Moderator
Seth M. Pantanelli, MD, MS, ABO
Panelists
Priya M. Mathews, MD, MPH, ABO
Saba Al-Hashimi, MD
Viewing Papers
Expand a paper title to the right to view the paper abstract and authors. Use the video link to jump to that poster in the session.
Presenting Author
Gerd U. Auffarth, MD, PhD
Co-Authors
Victor Augustin MD, Hyeck-Soo Son MD
Purpose
To report the long-term outcomes of the synthetic endothelial layer for treatment of chronic corneal edema
Methods
This retrospective study analyzed patients who received the artificial endothelial implant (EndoArt, EyeYon Medical, Israel) up to 5 years ago. Intraoperatively, air-gas bubble and in some cases, corneal sutures were used to secure the graft on the posterior stroma. Primary endpoint was change in central corneal thickness (CCT).
Results
Results: Mean follow-up was 40 months (range: 31-60 months). In all patients, the EndoArt led to significant reduction of CCT from 810.0�113.4 �m preoperatively to 511.7�31.0 �m at 6-months postoperatively (p=0.037). In patients 1 and 3, the central cornea remained clear and CCT stable at 3 and 5-years postoperatively, respectively. In patient 2, significant stromal scarring ultimately led to EndoArt explantation and penetrating keratoplasty at 31-months postoperatively.
Conclusion
Our study shows that the artificial lamella can effectively reduce CCT in eyes with chronic corneal edema. Patients with significant stromal scarring may benefit less from the efficacy of the artificial implant.
Presenting Author
Ruchi P Gour, MS
Co-Authors
Emma Hollick MA, MD, FRCOphth
Purpose
DSEK is usually reserved for more complex eyes where the view into the anterior chamber is very poor, as visualisation of the DMEK scroll can be limited in these cases. This novel technique highlights the use of vision blue dye to stain the leading edge of the donor in DSEK surgery prior to implantation, making it easier to visualise.
Methods
In very cloudy corneas, it is often difficult to see the leading edge of the DSEK donor to know where to grasp it with forceps, to advance the donor into the eye when using the Tan endoglide or Busin glide. Vision blue is used to stain the leading edge of the donor in DSEK surgery when it is in the Tan�s endoglide. The donor is loaded into the cartridge and the tip at the end of the cartridge is stained with vision blue dye for 10 seconds leading to a blue line at the edge of the donor. Excess dye is washed off with saline. The endoglide is advanced into the eye, the blue line is located, and forceps are used to grasp this line, to pull the graft into the anterior chamber.
Results
This technique helps the surgeon locate the edge of the donor as a blue line can be seen easily through the cloudy cornea. This indicates where the forceps need to grasp the tissue to advance the donor into the anterior chamber, thereby minimising graft manipulation and iatrogenic endothelial cell loss within the eye. This makes the graft insertion procedure more reliable and consistent, ensuring good surgical outcomes.
Conclusion
DMEK is the procedure of choice for most cases of endothelial dysfunction however DSEK has a role in challenging cases when the view of the anterior chamber is too poor to safely visualise the DMEK scroll. This technique has proved very helpful in our complex DSEK cases with advanced bullous keratopathy or opacity and a poor anterior chamber view.
Presenting Author
Konstantin I. Katmakov, PhD
Co-Authors
Nadezhda Pozdeyeva MD, Nikolay Pashtaev PhD, MD, Galina Usanova MD
Purpose
To assess the extent of endothelial cell loss as a result of preparing an ultra-thin transplant for posterior lamellar keratoplasty
Methods
Two groups of four pairs of donor corneas were formed. Group 1: corneal transplants for posterior lamellar keratoplasty, cut from the endothelial side with the usage of a femtosecond laser �Visum� (Optosystems, Troitsk); intact corneoscleral discs of the same donors served as the control. Group 2: donor corneas, on which the laser interface was applanated for 20 seconds from the endothelial side without femtolaser exposure; paired intact corneoscleral discs of the same donors were used as the control. Identification of live and dead endothelial cells was carried out with the usage of the fluorescent dyes Calcein Violet 450 and Propidium Iodide and a fluorescence microscope
Results
Endothelial loss resulting from the preparation of a 130 ?m thick transplant amounted to 11.4%. In the group within which only laser interface applanation was performed, this indicator was 12.8%. No statistically significant differences were found between the groups (p>0.05)
Conclusion
The results of the study have demonstrated the absence of damaging energy impact of the femtosecond laser "Visum" on the endothelium within the formation process of a 130 ?m thick transplant from the posterior corneal surface. The key reason leading to the death of the endothelium was the mechanical impact at the moment of its applanation.
Presenting Author
Ibrahim Qozat, MD
Co-Authors
Pranav Vasu MPH, Isabella Wagner BSc, Yazan Abubaker MD, Darby Miller MD, MPH, Syril Dorairaj MD, Paul Lentz BSc, Emily Dorairaj BSc
Purpose
to evaluate the incidence of postoperative cystoid macular edema (CME) after Descemet Stripping Automated Endothelial Keratoplasty (DSAEK)/ Descemet�s Membrane Endothelial Keratoplasty (DMEK) in vitrectomized eyes vs non-vitrectomized eyes within the first 6 postoperative months.
Methods
A retrospective cohort analysis of the TriNetX database was performed by querying all patients who underwent DSAEK/DMEK between 2004 and 2024. Propensity score matching (PSM) was conducted for age at index, sex, race, ethnicity, and diagnosis of Fuchs� dystrophy.�2160 patients were included in the study and were divided into two groups. The first group included 1080 patients who had prior vitrectomy before the undergoingDSAEK/DMEK. The second group included 1080 patients who did not have prior vitrectomy before undergoing DSAEK/DMEK. Outcome was the incidence of postoperative CME within 6 months after performing DSAEK/DMEK between the two groups. Odds ratios were calculated between cohorts.
Results
Patients who had prior vitrectomy before undergoing DSAEK/ DMEK were found to develop postoperative CME within the first 6 months of follow up (75 of 1080) in a significant higher incidence compared to those who did not undergo vitrectomy prior to performing DSAEK/DMEK (31 of 1080). (OR 2.525, 95% CI 1.647 - 3.827).
Conclusion
Postoperative CME was documented as a possible complication after DSAEK/DMEK. However, these data indicate that prior vitrectomy increases the incidence of developing postoperative CME after DSAEK/DMEK.
Presenting Author
Erika Ellis, MD, PhD
Co-Authors
Anthony Aldave MD, Promporn Patarajierapun MD, Angela Chen MD, Sophie Deng MD, PhD
Purpose
To assess the outcomes of endothelial keratoplasty (EK) in eyes with prior failed corneal transplantation.
Methods
A retrospective analysis of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping endothelial keratoplasty (DSEK) procedures performed in eyes with prior keratoplasty by 2 surgeons from Feb 2014 - May 2023. Preoperative, intraoperative and postoperative data was collected for all procedures, although only eyes with > 6 months of postoperative follow-up were included in the analysis of the primary outcome measures of DMEK and DSEK graft survival, corrected distance visual acuity (CDVA) and graft rejection. Secondary outcome measures included other postoperative complications, such as graft detachment, pupillary block, donor-related infection and cystoid macular edema (CME).
Results
151 EK procedures were included (110 DMEK and 41 DSEK procedures performed in 119 eyes of 114 patients. Mean preoperative LogMAR CDVA was 1.14 and mean best CDVA after surgery (recorded at any time point) was 0.39 logMAR. 79 (52.3 %) grafts failed during a mean follow-up of 2.8 (� 1.8) years; 1 (0.7%) due to primary graft failure and 78 (51.7 %) due to secondary graft failure. The graft survival rate was 92.5% at 1 year, 45% at 3 years and 29.3% at 5 years. Graft detachment developed after 56 procedures (37.1%), requiring rebubbling in half of these cases (28 procedures;18.5%). Endothelial rejection developed following 36 (23.8%) procedures and CME developed following 11 (7.3 %) procedures.
Conclusion
While EK for corneal transplant failure significantly improves CDVA, the incidence of graft detachment, endothelial rejection and CME are significantly higher than after EK for other indications. Additionally, as the graft survival rate is <50% three years after EK, alternative approaches are needed for the management of corneal transplant failure.
Presenting Author
Nicole R. Fram, MD, ABO
Co-Authors
Matthew Giegengack MD
Purpose
Evaluate the safety and efficacy of supplementation of corneal storage media with amphotericin B by comparing the primary graft failure/early regraft (PGF/ER) and fungal infection rates after corneal transplantation of corneas stored in amphotericin B-supplemented storage media (Ampho B) and non-supplemented storage media.
Methods
In this retrospective evaluation, data for all U.S. transplants of corneal tissue from a single eye bank over a 3-year period (2021 to mid-2023) were recorded, including storage media type, procedure type (penetrating keratoplasty [PK], Descemet stripping automated endothelial keratoplasty [DSAEK), or Descemet membrane endothelial keratoplasty [DMEK]), incidence of infection (bacterial, fungal, other) as reported via adverse reaction (AE) reports, and incidence of PGF/ER from AE reports. The rates of infection and PGF/ER complications for corneas stored in Ampho B storage media and those from unsupplemented media were compared.
Results
In all, the eye bank supplied tissue for 37,363 corneal transplants, 47.5% in storage media with amphotericin B and 52.5% in storage media with amphotericin B. The rate of PGF/ER was 0.48% with amphotericin B vs 0.40% without (p=0.272, odds ratio [OR] 1.188) and the rate of fungal infection was 0.006% (1/17,765) with amphotericin B and 0.056% (11/19,598) without (p=0.028, OR 0.10). Rates of PGF/ER were 0.30% with amphotericin B vs. 0.16% without amphotericin B in PK procedures (p=0.125, OR 1.926) ; 0.59% vs. 0.61% in DMEK (p=0.929, OR 0.98), and 0.49% vs. 0.42% in DSAEK (p=0.535, OR 1.17).
Conclusion
The use of storage media supplemented with amphotericin B resulted in a tenfold reduction in fungal infections compared to unsupplemented storage media, with no statistically significant increase in primary graft failure or early regraft rates.
Presenting Author
Itay Lavy, MD
Co-Authors
Nir Erdinest BScOptom, PhD, David Smadja MD
Purpose
This study aimed to evaluate the efficacy of ripasudil in managing various corneal edema conditions.
Methods
A single-center retrospective analysis involved 16 patients with 17 eyes. Diagnostic criteria was primarily corneal edema. The conditions were as follows: postcataract surgery (31.25%), postpenetrating keratoplasty (25%), post-DMEK (18.75%), Fuchs' endothelial corneal dystrophy (12.5%), and status post glaucoma surgery. Treated with topical administration of ripasudil HCL (Glanatec� 0.4%), administered three times a day or tailored to condition severity. Efficacy was assessed using pre- and posttreatment measurements of best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell count (ECC), along with slit-lamp and optical coherence tomography examinations.
Results
The average duration of ripasudil treatment was approximately 4.9 � 2.2 months. Significant improvements were observed in BCVA, changing from a pretreatment value of 1.106 � 0.817 logMAR to a posttreatment value of 0.56 � 0.57 logMAR (P = 0.0308). CCT also showed a significant reduction, from 619.50 � 56.36 ?m pretreatment to 572.5 � 75.48 ?m posttreatment (P = 0.0479). ECC showed a marginal but not statistically significant increase, from 849.00 � 570.72 cells/mm� pretreatment to 874.75 � 625.59 cells/mm� posttreatment (P = 0.9010).
Conclusion
The study provides robust evidence supporting the use of ripasudil in managing corneal edema. Significant improvements in key ocular metrics such as BCVA and CCT were observed, enhancing the overall quality of life for patients suffering from various forms of corneal edema.
Presenting Author
Leonard G Heydenrych, FRCOphth
Co-Authors
Eric Abdullayev MBA, MD, Benjamin Lambright MD
Purpose
A novel device and technique are reviewed when delivering a correctly oriented DMEK graft into complex anterior chambers without direct manipulation.
Methods
All grafts (n=13) were pre-loaded at the Lions World Vision Institute eye bank (Tampa, USA), and tri-folded with inverted endothelium in a glass cannula. Out of 13 patients � 5 had failed penetrating keratoplasties (PKP); during DMEK, 1 patient received an anterior vitrectomy and 1 patient received an anterior vitrectomy prior; 2 patients required glaucoma shunt trimming; 3 patients had a floppy iris and 1 patient a mid-dilated pupil ; 1 patient received a pars plana vitrectomy. The size of the main incision, number of sutures used, average time to correct graft unfolding, regression of central corneal thickness (CCT) and post-operative endothelial cell densities (ECD) were assessed.
Results
The incision was 3.2-3.5 mm. All grafts were delivered and unfolded independently into the anterior chamber through fluid insertion and were correctly oriented. 3-5 sutures were required to close the wound. The mean graft unfolding time was 28.89 seconds [95% CI, SD �8.18 (�28.31%)]. Mean central corneal thickness reduced by 211.22�m (28.37%). All grafts cleared within 4 weeks post-transplant. Mean post-operative visual acuity at last visit improved to 0.71 (decimal) [95% CI, SD �0.104 (�14.75%)] from 0.24 before surgery. Mean ECD at latest visit (3-12 months) post-operative was 1462 cells/mm2 [95% CI, SD �361.887 (�24.76%)] and mean CCT was 533.17�m [95% CI, SD �24.539 (�4.60%)].
Conclusion
A novel glass carrier allows spontaneous opening of the DMEK graft in the correct orientation and makes unfolding of the DMEK graft predictable in complex anterior chambers.
Presenting Author
Leonard G Heydenrych, FRCOphth
Co-Authors
Eric Abdullayev MBA, MD, Benjamin Lambright MD
Purpose
To establish if there is a difference in tapping rates and graft unfolding times when �No-touch� Endo-In DMEK is compared with standard DMEK.
Methods
Real time video (Zeiss) of 19 �no-touch� DMEK surgeries were reviewed retrospectively and compared with 19 real time videos retrospectively when standard DMEK was performed. Tapping rates and graft unfolding times were calculated until the grafts were opened completely, after graft injection into the anterior chamber . A two paired t test is used to calculate statistical significance after calculating the standard deviation and mean for each category.
Results
The mean tapping rate for �no-touch� Endo-In DMEK was 10.6315 taps [95% CI, SD �4.95 (�46.56%)] and for standard DMEK the mean graft tapping rate required was 146.5789 taps [95% CI, SD �76.829 (�52.41%)]. P = 0.0014 and �no-touch� Endo-In DMEK required 92.75% less taps to open the graft. The mean graft unfolding time for �no-touch� Endo-In DMEK was 7.8947 seconds [95% CI, SD �5.384 (�68.19%)] and for standard DMEK the mean graft unfolding time was 140.1053 seconds [95% CI, SD �63.008 (�44.97%)]. P = 0.0002 and Endo-In DMEK required 94.37% less time to completely open the graft.
Conclusion
�No touch� Endo-In DMEK required less time to open the graft and less taps to open the graft than when standard DMEK was used, after graft injection into the anterior chamber. All grafts were correctly oriented. In our assessment �no-touch� Endo-In DMEK requires less manipulation of the DMEK graft than when standard DMEK is used.
Presenting Author
Emine Esra Karaca, MD
Co-Authors
Anna Fabijanska PhD, Kas?m �ztoprak PhD, Feyza Dicle I??k MD, Ay�a Bulut Ustael MD, Ozlem Evren Kemer MD
Purpose
This study explores the potential of artificial intelligence to automate corneal endothelial cell counting and density estimation in DMEK patients using confocal microscopy images.
Methods
We retrospectively train an encoder-decoder convolutional neural network for cell center detection using clinically annotated patient data. The trained model detects cell centers in unseen patient images. Image processing techniques then define the region of interest and measure its size, enabling cell density estimation. The method�s performance is evaluated on DMEK patients at 1-18 month follow-up intervals.
Results
Our automatic method achieves good results, with a mean relative error of 23% compared to expert manual measurements. Expert cell density measurements from confocal and specular microscopy vary by 32% on average for the same patients.
Conclusion
Our study is foundational for automated ECD estimation and significantly impacts post-DMEK care. By enabling frequent ECD mon- itoring, we can detect graft complications earlier and tailor treatment using longitudinal ECD data.
Presenting Author
Ozlem Evren Kemer, MD
Co-Authors
Preethi Naveen MD, Emine Esra Karaca MD, Feyza Isik MD, Amar Agarwal FRCOphth, MS, FRCS, Soosan Jacob MS, FRCS, DNB
Purpose
The purpose of this study is to compare the clinical outcomes of two advanced endothelial keratoplasty techniques, Descemet Membrane Endothelial Keratoplasty (DMEK) and Pre-Descemet Endothelial Keratoplasty (PDEK).
Methods
A cross-sectional, comparative, and observational case series study conducted across two centers to evaluate and compare the outcomes of PDEK (n=64) and DMEK (n=149) in patients with pseudophakic bullous keratopathy. The patient demographics, surgical history (prior vitrectomy and glaucoma surgery), donor characteristics, pre and postoperative IOP, central corneal thickness, and best-corrected visual acuity (BCVA) will be analyzed. The primary endpoints will include the improvement in BCVA and the percentage loss of endothelial cell density. Secondary endpoints will involve changes in central corneal thickness, the percentage change in IOP, and the incidence of postoperative complications.
Results
The PDEK group demonstrated a significantly greater mean BCVA (logMAR) improvement (1.33 � 0.81 vs. 1.02 � 0.53, p=0.001) but a lower mean endothelial cell density (ECD) loss (50.42 � 10.68% vs. 60.97 � 15.58%, p<0.001) compared="" to="" the="" dmek="" group.="" pbk="" was="" more="" prevalent="" in="" the="" pdek="" group="" (95.31%="" vs.="" 77.18%),="" whereas="" fed="" was="" more="" common="" in="" the="" dmek="" group="" (22.81%="" vs.="" 4.68%,="" p="0.003)." the="" rebubbling="" rate="" showed="" no="" significant="" difference="" (13.81%="" vs.="" 10.60%).="" donor="" age="" was="" significantly="" lower="" in="" the="" pdek="" group="" (25.21="" �="" 7.28="" vs.="" 60.61="" �="" 5.85="" years,="">< />
Conclusion
PDEK demonstrated better BCVA improvement with reduced endothelial cell loss compared to DMEK, making it a strong choice for cases involving younger donors and pseudophakic bullous keratopathy. These findings provide valuable insights for selecting the optimal surgical technique based on patient and donor characteristics.
Presenting Author
Ay�a Bulut Ustael, MD
Co-Authors
Feyza Isik MD, Ozlem Evren Kemer MD, Dilara Altun MD, Mehmet Onen MD, Emine Esra Karaca MD
Purpose
To assess visual and anatomical outcomes of Descemet membrane endothelial keratoplasty (DMEK) after anterior chamber intraocular lens (ACIOL) removal and identify factors influencing surgical success.
Methods
We retrospectively reviewed 18 eyes (17 patients) undergoing DMEK post-ACIOL explantation from 2015-2024. Best-corrected visual acuity (BCVA), central corneal thickness (CCT), endothelial cell density (ECD), and complications were evaluated preoperatively at six months and 12 months. Multivariate analysis assessed risk factors for graft failure and glaucoma development.
Results
BCVA improved from 1.30�0.62 logMAR to 0.48�0.34 logMAR at 12 months(p<0.001),with 61%(95% CI: 36-82%) achieving ?20/40.Mean CCT decreased from 652�162?m to 538�52?m(17.5% reduction,p<0.001). Graft detachment occurred in 5 eyes(27.8%, 95% CI: 10-53%),all successfully reattached.Eight eyes (44.4%, 95% CI: 22-69%) developed secondary glaucoma,with 3 requiring surgical intervention.ACIOL duration >7.5 years (OR 3.2, 95% CI: 1.1-9.3, p=0.03) and pre-existing glaucoma(OR 2.8, 95% CI: 1.2-6.5, p=0.02) predicted poorer outcomes.Iris-fixated ACIOLs showed better outcomes than angle-supported ones(OR 2.7, 95% CI: 1.1-6.6, p=0.04).
Conclusion
DMEK after ACIOL removal can lead to significant visual and anatomical improvements, although secondary glaucoma is a notable risk. Therefore, careful patient selection and close postoperative monitoring are essential, particularly in cases of prolonged ACIOL retention and pre-existing glaucoma.
Presenting Author
Eric Abdullayev, MD, MBA, CEBT
Co-Authors
Arthur Kurz BSc
Purpose
Minimally invasive procedures have an advantage due to having small incisions compared to traditional surgical methods. We introduce the first needle delivery device for the eye bank prepared/preloaded endothelial grafts to be delivered into the recipient�s anterior chamber through the puncture
Methods
5 donor corneas with healthy endothelium were used. DMEK grafts were prepared with no-touch BLISTER hydro dissection and no-touch instant staining method, then trephined. All grafts with endothelium out were loaded in the new delivery device with a needle insertion tip and stored for 5 days in Optisol-GS at 2-8C. Grafts were unloaded, and endothelial viability evaluation was performed using specular microscopy and a new cell staining method. Images are digitally processed by the �ImageJ� image processing program. The percentage of the damaged cells was calculated. An artificial chamber with mounted donor corneas was used to recreate graft insertion through the puncture
Results
Mean preparation donor endothelial cells density was 2593 � 89 cells/mm� and post load - 2655 � 95 cells/mm�. On the first day following preload, the mean endothelial cell loss was 5%, which remained stable at day 5. Endothelial specular microscopy and staining confirmed viable endothelium. All 5 DMEK grafts were inserted through the needle puncture without difficulties. No fluid leaks were observed from the puncture wound
Conclusion
Eye bank-prepared DMEK grafts pre-loaded in the new delivery device with a needle insertion tip survive storage for several days and can be successfully inserted for transplantation through puncture without prior blade incision
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