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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 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.

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.

To report the results of correction of post-keratoplasty astigmatism by arcuate keratotomy performed with the Hanna arcitome (Moria).Service 5, Hôpital des 15-20, Paris VI University, Paris, France.Forty eyes operated on for post-keratoplasty astigmatism using the Hanna arcitome were retrospectively studied. Paired symmetrical arcuate keratotomies were performed on the graft button. Mean follow-up was 10.8 months +/- 11.2 (SD). Outcome measures included uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and subjective refraction. For statistical analysis, visual acuity data were transformed into logMAR units. The refractive data were analyzed using the Alpins method.By a mean of 10.8 +/- 11.2 months after surgery, the UCVA had improved a mean of 0.28 +/- 0.46 lines, which was significant (P = .013). The BSCVA remained stable. The mean subjective cylinder was 8.84 +/- 3.00 diopters (D) preoperatively and 4.88 +/- 2.50 D postoperatively (P.001). The changes in postoperative subjective cylinder values correlated with preoperative cylinder values (r(s) = 0.584; P.0001). The subjective axis was modified by 20 degrees or less in 27 eyes (67.5%). The mean surgically induced astigmatism was 8.07 +/- 3.83 D and the mean correction index, 0.96 +/- 0.46. One microperforation occurred and required suturing. Incisions were off center in 1 case, and 2 patients had an allograft rejection after the procedure.Arcuate keratotomy performed with the Hanna arcitome was effective in reducing post-keratoplasty astigmatism. The device enabled safer, easier arcuate incisions than with manual techniques. However, predictability and efficacy could be improved by a more accurate nomogram.

Objective To analyze graft reepithelialization after penetrating keratoplasty using organ-cultured donor tissue. Design Retrospective observational cohort study. Participants One thousand one hundred thirty-eight consecutive penetrating keratoplasties (1003 patients) performed between 1992 and 2004 were analyzed, and 1003 were included (1 graft per patient was included). Methods Slit-lamp examination after fluorescein staining. Main Outcome Measure Graft reepithelialization time was recorded. Results The average graft reepithelialization time was 4.6±13.2 days (range, 1–210 days; median, 2.5 days). Complete corneal epithelial healing was obtained in 1 day in 28.5% of patients, in 3 days in 65.8%, in 7 days in 93.6%, and in 14 days in 97.0%. Postoperative chronic epithelial defects occurred in 3.0% of patients. In univariate analysis, death-to-storage time, storage time, deswelling time, rejection risk, trephination size, suture method, use of dexamethasone ointment during surgery, use of sodium hyaluronate during surgery, and use of high postoperative steroid regimen significantly influenced the graft reepithelialization time ( P P = 0.045), use of sodium hyaluronate at the end of surgery (β = −0.17; P = 0.001), and steroid regimen (β = 0.09; P = 0.022) significantly influenced the graft reepithelialization time. Conclusions The use of sodium hyaluronate at the end of surgery to coat the ocular surface shortened graft reepithelialization time after penetrating keratoplasty using organ-cultured donor tissue. Graft reepithelialization time was longer in high-risk recipients, and it increased with high dexamethasone eyedrops regimen.

Objectif Nous avons etudie la biometrie du cristallin a l’aide de l’echographie en mode A et de l’Orbscan. Materiel et methodes Nous avons analyse prospectivement la biometrie du cristallin de 280 yeux normaux, en dehors d’une eventuelle ametropie, de 140 patients âges de 10 a 95 ans. L’epaisseur centrale du cristallin et le rayon de courbure anterieur du cristallin ont ete respectivement mesures a l’aide de l’echographie en mode A et de l’Orbscan. Ces deux parametres biometriques du cristallin ont ete correles a la mesure controlaterale, a l’âge et au sexe du patient, a la refraction subjective et aux autres parametres biometriques de l’œil : la profondeur de la chambre anterieure, l’angle irido-corneen, le diametre corneen, l’epaisseur corneenne, le diametre pupillaire, les rayons de courbure corneens anterieur et posterieur et la longueur du segment posterieur. Resultats Le rayon de courbure anterieur du cristallin n’etait correle a aucune autre variable (et en particulier, pas a l’equivalent spherique), mais la qualite de la mesure etait mediocre. En effet, la reproductibilite de cette mesure etait faible (14,4 % de difference entre deux mesures successives). La correlation avec l’œil controlateral etait faible (r s = 0,55 ; p s = 0,97 ; p s = 0,82 ; p s = - 0,72 ; p s = - 0,65 ; p s = - 0,68 ; p s = - 0,62 ; p Conclusion L’epaisseur du cristallin est principalement influencee par l’âge et est correlee a la profondeur de la chambre anterieure et a la mesure de l’angle irido-corneen. L’influence du vieillissement sur la biometrie du segment anterieur de l’œil se traduit essentiellement par une augmentation de volume du cristallin.

Objectif Le but de cette etude est d’evaluer la tolerance et l’efficacite de l’adjonction de 5-FU et d’heparine dans le liquide de vitrectomie pour prevenir la proliferation vitreoretinienne (PVR) dans la chirurgie du decollement de retine. Materiel et methodes Deux groupes consecutifs de 30 yeux presentant un decollement de retine rhegmatogene (stade C1 ou plus) ont ete prospectivement compares. Une association de 5 fluoro-uracile (5-FU) et d’heparine a ete ajoutee dans le liquide de vitrectomie d’un groupe. La tolerance clinique et l’efficacite ont ete evaluees regulierement durant 1 an. Resultats Le nombre de keratites le lendemain de l’intervention etait plus important dans le groupe traite (p = 0,005). Cette difference avait disparu une semaine apres l’intervention (p = 0,54). L’hyperhemie conjonctivale etait plus importante dans le groupe traite le lendemain et une semaine apres l’intervention (p = 0,04). En revanche, l’etat cutane, le Tyndall hematique, l’inflammation de la chambre anterieure et la pression intraoculaire n’etaient pas differents dans les deux groupes (p ≥ 0,14). Le nombre de re interventions a 1 mois et a 1 an n’etait pas significativement different (p ≥ 0,3). L’etat anatomique (« retine a plat ») et fonctionnel (acuite visuelle) n’etaient pas differents dans les deux groupes a 1 an (p ≥ 0,12). Conclusion L’adjonction de 5-FU et d’heparine dans le liquide de vitrectomie est bien toleree. Toutefois, son efficacite non demontree dans cette etude devrait etre evaluee sur un plus grand nombre d’yeux avec des stades de PVR moins evolues (stade B).

Orbscan is a recent optical device that combines the Placido disk of the videokeratoscope and a scanning slit. The scanning slit measures the elevation of both the corneal surface (anterior and posterior) and the anterior iris-lens surface. Biometric measures of the anterior segment such as corneal thickness, anterior chamber depth, corneal diameter, and iridocorneal angle are obtained using spatial coordinates of various ocular surfaces. Orbscan is not only a corneal topograph but a versatile device capable of measuring the biometry of the anterior segment of the eye.

Resume Les proprietes optiques de la cornee sont la transmission de la lumiere qui augmente avec la longueur d’onde dans le spectre de la lumiere visible (400 a 750 nm), la refraction de la lumiere (la cornee representant les deux tiers du pouvoir refractif total de l’œil) et la reflexion de la lumiere. Les mecanismes de regulation de l'hydratation corneenne permettant le maintien de la transparence corneenne sont complexes et reposent en grande partie sur la pompe endotheliale qui maintient le stroma dans un etat de deshydratation relative. L'hydratation du stroma depend de la pression intraoculaire, de la pression de gonflement du stroma, des fonctions de barriere et de pompe de l'endothelium et de l'epithelium corneens. L’evaporation a la surface corneenne joue un role modeste dans la fonction de deturgescence du stroma. Des mecanismes d’inhibition de la reaction inflammatoire et de l’angiogenese participent au maintien de la transparence corneenne. Le maintien de la barriere epitheliale est conditionne par les cellules souches limbiques qui renouvellent en permanence l’epithelium corneen. L'endothelium humain est un tissu tres stable. Il est quasiment incapable de se multiplier par mitose apres la naissance. La cicatrisation corneenne est un processus complexe faisant intervenir des systemes de degradation du tissu lese, des mecanismes de cicatrisation epitheliale, de cicatrisation stromale, de cicatrisation endotheliodescemetique et de remodelage stromal. L’innervation corneenne sensitive permet de declencher le reflexe corneopalpebral, assure une fonction trophique sur l'epithelium par liberation de neuropeptides et peut induire une inflammation neurogenique. Les apports nutritionnels se font essentiellement par les larmes (oxygene) et l’humeur aqueuse (nutriments). La cornee permet la diffusion intraoculaire des agents pharmacologiques.

Objective To analyze the outcome of graft central thickness after penetrating keratoplasty. Design Retrospective observational cohort study. Participants Eight hundred fifty-six consecutive penetrating keratoplasties (772 patients) performed between 1992 and 2001 were analyzed and 772 were included (1 graft per patient was included). Methods Slit-lamp examination and ultrasound pachymetry. Main Outcome Measures Slit-lamp findings, intraocular pressure, and graft central thickness were recorded. Results Patients were observed for an average of 55 months. The 36- and 60-month graft survival estimates were, respectively, 77.2% and 71.0%. The average graft central thickness in successful transplants was 655 μm at 1 week, 558 μm at 1 month, 533 μm at 6 months, 538 μm at 12 months, 558 μm at 24 months, 561 μm at 36 months, and 568 μm at 5 years. At each postoperative time point, the percentage of eyes with decreased, normal, and increased graft central thickness was significantly different according to slit-lamp findings. Of the patients with increased graft thickness, 46.2% had a simple outcome (normal intraocular pressure and normal slit-lamp findings), 28.6% experienced rejection, 15.8% experienced a graft nonimmunological event, and 9.4% experienced increased intraocular pressure. At each postoperative follow-up, subsequent graft survival was significantly lower in patients with increased graft thickness as compared with patients with normal or decreased graft thickness. When analyzing only patients with simple outcome, the relative risk of graft failure was 3.3 if graft thickness was increased at 1 month ( P Conclusions In conclusion, graft central thickness assessed by ultrasound pachymetry is a useful method for observing patients who have undergone penetrating keratoplasty. Even when slit-lamp examination reveals no complications, patients with an increase in graft thickness above the upper limit of normal for the postoperative time point under consideration are at greater risk of failure.

Objectif Evaluer la tolerance et l’efficacite de l’insert ophtalmique Mydriasert ® pour la dilatation pupillaire. Materiel et methodes Deux formes galeniques d’une association contenant de la tropicamide et de la phenylephrine ont ete comparees sur 160 yeux de 80 patients. Pour chaque patient, un insert Mydriasert ® (Ioltech) a ete place dans le cul-de-sac conjonctival de l’œil. La dilatation de l’œil controlateral a ete obtenue a l’aide des collyres Tropicamide Faure ® 0,50 % et Neosynephrine Faure ® 10 % (Novartis ophthalmics) instilles selon 3 frequences (5, 10 et 15 minutes). Le diametre pupillaire a ete mesure regulierement jusqu’a l’obtention de la mydriase maximale. Resultats La tolerance subjective et objective de l’insert est excellente. La taille de la mydriase maximale obtenue par l’insert est significativement superieure a celle obtenue par collyre quelle que soit la frequence d’instillation (p Conclusion Malgre la faible quantite de produit libere, Mydriasert ® permet d’obtenir une mydriase superieure a celle obtenue par les collyres habituels au prix toutefois d’un delai d’attente plus important.

Proliferative vitreoretinopathy (PVR) is the major cause of retinal detachment surgery failure. Many adjuvants were studied in vitro and on animals, some were studied on humans. Daunomycin seems to reduce PVR recidivism. 5-FU and steroids are nontoxic but their efficacy is not clear. Heparin reduced postoperative inflammation and seems to reduce PVR recidivism when associated with 5-FU. Associating heparin and steroids seems to reduce PVR in some groups of patients (aphakic, anterior PVR). Colchicine and retinoic acid per os are ineffective, silicone oil is effective as an internal tamponade but not as an adjuvant of PVR. Currently, no molecule has proven efficacy as an adjunctive treatment of PVR.

Objectif Analyser l’atteinte du segment anterieur de l’œil au cours du diabete. Materiel et methodes Le segment anterieur de 200 patients diabetiques et 200 patients non diabetiques a ete analyse de facon prospective. Les parametres etudies comprenaient le rayon de courbure, l’epaisseur corneenne centrale, la sensibilite corneenne centrale (Cochet Bonnet), les diametres pupillaires avant et apres dilatation par tropicamide et phenylephrine, le delai de dilatation, l’etat du cristallin et le tonus oculaire. Les atteintes du segment anterieur ont ete comparees dans les 2 groupes et ont ete correlees aux parametres du diabete (type, duree d’evolution, equilibre) au stade de la retinopathie diabetique et a l’eventuelle atteinte neurologique. Resultats Les parametres geometriques de la cornee (rayon de courbure, epaisseur) et le tonus oculaire ne sont pas influences par l’existence d’un diabete. En revanche le diabete a une influence significative sur la frequence de la cataracte (p Conclusion Le diabete influence la transparence du cristallin, la dilatation pupillaire pharmacologique et la sensibilite corneenne. La sensibilite corneenne est un parametre interessant a connaitre chez le diabetique malgre le caractere non specifique de l’atteinte et la subjectivite de la mesure.

Objectif Analyser la relation entre le keratocone et la myopie axile. Materiel et methodes Nous avons prospectivement analyse la refraction et la biometrie de 100 yeux consecutifs presentant un keratocone et de 100 yeux emmetropes. Les donnees biometriques (incluant la longueur du segment posterieur) ont ete obtenues a l’aide de l’echographie en mode A, de l’Orbscan et de la pachymetrie ultrasonique. Les donnees biometriques des 2 groupes ont ete comparees. Resultats La profondeur de la chambre anterieure, la longueur du segment posterieur et la longueur axiale de l’œil sont significativement differentes dans les 2 groupes (p Conclusion L’augmentation de la longueur du segment posterieur des keratocones et la correlation entre la longueur du segment posterieur et l’equivalent spherique dans le groupe keratocone suggerent l’existence d’une relation statistique entre le keratocone et la myopie axile.

Resume L'astigmatisme est souvent reduit a un cylindre oriente selon un axe. Cette expression « polaire » de l'astigmatisme regulier (cylindre et axe) rend difficile les analyses. Les difficultes sont dues au caractere directionnel des donnees (axe), au cycle non trigonometrique de l'astigmatisme (180°) et a l'ambiguite liee au choix du signe du cylindre (positif ou negatif). Les coordonnees cartesiennes, les vecteurs, les fonctions sinusoidales, les matrices et les nombres complexes sont des outils mathematiques interessants pour exprimer ou representer graphiquement l'astigmatisme. Ces expressions « non polaires » utilisent des fonctions trigonometriques qui necessitent de proceder a un doublement de l'axe. Le cylindre croise de Jackson est souvent employe, car cette ecriture decrit uniquement l'astigmatisme sans la composante spherique de l'ametropie (equivalent spherique nul). L'utilisation des coordonnees cartesiennes du cylindre croise de Jackson permet la disparition du caractere directionnel des donnees. Ceci revient a decomposer le cylindre croise de Jackson en deux cylindres croises de Jackson d'axe 0°/90° et d'axe 45°/135° representant respectivement la composante directe/indirecte de l'astigmatisme et la composante oblique de l'astigmatisme. Ces deux composantes peuvent definir un plan de l'astigmatisme. Les expressions « non polaires » permettent de calculer l'astigmatisme moyen, une variation d'astigmatisme et d'autres analyses complexes (enantiomorphisme, …) qui seraient difficiles avec la seule ecriture polaire de l'astigmatisme.

Aim: To investigate the influence of anticorneal antibodies on the outcome of transplantation in recipients before penetrating keratoplasty. Methods: 100 consecutive penetrating keratoplasties performed between July 1995 and June 1996 were included in this study. Donor corneoscleral rim cryosections were incubated with recipient serum. Fixation of recipient IgM on donor corneas was revealed with a polyclonal anti-human μ-chain antibody. The mean follow up time was 61 months. Five years after transplantation, 63% of patients were available for follow up. During the follow up period, 15% of keratoplasties failed because of irreversible rejection. Results: Anti-donor stromal lamellae IgM were found in 14 recipients. Anti-donor keratocyte IgM were present in 28 recipients. Dilution of recipient serum (up to 1/800) did not modify the results of positive crossmatch assays. Crossmatch assays performed with positive recipient sera and negative donor corneoscleral rims were negative. No significant influence of IgM crossmatch results on graft survival and rejection-free graft survival was found. Conclusion: Donor specific anticorneal stroma IgM were found in 28% of recipients before transplantation. This pre-immunisation was not associated with a higher risk of transplantation rejection.

Purpose. To present clinical, microbiologic, and histopathologic features of keratitis due to Candida parapsilosis. Methods. Clinicomicrobiologic evaluation of four patients (four eyes) with culture-proven C. parapsilosiskeratitis. The patients were evaluated for symptoms, visual acuity, clinical observations, microbiologic examination of corneal scrapings, and pathologic examination of corneal buttons. Results. Three cases were observed after penetrating keratoplasty, and one case occurred after inhalation of corticosteroids. Clinical presentation of C. parapsilosis keratitis showed a great diversity. There was one case of crystalline keratopathy and three cases of suppurative corneal infiltrate. Histopathology of corneal buttons showed interlamellar accumulations of yeast. Medical treatment included topical amphotericin B and systemic triazoles. Penetrating keratoplasty was required in three patients. Conclusion. Risk factors for C. parapsilosis keratitis may include corticosteroid use and prior corneal transplantation. The prognosis of C. parapsilosis keratitis with antifungal and surgical therapy may vary from good visual outcome to intraocular extension with phthisis bulbi.

Purpose To identify predictive factors for reversibility of corneal graft rejection. Methods The study design was a prospective cohort study. Among 440 consecutive penetrating keratoplasties performed at our institution, 79 grafts from 79 patients who developed signs of transplant rejection were included. Donor, recipient, surgical, and rejection variables were studied, at both univariate and multivariate levels. Results The rate of reversibility was 51% (40/79). The average postoperative time of rejection was 10.5 +/- 9.3 months, and the average time of visual acuity recovery in patients with reversible rejection was 2.4 +/- 2.3 months. In logistic regression, only two variables significantly influenced the rate of reversibility. The preoperative diagnosis (p = 0.04) influenced the rate of rejection reversibility; patients with bullous keratopathy or regraft were more likely to experience irreversible rejection than patients with keratoconus or Fuchs' dystrophy. The average graft thickness at the time of rejection diagnosis was 774 +/- 129 microm in patients with irreversible rejection and 681 +/- 118 microm in patients with reversible rejection (p = 0.001). Conclusion Rejection was reversible in half of the cases. Rejection was more likely to be irreversible in patients with marked increase in graft thickness and in patients transplanted for bullous keratopathy or graft failure. Donor variables did not influence rejection reversibility.

BACKGROUND The aim of this study was identification of predictive factors for postoperative visual acuity in patients with a clear organ-cultured graft and to analyze the change in visual acuity between 12 and 24 months after transplantation. METHODS The study design was a prospective cohort study. A total of 342 consecutive penetrating keratoplasties using donor organ-cultured grafts, performed in 324 patients, were included. Visual acuity, graft thickness, and graft endothelial cell density were recorded in patients with clear transplants. RESULTS At 24 months postoperatively, 25 (18.7%) of 134 patients had 20/200 or worse visual acuity and 66 (49.3%) had 20/40 or better visual acuity. Graft thickness took 1 month to decrease to normal values. A temporary graft thinning occurred at 6 months postoperatively, followed by recovery of normal graft thickness by 18 months. The average postoperative endothelial cell density was 1,533+/-598 cells/mm2 during the second year. The 24-month LogMAR (logarithm of minimal angle of resolution) visual acuity correlated with preoperative LogMAR visual acuity (beta=0.26, P=0.005), postoperative lens status (beta=-0.34, P=0.008), preoperative intraocular pressure (beta=0.50, P=0.020), and postoperative astigmatism (beta=0.17, P=0.040). Visual acuity (P=0.022) significantly improved between 12 and 24 months. Preoperative diagnosis (P < 0.0001) and postoperative lens status (P < 0.0001) significantly influenced the change in LogMAR visual acuity between 12 and 24 months. CONCLUSIONS Donor variables do not influence the visual acuity results of penetrating keratoplasty using organ-cultured donor tissue, whereas they have a strong influence on graft survival and graft endothelial cell density. Visual acuity improves during the first 2 years after transplantation. After keratoplasty, organ-cultured corneal grafts undergo dramatic modifications of their thickness and probably of their transparency.

AIMS—To evaluate the influence of intraocular lens (IOL) placement on triple procedure clinical results and to investigate whether it is appropriate to use phacoemulsification in patients with large lens nucleus. METHODS—40 consecutive penetrating keratoplasties combined with cataract extraction performed in a single institution were studied. Whenever possible a capsulorhexis was performed and the IOL was placed into the capsular bag. Phacoemulsification was used when the nucleus was too large to pass through the capsulorhexis. RESULTS—Out of 25 patients with an intact capsulorhexis phacoemulsification was used in 13 (52.0%) whereas the entire nucleus passed through the capsulorhexis in the remaining 12 patients (48%). The average 12 month visual acuity was 0.46 (SD 0.21) in patients with in the bag IOL (n = 23) and 0.29 (0.08) in patients with ciliary sulcus IOL (n = 13) (p = 0.04). Elevated intraocular pressure occurred in 26.1% (6/23) of patients with in the bag IOL and 61.5% (8/13) of patients with ciliary sulcus IOL (p = 0.08). The average postoperative graft thickness at 18 months was 552 (27) µm in the former group and 650 (29) µm in the latter group (p = 0.04). No significant difference in graft survival, postoperative endothelial cell density, astigmatism, and videokeratoscopic measurements was found between both groups. CONCLUSION—In the bag placement of the intraocular lens during the triple procedure results in better outcome of transplantation than ciliary sulcus placement of the IOL. Phacoemulsification allows removal of large nuclei through a 5 mm capsulorhexis without performing relaxing incisions out towards the periphery of the capsule. Keywords: corneal transplantation; graft survival; intraocular lens; triple procedure; visual acuity

To report the results of arcuate keratotomy performed with the Hanna arcitome in patients with postkeratoplasty astigmatism.Department of Ophthalmology, Saint-Antoine Hospital, Paris VI University, Paris, France.This retrospective study comprised 22 eyes (22 patients) with postkeratoplasty astigmatism. Paired symmetrical arcuate keratotomy was performed with the Hanna arcitome. Outcome measures included refraction, videokeratography, and keratometry.At 6.6 months +/- 8.9 (SD) after surgery, the mean increase in best spectacle-corrected visual acuity (BSCVA) was 2.1 +/- 2.4 lines. Thirteen eyes gained 2 lines or more of BSCVA, and 15 gained 3 lines or more of uncorrected visual acuity. Two patients had a decrease in BSCVA: 1 had lens opacification unrelated to arcuate keratotomy and 1, increased corneal irregularity. Mean refractive astigmatism was 6.94 +/- 2.11 diopters (D) preoperatively and 3.85 +/- 1.95 D postoperatively (P.01). Mean change in keratometric astigmatism was -51 +/- 36%. Astigmatism decreased in 21 eyes as measured by manifest refraction, keratometry, and videokeratography; it increased in 1 cornea with a microperforation.The results of arcuate keratotomy performed with the Hanna arcitome were comparable to those with freehand relaxing incisions. The instrument made safer and more uniform arcuate incisions than a freehand technique.

Purpose To try to facilitate evaluation of corneal stroma during organ culture by means of light microscopy. Methods Corneal stroma of 53 consecutive organ-cultured corneas was studied by means of light microscopy during endothelial quality control. Out of 9 corneas with bad stromal evaluation, 2 were studied by means of transmission electron microscopy, and 7 were grafted. From the remaining 44 corneas with a normal light microscopic appearance, 35 were grafted. Results Stromal abnormalities consisted of bright visible structures with a cell-like shape corresponding to keratocyte injuries (i.e. cellular edema, light and dark vacuoles, cell membrane disruption and, finally, internal cytolysis) as observed by TEM. At 3 months postoperatively no clinical differences between the two groups of transplants were observed. Conclusion Corneal stroma can be evaluated qualitatively and easily by means of light microscopy during organ culture. Further studies are needed to investigate whether the presence of lysed keratocytes in the graft's stroma actually influences the outcome of transplantation.

Purpose To analyze the influence of various factors on the post-operative refractive power after anterior lamellar keratoplasty (ALK) and penetrating keratoplasty (PK) in eyes with corneal diseases not involving the corneal endothelium. Methods Retrospective comparative case series. Two hundred and thirty-eight consecutive eyes of 238 patients with clear graft and at least one post-operative Orbscan examination performed after suture removal were retrospectively analyzed. Multivariate analysis of recipient and surgical parameters was performed by multivariate regression. Results The average Orbscan 3-mm corneal power was 47.1 D with a wide 95%-confidence interval [40.3 D; 53.9 D]. It was 47.9 D for ALKs and 46.2 D for PKs (p 0.5). Conclusion The post-operative, suture-out, corneal refractive power is higher after ALK compared with PK and it features important variability. In ALK eyes, non-oversized grafts result in post-operative corneal power close to normal values and corneal diseases associated with stromal thinning result in higher post-operative corneal power. Taking into account these parameters at the time of surgery may help decreasing the post-operative spherical refractive error.

Purpose To analyze risk factors for endothelial cell loss after corneal transplantation. Methods Cohort study including 1438 consecutive eyes of 1438 patients who underwent Penetrating Keratoplasty, Anterior Lamellar Keratoplasty, or Descemet Stripping with Endothelial Keratoplasty between 1992 and 2010. To describe post-operative endothelial cell loss, the biphasic linear model was fitted to grafts with at least 2 (early phase) or 3 (late phase) endothelial cell density (ECD) measurements in time: ECD = ECD0 – (t * E), for t 1 year (late phase). The least squares estimates were used to calculate the coefficients of the various equations for each eye. Results The average follow-up time was 45.9+39.3 months (mean+SD). The early-phase and late-phase annual endothelial cell loss (ECL) were, respectively, -24.7+18.8% (n=921) and -10.8+10.3% (n=664). Overall, the model-predicted cell loss was lower than the observed cell loss in the early phase and higher in the late phase. In multivariate analysis, 5 variables significantly influenced the early-phase endothelial cell loss: graft storage time, recipient rejection risk, preoperative hypertony, surgical group, and rejection episodes. Three variables significantly influenced the late-phase endothelial cell loss: recipient rejection risk, surgical group, and rejection episodes. Conclusion Extending the graft organ culture time beyond 3 weeks results in higher early cell loss. High-risk recipient and rejection episodes are important risk factors for cell loss. ALK induces minimal cell loss whereas keratoplasty in eyes with impaired recipient endothelium is associated with high cell loss.

Purpose To compare anterior lamellar keratoplasty (ALK) with the reference surgical technique (penetrating keratoplasty [PK]) for risk of rejection. Design Retrospective, comparative case series. Methods setting: Institutional. patients: One hundred forty-nine consecutive ALK procedures (ALK group) and 149 matched PK procedures (PK group) performed for optical indication in eyes with corneal diseases not involving the corneal endothelium (ie, keratoconus, scars after infectious keratitis, stromal dystrophies, and trauma). main outcome measures: Three-year graft survival and cumulative incidence of rejection episodes. Results The 3-year overall graft survival was 98.3% in the ALK group and 94.3% in the PK group ( P = .03). The 3-year cumulative incidence of irreversible rejection was 0.0% in the ALK group and 5.2% in the PK group ( P = .02). The 3-year cumulative incidence of rejection episodes was 10.0% in the ALK group and 23.2% in the PK group ( P = .01). The average graft-to-rejection episode time was 21.6 ± 22.0 months in the PK group and 19.4 ± 12.7 months in the ALK group ( P = .76). Conclusions ALK techniques dramatically decrease the risk of irreversible endothelial and stromal rejection after corneal transplantation. Immune-mediated rejection episodes are observed after ALK, but its lower graft failure rate compared with PK is at least partly the result of the absence of endothelial rejection. In addition, the incidence of rejection episodes after ALK was 50% less than that observed after PK.

Purpose To analyze the variation of the objective refraction induced by pharmacological pupillary dilation in a normal population. Methods The objective refraction obtained by an auto-kerato-refractometer was analyzed before and after maximum pupillary dilation obtained by 0.5% Tropicamide and 10% Phenylephrine. 200 phakic eyes of 100 patients aged from 15 to 76 years were prospectively included. The refractive data were expressed in a dioptric space by 3 Cartesian coordinates (X, Y, Z). Results After pupil dilation, the mean refraction ranges from -0.08(+0.11)×90.2° to +0.41(+0.10)×90.3° this equal to an astigmatic vectorial variation of (+0.03)×89.6°. The spherical equivalent increases significantly (hyperopization of +0.49D: +0.24D vs +0.74D p

Purpose To compare the corneal thickness of eyes with high myopia with that of emmetropic eyes. Methods One hundred corneas of 50 myopic patients (axial length >26 mm) and 100 corneas of 50 emmetropic patients (spherical equivalent between –1D and +1D) were prospectively analysed by means of Orbscan and ultrasonic pachymetry. The location of related points to apex, which were quantified using the rectangular coordinates (x, y) of the thinnest point, were used to determinate the location of the quadrant and the distance between this thinnest point and the centre (Pythagoras theorem). Results In the myopic group, the axial length was 27.2+/-1.6mm (26.1 to 33.1mm) and the subjective spherical equivalent was –8.17+/-1.72D (-19.2 to –5.6D). As compared with emmetropic eyes the corneal thickness was significantly lower (p

Purpose To investigate the correlation between the eye axial length and the corneal biometric parameters in a normal population. Methods We prospectively recorded axial length, ultrasonic pachymetry and corneal topography (Orbscan) of 250 healthy eyes (excluding high myopia) of 125 patients aged from 10 to 80 years. Three refractive subgroups (hyperopia, emmetropia, myopia) were defined according to the subjective spherical equivalent (emmetropia -1D to +1D). Corneal biometric parameters were compared in these 3 groups and were correlated with the axial length. Results No significant correlation was found between axial length and the corneal biometric parameters (i.e., pachymetry, anterior corneal curvature, corneal cylinder, corneal diameter, asphericity, irregularity, irregular astigmatism, location of thinnest point…)(r≤0.09 p≥0.07). The three subgroups were not significantly different for the corneal biometric parameters (p>0.13) except for the corneal curvature (hyperopia, 42.89D; emmetropia, 43.69D, myopia, 44.37D; p 0.14). Conclusion Although corneal curvature is relevant to spherical refraction, axial length does not seem to have a significant influence on the biometric parameters of the cornea.

Purpose To investigate the relationship between refractive astigmatism and corneal (anterior and posterior) astigmatism in normal eyes. Methods We prospectively recorded refractive astigmatism and corneal astigmatism (Orbscan) of 500 healthy eyes (including ametropia) of 250 patients. Astigmatism data was analyzed using polar values (cylinder, axis) and rectangular coordinates (x,y) which respectively represent WTR/ATR component (Jackson 0°/90°) and oblique component (Jackson 45°/135°). Internal astigmatism and enantiomorphism (mirror-image symmetry between both eyes) were calculated. Results Anterior corneal cylinder showed higher correlation with subjective cylinder (r: 0.84 to 0.89 p 0.05). The relative proportion of the anterior corneal astigmatism in the subjective astigmatism increased with the subjective cylinder (r=0.54 p

Purpose To assess the refractive and topographic outcome after Intracorneal ring segment (ICRS) implantation in the management of keratoconus. Methods Prospective case series of 10 keratoconic eyes (10 patients) with ICRS implantation (KERARING Mediphacos Inc., Belo Horizonte, Brazil). All patients were contact-lens intolerant. The main outcome measure were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refraction, keratometry, SAI and SRI. Patients were examined before ICRS implantation and 3 months afterward. Results Mean preoperative keratometry was 50.94 ± 5.56 Diopters (D) (range 45.81 – 59.32). KERARING implantation decreased the spherical equivalent by 1.60 ± 3.31 D and the average keratometric values by 2.05 ± 1.49 D. UCVA significantly increased from 0.16 ± 0.16 to 0.26 ± 0.25 (P 0.05) and SRI increased from 1.30 ± 0.38 to 1.56 ±0.52 (P>0.05). Conclusion ICRS implantation improved UCVA and BCVA in the majority of the keratoconus patients. The treatment was more efficient for patient with low preoperative keratometry values.

To analyse the reproducibility of corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann-correlated intraocular pressure (IOPg) and corneal-compensated intraocular pressure (IOPcc) obtained with the ocular response analyzer (ORA).This is a prospective study, nonmasked, of eight successive examinations with the ORA device in 60 normal eyes. Using 30 eyes (one eye per subject), the reproducibility was assessed by comparing the first series of four examinations to the second four and by calculating the within-subject coefficient of variation. The correlation and difference with the fellow eye were analysed, respectively.The mean values were 10.7 ± 1.8 mmHg, CRF; 10.6 ± 1.6 mmHg, CH; 15.9 ± 3.9 mmHg, IOPg and 16.2 ± 3.7 mmHg, IOPcc. The reproducibility was significantly different for CRF (5.2 ± 5.9%), CH (7.3 ± 8.6%), IOPg (7.7 ± 6.7%) and IOPcc (10.1 ± 8.0%); p0.001. Considering the reproducibility, CRF correlated with CH (rs = 0.55; p0.001) and showed to be independent of IOPg and IOPcc. The score spread was best for CRF (2.6 ± 1.5 mmHg; 24.0%) compared to IOPg (4.3 ± 1.5 mmHg; 28.1%) and CH (3.1 ± 1.7 mmHg; 29.9%) and worst for IOPcc (5.5 ± 2.5 mmHg; 34.4%). The lowest difference with the fellow eye was observed for CRF (5.0%; p = 0.09). The correlation with the fellow eye was high, especially for IOPcc and CRF (rs0.9; p0.001) followed by IOPg and CH (rs0.8; p0.001).The ORA device provides reproducible information on viscoelastic properties of the cornea in normal eyes notably CRF and CH. IOPcc was less reproducible. Four measurements per eye were necessary to reach a 10% precision and six for 5%.

PURPOSE To analyze morphometry of corneal epithelial cells in normal eyes and after anterior lamellar keratoplasty (ALK) using confocal microscopy. METHODS This retrospective comparative case series included 29 eyes of patients who had undergone ALK (ALK group) and 29 subjects before refractive surgery with normal corneas (control group). The Heidelberg Retina Tomograph II with the Cornea Module was used. Images were recorded and analyzed with Image J software. Morphometric parameters used to analyze epithelial cells were cell area, coefficient of variation of cell area, perimeter, circularity, and Feret diameter. RESULTS Confocal microscopy was performed between 3 and 70 months after surgery. For basal epithelial cells, no significant differences between right eyes and left eyes were found in normal eyes for all morphometric parameters (P 0.40). The mean epithelial cell area increased during central and vertical migration (migration of epithelial cells from the basal stratum to the outermost layer) (P < 0.001). The mean basal cell area in the central zone was significantly higher (P < 0.001) after ALK in the ALK group than that in the control group. After ALK, the mean basal cell area decreased with postoperative time (rS = -0.78; P < 0.001) and returned to normal 24 months after transplantation (P = 0.27). Comparison of both groups showed significant differences in cell perimeter, circularity, and Feret diameter of basal cells and intermediate cells (P ≤ 0.001). CONCLUSION Morphometric analysis of the corneal basal epithelium seems to be a relevant tool to assess the epithelial condition.

Purpose To analyze the variation of best corrected visual acuity (BCVA) obtained with rigid gas permeable (RGP) lenses in keratoconic eyes compared to best spectacle-corrected visual acuity (BSCVA). Methods We prospectively recorded visual acuity data (BSCVA and BCVA with RGP), subjective refraction, keratometric readings and lens geometry in 135 eyes of 78 patients with keratoconus. Acuity data was converted into LogMAR units for statistical analysis. BSCVA was compared to BCVA with RGP lenses, and the differences were correlated with all parameters. Results The decimal BSCVA and decimal BCVA with RGP lenses was 0.36 (0.44 LogMAR, 20/56) and 0.70 (0.15 LogMAR, 20/29), respectively. The mean difference after RGP lens fitting was +2.83 lines ±2.55 (range 0-11.6). The gain was superior to 1 line in 70%, 3 lines in 40% and 6 lines in 16%. The difference was correlated with the BSCVA (rS=0.90 p

Purpose To compare various indices calculated using refractive data to quantify defocus. Methods Subjective refraction, pupil diameter (Colvard) and asphericity (Orbscan) were prospectively recorded in 200 healthy eyes (including ametropia) of 121 patients. Refractive data were expressed by a sinusoidal curve in one plane (power / meridian) and by a vector in a 3D dioptric power space. The three Cartesian coordinates of the vector respectively represented the spherical equivalent, WTR/ATR component (0°/90° Jackson), and oblique component (45°/135° Jackson). The defocus was quantified by the root-mean-square (RMS) value of the power curve and the length of the vector. Correlations between uncorrected visual acuity (UCVA) in LogMAR units and principal parameters including defocus indices and refractive parameters were analyzed. Results The length of the power vector and the RMS index provided the highest correlation with UCVA (rs=0.90 p 0.20) with UCVA. Conclusion The length of the sphero-cylindrical vector is clinically relevant to quantify the defocus with the aid of a single index using both spherical and astigmatic components of refraction. The UCVA is mainly explained by the ametropia.

PURPOSE To compare optical low-coherence reflectometry (OLCR) and ultrasound pachymetry in measuring corneal graft thickness in patients after keratoplasty. METHODS We retrospectively measured the central graft thickness in 41 eyes of 41 patients with the OLCR pachymeter (Haag Streit, Koeniz, Switzerland) and the SP-2000 contact ultrasound pachymeter (Tomey, Nagoya, Japan). Five separate measurements were performed on each eye with both methods. Mean, SD, repeatability, and coefficient of variation of measurements were calculated, and the correlation between the 2 methods was studied with Spearman regression. RESULTS Mean central graft thickness was 546 +/- 51 (SD) microm with the contact ultrasound pachymeter and 546 +/- 47 microm with the OLCR pachymeter. The correlation between both methods was strong (rs = 0.96). No significant differences in mean SD of measurements were observed between OLCR pachymetry (mean SD = 4.66 microm) and contact ultrasound pachymetry (mean SD = 4.88 microm). The repeatability of both methods was comparable (P = 0.06) and high (the average coefficient of variation of the central corneal graft thickness was 0.9% with both pachymeters). The postoperative time did not affect the correlation between both pachymeters (P > 0.05). CONCLUSIONS Central corneal graft thickness values obtained with the OLCR pachymeter were similar to those obtained with a contact ultrasound pachymeter. In some cases of lamellar keratoplasty, the corneal refractive index could change at the interface level that could affect OLCR measurements.

Purpose: To analyze the late changes in refraction, cornea topography, and pachymetry after penetrating keratoplasty. Methods: We have retrospectively analyzed data of 64 eyes of 56 patients with a clear corneal graft andno other ocular diseases. The eyes were examined soon and several years after all sutures were removed, at 19.5 ′ 3.1 months and 76.8 ′ 25.2 months, respectively, after keratoplasty. All eyes were examined using the EyeSys 2000 videokeratograph and the Tomey SP2000 ultrasonic pachymeter. Corneal surface regularity was studied using the indices provided by the Holladay Diagnostic Summary (ie, asphericity coefficient Q; comeal uniformity index CU; predicted corneal acuity PCA). Irregular astigmatism was quantified using semimeridian data from videokeratographs (refractive power symmetry index). Results: Visual acuity increased by an average of 0.35 ′ 0.93 lines (P = 0.002) between the 2 examinations, whereas no significant changes in refraction and videokeratoscopy (ie, power, indices, and irregular astigmatism) were observed (P ≥ 0.08). Central corneal thickness significantly increased from 542 ′ 31 μm to 572 ′ 38 μm (P < 0.001). Change in BSCVA did not significantly correlate with the change in refraction, in topographic indices, or in irregular astigmatism (r s ≤ 0.13; P ≥ 0.16). Conclusion: Late after penetrating keratoplasty, best corrected visual acuity shows a small but statistically significant improvement, whereas refraction and corneal surface regularity are stable. This late improvement in visual acuity is not explained by current techniques.

Infectious crystalline keratopathy (ICK) is a rare complication of penetrating keratoplasty characterised by an indolent infectious keratitis in which needle-like, branching crystalline opacities are seen within the corneal stroma, in the absence of appreciable corneal or anterior segment inflammation.1 We report an unusual case of recurrent ICK which occurred in two successive corneal grafts. A 63 year old man underwent penetrating keratoplasty for aphakic bullous keratopathy. The immediate postoperative course was uneventful. Topical corticosteroid (dexamethasone 0.1%) was initially given four times daily, and then was tapered to twice daily. Seven months after transplantation, visual acuity decreased to counting fingers with no other symptoms. Slit lamp examination showed a focal area of non-suppurative branching intrastromal white opacities (Fig 1). Corneal scrapings for diagnostic smears and …

AIMS—To detect the presence of guttae by means of light microscopy during organ culture and to evaluate the influence of the presence of guttae in the donor tissue on transplantation outcome. METHODS—Donor corneas were investigated for the presence of guttae by means of light microscopy at the end of organ culture. Recipient corneal buttons from patients with severe Fuchs' dystrophy and donor corneas with advanced guttae were first studied by light microscopy and subsequently by transmission electron microscopy. Lastly, 168 consecutive donor corneas were evaluated for the presence of guttae and issued for transplantation. RESULTS—Corneal specimens with Fuchs' dystrophy displayed numerous round highly reflecting guttae at the level of the corneal endothelium. Donor corneas with advanced guttae showed less numerous guttae. Among 168 organ cultured donor corneas issued for transplantation, low density guttae were found in 43 (25.6%) corneas. The endothelial cell density and figure coefficient were significantly lower and organ culture time was significantly higher in the cornea guttata group than in the control group. The presence of grouped guttae significantly decreased the adjusted graft survival. The incidence of postoperative stage 3 cornea guttata was significantly higher when grouped guttae were found (5/6) than when no guttae or scattered guttae were found (8/101). CONCLUSION—Cornea guttata can be detected during organ culture by means of light microscopy. It is associated with a decrease in endothelial cell figure coefficient and cell density. The presence of grouped guttae is associated with poorer graft survival and more frequent stage 3 cornea guttata in the graft after transplantation.

AIMS—Donor organ cultured corneal tissue selection before penetrating keratoplasty is carried out by taking into account different variables. The objective was to identify preoperative variables which are significantly and independently associated with transplant outcome and should effectively be taken into account before transplantation. METHODS—231 consecutive penetrating keratoplasties were prospectively studied using organ cultured tissue. Morphometric analysis of the donor corneal endothelium was performed before transplantation. Graft survival and endothelial cell density, during the second year following transplantation, were studied both at a univariate and multivariate level. RESULTS—Recipient age, recipient rejection status, and preoperative diagnosis significantly influenced graft survival. Graft survival was higher when using corneal tissue from donors older than 80 years. Postoperative endothelial density decreased with preservation time and coefficient of variation after preservation. It increased with endothelial cell density after preservation and deswelling time, and correlated with preoperative diagnosis. CONCLUSION—Organ cultured corneas with endothelial cell density after preservation

Resume Nous rapportons le cas d’une femme de 67 ans sans antecedent ophtalmologique, adressee pour la prise en charge d’une keratite infectieuse post-traumatique avec un tissu de vetement un mois auparavant au Portugal, et s’aggravant malgre un traitement antibiotique topique fortifie. A l’entree, l’acuite visuelle etait limitee a « perception lumineuse ». Un abces corneen de 11 mm de diametre infiltrait toute l’epaisseur de la cornee. Le diagnostic microbiologique et la microscopie confocale ont revele la presence d’un champignon filamenteux saprophyte de l’environnement : Cylindrocarpon lichenicola qui est responsable de keratites de maniere exceptionnelle. Devant le risque de perforation corneenne, une keratoplastie transfixiante a ete realisee malgre un traitement par voriconazole et amphotericine B. Les suites ont ete simples avec une absence de recidive a un an. Une etiologie fongique doit etre suspectee devant toute keratite d’origine traumatique. Des examens microbiologiques specifiques et une microscopie confocale doivent etre realises precocement afin de ne pas retarder la prise en charge adaptee.

To the Editor: It is well established that immunosuppression after organ transplantation carries an increased risk of certain malignant tumors. Of these tumors, those of the skin and lip and lymphomas are the most common.1 We report a carcinoma of the corneoscleral limbus in a patient who was treated with cyclosporine after undergoing heart transplantation. A 60-year-old man was referred because of a tumor of the corneoscleral limbus in his left eye. He had undergone a heart transplantation five years earlier. The patient had not previously had cancer or ocular disease, and he had not worn contact lenses. After undergoing . . .

Aim To evaluate the variability of the measurements obtained with the Ocular Response Analyzer (ORA), particularly for the corneal hysteresis (CH), corneal resistance factor (CRF) and the corneal-compensated intraocular pressure (IOPcc). Material and Methods Both eyes of 30 healthy volunteers were prospectively measured with the ORA, including ametropia. The standard deviation (SD) and coefficient of variation (CoV) were calculated according to the mean values. The difference between the mean values of eight repeated measurements and the mean values of five or less repeated sessions were illustrated in a diagram. The difference with the fellow eye was expressed in percentage. Results The mean values and SD/CoV obtained after five measurements were 16.04 ± 1.81/ 0.11 for the IOPcc, 10.64 ± 1.04/ 0.10 for the CH, and 10.72 ± 0.87/ 0.08 for the CRF. The mean values of five repeated exams only differed by 2.05% CRF, 2.51% CH, and 3.19% IOPcc from the mean values of eight exams, where as two exams differed by 3.9% CRF and 7.1% IOPcc. Discussion The ORA is at present the only device capable of quantifying the CH and CRF. Our mean values conformed to the mean values of recent studies from other authors. Regarding to the clinical application of the ORA the variability of the results makes it difficult to analyze the complexity of the biomechanical, especially if modified by surgery or other pathologies. Conclusion We obtained repeatable scores especially for the CRF followed by the CH and lower results for the IOPcc. The variability of the results should be compensated by increasing the number of measurements depending on the required parameter. Further studies and technical evolution will help to improve standard methods to quantify visco-elastic properties of the cornea.

To compare 3 techniques used for removing the recipient stroma during anterior lamellar keratoplasty (ALK): the "big-bubble" technique, manual dissection using a crescent blade and slitlamp operating microscope, and microkeratome lamellar cut.Retrospective comparative cohort study of 69 consecutive ALKs and 69 consecutive penetrating keratoplasties (PKs). Manifest refraction, slitlamp examination, Goldmann tonometry, ultrasound pachymetry, specular microscopy, and confocal microscopy findings were recorded.The 12-month graft survival estimate was 98.5% in the ALK group and 94.1% in the PK group (P = .19). Higher endothelial cell density was found after ALK (P.001). At 12 months (before suture removal), 53% of eyes that underwent ALK and 44% of eyes that underwent PK had 20/40 or better spectacle-corrected visual acuity (P = .24). In keratoconic eyes, these values were 83% and 69%, respectively (P = .18). Significant differences in visual acuity, corneal central thickness, and keratocyte density among ALK subgroups were found, with the best results obtained using the big-bubble technique and the worst results obtained using the microkeratome. In eyes that underwent ALK, visual acuity increased with keratocyte density.Better results were obtained after ALK vs PK, and the big-bubble technique seemed to provide the best results.