplantation was required and in 4 cases (21%) «à chaud» keratoplasty was performed. Significant risk factors associated with infectious keratitis were: soft contact lens extended wear, history of persistent epithelial defects, number of quadrants of corneal vascularization, re-epithelialization time after amniotic membrane or corneal transplantation, and use of corticosteroid or cyclosporin eye drops.Infectious keratitis in LSCD is frequent and severe. The restoration of the epithelial barrier integrity and a careful use of therapeutic contact lenses may help to prevent infection.

Objective To compare deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in eyes with corneal diseases not involving the corneal endothelium (keratoconus, scars after infectious keratitis, stromal dystrophies, and trauma). Design Retrospective, comparative case series. Participants One hundred forty-two consecutive DALK (DALK group; big-bubble technique or manual lamellar dissection using a slitlamp) and 142 matched PK (PK group). Methods Three models were used to describe the postoperative outcomes of the endothelial cell density. A joint regression model was used to predict long-term graft survival. Visual acuity, ultrasound pachymetry, specular microscopy, and optical coherence tomography (OCT) findings were recorded. Main Outcome Measures Postoperative endothelial cell loss and long-term predicted graft survival. Results The average 5-year postoperative endothelial cell loss was −22.3% in the DALK group and −50.1% in the PK group ( P P P P P >0.05). Conclusions Long-term, model-predicted graft survival and endothelial densities are higher after DALK than after PK. The big-bubble technique gives better results than manual dissection and PK. Compared with PK, manual dissection provides higher survival of both the corneal endothelium and graft, but lower visual acuity. Financial Disclosure(s) The authors have no proprietary or commercial interest in any materials discussed in this article.

To describe the incidence, clinical features, and evolution of paracentral retinal holes occurring after macular surgery.A retrospective non-randomized study of 909 patients operated on for either a macular hole (MH, n = 400 patients) or an epiretinal membrane (ERM, n = 509 patients) between 2004 and 2009. Six patients (0.6%) developed a paracentral macular hole after surgery. Their clinical, auto-fluorescence, and optical coherence tomography (OCT) characteristics as well as their visual outcomes were studied.The mean age of patients was 70 years. Paracentral holes occurred approximately 5 weeks after surgery (with a range of 2-12 weeks). All patients were asymptomatic. Five patients underwent ILM peeling during initial surgery. Paracentral retinal holes were located superiorly to the fovea in three cases and temporally in the other three cases. Mean pre-operative BCVA was 20/200 and mean post-operative BCVA was 20/40. The eye where the eccentric MHs were closest to the fovea (inferior to 1 optic disc area) had the poorest final visual acuity. Autofluorescence imaging showed a bright fluorescence in paramacular holes. On OCT images, they were shown to be flat full-thickness holes. No treatment was attempted. No rhegmatogenous complications or choroidal neovascularization occurred in any of the patients. Mean follow-up was 2 years.In summary, paracentral MHs are uncommon complications which can occur at the site where ILM peeling has been initiated or completed. Except for the closest holes to fovea, they have good visual prognosis and do not require any treatment underlining the importance of initiating the ILM peeling as far as possible from the fovea.

Resume But Identifier les facteurs pronostiques et le choix du tamponnement approprie a la prise en charge des corps etrangers intraoculaires (CEIO) du segment posterieur. Patients et methodes Cinquante-sept cas consecutifs ont ete retrospectivement analyses au Centre hospitalier national d’ophtalmologie des XV–XX entre le 1 er janvier 2004 et le 31 decembre 2007. Des analyses univariees et multivariees ont ete realisees pour identifier d’eventuels facteurs pronostiques. Plusieurs parametres ont ete mesures : meilleure acuite visuelle corrigee (MAVC) pre- et postoperatoire, nature et taille du CEIO, porte d’entree, delai entre le traumatisme et l’ablation chirurgicale, localisation precise du CEIO, existence d’un decollement retinien initial, choix de la methode de tamponnement (aucun, gaz ou huile de silicone), complications (siderose, endophtalmie ou decollement de retine avec proliferation vitreoretinienne). Resultats Les CEIO metalliques representaient 80,7 % (= 46). La retine inferieure etait la localisation preferentielle avec 47,4 % (= 27). La MAVC initiale etait 1,47 et la MAVC finale de 1,03 (echelle LogMar). Le suivi moyen etait de 20,7 mois (12–60) ; 24,56 % (= 14) avaient un decollement de retine initial, avec un pronostic statistiquement plus mauvais. L’AV finale etait meilleure dans le groupe avec tamponnement par gaz (= 16) compare au groupe silicone (= 21) ou sans tamponnement (= 20). Le facteur pronostique le plus important retrouve etait la MAVC initiale. Le delai de l’extraction du CEIO etait un facteur predictif significatif avec une limite retrouvee a la premiere semaine. Une porte d’entree sclerale ou corneosclerale avait un meilleur pronostic. Cinq cas de sideroses (8,7 %) lies a un retard de prise en charge et deux cas d’endophtalmies (3,5 %) ont ete retrouves (en depit d’une antibio-prophylaxie). Aucune difference statistique n’a ete retrouvee concernant la localisation du CEIO sur la retine, la taille ou la nature du CEIO. Apres plusieurs interventions, il persistait neuf cas de decollements de retine, soit 15,78 %. La MAVC finale etait superieure ou egale a 20/40 dans 39,3 % des cas et 17,5 % avaient une perception lumineuse positive ou negative. Conclusion Le pronostic d’un traumatisme par CEIO est du a une combinaison complexe de parametres. Neanmoins de bons resultats peuvent etre obtenus sans tamponnement par silicone. Les facteurs pronostiques principaux lies a un meilleur resultat visuel etaient l’AV initiale, le delai de prise en charge chirurgicale initiale (premiere semaine), l’absence de decollement retinien initial, l’orifice d’entree plutot scleral que corneen. Les principales complications sont representees par la siderose des la troisieme semaine, le decollement de retine par proliferation vitreoretinienne et l’endophtalmie. La localisation, la taille et la nature du CEIO n’etaient pas des facteurs predictifs statistiquement significatifs.

Resume Introduction La pathogenie des fossettes colobomateuses compliquees de decollement sereux retinien (DSR) de la macula reste controversee. Son traitement l’est aussi. A travers cette etude, qui a la particularite de comprendre la plupart des techniques proposees, nous rapportons notre experience dans le traitement de cette pathologie. Patients et methodes C’est une etude monocentrique retrospective a propos de vingt patients presentant un DSR maculaire secondaire a une fossette colobomateuse entre 1983 et 2009. Differents traitements ont ete realises : les patients au tout debut de l’etude ont eu un traitement simple par laser peripapillaire. Puis, un traitement associant le laser peripapillaire et une injection intravitreenne de gaz (C3F8) avec positionnement tete vers le bas pendant deux semaines a ete realise apres echec du laser, puis d’emblee. Au cours des dernieres annees, les patients ont ete traites en premiere intention par une vitrectomie avec ou sans pelage de la membrane limitante interne (MLI), laser peripapillaire peroperatoire et tamponnement par gaz (C2F6). Resultats Notre serie est composee de vingt patients : Neuf hommes et 11 femmes. L’âge moyen des patients au moment du diagnostic etait de 29 ans (neuf a 60 ans). La duree moyenne entre le debut des symptomes et la prise en charge therapeutique etait de 6,1 mois. Aucun patient n’avait eu de decollement posterieur du vitre lors du diagnostic. Six patients ont ete traites par du laser peripapillaire avec succes dans deux cas. Onze patients (dont trois avaient eu un echec au laser seul) ont eu un traitement par laser associe a l’injection intravitreenne de gaz avec 72 % de succes. Huit patients (dont deux avaient eu un echec au laser gaz) ont eu une vitrectomie avec dissection de la hyaloide posterieure associee au laser gaz avec succes dans 87 % des cas sans recidive. Parmi eux, cinq ont eu un pelage de la MLI au cours de la vitrectomie. La duree de suivi moyenne globale de tous les patients etait de 60 mois allant de deux mois a dix-sept ans. Conclusion Notre etude montre qu’en cas de DSR maculaire compliquant une fossettte colobomateuse, un traitement precoce par vitrectomie, pelage de la MLI, laser peripapillaire et tamponnement par gaz s’accompagne d’un bon resultat anatomique et fonctionnel. Ce traitement est superieur aux autres traitements moins invasifs. La tomographie en coherence optique (OCT) constitue un outil important permettant le diagnostic et le suivi postoperatoire des patients.

To compare the safety and functional outcomes of 25-gauge and 23-gauge (G) micro-incision vitrectomy surgery (MIVS) instrumentation with the standard 20-G vitrectomy system in the treatment of epiretinal membranes (ERM). A retrospective comparative study of 553 consecutive cases with epiretinal membrane who underwent pars plana vitrectomy. Twenty-gauge, 25-gauge and 23-gauge vitrectomy was performed respectively in 347, 91, and 115 eyes. Surgery duration, visual acuity improvement, intraocular pressure variation, intraoperative and postoperative complications were analyzed. The mean surgical time in the 23-G group and in the 25-G group was shorter than in the 20-G group (P

The aim of this work was to determine the diagnostic performance of real-time polymerase chain reaction (RT-PCR) and to assess intraocular specific antibody secretion (Goldmann-Witmer coefficient) on samples from patients with signs of posterior uveitis presumably of infectious origin and to target the use of these two biologic tests in the diagnostic of Toxoplasma/viral Herpesviridae posterior uveitis by the consideration of clinical behavior and delay of intraocular sampling.Aqueous humour and/or vitreous fluid were collected from patients suspected of having posterior uveitis of infectious origin at presentation (140 samples). The diagnosis was confirmed by quantification of antibodies with the Goldmann-Witmer coefficient (GWC) and for detection of Herpesviridae and Toxoplasma gondii genomes with RT-PCR. Forty-one patients had final diagnosis of uveitis of non-Toxoplasma/non-viral origin and 35 among them constituted the control group. The main outcome measures were sensitivity, specificity, and positive and negative predictive values (PPV and NPV).When pre-intraocular testing indication was compared with final diagnosis, GWC was a more sensitive and specific method than RT-PCR, and was successful in detecting T. gondii, especially if the patient is immunocompetent and the testing is carried out later in the disease course, up to 15 months. For viral Herpesviridae uveitis, the sensitivity and PPV of PCR evaluation was higher than detected with GWC with respectively 46% compared with 20% for sensitivity and 85% versus 60% for PPV. In either viral retinitis or toxoplasmosis infection, RT-PCR results were positive from 24 h, although GWC was not significant until 1 week after the onset of signs. In toxoplasmosis patients, positive RT-PCR results were statistically correlated with the chorioretinitis area (more than three disc areas; p = 0.002), with the age older than 50 (p = 0.0034) and with a clinical anterior inflammation (Tyndall ≥1/2+) and panuveitis; (p = 0.0001).For the diagnosis of viral or toxoplasmosis-associated intraocular inflammation, the usefulness of laboratory diagnosis tools (RT-PCR and GWC) depends on parameters other than the sensitivity of the tests. Certain patient characteristics such as the age of the patients, immune status, duration since the onset of symptoms, retinitis area, predominant site and extent of inflammation within the eye should orientate the rational for the choice of laboratory testing in analysis of intraocular fluids.

Purpose To analyze the modifications to the vitreous body after femtosecond laser–assisted laser in situ keratomileusis (LASIK) for myopia. Setting Centre Hospitalier National Des Quinze-Vingts, Paris, France. Design Case series. Methods B-scan ultrasonography of the posterior ocular segment was performed the day before and 48 hours after femtosecond LASIK for myopia. Posterior vitreous detachment (PVD) was diagnosed by the presence of a low-reflected mobile echogenic membrane partially or completely detached from the retina. Eyes with signs of partial or total PVD on preoperative examination were excluded. Occurrence of total or partial PVD after surgery was the main outcome measure. Results Thirty-one eyes of 18 patients (10 women; mean age 28 years ± 5 [SD]) were included in the study. The mean preoperative spherical equivalent was −4.38 diopters (D) (range −2.88 to −6.75 D). After surgery, 5 eyes (16%) developed partial or total PVD. The remaining 26 eyes had no signs of PVD postoperatively. Conclusion Although less vacuum is required to create a corneal flap with a femtosecond laser than with a conventional microkeratome, the incidence of PVD after femtosecond laser–assisted LASIK was similar to that reported for microkeratome-assisted LASIK. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Resume Introduction Etudier les caracteristiques des keratites bacteriennes afin d’identifier des facteurs de risque et des facteurs pronostics. Patients et methodes Etude retrospective sur 111 yeux de 105 patients hospitalises entre 2005 et 2006 pour une keratite bacterienne confirmee (identification d’un germe au laboratoire) ou fortement suspectee (evolution favorable sous traitement antibiotique sans germe identifie sur les prelevements). Resultats Les principaux facteurs de risque retrouves etaient le port de lentilles de contact (39,6 %), une pathologie de la surface oculaire (36,9 %), une chirurgie oculaire (27,9 %) et un traumatisme oculaire (11,7 %). Les cocci Gram+ representaient 46,8 % des cas ( Staphylococcus ), les bacilles Gram− 19,8 % ( Pseudomonas ), les bacilles Gram+ 7,2 % ( Proprionibacterium et Corynebacterium ), les cocci Gram− 2,7 % ( Branhamella ) et les coccobacille Gram− 0,9 % ( Moraxella ). Dans 22,5 % des cas aucun germe n’a ete retrouve. Dans 25,6 % des cas, deux germes ou plus ont ete retrouves. Le suivi moyen etait de 6,5 mois. Le taux de guerison de l’infection etait de 77,5 % avec un traitement purement medical et 99,1 % avec un traitement medicochirurgical. Une greffe de membrane amniotique a ete realise dans 16,2 % des cas et une keratoplastie a chaud dans 8,1 %. L’acuite visuelle moyenne initiale etait a 0,04 et l’acuite visuelle finale a 0,14. L’acuite visuelle finale moyenne est 0,09 pour les Gram+ et 0,44 pour les Gram− ( p = 0,03). Conclusion Les keratites bacteriennes sont des infections graves engageant le pronostic visuel. Les keratites a germe Gram+ sont les plus frequentes, sauf chez les porteurs de lentilles, et plus severes.

Objective To analyze graft survival and the outcome of the corneal endothelium after corneal transplantation in a single model to predict the long-term prognosis of these grafts. Design Cohort study. Data were recorded prospectively and then analyzed retrospectively. Participants One thousand one hundred forty-four consecutive eyes of 1144 patients who underwent corneal transplantation between 1992 and 2006. Interventions Penetrating keratoplasty and deep anterior lamellar keratoplasty. Main Outcome Measures Slit-lamp examination and wide-field specular microscopy results. A joint analysis of endothelial cell loss and time to graft failure was undertaken. From midterm simultaneous analysis of graft survival and endothelial cell loss, long-term graft survival was predicted. Results The observed 5- and 10-year graft survival estimates were, respectively, 74% and 64%. The average endothelial cell density (cell loss) was 2270 cells/mm 2 before surgery, 1058 cells/mm 2 (–53%) during the sixth postoperative year, and 865 cells/mm 2 (–61%) during the 10th postoperative year. Overall, the predicted graft survival estimate was 27% at 20 years and 2% at 30 years. Both observed and predicted graft survival were higher in patients who had undergone lamellar keratoplasty than in patients who had undergone penetrating keratoplasty and had normal recipient endothelium and higher in patients who had undergone penetrating keratoplasty and had normal recipient endothelium than in patients who had undergone penetrating keratoplasty and had impaired recipient endothelium. Conclusions For corneal diseases involving the endothelium, penetrating keratoplasty seems to be a good therapeutic approach in elderly patients because the graft life-span may be similar to the patient life expectancy. Conversely, for younger patients, penetrating keratoplasty is only a midterm therapeutic approach. For corneal diseases not involving the endothelium, deep anterior lamellar keratoplasty seems to be a promising therapeutic approach with higher long-term expected survival. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.