This study describes the clinical and genetic features of Meesmann epithelial corneal dystrophy (MECD) in two unrelated families and reports new genotype-phenotype associations. Ten patients from a Lebanese family (n = 4) (Family 1) and a Spanish family (n = 6) (Family 2) underwent ophthalmologic evaluation, in vivo confocal microscopy (IVCM), anterior segment optical coherence tomography (AS-OCT) with epithelial thickness mapping (ET-map), and targeted next-generation sequencing (NGS) using a custom-designed 133-gene panel associated with anterior segment dystrophies. In Family 1, a novel homozygous KRT12 c.1181T>C (p.Leu394Pro) variant was identified in the symptomatic proband and his clinically asymptomatic brother, while both parents, who were first cousins, were heterozygous for this nucleotide variant. The proband also carried the heterozygous KRT3 c.250C>T (p.Arg84Trp) variant, which has been previously reported but, to our knowledge, has not been described in co-occurrence until now. In addition, the proband showed a complex phenotype with signs of MECD and epithelial basal membrane alterations consistent with epithelial basement membrane dystrophy (EBMD). In Family 2, four affected members carried the KRT3 c.1492G>A (p.Glu498Lys) variant in heterozygosity, which has been previously described. The elderly members affected showed typical signs of MECD and EBMD. To our knowledge, these concomitant alterations have not been previously described with genetical confirmation. In conclusion, this study provides the first evidence that the co-occurrence of variants in two Meesmann corneal dystrophy-associated genes (KRT3 and KRT12) can jointly account for the disease phenotype. We also highlight the association of MECD with EBMD in both families. Characterization using IVCM and AS-OCT ET-Map provides a deeper understanding of the morphological changes and phenotypic variability in MECD, confirming the utility of this multimodal imaging approach for diagnosis and management.

Background and Objectives: To assess refractive and visual outcomes following phacoemulsification using a novel algorithm for toric intraocular lens (IOL) surgery. Setting: Private practice, Spain. Design: Prospective observational study. Materials and Methods: The algorithm was designed to control the topographic position of the principal meridians (flat and steep) after cataract surgery in eyes without associated corneal pathology or previous corneal surgery. It is well known that a toric IOL must be positioned along the steep meridian. Therefore, it is crucial to predict both the postoperative position of the steep meridian and its magnitude. Data from patients who were planned for refractive lens exchange or cataract surgery using the Pešić-Barraquer algorithm and implantation of a toric IOL in eyes with different degrees of astigmatism were used to assess the effect of residual astigmatism on 6-month postoperative monocular uncorrected and corrected distance logMAR visual acuity values (UDVA and CDVA). Vector analysis was performed with J0 and J45 evaluations, and centroid errors in postoperative refractive astigmatism prediction error were calculated in the spectacle plane using the “Astigmatism Double-Angle Plot Tool”. Results: Three hundred and six eyes of 250 patients with a mean age of 69.0 years ± 8.6 were enrolled in the study. The mean preoperative corneal astigmatism measured with Pentacam was 1.43 D ± 0.83 (SD). One hundred and eighty-four eyes (60.13%) had “against-the-rule” (ATR) astigmatism, 67 (21.90%) had “with-the-rule” (WTR) astigmatism, and 55 (17.97%) eyes had “oblique” corneal (OBL) astigmatism preoperatively. The mean absolute astigmatic prediction error in residual astigmatism was 0.31 D ± 0.28. Eyes with preoperative ATR corneal astigmatism had lower mean absolute errors compared to the eyes with WTR astigmatism (0.29 D ± 0.26 and 0.34 D ± 0.31, respectively). Centroid error in predicted residual astigmatism was 0.08 D ± 0.41 @4°. All eyes achieved residual refractive astigmatism within the 1.00 D range, and 55.23% had no residual astigmatism in the spectacle plane. Mean postoperative refractive astigmatism at the spectacle plane was 0.24 D ± 0.29. There were no postoperative complications. Additional statistical analysis of 310 eyes confirmed that when the main incision is not placed on one of the three meridians (flat, steep, or 45-degree bisector), the axis of astigmatism induced by the incision is significantly altered. Exploratory subgroup analyses demonstrated comparable prediction accuracy across incision positions, preoperative astigmatism types, and surgeons, further supporting the robustness of the proposed algorithm. Conclusions: In addition to enabling more accurate prediction of postoperative refractive residual astigmatism in patients undergoing toric IOL implantation, our newly proposed algorithm provides surgical pearls to facilitate preoperative and intraoperative management of corneal astigmatism, highlighting the importance of precise incision placement for optimal refractive outcomes.

BACKGROUND:To report the 1-year clinical outcomes of decellularised human corneal stromal lamina implantation, with or without autologous adipose-derived adult stem cells (ADASCs), for advanced keratoconus in a European cohort. METHODS:In this prospective, randomised Phase I/IIa trial, 10 eyes of 10 patients were allocated to decellularised stromal lamina implantation alone (G-1; n = 5) or lamina recellularised with 1.0 × 106 autologous ADASCs plus 2.0 × 106 additional ADASCs injected into the stromal pocket (G-2; n = 5). All procedures used femtosecond laser-assisted 9.5-mm intrastromal dissection. RESULTS:No major intraoperative complications occurred except one G-2 micro-tear that resolved. No clinically relevant inflammation, rejection, or graft failure was observed; transparency was restored in all eyes by 3-6 months. At 12 months, central corneal thickness increased by 118.4 μm in G-1 and 121.2 μm in G-2. Decimal UDVA improved by 2.14 ± 0.71 lines in G-1 and 1.30 ± 0.84 lines in G-2; decimal CDVA improved by 2.48 ± 0.66 and 1.43 ± 0.53 lines, respectively. Manifest sphere improved to -1.10 D in G-1 and -0.58 D in G-2, whereas manifest cylinder changed minimally in both groups. Keratometric indices remained largely unchanged. In vivo confocal microscopy demonstrated progressive cellular repopulation of the implanted lamina during follow-up in both groups. CONCLUSIONS:Decellularised stromal lamina implantation, with or without autologous ADASCs, was safe and feasible, maintaining corneal transparency and producing sustained stromal thickening with clinically meaningful visual and refractive improvement at 12 months. Larger adequately powered studies with longer follow-up are required to assess clinical efficacy.

Starbursts are entoptic visual phenomena perceived as radial spikes around point light sources, frequently reported under scotopic conditions or following ocular surgeries such as LASIK or intraocular lens implantation. While starbursts have traditionally been attributed to high-order optical aberrations, in particular spherical aberration, we hypothesize that crystalline lens suture patterns may play a dominant role in the formation of starbursts through light diffraction. This study investigates the contribution of lens suture diffraction to starburst formation and compares it to the influence of high-order spherical aberrations. Using ex vivo porcine crystalline lenses mounted in a mechanical expansion unit, we performed through-focus imaging and aberrometric analysis with a custom optical system. Suture patterns were segmented and used to simulate diffraction-based point-spread functions (PSFs) by convolving them with a Gaussian point source. Simulated PSFs were compared to those generated using fourth- and sixth-order spherical aberration parameters. A cross-correlation analysis and angular detection of diffraction spikes were performed to assess the similarity between experimental and simulated PSFs. Results demonstrate that diffraction by crystalline lens sutures generates starburst-like PSFs, independent of high-order aberrations. Through-focus simulations revealed asymmetric Strehl ratio distributions when suture diffraction was included, suggesting that sutures significantly degrade optical quality over a broader dioptric range. Cross-correlation coefficients ( τ ) between experimental and simulated PSFs exceeded 0.7 in all cases, and diffraction spike orientations showed high angular consistency, confirming the predictive value of the suture diffraction model. Our findings support the hypothesis that lens sutures are the primary source of starburst formation via diffraction, with spherical aberration acting as a secondary factor.

Purpose This study aims to compare the results of the Finger Count Test (FCT) for “Counting fingers” (CF) and “Hand movement” (HM) with the visual acuity (VA) obtained from the Berkeley Rudimentary Vision Test (BRVT) in low vision patients with different pathologies. Methods Uncorrected visual acuity was estimated using BRVT and using the corresponding CF or HM in 38 low vision patients (VA range between 1.40 and 3.50 logMAR). Detailed ocular pathologies were recorded for each patient. Patients were categorized into two groups: one with severe visual field defects (constrictions of the central visual field or central scotomas) due to any cause and a general group which included all other ocular pathologies. Results The mean age was 67 years, with an age range from 26 to 92 years. The General group revealed a median VA of 2.00 logMAR for CF and 2.60 logMAR for HM (p < 0.001). This study showed a large variation of VA from BRVT in the Visual field group and considerable overlap with the VA results for CF and HM; with a median VA of 2.10 logMAR for CF and 2.30 logMAR for HM (p = 0.824). Conclusion The VA found in this study for CF confirmed values from earlier studies, while VA for HM was found to be slightly worse. These findings allow a translation of older VA data of CF and HM to logMAR for proper statistical analysis. Patients with central visual field defects showed a large variation of measured VA with BRVT.

Background/Objectives: to report a novel KRT3 Meesmann corneal dystrophy (MECD) mutation and its clinical findings in a Spanish family, thus completing the international database. Case series study. Methods: Two generations of three family members were studied. The clinical ophthalmologic evaluation was made including best-corrected visual acuity (BCVA), biomicroscopy with and without fluorescein, fundoscopy, Schirmer test I, non-invasive break-up time (NiBUT), and esthesiometry. In vivo confocal microscopy (IVCM), anterior segment optical coherence tomography (AS-OCT) with an epithelial map, and genetic analysis were also performed. Results: A novel heterozygous mutation in the KRT3 gene c.1527G>T (p. Glu509Asp) was identified. Biomicroscopy revealed bilateral multiple corneal intraepithelial cysts. IVCM showed numerous and relatively small microcysts (12–32 µm), hyperreflective materials, subepithelial nerve and Bowman’s layer alterations. AS-OCT scan revealed diffuse hyperreflectivity and the epithelial map displayed thickening of the corneal epithelium in the interpalpebral zone (proband: 52–68 µm and father’s proband: 55–71 µm) with a slightly thinned cornea. Conclusions: We identified a new mutation in the KRT3 gene–c.1527G>T (p. Glu509Asp) in a Spanish family with MECD. A comprehensive characterization of the clinical signs, using different techniques, especially an epithelial map, could be useful to diagnose and monitor epithelial changes by quantitative measures. Epithelial map changes provide better understanding of MECD differential epithelial behavior and its progression changes. Larger studies will be necessary to better understand these specific patterns and clinically evaluate new therapies.

PURPOSE:To evaluate anatomical and functional outcomes, and complications, of Boston type 1 keratoprosthesis with autologous oral mucosa graft (B1KProM) to reconstruct and protect the ocular surface of eyes with severe conditions. DESIGN:Retrospective interventional case series. METHODS:Data from 19 eyes of 19 patients (12 males; mean age of 61 ± 18 years) with irreversible corneal opacification (autoimmune diseases [11], chemical burns [5], or other [3]), who underwent B1KProM surgery. Anatomical success was defined as retention of the keratoprosthesis during the follow-up and functional success as postoperative best-corrected visual acuity (BCVA) ≤1.3 logMAR at the last follow-up. RESULTS:The median mucosal reepithelialization time was 3 weeks. Mucosal complications were poor epithelization, overgrowth, and necrosis and occurred in 14 episodes in 9 eyes (47%), all successfully managed, except in 2 eyes with concomitant extrusion. The incidence of other complications was under previously described ranges. Anatomical failure occurred in 4 of 19 cases (21%), all of them with autoimmune diseases. Cumulative probability of anatomical success was 89%, 80%, and 40% at 12, 24, and 36 months, respectively. BCVA ≥20/200 was found at some point postoperatively in 11 of 12 cases (92%) with visual potential. Cumulative probability of functional success was 89%, 78%, and 29% at 12, 24, and 36 months, respectively. The mean follow-up was of 18±12 months (range: 1-36 months). CONCLUSIONS:B1KProM emerges as a promising option for patients with complex ocular surface conditions. Mucosal complications were frequent but manageable. Further research is essential to confirm its long-term effectiveness.

PURPOSE:The aim of this study was to describe the clinical features and endothelial involvement in a case of Mpox virus keratitis by in vivo confocal microscopy (IVCM). METHODS:This is a case report. RESULTS:A 35-year-old man presented with redness, photophobia, pain, tearing, and a low visual acuity of 0.09 (decimal) in the left eye with a 6-week history of Mpox and corneal trauma. Previous testing of blood, interdigital skin lesions, and conjunctival and eyelid margin swabs confirmed the presence of Mpox by polymerase chain reaction. Biomicroscopy displayed superficial stromal infiltrates with a continuous but irregular epithelium. IVCM revealed the presence of pseudoguttata, loss of defined cell boundaries, infiltration of inflammatory cells in the endothelial layer, endothelial ridges, and precipitated pigmented granules, consistent with endotheliitis. After this episode, the patient had 4 reactivations, also treated with topical corticoids and oral tecovirimat 600 mg twice a day for 2 weeks. On the fourth reactivation, this treatment was extended to 4 weeks. On the last visit, the patient presented a visual acuity of 0.5 with disciform keratitis and reduced endotheliitis signs. The endothelial cell density remained normal during the follow-up (2763 ± 376 cell/mm 2 at baseline and 2795 ± 238 cell/mm 2 at the last visit). Polymegathism and pleomorphism showed altered values during the follow-up. CONCLUSIONS:Patients with an altered corneal epithelial barrier could suffer Mpox endotheliitis, like other DNA viruses, before disciform keratitis appears. IVCM is a useful tool for the early detection of endotheliitis and for describing its evolution, improving patient care.

PURPOSE:To report the causes of pseudophakic intraocular lens (IOL) explantation in Spain over a 20 year period.METHODS:Multicenter observational prospective study of a consecutive series of cases corresponding to pseudophakic intraocular lenses explantations performed in 22 Spanish clinical centres from 2002 to 2021, within a national clinical research network. The clinical data of all IOL explantation patients was evaluated, and the different causes for IOL explantation were systematically analyzed.RESULTS:From a total of 1013 pseudophakic explantations, 919 cases were included in this investigation. The mean age of the patients at the time of explantation was 66.3 years, and 142 (15.45%) were women. Over the 20 years of the study, the five main reasons for explanting lenses in the last 20 years in Spain according to the Iberia RETICS database were: dislocation / decentration / misalignment (43.08%), bullous keratopathy (16.79%), neuroadaptation failure (13.85%), IOL opacification (9.71%), refractive surprise (6.87%). Other causes, less frequent, were uveitis / endophthalmitis / infection with 39 cases (4.25%); IOL substitution for reasons other than multifocal IOL neuroadaptation failure 3 cases (0.33%); and other causes, 47 cases (5.13%). Hydrophobic lenses were the most frequently explanted with a ratio of 47.1%.CONCLUSIONS:Over the 20 years of the study, the five main reasons for explanting lenses in the last 20 years in Spain according to the Iberia RETICS database were: dislocation / decentration / misalignment, bullous keratopathy, neuroadaptation failure, IOL opacification, and refractive surprise.

Purpose:Cataracts are typically treated by phacoemulsification followed by intraocular lens implantation. Studies of mouse models of cataract surgery have revealed that lens epithelial cells rapidly remodel their transcriptome to express proinflammatory cytokines after lens fiber cell removal, but it is currently unknown whether this response is conserved in human lenses. This study seeks to fill this knowledge gap. Methods:Human cadaver eyes from 70 to 89 year old individuals were prepared for the human capsular bag model of cataract surgery. The central epithelium was preserved in RNAlater during culture preparation, then the equatorial epithelium was either immediately preserved in RNAlater after the culture was created, or 24 h later. Gene expression profiles were generated by bulk sequencing of RNA isolated from these tissue samples. The transcriptomic response of human cadaver-derived lens epithelial cells to culture in this "capsular bag" model was characterized by bioinformatic analysis. The human response was directly compared to that of 24-month-old mouse lens epithelial cells subjected to fiber cell removal surgery. Results:Human lens epithelial cells remodel approximately a third of their transcriptome by 24 h after surgery, and like mice, this response consists of induction of proinflammatory cytokine genes, upregulation of fibrotic markers and downregulation of genes controlling the lens epithelial phenotype. Conclusions:These observations demonstrate that humans and mice have similar responses to cataract surgery and support the use of mice to study the response of lens epithelial cells to cataract surgery, suggesting that identified injury response mechanisms can be leveraged to elucidate new approaches to improve the outcomes of cataract surgery.

Purpose: Computational models can help clinicians plan surgeries by accounting for factors such as mechanical imbalances or testing different surgical techniques beforehand. Different levels of modeling complexity are found in the literature, and it is still not clear what aspects should be included to obtain accurate results in finite-element (FE) corneal models. This work presents a methodology to narrow down minimal requirements of modeling features to report clinical data for a refractive intervention such as PRK. Methods: A pipeline to create FE models of a refractive surgery is presented: It tests different geometries, boundary conditions, loading, and mesh size on the optomechanical simulation output. The mechanical model for the corneal tissue accounts for the collagen fiber distribution in human corneas. Both mechanical and optical outcome are analyzed for the different models. Finally, the methodology is applied to five patient-specific models to ensure accuracy. Results: To simulate the postsurgical corneal optomechanics, our results suggest that the most precise outcome is obtained with patient-specific models with a 100 µm mesh size, sliding boundary condition at the limbus, and intraocular pressure enforced as a distributed load. Conclusions: A methodology for laser surgery simulation has been developed that is able to reproduce the optical target of the laser intervention while also analyzing the mechanical outcome. Translational Relevance: The lack of standardization in modeling refractive interventions leads to different simulation strategies, making difficult to compare them against other publications. This work establishes the standardization guidelines to be followed when performing optomechanical simulations of refractive interventions.

Purpose: To test whether any part of Soemmerring's rings developed, in‐vivo, in adults could be transparent and how this transparency relates to morphological factors. Methods: Sixteen Soemmerring's rings were extracted from donor eye globes. After frontal imaging, they were thickly sectioned sagittally in order to analyse the degrees of transparency of the cross‐section both at the periphery and center. All samples were also histologically analysed using alpha smooth muscle actin, Vimentin, wheat germ agglutinin and DAPI in order to correlate transparency to certain morphological factors. Results: When viewed frontally within the dark field, all Soemmerring's ring samples were apparently opaque. However, after sectioning, 20 of the 30 samples were more transparent in the center than at the periphery. Of the morphological factors that we analysed, only lens fibre organization at the bow region and an increased area of mature lens fibre cells had a significant relation to the degree of transparency at the center of cross‐sections. Conclusions: Soemmerring's rings can maintain the ability to produce organized and transparent areas of lens cells.

Cataract and keratoplasty constitute one of the most common association in anterior segment eye surgery. This includes both the technical aspects of the combined procedures (of cataract surgery with each of the different modalities of keratoplasty) and, possibly in a more relevant way, the indications and decision tree for the different scenarios and treatment options, including combined vs. sequential and, in the latter case, in which order. This presentation will review the development and current concepts regarding these topics, from the theory to the practical application, with examples in specific clinical cases.

Background: To assess intraocular pressure (IOP) changes and complications after XEN45 implants in medically controlled eyes (MCE) vs. medically uncontrolled eyes (MUE). Methods: A retrospective study, in a tertiary referral hospital, on mild-to-moderate primary open-angle glaucoma (POAG) cases under topical medication, including 32 eyes with IOP < 21 mmHg (MCE group) and 30 eyes with IOP ≥ 21 mmHg (MUE group). The success criteria using Kaplan–Meier analysis was IOP < 21 mmHg without medications (complete success) or fewer drugs than preoperatively (qualified success) at the last visit, without new surgery or unresolved hypotony. Results: No significant preoperative differences were found between the groups. The mean IOP was 15.6 ± 3.8 mmHg in MCE and 15.1 ± 4.1 mmHg in the MUE group (p > 0.05; Mann–Whitney test) at the end of the follow-up (mean of 26.1 ± 15.6 months and 28.3 ± 15.3 months, respectively) (p = 0.414, Mann–Whitney Test). The device caused a significant IOP reduction at 24 h in both groups. Thereafter, the MCE group significantly tended to increase IOP, recovering baseline values at 1 month and maintaining them until the end of the follow-up. In contrast, in the MUE group, the IOP values tended to be similar after the first reduction. No relevant complications and no significant differences between the groups in the survival analysis were found. Conclusions: XEN45 provided stable IOP control in both the MCE and MUE group without important complications in the medium term. The IOP increasing in the MCE group, after a prior decrease, led to restored baseline values 1 month after surgery. The homeostatic mechanism that causes the rise in the IOP to baseline values and its relationship with failure cases remains to be clarified.

To determine the differential risk factors for retinal detachment (RD) after Boston Type 1 Keratoprosthesis (B1KPro) during the first year after surgery (early RD; ERD) and afterwards (late RD; LRD). Retrospective cohort study of 94 eyes (90 patients) undergoing B1KPro implantation at Centro de Oftalmología Barraquer from June 2006 to July 2022 with a minimum follow-up of one year. The incidence of RD in the whole sample after B1KPro implantation was 29 What is new:

The Boston Keratoprosthesis (BKPro) serves as a medical solution for restoring vision in complex cases of corneal blindness. Comprising a front plate made of polymethylmethacrylate (PMMA) and a back plate of titanium (Ti), this device utilizes the beneficial biomaterial properties of Ti. While BKPro demonstrates promising retention rates, infection emerges as a significant concern that impacts its long-term efficacy. However, limited research exists on enhancement of BKPros through intrinsic infection-preventing mechanisms. In this regard, metal ions, especially the well-known Ag+ ions, are a promising alternative to obtain implants with innate antibacterial properties. However, little information is available about the effects of Ag in corneal tissue, especially within human corneal keratocytes (HCKs). In this work, an electrodeposition treatment using a constant pulse is proposed to attach Ag complexes onto rough Ti surfaces, thus providing antibacterial properties without inducing cytotoxicity. Complete physicochemical characterization and ion release studies were carried out with both control and Ag-treated samples. The possible cytotoxic effects in the short and long term were evaluated in vitro with HCKs. Moreover, the antibacterial properties of the silver-treated surfaces were tested against the gram-negative bacterial strain Pseudomonas aeruginosa and the gram-positive strain Staphylococcus epidermidis, that are common contributors to infections in BKPros. Physicochemical characterization confirmed the presence of silver, predominantly in oxide form, with low release of Ag+ ions. Ag-treated surfaces demonstrated no cytotoxicity and promoted long-term proliferation of HCKs. Furthermore, the silver-treated surfaces exhibited a potent antibacterial effect, causing a reduction in bacterial adhesion and evident damage to the bacterial cell walls of P. aeruginosa and S. epidermidis. The low release of Ag+ ions suggested reactive oxygen species (ROS)-mediated oxidative stress imbalance as the bactericidal mechanism of the silver deposits. In conclusion, the proposed electrodeposition technique confers antibacterial protection to the Ti backplate of BKPro, mitigating implant-threatening infections while ensuring non-cytotoxicity within the corneal tissue.

PURPOSE:Detection of graft failure of post-penetrating keratoplasty (PKP) patients from the proprietary dataset using algorithms trained in Automated Deep Learning (AutoML). METHODS:This was an observational cross-sectional study, for which AutoML algorithms were trained following the success/failure labeling strategy based on clinical notes, on a cohort corresponding to 220 images of post-keratoplasty anterior pole eyes. Once the image quality criteria were analyzed and the dataset was pseudo-anonymized, it was transferred to the Google Cloud Platform, where using the Vertex AI-AutoML API, cloud- and edge-based algorithms were trained, following expert recommendations on dataset splitting (80% training, 10% test, and 10% validation). RESULTS:The metrics obtained in the cloud-based and edge-based models have been similar, but we chose to analyze the edge model as it is an exportable model, lighter and cheaper to train. The initial results of the model presented an accuracy of 95.83%, with a specificity of 91.67% and a sensitivity of 100%, obtaining an F1SCORE of 95.996% and a precision of 92.30%. Other metrics, such as the area under the curve, confusion matrix, and activation map development, were contemplated. CONCLUSION:Initial results indicate the possibility of training algorithms in an automated fashion for the detection of graft failure in patients who underwent PKP. These algorithms are very lightweight tools easily integrated into mobile or desktop applications, potentially allowing every corneal transplant patient to have access to the best knowledge to enable the correct and timely diagnosis and treatment of graft failure. Although the results were good, because of the relatively small dataset, it is possible the data have some tendency to overfitting. AutoML opens the possibility of working in the field of artificial intelligence by computer vision to professionals with little experience and knowledge of programming.

The Boston keratoprosthesis (BKPro) is a medical device used to restore vision in complicated cases of corneal blindness. This device is composed by a front plate of polymethylmethacrylate (PMMA) and a backplate usually made of titanium (Ti). Ti is an excellent biomaterial with numerous applications, although there are not many studies that address its interaction with ocular cells. In this regard, despite the good retention rates of the BKPro, two main complications compromise patients' vision and the viability of the prosthesis: imperfect adhesion of the corneal tissue to the upside of the backplate and infections. Thus, in this work, two topographies (smooth and rough) were generated on Ti samples and tested with or without functionalization with a dual peptide platform. This molecule consists of a branched structure that links two peptide moieties to address the main complications associated with BKPro: the well-known RGD peptide in its cyclic version (cRGD) as cell pro-adherent motif and the first 11 residues of lactoferrin (LF1-11) as antibacterial motif. Samples were physicochemically characterized, and their biological response was evaluated in vitro with human corneal keratocytes (HCKs) and against the gram-negative bacterial strain Pseudomonas aeruginosa. The physicochemical characterization allowed to verify the functionalization in a qualitative and quantitative manner. A higher amount of peptide was anchored to the rough surfaces. The studies performed using HCKs showed increased long-term proliferation on the functionalized samples. Gene expression was affected by topography and peptide functionalization. Roughness promoted alpha-smooth muscle actin (alpha-SMA) overexpression, and the coating notably increased the expression of extracellular matrix components (ECM). Such changes may favour the development of unwanted fibrosis, and thus, corneal haze. In contrast, the combination of the coating with a rough topography decreased the expression of alpha-SMA and ECM components, which would be desirable for the long-term success of the prosthesis. Regarding the antibacterial activity, the functionalized smooth and rough surfaces promoted the death of bacteria, as well as a perturbation in their wall definition and cellular morphology. Bacterial killing values were 58 % for smooth functionalised and 68 % for rough functionalised samples. In summary, this study suggests that the use of the dual peptide platform with cRGD and LF1-11 could be a good strategy to improve the in vitro and in vivo performance of the rough topography used in the commercial BKPro.

Limbal epithelial stem cell deficiency is one of the most difficult histopathological causes of corneal opacity and keratoplasty failure. Its implication in the medical and surgical treatment of several corneal diseases has been widely described, but its treatment and clinical results have variable success rates. Several surgical techniques have been proposed in the past century, being limbal autografts from the fellow healthy eye, the one with the most long-term survival rate. The classification of the ocular surface reconstructive techniques is nowadays well defined, and the tissue options and donor sources have been widely described by researchers. Recent advances like Simple limbal epithelial transplantation (SLET) are providing new promising results, waiting until the research in ex vivo expansion and transplantation of isolated limbal stem cells becomes available to the general corneal surgeon.