BACKGROUND: Posterior chamber intraocular lens (IOL) dislocation is a common complication of cataract surgery. Dislocated IOLs often require surgical intervention due to the potentially severe risks of leaving this condition untreated. If a patient with extremely low corneal endothelial cell density (ECD) presents with IOL dislocation, the surgeon faces a crucial dilemma of choosing the most optimal surgical treatment option. We sought to investigate the efficacy and safety of retropupillary iris claw intraocular lens (R-IOL) implantation in patients with IOL dislocation and extremely low (< 1000 cells/mm2) ECD.
METHODS: We retrospectively reviewed the medical records of nine patients (all men) whose pre-operative ECD was < 1000 cells/mm2 and who underwent R-IOL implantation due to intraocular subluxation or total dislocation into the vitreous cavity between 2014 and 2020. We evaluated corneal endothelial function and visual outcomes after surgery.
RESULTS: Nine patients were included in this study. The mean age at diagnosis was 64.89 ± 7.15 years (range 57-76 years), and the follow-up duration was 37.93 ± 23.72 months (range 18.07-89.07 months). No patients developed bullous keratopathy during follow-up. Compared to the initial ECD, corneal thickness (CT), coefficient variation of cell area (CV) and percentage of hexagonal cells (HEX), there was no statistically significant decrease in the ECD, CV, and HEX at last follow-up (P = 0.944, 0.778, 0.445, 0.443). There was significant improvement in the mean uncorrected distance visual acuity (UDVA) at the last follow-up (average 0.13 logMAR, 20/27 Snellen) compared to the pre-operative mean UDVA (average 1.09 logMAR, 20/250 Snellen) (P < 0.01).
CONCLUSIONS: R-IOL implantation did not result in a statistically significant decline in corneal endothelial function in patients with preoperatively low ECD, and it significantly improved the mean UDVA postoperatively. R-IOL implantation appears to be a safe and effective treatment modality for intraocular lens dislocation in patients with low ECD (< 1000 cells/mm²); however, long-term follow-up studies are warranted to corroborate these findings.

Post-corneal transplantation endothelial decompensation and subsequent bullous keratopathy often result in unfavorable clinical outcomes regardless of the treatment strategy employed. In this report, we present the outcomes of a patient managed with in vitro expanded human corneal endothelial cell (HCEC) transplantation facilitated by a nanocomposite gel (NC gel) sheet over 16 years. A 40-year-old male patient who presented with signs of graft failure after penetrating keratoplasty underwent HCEC transplantation. Additionally, HCECs were obtained from a deceased donor, cultured in vitro, and transplanted onto an NC gel sheet as a temporary scaffold to support the transplanted cells until engraftment. At the 16-year follow-up, the cornea had remained stable and did not exhibit active disease manifestations. Notably, no new bullae were formed, and the epithelial surface appeared smooth without signs of active fluid transport abnormalities. Although a slight reduction in corneal thickness was observed, the disease-free region at the time of the intervention remained transparent. HCEC transplantation with NC gel sheets is a promising, minimally invasive approach for achieving long-term corneal stability in cases of bullous keratopathy following corneal graft failure. Importantly, this technique circumvents the need for complex procedures and utilizes corneal endothelial precursors derived from donor corneas discarded for lack of sufficient endothelial cells. After in vitro culture, these cells were successfully transplanted in three patients, proving that one donated eye can be useful in treating three eyes of three patients. This technique addresses the donor cornea shortage concerns and makes our concept \"an-eye-for-eyes\", a reality.

The Klotho loss-of-function mutation is known to cause accelerated senescence in many organs, but its effects on the cornea have not been published. The present study aims to investigate the effects of the Klotho null mutation on cornea degeneration and to characterize the pathological features. Mouse corneas of Klotho homozygous, heterozygous, and wild-type mice at 8 weeks of age for both genders were subject to pathological and immunohistological examinations. The results show an irregular topography on the corneal surface with a Klotho null mutation. Histological examinations revealed a reduced corneal epithelial cell density, endothelial cell-shedding, and decreased cornea stromal layer thickness in the absence of the Klotho function. Furthermore, guttae formation and the desquamation of wing cells were significantly increased, which was comparable to the characteristics of Fuchs endothelial corneal dystrophy and bullous keratopathy. The mechanism analysis showed multi-fold abnormalities, including oxidative stress-induced cornea epithelium apoptosis and inflammation, extracellular matrix remodeling in the stroma, and a disruption of epithelial repair, presumably through the epithelial-mesenchymal transition. In conclusion, cornea degeneration was observed in the Klotho loss-of-function mutant mice. These pathological features support the use of Klotho mutant mice for investigating age-related cornea anomalies, including Fuchs endothelial corneal dystrophy, bullous keratopathy, and dry eye diseases.

To describe discrepancies between clinical observation and current teachings in corneal endothelial disease, particularly in Fuchs endothelial dystrophy and its potential association with primary open angle glaucoma.
Perspective.
A perspective is presented on Fuchs dystrophy, a disorder that commonly presents with a compromised endothelium but minimal stromal edema, indicating that the corneal imbibition pressure is relatively \"too high.\"
The discrepancy between the relative lack of stromal edema in the absence of an endothelial cell layer cannot be explained by the current theories involving a circulatory pumping mechanism over the endothelial cell layer, but may point to the following: (1) secondary involvement of the corneal endothelium in Fuchs dystrophy; (2) separate hydration systems for maintaining the imbibition pressure (vertical static hydration) and corneal nutrition (horizontal dynamic hydration); (3) the cornea as net contributor of aqueous humor; (4) a close relationship between the corneal imbibition and intraocular pressure, with potentially a shared regulatory system; and (5) a potential steroid-type hormone dependency of this regulatory system.
Clinical observation shows that the stromal imbibition pressure is \"too high\" in Fuchs endothelial dystrophy, indicating that it may not primarily be an endothelial disease, but a type of \"corneal glaucoma.\"

The cornea is a fundamental ocular tissue for the sense of sight. Thanks to it, the refraction of two-thirds of light manages to participate in the visual process and protect against mechanical damage. Because it is transparent, avascular, and innervated, the cornea comprises five main layers: Epithelium, Bowman\'s layer, stroma, Descemet\'s membrane, and endothelium. Each layer plays a key role in the functionality and maintenance of ocular tissue, providing unique ultrastructural and biomechanical properties. Bullous Keratopathy (BK) is an endothelial dysfunction that leads to corneal edema, loss of visual acuity, epithelial blisters, and severe pain, among other symptoms. The corneal layers are subject to changes in their biophysical properties promoted by Keratopathy. In this context, the Atomic Force Microscopy (AFM) technique in air was used to investigate the anterior epithelial surface and the posterior endothelial surface, healthy and with BK, using a triangular silicone tip with a nominal spring constant of 0.4 N/m. Six human corneas (n = 6) samples were used for each analyzed group. Roughness data, calculated by third-order polynomial adjustment, adhesion, and Young\'s modulus, were obtained to serve as a comparison and identification of morphological and biomechanical changes possibly associated with the pathology, such as craters and in the epithelial layer and exposure of a fibrotic layer due to loss of the endothelial cell wall. Endothelial cell membrane area and volume data were calculated, obtaining a relevant comparison between the control and patient. Such results may provide new data on the physical properties of the ocular tissue to understand the physiology of the cornea when it has pathology.

OBJECTIVE: To present the outcomes of a patient with anterior chamber intraocular lens (ACIOL) related endothelial decompensation who underwent Descemet membrane endothelial keratoplasty (DMEK) and cataract surgery with intraocular lens (IOL) implantation in the capsular bag (so-called triple DMEK) combined with ACIOL removal (quadruple DMEK) in both eyes.
METHODS: Case report.
RESULTS: A 58-year-old female patient was referred due to decreased visual acuity within the last 18 months. She had a history of iris-claw ACIOL implantation 17 years before. The corrected distance visual acuity (CDVA) was 20/40 in both eyes. Due to low endothelial cell density and increased corneal thickness, ACIOL removal combined with triple DMEK (as quadruple DMEK) was performed for both eyes. Despite a graft detachment that was successfully managed with re-bubbling in the first eye, both eyes showed an increase in the CDVA (20/25 and 20/32, respectively) without any other significant complications in the follow-up of the patient. The corneas of both eyes were clear postoperatively.
CONCLUSIONS: This case report demonstrated that quadruple DMEK may provide feasible management for chronic endothelial cell decompensation secondary to iris-claw ACIOL implantation.

UNASSIGNED: The amniotic membrane (AM), the inner layer of the placenta, is a semitransparent, avascular, and thin tissue that is useful due to its structure. Amniotic membrane transplantation (AMT) avoids the need for keratoplasty to prevent corneal perforating. The purpose of the study was to evaluate the visual (gain of or no change in visual acuity) and corneal outcomes (closure of the ulcer or corneal healing) of AMT in patients with ocular surface diseases.
UNASSIGNED: This was a retrospective case control study (success or failure of the surgery). It was undertaken at a single academic center. The study cohort consisted of subjects with ocular surface diseases. Patients were treated with AMT for refractory ocular surface diseases. They were divided into five subgroups according to the preoperative diagnosis. The technique of AMT used was the onlay method with two layers of AM. Primary outcome measures included best corrected visual acuity (BCVA), the number of AMTs, and reepithelization of the corneal epithelium at the end of the treatment. Two weeks to six months were given to consider epithelial closure. Treatment success was defined as corneal healing within 6 months.
UNASSIGNED: A total of the 66 eyes of 66 patients (39 male/27 female) with a mean age of 44 ± 23 years (range 1-88 years) were included in the study. A single AMT procedure achieved epithelial closure in 74.2% (n = 49) of the eyes (53% in <15 days, 19.6% in 15-30 days, and 1.5% in 1-6 months). The fastest reepithelization occurred in neurotrophic keratopathy, 76.9% of which cases occurred within 15 days after the AMT procedure. Treatment failure was observed in five patients (7.5%), four with keratitis and one with neurotrophic keratopathy. The highest closure rates were found in persistent epithelial defects, graft-versus-host disease (GvHD), and bullous keratopathy, although there was no statistically significant difference in BCVA. Pairwise comparisons were made of neurotropic keratoplasty versus bullous keratopathy (P = 0.025), neurotrophic keratopathy versus keratitis (P = 0.004), GVHD versus keratitis (P = 0.003), and lastly, GvHD versus bullous keratopathy (P = 0.023).
UNASSIGNED: AMT is a safe, valuable, and fast treatment technique to treat corneal epithelial defects stemming from different etiologies that are refractory to conventional treatment.

OBJECTIVE: Evaluation of structural and immunohistochemical features of cornea in Fuchs endothelial corneal dystrophy (FECD) and bullous keratopathy (BK).
METHODS: Group 1 - 44 patients (46 eyes) with FECD, group 2 - 42 patients (42 eyes) with BK. All patients underwent keratoplasty. Preoperative anterior segment optical coherence tomography (AS-OCT, RTVue-100, Optovue, USA) was performed. Endothelium-Descemet membrane (EDM) complexes, corneal buttons were obtained intraoperatively. Morphological (H&E staining) and immunohistochemical (primary antibodies to pancytokeratin, vimentin, fibronectin) studies were performed at the light microscope level (Leica DM-2500, Leica Application Suite V4.8, Leica Microsystems, Switzerland).
RESULTS: A direct correlation is found between the results of DM analysis in vivo with OCT and ex vivo with light microscopy. DM thickness (AS-OCT) was significantly greater in FECD (23.0 [19.0; 27.0] μm), than in BK (13.0 [12.0; 14.0] μm). Morphological study of EDM and corneal buttons showed similar difference in DM thickness: 17.9 [16.1; 20.0] μm in FECD and 11.9 [11.3; 13.0] μm in BK. Irregular optical density of stroma is a feature of edema and local fibrosis. In FECD and BK pancytokeratin is expressed in epithelial and endothelial cells, vimentin - in keratocytes, macrophages and vascular endothelium, fibronectin - in DM. In FECD, vimentin is expressed in endothelial cells.
CONCLUSIONS: FECD and BK are associated with different DM\' and endothelium\' abnormalities, which lead to similar changes of stroma and epithelium. AS-OCT is a useful method of FECD and BK in vivo diagnostics and the selection of treatment option.
UNASSIGNED: Изучение структурных изменений роговицы при эндотелиальной дистрофии (ЭД) Фукса и вторичной буллезной кератопатии (БК).
UNASSIGNED: В 1-ю группу вошли 44 пациента (46 глаз) с ЭД Фукса, во 2-ю — 42 пациента (42 глаза) со вторичной БК. Всем пациентам выполнена оптическая когерентная томография (ОКТ) роговицы (RTvue-100, «Optovue», США). При кератопластике получены образцы десцеметовой мембраны и эндотелия (ДМ-Э) и полнослойной роговицы для гистологического исследования и иммуногистохимического анализа экспрессии панцитокератина, виментина, фибронектина. Морфометрический анализ выполнен с помощью микроскопа Leica DM-2500, Leica Application Suite V4.8 («Leica Microsystems», Швейцария).
UNASSIGNED: Выявлена прямая корреляционная связь между результатами анализа ДМ in vivo при ОКТ и ex vivo при световой микроскопии. По данным ОКТ толщина ДМ при ЭД Фукса составила 23,0 [19,0; 27,0] мкм, при вторичной БК — 13,0 [12,0; 14,0] мкм (p<0,001). Гистологическое исследование ДМ-Э и полнослойных роговиц показало, что толщина ДМ при ЭД Фукса была 17,9 [16,1; 20,0] мкм, при вторичной БК — 11,9 [11,3; 13,0] мкм (p<0,001). Неравномерная оптическая плотность стромы — признак отека и очагов фиброза. При ЭД Фукса и вторичной БК отмечена экспрессия панцитокератина эндотелиальными и эпителиальными клетками, виментина — кератоцитами, макрофагами и эндотелиоцитами сосудов, фибронектина — ДМ. Особенность ЭД Фукса — экспрессия виментина эндотелиальными клетками.
UNASSIGNED: Патогенез ЭД Фукса и вторичной БК включает различные изменения ДМ и эндотелия, которые приводят к сходным нарушениям структуры стромы и эпителия. Применение ОКТ целесообразно для диагностики ЭД Фукса и вторичной БК in vivo и выбора тактики лечения.

To identify primary cilia in human corneal endothelial cells (CECs) obtained from patients with bullous keratopathy (BK).
This study involved CEC specimens obtained from 10 eyes of 10 consecutive patients (three males and seven females; mean age: 74.5 years, range: 68-90 years) with BK who underwent Descemet\'s stripping automated endothelial keratoplasty at Baptist Eye Institute, Kyoto, Japan between August 2019 and September 2020. Three corneal buttons obtained from 3 patients who underwent penetrating keratoplasty for keratoconus were used as \'non-BK\' controls. All specimens were evaluated with immunofluorescence staining using an antibody against acetylated α-tubulin.
Ciliary expression was observed in six of the 10 CEC specimens; i.e. in two specimens obtained from BK patients after glaucoma surgery (trabeculectomy), in two specimens obtained from patients with Fuchs endothelial corneal dystrophy, and in two specimens obtained from a patient with BK after laser iridotomy for primary angle closure. There was acetylated α-tubulin staining but no hair-like structures in two specimens, and ciliary expression was unknown in two specimens due to the absence of cells. The length of the primary cilia varied between all specimens. In contrast, no primary cilia were observed in the corneal buttons obtained from the three keratoconus patients.
The findings in this study clearly demonstrate the expression of primary cilia in the CECs of patients afflicted with BK.

UNASSIGNED: We describe a combined Descemet Membrane Endothelial Keratoplasty (DMEK) using the Cornea-press (C-Press) technique, with implantation of a new sutureless, scleral fixated intraocular lens (IOL) (Carlevale, Soleko), in a case of bullous keratopathy and IOL mispositioning.
UNASSIGNED: Two scleral pockets were created along two scleral radial incisions, 180° apart, followed by two 23 G sclerotomies at the pockets\' sites. After removal of the dislocated IOL through a corneoscleral incision, posterior vitrectomy was completed. The Carlevale IOL was injected into the anterior chamber (AC) and placed above the iris. The haptics were then externalized using opening distal forceps through the sclerotomies, and the plugs were secured in the scleral pockets. DMEK was then performed using the \"C-press\" technique, where corneal indentation allowed to artificially shallow the AC to ensure successful graft unrolling. Fifteen months postoperatively, the cornea was clear, the Carlevale IOL well positioned, and the patient\'s vision improved.
UNASSIGNED: DMEK using the C-Press technique, combined with a sutureless, scleral-fixated IOL such as the Carlevale in a single procedure, may be a safe and effective option to restore vision in case of bullous keratopathy and dislocated IOL.