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The Descemet membrane (DM) is the basement membrane of corneal endothelial cells, which are responsible for maintaining corneal transparency. DM detachment (DMD) can occur due to various reasons, with the most common etiology being post-surgical. Older age, blunt instruments, and faulty surgical technique predispose to the intraoperative or postoperative occurrence of DMD, and one should have a high index of suspicion for DMD in cases with unexplained or an atypical pattern of corneal edema after surgery. Prompt intervention for DMD management is imperative to effect early visual rehabilitation, decrease corneal morbidity, and avoid permanent damage leading to scarring of the cornea. Various classifications of DMD and management protocols have been described. Anterior-segment optical coherence tomography (AS-OCT) imaging is the most effective imaging to detect DMD and quantify its extent. Desmetopexy with air/gas is the initial treatment of choice and could be aided by suture fixation. Non-responsive cases might need endothelial keratoplasty., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: The purpose of this study was to investigate the differences in guttae ultramorphology and their relation to visual function in eyes with Fuchs endothelial corneal dystrophy (FECD)., Methods: Thirty FECD eyes without ocular comorbidities were included. Visual functional parameters (best-corrected visual acuity with high-contrast and low-contrast letters and contrast sensitivity/LogCS) and corneal morphology measured with Scheimpflug tomography (Pentacam) were assessed. The surgically removed Descemet membranes were examined by light and transmission electron microscopy., Results: Preoperative mean best-corrected visual acuity (logarithm of the minimum angle of resolution) was 0.52 ± 0.18, LogCS 0.96 ± 0.21 and central corneal thickness 640 ± 55 μm. All eyes had signs of subclinical corneal edema in Scheimpflug tomography; clinically visible corneal edema was present in 40% of eyes. Histological findings included a posterior fibrillar zone (PFZ) in 10 specimens (33%) and abnormal collagen depositions in Descemet membranes in 14 specimens (47%). Guttae buried within the PFZ were present only in eyes with clinically visible edema (n = 4, 13%). There was no difference in visual function results and tomography parameters between eyes with and without PFZ or between protruding guttae and guttae embedded in a PFZ, respectively., Conclusions: Guttae morphology and density were not correlated with visual functional parameters. Guttae buried in a PFZ occurred only in eyes with clinically manifest edema, and thereby, they are an ultramorphological sign for advanced FECD. Subclinical edema was present in all eyes and might be more relevant for quality of vision than guttae ultramorphology., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Fuchs endothelial corneal dystrophy (FECD) is a leading cause of corneal endothelial degeneration resulting in impaired visual acuity. Excessive deposition of extracellular matrix (guttae) on Descemet's membrane (DM) is the hallmark of FECD. We sought to detect the guttae area rapidly using aniline blue (AB) staining in FECD mouse model. FECD mouse model was established via ultraviolet A (UVA) exposure. Masson's trichrome staining was utilized to stain the corneal sections. AB staining was utilized to stain both whole cornea tissues and stripped Descemet's membrane-endothelium complex (DMEC) flat mounts, while immunofluorescence staining of collagen I was employed to stain guttae areas. In Masson's trichrome staining, corneal collagen fibrils were stained blue with AB. The DMEC flat mounts were stained into relative dark blue areas and relative light blue areas using 2% AB staining. The areas of dark blue could almost overlap with collagen I-positive areas, and have an acellular centre and a moderately distinct boundary line with the surrounding corneal endothelial cells. In conclusion, AB staining is a rapid and effective method for the evaluation of the guttae areas in the FECD mouse model., (© 2024 John Wiley & Sons Australia, Ltd.)

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.)

Objective: To report corneal epithelial and corneal endothelial cell (CEC) changes following Descemet stripping only (DSO) with and without topical ripasudil using in vivo confocal microscopy (IVCM)., Methods: Prospective interventional case series of patients who underwent DSO for Fuchs endothelial dystrophy with or without postoperative topical ripasudil (4%, 6 times per day). Patients underwent IVCM (ConfoScan 3; NIDEK Technologies, Padova, Italy) at baseline, monthly until corneal clearance, and then every 6 months. En face images were obtained of the epithelium, anterior and posterior corneal stroma, and endothelium of the central and superior cornea. The epithelial and endothelial layer images were evaluated qualitatively., Results: IVCM imaging was obtained from 34 patients, 26 (76%) of whom were supplemented with ripasudil and 8 (24%) of whom were not. Two eyes (6%) did not clear and required a keratoplasty. IVCM confirmed epithelial and endothelial cell morphology changes and reestablishment of a CEC mosaic. Hyperreflective nuclei, pleomorphism, multinucleated cells, and pseudoguttae were identified within the descemetorhexis. In patients on ripasudil, epithelial cells demonstrated transition from stratified squamous to spindle cell shape in regions of ripasudil-induced honeycomb edema. Migrating cells adopted an amoeboid shape and cytoplasm elongation when crossing to central stroma. Transient epithelial cell morphology changes and endothelial cell amoeboid shape changes appear to be uniquely associated with ripasudil. Rarely, figures were noted in both ripasudil-treated and non-ripasudil-treated corneas that resembled mitotic bodies., Conclusions: CECs display a range of adaptive mechanisms during healing to re-form the endothelial mosaic following DSO. Ripasudil administration appears to induce unique epithelial and endothelial cell changes., (Copyright © 2024 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: To report a case of a retrocorneal fibrous membrane and corneal decompensation following uncomplicated phacoemulsification in an eye with pseudoexfoliative glaucoma., Method: Case report and literature review., Results: A monocular 83-year-old female developed corneal decompensation 1 year after uncomplicated cataract extraction via phacoemulsification. She had a history of pseudoexfoliative glaucoma and had undergone 3 rounds of selective laser trabeculoplasty in the same eye 3 years prior. Given the resulting corneal edema, the patient underwent Descemet's membrane endothelial keratoplasty, at which time a retrocorneal fibrous membrane was identified. Peeling of the membrane was surgically challenging and resulted in an intraocular hemorrhage intraoperatively and a small iridodialysis because the membrane had extended over the angle and iris. Postoperatively, the cornea cleared well, and vision improved significantly. However, vision was ultimately limited by macular pathology. Pathologic examination demonstrated Descemet's membrane with an attached fibrocellular membrane. Immunostaining for smooth muscle actin was positive within the membrane compatible with a retrocorneal membrane. We also present a review of the literature on modern causes of retrocorneal fibrous membranes., Conclusions: Retrocorneal fibrous membranes are encountered most commonly following corneal transplantation and may be surgically challenging to remove. We present the first case of a pathologically proven retrocorneal fibrous membrane following uncomplicated cataract surgery via phacoemulsification and selective laser trabeculoplasty., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Aim: To investigate the interest of chromatic confocal microscopy (CCM) to characterise guttae in Fuchs endothelial corneal dystrophy (FECD)., Methods: Descemet's membranes (DM) were obtained during endothelial keratoplasty in patients with FECD and pseudophakic bullous keratopathy (PBK). They were compared with healthy samples obtained from body donation to science. Samples were fixed in 0.5% paraformaldehyde and flat mounted. Surface roughness of DMs was quantified using CCM and the AltiMap software that provided the maximum peak (S p ) and valley (S v ) heights, the mean square roughness (R q ) and the asymmetry coefficient (S sk )., Results: The physiological roughness of healthy samples was characterised by an R q of 0.12±0.05 µm, which was two times rougher than in PBK (R q =0.06±0.03 µm), but both were still flat with a symmetrical distribution between peaks and valleys (S sk close to 0, n peaks =n valleys ), smaller than 1 µm. In FECD, the maximum peak height was 5.10±2.40 µm, up to 5.8 and 8.3 times higher than the control and PBK, respectively. The maximum valley depth was half than the peak (2.28±0.89 µm). The surface with guttae was very rough (R q =0.45±0.14 µm) and the S sk =1.84± 0.43 µm, greater than 0, confirms an asymmetric surface with high peaks and low valleys (n peaks >n valleys ). Moreover, the CCM provided quantitative parameters allowing to distinguish different types of guttae from different patients., Conclusions: CCM is an innovative approach to describe and quantify different morphologies of guttae. It could be useful to analyse the different stages of FECD and define subgroups of patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Keratoconus eyes develop corneal decompensation more often compared to eyes with primary congenital glaucoma (PCG) following Descemet's membrane (DM) tear. This study was conducted to compare the posterior corneal morphology in areas with DM breaks with regards to DM and pre-Descemet's layer (PDL) between the two. In this cross-sectional comparative study, anterior segment optical coherence tomography (AS-OCT) scans of the posterior cornea of advanced keratoconus eyes with hydrops ( n = 12), PCG eyes with Haab's striae ( n = 15), and healthy control eyes ( n = 14) were compared for DM-PDL morphology. These were further corroborated by the histopathology of corneal buttons from keratoconus ( n = 14) and PCG ( n = 13) cases obtained following penetrating keratoplasty and compared with controls (enucleated retinoblastoma globes, n = 6) on light microscopy and collagen IV immunostaining. AS-OCT showed a thicker median DM/PDL complex in PCG (80 µm) versus keratoconus eyes (36 µm, P = 0.01; Kruskal-Wallis test). The median height and length of detached DM-PDL were significantly more in keratoconus versus PCG (145 μm, 1766.1 ± 1320.6 μm vs. 26.5 μm, 453.3 ± 303.2 μm, respectively, P = 0.012; Kruskal-Wallis test). Type-1 DM/PDL detachment (seen as a characteristic taut chord) in keratoconus (90%) was the most common morphological pattern versus intracameral twin protuberance (92%) following DM breaks in PCG. Histopathology confirmed thicker DM in PCG (median: 63.4 μm) versus keratoconus eyes (median: 33.2 µm) or controls (27.1 μm) ( P = 0.001; Kruskal-Wallis test). Greater height/length of DM/PDL detachment compounded by poor healing response (lower DM/PDL thickness) probably causes more frequent corneal decompensation in keratoconus eyes when compared to PCG eyes following DM tears., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: Fuchs endothelial corneal dystrophy (FECD) is characterized by Descemet's membrane (DM) abnormalities, namely an increased thickness and a progressive appearance of guttae and fibrillar membranes. The goal of this study was to identify abnormal extracellular matrix (ECM) proteins expressed in FECD DMs and to evaluate their impact on cell adhesion and migration., Methods: Gene expression profiles from in vitro (GSE112039) and ex vivo (GSE74123) healthy and FECD corneal endothelial cells were analyzed to identify deregulated matrisome genes. Healthy and end-stage FECD DMs were fixed and analyzed for guttae size and height. Immunostaining of fibronectin, tenascin-C, osteopontin, and type XIV collagen was performed on ex vivo specimens, as well as on tissue-engineered corneal endothelium reconstructed using healthy and FECD cells. An analysis of ECM protein expression according to guttae and fibrillar membrane was performed using immunofluorescent staining and phase contrast microscopy. Finally, cell adhesion was evaluated on fibronectin, tenascin-C, and osteopontin, and cell migration was studied on fibronectin and tenascin-C., Results: SPP1 (osteopontin), FN1 (fibronectin), and TNC (tenascin-C) genes were upregulated in FECD ex vivo cells, and SSP1 was upregulated in both in vitro and ex vivo FECD conditions. Osteopontin, fibronectin, tenascin-C, and type XIV collagen were expressed in FECD specimens, with differences in their location. Corneal endothelial cell adhesion was not significantly affected by fibronectin or tenascin-C but was decreased by osteopontin. The combination of fibronectin and tenascin-C significantly increased cell migration., Conclusions: This study highlights new abnormal ECM components in FECD, suggests a certain chronology in their deposition, and demonstrates their impact on cell behavior.

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.)

Purpose: To evaluate Descemet membrane (DM) morphology in eyes with primary congenital glaucoma (PCG) in vivo using high-definition anterior segment optical coherence tomography (ASOCT) and on histopathology., Methods: Corneal scans of patients with PCG (22 eyes of 15 patients) were evaluated for DM morphology and anterior chamber angle using ASOCT. The DM thickness in PCG eyes was compared with fellow eyes (8 eyes) of unilateral patients with PCG and healthy controls (12 eyes) on ASOCT. The DM morphology was also compared on the histopathology of corneal tissues (9) obtained from PCG eyes after keratoplasty and enucleated eyes of retinoblastoma (6 controls) on light microscopy with immunostaining for collagen IV., Results: On ASOCT, all affected eyes showed the presence of either a thickened DM complex or a hyper-reflective double layer representing the thickened DM and pre-Descemet layer (PDL), unlike a single membrane in the controls and fellow eyes. On ASOCT, among patients with PCG, the DM showed significant thickening (32.0 ± 11.2 μm) versus fellow eyes (14.4 ± 3.3 μm) and controls (11.5 ± 1 μm) (P < 0.001; analysis of variance). The thickened DM complex continued peripherally into the trabecular meshwork as an abnormal membrane in 16/22 affected eyes. On histopathology, thickening of DM was also more among PCG eyes (median: 67.9 μm range: 27.2-214.9) versus controls (median: 27.7 μm, range: 22.1-36.1; P = 0.005) as also of PDL (median: 14 μm, range: 5.9-30.5) of PCG versus (median 3.5, range: 1.3-6.7 μm) in controls; P = 0.014., Conclusions: Thickening of DM and PDL occurs in eyes with PCG and is seen to have a peripheral extension upto the angle recess., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To describe the validation and implementation of an automated system for the detection and quantification of guttae in Fuchs endothelial corneal dystrophy (FECD)., Design: Observational reliability study., Methods: Patients with FECD underwent retroillumination corneal photography, followed by determination of the distributions and sizes of corneal guttae by an automated image analysis algorithm. Performance of the automated system was assessed via (1) validation against manual guttae segmentation, (2) reproducibility studies to ensure consistency, and (3) evaluation for agreement with the Krachmer scale. It was then deployed to perform large-scale guttae assessment with anatomic subregion analysis in a batch of 40 eyes., Results: Compared to manual segmentation, the automated system was reasonably accurate in identifying the correct number of guttae (mean count of 78 guttae per 1 × 1 mm test frame, overestimation: +10 per frame), but had a tendency to significantly overestimate guttae size (mean guttae size 1073 μm 2 , overestimation: +255 μm 2 ). Automated measurements of guttae counts and sizes were reproducible within a 1% discrepancy range across repeat intra-eye assessments. Automated guttae counts, interguttae distances, and density of interguttae gaps lesser than 40 μm (ie, D40 density) were highly correlated with the Krachmer scale (P < .001 for all). Large-scale guttae assessment demonstrated the automated system's potential to selectively identify a region of the corneal endothelium most affected by densely packed guttae., Conclusions: Automated guttae assessment facilitates the precise identification and quantification of guttae characteristics in FECD patients. This can be used clinically as a personalized descemetorrhexis zone for Descemet stripping only and/or Descemet membrane transplantation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Descemet's membrane detachment (DMD) is a rare but potentially serious complication of cataract surgery. Although there are no consensual guidelines regarding the diagnosis or treatment of DMD, incorrect treatment may result in irreversible corneal changes with visual sequellae. The purpose of our study is to describe the diagnosis and treatment of DMD., Methods: We report a series of 9 cases of DMD, their diagnosis, treatment and outcomes. We tested the HELP protocol retrospectively against our 9 real-life cases., Results: Two cases recovered with simple medical management, 4 required air-bubble descemetopexy, and three required keratoplasty. Our study revealed that the main factor associated with poor outcomes is late diagnosis and management., Conclusion: Our series illustrates the importance of proactive management and timely diagnosis by performing anterior segment OCT in the setting of persistent postoperative corneal edema., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: To describe the clinical characteristics and treatment of spontaneous Descemet membrane (DM) detachment occurring decades after penetrating keratoplasty (PK)., Methods: A multicenter interventional case series design was used. We reviewed the medical records of 4 patients with a history of PK presenting with spontaneous DM detachment at 3 university hospitals in Israel and an ocular surgery institute in The Netherlands in 2016 to 2019. Patient demographic and clinical data, postoperative best corrected visual acuity, findings on preoperative and postoperative anterior segment optical coherence tomography (AS-OCT), and graft survival were recorded., Results: Patients were aged 46 to 50 years. All had undergone PK for keratoconus 20 to 26 years previously. Patients presented within 18 to 180 days of onset of visual disturbance. Symptoms included sudden painless visual loss (2 patients), gradual visual loss and foreign body sensation (1 patients), and visual loss not otherwise specified (1 patient). Slit-lamp examination showed corneal edema, and AS-OCT showed DM detachment of variable extent. In 2 patients, the initial diagnosis was graft rejection and failure. Treatment consisted of anterior chamber injection of air (n = 3) or 20% SF6 (n = 1). In 3 patients, the DM reattached and the cornea regained its clarity. The fourth patient had persistent DM detachment that required repeated PK., Conclusions: Spontaneous DM detachment can mimic late graft failure in patients after PK. If diagnosed early, DM reattachment may be performed by air/gas injection, avoiding repeated keratoplasty. Eyes with presumed late penetrating graft rejection or failure should be examined by AS-OCT to exclude DM detachment.

Purpose: To investigate the presence of pre-Descemet corneal dystrophy (PDCD) in association with X-linked ichthyosis (XLI) in an 11-year-old boy using multimodal imaging and genetic analysis., Methods: Corneal opacities were examined and imaged with slit-lamp biomicroscopy, anterior segment optical coherence tomography, noncontact specular microscopy, and in vivo confocal microscopy. Cytogenomic array analysis was performed using genomic DNA isolated from the patient., Results: Corneal opacities characteristic of PDCD located in the posterior corneal stroma just anterior to Descemet membrane were identified by slit-lamp biomicroscopy. A pre-Descemet hyper-reflective line, consistent with these opacities, was seen with anterior segment optical coherence tomography. Scheimpflug tomography revealed a bimodal peak light scattering. In vivo confocal microscopy findings were unremarkable. Copy number analysis identified a 4389 kbp hemizygous deletion on the X chromosome (chr. X: 6,540,898-8,167,604), resulting in the deletion of 4 genes, including the known locus of XLI, the STS gene., Conclusions: This report demonstrates that PDCD-associated XLI may present in children and that the diagnosis may be confirmed through multimodal imaging in conjunction with genetic analysis.

Purpose: To describe the risk factors, management, and outcome of delayed Descemet membrane (DM) detachment after penetrating keratoplasty (PK) for keratoconus., Methods: We report 7 eyes from 6 cases and combine these data with 7 previous case reports identified by a search of PubMed., Results: DM detachment occurred at a median of 25 years (range, 7-33 years) after PK. One individual had bilateral detachments. There was typically a mild ocular discomfort accompanied in some cases by a rapid onset of visual blur. Cases were often treated for allograft rejection before a DM detachment was suspected and confirmed by optical coherence tomography. Detachments were limited to the donor tissue in 11 eyes, but a DM break was identified at the time of onset in only 4 eyes. Thinning of the host corneal rim with ectasia was reported in 8 eyes (57%). In 3 eyes, the detachment resolved spontaneously, but in 2 eyes, a detachment was still present at 12 months. Gas tamponade to reattach the DM was performed in 9 eyes and was effective in 4 eyes. Five eyes underwent a repeat PK or endothelial keratoplasty. Histology showed fibroblastic proliferation on the stromal surface of the folded DM., Conclusions: The cause for DM detachment many years after PK is unknown, although progressive thinning of the host cornea and secondary graft ectasia may be implicated. Gas tamponade can be effective, but a repeat keratoplasty might be necessary. DM detachment should be included in the differential diagnosis for late-onset corneal edema after PK.

Purpose: To examine the optical coherence tomography (OCT) and histologic features of Descemet membrane detachment (DMD) to ascertain the involvement of the pre-Descemet layer (PDL)., Design: Retrospective, observational case series., Methods: Clinical, histopathologic, and OCT features of a cohort of 41 cases with diagnosis of DMD from 4 centers were studied. OCT images were evaluated independently by 3 observers for number of detached layers (1 or 2), reflectivity, configuration (straight line or wavy), distance from posterior stroma, and presence or absence of a tear with any scrolling of the torn edges. Five had a histology specimen. The main outcome measure was the involvement of the PDL in DMD and its confirmation by histology., Results: Three types of DMD were identified: type 1, where the PDL and DM were detached together; type 2, where only the DM was detached; and mixed, where the PDL and DM were detached but also separated from each other. These were further found to be rhegmatogenous or nonrhegmatogenous depending on the presence of absence of a tear in DM or both layers. Histology confirmed involvement of PDL in all 5 cases and showed it to be infiltrated by cells in 3 of 5 cases., Conclusions: The PDL is involved in DMD. This fact significantly changes our understanding of DMD and could have implications for management. The detached PDL can be infiltrated with cells. A prospective study in relation to etiology and types of DMD is needed., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to assess structural and histological changes associated with pre-Descemet corneal dystrophy with multimodal in vivo imaging., Methods: Retrospective case series including eight corneas from four unrelated male patients with pre-Descemet corneal dystrophy characterized by the presence of punctiform gray opacities located just anterior to the Descemet membrane at slit-lamp examination of both eyes. In vivo confocal microscopy images were obtained in the central, paracentral, and peripheral corneal zones from the superficial epithelial cell layer down to the corneal endothelium in both eyes. Spectral domain optical coherence tomography scans (central and limbal zones) and mapping of both corneas were acquired., Results: Diffuse small extracellular stromal deposits, presence of enlarged hyperreflective keratocytes in the posterior stroma with either hyperreflective or hyporeflective intracellular dots, and presence of activated keratocytes in the very anterior stroma were observed in all corneas with in vivo confocal microscopy. Spectral domain optical coherence tomography scans showed a hyperreflective line anterior to Descemet's membrane running from limbus to limbus and associated with a second thinner hyperreflective line just beneath Bowman's layer. Fine hyperreflective particles were observed in the posterior, mid, and anterior stroma on optical coherence tomography scans., Conclusion: The clinical presentation and structural anomalies found in isolated sporadic pre-Descemet corneal dystrophy are in favor of a degenerative process affecting corneal keratocytes with no epithelial or endothelial involvement. The maximum damage is found just anterior to the Descemet membrane resulting in pre-Descemet membrane location of stromal opacities. Multimodal imaging of cornea reveals that the disorder affects the whole stroma and it permits better understanding of pre-Descemet corneal dystrophy pathophysiology together with ascertained diagnosis.

Basement membranes are layers of extracellular matrix which anchor the epithelium or endothelium to connective tissues in most organs. Descemet's membrane- which is the basement membrane for the corneal endothelium- is a dense, thick, relatively transparent and cell-free matrix that separates the posterior corneal stroma from the underlying endothelium. It was historically named Descemet's membrane after Jean Descemet, a French physician, but it is also known as the posterior limiting elastic lamina, lamina elastica posterior, and membrane of Demours. Normal Descemet's membrane ultrastructure in humans has been shown to consist of an interfacial matrix that attaches to the overlying corneal stroma, an anterior banded layer and a posterior non-banded layer-upon which corneal endothelial cells attach. These layers have been shown to have unique composition and morphology, and to contribute to corneal homeostasis and clarity, participate in the control of corneal hydration and to modulate TGF-β-induced posterior corneal fibrosis. Pathophysiological alterations of Descemet's membrane are noted in ocular diseases such as Fuchs' dystrophy, bullous keratopathy, keratoconus, primary congenital glaucoma (Haab's striae), as well as in systemic conditions. Unrepaired extensive damage to Descemet's membrane results in severe corneal opacity and vision loss due to stromal fibrosis, which may require penetrating keratoplasty to restore corneal transparency. The purpose of this article is to highlight the current understanding of Descemet's membrane structure, function and potential for regeneration., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: To describe the diagnostic accuracy of 3-dimensional (3D) endothelium-Descemet's membrane complex thickness (En-DMT) in Fuchs' endothelial corneal dystrophy (FECD) and determine its potential role as an objective index of disease severity., Design: Observational case-control study., Participants: One hundred four eyes of 79 participants (64 eyes of 41 FECD patients and 40 eyes of 38 healthy controls)., Methods: All participants received high-definition OCT imaging (Envisu R2210; Bioptigen, Buffalo Grove, IL). Fuchs' endothelial corneal dystrophy was classified clinically into early-stage (without edema) and late-stage (with edema) disease. Automatic and manual segmentation of corneal layers was performed using a custom-built segmental tomography algorithm to generate 3D maps of total corneal thickness (TCT) and En-DMT of the central 6-mm cornea. Regional En-DMT, regional TCT, and central-to-peripheral total corneal thickness ratio (CPTR) were evaluated and correlated to the clinical severity of FECD. Intraclass correlation coefficients (ICCs) and Bland-Altman plots were used to assess the reliability of the repeated measurements in all eyes., Main Outcome Measures: Central-to-peripheral total corneal thickness ratio and average En-DMT and TCT of central, paracentral, and peripheral regions., Results: In FECD, a significant increase in En-DMT, CPTR , and TCT was found compared to controls (P < 0.001). For identifying FECD, average En-DMT of paracentral and peripheral regions achieved 94% sensitivity and 100% specificity (cutoffs, 19 μm and 20 μm, respectively), whereas CPTR showed 94% sensitivity with a 73% specificity (cutoff, 0.97). Regarding early-stage FECD, average En-DMT of central zones achieved 92% sensitivity and 97% specificity (cutoff, 18 μm), whereas CPTR showed 90% sensitivity and 88% specificity (cutoff, 0.97). The average En-DMT of central, paracentral, and peripheral regions was correlated highly with FECD clinical stage (Spearman's ρ = 0.813, 0.793, and 0.721, respectively; all P < 0.001), compared with CPTR and mean TCT of paracentral zones (0.672 and 0.481, respectively; P < 0.001). The ICC values ranged from 0.98 (En-DMT) to 0.99 (TCT) with a good agreement between the automatic and manual measurements., Conclusions: Regional 3D En-DMT is a novel diagnostic tool of FECD that can be used to quantify the disease severity with excellent reliability., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the factors associated with endothelial survival after Descemet's membrane endothelial keratoplasty (DMEK) in eyes of Asian patients with bullous keratopathy (BK)., Methods: In this retrospective, consecutive interventional case series, 72 eyes of 72 patients who underwent DMEK were evaluated. Best corrected visual acuity (BCVA) and corneal endothelial cell density (ECD) were assessed at 12 months postoperatively. Multiple regression analysis was performed to assess parameters such as age, sex, axial length, preoperative visual acuity, re-bubbling, the ratio of graft to cornea area, iris damage scores, types of filling gases, air or SF6 volume in the anterior chamber (AC) on postoperative day 1, and ECD loss rates at 12 months postoperatively., Results: BCVA improved significantly at 12 months after DMEK (P < .001). The rate of ECD loss at 12 months after DMEK was 54.4 ± 16.1%. Multiple linear regression analysis showed that a larger ratio of graft to corneal area (P = 0.0061) and higher donor ECD (P = 0.042) were the primary factors for a lower ECD loss rate at 12 months after DMEK., Conclusion: A relatively larger graft size compared to the host cornea and more donor ECD might help endothelial survival in patients with BK. Moreover, for such patients, the surgeon should attempt to use a relatively larger graft size when performing DMEK, particularly in Asian eyes., Competing Interests: The authors have declared that no competing interests exist.

Descemet membrane detachment (DMD) is a potential vision-threatening complication that occurs most commonly after cataract surgery. DMD has also been reported to occur in various other surgeries such as keratoplasty, iridectomy, vitrectomy, trabeculectomy, holmium laser sclerostomy, alkali burn, and viscocanalostomy. Major risk factors include advanced age, preexisting endothelial diseases like Fuchs dystrophy or abnormality in the Descemet membrane and stromal interface, hard cataract, prolonged surgical time, ragged clear corneal incisions, and inadvertent trauma with blunt instruments or phacoemulsification probe. Most DMDs are peripheral and resolve spontaneously. Large, central DMDs if not managed appropriately may lead to corneal decompensation and opacification. Several authors have classified DMD depending on its configuration, height, extent, length, and position with respect to pupil. Anterior segment optical coherence tomography has been used to confirm and classify DMD and can also aid in deciding the management plan. Spontaneous reattachment of the DM with conservative management may occur in cases with small, peripheral, planar DMD with nonscrolled edges. Cases with nonplanar, central DMD, scrolled edges, and length >2 mm, however, have to be managed surgically. Descemetopexy is the gold standard for the management of DMD. Other management options include mechanical tamponade, suture fixation, descemetotomy, interface drainage, and keratoplasty. Prompt diagnosis and timely management often leads to a good visual outcome., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: None

Purpose: To describe a case of postsurgical corneal decompensation in a patient with Fuchs endothelial dystrophy with a sectoral Descemet detachment and corneal edema that was successfully managed with a targeted Descemet stripping only (DSO) procedure., Methods: This is a case report and review of the literature., Results: A female patient with Fuchs endothelial dystrophy presented with a 6-month history of a persistent sectoral Descemet membrane detachment after cataract surgery with overlying corneal edema. Specular microscopy demonstrated moderate cell dropout with a cell density of 929 cells/mm in the affected eye. Intracameral air injection was attempted without improvement, and a sectoral DSO procedure was performed. Netarsudil and prednisolone were used postoperatively, and she demonstrated gradual improvement with resolution of the edema by postoperative week 10 and a central endothelial cell density of 675 cells/mm by postoperative month 8., Conclusions: DSO is a viable therapy in certain cases of postsurgical corneal decompensation.

Purpose: To report a patient with chronic ocular graft versus host disease who achieved long-term stability of a descemetocele using prosthetic replacement of the ocular surface ecosystem (PROSE) treatment., Methods: Case report and literature review., Results: A 60-year-old white man, who underwent PROSE treatment 4 years earlier to address severe dry eyes secondary to ocular graft versus host disease, developed a central corneal ulcer that resulted in descemetocele formation. Because of the risks of surgical intervention in an immunocompromised patient with severe ocular surface disease, the descemetocele was monitored closely as the patient continued PROSE device wear. After 1 year with continued PROSE therapy, the patient's descemetocele remained stable without perforation and corrected visual acuity stabilized at 20/50 in the affected eye., Conclusions: This is the first case that reports stabilization of a descemetocele with a PROSE device. For patients at high risk for postsurgical complications, PROSE treatment could be considered as an alternative to corneal transplantation and as an adjunct to other ocular therapies in patients with descemetocele formation.

Purpose: To evaluate the performance of 3-dimensional (3D) endothelium/Descemet membrane complex thickness (En/DMT) maps vs total corneal thickness (TCT) maps in the diagnosis of active corneal graft rejection., Design: Cross-sectional study., Methods: Eighty-one eyes (32 clear grafts and 17 with active rejection, along with 32 age-matched control eyes) were imaged using high-definition optical coherence tomography (HD-OCT), and a custom-built segmentation algorithm was used to generate 3D color-coded maps of TCT and En/DMT of the central 6-mm cornea. Regional En/DMT and TCT were analyzed and compared between the studied groups. Receiver operating characteristic curves were used to determine the accuracy of En/DMT and TCT maps in differentiating between studied groups. Main outcome measures were regional En/DMT and TCT., Results: Both regional TCT and En/DMT were significantly greater in actively rejecting grafts compared to both healthy corneas and clear grafts (P < .001). Using 3D thickness maps, central, paracentral, and peripheral En/DMT achieved 100% sensitivity and 100% specificity in diagnosing actively rejecting grafts (optimal cut-off value [OCV] of 19 μm, 24 μm, and 26 μm, respectively), vs only 82% sensitivity and 96% specificity for central TCT, OCV of 587 μm. Moreover, central, paracentral, and peripheral En/DMT correlated significantly with graft rejection severity (r = 0.972, r = 0.729, and r = 0.823, respectively; P < .001)., Conclusion: 3D En/DMT maps can diagnose active corneal graft rejection with excellent accuracy, sensitivity, and specificity. Future longitudinal studies are required to evaluate the predictive and prognostic role of 3D En/DMT maps in corneal graft rejection., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To study the outcomes of Descemet membrane (DM) suturing for moderate to severe Descemet membrane detachment (DMD) after cataract surgery., Methods: This is a retrospective case review of all patients who underwent DM suturing for moderate to severe DMD after cataract surgery in a tertiary training eye care hospital from January 2017 to December 2017. Demographic details, type of cataract, type of cataract surgery, intraoperative complications, severity of DMD, time to repair, and post-DM suturing visual and clinical outcomes were documented., Results: Forty-nine patients were included during the study period with a mean age of 67.7 ± 9.7 years. In total, 79.5% had immature cataracts. Median precataract LogMAR visual acuity was 0.78 (IQR 0.69-1.13). In total, 61.2% underwent manual small-incision cataract surgery, 32.6% had phacoemulsification, 2% had extracapsular cataract extraction (ECCE), and 6% underwent small-incision cataract surgery with trabeculectomy. In total, 44.9% were operated on by trainees and 55.1% were operated on by consultants. In total, 22.4% had primary air descemetopexy during the cataract surgery and failed treatment. All patients had attached DM in the immediate postoperative period. None of them had secondary angle closure glaucoma. At the final follow-up, 42 (85.7%) had clear corneas and 7 (14.3%) had corneal decompensation needing endothelial keratoplasty. Of these 7 patients, 2 (28.5%) had Fuchs dystrophy and 3 (42.8%) had associated DM loss. The median LogMAR visual acuity at the final follow-up was 0.39 (IQR 0.3-0.78)., Conclusions: DM suturing can reattach DM, especially in moderate to severe, recurrent DMD with fewer postoperative complications and thereby reduce the need for corneal transplantation.

Gonioscopy-assisted transluminal trabeculotomy (GATT) is a surgery that opens the trabecular meshwork (TM) circumferentially after cannulation of the Schlemm canal (SC) with a flexible illuminated microcatheter or suture. The main purpose of this case report was to describe a new complication of GATT. Herein, we report a case of partial SC, TM, and Descemet membrane (DM) separation during GATT. The patient was a 60-year-old man with a history of glaucoma who underwent GATT. SC, TM, and DM separation occurred intraoperatively during 360 degrees trabeculotomy. The separated tissue fragment was removed from the anterior chamber and later confirmed to be a part of the SC, TM, and DM by histopathologic examination. In our patient, this complication did not cause surgical failure. Various complications associated with GATT have been reported previously. Partial SC, TM, and DM separation may occur during this surgery.

Purpose: To characterise the corneal deposits of macular corneal dystrophy and correlate with high-resolution optical coherence tomography (OCT)., Methods: A total of 23 eyes of 15 patients were evaluated for clinical features on slit lamp biomicroscopy, and high-resolution OCT was performed to correlate the clinical findings. The deposits were characterised based upon their location and level in the corneal layers., Results: Mean age was 31.5 (Range 20-67) years. The stromal deposits were restricted to central 8 mm in 9 eyes; in the rest of the 14 eyes, the deposits were seen in both central and peripheral cornea. In one patient, no such distinction could be made due to diffuse nature of the deposits throughout the cornea with sparing of 1-2 mm of the cornea internal to the limbus. The central deposits were in the anterior stromal layers, while the peripheral deposits were in the deep stromal corneal layers and non-contiguous with the anterior stromal deposits. In one patient aged 67 years, the peripheral deposits in deep corneal layers were more prominent than the central anterior stromal deposits and were associated with a significant thickening of Descemet membrane., Conclusions: MCD exhibits a clinically diverse presentation as revealed on the clinical and optical coherence tomography study. Immunophenotype and genotype-phenotype correlation may further help in understanding various clinical presentations of MCD.

Competing Interests: There are no conflicts of interest.

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.

Competing Interests: There are no conflicts of interest.