BACKGROUND: The prevalence of rejection is 10-30% in penetrating keratoplasty (PKP) case, and the rate is higher in cases of high-risk patients. Although using topical corticosteroids is a standard method for management the rejection of post-PKP patients, it may not be sufficiently potent in high-risk patients. Topical administration of tacrolimus (TAC) may be effective in suppression rejection after corneal transplantation. This study aimed to investigate the efficacy and safety of topical TAC in high-risk PKP patients in Japan.
METHODS: This study was a single centre, single-blinded, randomized controlled trial. Patients with a history of PKP, graft rejection, atopic dermatitis, or deep corneal neovascularisation who underwent PKP were enrolled. They were randomly assigned to receive 0.1% TAC ophthalmic suspension or artificial tear (AT) up to week 52 after surgery. All participants received 0.1% betamethasone up to week 13 after surgery then they received 0.1% fluorometholone up to week 52. The incidence of immunological rejection during the observation period was the main outcome measure in this study.
RESULTS: Thirty patients were enrolled in this study, and 12 eyes in the TAC group and 13 eyes in the AT group completed the study, respectively. Five out of 30 patients discontinued participation after providing informed consent. No serious adverse effects were developed in patients who received 0.1% TAC ophthalmic suspension. No rejection episodes occurred in the TAC group, while one eye in the AT group had rejection. Graft clarity, best spectacle-corrected visual acuity, intraocular pressure, and corneal endothelial cell density were not significantly different between the TAC and AT groups.
CONCLUSIONS: Our results demonstrated that good tolerability of 0.1% TAC ophthalmic suspension. However, we failed to demonstrate its efficacy in preventing immunological rejection in high-risk patients undergoing PKP.
BACKGROUND: This study was first registered in the University Hospital Medical Information Network (UMIN000029669, Date of registration: November 1, 2017). With the enforcement of the Clinical Trial Act in Japan, the study re-registered in the Japan Registry of Clinical Trials (jRCTs031180342, Date of registration: March 18, 2019).

To compare graft survival of endothelial keratoplasty (EK) versus penetrating keratoplasty (PK) in patients with iridocorneal endothelial (ICE) syndrome and identify ocular features associated with graft survival.
Observational, prospective, cohort study. A total of 30 806 first grafts performed between 1985 and 2020 were identified through the Australian Corneal Graft Registry and included in this observational, prospective cohort study. A total of 196 eyes underwent a primary corneal graft for ICE syndrome. Kaplan-Meier graft survival plots and Chi-squared tests were performed to identify graft survival rates for EK and PK. A history of raised intraocular pressure (IOP) was also recorded and analysed. Graft survival of eyes with ICE syndrome were compared to that of other indications.
Grafts performed for ICE syndrome increased to 0.8% of all cases during the 2005 to 2020 period compared with 0.5% between 1985 to 2004 (χ2 =9.35, p = 0.002). From 2010, EK surpassed PK as the preferred graft type. Survival of primary grafts in eyes with ICE syndrome was lower than for other indications (log-rank = 56.62, p < 0.001). Graft survival was higher following PK than Descemet stripping (automated) endothelial keratoplasty (DS(A)EK) (log-rank = 10.56, p = 0.001). Graft survival was higher in eyes without a history of raised IOP compared to those with a reported history of raised IOP (log-rank = 13.06, p < 0.001).
ICE syndrome carries a poor prognosis for graft survival. DS(A)EK had a poorer prognosis than PK. A history of raised IOP is associated with higher risk of graft failure.

This study aims to analyze the pattern of follow-ups and the reasons for follow-up loss in keratoplasty cases in a tertiary eye care center.
This is a single-center retrospective cross-sectional study. During the study period, 165 eyes underwent corneal transplantation. The data on the demographic features of the recipients and the indications of keratoplasty, including visual acuity before and after surgery, duration of follow-up, and the condition of the graft at the last follow-up, were collected. The primary outcome was to determine the factors causing lost-to-follow-up (LTFU) among graft recipients. LTFU was defined when a patient failed to adhere to any of the following seven follow-up visits since the surgery: 4 ± 2 weeks, 3 ± 1 months, 6 ± 1 months, 12 ± 2 months, 18 ± 2 months, 24 ± 3 months, and 36 ± 6 months. The secondary outcome was to analyze the best-corrected visual acuity (BCVA) among patients available for the final follow-up.
The recipient follow-up rates at 6, 12, 18, 24, and 36 months were 68.5%, 57.6%, 47.9%, 42.4%, and 35.2%, respectively. Old age and distance to the center were significant factors for lost-to-follow-up. A failed graft as an indication for transplantation and those undergoing penetrating keratoplasty for optical purposes were significant factors for completing follow-up.
The inability to follow-up after corneal transplantation is a common challenge. Elderly patients and those living in remote areas must be prioritized for follow-ups.

OBJECTIVE: The purpose of this study was to compare glaucoma therapy escalation (GTE), graft survival, vision, and glaucoma following penetrating keratoplasty (PK group) and Descemet stripping automated endothelial keratoplasty (DSAEK group) to treat pseudophakic bullous keratopathy (PBK).
METHODS: This cohort included cases of PBK managed with PK from 2009 to 2014. We compared the incidences and determinants of GTE, graft survival, and visual disability. P < 0.05 was statistically significant.
RESULTS: There were 58 eyes in the PK group and 117 eyes in the DSAEK group. The incidence of GTE in the PK and DSAEK groups at the last follow-up was 34.2% (95% confidence interval [CI]: 19.5-48.9) and 46.6% (95% CI: 27.7-65.4), respectively. The risk of GTE was similar between the groups (relative risk [RR] = 1.36 [95% CI: 0.94-1.98], P = 0.12). GTE was significantly associated with graft survival in the PK group (RR = 3.25 [95% CI: 1.5-7.0], P < 0.001) and the DSAEK group (RR = 3.77 [95% CI: 2.6-5.6], P < 0.001). Glaucoma (P = 0.001) and previous keratoplasty (P < 0.001) were significant predictors for GTE. At the final follow-up visit, severe visual disability was not significantly different between the groups (RR = 0.9 [95% CI: 0.3-2.9], P = 0.88). There was a statistically significant improvement in vision after DSAEK (P < 0.001) but not after PK (P = 0.67).
CONCLUSIONS: GTE was similar in eyes with PBK managed by PK or DSAEK. Glaucoma and previous keratoplasty were predictors of GTE post-keratoplasty. DSAEK gave better visual outcomes than PK for managing PBK.

OBJECTIVE: The aim of this study was to analyze real-world practice patterns and graft survival after corneal transplantation for infectious keratitis in the Netherlands.
METHODS: All consecutive keratoplasties for infectious keratitis registered in the Netherlands Organ Transplant Registry were included. Graft survival was analyzed using Kaplan-Meier survival curves with Cox regression to compare the 3 most common pathogens with subgroup analysis for type and reason of transplantation, sex, and graft size. Multivariable analysis was performed using the same explanatory factors.
RESULTS: Between 2007 and 2017, 1111 keratoplasties for infectious keratitis were registered in the Netherlands Organ Transplant Registry. The most common pathogens were viruses (n = 437), bacteria (n = 271), and Acanthamoeba (n = 121). Human leukocyte antigen (HLA) matching did not provide a significant survival benefit, whereas emergency procedures showed worse graft survival [hazard ratio (HR) = 0.40, P = 0.120; HR = 2.73, P < 0.001, respectively]. Graft size >8.5 mm was significantly worse than graft size 8.5 mm (HR = 2.062, P = 0.010). In therapeutic keratoplasty, graft survival was significantly worse for Acanthamoeba than viral keratitis (HR = 2.36, P = 0.008). In the multivariable model, adjusting for graft size, type, and reason for transplantation, viral and bacterial keratitis did not differ significantly in graft survival, and Acanthamoeba showed a significantly worse prognosis (vs. viral keratitis, HR = 2.30, P < 0.001; bacterial keratitis, HR = 2.65, P < 0.001).
CONCLUSIONS: Viral keratitis was the most common indication for transplantation, followed by bacterial and Acanthamoeba keratitis. HLA matching did not offer protection over elective non-HLA-matched procedures, whereas emergency procedures and grafts sized >8.5 mm showed poor survival. In optical keratoplasty, survival is high for all pathogens, whereas in therapeutic keratoplasty Acanthamoeba shows poor outcome.

To analyze the impact on eye donation and corneal transplantation during the COVID-19 pandemic in a tertiary eye hospital in south India.
A retrospective analysis of the donor and recipient records during the study period from January 2020 to May 2021 was conducted and tabulated in Microsoft Excel 2013. Demographic details of the donor, utility rate, cause of death, culture characteristics, storage methods, wet lab usage, and the surgical donor outcomes were evaluated. Additionally, the postoperative workup of the recipients, diagnosis, graft infection and rejection episodes, development of COVID-19 postoperatively, and outcome in terms of visual acuity at one, three, and six months were also noted.
A total of 466 eyes from 249 donors were received during the study period. The mean age of the donor population was 62.43 years (20.9). The corneal transplantation utility rate was 36.4% (n = 170). Fifty-one percent of the total transplant surgeries were for therapeutic purposes. This was followed by penetrating optical keratoplasty (34%), Descemet\'s stripping endothelial keratoplasty (9%), and patch grafts (3%). Seventeen (10%) graft rejection episodes were noted and nine (53%) had complete resolution after medical treatment.
Proper preventive measures are key to carrying out safe and efficient eye banking activities even during a deadly pandemic, as COVID-19 transmission via transplantation is rare.

To compare outcomes of femtosecond-enabled deep anterior lamellar keratoplasty (FE-DALK) and standard deep anterior lamellar keratoplasty (S-DALK).
An open label, randomized controlled trial (Kensington Eye Institute, Toronto, ON, Canada) including 100 eyes of 97 participants with either keratoconus or corneal scarring, randomized to either FE-DALK (n = 48) or S-DALK (n = 49).
postoperative astigmatism and surgically induced corneal astigmatism (SIA) - both at 15 months.
6-, 12- and 15-month postoperative uncorrected- and best spectacle-corrected visual acuity, steep and flat keratometry, manifest sphere and astigmatism, rate of conversion to penetrating keratoplasty (PK), big-bubble success, central corneal thickness, endothelial cell count and complications.
In intention-to-treat analysis, mean postoperative astigmatism in the FE-DALK (n = 30) and S-DALK (n = 30) groups at 15 months was 7.8 ± 4.4 D and 6.3 ± 5.0 D, respectively (p = 0.282) with an adjusted mean difference of 1.3 D (95% CI -1.08, +3.65). Mean SIA (arithmetic) was 9.2 ± 7.8 and 8.8 ± 5.4 D, respectively (p = 0.838) with a mean difference of 0.4 D (95% CI -3.13, +3.85). In an analysis of successful DALK cases only, mean postoperative astigmatism in the FE-DALK (n = 24) and S-DALK (n = 20) groups at 15 months (after excluding 4 eyes with AEs) was 7.3 ± 4.4 and 6.2 ± 4.9 D, respectively (p = 0.531) with an adjusted mean difference of 0.9 D (95% CI -1.94, +3.71). Mean SIA (arithmetic) was 9.1 ± 7.8 and 7.9 ± 4.6 D, respectively (p = 0.547) with a mean difference of 1.2 D (95% CI -2.70,+5.02). Comparison of secondary outcomes showed only weak statistical evidence.
In this randomized controlled trial, FE-DALK and S-DALK showed comparable functional and anatomical outcomes.

OBJECTIVE: The purpose of this study was to assess the role of combined surgical treatment of therapeutic penetrating keratoplasty and pars plana vitrectomy in the anatomical and functional outcome of infectious keratitis endophthalmitis.
METHODS: This study reviewed the medical records of 4 participating centers in the United States and Mexico. This study included patients with a clinical diagnosis of infectious keratitis endophthalmitis who had been treated with an early therapeutic penetrating keratoplasty and pars plana vitrectomy as the main treatment for endophthalmitis. From each medical record, the study retrieved demographic data, relevant medical and drug history, baseline clinical manifestation of endophthalmitis, best-corrected visual acuity, and the need for enucleation/evisceration for the control of the infection or any other reason through the follow-up.
RESULTS: The study included 48 patients (50.15 ± 20.6 years). The mean follow-up time was 13 ± 0.5 months. The mean best-corrected visual acuity at baseline was 2.1 ± 0.25 logarithm of the minimum angle of resolution. At month 12 was 2.09 ± 0.61 logarithm of the minimum angle of resolution ( P = 0.9). The overall prevalence of enucleation/evisceration was 8.3% (95% confidence interval: 2.32%-19.98%). The prevalence of a vision of no-light perception was 20.8% (95% confidence interval: 2.32%-19.98%).
CONCLUSIONS: Combined surgery for severe cases of infectious keratitis endophthalmitis eradicates the infection in most cases, while significantly improving the overall outcomes.

OBJECTIVE: To utilize data mining for analysis of corneal transplantations (CT) in Florida from 2005-2014, segmented by demographics, geography, and transplantation technique.
METHODS: A retrospective, database study was performed utilizing data queried from the Healthcare and Cost Utilization Project using Current Procedural Terminology codes for lamellar keratoplasty (ALK), endothelial keratoplasty (EK), and penetrating keratoplasty (PKP). Payer status, ethnic group, age, gender, and geography (urban versus rural) was extracted from each surgical encounter and reconfigured to provide a \"clean\", congruous dataset for statistical analysis. This Institutional Review Board-approved study did not utilize identifiable patient information; thus, individual informed consent was not required.
RESULTS: From 2005-2014, CT (n=28,607) represented less than 1% of the total ambulatory surgeries (n=12,695,932) performed in Florida. EK volume increased while PKP and ALK volume decreased, year-over-year. Statistical significance was found between transplantation technique by sex (P<0.001) and ethnic group (P<0.001). The largest sex discrepancy was EK (59% female, 41% male). White patients underwent relatively fewer PKP than EK (71% vs. 83% of totals), while Black patients underwent relatively more PKP than EK (14% vs 6% of totals). Statistical significance was found between techniques by payer (P<0.001). Medicare was the most common payer for all techniques, but ALK and PKP had higher percentages of private insurance and self-pay. No statistical significance was found between techniques by geographic location. Corneal edema (22.4%), endothelial dystrophy (17.5%), and bullous keratopathy (10.9%) were erroneously coded as indications for ALK. Corneal scars (2.5%) and corneal opacity (1.7%) were erroneously coded as indications for EK.
CONCLUSIONS: CT rates in Florida appear to overrepresent the female sex and underrepresent ethnic minorities, with propensities between PKP and African Americans, EK and female patients, and EK and Medicare reimbursement. Our study further confirms the utility of data mining for providing efficient, detailed, and practical insights into ophthalmology procedures, while highlighting the intrinsic challenges of large datasets.

BACKGROUND: To evaluate the efficacy of the topical administration of immunosuppressants and corticosteroids in tapering doses in the management of patients with high-risk keratoplasty.
METHODS: One hundred and six patients treated with topical immunosuppressants (50 eyes in the FK506 group and 56 eyes in the CsA group) and corticosteroid eye drops in tapering doses were enrolled in the study. The rates of rejection episodes, irreversible rejection, graft survival, and related influential factors were evaluated.
RESULTS: The mean follow-up period was 48.1 ± 7.9 months (range, 36-60 months). The rates of rejection episodes and irreversible rejection were 14.0% and 6.00% in the FK506 group and 37.5% and 7.1% in the CsA group, respectively. Kaplan-Meier survival analysis demonstrated a significantly higher graft survival rate in the FK506 group (81.6%±5.3%, 71.1%±6.3%) compared with that in the CsA group (71.1%±6.3%, 57.5%±7.5%) at 3 and 5 years after surgery (P = 0.006). Multivariate logistic regression revealed that preoperative risk score ≥ 3 (P = 0.016) and endothelial immune rejection (P = 0.033) were risk factors associated with graft survival.
CONCLUSIONS: Topical administration of tacrolimus and corticosteroids in tapering doses is effective in decreasing the incidence of immune rejection in high-risk keratoplasty. Careful instruction of patients on the reasonable use of topical tacrolimus is critical to avoid immune rejection induced by sudden discontinuation of medication.