BACKGROUND: Cataract surgery in patients after penetrating keratoplasty (PKP) is often challenging because of changes in corneal structure induced by PKP and primary corneal disease. Femtosecond laser-assisted cataract surgery offers several advantages over conventional phacoemulsification, and has been widely used in complicated cataract surgery.
METHODS: We report the use of femtosecond laser-assisted cataract surgery in 3 challenging cases after penetrating keratoplasty. Case 1 involved a patient with hard nuclear grade IV° cataract. After surgery, his corrected distance visual acuity (CDVA) improved from 20/400 to 20/25, and the endothelial cell loss (ECL) % was 12.05 % at 3 months postoperatively. The rotation of the toric IOL in Case 1 was 2°. Case 2 involved a patient with severe nuclear cataract and an endothelial cell density of 837 cells/mm2. After surgery, the CDVA improved from 20/100 to 20/40. The ECL% was 4.06% at 1 week postoperatively. Case 3 was a 91-year-old woman with a short axis length of 21.35 mm and an endothelial cell density number of 1238 cells/mm2. After surgery, the CDVA improved from light perception to 20/133, and the ECL% was 26.09% at 1 week postoperatively; ECL% was 2.67% at 1 month post-operation. The corneal grafts were transparent.
CONCLUSIONS: Femtosecond laser-assisted cataract surgery seems to be an effective, predictable, and safe approach for challenging patients after PKP, and improves visual recovery and optimal refractive outcomes.

BACKGROUND: Ochrobactrum anthropi is widely distributed and primarily infects patients with compromised immune functions . Historically, O. anthropi has been considered to possess low toxicity and pathogenicity; however, recent studies suggest that it may in fact cause severe purulent infections. In this case study, we examine a case of O. anthropi infection following corneal transplantation, exploring the occurrence and outcomes of such post-operative infections.
METHODS: A retrospective analysis of cases involved examinations, genetic testing for diagnosis, and subsequent treatment. In patients undergoing partial penetrating keratoplasty with a fungal corneal ulcer perforation, anterior chamber exudation and purulence were observed post-surgery. Despite antifungal treatment, genetic testing of the anterior chamber fluid and purulent material confirmed O. anthropi infection. The use of antimicrobial treatment specifically targeting O. anthropi was found to be effective in treating the infection.
CONCLUSIONS: Inflammatory reactions following corneal transplantation should be should be monitored for the presence of other infections. Genetic testing has significant implications for clinical diagnosis and treatment.

OBJECTIVE: To summarize the outcomes of corneal sight rehabilitating surgery in Stevens-Johnson syndrome (SJS).
METHODS: This is a retrospective analysis of a consecutive case series. Twenty-four eyes of 18 SJS patients were included in this study. The ocular parameters, surgical procedures, postoperative complications, and additional treatments of the cases were reviewed.
RESULTS: A total of 29 corneal sight rehabilitating surgeries, which consists of 9 keratoplasties, 8 Keratolimbal allograft (KLAL) and 12 combined surgeries (keratoplasty and KLAL simultaneously) were performed on the 24 eyes. All patients were treated with glucocorticoid eyedrops and tacrolimus eyedrops for anti-rejection treatment without combining systemic immunosuppression, except two patients who were prescribed prednisone tablets for the management of systemic conditions. The mean follow-up period was 50.6 ± 28.1 months. The optimal visual acuity (VA) (0.74 ± 0.60 logarithm of the minimum angle of resolution [logMAR]) and endpoint VA (1.06 ± 0.82 logMAR) were both significantly better than the preoperative VA (1.96 ± 0.43 logMAR) (95% CI, p = 0.000). 57.1% patients (8/14) were no longer in the low vision spectrum, and 88.9% patients (8/9) were no longer blind. The mean epithelialization time was 7.1 ± 7.6 weeks. The success rate was 86.7%. Additional treatments for improving epithelialization included administration of serum eyedrops (n = 10), contact lens (n = 15), amniotic membrane transplantation (n = 6), and tarsorrhaphy (n = 8). Complications included delayed epithelialization (n = 4, over 12 weeks), glaucoma (n = 11), and severe allograft opacity (n = 4). Only one graft rejection was observed.
CONCLUSIONS: Keratoplasty and KLAL can remarkably enhance VA and improve low vision or even eliminate blindness for ocular complications of SJS. The outcome of the surgeries was correlated with the preoperative ocular situation and choice of operative methods.

BACKGROUND: Ocular surface disorder after ocular radiation therapy, even though commonly reported, is often overlooked. Any delay in diagnosis may lead to complications that threaten vision. The presented case highlights the clinical outcome of a severe post-radiation disorder of the ocular surface, the importance of intensive therapy, and the limitations of further surgical interventions.
METHODS: A 34-year-old woman was referred for a second opinion due to a years-long history of pain and redness in her right eye (OD) after proton beam therapy for recurrent iris melanoma. The patient then developed post-radiation retinopathy with macula edema, secondary glaucoma, cataract, as well as a severe ocular surface disorder with corneal decompensation and band keratopathy. Several surgical treatments have been attempted, including phacoemulsification with IOL implantation and trabeculectomy with mitomycin C. Due to refractory glaucoma, Baerveldt glaucoma drainage was then necessary. Given the worsening clinical presentation of post-radiation ocular surface disorder with progressing band keratopathy, the possibility of penetrating keratoplasty (PKP) was discussed.
CONCLUSIONS: The continuous worsening of clinical symptoms of the disorder of the ocular surface after proton beam radiotherapy can be the result of a post-radiation syndrome. Gradual expansion of ischemia, vasculitis, and inflammatory mediators compresses the retinal tissue, leading to recurrent macular edema as well as to secondary glaucoma and corneal decompensation. Band keratopathy is occasionally noted and seems to result from severe post-radiation disorder of the ocular surface. However, PKP would typically be indicated in cases of corneal perforation, uncontrolled infectious keratitis, or for improving vision in the presence of corneal opacification, none of which applied to our patient. Furthermore, post-radiation keratopathy implies compromised corneal stromal lymphogenesis and angiogenesis, both of which are now considered essential conditions for allograft rejection. Moreover, a previously performed Baerveldt glaucoma drainage surgery can affect the survival rate of the endothelial cells of the recipient cornea. Therefore, a penetrating or endothelial keratoplasty should be viewed as a high-risk procedure. In this instance, the rigorous treatment of the severe ocular surface disorder was crucial. We managed our patient\'s complex situation by following the latest guidelines set by the Tear Film & Ocular Surface Society and aimed to alleviate the symptoms as effectively as possible. In conclusion, careful decision-making regarding surgical treatment options should be considered, taking into account the complexities and potential risks involved.
Eine 34-jährige Frau wurde wegen Schmerzen und Rötungen am rechten Auge seit Jahren überwiesen. Ihre Krankengeschichte ergab eine Exzision eines Irismelanoms im Alter von 29 Jahren. Aufgrund eines Rezidivs wurde daraufhin eine Protonenstrahlentherapie durchgeführt. Infolgedessen entwickelte die Patientin nach der Strahlentherapie eine Retinopathie mit Makulaödem, sekundärem Glaukom, Katarakt sowie einer schweren Störung der Augenoberfläche mit Hornhautdekompensation und einer Bandkeratopathie. Es wurden mehrere chirurgische Eingriffe unternommen, darunter die Phakoemulsifikation mit IOL-Implantation und die Trabekulektomie mit Mitomycin C. Aufgrund des refraktären Glaukoms war schließlich auch eine Baerveldt-Implantation erforderlich. Trotz vielfältiger therapeutischer Ansätzen zur Befeuchtung zeigte sich keine Verbesserung des Problems der Augenoberfläche. Aufgrund der Verschlechterung der klinischen Präsentation der Augenoberflächenstörung wurde die Möglichkeit einer perforierenden Keratoplastik in Betracht gezogen. Es bleibt jedoch fraglich, ob solche Patienten von einer perforierenden Keratoplastik profitieren würden, da die resultierende Lymph- und Hämangiogenese des Hornhautstromas wesentliche Risikofaktoren für die Abstoßung von Fremdgewebe darstellen.

BACKGROUND: To report the nursing experience of a case of corneal contact lens wearer receiving the 2nd keratoplasty due to corneal ulcer and perforation caused by Pythium insidiosum infection.
METHODS: A 30-year-old female patient had blurred vision after deep anterior lamellar keratoplasty for a right corneal ulcer. At the 5th week, the right eye appeared the symptoms, such as redness and pain. The anterior segment photography was performed on the eye, and the result showed that the epithelium was missing in the right eye lesion area, and a large number of longitudinal and transversal streaks were visible from the epithelium to the stroma, with fungus filaments to be discharged. Upon macro-genome sequencing of the corneal secretion, a P. insidiosum infection was observed. Then, the patient underwent the keratoplasty, and 3 weeks later, the corneal implant showed a tendency to dissolve, the sutures were partially loosened, and the eye was almost blind. Subsequently, the patient was admitted to our hospital and subject to the 2nd penetrating keratoplasty of the right eye (allograft). After surgery, linezolid and azithromycin injections were given through intravenous drip and local drip of the eye for anti-inflammation, and tacrolimus eye drops for antirejection.
RESULTS: Postoperatively, the patient showed signs of recovery with slight corneal edema and visible pupil, leading to discharge with improved vision. The corneal implant was normal 1 week after surgery and the vision of the right eye was hand move/before eye at the 6th month of follow-up. Continuous care and removal of sutures 3 months post-surgery contributed to a successful outcome, with the patient achieving hand motion vision 6 months after the procedure.
CONCLUSIONS: Corneal ulcer caused by P. insidiosum infection not only needs timely and effective keratoplasty intervention, but also requires perfect nursing measures.

OBJECTIVE: We describe the management of a case of severe corneal melting after corneal cross-linking (CXL) treated with a staged approach using a conjunctival flap followed by deep anterior lamellar keratoplasty (DALK).
METHODS: A 12-year-old male developed severe corneal melting with pending perforation after an accelerated epithelium-off CXL protocol. We initially treated the patient with a conjunctival flap to prevent perforation. Three months later, we performed DALK to restore vision.
RESULTS: Conjunctival flap surgery allowed us to avoid corneal perforation and penetrating keratoplasty (PK) à chaud. Once the inflammation had resolved, we recessed the conjunctiva and performed DALK for optical purposes. Twelve months later, the graft was clear and the corrected visual acuity was 20/25 (Snellen). No complications occurred after surgery.
CONCLUSIONS: Although CXL is considered a safe procedure, in rare cases it can lead to serious complications, such as corneal haze, infectious and non-infectious keratitis, stromal melting and perforation. Corneal melting and perforation are usually managed by emergency PK. Herein we suggest a staged approach involving an emergency conjunctival flap followed by DALK at a later time that allowed us to avoid PK à chaud.

BACKGROUND: This study aims to evaluate visual outcome, central corneal thickness, and re-bubbling rate in a cohort with undersized sequential Descemet Membrane Endothelial Keratoplasty (DMEK) due to endothelial graft decompensation following primary penetrating keratoplasty (PK).
METHODS: All patients who received a sequential DMEK (n = 16) or triple DMEK (n = 2) after failed primary PK between November 2020 and June 2022 were retrospectively evaluated. Analyzed parameters were corrected distance visual acuity (CDVA), central corneal thickness (CCT), re-bubbling rate and graft survival.
RESULTS: 18 eyes of 18 patients were included. All patients underwent a DMEK with undersized graft after failed PK(s). Mean time between the last PK and DMEK was 102 ± 82 weeks. Mean follow-up time was 8.9 ± 4.6 months. CDVA increased significantly from 1.12 ± 0.60 logMAR preoperatively to 0.64 ± 0.49 logMAR 6 weeks postoperatively (p = 0.013). Mean CCT decreased significantly from 807 ± 224 μm before to 573 ± 151 μm 6 weeks after DMEK (p = 0.003). Re-bubbling was necessary in eight eyes (44.4%) after a median time of 7 days. The 12-month Kaplan Meier survival was 66.7%.
CONCLUSIONS: In case of endothelial graft decompensation without stromal scars after primary PK, a DMEK can be performed for selected patients who had satisfying CDVA before the endothelial decompensation. Prior to DMEK indication, an AS-OCT should routinely be performed to circularly search for posterior steps at the PK graft margin, as well as shortly after DMEK to exclude a detachment of the endothelial graft. All patients should be informed about a higher re-bubbling rate in comparison to primary DMEK.

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CONCLUSIONS: This case series is the first to illustrate mixed infection from Pythium sp. and fungal species in corneal ulcer.
OBJECTIVE: This case series aimed to alert all toward the possibility of both Pythium sp. and fungal species infection in case of nonresponding corneal ulcer treated with either antifungals or antipythium drugs alone. Increased suspicion of mixed infection in case of nonresponding fungal/ Pythium keratitis may facilitate early and prompt management.
METHODS: Six patients presented with signs of either fungal or Pythium keratitis. They underwent ophthalmological examinations, smear examinations, cultures, and polymerase chain reaction (PCR). Therapeutic penetrating keratoplasty was performed in cases where symptoms worsened after treatment with either antifungal or antipythium drugs. The half corneal button (HCB) was shared for histopathological and microbiological examinations. In the first case, smear examination from corneal scraping (CS) revealed Pythium -like filaments, which were confirmed with PCR; however, Aspergillus nidulans grew in culture. In the second case, iodine-potassium iodide (IKI) staining was positive for Pythium ; however, PCR was positive for both Pythium and fungus, which was further confirmed by DNA sequencing. In the third case, IKI staining and HCB were positive for Pythium ; however, PCR was positive for fungus, which was identified as Candida saitoana with DNA sequencing. In the fourth case, Pythium grew in the CS culture; however, Candida sp. grew in the HCB culture. In the fifth case, Cladosporium sp. grew in culture from CS; however, Pythium insidiosum grew from the anterior chamber exudate after therapeutic penetrating keratoplasty. In the sixth case, smear examination revealed septate fungal filaments, and Cladosporium sp. grew in culture; however, HCB on histopathological examination showed features of Pythium keratitis.
CONCLUSIONS: In unresponsive cases of Pythium or fungal keratitis, diagnostic modalities such as IKI and PCR should be implemented as a routine practice, in addition to smears and cultures.

This is the case series of three patients of infectious crystalline keratopathy (ICK) presented to us after undergoing penetrating keratoplasty between 2010 to 2020. The lesions showed classical crystalline patterns and clinical diagnosis was made. The patients were treated by broad spectrum antibiotics till the complete resolution of the lesions. The cases highlight the clinical features, diagnosis and management of this rare and resistant disease.