BACKGROUND: Anterior chamber-associated immune deviation (ACAID) is an active immunotolerance mechanism, which is induced by placing antigen into the anterior eye chamber as long as a major surgical trauma is avoided. For this reason, ACAID may be a major contributor to the favorable immunologic outcomes in Descemet membrane endothelial keratoplasty (DMEK). Rodent models have demonstrated the importance of a functional spleen for the development of an ACAID.
OBJECTIVE: This study aimed to investigate whether splenectomy leads to increased rejection rates after DMEK in humans.
METHODS: A retrospective evaluation was conducted on the course following DMEK at the Eye Center, Medical Center, University of Freiburg, for patients with a self-reported history of splenectomy compared to patients without this condition. Potential study patients were contacted by mail. A questionnaire to self-report splenectomy and the time thereof was sent out. The medical records of all consenting patients at the Eye Center were reviewed for graft survival and immune reactions.
RESULTS: We asked 1818 patients after DMEK to report their history of splenectomy. A total of 1340 patients responded and were included in the study. Of these 1340 patients, 16 (1.2%) reported a history of splenectomy (ie, 26 DMEKs, with 10 patients being transplanted in both eyes and 6 patients being transplanted in 1 eye; median age at surgery 73.7, range 66.7-76.1 y). The remaining patients (1324 patients, ie, 1941 eyes) served as controls, with 1941 DMEKs (median age at surgery 71.5, range 64.1-77.2 y). Five (19%) out of the 26 eyes from the splenectomy group required a second transplant due to dislocation (n=2.8%), failure (n=2.8%), and rejection (n=1.4%). Kaplan-Meier analysis revealed no relevant difference compared with controls.
CONCLUSIONS: Our results suggest that splenectomy has no major effect on the outcome following DMEK. Subsequent, ACAID may not be the main reason for the favorable immunological outcomes in DMEK, or the camero-splenic axis may be subordinate in humans. However, we only included 16 patients who underwent splenectomy, so it might be possible that we missed a minor effect.

BACKGROUND: To compare the difference in rebubbling rates between patients undergoing Descemet membrane endothelial keratoplasty (DMEK) with endothelium-in using a standard IOL cartridge and those with endothelium-out DMEK utilizing a no-touch technique with borosilicate glass cartridge transplantation.
METHODS: This retrospective study included all eyes that underwent preloaded endothelium-in or endothelium-out DMEK transplantation from June 2019 to December 2023 at the Hanusch Hospital, Vienna, Austria. All DMEKs were harvested, prepared and preloaded at the European Eye Bank of Venice, Italy. DMEK surgeries were done by one experienced surgeon and the procedure was completed by air tamponade of the anterior chamber.
RESULTS: Overall, 32 eyes each of 31 endothelium-out patients and of 29 endothelium-in patients were included. 32 preloaded endothelium-in procedures were followed by 32 preloaded endothelium-out procedures. Rebubbling rate for endothelium-in was 15/32 (47%) and for endothelium-out was 7/25 (28%) (p = 0.035, Pearson\'s chi-squared test). Donor age was the most important variable for rebubbling in a random forest algorithm model (ROC: 0.69).
CONCLUSIONS: Rebubbling rate in endothelium-out DMEK was less than two-thirds compared to endothelium-in DMEK favoring no-touch endothelium-out DMEK as the preferred technique of DMEK transplantation.

UNASSIGNED: To evaluate if an intraoperative-OCT (iOCT) optimized surgical protocol without prolonged overpressure is non-inferior to a standard protocol during Descemet membrane endothelial keratoplasty (DMEK).
UNASSIGNED: Sixty-five pseudophakic eyes of 65 patients with Fuchs endothelial dystrophy scheduled for routine DMEK were recruited in this prospective non-inferiority international multicenter randomized control trial. Subjects were randomized to the control arm (n=33) without iOCT-use and raising the intraocular pressure above normal physiological limits for 8 minutes (i.e., overpressure) or the intervention arm (n=32) with OCT-guidance to assess graft orientation and adherence, while refraining from prolonged overpressure. The primary outcome was the incidence of postoperative surgery-related adverse events (AE). The non-inferiority margin was set at a risk difference of 10%. Secondary outcomes included iOCT-aided surgical decision making, surgical times, and endothelial cell density (ECD) corrected distance visual acuity (CDVA) at 6 months follow-up.
UNASSIGNED: In the intervention group, 12 subjects developed 13 AEs compared to 13 AEs in 10 subjects in the control group (P=0.644). The risk difference measured -0.32% (95%CI: -10.29 - 9.84). The ECD and CDVA did not differ between the two groups 3 and 6 months postoperatively (P=>0.05). Surgeons reported that iOCT aided surgical decision-making in 40% of cases. Surgery and graft unfolding time were, respectively, 13% and 27% shorter in the iOCT-group.
UNASSIGNED: iOCT-guided DMEK surgery with refraining from prolonged over-pressuring was non-inferior compared to conventional treatment. Surgery times were reduced considerably and iOCT aided surgical decision-making in 40% of cases. Refraining from prolonged overpressure did not affect postoperative ECD or CDVA.
UNASSIGNED: https://clinicaltrials.gov/ct2/show/NCT03763721 (NCT03763721).

The purpose of this study was to describe a case and clinical course of simultaneous anterior chamber phakic intraocular lens (AC-pIOL) removal, implantation of a posterior chamber phakic intraocular implantable collamer lens (ICL), and Descemet membrane endothelial keratoplasty (DMEK). This was a case report of a 44-year-old male with a unilateral decompensated cornea from a displaced Duet-Kelman lens on his left eye that underwent pIOL extraction and implantation of a posterior chamber phakic intraocular ICL and simultaneous DMEK. After 6 months, the cornea of the left eye had regained clarity, the Descemet membrane was graft stable, and the ICL implanted was centered with good vault. Postoperative anisometropia was avoided. There was no development of cataracts or other complications. The simultaneous pIOL extraction, ICL implantation, and DMEK in our case showed good results with full restoration of anterior segment anatomy and return of transparency of the cornea. The current case shows the feasibility of the simultaneous approach instead of sequential as an alternative for patients with endothelial disease associated with AC pIOLs, restoring vision and anatomy and also avoiding postoperative anisometropia.

Pediatric corneal transplant is a highly demanding and technically challenging procedure for the cornea surgeon in today\'s era. These cases pose unique challenges in clinical and surgical management. The indications of pediatric corneal transplant can be therapeutic, tectonic, optical, and cosmetic. Pediatric patients undergoing corneal transplants are at a high risk of graft infection, failure, rejection, dehiscence, and amblyopia due to young age, robust immune system, increased incidence of trauma, and compliance issues. The other factors contributing to graft failure can be allograft rejection, secondary glaucoma, corneal vascularization, multiple surgeries, vitreous prolapse, and lack of treatment compliance. A successful corneal transplant in children depends on meticulous preoperative evaluation, uneventful surgery, the expertise of a corneal surgeon, and regular and timely postoperative follow-up. Therapeutic and optical penetrating keratoplasty are the most commonly performed transplants in children. However, with the advancements in surgical technique and management protocol, the current focus has shifted toward lamellar keratoplasty. Lamellar keratoplasty offers early visual recovery and potentially fewer complications. Visual rehabilitation through corneal transplant in otherwise blind eyes can be a boon for the children. Recently, keratoprostheses have been promising in children with multiple graft failures. The current review gives insights into epidemiology, etiology, indications, clinical characteristics, investigations, management options, recent advances, and the future of pediatric corneal transplants. As surgical techniques continue to grow and comprehension of pediatric corneal transplants is improving, we can safeguard these eyes with the best possible anatomical and functional outcomes.

BACKGROUND: Epithelial ingrowth is a rare but potentially sight-threatening complication caused by the invasion of corneal or conjunctival epithelial cells into the eye during ocular surgeries. DMEK is emerging as a widely used surgery for endothelial keratoplasty with its improved safety profile. We describe a case of epithelial ingrowth in the graft-host interface after uneventful DMEK associated with vitreous prolapse in the anterior chamber.
METHODS: An 81-year-old female with Fuchs endothelial dystrophy underwent DMEK for corneal decompensation following cataract surgery. During the DMEK procedure, vitreous prolapse was observed around the intraocular lens (IOL). Her early postoperative course was unremarkable, but a dense paracentral interface opacity was observed during the 3-month follow-up. The area of epithelial ingrowth was imaged with optical coherence tomography (OCT) as a uniform nodule with a discrete increase in interface hyperreflectivity. A low-energy YAG laser was applied to remove the opacity. She maintained good vision and clear cornea without reoccurrence after treatment.
CONCLUSIONS: We propose that, in addition to the introduction of epithelial cells during surgery, vitreous retention in the anterior chamber may be a risk factor by providing a scaffold that potentially aggravates epithelial ingrowth in DMEK. Our case demonstrated that early YAG intervention may disrupt interface epithelial cell growth, and the transmitted laser energy may fragment the scaffold vitreous noninvasively.

OBJECTIVE: 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.
CONCLUSIONS: 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.

BACKGROUND: Descemet membrane endothelial keratoplasty (DMEK) is commonly used to treat endothelial pathologies in bicameral pseudophakic eyes with a normal depth of the anterior chamber. However, performing this procedure on eyes that have undergone vitrectomy carries a higher risk of complications. Therefore, this report presents a novel technique for improving the unfolding of a DMEK graft in a vitrectomized eye.
METHODS: A 49-year-old man with a history of complicated cataract surgery one year prior was referred to our clinic with pseudophakic bullous keratopathy in his left eye. The surgery involved a posterior capsular rupture, anterior vitrectomy, and implantation of a sulcus three-piece intraocular lens. DMEK and anterior vitrectomy were performed. However, the conventional tap technique was unsuccessful in unfolding the DMEK graft, owing to intraoperative hypotony and an inability to flatten the anterior chamber.
CONCLUSIONS: To minimize excessive manipulation of the donor tissue, a 27-gauge cannula attached to a 3-cc syringe was used. A cannula was introduced through paracentesis near the edge of an unfolded DMEK graft. We then created a suction force by pulling back the plunger while slowly moving the needle backward during the graft unfolding. The postoperative course was uneventful, with a clear and fully attached DMEK graft.
CONCLUSIONS: This technique reduces the complexity of DMEK graft unfolding in vitrectomized eyes, enabling easier and more controlled unfolding. However, further research with larger patient populations is required to determine the clinical relevance of this method.

Corneal endothelial keratoplasty has been the primary treatment method of endothelial decompensation, but it is often limited in clinical practice due to global shortage of donor cornea. Here, we explored using an ultra-thin allogeneic cornea-derived matrix (uACM) films as a substrate for constructing bioengineered corneal endothelial grafts. We evaluated the films\' optical, mechanical, and structural properties, and measured the composition of the extracellular matrix. The uACM was an ultrathin and curved cornea-shaped film with favorable optical and mechanical properties. The fabrication process efficiently preserved corneal extracellular matrix composition and significantly decreased cellular components. Moreover, human corneal endothelial cells and rabbit corneal endothelial cells (RCECs) can adhere and grow on the uACM films with a positive expression of the corneal endothelial functional markers Na+/K+-ATPase and ZO-1. The successful transplantation of uACM with RCECs grafts into the rabbit model of endothelial dysfunction via Descemet membrane endothelial keratoplasty resulted in prompt restoration of corneal transparency and thickness. During the four-week follow-up period, the uACM with RCECs implanted eyes exhibited comparable corneal transparency, central corneal thickness, and endothelial cell count to that of the healthy rabbit. Histologic examination revealed that the grafts were successfully attached and integrated onto the posterior surface of the corneal stroma. The uACM achieved biomimetic reconstruction in terms of both composition and structure, and can be used to construct the bioengineered corneal endothelial grafts. These results indicate that constructing bioengineered corneal endothelial grafts from discarded human corneal tissues may pave the way for generating high-quality corneal endothelial grafts for transplantation.

OBJECTIVE: To understand whether the preoperative morphology of the posterior corneal surface influences the rate of re-bubbling after Descemet membrane endothelial keratoplasty (DMEK).
METHODS: After retrospectively analyzing the medical records of patients undergoing DMEK, in this multicentric cross-sectional study, we performed a binomial logistic regression analysis to assess significant predictors of re-bubbling and re-transplantation after surgery. Analyzed parameters included the preoperative diagnosis, anterior and posterior surface K1/K2, central corneal thickness, posterior Q value, and other posterior corneal surface parameters evaluated on the elevation maps produced by anterior segment optical coherence tomography. Results were stratified based on the surgeons\' experience.
RESULTS: We included 202 eyes of 202 patients with a mean age of 69.5 ± 12.4 years; 154 eyes were operated by a high-volume surgeon and 48 by one with less experience; 48 eyes (23.8%) underwent ≥ 1 re-bubbling and 14(6.9%) ≥ 1 re-transplantation. The presence of positive/less-negative posterior corneal irregularities and irregularities with greater absolute height had a significantly higher risk of re-bubbling in both the expert and less expert group (OR = 2.85 and 1.42, OR = 3.22 and 3.01, respectively, p < 0.05), whereas more negative posterior K1 and K2 were significant risk factors only in the former group (OR = 0.67 and 0.55, respectively, p < 0.05). Endothelial decompensation other than Fuchs and pseudophakic bullous keratopathy, more negative posterior Q values and smaller distances between center, and the highest/lowest posterior corneal surface irregularity correlated with an increased risk of graft failure (OR 1.23, 1.21, and 1.29, respectively, p < 0.05).
CONCLUSIONS: Posterior corneal surface morphology significantly influences the risk of re-bubbling after DMEK.