Purpose: to evaluate the outcome of voriconazole intrastromal injection as a primary treatment of clinically presumed fungal keratitis in pediatric age. Methods: Retrospective study performed in a tertiary care hospital and included 13 eyes of 13 children less than 18 years old presented with feathery corneal infiltration after trauma with organic material. Intrastromal voriconazole injection (200ug/0.1 ml) was done upon clinical diagnosis of fungal keratitis followed by topical antifungal eye drops. Reinjection was done after 48 hours of the 1st injection if no clinical improvement found. Outcome measures were the response to treatment, number of injections, duration of hospitalization and complications. Results: The mean age of children included was 7± 2.8 years (range: 4-12 years). Ten cases (77%) had clinical improvement after 24 hours of single intrastromal injection. One case improved after a second intrastromal injection of voriconazole and two cases had three injections before clinical improvement. Duration of hospitalization ranged from 2–7 days (2.5 ± 0.8 days). After 3 months of follow up all cases developed localized corneal opacity and none developed recurrence of infection. Conclusions: Early intracorneal injection of voriconazole is a safe and effective way to treat cases of fungal keratitis in children.

Purpose: To evaluate changes in corneal biomechanics after LASIK and F-SMILE. Setting: Elite Eye Center, Tanta, Egypt. Design: Prospective, randomized, unmasked, interventional comparative case series. Patients and methods: A total of 60 eyes were equally divided into two groups; group A: received LASIK and group B: received F-SMILE. Pentacam and CorVis ST parameters were compared before and 6 months after procedures.P <= 0.05 was used for significance of results. Results: bIOP decreased by 0.762 +/- 1.211 mmHg in group A (p = 0.092), and by 2.52 +/- 1.389 mmHg in group B (p < 0.001) and the difference between groups became significant (p = 0.001). A1 increased significantly in group A only (p = 0.036); while A2 decreased insignificantly in both groups. DAR increased significantly in both groups (p < 0.001,p = 0.022), but the difference between groups remained insignificant (p = 0.461). IR increased significantly in group A only (p < 0.001) and the difference between groups became significant (p = 0.026). ARTH decreased in both groups (p = 0.245,p = 0.695) and the difference remained insignificant (p = 0.928). SP-A1 decreased in group A by 8.89 +/- 1.38 mmHg/mm (p = 0.637), and by 32.6 +/- 4.39 mmHg/mm in group B (p < 0.001) and the postoperative difference between groups was significant (p = 0.013). CBI increased significantly in group A (p < 0.001), but insignificantly in group B (p = 0.098) and postoperative difference between groups was highly significant (p < 0.001). A significant correlation was found between change in CCT and corresponding changes in DAR, IR, and ARTH after surgery in both groups. Conclusion: The significant differences between groups postoperatively as regards bIOP (p = 0.001), IR (p = 0.026), SP-A1 (p = 0.013), and CBI (p < 0.001) indicate stiffer corneas after F-SMILE and suggest less influence on corneal biomechanics than LASIK.

Purpose: To assess the changes in ocular high order aberrations after collagen cross linking for keratoconus. Patients and Methods: This study included 30 eyes with confirmed KCN. Baseline evaluation focused on: UDVA and BSCVA using logMAR notation, MRSE, corneal topography using Orbscan IIZ and wave-front aberrometry using Zywave II. CXL was performed per ‘Dresden protocol’ through a 30-minutes exposure to 370 nm UVA with an irradiance of 3 mW/cm 2. Patients had comprehensive ophthalmic evaluation after 6 months with special attention to: UDVA, BSCVA, MRSE, corneal topography and wave-front aberrometry changes. Results: The mean age was 25.5±5.84 (20:31) years. After 6 months, there was a significant decrease in corneal thickness from 493.2± 24.17µ to 486.7±24.26µ (P<0.05) and a significant decrease in K max from 47.4±1.17D to 46.1±1.17D (P<0.05). BSCVA improved from preoperative value (0.00:0.5 logMAR (median 0.3)) to 6 months’ value (0.1:1.00 logMAR (median 0.2) (P <0.05). Preoperative MRSE was -7.25: -0.5D (median -2.85D) and at 6 months was -6.25: -0.5D (median - 2.125D) (P<0.05). A significant correlation was found at 6 months between changes in both BSCVA and: K max (P<0.001), corneal thickness (P<0.05), vertical coma (P<0.001) and trefoil (P<0.001). Conclusions: Improvement in HOA was detected after CXL for KCN. The changes in total, vertical coma and vertical trefoil aberrations were significantly correlated with postoperative improvement in BSCVA. Thus, improvement in HOA profile after CXL is one of the explanations of improvement in visual function after CXL in KCN.

Aim of the Work To evaluate the incidence and risk factors for development of retinopathy of prematurity (ROP) in the biggest neonatal intensive care unit (NICU) in Itay Elbaroud City, Behera province, Egypt. Methods We studied data of 240 newly born infants with gestational age (GA) ≤34 weeks or birth weight (BW) ≤2000 g or infants with unstable course who were admitted to the biggest NICU in Itay Elbaroud City, Behera province, Egypt, 
between October 1, 2018 and October 31, 2020. There is no standard screening system in Egypt. Furthermore, we had screened babies more than 1500 g, more than 32 weeks and found signs of ROP, so we decided to expand our inclusion criteria to include babies up to 2000 g of birth weight and up to 34 weeks gestational age in addition to older and heavier babies with unstable course in NICUs. Clinical information about perinatal neonates was collected by reviewing medical charts. The main outcomes are the incidence and severity of ROP. The relationship of clinical risk factors and the development of ROP were analyzed. Results The overall incidence of ROP was 34.1%, and the overall incidence of type 1 ROP was 26.3% of infants. ROP was significantly associated with GA (odds ratio; OR: 6.8; (3.7–12.3), BW (OR: 4.1; 2.3–7.3), apnea, supplementary oxygen administration, and thrombocytopenia. Conclusion The incidence of ROP is high in Itay Elbaroud city, Behera Province, Egypt. Immaturity, low birth weight, low gestational age, oxygen administration, apnea, thrombocytopenia, and jaundice are important risk factors for development of ROP.

Purpose: To study the pattern electroretinogram changes in primary open-angle glaucoma patients in correlation with visual field changes and optical coherence tomography measurements of retinal nerve fiber layer thickness in the peripapillary region in an attempt to evaluate the clinical value of pattern electroretinogram as an objective test of functional deficit in glaucoma. Patients and Methods: The study included 81 eyes of 81 participants: 50 primary open-angle glaucoma patients, 16 primary open-angle glaucoma suspects, and 15 controls. All subjects underwent visual field testing using 24-2 Humphrey standard automated perimetry, peripapillary retinal nerve fiber layer average thickness using the 3.4-mm circular scan of the Heidelberg OCT spectralis and pattern electroretinogram using CSO RetiMax device in accordance with the International Society for Clinical Electrophysiology of Vision guidelines. Results: We had three main groups: normal, glaucoma suspect, and primary open-angle glaucoma patients, and the last group included three subgroups: mild, moderate, and severe. There was significant difference in the visual field mean deviation, peripapillary retinal nerve fiber layer average thickness, and most pattern electroretinogram measured parameters between the three main groups and in between primary open-angle glaucoma subgroups. There was significant positive correlation between visual field mean deviation and the peripapillary retinal nerve fiber layer average thickness, P50 amplitude, and P50-N95 amplitude (p < 0.001, p = 0.018, and p < 0.001, respectively). Significant negative correlation was also found between peripapillary retinal nerve fiber layer average thickness and N95 amplitude (p < 0.001). Significant positive correlation was found between retinal nerve fiber layer average thickness and P50-N95 amplitude (p = 0.001). Significant negative correlation was found between peripapillary retinal nerve fiber layer average thickness and N95 amplitude (p = 0.001) and significant positive correlation of retinal nerve fiber layer average thickness with P50-N95 amplitude (p = 0.017) in primary open-angle glaucoma patients. Conclusion: Peripapillary retinal nerve fiber layer average thickness shows significant negative correlation with pattern electroretinogram N95 amplitude and a significant positive correlation with P50-N95 amplitude. In combination with optical coherence tomography, pattern electroretinogram can be used to objectively assess functional loss in glaucoma.

Purpose The aim of this study was to evaluate the changes in anterior segment parameters by ultrasound biomicroscopy (UBM) after laser peripheral iridotomy (LPI) in eyes with narrow drainage angles.Patients and methods A prospective study was conducted on 20 eyes of 20 different patients with primary angle-closure glaucoma in need for LPI. Patients underwent a detailed ophthalmic examination including slit lamp examination, intraocular pressure measurement, and gonioscopy. UBM was performed before and 1 week after LPI. Quantitative parameters included angle-opening distance (AOD), iris thickness, trabecular-iris angle, trabecular-ciliary process distance, iris-lens contact distance (ILCD), and iridocorneal angle recess area (ICA).Results The mean age of the patients was 55±9.6 years (range: 40–80 years), and 12 patients were females. LPI was performed in the supero-temporal quadrant in 12 eyes and in the supero-nasal quadrant in eight eyes. On gonioscopy, none of the angle structures were seen on primary gaze in the four quadrants in two eyes, in three quadrants in eight eyes, and in two quadrants in 10 eyes. After LPI, ILCD increased significantly in 10 eyes (P<0.001), whereas AOD and ICA widened significantly in all eyes (P<0.0001). Most of the AOD widening was noted in the temporal quadrant followed by the superior quadrant. ICA increase was largest in the temporal quadrant. ILCD increased significantly with flattening of the convex iris. There was no significant change in the anterior chamber depth, lens thickness, trabecular-ciliary process distance, or iris thickness after LPI.Conclusion LPI significantly changed the morphology and parameters of anterior segment in eyes with narrow drainage angles, with obvious widening of the drainage angle. Unlike gonioscopy, these changes could be objectively highlighted and quantified accurately by UBM.

We evaluated the visual and refractive outcomes after phakic visian toric implantable collamer lens (ICL) insertion in stable keratoconus (KC). This retrospective study investigated toric ICL implantation in 14 eyes of 8 patients with stable KC. After 6mo, the mean uncorrected distance visual acuity improved significantly from 0.77 to 0.15 logMAR. The mean best corrected distance visual acuity (BCDVA) improved from 0.18±0.1 to 0.15±0.1 logMAR. Fifty percent of eyes maintained their preoperative BCDVA; 42.8% gained one line. There was no statistical difference in high order or coma aberration. The mean refractive manifest spherical equivalent (MSE), mean refractive manifest spherical error, mean manifest astigmatism decreased significantly postoperatively. At 6mo postoperatively, our achieved mean spherical equivalent was approximately 74%. No intraoperative or postoperative complications occurred. Toric ICL implantation was effective, predictable and safe to correct refractive error and improve visual acuity in patients with stable KC.

Purpose To compare the efficacy, safety and stability of standard epithelium-off cross-linking (SCXL) versus accelerated epithelium-off cross-linking (ACXL) and transepithelial epithelium-on cross-linking (TCXL) in the treatment of progressive keratoconus (KC) in children. Methods This prospective multicentre controlled trial included 271 eyes (136 children) with grade 1-3 progressive KC who were randomized to undergo SCXL (n = 91, as a control group), ACXL (n = 92) or TCXL (n = 88). Uncorrected and corrected distance visual acuity, subjective refraction, pachymetry, keratometry and corneal topography measurements were recorded preoperatively and 6, 12 and 24 months postoperatively. Results At 1 year, there was no significant difference in uncorrected distance visual acuity, refractive sphere, cylinder, spherical equivalent or Kmax between the ACXL and SCXL groups; however, during year 2, ACXL regressed while SCXL continued to improve. After 2 years, there were significant differences in all visual, refractive and keratometric components between SCXL and both ACXL and TCXL (p < 0.0001) and between ACXL and TCXL (p < 0.0001). KC progressed in 5.4% of patients who had ACXL and 28.4% of those who had TCXL but in none of those who had SCXL. Vernal keratoconjunctivitis was documented in 43.3% of eyes that progressed postoperatively. Conclusion SCXL was more effective for paediatric KC and achieved greater stability than either ACXL or TCXL, and ACXL was superior to TCXL. SCXL also achieved marked improvement in both myopia and spherical equivalent; however, these refractive outcomes were unpredictable and uncontrollable. TCXL had a 28.4% failure rate within 2 years. SCXL is preferable for management of paediatric KC.

PURPOSE:To compare the safety and efficacy of standard 30 min epithelium-off cross-linking (CXL) versus photorefractive keratectomy (PRK) combined with accelerated epithelium-off cross-linking (AXL) for the treatment of progressive keratoconus (CXL-Plus).METHODS:This study was a prospective multicentre comparative clinical study. A total of 125 eyes of 75 patients with grade 1 keratoconus and documented progression were divided into two groups. Group A included 58 eyes treated with standard CXL. Group B included 67 eyes treated with combined PRK and AXL. The recorded data included UDVA, CDVA, subjective and objective refraction, keratometry and pachymetry using corneal topographies preoperatively and postoperatively at 3, 6, 12 and 24 months of follow-up.RESULTS:In group A, at 24 months of UDVA and CDVA were improved from 1.12 ± 0.38 and 0.58 ± 0.42 to 0.66 ± 0.20 and 0.20 ± 0.12 (LogMAR±SD). The spherical equivalent was reduced from 4.03 ± 1.18 to 1.78 ± 1.04 D. The cylinder reduction was 0.32 ± 0.19 D. In group B, at 24 months of UDVA and CDVA were improved from 1.26 ± 0.52 and 0.68 ± 0.36 to 0.58 ± 0.28 and 0.20 ± 0.16 (LogMAR ± SD). The spherical equivalent was reduced from 4.23 ± 0.95 to 1.92 ± 0.74 D. The cylinder reduction was ±1.76 D.CONCLUSION:Surprisingly, standard CXL showed close results to CXL-Plus at the 24th follow-up month. Standard CXL acted as a stabilizing procedure associated with a late myopic component reduction. CXL-Plus acted as a refractive and stabilizing procedure with an early effect on both the myopic and the astigmatic component but no later improvements. Standard CXL seems to be more powerful than AXL in its long-term effect. Therefore, in the future, we want to test the combination of PRK with standard CXL.

Purpose: To evaluate the effectiveness and safety of combined epithelium-off cross-linking (CXL) with photorefractive keratectomy (CXL Plus) for correction of the myopic and astigmatic components of keratoconus. Methods: Seventy-nine eyes of 46 patients who underwent CXL Plus were enrolled in this retrospective, multicenter, noncomparative clinical study. Uncorrected distance visual acuity, corrected distance visual acuity, refraction, keratometry, and pachymetry measurements were recorded preoperatively and at 3, 6, 12, and 18 months during follow-up. Results: The mean (±SD) preoperative uncorrected distance visual acuity and corrected distance visual acuity were 1.00 ± 0.22 logarithm of the minimum angle of resolution (logMAR) and 0.62 ± 0.38 logMAR, respectively, and improved to 0.71 ± 0.36 logMAR and 0.32 ± 0.18 logMAR postoperatively. The mean k value, mean corneal thickness at the thinnest location, and mean myopic and astigmatic components decreased from 46.58 ± 0.97 D, 473 ± 29 μm, 3.65 ± 1.72 D, and 1.83 ± 0.69 D preoperatively to 43.79 ± 1.17 D, 431 ± 38 μm, 1.02 ± 0.78 D, and 1.15 ± 0.26 D, respectively, during follow-up. Eleven eyes had delayed epithelial healing, 2 had stromal opacities, 1 had primary herpes simplex keratitis, and 5 showed progression of keratoconus. Conclusions: CXL Plus improved the refractive status of keratoconus during 18 months of follow-up, despite its potential early postoperative complications of delayed epithelial healing and corneal haze. CXL Plus reduced the myopic component more than the astigmatic component of keratoconus. However, the safety and stability of the procedure were offset by longer-term postoperative complications and a high rate of postoperative progression of keratoconus.

PURPOSE:To analyze the visual and refractive outcomes of combined accelerated cross-linking with femtosecond laser intracorneal ring segment implantation for the treatment of pediatric keratoconus. MATERIALS AND METHODS:This retrospective multicenter noncomparative clinical study included 63 eyes of 37 patients (age, 9-17 years) who underwent between August and September 2016 combined cross-linking with intracorneal ring segment implantation for keratoconus. Preoperative and postoperative (6, 12, and 18 months) uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), subjective refractions, keratometry (K), and pachymetry measurements were compared. RESULTS:The postoperative spherical equivalent refraction was within ±1 D, ±2 D, and ±3 D in 19 (30.2%), 27 (42.9%), and 37 (58.8%) eyes, respectively. Only 27 eyes achieved the attempted preoperative spherical equivalent refraction. The mean spherical equivalent refraction significantly improved from -6.01 ± 2.97 to -3.13 ± 2.78 D postoperatively (P < 0.0001). The mean K average reading significantly decreased from 48.75 ± 4.25 to 46.65 ± 3.89 D postoperatively (P < 0.0001). The mean postoperative myopic, astigmatic, and spherical equivalent corrections were -2.17 ± 2.19, -1.52 ± 2.03, and -2.93 ± 2.35 D, respectively. The mean UDVA and CDVA showed significant improvements (0.89 ± 0.33 to 0.40 ± 0.28, P < 0.0001; 0.35 ± 0.31 to 0.25 ± 0.24, P = 0.004; respectively) at 18 months postoperatively. Keratoconus progression, segment migration, and segment extrusion were seen in four (6.4%), one (1.6%), and three (4.7%) eyes, respectively, probably contributing to the lower mean postoperative CDVA. CONCLUSION:Cross-linking plus is only partially effective for pediatric keratoconus. Despite some improvements in vision and keratometry measures, it resulted in complications such as keratoconus progression, segment extrusion, and segment migration that affected the vision in some patients. These findings suggest an assessment of standard epithelium-off collagen cross-linking as a sole procedure to treat pediatric keratoconus in future studies.

Purpose The aim of this work was to study the effectiveness and potential complications of adjunctive intraoperative mitomycin-C (MMC) application combined with limbal-conjunctival autografting after primary pterygium excision. Patients and methods Fifty-seven eyes of 43 patients with primary pterygia were randomized to receive pterygium excision, followed by either a free conjunctival autograft (control group, n = 27) or an adjunctive intraoperative MMC 0.02% application for 2 min and limbal-conjunctival autograft (triple procedure group, n = 30). All patients were followed for 12 months. Results After 1 year, the recurrence rate was 14.81 and 0% in the control and the triple procedure groups, respectively (P < 0.05). Most complications were transient and mild. The duration of surgery was significantly shorter in the control group (P < 0.01). The surgery did not significantly alter the corrected distance visual acuity or the average absolute astigmatism in either group. Conclusion Simple excision of pterygium combined with adjunctive intraoperative MMC 0.02% application for 2 min and limbal-conjunctival autografting is a safe and effective way of treating primary pterygia.

Purpose This is a prospective investigational study that was performed at Tanta University Eye Hospital, Tanta, Egypt to evaluate the role of ultrasound biomicroscopy (UBM) in planning secondary implantation of intra ocular lens (IOL) in aphakia. Methods Preoperative UBM was performed for the assessment of anterior segment of 30 aphakic eyes admitted for secondary IOL implantation with special attention to central corneal thickness (CCT), anterior chamber depth (ACD), ciliary sulcus (CS), anatomical changes, and posterior capsular (PC) integrity which had been assessed by measuring the remnants of PC with special attention to the 12, 3, 5, 6, 7, and 9 o'clock meridians. Results This study involved 30 eyes in 27 patients; 16 males and 11 females. The mean age was 8.39 ± 2.36 years. The causes of aphakia were: congenital cataract extraction in14 eyes (46.7 %); trauma in 14 eyes (46.7 %); and after extracapsular cataract extraction in 2 eyes (6.6 %). The mean CCT was 0.61 + 0.35 mm and the mean ACD was 3.03 + 0.41 mm. The ciliary sulcus was patent in 28 eyes (93.4 %). Posterior synechia was observed in 8 eyes (26.7 %), lens remnants in 11 eyes (36.7 %), corneal scars in 11 eyes (36.7 %), and vitreous in anterior chamber in 1 eye (3.3 %). The integrity of PC was illustrated with a diagram. Conclusions UBM is a useful device to evaluate aphakic eyes before secondary IOL implantation through good evaluation of the anterior segment with special attention to the posterior capsular integrity, ciliary sulcus, anterior chamber depth, corneal thickness, and detection of any structural changes in the anterior segment resulting from the remote cause of aphakia.

Purpose: To determine the immediate endothelial cell loss (ECL) resulting from insertion of a precut donor button using the Neusidl Corneal Inserter (NCI) and compare it with the previously published ECL resulting from insertion of a folded donor button using non-coapting forceps.Methods: Ten corneas were precut for Descemet stripping automated endothelial keratoplasty and trephinated to a diameter of 8.0 mm (n = 5) or 8.5 mm (n = 5). Each tissue was placed onto the platform of a new NCI spatula and inserted into a cadaveric whole globe through a 5.2 mm incision. The tissue was carefully removed and stained with trypan blue and alizarin red to detect damaged endothelium. ECL was estimated using Adobe Photoshop planimetry. Mean ECL was compared with previously reported studies of forceps insertion with a one-sample t test, using SPSS v. 19. Geographic patterns of ECL were also documented.Results: Mean ECL was 15.6% (95% confidence interval, 13.8-17.4). We were unable to detect a difference in ECL compared with previous insertion methods studied (P < 0.001). The pattern of damage from the NCI was different than that previously seen with forceps insertion.Conclusion: Immediate endothelial damage resulting from use of the NCI for insertion of Descemet stripping automated endothelial keratoplasty tissue is comparable with that seen with a standard forceps technique, but with a different damage pattern.

PURPOSE: To describe a case where specular microscopy data relayed misleading information regarding the quality of a cornea processed in an eye bank for endothelial keratoplasty. METHODS: A cornea was prepared by microkeratome for endothelial keratoplasty and was evaluated with routine slit lamp and specular microscopy. In addition, the tissue was stained with trypan blue and alizarin red S to demonstrate the efficacy of the preliminary evaluation with endothelial viability studies. The stained cornea was photographed, and the percent cell death was calculated using Adobe Photoshop analysis. RESULTS: The preresection central endothelial cell density was 2608 cells/mm 2 . In comparison, the post-cut density was 2978 cells/mm 2 , a figure that represents a 14.19% cell gain. Viability staining with analysis showed 43.77% cell damage. CONCLUSIONS: Reliance on specular microscopy for determination of endothelial viability can lead to misleading conclusions, as demonstrated in this case study. doi:10.7706/ijeb.v1i2.27

Recent evidence demonstrated a correlation between apoptosis and neprilysin expression. The aim of this study was to investigate the immunohistochemical expression of Fas ligand (FasL) and neprilysin in keratoconic corneas in comparison to normal cadaver corneas to evaluate if such molecules play a role in the pathogenesis of keratoconus. We studied the expression of FasL and neprilysin in corneal specimens removed during penetrating keratoplasty in 15 cases with keratoconus and compared them with 5 normal cadaver corneas. In keratoconus, FasL was expressed in epithelium, endothelium and sub-Bowman's stroma only, while neprilysin was expressed in epithelium, endothelium and all stromal layers. All normal corneas showed weak expression of both markers in basal epithelial layer only. In keratoconus, corneal epithelium with higher expression of FasL may evoke apoptosis in keratocytes, while neprilysin could prevent possible rescue of keratocytes from apoptosis.

Purpose: To evaluate the endothelial cell survival and stromal bed quality when creating deep stromal cuts with a low-pulse energy, high-frequency femtosecond laser to produce "ultrathin" tissue for Descemet stripping automated endothelial keratoplasty.Methods: Seventeen corneas were used for this study. Five corneas were cut with the laser at a depth of 420 to 500 mm to produce a tissue thickness of approximately <= 70 mu m. Five corneas served as an uncut comparison group. Vital dye staining and computer digitized planimetry analysis were performed on these corneas. The 7 remaining corneas were cut for scanning electron microscopy evaluation.Results: The mean central posterior stromal thickness of cut corneas was 60.6 mu m (range, 43-72 mu m). Endothelial cell damage in cut and comparison corneas was 3.92% +/- 2.22% (range, 1.71%-6.51%) and 4.15% +/- 2.64% (range, 1.21%-7.01%), respectively (P = 0.887). Low-magnification (x 12) scanning electron microscopy revealed a somewhat irregular-appearing surface with concentric rings peripherally. Qualitative grading of higher magnification (x50) central images resulted in an average score of 2.56 (between smooth and rough).Conclusions: Ultrathin tissue for Descemet stripping automated endothelial keratoplasty can be safely prepared with minimal endothelial cell damage using a low-pulse energy, high-frequency femtosecond laser; however, the resulting stromal surface quality may not be optimal with this technique.

PURPOSE:The purpose of this study was to evaluate outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using anterior stromal flawed (ASF) donor corneas that were unsuitable for use in full-thickness penetrating keratoplasty as a result of stromal scars, pterygia, or previous corneal refractive surgery and to compare results with DSAEK using standard tissue.METHODS:We conducted a review of our initial 42 (19 with 6-month follow up) consecutive DSAEK surgeries using ASF tissue compared with 357 (199 with 6-month follow up) time-matched controls using standard tissue. Intraoperative and perioperative complications, including dislocations and primary graft failures, were compared. Six-month best spectacle-corrected vision, incidence of rejection episodes, postoperative refractive astigmatism, keratometric values, pre- and postoperative topography-derived surface asymmetry index, and surface regularity index were compared.RESULTS:One surgeon-cut ASF tissue was perforated before surgery and was discarded. No surgeon-cut standard tissue was perforated. No intraoperative complications and no episodes of primary graft failure or pupillary block glaucoma occurred in either group. One (2.4%) postoperative graft dislocation and one (5.2%) graft rejection episode occurred in the study group. There were 10 (2.8%) dislocations and 8 (2.2%) graft rejection in the controls. A statistically similar significant improvement in best spectacle-corrected vision occurred in both groups. Corneal topography, pachymetry, and manifest astigmatism were not significantly different between groups.CONCLUSION:Postoperative results of DSAEK using donor tissue excluded from use in penetrating keratoplasty as a result of stromal flaws are equivalent to results using standard donor tissue. Central corneal thickness measurements should be performed before cutting to avoid tissue perforation. The use of ASF tissue for DSAEK will expand the cornea donor pool.

Purpose: To evaluate and quantify the degree and pattern of donor endothelial cell damage, which occurs with mechanical trephination of donor corneal tissue.Method: Twenty donor corneal-scleral tissues were used for these paired experiments. The tissues were randomized for trephination with 10 tissues trephinated by an 8.0-mm-diameter Barron trephine (Katena, Denville, NJ), and 10 tissues trephinated with an 8.0-mm-diameter UltraFit Coronet trephine (distributed by Angiotech, British Columbia, Canada) by the same investigator. Trephinated corneal buttons were then stained with vital dye stain, and the endothelial layer image captured with digital photography. The images were then analyzed by digital planimetry, and the pattern and quantity of endothelial damage was determined by an investigator who was masked to the specific trephine used for the individual tissue.Results: Trephination created a pattern of circular damage at the edge of the donor button in every case with no break in continuity Of the circle, but some portions of the circle were wider than others. Occasional, scattered, peripheral small areas also displayed damage, but no significant striae, stretch, or other central damage was noted in any donor. The mean percent damage in the series was 6.35% +/- 0.90% (range: 4.33%-7.78%). The UltraFit Coronet trephinations averaged damage of 5.64% +/- 0.85% (range: 4.33%-6.69%), and the Barron trephinations averaged damage of 6.50% +/- 0.95% (range: 4.92%-7.78%). Although 8 of 10 experimental pairs of trephinations demonstrated less peripheral endothelial damage with the UltraFit Coronet trephine, the mean damage between each group did not reach statistical significance in this small series. (P = 0.08)Conclusions: Donor mechanical trephination of full-thickness corneal tissue creates relatively consistent amounts of peripheral edge damage and likely no central endothelial damage. There may exist differences in edge damage between different mechanical trephination systems, and a direct comparison to laser-created trephination is needed.