Wound Dehiscence After Penetrating Keratoplasty

Investigation of mechanical strength and structure of corneal graft-host junction

Dehiscence is a common complication of corneal transplant surgery involving separating the graft from the host eye. The present article aims to investigate fundamental insights into the mechanical and structural aspects of the graft-host junction (GHJ) of a graft that survived in a patient for 13 years after penetrating keratoplasty (PK). Additionally, it adopts the sutur retention strength (SRS) test procedure defined in ISO:7198-2016 and aims to provide a comprehensive test protocol to study the biomechanics of the GHJ in extracted PK buttons. A 9 mm corneal button with GHJ was extracted from a 46-year-old patient who underwent PK 13 years back. The strength of the GHJ was quantified using the SRS test. Corresponding control results were obtained from the SRS tests of a corneoscleral button with no history of any refractive procedure. Birefringence, histological, and scanning electron microscopy (SEM) imaging were used to visualize the microstructural details of the GHJ. The strength of the GHJ was observed to be ten times lower than the native cornea. Histopathological features, such as fragmented Bowman's layer, and fibrosis with a clear demarcation line between host and graft tissue, were observed at the GHJ, suggesting a weak bond across the GHJ. The low strength of the GHJ in PK indicates the high susceptibility of the GHJ towards wound dehiscence.

Incidence of wound dehiscence after keratoplasty: a meta-analysis of observational studies

Background

The comprehensive investigation of the association between keratoplasty and wound dehiscence remains limited, despite corneal disease being a leading cause of visual impairment.

Methods

A meticulous search strategy was executed across prominent databases such as Web of Science, PubMed, Cochrane Library, and Embase. Data relevant to our research objective were extracted from eligible studies. The methodological quality of each study was assessed using the ROBINS-I tool, while statistical analysis was conducted utilizing STATA 17.0. To evaluate potential publication bias, the Funnel plot and Egger's test were employed.

Results

A total of 11 articles were deemed suitable for inclusion in our analysis. Our findings indicate that the overall incidence of wound dehiscence following keratoplasty was estimated to be 1.9% (95% CI: 0.013, 0.026), although substantial heterogeneity was observed (I2 = 72.798%). Notably, developed countries exhibited a higher incidence of wound dehiscence compared to their developing counterparts. Furthermore, the occurrence of wound dehiscence was found to be lower in deep anterior lamellar keratoplasty (DALK) procedures when compared to penetrating keratoplasty (PK). Analysis utilizing Egger's linear regression method yielded no evidence of publication bias (p = 0.91). Moreover, within the first year post-keratoplasty, approximately 31.4% of patients experienced wound dehiscence (95% CI: 0.149, 0.503), and 43.1% exhibited a decline in best-corrected visual acuity (BCVA) (95% CI, 0.341, 0.522).

Conclusion

The results of our study unveiled the occurrence rate of wound dehiscence following keratoplasty, exhibiting variations based on economic level and the specific surgical procedure employed. Furthermore, onset time of wound dehiscence and visual acuity warrant consideration.

Long-Term Outcomes of Bowman Layer Inlay Transplantation for the Treatment of Progressive Keratoconus

PURPOSE

To report long-term clinical outcomes and estimated success rates after Bowman layer (BL) inlay transplantation in eyes treated for progressive keratoconus (KC).

METHODS

Thirty-five eyes (29 patients) with progressive KC underwent BL inlay transplantation. Best-corrected spectacle and contact lens visual acuity, Scheimpflug-based corneal tomography [simulated and maximum keratometry (Kmax)], central corneal thickness, thinnest point thickness, complications, and success rate were evaluated up to 8 years postoperatively for the total group and 2 subgroups [group 1: preoperative Kmax > 69 diopter (D) (n = 26); group 2: preoperative Kmax < 69D (n = 9)].

RESULTS

Mean logarithm of the minimum angle of resolution best contact lens-corrected visual acuity for the total group and the 2 subgroups did not change from preoperative up to the last available follow-up (all P > 0.05), whereas best spectacle-corrected visual acuity improved for group 1 ( P = 0.03). Group 1 showed an average Kmax reduction of 7D in the first month ( P < 0.001) with no further changes up to 8 years postoperatively ( P > 0.05), whereas no significant changes were observed in group 2 (all P > 0.05). Postoperative KC progression occurred in 4 eyes (n = 3 group 1, n = 1 group 2) and 1 eye (group 2) underwent retransplantation for unsatisfactory visual performance. Kaplan-Meier analysis showed an estimated success rate of 85% at the 5 to 8 years follow-up in group 1 and of 75% at the 5 to 7 years follow-up for group 2.

CONCLUSIONS

BL inlay transplantation stabilized KC in most eyes along with preservation of contact lens tolerance up to 8 years postoperatively and may be a successful treatment option, in particular for eyes with progressive advanced KC (Kmax > 69D).

Traumatic wound dehiscence after penetrating keratoplasty: Clinical features and outcome in 53 cases in Yemen

AIMS:

Penetrating keratoplasty (PKP) carries the risk of developing wound dehiscence, which can lead to vision loss. The main aim of this study is to analyze the management and outcome of surgery for traumatic wound dehiscence occurring in patients who had PKP.

SUBJECTS AND METHODS:

This retrospective study included post-PKP patients who sustained traumatic wound dehiscence at the Cornea Unit in Yemen Magrabi Eye Hospital between 2008 and 2016. Fifty-three eyes with a history of wound dehiscence were treated with primary wound closure. Patient files were reviewed for type and time of injury, distance visual acuity (VA), and outcome.

RESULTS:

Ruptured globe with dehiscence of wound occurred on average 2.4 years (3 months to 13 years) after PKP. The mean age at wound dehiscence was 22.27 years and males accounted for 77.4% (41). All patients were managed with primary closure of the wound. Lensectomy of traumatic or dislocated lens was the most frequent additional surgical procedure (14, 26.4%), followed by anterior vitrectomy (6, 11.3%). In the end, 43 (81.1%) grafts remained clear. In the last follow-up, 34 eyes (64.1%) had best-corrected VA of 20/200 or better and two eyes had no perception of light.

CONCLUSION:

Rupture globe and wound dehiscence occurs after PKP at the graft–host junction. Wound dehiscence is a lifelong risk after PKP and wound weakness persisted for a long period after PKP. Visual outcome and graft survival are generally poor after the injury, and the restoration of a satisfactory visual result is possible if treated early.

Comparative Evaluation Of Clinical Characteristics And Visual Outcomes Of Traumatic And Non-Traumatic Graft Dehiscence Following Corneal Transplantation Surgery

Purpose

To compare patient demographics, clinical associations and visual outcomes between traumatic and non-traumatic wound dehiscence, following corneal transplantation.

Methods

Retrospective review of all patients presenting with post-keratoplasty wound dehiscence to the Royal Victorian Eye and Ear Hospital between January 2005 and December 2017. Patients with wound dehiscence following keratoplasty of any cause were included.

Results

Of 71 eyes from 71 patients included, 60 (85%) were penetrating keratoplasty patients. The mean age was 56.4 years (SD=22.7, range 17.6-97) and 62% (n = 44) of patients were male. There were 28 (39%) cases of traumatic dehiscence and 43 (61%) cases of non-traumatic dehiscence. The median time interval from keratoplasty to dehiscence was significantly less in non-traumatic patients than traumatic patients (0.2 years, IQR 0.1-2.0 vs 2.3 years, IQR 0.3-14.8, p=0.01). There was no significant difference in best-corrected visual acuity at 6 months between traumatic and non-traumatic dehiscence (6/60 vs 6/36, p=0.62), suture technique (continuous vs interrupted, p=0.12), or graft type (penetrating keratoplasty vs deep anterior lamellar keratoplasty) after adjusting for keratoconus (p=0.41).

Conclusion

Post-keratoplasty wound dehiscence is a serious complication and can cause significant loss of vision. While the risk of dehiscence is lifelong, the first 3 years post-keratoplasty carry the highest risk, with non-traumatic dehiscence tending to occur earlier than traumatic dehiscence.

Bowman layer transplantation: 5-year results

PURPOSE

The purpose of this study was to evaluate the 5-year clinical results of isolated Bowman layer (BL) transplantation in the treatment of advanced keratoconus.

METHODS

In this prospective, single-center, interventional case series at a tertiary referral center, 20 eyes of 17 patients with advanced keratoconus underwent BL transplantation, i.e. an isolated Bowman layer graft was positioned into a manually dissected mid-stromal pocket. Scheimpflug-based corneal tomography measurements, best corrected spectacle and contact lens visual acuities (BSCVA and BCLVA), endothelial cell density, and complications were evaluated up to 5 years after surgery.

RESULTS

Measured simulated and maximum keratometry (Kmean and Kmax) values were stable up to 5 years after surgery (P = .310 and P = .195 for 5 years compared to 1 month follow-up, respectively), following an initial decrease from pre- to 1 month postoperatively (P < .001 each). Mean LogMAR BSCVA remained stable (P > .99), after an initial improvement from pre- to 12 months postoperatively (P = .007). Mean BCLVA did not change from preoperative to 5 years postoperatively (P = .219). During all postoperative follow-ups, mean densitometry values were higher than preoperatively (P < .001). A corneal hydrops occurred in one eye at 4.5 years postoperatively; no other postoperative complications were observed. Kaplan-Meier analysis showed an estimated success rate of 84% at 5 years postoperatively. Endothelial cell density remained stable from before to 5 years after surgery (P = .319).

CONCLUSIONS

After early postoperative corneal flattening, topographies were stable up to 5 years after BL transplantation, preserving BCLVA and contact lens tolerance, potentially allowing long term postponement of penetrating or deep anterior lamellar keratoplasty.

Bowman layer transplantation to reduce and stabilize progressive, advanced keratoconus

OBJECTIVE

To evaluate the clinical outcome of mid-stromal isolated Bowman layer transplantation, a new surgical technique to reduce and stabilize ectasia in eyes with advanced keratoconus, to postpone penetrating keratoplasty or deep anterior lamellar keratoplasty, and to enable continued daily contact lens wear.

DESIGN

Prospective, nonrandomized cohort study at a tertiary referral center.

PARTICIPANTS

Twenty-two eyes of 19 patients with progressive, advanced keratoconus not eligible for ultraviolet cross-linking.

INTERVENTIONS

The mid-stroma was manually dissected and an isolated donor Bowman layer was positioned within the stromal pocket.

MAIN OUTCOME MEASURES

Before and up to 36 months after surgery (mean follow-up, 21±7 months), best spectacle-corrected visual acuity (BSCVA), best contact lens-corrected visual acuity (BCLVA), Scheimpflug-based corneal tomography measurements, endothelial cell density, biomicroscopy, refraction, and intraoperative and postoperative complications were recorded.

RESULTS

Two surgeries were complicated by an intraoperative perforation of Descemet membrane; no other intraoperative or postoperative complications were observed. Maximum keratometry decreased on average from 77.2±6.2 diopters (D) to 69.2±3.7 D (P < 0.001) at 1 month after surgery and remained stable thereafter (P ≥ 0.072). Mean BSCVA improved from 1.27±0.44 logarithm of the minimum angle of resolution units before surgery to 0.90±0.30 logarithm of the minimum angle of resolution units 12 months after surgery (P < 0.001), whereas BCLVA remained stable (P = 0.105). Mean thinnest-point pachymetry increased from 332±59 μm before surgery to 360±50 μm at the latest follow-up (P = 0.012), and no change in endothelial cell density was found (P = 0.355).

CONCLUSIONS

With isolated Bowman layer transplantation, reduction and stabilization of corneal ectasia was achieved in eyes with progressive, advanced keratoconus. Given the low risk for complications, the procedure may be performed to postpone penetrating or deep anterior lamellar keratoplasty.

Blowout Fracture after Descemet's Stripping Automated Endothelial Keratoplasty

We present the case of an 86-year-old woman who developed a blowout fracture after Descemet's stripping automated endothelial keratoplasty (DSAEK). Sixteen months after DSAEK, she suffered a blow to her left eye caused by a fall. Computed tomography confirmed the presence of a blowout fracture of the inferior wall of the left orbit with soft tissue prolapsing into the orbit. The patient complained of no abnormal symptoms, and her operated cornea was intact and clear. There was no abnormal finding in both the anterior and posterior segments. This case highlights that the DSAEK technique provides adequate tectonic stability of the globe throughout the traumatic event in contrast to penetrating keratoplasty, which can lead to devastating vision damage after trauma.

Spontaneous wound dehiscence after penetrating keratoplasty

Spontaneous wound separation may be developed even months after suture removal especially in the context of long-term corticosteroid therapy. A 68-year-old Caucasian woman presented to our cornea clinic with spontaneous wound dehiscence after her third penetrating keratoplasty (PKP) which was performed three years ago. An Ahmed glaucoma valve (New World Medical, Ranchos Cucamonga, CA) was inserted ten months after the third PKP, which successfully controlled intraocular pressure (IOP). At the examination, the last sutures were removed eight months ago and she was using flourometholone 0.1 % (Sina Darou, Tehran, Iran) with a dose of once a day. There was one quadrant of wound dehiscence from 8 to 11 òclock associated with anterior wound gape and severe corneal edema. Resuturing was performed for the patient. At the one month examination, the corneal edema was resolved and best corrected visual acuity was 20/200 mainly due to previous glaucomatous optic neuropathy. Caution about the prolonged use of corticosteroids is necessary. Topical immunosuppressives could be a promising choice in this field.

Comparative cost-effectiveness analysis of descemet stripping automated endothelial keratoplasty versus penetrating keratoplasty in the United States

PURPOSE

To perform a comparative cost-effectiveness analysis of Descemet stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) for corneal endothelial disease.

DESIGN

Retrospective cost-effectiveness analysis.

METHODS

This cost-effectiveness analysis was performed from a third-party payer perspective with a 5-year time horizon. Probabilities of outcomes and complications of each of the procedures were calculated based on review of the published literature. A model was constructed to compare the costs and utilities associated with DSAEK and PK. Costs of donor tissue preparation, surgery, follow-up, postoperative complications, and procedures were considered. Utility values were based on quality-adjusted life years associated with visual acuity outcomes. Both costs and utilities were discounted at 3% per year. Sensitivity analyses were performed on key model inputs.

RESULTS

Base case analysis found DSAEK to be less costly compared with PK ($9362 vs $10 239), with greater utility (3.15 vs 2.47 quality-adjusted life years). Sensitivity analyses revealed that even at graft failure rates for DSAEK approaching the rates for PK, DSAEK would still reduce costs. Varying the dislocation rate in our model showed that even at dislocation rates approaching 50%, DSAEK remained less costly. Further, with DSAEK rejection rates as high as 28%, DSAEK would remain a dominant procedure over PK.

CONCLUSIONS

Comparative cost-effectiveness analysis of DSAEK versus PK indicates favorable cost and utility outcomes associated with DSAEK for treatment of corneal endothelial disease. Longer follow-up of DSAEK outcomes will provide more accurate information regarding long-term cost-effectiveness of the procedure.

Traumatic wound rupture after Boston type 1 keratoprosthesis implantation

OBJECTIVE

To describe the incidence, characteristics, causes, treatment, and outcomes of traumatic wound rupture in patients with Boston type 1 keratoprosthesis (KPro).

DESIGN

Retrospective case series.

PARTICIPANTS

We studied 136 eyes of 122 patients who underwent KPro implantation at a single institute between November 2004 and May 2011.

METHODS

A chart review was performed to determine the incidence, characteristics, causes, treatments, and outcomes of traumatic wound rupture.

RESULTS

The 4 eyes of 4 patients that sustained traumatic wound rupture resulted in an incidence of traumatic wound rupture of 2.9% (4/136). This complication occurred, on average, at 4.2 months (range, 1-9 months) after the KPro was implanted. All ruptures occurred at the graft-host junction. The 2 eyes that had complete keratoprosthesis extrusion experienced decreased vision postrupture, from hand motions to no light perception, and 20/300 to count-fingers vision, respectively. One eye that had 4 clock hours of superior wound rupture recovered vision postrupture from light perception to 20/40. One eye that had 2 clock hours of superior wound rupture maintained a stable vision of 20/125 after repair.

CONCLUSIONS

The incidence of traumatic wound rupture after keratoprosthesis is comparable to that after penetrating keratoplasty. Patients should be aware that traumatic rupture is a lifelong concern and should use protective measures to prevent this complication from occurring.

Traumatic wound dehiscence after penetrating keratoplasty: case series and literature review

PURPOSE

Blunt trauma after penetrating keratoplasty (PK) is a high risk for wound rupture at the donor-recipient interface. We present 6 cases of traumatic wound dehiscence after PK; we describe the morphologic and functional outcome after surgical intervention and provide a review of the current literature.

METHODS

Six patients with a traumatic wound dehiscence after PK were analyzed retrospectively from the files of the University Eye Hospital Hamburg-Eppendorf (1998-2009). In addition, a comprehensive literature review was performed.

RESULTS

The indications for PK were keratoconus, corneal scars, and Fuchs endothelial dystrophy. The age range was 22-81 years; the time span between PK and globe rupture was 1 month to 27 years. The cause of the dislocation was a fall or blunt trauma, through a branch, airbag, fist, or finger. The corrected distance visual acuity (CDVA) pretrauma ranged between hand movement and 20/32. The CDVA after wound repair was 20/400 to 20/25 depending on the severity of the trauma. In 3 of the 6 cases, visual rehabilitation was superior to the pretrauma vision, whereas in 3 cases the pretrauma CDVA could not be reached.

CONCLUSIONS

If a timely and adequate treatment of the traumatically dislocated transplant can be given, it is likely that the transplant will survive. Nevertheless, severely reduced visual acuity (i.e., < hand movement) and lens damage at the time of trauma are the most reliable predictors for the final visual outcome. A permanent loss of visual acuity is related rather to the intraocular damage (vitreous loss, vitreous bleeding, retinal tears, and retinal detachment) than to the readapted transplant itself.

Endothelial Keratoplasty: From DLEK to DMEK

The last decade has heralded a revolutionary shift in the treatment of corneal endothelial disease. Only 15 years ago, the only surgical treatment for pseudophakic bullous keratopathy and Fuchs dystrophy was penetrating keratoplasty (PK). Although used successfully for over a century, PK requires many months of refractive adjustments before the eye achieves visual stability. Starting with the advent of posterior lamellar keratoplasty in the late 1990s, a number of procedures have been developed, refined, and widely adopted, which have given patients faster recoveries and improved globe stability in comparison to traditional corneal transplantation. Each iteration of endothelial keratoplasty (EK) has involved the increasingly selective transplantation of corneal endothelial cells. Preliminary results of the most recent form of EK, Descemet's membrane EK, suggest that pure endothelial cell transplantation is on the horizon.

Secondary "thin-DSEK" after long-term graft failure in DLEK: a double transplanted cornea

PURPOSE

To describe a case of secondary "thin Descemet stripping endothelial keratoplasty" ("Thin-DSEK"), for borderline decompensation 6 years after an initial deep lamellar endothelial keratoplasty (DLEK).

METHODS

In a 31-year-old man, who initially underwent a DLEK for bullous keratopathy in the presence of a phakic intraocular lens, a secondary Thin-DSEK was performed, while leaving the entire DLEK graft (including the donor Descemet membrane and the endothelium) in situ.

RESULTS

After the initial DLEK, the best-corrected visual acuity (BCVA) improved from 20/200 (0.1) to 20/25 (0.8). Six years later, the transplanted cornea showed intermittent decompensation with a decrease in BCVA again to 20/200 (0.1). After the secondary Thin-DSEK, the BCVA improved again to 20/25 (0.8) at 1 month postoperatively and remained stable thereafter.

CONCLUSIONS

Our case may show that a secondary DSEK may be a simple and effective treatment to manage secondary graft failure after DLEK. Despite the presence of a "double" stromal interface in the visual axis, secondary Thin-DSEK may provide visual rehabilitation similar to that after primary Thin-DSEK.

Deep anterior lamellar keratoplasty in patients with keratoconus: big-bubble technique

PURPOSE

To evaluate the visual and refractive outcomes after deep anterior lamellar keratoplasty (DALK) using the big-bubble technique in eyes with keratoconus.

METHODS

In this case series, eyes with moderate to advanced keratoconus underwent DALK. All of them had unacceptable spectacle-corrected visual acuity or were contact lens intolerant. DALK was performed using the big-bubble technique. Full thickness donor cornea without Descemet's membrane (DM) was sutured to the recipient bed with three different suturing techniques. The visual acuity (presented in logMAR), refractive status, intraoperative and postoperative complications were evaluated.

RESULTS

A total of 129 consecutive eyes of 121 patients were included. In 3 eyes, the operation was converted to penetrating keratoplasty. Therefore, 126 eyes (79 male) were enrolled in the study. Mean patient age at the time of surgery was 26.08 +/- 7.6 years. Mean follow-up period was 21.62 +/- 9.0 months. Mean preoperative corrected visual acuity was 1.27 +/- 0.4 logMAR, increasing to 0.25 +/- 0.2 logMAR at final follow-up examination (P < 0.001). Postoperative mean spherical equivalent refractive error, refractive and keratometric astigmatism were -3.41 +/- 3.1 D, 3.04 +/- 2.3 D, and 3.67 +/- 2.1 D, respectively. Bared DM was achieved in 103 eyes, whereas in 23 eyes pre-Descemet dissection was performed. DM perforation occurred in 5 eyes. The main complications encountered were filamentary keratitis, subepithelial graft rejection, and astigmatism.

CONCLUSIONS

: DALK using the big-bubble technique appears to be a safe and effective procedure for eyes with moderate to advanced keratoconus. In case of extensive intraoperative DM perforation, it does not pose any limitation to ongoing penetrating keratoplasty.

Traumatic wound dehiscence and lens extrusion after penetrating keratoplasty

PURPOSE

The purpose of this study was to investigate risk factors for and results of treatments in patients with traumatic wound dehiscence and lens extrusion after penetrating keratoplasty.

METHODS

In this retrospective case series, 7 eyes (4 right eyes and 3 left eyes) of 7 patients who had traumatic wound dehiscence and lens extrusion were studied at Rassoul Akram Hospital. Six patients were male and one patient was female. After emergency treatment for the trauma, the wound was checked under general anesthesia, and anterior vitrectomy was performed. The iris was repositioned as needed and the dehiscence site was sutured in all patients using 10-0 nylon thread. Follow up was similar to that after keratoplasty. All recorded data were statistically analyzed using SPSS software (version 15; SPSS Inc., Chicago, IL).

RESULTS

Mean age at trauma was 21 years (range, 10-30 years), and the mean interval between keratoplasty and trauma was 15.6 months (range, 2.5-26.5 months). Mean best-corrected visual acuity of patients before blunt trauma and after final treatment was 20/80 and 20/160, respectively. In one case, visual acuity decreased to light perception after final treatment. The dehiscence site was superior to the graft in 4 patients. Hitting by a hand was the cause of most cases of blunt trauma. No cases of endophthalmitis were seen.

CONCLUSION

Patients who undergo penetrating keratoplasty are susceptible to graft wound dehiscence resulting from trauma, especially during the first year after keratoplasty. This type of dehiscence is more prevalent in young people, who engage in more social activities and are more exposed to trauma that may lead to blindness. Patient education about the effects of trauma, use of protective eye shields by patients, and performance of lamellar keratoplasty instead of penetrating keratoplasty can decrease trauma and its effects in these patients.

Traumatic wound dehiscence after deep anterior lamellar keratoplasty: protective role of intact descemet membrane after big-bubble technique

PURPOSE

To describe a case of traumatic wound dehiscence after deep anterior lamellar keratoplasty.

METHOD

Observational case report.

CASE REPORT

A 31-year-old man who had undergone deep anterior lamellar keratoplasty using big-bubble technique for keratoconus 3 months earlier presented to emergency room after blunt trauma.On examination, visual acuity was counting fingers at 2 m. The corneal graft wound dehisced from 12 to 3 o'clock (90 degrees) with localized suture ruptures, but the anterior chamber was deep and the Seidel test was negative. Surprisingly, there was intact Descemet membrane prolapsed through the corneal wound gap.

CONCLUSION

This case indicates that intact Descemet membrane remaining after big-bubble technique might reduce the severity of ocular injury after traumatic wound dehiscence.

Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology

OBJECTIVE

To review the published literature on safety and outcomes of Descemet's stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea.

DESIGN

Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives.

RESULTS

The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection (mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from -0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%).

CONCLUSIONS

The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

[Traumatic wound dehiscence after keratoplasty]

PURPOSE

To assess the patient characteristics, risk factors, and outcomes of penetrating keratoplasty wound dehiscence.

PATIENTS AND METHOD

Retrospective chart review of 11 eyes of 11 patients with corneal grafts who underwent repair of penetrating keratoplasty wound dehiscence from January 1986 to January 2006 in the Ophthalmology Department at the Besançon Minjoz Hospital (France).

RESULT

The mean time between penetrating keratoplasty and wound dehiscence was 3.3 years (range, 1-140 months). In all cases, dehiscence involved the junction between graft and host. The mean age at time of wound dehiscence was 47 years (range, 23-89 years). Falls were the most common mechanism of trauma, especially in the elderly population. There was a wide range of visual outcomes in the 11 patients, with six patients with best corrected visual acuity less than 1/20. There were no cases of endophthalmitis.

CONCLUSION

Patients with corneal transplants have a life-long risk for wound traumatic dehiscence. This complication may be reduced by the regular use of eye protection by all corneal transplantation patients.

Deep Anterior Lamellar Keratoplasty in Korean Patients With Avellino Dystrophy

PURPOSE

To evaluate the surgical outcome of deep anterior lamellar keratoplasty (DALK) in Korean patients with Avellino dystrophy.

METHODS

A retrospective study was performed in 4 eyes (4 patients) with recurrent Avellino dystrophy after phototherapeutic keratectomy (PTK). Genetic study was performed on 2 patients to confirm the diagnosis. Partial-thickness donor cornea (devoid of endothelium and Descemet membrane) was transplanted onto a recipient bed after deep lamellar dissection and removal of recipient stroma. Visual acuity, refractive error, keratometry values, topographic astigmatism, and complications were evaluated after a follow-up period of at least 14 months.

RESULTS

The mean age of the patients was 52.5 +/- 3.32 years, and the mean follow-up period was 17.5 +/- 3.11 months. Visual acuity was improved to > or = 20/25 in all cases. Postoperative topographic astigmatism ranged from 1.2 to 4.9 D. In 1 case, double anterior chamber developed after the operation, which resolved after gas injection into the anterior chamber. During the follow-up period, there were no signs of graft rejection, and all grafts were transparent except one, in which small opacity recurred in the peripheral corneal stroma 13 months postoperatively.

CONCLUSIONS

DALK is considered a good primary surgical option in patients with recurrent Avellino dystrophy after PTK.

Corneal wound dehiscence after penetrating keratoplasty

PURPOSE

To describe the clinical features of corneal wound dehiscence after penetrating keratoplasty (PK) after trauma and suture removal.

METHODS

A retrospective review of all eyes needing resuturing in the 5-year period of July 2000 to June 2005 was performed. In total, 76 eyes of 76 patients needed wound resuturing. The indications were early wound leak, wound dehiscence, broken suture, or loose suture. In 29 of the 76 cases, the indication for resuturing after PK was wound dehiscence. Of these, 19 were caused by trauma, and in 10 eyes, dehiscence shortly followed suture removal.

RESULTS

The interval between original PK and traumatic wound dehiscence caused by trauma ranged from 15 days to 33 years. In 5 eyes, it was >15 years. Nine eyes (47%) with traumatic dehiscence had final visual acuity better than 6/60, whereas 8 eyes (80%) with suture removal dehiscence had final visual acuity better than 6/18. Most of the dehiscence in the traumatic group was located in the inferior 2 quadrants, in contrast to temporally in the postsuture removal group. The time interval between PK and suture removal in the postsuture removal group was 16 +/- 4 months, and 7 (70%) patients had a continuous suture. Post-suture removal dehiscence was more common when corneal edema was the indication for grafting.

CONCLUSIONS

Eyes with traumatic wound dehiscence have worse visual outcome than those with dehiscence after suture removal. Patients should be cautioned about the risks and consequences of wound dehiscence. The suture may be left in place longer in older patients or when corneal edema is the indication for grafting.

Femtosecond-laser–assisted Descemet's stripping endothelial keratoplasty

To our knowledge, we describe the first patient with pseudophakic bullous keratoplasty treated with femtosecond-laser-assisted endothelial keratoplasty. A 5.5 mm corneoscleral tunnel incision was made; after Descemet's membrane was stripped, an 8.0 mm posterior lamellar corneal disk prepared with a femtosecond laser was inserted into the anterior chamber against the recipient cornea without the use of corneal sutures. Four months postoperatively, the posterior corneal disk was clear and the induced astigmatism was 2.1 diopters, demonstrating a functional corneal endothelial layer. The femtosecond laser offers a new surgical approach for minimally invasive endothelial keratoplasty in corneal endothelial disorders.