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Purpose: To determine if early central corneal thickness (CCT) and best-corrected visual acuity (BCVA) changes indicate graft detachment after uncomplicated Descemet membrane endothelial keratoplasty (DMEK)., Methods: In this analysis of our prospectively collected ADDA registry data ( https://drks.de/search/de/trial/DRKS00027180 ), 45 pseudophakic eyes underwent DMEK surgery at the Department of Ophthalmology, RWTH Aachen University. Anterior segment optical coherence tomography (AS-OCT), the presence of stromal ripples on the posterior corneal surface, and BCVA measurements were assessed prior to, 1 day, 1 week, 1 month, and 6 months after surgery., Results: Eyes were categorized into three groups: no graft detachment (group 1) (20/45; 44.4%), < 1/3 graft detachment (group 2) (14/45; 31.1%), ≥ 1/3 graft detachment followed by rebubbling (group 3) (11/45; 24.4%). Eyes in group 3 had a greater CCT prior to (746.8 ± 95.8 µm vs. 665.0 ± 74.4 µm, P = 0.041), and 1 week (666.8 ± 119.5 µm vs. 556.5 ± 56.8 µm, P = 0.001) after DMEK compared to group 1. By 1 month, CCT in all groups aligned. Comparing prior to and 1 week after DMEK, none of the eyes in group 1 had an increase in CCT, while the CCT increased in 25.0% of eyes in group 2 and 22.2% in group 3. In group 1, 90.0% had a CCT of < 600 µm 1 week after DMEK, compared to only 50.0% in group 2 and 36.4% in group 3. In group 1, 90.0% (18/20) had an improved BCVA 1 week after DMEK, while in groups 2 and 3, 86.7% (12/14) and 18.2% (2/11) improved, respectively. One patient in group 3 showed posterior stromal ripples 1 day and 1 week after DMEK., Conclusion: If 1 week after uncomplicated DMEK CCT is < 600 µm and has decreased from before surgery, BCVA has improved, and there are no posterior stromal ripples, a graft detachment ≥ 1/3 and the need for rebubbling are very unlikely. In all other cases, meticulous slit-lamp and OCT inspection of the peripheral graft for detachments should be advised., (© 2024. The Author(s).)

Purpose: To report a case of severe verrucous posterior polymorphous corneal dystrophy (PPCD) and cataract, which was treated with Descemet membrane endothelial keratoplasty (DMEK) and simultaneous cataract surgery as a triple procedure (Triple-DMEK)., Methods: A 62-year-old female patient presented to our department for co-evaluation of advanced PPCD with cataract and progressive light sensitivity in both eyes. The clinical examination demonstrated unusual clinical findings with prominent verrucous lesions on the posterior surface of the cornea without corneal decompensation. We performed a Triple-DMEK in case of simultaneous cataract. The corneal tissue was examined by light and transmission electron microscopy., Results: Intraoperatively, it was difficult to remove the verrucous structures completely after classical descemetorhexis. Light microscopic examination demonstrated epithelium-like transformation of the corneal endothelium by immunostaining (cytokeratin AE1/3 staining). Transmission electron microscopy revealed thickening of Descemet's membrane (18.5 to 30.0 µm). The anterior banded layer had a normal structure and was slightly thickened (3.5 to 5.5 µm). A normal posterior non-banded layer (PNBL) was observed but thinned (2.5 to 4.0 µm) or missing. It was followed by an altered PNBL with abnormal fibrillary inclusions, which was strongly and variably thickened (11.0 to 24.5 µm). The corneal endothelium was degenerated, partially absent, and epithelial-like altered. The nodular lesions were found to consist of a few degenerated cells that were embedded in an amorphous extracellular matrix interspersed with collagen fibers, which were not arranged in regular lamellae, forming the corneal stroma. The occurrence of pigment granules among the cellular debris suggested that the cells were endothelial cells. The corrected distance visual acuity improved from 20/50 to 20/30 in the right eye (+ 0.00/- 1.75/157°) and from 20/60 to 20/30 in the left eye (+ 0.00/- 1.75/33°), with significant improvement in light sensitivity., Conclusion: The clinical and ultrastructural findings seem to be an unusual variant of the typical characteristic appearance of a PPCD. This case demonstrates that Triple-DMEK is feasible even in very advanced dystrophic changes of the posterior corneal surface, with good morphological and functional results., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: To objectify the indication for re-bubbling by analyzing graft detachments (GDs) after Descemet membrane endothelial keratoplasty., Methods: In this retrospective monocentric observational study, re-bubbling cases of 450 Descemet membrane endothelial keratoplasties and the percentage of the residual gas filling (RGF) in the anterior chamber on the first postoperative day were collected. The number/location/extent of GDs and the corneal thickness above GDs were analyzed using anterior segment optical coherence tomography., Results: From a total of 450 grafts, 384 (85.3%) had at least a minimal degree GD. One hundred twenty-two of 450 grafts (27.1%) underwent at least 1 re-bubbling. The mean RGF was significantly lower in eyes with GD (67.7 ± 12.6%) than in eyes without GD (74.2 ± 11.3%). GDs occurred most frequently in the inferotemporal quadrant (46.0%). GDs were significantly more likely to require a re-bubbling when the central parts of the graft were affected (94.0% vs. 35.7%). The number of detachments per graft was directly proportional to the re-bubbling rate. The GDs which required a re-bubbling were on average 56 μm higher and 461 μm wider than the untreated ones. The cornea above the GDs that needed a re-bubbling was significantly thicker than above the untreated GDs (mean 988 ± 102 μm vs. 951 ± 99 μm)., Conclusions: The RGF seems to be a major influencing factor for graft attachment. The most susceptible location of the GD is inferotemporal. The main factors that need to be investigated to decide if a re-bubbling is required are the number of detachments per graft, their dimensions, whether the central portions of the graft are involved, and the corneal thickness above GDs., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to report on the occurrence of corneal guttae after Descemet membrane endothelial keratoplasty (DMEK)., Methods: In this retrospective case series, 13 eyes of 13 patients who underwent DMEK at 2 tertiary referral centers between 2007 and 2021 (average available follow-up 73 ± 52 months, range 18-174 months) and showed corneal guttae during postoperative examinations were included. Eye bank images were retrospectively reviewed., Results: Occurrence of guttae was observed by specular microscopy in 13 eyes. In 11 cases, presence of guttae was confirmed by confocal microscopy and in 1 case by histology. Five eyes showed an increase in guttae density during the postoperative course. Surgery indications were Fuchs endothelial corneal dystrophy (n = 11), pseudophakic bullous keratopathy (n = 1), and DMEK graft failure after allograft rejection (n = 1); the latter eye had shown no signs of guttae after primary DMEK. Two eyes with guttae required a repeat DMEK due to graft failure. At the last available follow-up, all 11 remaining eyes had clear corneas and 10 eyes had a best-corrected visual acuity of ≥0.9 (decimal). During donor cornea processing in the eye bank, no guttae were observed on the donor tissue., Conclusions: Corneal guttae can occur after DMEK including in eyes operated for indications other than Fuchs endothelial corneal dystrophy and most likely guttae were present on the donor graft but were not detectable by routine slit-lamp and light microscopy evaluation in the eye bank. Postoperative guttae density varies among patients and especially small isolated guttae do not seem to affect clinical outcomes., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to describe the feasibility of Descemet membrane endothelial keratoplasty (DMEK) as a treatment modality for spontaneous detachment of DM (DMD) decades after penetrating keratoplasty (PK) for keratoconus., Methods: We describe the clinical characteristics and therapeutic surgical approach in 6 eyes of 5 patients with DMD. Clinical images, anterior segment optical coherence tomography scans, and histological findings are presented., Results: Mean age of patients at time of diagnosis was 60 years (range 56-66 years). Mean interval between PK and occurrence of DM detachment was 36 years (range 29-45 years). In 4 of 6 eyes, air injections into the anterior chamber were initially attempted to reattach DM to the stroma but without long-lasting effect. Two eyes underwent repeat PK because of pronounced ectasia after long-standing DMD and stromal scars. DMEK was performed successfully in 4 eyes leading to an increase in visual acuity and a reduction in central corneal thickness. Electron microscopy showed abnormal vacuolar inclusions and collagenous material in the posterior nonbanded layer and a separation of the anterior banded layer from the posterior nonbanded layer., Conclusions: This case series provides evidence that DMEK is a viable option in eyes with spontaneous DM detachment after PK. Visual outcome is limited by the persisting high astigmatism in the ectatic cornea. Illustrated by a small series of patients, the results of DMEK in this condition are presented and new findings about the pathophysiology are given., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to report a novel surgical technique for altering donor Descemet membrane endothelial keratoplasty (DMEK) curvature to match host posterior stroma in a patient with advanced keratoconus (KC) and endothelial decompensation., Methods: We report a 56-year-old man with Fuch endothelial dystrophy and KC, who underwent DMEK due to endothelial decompensation. A triangular area of graft detachment centered on the apex of cones persisted after repeat gas tamponade. A radial incision from the graft edge to the apex was used to allow overlapping of the graft, thereby increasing the grafts curvature., Results: The use of a radial incision in the Descemet membrane (DM) graft was made to allow the graft overlap and adapt to the new shape. By matching the donor curvature to that of the hosts posterior curvature, full adhesion of the graft was achieved with the use of a short-acting air bubble by 1 week after the procedure., Conclusions: The mismatch in the curvature of the DM graft and the host posterior corneal surface, in cases with KC or very steep corneas, should be taken into consideration because it can lead to redundancy folds. These can result in atypical, conical detachments, distinct from the typical peripheral detachments seem commonly in DMEK. A single radial incision in the DM graft combined with air tamponade is a feasible treatment option in cases where DMEK fails to attach because of apparent curvature mismatch between the donor and host., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background/aims: To analyse graft detachments prior to rebubbling, the influence of rebubbling on the postoperative outcome after Descemet membrane endothelial keratoplasty (DMEK) and the need for rebubbling on the contralateral eye., Methods: In this retrospective cohort study, out of 1541 DMEKs, optical coherence tomography scans and clinical records of 499 eyes undergoing rebubbling after DMEK at the University Hospital of Cologne, Cologne, Germany, were examined. Main Outcome measures were (a) number, localisation and size of graft detachments; (b) influence of rebubbling/s on postoperative outcome after 12 months; and (c) rebubbling risk of the contralateral eye after DMEK., Results: Mean number of detachment areas was 2.02±0.9. Mean lateral diameter of all detachments was 4534.76±1920.83 μm. Mean axial diameter was 382.53±282.02 μm. Detachments were equally distributed over all regions of the cornea. Best spectacle corrected visual acuity ( BSCVA) after 12 months was 0.197±0.23 logarithm of the minimum angle of resolution, endothelial cell density (ECD) was 1575.21 ± 397.71 cells/mm 2 and mean central corneal thickness (CCT) was 566.37 ± 68.11 μm. BSCVA, CCT, ECD or endothelial cell loss of all rebubbled patients were not influenced by the number of rebubblings or the time between DMEK and rebubbling. Of the rebubbled patients, which received a DMEK subsequently on the other eye, 193 (58.8%) also received a rebubbling, which was significantly higher, when compared to the overall rebubbling rate of 32.3% (p=0.000)., Conclusions: The overall number of rebubblings has no influence on the postoperative outcome after DMEK, if a rebubbling becomes necessary. Patients who received a rebubbling on one eye have an elevated risk for a rebubbling on the fellow eye., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: None

Purpose: To report the clinical properties and risk factors for corneal Descemet membrane (DM) folds after deep anterior lamellar keratoplasty (DALK) in patients with keratoconus., Methods: This is a retrospective case-control study. Study participants-experimental group: 44 eyes with DM folds after DALK; control group: 135 eyes without DM folds after DALK., Results: Forty eyes with DM folds were displayed as 1 or 2 translucent lines in the DM layer. Three eyes appeared as several arcuate shape lines, and 1 eye presented as a radial shape. DM folds impaired corrected visual acuity after DALK (P = 0.018). Age older than 20.5 years at surgery and disease duration longer than 5.5 years were independent risk factors for DM fold formation after DALK surgery (odds ratio 5.39, 95% confidence interval: 2.11-13.73, P < 0.001; 6.60, 95% confidence interval: 2.92-14.94, P < 0.001). Preoperative Kmean, Kmax, central corneal thickness, anterior chamber depth, sex, history of rigid gas permeable contact lens wearing, Vogt striae, stromal scar, and intraoperative microperforation had no influence on the occurrence of DM folds (P1 = 0.775, P2 = 0.896, P3 = 0.555, P4 = 0.182, P5 = 0.656, P6 = 0.237, P7 = 1.000, P8 = 0.587, and P9 = 0.798)., Conclusions: DM folds impaired postoperative corrected visual acuity. The risk factors for DM folds included age older than 20.5 years and disease duration longer than 5.5 years.

Purpose: To challenge the current consensus on the mechanism causing corneal hydrops in eyes with keratoconus (KC)., Design: Retrospective, interventional case series., Methods: Sixteen eyes of 10 patients with comorbid KC and Fuchs endothelial corneal dystrophy (FECD) underwent uncomplicated Descemet membrane endothelial keratoplasty (DMEK), and 5 eyes of 5 patients with KC alone underwent Bowman layer (BL) transplantation complicated by inadvertent perforation of the posterior corneal stroma and Descemet membrane (DM). The presence or absence of hydrops was assessed by intra- and postoperative optical coherence tomography and by slit-lamp biomicroscopy., Results: None of the 16 DMEK eyes manifested a hydrops at any time during or after surgery. By contrast, all 5 eyes undergoing BL transplantation complicated by posterior corneal perforation demonstrated a corneal hydrops, evident both intra- and postoperatively., Conclusions: In eyes with KC, even the complete removal of DM did not produce a hydrops, whereas a combined defect in DM and the posterior corneal stroma seemed to consistently elicit a typical corneal hydrops., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose of Review: Endothelial keratoplasty has evolved tremendously since its inception. Thick Descemet stripping automated endothelial keratoplasty (DSAEK) grafts have made sway for slimmer ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). This review discusses the recent literature comparing outcomes of UT-DSAEK, DSAEK, and Descemet membrane endothelial keratoplasty (DMEK)., Recent Findings: DMEK provides quick visual recovery and has remarkably low incidence of graft rejection. However, the learning curve is long compared to DSAEK. UT-DSAEK utilizes donor grafts less than 100-μm thick. Recent studies comparing DMEK and UT-DSAEK have shown DMEK has better visual outcomes with similar rejection rates., Summary: UT-DSAEK remains an excellent surgical option for endothelial keratoplasty in eyes with complex anterior segment anatomy. The visual outcomes after UT-DSAEK have been shown to be superior when compared with DSAEK. Recent studies show that DMEK provides better visual outcomes compared with UT-DSAEK.

Recurrence of herpes simplex virus (HSV) keratitis is a problem of keratoplasty and the prognosis is often poor in spite of oral acyclovir (ACV) prophylaxis. This 64-year-old woman was a known case of recurrent HSV endotheliitis with irreversible corneal oedema in the left eye for 2 years. She underwent Descemet membrane endothelial keratoplasty with intraocular lens implantation under perioperative oral ACV and prednisolone. After 4 weeks, her cornea cleared with the best-corrected vision of 6/9. After 2.5 months, she presented with sudden photophobia and visual loss. An increasing focal endothelial lesion was noticed even after oral ACV. Suspecting fungal interface infection, anterior chamber tap was done for PCR for panfungal and viruses. It was only positive for HSV. Oral ACV was changed to oral valacyclovir. The patient responded dramatically within 2 weeks, and after 12 weeks, the lesion disappeared completely, leaving behind a faint scar with 6/9 p vision. Oral valacyclovir, a prodrug of ACV, may work better than oral ACV., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare the graft thickness of eye bank precut grafts with graft thickness measured 1 year after Descemet stripping automated endothelial keratoplasty (DSAEK) and to correlate the graft thickness of eye bank precut grafts with best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) 1 year after DSAEK., Methods: This was a retrospective registry study of 183 eyes of 179 DSAEK patients. Grafts were cut in the eye bank after 1 day in dextran-containing medium, and thickness was measured by optical coherence tomography immediately after precutting. Examinations 1 year after DSAEK included optical coherence tomography for graft thickness, BSCVA, and specular microscopy. Patients were divided into 2 groups based on the median graft thickness. The correlations between original graft thickness and graft thickness measured 1 year later, BSCVA, and ECD were analyzed by linear regression analyses., Results: Graft thickness decreased from 116 ± 36.8 μm before to 100 ± 36.8 μm 1 year after DSAEK (R =0.901, P <0.0001). Mean BSCVA 1 year after DSAEK was 0.24 logMAR in eyes without ocular comorbidity. BSCVA was 0.25 ± 0.16 (0.21-0.28) and 0.20 ± 0.11 (0.18-0.23) in eyes with a graft thickness above or below 111 μm, respectively (P = 0.04). ECD loss 1 year after surgery did not correlate with graft thickness (R = 0.0006, P <0.875)., Conclusions: Graft thickness measured immediately after precutting correlates strongly with graft thickness measured 1 year after DSAEK. This study suggests that ultrathin grafts provide better visual acuity 1 year after DSAEK than regular grafts.

Purpose: The purpose of this study is to identify predictors for the best-corrected visual acuity (BCVA), central corneal thickness (CCT), and the endothelial cell density (ECD) after primary Descemet's membrane endothelial keratoplasty (DMEK)., Methods: In a prospective observational study, 108 eyes with Fuchs' endothelial dystrophy underwent a primary DMEK. Preoperative data, histologic parameters from host's Descemet's membrane, and follow-up data of the first eye were analyzed in regard to BCVA, CCT, and ECD, 12 months after surgery., Results: Overall, 12 months postoperative, the BCVA improved to 0.11 ± 0.11 logMAR, the CCT declined to 529 ± 42 µm, and the ECD measured 1675 ± 418 cells/mm 2 . A significant influence of the preoperative CCT on postoperative BCVAs and CCTs was observed (r = 0.299, p = 0.014 and r = 0.507, p < 0.001, respectively). Especially eyes with a CCT <625 µm demonstrated a better BCVA (0.05 ± 0.07 logMAR) than eyes with a CCT ≥625 µm (0.13 ± 0.11 logMAR, p = 0.002). Furthermore, the identification of eyes with an early visual restitution was possible by considering follow-up data of the first eye. A preoperative CCT ≥625 µm was also sensitive to identify eyes with a persistent corneal swelling. The anterior banded layer thickness, which was obtained histologically, correlated to the preoperative CCT and the frequency of graft detachments (r = 0.601, p = 0.023 and r = 0.652, p = 0.041, respectively). Furthermore, a graft's baseline ECD ≤2100 cells/mm 2 was found to be a risk factor for an ECD deterioration under 1000 cells/mm 2 (1.8% vs. 15.8%, p = 0.020)., Conclusions: Simple clinical parameters, such as the preoperative CCT, the course of visual restitution of the first eye, and the graft's baseline ECD, are efficient predictors for relevant outcome parameters after DMEK and therefore may be used for stratification. Furthermore, our findings indicate that a DMEK should be performed in eyes with Fuchs' endothelial corneal dystrophy, if possible, before the CCT exceeds 625 µm to maintain good clinical results.

Purpose: To present our experience of Descemet stripping endothelial keratoplasty (DMEK) graft luxation into the vitreous cavity in 2 cases., Methods: DMEK was performed in 2 patients with aphakic bullous keratopathy. The indications for keratoplasty were endothelial failure caused by chronic intermediate uveitis and glaucoma in 1 case and decompensated previous penetrating keratoplasty in the other. Both cases had enlarged pupils and had previously undergone pars plana vitrectomy. In both cases, the DMEK graft dislocated into the vitreous cavity during unfolding maneuvers and could not be retrieved during the same procedure., Results: No signs of retinal detachment were observed during follow-up (6 months and 1 year). Although visualization of the graft was not possible on examination, B-scan confirmed the presence of the lenticule lying over the retina. One case underwent repeat DMEK, and 1 case underwent repeat penetrating keratoplasty. In 1 case, the graft was retrieved after a month and sent for histopathology. In both cases, corneal transparency and corrected visual acuity improved to full potential after the final procedure. Histopathology of the retrieved graft showed only endothelial cell loss and no fibrocellular proliferation., Conclusions: The risk of fibrous proliferation and retinal detachment after posterior dislocation of DMEK grafts may be less than in grafts including corneal stroma, but pars plana vitrectomy and retrieval of the dislocated corneal transplant are still indicated after revision corneal transplant surgery where visual symptoms or signs of fibrotic change around the dislocated graft are evident.

Purpose: To compare clinical outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) in the treatment of corneal endothelial dysfunction., Design: Patient and outcome-masked, randomized controlled clinical trial., Participants: Patients with damaged or diseased endothelium from Fuchs endothelial dystrophy or pseudophakic bullous keratopathy who were considered good candidates for DMEK or UT-DSAEK., Methods: Study eyes were randomized by the eye bank to UT-DSAEK or DMEK 1 to 2 days before surgery., Main Outcome Measures: The primary outcome of the trial was best spectacle-corrected visual acuity (BSCVA) at 6 months. Secondary outcomes included 3- and 12-month BSCVA; 3-, 6-, and 12-month endothelial cell counts; intraoperative and postoperative complications; and change in pachymetry., Results: A total of 216 patients with endothelial dysfunction were screened, and 50 eyes of 38 patients were enrolled by 2 surgeons at Casey Eye Institute at Oregon Health & Science University in Portland, Oregon, and at Byers Eye Institute at Stanford University in Palo Alto, California. Overall, we found DMEK to have better visual acuity outcomes compared with UT-DSAEK after correcting for baseline visual acuity: compared with UT-DSAEK, those randomized to DMEK had 1.5 lines better BSCVA at 3 months (95% confidence interval [CI], 2.5-0.6 lines better; P = 0.002), 1.8 lines better BSCVA at 6 months (95% CI, 2.8-1.0 lines better; P < 0.001), and 1.4 lines better BSCVA at 12 months (95% CI, 2.2-0.7 lines better; P < 0.001). Average endothelial cell counts were 1963 cells/mm 2 in DMEK and 2113 cells/mm 2 in UT-DSAEK at 6 months (P = 0.17) and 1855 cells/mm 2 in DMEK and 2070 cells/mm 2 in UT-DSAEK at 12 months (P = 0.051). Intraoperative and postoperative complication rates were similar between groups., Conclusions: Descemet membrane endothelial keratoplasty had superior visual acuity results compared with UT-DSAEK at 3, 6, and 12 months in patients with isolated endothelial dysfunction with similar complication rates., (Published by Elsevier Inc.)

Purpose: To investigate functional and anatomical results up to 12 months after Descemet's membrane endothelial keratoplasty (DMEK) for Fuchs' endothelial dystrophy (FED) versus bullous keratopathy (BK) in consideration of morphologic characteristics on host's endothelium-Descemet's membranes (EDM)., Methods: In a prospective consecutive case series, 119 eyes underwent a primary DMEK for FED or BK. Intraoperatively obtained EDM were investigated immunohistologically. Clinical and morphological parameters were compared between FED and BK., Results: Overall, the 12-months best-corrected visual acuity (BCVA) was 0.14 logMAR, and 0.10 logMAR in eyes without vision-limiting comorbidities; thereby no differences were revealed between eyes with FED and BK up to 12 months postoperative (p = 0.186 and p = 0.095, respectively). Correspondingly, the mean central corneal thickness (CCT) measured 520 vs. 529 µm and the mean endothelial cell density (ECD) was 1743 vs. 1457 cells/mm 2 for FED and BK, 12 months postoperative. Regarding CCT and ECD, no differences were observed between the groups (p = 0.181 and p = 0.112, respectively). The overall detachment rate was 40% (48/119). Comparing FED and BK the detachment rates did not differ, which were 41% vs. 39% and 43% vs. 35%, in pseudophakic eyes (p = 0.554 and p = 0.601, respectively). Yet, the distribution of recurring graft detachments differed between FED and BK; secondary re-detachments were more frequent in the FED group (7 cases). Regarding histologic investigations, a lower ECD was found in specimens with BK, no differences were revealed for EDM and anterior banded layer thicknesses. Immunohistologically, differences in the distribution of fibronectin and cytokeratin were observed. A rarification of matrix proteins was found in EDM complexes with FED., Conclusions: DMEK produces similar results for FED and BK. However, the postoperative course may differ with regard to the recurrence of secondary graft detachments that may be associated by histopathologic particularities.

Aims: To describe the long-term outcomes of deep anterior lamellar keratoplasty (DALK) performed after Descemet stripping automated endothelial keratoplasty (DSAEK) in cases of infection and residual stromal opacity., Methods: Ten eyes of nine consecutive patients undergoing DALK after DSAEK at a single tertiary referral center (SNEC) from 2011 to 2016 were analyzed for best spectacle-corrected visual acuity (BSCVA), refraction, spherical equivalent (SE) and cylinder, as well as graft diameters, survival, and complications., Results: The mean pre-DSAEK BSCVA was 1.73 ± 0.76 LogMAR. At a mean follow-up of 9.8 ± 7.1 months, visual acuity had improved significantly (p = 0.028) to 1.09 ± 0.55 LogMAR after DSAEK. DALK was performed at 10.3 ± 7.2 months after DSAEK because of residual stromal scarring in nine and a corneal infection in one case. At the last follow-up visit (19.4 ± 13.9 months) after DALK, BSCVA had improved to 0.38 ± 0.6 LogMAR, significantly better than after DSAEK alone (p = 0.015) and before DSAEK (p = 0.018). Spherical equivalent (- 4.8 ± 3.5 D) and cylinder (- 2.5 ± 2.0 D) did not show significant changes compared to after DSAEK (SE p = 0.17; cylinder p = 0.19) or 3 months after DALK (SE p = 0.17; cylinder p = 0.46). One endothelial graft failed 3 months after DALK. Kaplan-Meier estimated average survival for all cases was 45.3 (95% CI 36.6-54.0) months. The cumulative survival probability for the entire cohort was 90% at 1, 2, and 4 years of follow-up., Conclusions: DALK surgery after DSAEK can improve vision in cases of residual host scarring and treat host corneal infection, while avoiding open-sky surgery and sparing a healthy endothelial graft.

Purpose: To evaluate the risk factors for early graft detachment in Descemet membrane endothelial keratoplasty (DMEK)., Design: Case-control study., Methods: Participants: A total of 173 donor corneas and 173 eyes of the patients following DMEK or DMEK in combination with phacoemulsification and intraocular lens implantation were included., Intervention: Pre-stripped DMEK grafts were transplanted using pull-through technique. At the end of surgery, the anterior chamber was filled with air, which was removed 3 hours later only if pupillary block was suspected. Rebubbling was performed in all cases with graft detachment, independently of its extension, as documented by means of anterior segment optical coherence tomography. The donor characteristics were collected from the eye bank database and matched with the recipient database., Main Outcome Measures: Donor and recipient characteristics affecting graft detachment using univariate and multivariate analysis., Results: The combination of DMEK with cataract removal and IOL implantation (odds ratio [OR] = 5.31, 95% confidence interval [CI] 2.03-13.86, P < .002) and air fill of ≤75% of anterior chamber height at 2-3 hours postoperatively (OR = 2.66, 95% CI 1.12-6.34, P = .027) were found to be independent risk factors for postoperative graft detachment., Conclusions: Cataract removal at the time of DMEK is a risk factor for early graft detachment and therefore sequential surgery may be preferred over combined surgery in an attempt at minimizing rebubbling. Air level in the anterior chamber should be monitored and maintained above 75% in the early hours following surgery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Descemet membrane endothelial keratoplasty (DMEK) has been improved over the last decade. The aim of this study was to compare the clinical outcome of the recently introduced liquid bubble method compared to the standard manual preparation., Methods: This retrospective study evaluated the outcome of 200 patients after DMEK surgery using two different graft preparation techniques. Ninety-six DMEK were prepared by manual dissection and 104 by the novel liquid bubble technique. The mean follow-up time was 13.7 months (SD ± 8, range 6-36 months)., Results: Best corrected mean visual acuity (BCVA) increased for all patients statistically significant from baseline 0.85 logMAR (SD ± 0.5) to 0.26 logMAR (SD ± 0.27) at the final follow-up (Wilcoxon, p = 0.001). Subgroup analyses of BCVA at the final follow-up between manual dissection and liquid bubble preparation showed no statistically significant difference (Mann-Whitney U Test, p = 0.64). The mean central corneal thickness was not statistically different (manual dissection: 539 µm, SD ± 68 µm and liquid bubble technique: 534 µm, SD ± 52 µm,) between the two groups (Mann-Whitney U Test, p = 0.64). At the final follow-up, mean endothelial cell count of donor grafts was statistically not significant different at the final follow-up with 1761 cells/mm 2 (-30.7%, SD ± 352) for manual dissection compared to liquid bubble technique with 1749 cells/mm 2 (-29.9%, SD ± 501) (Mann-Whitney U-Test, p = 0.73). The re-DMEK rate was comparable for manual dissection with 8 cases (8.3%) and 7 cases (6.7%) for liquid bubble dissection (p = 0.69, Chi-Square Test)., Conclusion: Regarding the clinical outcome, we did not find a statistical significant difference between manual dissection and liquid bubble graft preparation. Both preparation techniques lead to an equivalent clinical outcome after DMEK surgery.

Purpose: To describe a bimanual vitrectomy technique for the removal of a descemet-stripping automated endothelial keratoplasty donor graft dislocated into the vitreous cavity., Methods: The surgical technique requires the use of a temporary keratoprosthesis and external chandelier illumination to overcome corneal edema and visualization of the dislocated donor graft, respectively. A bimanual pars plana vitrectomy approach is then performed with intraocular forceps and the vitrectomy handpiece for segmentation and removal of the dislocated graft. Penetrating keratoplasty is then performed to restore corneal clarity., Results: This surgical technique allows for the dislocated descemet-stripping automated endothelial keratoplasty donor graft to be removed from the vitreous cavity safely in an efficient manner., Conclusion: The technique of bimanual pars plana vitrectomy with a temporary keratoprosthesis and external chandelier illumination can successfully remove a descemet-stripping automated endothelial keratoplasty donor graft dislocated into the vitreous cavity without the need for a large wound for donor graft explantation.

Purpose: To evaluate the utility of endothelial/Descemet membrane complex (En/DM) characteristics in diagnosing corneal graft rejection., Design: Diagnostic reliability study., Methods: One hundred thirty-nine eyes (96 corneal grafts post penetrating keratoplasty or Descemet stripping automated endothelial keratoplasty: 40 clear, 23 actively rejecting, 24 rejected, and 9 nonimmunologic failed grafts; along with 43 age-matched control eyes) were imaged using high-definition optical coherence tomography. Images were used to describe En/DM and measure central corneal thickness (CCT) and central En/DM thickness (DMT). En/DM rejection index (DRI) was computed to detect the relative En/DM thickening to the entire cornea., Results: In actively rejecting grafts, DMT and DRI were significantly greater than controls and clear grafts (28, 17, and 17 μm and 1.5, 1 and 1, respectively; P < .001). Rejected grafts had the highest DMT and DRI compared to all groups (59 μm and 2.1; P < .001). DMT and DRI showed excellent accuracy, significantly better than that of CCT, in differentiating actively rejecting from clear grafts (100% and 96% sensitivity; 92.5% and 92.5% specificity), actively rejecting from rejected grafts (88% and 83% sensitivity; 91% and 83% specificity), and nonimmunologic failed from rejected grafts (100% and 100% sensitivity; 88% and 100% specificity). DMT correlated significantly with rejection severity (P < .001)., Conclusions: In corneal grafts, in vivo relative thickening of the En/DM is diagnostic of graft rejection as measured by DMT and DRI. These indices have excellent accuracy, sensitivity, and specificity in detecting graft immunologic status, superior to CCT. DMT is a quantitative index that correlates accurately with the severity of rejection., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Descemet's membrane endothelial keratoplasty (DMEK) can replace just the corneal endothelium and respect the natural corneal anatomy. Currently, the technique of endothelial graft preparation remains manual and non-standardized., Purpose: To report anatomic and functional results after DMEK, and compare two techniques of graft preparation., Methods: Single-center retrospective study, including 64 eyes of 64 patients undergoing DMEK, from September 2014 to February 2016 at Clermont-Ferrand University Medical Center. The "classic" preparation was used in 44 patients (group 1) and the "variant" preparation was used in 20 patients (group 2). An analysis of functional parameters (visual acuity), anatomy (pachymetry, corneal edema, endothelial cell count) and keratometry (sphere, cylinder, mean keratometry) was performed during the first postoperative year., Results: The mean follow-up was 10.0±2.5 months. The average preparation time was 12.3±8.1minutes, with 14.4±8.8 in group 1 versus 7.8±3.0 in group 2 (P<0.001). At six months, the best corrected distance visual acuity was significantly better in group 1 with an acuity of 0.28±0.28 LogMAR in group 1 and 0.37±0.30 LogMAR in group 2 (P<0.01). The best corrected near visual acuity was also better in group 1 at 6 months, with an acuity of 0.29±0.24 LogMAR (P<0.001) in group 1 and 0.37±0.28 LogMAR in group 2 (P=0.02). Improvement in visual acuity was continuous for the 2 groups. At 6 months, endothelial cell loss was greater in group 1 than in group 2, but the difference was not significant (P=0.44). Central corneal thickness was similar between the 2 groups. Finally, no change in keratometry parameters was found between preoperative data and 6 months in each group or between the two groups., Conclusion: DMEK led to an improvement in all parameters as well as rapid visual rehabilitation. The new variation in preparation saved a considerable amount of time without decreasing graft survival or postoperative results., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

The purpose of this article is to examine outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed with cornea bank (CB) prestripped tissue and surgeon stripped tissue (SST).This retrospective study examined subjects who underwent DMEK with CB or surgeon prepared tissue for Fuchs endothelial corneal dystrophy. Best-corrected visual acuity (BCVA), corneal thickness, endothelial cell count (ECC), and complications were examined before and throughout a 6-month postoperative period.Eleven CB and 22 SST subjects were included. Six months after surgery, BCVA was 20/20 or better in 36.4% of CB and 22.7% of SST subjects (P = .43). Median logMAR BCVA was 0.10 (0.00-0.20, 20/25) in group CB and 0.10 (0.10-0.30, 20/25) in group SST. Median preoperative corneal thickness was 614.0 μm (577.5-662.0 μm) and 658.0 μm (606.0-689.0 μm) in CB and SST subjects, respectively (P = .37). Six months after surgery, median corneal thickness was lower in the CB group (571.0 μm [478.0-592.0 μm]), than in the SST group (576.0 μm [531.0-607.0 μm], P = .02). At 6 months, median ECC was 1500.0 cell/mm (1321.5-2049.0 cell/mm, 41% decrease) in group CB and 1403.0 cell/mm (972.5-2010.7 cell/mm, 46% decrease) in group SST (P = .70). Rebubbling was required in 5 CB (45.5%) and 15 SST (68.2%) subjects (P = .39).Fuchs' dystrophy patients have good anatomic and functional DMEK results. Similar outcomes and complication rates occurred with eye bank and surgeon prepared donor tissue.

Purpose: Trypan blue (TB) is used for visualization of the endothelium-Descemet membrane graft during Descemet membrane endothelial keratoplasty (DMEK). However, TB is assumed to have a dose-dependent toxic effect on the corneal endothelium. We retrospectively compared a lutein/zeaxanthin and Brilliant Blue (LZ/BB)-based dye for preparation and transplantation of the graft in DMEK to TB., Methods: In 20 patients, a dye composed of 1% LZ /0.025% BB was used, and in 22 patients, 0.06% TB was used for graft visualization in DMEK. We evaluated the rebubbling rate, best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), and endothelial cell density (ECD) before and 3 and 6 months after transplantation., Results: Staining of endothelium-Descemet membrane with LZ/BB was faint but sufficient. There was no significant difference between both groups, except in CCT after 3 months, which was lower in the LZ/BB group (P = 0.02). In the LZ/BB group, BSCVA improved from 0.48 ± 0.39 before DMEK to 0.19 ± 0.09 after 6 months (P < 0.05) (20% rebubbling rate). Donor ECD decreased from 2735 ± 259 cells/m preoperatively to 1876 ± 316 cells/mm (P < 0.0001) at 6 months (31.4%). CCT decreased from 642 ± 130 μm preoperatively to 519.8 ± 38 μm (P < 0.0001) at 6 months. In the TB group, BSCVA improved from 0.43 ± 0.27 to 0.17 ± 0.14 (P = 0.0003) at 6 months (30% rebubbling rate). ECD decreased from 2825 ± 263 to 1777 ± 302 cells/mm (P < 0.0001) after 6 months (36.3%), CCT from 638 ± 48 μm preoperatively to 531 ± 48 μm (P < 0.0001) at 6 months., Conclusions: LZ/BB-based dyes are suitable for DMEK with outcomes comparable to TB. However, available formulas result in faint staining, discouraging their routine use in donors with assumed difficult preparation.

Purpose: To analyze the role of initial intraoperative intraocular pressure (IOP) in graft adhesion in Descemet membrane endothelial keratoplasty (DMEK) during early follow-up., Methods: This retrospective, observational, single-center case series included 118 eyes from 118 consecutive patients treated between May and July 2015 for DMEK or combined DMEK and phacoemulsification (triple-DMEK). Exclusion criteria were previous eye surgery other than cataract surgery, loss of follow-up, any application of IOP-lowering medication before and after surgery, and low intraindividual repeatability of IOP measurements. The main outcome measure was graft adhesion that was correlated to the magnitude of IOP measured by Schiötz tonometry intraoperatively., Results: Fifty-four eyes of 118 (45.8%) patients undergoing DMEK met the above-mentioned inclusion and exclusion criteria. In 43 (79.6%) eyes, complete graft adhesion was achieved at 1-week follow-up examination. Differences of the initial IOP in the presence of the air bubble were not statistically significant between eyes with complete and incomplete graft adhesion., Conclusions: Incomplete graft adhesion during early follow-up could not be associated with the magnitude of the initial IOP in DMEK. We found no evidence that higher IOP values enhance graft adhesion resulting in lower rebubbling rates after DMEK.

Purpose: Correct early graft attachment is believed to be crucial for final visual outcome after Descemet membrane endothelial keratoplasty (DMEK). Nonetheless, it is not yet known which imaging technique gives superior results for examining early postoperative graft adherence status. We compared imaging data taken with two different OCT devices to examine the development of graft adherence immediately after DMEK and to determine the superior device in terms of visualization of graft adherence., Methods: Ten consecutive patients (1 man/9 women) were examined three times postoperatively within the first 7 h after DMEK surgery using spectral domain OCT (SD-OCT) and time domain OCT (TD-OCT), as prospective case series and retrospective image data analyses. The parameters analyzed were localization and number, visibility and size of graft detachments., Results: TD-OCT was able to detect a greater number of graft detachments after DMEK; however, SD-OCT provided better resolution of minor detachments. Graft detachments varied in position and degree at different time points immediately after surgery. All patients had some graft detachment within the first 7 h after DMEK surgery., Conclusions: TD-OCT enabled better overall analysis of graft detachments, even in the periphery, whereas SD-OCT allowed for the detection of even minor detachments, which suggests that a combination of the two techniques is optimal. Our results indicate that dynamic processes affecting the DMEK graft immediately after transplantation are responsible for changes in the attachment of donor tissue at an early postoperative stage. Modulation of early graft attachment may improve the final graft attachment.

Purpose: To describe the histologic features of postmortem eyes after Descemet membrane endothelial keratoplasty (DMEK) and their potential clinical implications., Design: Histopathologic study., Participants: Eleven postmortem DMEK corneas of 8 patients who underwent surgery for Fuchs endothelial dystrophy, with an average postoperative time of 4±1.9 years (range, 7 months-6.5 years)., Methods: Eleven corneas transplanted with a DMEK graft were procured after death and processed for light microscopy evaluation., Main Outcome Measures: Histologic findings at the donor-host interface and at the host edge., Results: Of the 11 corneas available for analysis, 9 showed normal anatomic features in the corneal center; that is, the donor-host interface resembled that of a virgin eye. One eye also had an anatomically normal periphery, but the remaining 10 eyes showed specific abnormalities in the periphery. Nine demonstrated overlapping of the DMEK graft onto the host edge of the descemetorhexis (and in 6 of these, the overlapping tissue showed a contracted inward fold at its peripheral edge with scar tissue); 1 eye showed a dense, acellular scar overlying a portion of the DMEK graft that clinically had shown a detachment followed by spontaneous adherence; 3 eyes showed subtle graft folds with scar tissue anteriorly; in 2 eyes (of the same patient), the anterior banded layer of the host Descemet membrane (DM) was still in situ across the cornea (both of these eyes had required rebubbling); and 2 eyes showed host DM remnants within the corneolimbal tunnel incision that may have interfered with incisional wound healing., Conclusion: Incomplete host DM removal may relate to postoperative DMEK graft detachment and wound instability. Graft detachments may reattach with interface scarring. Rebubbling procedures may be performed within 4 to 6 weeks, before portions of the detached graft scar. Subtle DMEK graft folds may explain subjective reports of monocular diplopia., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Xeroderma pigmentosum (XP) mainly affects the ocular surface; however, endothelial damage may also occur. We would like to report changes in the endothelial-Descemet layer and review the literature on similar findings in patients with XP, including the role of Descemet stripping automated endothelial keratoplasty (DSAEK) in the management of a 21-year-old man who presented with nonresolving corneal edema in the right eye after excision biopsy for conjunctival intraepithelial neoplasia. His best-corrected visual acuity (BCVA) was 20/200 in the right eye and 20/20 in the left eye. On general examination, there was patchy hyperpigmentation of the exposed areas of skin suggestive of XP. On examination of the right eye, there was stromal edema involving the exposed half of cornea. The left eye appeared normal. Pachymetry readings were 860 and 600 μm in the right and left eye, respectively. Descemet stripping automated endothelial keratoplasty was performed for endothelial dysfunction and the stripped endothelium, and Descemet membrane (DM) was sent for histopathologic evaluation. Postoperatively, the donor lenticule was well apposed and the overlying stromal edema resolved. The patient achieved a BCVA of 20/30 in the right eye without progression of corneal scarring at 1-year follow-up. In the meanwhile, however, the left eye developed corneal edema. Histopathology revealed gross attenuation of endothelial cells with uniform thickness of the DM. Corneal endothelial dysfunction in XP is amenable to treatment with DSAEK.

Aim: To evaluate the prevalence of guttae in donor grafts following corneal transplantation and to examine the possible effect of guttae on postoperative results., Methods: Retrospective cohort study. We reviewed the medical records of all keratoplasties performed at the Villa Serena-Villa Igea private hospitals (Forlì, Italy) between January 2005 and July 2014. Endothelial specular microscopy images were examined to identify the presence of guttae. Donor's age, patient's age, indication for surgery, surgical procedure, postoperative visual acuity, and endothelial cell density were also noted., Results: A total of 11 068 postoperative specular microscopy pictures were available for 1116 of 2332 eyes (47.9%) that underwent keratoplasty at our institution. Guttae were identified in 42 of 946 eyes (4.44%) following penetrating or endothelial keratoplasty, and in 3 of 170 eyes (1.76%) following anterior lamellar keratoplasty. Twenty-seven of these photos demonstrated a few isolated scattered guttae, nine showed widespread guttae with small patches, and nine demonstrated large patches of guttae. Last documented best spectacle-corrected visual acuity did not differ between patients with or without guttae (logarithm of the minimum angle of resolution (logMAR) 0.22±0.24 (approximately 20/32) vs 0.29±0.45 (approximately 20/40), p=0.25) nor did the groups differ in their 24-month postoperative endothelial cell density (1633±427 vs 1555±454 cells/mm(2), p=0.56). No graft with postoperative guttae failed during the follow-up period of this study., Conclusions: Guttae can be found in approximately 4% of post-keratoplasty grafts. At least for the initial two postoperative years, they do not negatively affect vision, endothelial cell density or graft survival., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: To investigate Descemet graft (DG) detachment rate after Descemet membrane endothelial keratoplasty (DMEK) in relation to DG position., Methods: A total of 175 consecutive pseudophakic eyes that underwent DMEK (175 eyes for Fuchs endothelial dystrophy) from September 2009 through February 2014 at the Tübingen Eye Hospital DG position were studied retrospectively by surgical video at the end of an operation. A group of 45 eyes showed a decentration of the DG with a stromal gap of ≥1.5 mm over at least 3 clock hours between the descematorhexis edge and the DG. DG detachment was documented at a mean follow-up of 13.9 ± 3.7 months after surgery. DG detachment was defined as a detachment of 20 % or more of the DG surface area. Various donor characteristics and patient characteristics were analyzed., Results: The best spectacle-corrected visual acuity (BCVA) in the group of eyes with central well-positioned DG differed significantly from those of eyes with decentered DG. The preoperative BCVA in the central well-positioned DG group was 0.63 ± 0.40 logMAR, and in the decentered DG group 0.91 ± 0.51 logMAR (P < 0.001). The postoperative BCVA in the group of eyes with central well-positioned DG was 0.12 ± 0.11 logMAR, and in the group with decentered DG 0.23 ± 0.29 logMAR (P < 0.001). Endothelial cell density and patient characteristics such as age, gender, and intraocular pressure did not differ significantly between the two groups. The group of eyes with central well-positioned DG showed DG detachment in 12 %; the group with decentered DG findings had DG detachment in 87 % (P < 0.001) at the 12 month follow up., Conclusion: The present findings demonstrate the importance of central well-positioned DG and the relation of disease severity. Central well-positioned DG may reduce the incidence of DG detachment. Overlapping of the donor DG and the host Descemet membrane seems to be responsible for DG detachment. One possible way to enhance graft adhesion could be a larger descematorhexis, which avoids an overlapping. The second possible way could be not waiting too long for surgery to reduce disease severity.

Importance: The management of graft failure is increasingly relevant with the spread and growing acceptance of endothelial keratoplasty., Objectives: To investigate the functional and anatomical results of secondary Descemet membrane endothelial keratoplasty (DMEK) for graft failure after Descemet stripping endothelial keratoplasty (DSEK) and to histologically analyze the stroma-to-stroma interface with respect to clinical implications., Design, Setting, and Participants: In a single-surgeon prospective comparative case series at the Department of Ophthalmology, Charité-University Medicine Berlin, Berlin, Germany, 8 eyes (3.8%) of 210 consecutively performed DMEK procedures underwent a secondary DMEK for graft failure after DSEK from March 1, 2012, through February 28, 2013. Those cases were compared with the eyes of a reference collective (n = 30) and matched-pairs group (n = 8) after primary DMEK for Fuchs endothelial dystrophy., Intervention: Descemet membrane endothelial keratoplasty., Main Outcomes and Measures: Postoperative best-corrected visual acuity (BCVA) and central corneal thickness at 1, 3, 6, and 12 months. Intraoperatively obtained DSEK graft lenticels were investigated immunohistochemically., Results: Patients with graft failure after DSEK had a mean (SD) age of 79.4 (7.2) years (range, 70-90 years). Preoperatively, the mean (SD) BCVA was 1.13 (0.50) logMAR (20/250 Snellen equivalents), and the mean (SD) central corneal thickness measured 704 (161) µm. Twelve months postoperatively, the mean (SD) corneal thickness decreased to 524 (27) µm after secondary and 516 (27) µm after primary DMEK (P = .57). A mean (SD) BCVA of 0.38 (0.36) logMAR (20/50 Snellen equivalents) was achieved after secondary DMEK compared with 0.15 (0.15) logMAR (20/28 Snellen equivalents) after primary DMEK. Histologically, failed DSEK graft lenticels presented condensations of collagen layers. Fibronectin and cytokeratin were accumulated along the stroma-to-stroma interface; vimentin was found in loosened graft stroma., Conclusions and Relevance: These data suggest that DMEK might be considered a feasible choice in patients with graft failure after DSEK. However, the visual restitution might be impeded because of preceded depositions of matrix proteins within the corneal stroma and the stroma-to-stroma interface, which are associated with corneal fibrosis. Thereby, fibrotic processes might be avoided by performing a secondary DMEK in an early phase of graft failure.

Purpose: To describe the utility of a new intraoperative optical coherence tomographer (OCT) to evaluate endothelio-Descemet graft orientation during Descemet membrane endothelial keratoplasty (DMEK) procedures., Methods: Prospective, observational, and single-center pilot case series including 14 eyes of 14 patients consecutively scheduled for DMEK surgery. After injecting the graft into the anterior chamber, the graft orientation was assessed with the help of anterior segment OCT. The surgical time and unfolding time were measured. The postoperative measurements included best-corrected visual acuity, central pachymetry, and specular microscopy at 1 month., Results: Using the OCT images, it was possible to evaluate the graft orientation in all cases. The mean unfolding time was 6.1 ± 3.0 minutes, the mean best-corrected visual acuity was 0.3 ± 0.3 logarithm of the minimum angle of resolution, the mean decrease in central pachymetry was 213 ± 177 μm, and the mean central endothelial cell count was 1906 ± 319 cells per square millimeter., Conclusions: Live intraoperative OCT is useful to visualize and assess graft orientation in DMEK surgery. It enables faster graft positioning with less graft manipulation in the presence of severe corneal edema.

Background: Peripheral corneal graft detachment after Descemet's membrane endothelial keratoplasty (DMEK) is a frequently occurring postoperative complication. The natural course of these persistent peripheral detachments over time is not known., Methods: 166 patients were surveyed by slit-lamp-adapted optical coherence tomography (SL-OCT) directly after surgery, during first postoperative week, 4 weeks, 3, 6 and 12 months, postoperatively. Patients with a persistent peripheral graft detachment 4 weeks after DMEK (n=16) were observed for their spontaneous course up to 1 year postoperatively., Results: Persistent graft detachments could be characterised into two phenotypes: peripheral roll (n=11; 69%) and laminar detachment (n=5; 31%). Maximal length of the detachment did not change in peripheral rolls during observation period (12 months vs 4 weeks, 578±122 µm vs 593±106 µm, p=0.74), whereas laminar detachments spontaneously attached to the host's stroma (12 months vs 4 weeks, 0 µm vs 1088±295 µm, p≤0.001). Central corneal thickness and (peripheral) corneal thickness above the detached area did not significantly change in either group., Conclusions: Persistent peripheral graft detachments after DMEK occurred in 10% of patients and had two distinct OCT-phenotypes. Peripheral rolls did not change during the first 12 months, postoperatively. By contrast, peripheral laminar detachments attached spontaneously even months after surgery. Corneal thickness reduction was only observed above peripheral laminar detachment, but not above peripheral rolls., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: To evaluate graft size on outcome following Descemet stripping automated endothelial keratoplasty (DSAEK) METHODS: Consecutive patients who had undergone a DSAEK for Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK) with at least 1 year of follow-up. Patients were divided into three groups according to the size of the donor trephine: <9, 9 and 9.5 mm. Main outcomes were postoperative best corrected visual acuity (BCVA) and graft failure. Grafts were prepared using an automated microkeratome. For larger grafts (≥9 mm), a manual dissection of the residual peripheral ring of anterior lamella was performed before trephination. Donor age, endothelial cell density (ECD) and postmortem times; recipient details including risk factors, comorbidity, surgical complications and postoperative BCVA and graft survival were analysed., Results: Of 174 patients, 131 were included: 84 (64%) with FED and 47 (36%) with PBK. Mean preoperative and postoperative BCVA were 1.01±0.76 and 0.2±0.2 logMAR, respectively, at 12 months with 80.5% achieving 20/40 or better. Postoperative BCVA was significantly associated with ECD (p=0.005), PBK or FED (p=0.004), risk factors (p=0.007) and comorbidity (p=0.016). Eleven patients (8.40%) experienced endothelial graft failure; 17.86% for <9 mm, 7.69% for 9 mm and 3.84% for 9.5 mm trephine sized grafts. Graft failure was significantly associated with ECD (p=0.039) and graft trephine size (p=0.04)., Conclusions: Larger grafts occupy a smaller chord length in the eye than the trephine size and are expected to provide 10%-20% more endothelial cells. Increased graft size and donor ECD is significantly associated with a reduced graft failure rate., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: To assess the results of a single eye bank preparing a high volume of Descemet membrane endothelial keratoplasty (DMEK) tissues using multiple technicians to provide an overview of the experience and to identify possible risk factors for DMEK preparation failure., Design: Cross-sectional study., Methods: setting: Lions VisionGift and Wilmer Eye Institute at Johns Hopkins Hospital., Study Population: All 563 corneal tissues processed by technicians at Lions VisionGift for DMEK between October 2011 and May 2014 inclusive., Observation Procedures: Tissues were divided into 2 groups: DMEK preparation success and DMEK preparation failure., Main Outcome Measures: We compared donor characteristics, including past medical history., Results: The overall tissue preparation failure rate was 5.2%. Univariate analysis showed diabetes mellitus (P = .000028) and its duration (P = .023), hypertension (P = .021), and hyperlipidemia or obesity (P = .0004) were more common in the failure group. Multivariate analysis showed diabetes mellitus (P = .0001) and hyperlipidemia or obesity (P = .0142) were more common in the failure group. Elimination of tissues from donors either with diabetes or with hyperlipidemia or obesity reduced the failure rate from 5.2% to 2.2%. Trends toward lower failure rates occurring with increased technician experience also were found., Conclusions: Our work showed that tissues from donors with diabetes mellitus (especially with longer disease duration) and hyperlipidemia or obesity were associated with higher failure rates in DMEK preparation. Elimination of tissues from donors either with diabetes mellitus or with hyperlipidemia or obesity reduced the failure rate. In addition, our data may provide useful initial guidelines and benchmark values for eye banks seeking to establish and maintain DMEK programs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To compare confocal features of grafts following deep anterior lamellar keratoplasty (DALK) using a donor without Descemet membrane (DM) versus a full-thickness donor with intact DM and endothelium., Methods: This retrospective comparative study examined 45 eyes from patients with keratoconus who underwent DALK using the big-bubble technique. The big-bubble technique yielded a bared DM in all keratoconic eyes. Twenty-seven eyes received tissue from a donor without DM (group 1), while 18 received tissue from a full-thickness donor with an intact DM and endothelium (group 2). A group of normal eyes (n = 28, group 3) served as controls. Confocal microscopy was used to determine keratocyte density, explore the donor-recipient interface including clarity and reflectivity, evaluate endothelial cell density and morphology, as well as measure interface depth and central corneal thickness., Results: Mean follow-up duration was 20.2 ± 8.6 months and 29.6 ± 17.0 months in groups 1 and 2, respectively (p = 0.13). Confocal scan demonstrated that the keratocyte profiles and distribution were more similar to normal corneas in group 2. Significantly more severe interface haziness was observed when donor DM and endothelium was retained (mean interface reflectivity value of 102.7 ± 22.1 versus 161.7 ± 30.0 light reflectance units in groups 1 and 2, respectively, p&lt;0.001)., Conclusions: Graft cellular profiles and healing response at the donor-recipient interface can be profoundly affected depending on whether donor DM and endothelium is removed or retained.

Purpose: Hardiness of a Descemet membrane endothelial keratoplasty (DMEK) graft is not well established. The aim of this study was to report a case of graft survival after intraoperative inversion., Methods: We describe a case of a 76-year-old man with Fuchs corneal dystrophy who underwent DMEK in the left eye. After deployment of the graft and a 15-minute sulfur hexafluoride gas fill, the graft was noted to be inverted. The graft was then reoriented and properly positioned., Results: Because of progressive graft detachment, rebubble was required at 2 weeks after surgery. At 2 months after surgery, the graft was clear and fully adherent. Specular microscopy revealed 27.9% endothelial cell loss of the donor cornea., Conclusions: Despite intraoperative inversion, this DMEK graft remained viable without excessive endothelial cell loss.

Objectives: To study the histopathologic and optical coherence tomography changes after Descemet's Stripping Endothelial Keratoplasty in rabbits., Materials and Methods: Descemet's Stripping Endothelial Keratoplasty was performed in 14 rabbit eyes and descemetorhexis was performed in 10 rabbits, as control. Histopathologic examination and anterior-segment optical coherence tomography were conducted in the Descemet's Stripping Endothelial Keratoplasty group at 1, 2, 4, and 8 weeks. For the control group, histopathologic examination was performed before surgery and at 1, 2, 4, and 8 weeks after surgery., Results: In the Descemet's Stripping Endothelial Keratoplasty group, corneas cleared completely within 2 weeks of surgery. Moreover, in most cases, the retained Descemet's membrane was present at the peripheral donor-host interface. The retrocorneal fibrocellular membrane also was seen in the peripheral Descemet's membrane stripped area without donor coverage. Anterior-segment optical coherence tomography revealed that the stroma deturgesed most rapidly between weeks 1 and 2., Conclusions: Retained Descemet's membrane was not the cause for graft dislocation and the retrocorneal fibrocellular membrane may be a kind of protective reaction to denuded endothelium.

Purpose: To investigate pathomechanisms involved in graft detachment after Descemet's membrane endothelial keratoplasty (DMEK) and its clinical implications., Methods: In a prospective case series, 30 eyes with Fuchs' endothelial dystrophy underwent DMEK. Intraoperatively obtained recipients' endothelium-Descemet's membranes (EDMs) were investigated histologically and immunohistochemically. The postoperative donor graft status was categorized as attached or detached. Clinical and morphological parameters were analysed between the study groups., Results: The detachment rate was 40% (12/30). There was no significant difference in postoperative visual acuity between the groups, but visual recovery was delayed in eyes with initially detached grafts. Gender, age, preoperative central corneal thickness or best corrected visual acuity did not influence the detachment rate. However, separation and disruption of the anterior banded layer (ABL) were frequently observed in patients with graft detachment, and ABL thickness was identified as a significant predictor for graft detachment. The ABL thickness was 2.5 ± 0.9 μm and 3.5 ± 1.6 μm in patients with attached and detached grafts, respectively. Immunohistologically, a deficiency of fibronectin and cytokeratin was observed within the ABL of patients with detached grafts. In contrast, a complete removal of the EDM with residual stromal collagen fragments was observed in patients with adherent grafts., Conclusions: Incomplete removal of the EDM, with residual ABL fragments on the recipients' corneal stroma, may be a risk factor for graft detachment after DMEK. The separation and disruption of the ABL might be promoted by a deficiency of matrix proteins, stronger biomechanical properties and a firm adherence to the posterior corneal stroma., (© 2014 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: The aim of this study was to evaluate preparation outcomes of tissue prepared for Descemet membrane endothelial keratoplasty (DMEK) from diabetic and nondiabetic donors., Methods: In this nonrandomized, consecutive case series, DMEK grafts were prepared from diabetic and nondiabetic donors by experienced technicians in 2 eye banks using slightly different, modified submerged manual preparation techniques to achieve "prestripped" graft tissue. Graft preparation results were analyzed retrospectively. The main outcome measure was the rate of unsuccessful (failed) DMEK graft preparations, defined as tears through the graft area that prevent tissue use., Results: A total of 359 corneas prepared from 290 donors (114 diabetic and 245 nondiabetic) were included in the statistical analysis of graft preparation failure. There were no significant differences between diabetic and nondiabetic donor tissue characteristics with respect to donor age, death to preservation time, death to preparation time, endothelial cell density, percent hexagonality, or coefficient of variation. DMEK tissue preparation was unsuccessful in 19 (5.3%) cases. There was a significant difference in the site-adjusted rate of DMEK preparation failure between diabetic [15.3%; 95% confidence interval (CI), 9.0-25.0] and nondiabetic donors (1.9%; 95% CI, 0.8-4.8), and the corresponding site-adjusted odds ratio of DMEK graft preparation failure in diabetic donor tissue versus nondiabetic donor tissue was 9.20 (95% CI, 2.89-29.32; P = 0.001)., Conclusions: Diabetes may be a risk factor for unsuccessful preparation of donor tissue for DMEK. We recommend caution in the use of diabetic tissue for DMEK graft preparation. Further study is needed to identify what subset of diabetic donors is at risk for unsuccessful DMEK graft preparation.