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The aim of this study was to report our experience in managing different types of Descemet membrane (DM) ruptures during deep anterior lamellar keratoplasty (DALK).This study was a retrospective, consecutive, interventional case series of 1573 DALK procedures conducted on 1244 patients, performed between 2002 and 2017. Inclusion criteria consisted of a minimum of 24-month follow-up. DM rupture incidence, location, and surgical approach for repair were recorded. Postoperative measures were investigated only in eyes that experienced DM ruptures and included best spectacle-corrected visual acuity, endothelial cell loss, double anterior chamber, pupillary block, need for rebubbling, graft clarity, and rejection episodes.One thousand four hundred forty-three eyes met the inclusion criteria. DM ruptures occurred in 119 eyes (8.25%). Seventy-eight percent of DM ruptures were microruptures (≤2 mm), and they occurred more frequently during manual DALK cases. Macroruptures were less frequent (22%), and they occurred more frequently during subtotal and total anterior lamellar keratoplasty (STALK-TALK) cases. In general, DM ruptures mainly occurred in the peripheral cornea (95% of cases). One hundred (84%) of the 119 ruptures resolved by the first postoperative day. Nineteen cases (16%) developed double anterior chamber; all resolved by using different strategies. No intraoperative penetrating keratoplasty conversion was recorded. Pupillary block occurred in 7 cases (5.9%), but no Urrets-Zavalia syndrome was observed. The average postoperative endothelial cell loss was 410 ± 39 cells/mm 2 (19%) at 1-year follow-up, and there was no significant difference between cases requiring a rebubbling and cases that did not ( P = 0.896). All grafts but one were clear at the last follow-up. Graft failure from endothelial decompensation occurred in this lone case (0.8%).It is worth trying to repair all DM ruptures in DALK, and immediate penetrating keratoplasty conversion should be avoided. Understanding the physiomechanical mechanisms in DALK allows to correctly choose a proper rescue strategy to successfully repair DM ruptures.

Cataract surgery in the setting of small pupil represent a major challenge and it is associated with a higher risk of complications. When pharmacologic pupil dilation fails, mechanical pupil expansion devices are needed to obtain and maintain sufficient intraoperative mydriasis. The purpose of this review is to assess the pupil expansion devices currently available.A variety of pupil expansion devices are offered on the market. They differ for design, material, shape, size, cost, and easiness of insertion/removal, nonetheless they all seem to be effective in improving the pupil size and easing the cataract surgery.Mechanical pupil expansion can be effectively achieved with a variety of devices, which are well tolerated and can facilitate cataract surgery in the setting of poor mydriasis.

Purpose Residual bed thickness in DALK should be less than 80μm to provide optimal visual outcomes. “Peeling-off” is a manual DALK technique, which separates the anterior stroma by pulling the deep stromal lamellae following the plane of their lowest adhesion, which is usually very deep. The purpose of this study is to measure the residual bed thickness achievable with this technique. Methods Retrospective case series of “Peeling-off” DALK cases performed between January 2014 and January 2021 with at least 1 year of follow-up. Indications for DALK, intraoperative and postoperative complications, residual recipient bed thickness at 1 day and at 1 month after surgery, and postoperative best corrected visual acuity (BCVA) at 1 year of follow up were evaluated. Results 42 eyes (42 patients) underwent DALK performed with “Peeling-off” technique. Indications for surgery were keratoconus in 33 eyes and stromal scar in 9 eyes. “Peeling-off” technique was used as a rescue approach to perform a DALK after a failed Big-Bubble in all cases, and also failed Air-Visco-Bubble in some cases. No intraoperative and postoperative complications were recorded. Residual recipient bed thickness was deep and regular, measuring 42 microns at 1 day postoperative (range 21–65 microns) and 23 microns (range 17–26 microns) at 1 month postoperative. Mean postoperative BCVA at 1 year of follow up was 0.18 logMAR ± 0.09. Conclusion “Peeling-off” DALK is a valuable manual technique that achieves a deep stromal plane with optimal visual outcomes.

Purpose To describe a series of patients who underwent deep anterior lamellar keratoplasty (DALK) after previous anterior lamellar keratoplasty (ALK) to improve their visual outcomes. Methods This is a retrospective case series of 9 DALK eyes (9 patients) with a history of previous ALK and an unsatisfactory visual outcome. Surgery was performed in all cases at least 3 years after ALK. Cannula big bubble, air viscobubble, and manual dissection techniques were performed. Preoperative and postoperative best-corrected visual acuity, residual recipient bed thickness, and endothelial cell count were evaluated. Follow-up was at least 24 months for all eyes. Results Two subtotal anterior lamellar keratoplasties (through 1 type 1 big bubble and 1 air viscobubble) and 7 manual dissection DALKs were achieved. A small rupture of the residual recipient bed occurred during 1 case, and it was managed without penetrating keratoplasty conversion. Mean best-corrected visual acuity improved from 0.64 to 0.09 logMAR. Postoperative residual recipient central bed thickness was less than 80 μm in all cases. No postoperative complications were recorded at the last follow-up (24-36 months postoperatively). Conclusions Different DALK techniques can be successfully used to improve visual acuity in previous ALK eyes with an unsatisfactory visual outcome.

Purpose: To report how to manage a specific type of Descemet’s membrane (DM) rupture during manual DALK with a concurrent donor–recipient disparity of curvature. Methods: Case report of two patients that had DM rupture during manual DALK with a concurrent donor–recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a “DSEK autograft,” was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. Results: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). Conclusion: The existence of a donor–recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor–recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

Purpose: The aim of this study was to describe a surgical technique to perform deep anterior lamellar keratoplasty (DALK) despite inadvertent full thickness trephination in one quadrant. Methods: Case report of a 19-year-old boy who underwent DALK for visually significant post-infectious stromal scar in his left eye. An unintentional full thickness trephination occurred in the upper-nasal quadrant at the beginning of the surgery. After suturing the perforated area, manual DALK was performed, and an air bubble was left in the anterior chamber. Evaluated outcomes included best spectacle corrected visual acuity (BSCVA), residual recipient bed thickness, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double anterior chamber. Results: The surgery was completed without any further complications. No double anterior chamber or Urrets–Zavalia syndrome was observed on the first postoperative day. Mean residual recipient bed thickness was 72 μm and regular. ECC was 2446 cell/mm2. BSCVA at 18 months of follow-up was 0.9. There were no episodes of rejection, and the graft remained clear at the last follow-up (4 years). Conclusion: Inadvertent partial full thickness trephination of the recipient cornea is a largely preventable but possible complication during DALK. Penetrating keratoplasty conversion can be avoided by performing a manual dissection DALK.

Purpose: To report our surgical experience of deep anterior lamellar keratoplasty (DALK) performed in eyes with scarring resulting from a corneal penetrating wound without tissue loss. Methods: Case series of three eyes of three patients that underwent DALK for poor vision due to a scar resulting from a previous corneal penetrating wound. Surgery was performed at least 1 year after the initial injury. Manual dissection technique was used in all cases. Preoperative and postoperative best correct visual acuity (BCVA), postoperative residual bed thickness, and postoperative endothelial cell count (ECC) were evaluated. Results: Preoperative BCVA ranged from 1.3 to 1.0 LogMAR. Two eyes were pseudophakic and one eye had a traumatic cataract. Manual DALK was successfully accomplished in all three cases. The mean residual recipient bed thickness was 103 µm (range 68–130 µm). The mean endothelial cell loss at the 6th month of follow-up was 6% (range 3%–11%) with a further 1% decrease at 4 years. One of the patients underwent cataract surgery and limbal relaxing incisions 1 year after DALK having a total endothelial cell loss of 4.8% at 2 years of follow-up. BCVA at 2 years of follow-up was 0.1 LogMAR (range 0.22–0.0 LogMAR). No episode of rejection was recorded, and all grafts remained clear at last follow-up (5 years, range 4–6 years). Conclusions: Manual DALK should be considered in cases of corneal scars in optical zone resulting from penetrating wound.

Deep anterior lamellar keratoplasty (DALK) is the ideal surgery for corneal stromal diseases with a healthy endothelium. This technique offers substantial advantages compared with penetrating keratoplasty, primarily the avoidance of endothelial rejection and longer graft survival. Several DALK techniques have been described and classified into 2 categories, descemetic DALK (dDALK) and predescemetic DALK (pdDALK) depending on whether Descemet membrane-endothelium was thought to be exposed or minimal residual stroma was left behind. This classification was crucial to identify the conditions to achieve good visual outcomes with pdDALK techniques. The recent description of Dua's layer, also known as the pre-Descemet layer, has demonstrated that a very thin layer of stroma exists in some instances where Descemet membrane was thought to be completely exposed. This concept has generated a discrepancy between the previous and current applications of the terms "dDALK" and "pdDALK." We offer a summary of the published literature and a proposal for a new and more appropriate DALK nomenclature. We suggest adding the terms subtotal anterior lamellar keratoplasty (STALK) and total anterior lamellar keratoplasty (TALK).

Fuchs endothelial corneal dystrophy (FECD) is the most common indication for corneal transplantation in the United States, accounting 36% of the almost 47,000 transplants performed in 2016. Although the surgical management of FECD has undergone a revolution over the past 20 years, its pathogenesis remains elusive, with multiple putative disease pathways and an ever increasing number of candidate genes thought to play a role. This review will summarize the recent advancements in our understanding of the biology of FECD, including potential parallels with neurodegenerative disease like amyotrophic lateral sclerosis and will highlight prospects for future treatment advances.

Purpose of review Corneal diseases are often associated with lens opacity. The present article reviews the recent advances in the management of cataract and corneal transplant. Recent findings Thanks to the development of lamellar transplant techniques and the evolution of cataract surgery, we now have several strategies to address corneal diseases and cataract including 'lamellar triple procedure'. Numerous precautions have been identified to have a successful surgery with good visual recovery. Summary Corneal diseases associated with cataract can be successfully managed using separate or combined surgical procedures, as appropriate. In most cases the intraocular lens power can be calculated with a predictable outcome.

In the last years there have been many developments regarding corneal diseases and treatments.

To describe the use of irrigating single-port cannulas to unfold Descemet membrane endothelial keratoplasty (DMEK) grafts when traditional tapping techniques are challenging.This study is a retrospective, comparative, nonrandomized, interventional case series that includes 143 DMEKs performed between February 2014 and November 2015. All eyes were divided into 2 groups: in one group, there were 48 cases that underwent DMEK using tap techniques only (Tapping DMEK group), and in another group, there were 30 cases in which irrigating cannulas were used to unfold the graft as a secondary approach (Cannula DMEK group). Intraocular manipulation time and total graft manipulation time were assessed. Uncorrected visual acuity, best spectacle-corrected visual acuity, and endothelial cell count were evaluated at 6 and 12 months postoperatively. We also reviewed DMEK procedures performed between December 2015 and January 2017 to evaluate the use of irrigating cannulas to unfold the graft.All grafts were clear. There was a statistically significant improvement in uncorrected visual acuity and best corrected visual acuity at 6 and 12 months postoperatively in both groups (P0.01). Endothelial cell loss was 32.10% and 32.11% at 12 months in the Cannula and Tapping DMEK groups, respectively (P0.05). Total graft manipulation time was 3 minutes 40 ± 22 seconds in the Cannula DMEK group and 3 minutes 07 ± 26 seconds in the Tapping DMEK group (P0.01). Irrigating cannulas were used as a secondary approach in a smaller percentage of cases between December 2015 and January 2017 (26.2%) compared with DMEK performed during this study (38.5%).When it is difficult to unscroll the endothelium-Descemet membrane graft using only tap techniques, the use of Sarnicola cannulas is useful and effective without negatively affecting the postoperative endothelial cell count.

PURPOSE To determine the efficacy and safety of amniotic membrane transplantation for trabeculectomy in patients with previous failed filtering blebs. METHODS A consecutive series of 19 eyes from 18 patients with 1 or more failed trabeculectomies were enrolled in this retrospective study. Trabeculectomy, with amniotic membrane positioned as a "graft" under the scleral flap, was performed, and the intraocular pressure (IOP), number of antiglaucoma medications, appearance of the filtering bleb, and intraoperative and postoperative complication data were retrospectively analyzed for a period of 24 months. Success was defined as IOP

PurposeTo investigate the efficacy of early therapeutic deep anterior lamellar keratoplasty (DALK) in eradicating fungal keratitis that is poorly responsive to medical treatment.Patients and methodsTwenty-three eyes (23 patients) underwent early therapeutic DALK within 15 to 50 days from the onset of symptoms. The adopted eligibility criteria for early DALK included the following: active fungal keratitis affecting the optical zone with ulcer confined in the 6.00 mm central cornea; deeper than 150 μm but not exceeding 300 μm; and poorly responsive to medical treatment.ResultsThe big bubble technique was accomplished in 74% (17) of eyes, whereas manual dissection was performed in the remaining 26% (6) of eyes. Histopathological examination did not show any sign of fungal colonization in the peripheral and deep stromal lamellae in any case. All grafts were transparent postoperatively, and no recurrence of infection occurred. Median best spectacle corrected visual acuity significantly improved from 2.0 (1.0 interquartile range) logMAR to 0.1 (0.1 interquartile range) logMAR (P0.01). The mean follow-up was 32±10 months. Neither episode of rejection nor graft failure was noted during the follow-up period.ConclusionEarly DALK could represent a safe therapeutic approach to eradicate fungal keratitis that affects the optical zone and is poorly responsive to medical treatment.

PURPOSE To evaluate outcomes and possible advantages of 2 different techniques of deep anterior lamellar keratoplasty (DALK) in patients with keratoconus: cannula big-bubble DALK and needle big-bubble DALK (Anwar technique). METHODS This is a retrospective, nonconsecutive, comparative study of 507 eyes affected by keratoconus that underwent DALK between 2002 and 2012. Needle DALK and cannula DALK techniques were performed in 266 eyes and 241 eyes, respectively. When big bubble (BB) failed, air viscobubble (AVB) was used as a rescue bubble technique. When AVB failed, manual dissection was performed. Main outcomes analyzed were the frequency of descemetic deep anterior lamellar keratoplasty (dDALK) and predescemetic deep anterior lamellar keratoplasty (pdDALK), BB and AVB formation, Descemet membrane rupture, and penetrating keratoplasty conversion. RESULTS The rate of dDALK achieved was higher (P < 0.01) in the cannula DALK group (94%; 198 BB and 28 AVB) than in the needle group (78%; 161 BB and 46 AVB). The remainder of cases involved pdDALK: 59 cases (22%) and 15 cases (6%) of the needle DALK group and cannula DALK group, respectively. Microperforation occurred in 18 cases spread between both groups. Macroperforation occurred in 5 cases in the needle DALK group. A double chamber occurred in seven cases, between both groups. No penetrating keratoplasty conversion was needed. CONCLUSIONS The use of a smooth cannula during the DALK procedure yields a statistically higher percentage of dDALK and makes the maneuver more manageable compared with air injection with a needle. When BB fails, AVB seems to be a good rescue technique to achieve dDALK.

Purpose:To evaluate the success (eradication of infection) or failure (recurrence of infection in the cornea or sclera, or endophthalmitis) of early therapeutic deep anterior lamellar keratoplasty (DALK) for active Acanthamoeba keratitis (AK) poorly responsive to medical treatment.Methods:Retrospect

Deep anterior lamellar keratoplasty (DALK) is currently the procedure of choice to restore transparency and curvature in corneal stromal diseases with a healthy endothelium. Preserving the endothelium

Purpose To determine corneal graft survival rates up to 10 years in a large consecutive series of deep anterior lamellar keratoplasties (DALKs). Methods A retrospective, consecutive, noncomparative cases series of DALK procedures in a total of 806 eyes of 711 patients with stromal diseases and healthy endothelium performed between 2000 and 2009. Inclusion criterion was surgery performed by a single surgeon (660 eyes), with at least 6 months of follow-up. Graft survival was analyzed using the Kaplan-Meier method. Endothelial loss was analyzed with the Gaussian distribution and the χ methods. Follow-up time, and preoperative and postoperative endothelial cell density (ECD) were considered in the analyses. Results Six hundred sixty eyes of 502 patients met the entry criteria. Mean length of follow-up was 4.5 years (range, 0.5-10 years). We report an average graft survival rate of 99.3% (range, 98.5%-100%); 3 eyes (0.45%) experienced graft failure and 1 eye (0.15%) developed late endothelial failure because of an intraoperative complication. Predominant indications for DALK in this series were keratoconus (74%), postherpetic keratitis scarring (15%), and corneal stromal opacities of different etiology (11%). Endothelial loss from preoperative levels averaged 11% (range, 10%-13%) at 6 months through 10 years after DALK. ECD was unchanged between 6 months postoperatively and the last follow-up visits. Conclusions DALK is a successful form of transplantation in stromal corneal disorders with healthy endothelium, with higher long-term graft survival rates and stable ECD 6 months postoperatively. DALK survival rates do not vary significantly over time.

Purpose To report our clinical experience and 4-year follow-up results of Descemet stripping automated endothelial keratoplasty (DSAEK) with the suture pull-through insertion technique. Methods This is a retrospective study of 195 eyes in which a posterior lamellar keratoplasty was performed between 2007 and 2011. The insertion of a folded donor lenticule was performed with a double-armed 10-0 suture using a straight transchamber needle and half-circle needle. Endothelial cell density was measured annually up to 4 years after the surgery, and cell loss was calculated based on the median preoperative donor endothelial cell density. Postoperative complications, primary graft failure, pupillary block, and dislocation of the donor tissue were assessed. Results All patients underwent uncomplicated DSAEK. Data were available for 195 eyes (100%) at 1 year, 186 eyes (95.3%) at 2 years, 176 eyes (90.2%) at 3 years, and 160 eyes (82%) at 4 years. Median preoperative donor endothelial cell density was 2688 cells/mm 2 [interquartile range (IQR) 207.5 cells/mm 2 ], which decreased by 27% at 1 year (1956 cells/mm 2 , IQR 264.8 cells/mm 2 ), 31% at 2 years (1855 cells/mm 2 , IQR 320.5 cells/mm 2 ), 35% at 3 years (1756.5 cells/mm 2 , IQR 306.5 cells/mm 2 ), and 36% at 4 years (1709.5 cells/mm 2 , IQR 288,0 cells/mm 2 ). Nine patients (4.6%) had a dislocation of donor tissue; all were successfully reattached with a second air injection. Only three eyes (1.5%) developed graft failure. Pupillary block was present in 15 eyes (7.7%). Conclusion DSAEK with suture pull-through insertion of donor graft represents a simplified and safe technique that has endothelial cell loss comparable with other techniques and low rates of intraoperative and postoperative complications.