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ObjectivesTo describe a new surgical technique to correct a high astigmatism following modified deep anterior lamellar keratoplasty (DALK) and to evaluate the associated clinical outcomes.MethodsRetrospective interventional case series included eyes with high astigmatism following modified DALK performed between July 2012 and June 2016. The prevalence of keratometric astigmatism (KA) higher than 4.5 diopters (D) was evaluated after complete suture removal. Surgical correction was obtained by opening the surgical wound at the steeper meridian and carrying out a blunt dissection at the graft–host surface of contact under keratoscopic control. KA, Refractive astigmatism (RA), and best spectacle-corrected visual acuity (BSCVA) were measured preoperatively and at 1, 12, and 24 months postoperatively. Vector analysis of 1 year change in KA was performed.ResultsHigh astigmatism was found in 47 of 511 eyes (9.2%). KA (mean ± standard deviation [SD]) decreased from 7.67 ± 2.78 to 3.10 ± 1.37 D at 1 month after astigmatic correction (p < 0.001) with no subsequent significant change. Vector analysis of 1 year change in KA: surgically induced astigmatism was 5.30 ± 3.29 D and mean absolute angle of error was 6.97 ± 4.25°. BSCVA improved from 0.21 ± 0.20 logMAR preoperatively to 0.11 ± 0.13 logMAR (p < 0.001); RA decreased from 6.32 ± 2.56 to 2.61 ± 1.05 D (p < 0.001). No intra- or post-operative complications occurred.ConclusionsHigh astigmatism is present in <10% of cases after modified DALK and can be effectively managed by means of blunt relaxing dissection at the graft–host junction.

The retinal pigment epithelium (RPE) is essential for maintaining retinal integrity, and its dysfunction underlies several progressive ocular diseases, including age-related macular degeneration, choroidal neovascularization (CNV), inherited retinal disorders (IRDs), and proliferative vitreoretinopathy (PVR). Although current therapies have improved disease management, they mainly target secondary pathological mechanisms and do not directly preserve or restore RPE function. Moreover, the delivery of therapeutic molecules or genes to the RPE remains a major challenge due to the presence of multiple ocular barriers and the need for sustained, localized action. Nanomedicine offers innovative solutions to these limitations by enabling precise, controlled, and cell-specific delivery of drugs and genetic materials. Engineered nanocarriers can be optimized to traverse ocular barriers, enhance bioavailability, and modulate the retinal microenvironment. This review summarizes recent advances in nanoscale delivery systems for RPE-targeted therapies, focusing on design principles, targeting strategies, and therapeutic applications, and discusses the translational challenges that must be addressed to bring nanotechnology-based treatments closer to clinical application.

Herpes simplex virus (HSV) is one of the most common etiologic agents of corneal disease and a significant cause of corneal blindness worldwide. Although most cases can be successfully managed with medical therapy, HSV keratitis associated with visually significant stromal scarring often requires corneal transplantation for visual rehabilitation. While penetrating keratoplasty (PK) represented the traditional keratoplasty technique, the past few decades have seen a shift towards lamellar keratoplasty procedures, including deep anterior lamellar keratoplasty and mushroom keratoplasty. This paper describes the current surgical techniques and perioperative antiviral prophylaxis regimen for herpetic keratitis and reviews their postoperative clinical outcomes.

The genus Alternaria comprises several species of dematiaceous hyphomycetes known to cause opportunistic infections in humans. Over the past two decades, fungal infections have emerged as a significant cause of morbidity and mortality, particularly among immunocompromised individuals. Such infections often occur following disruption of the skin or corneal epithelial barrier, especially in patients with pre-existing ocular conditions or compromised immune status. This case report describes a rare instance of fungal keratitis (FK) caused by Alternaria citri in a 71-year-old male who presented with an acute onset of eye infection. The patient showed a favorable response to treatment with voriconazole.

The retina, the part of the eye, translates the light signal into an electric current that can be sent to the brain as visual information. To achieve this, the retina requires fine-tuned vascularization for its energy supply. Diabetic retinopathy (DR) causes alterations in the eye vascularization that reduce the oxygen supply with consequent retinal neurodegeneration. During DR, the mammalian target of rapamycin (mTOR) pathway seems to coordinate retinal neurodegeneration with multiple anabolic and catabolic processes, such as autophagy, oxidative stress, cell death, and the release of pro-inflammatory cytokines, which are closely related to chronic hyperglycemia. This review outlines the normal anatomy of the retina and how hyperglycemia can be involved in the neurodegeneration underlying this disease through over activation or inhibition of the mTOR pathway.

The pivotal role of p53 in the regulation of a vast array of cellular functions has been the subject of extensive research. The biological activity of p53 is not strictly limited to cell cycle arrest but also includes the regulation of homeostasis, DNA repair, apoptosis, and senescence. Thus, mutations in the p53 gene with loss of function represent one of the major mechanisms for cancer development. As expected, due to its key role, p53 is expressed throughout the human body including the eye. Specifically, altered p53 signaling pathways have been implicated in the development of conjunctival and corneal tumors, retinoblastoma, uveal melanoma, and intraocular melanoma. As non-selective cancer chemotherapies as well as ionizing radiation can be associated with either poor efficacy or dose-limiting toxicities in the eye, reconstitution of the p53 signaling pathway currently represents an attractive target for cancer therapy. The present review discusses the role of p53 in the pathogenesis of these ocular tumors and outlines the various pharmacological activators of p53 that are currently under investigation for the treatment of ocular malignancies.

PurposeTo design and validate the efficacy of three-dimensional (3D) printed smart storage glide (SSG) which is capable of preserving and delivering posterior lenticules for Descemet stripping automated endothelial keratoplasty (DSAEK).MethodsLaboratory investigation (A) was followed by clinical validation (B). Unsuitable corneas for transplantation (n=20) were used for study A. These tissues were cut using a standard microkeratome, punched and loaded into the SSG and preserved for 7 days in transport media. Endothelial cell density (ECD), Trypan blue and Alizarin red staining for endothelial morphology, thickness measurements and glucose uptake, cell apoptosis and immunostaining post preservation were analysed. For study B, clinical grade corneas (n=14) were preloaded in SSG and grafted in patients with indications of Fuchs’ dystrophy (n=8), pseudophakic bullous keratopathy (n=3), posterior polymorphous dystrophy (n=2), and previous DSAEK failure (n=1). Standard DSAEK included descemetorhexis under air and bimanual delivery of the tissue under infusion of buffered saline solution through an anterior chamber maintainer placed at the 12 o’clock position. Main outcome measures for study B were less surgical time, best spectacle-corrected visual acuity (BSCVA), speed of visual recovery, and ECD.ResultsFor study A, an average ECD loss was 2.30±3.21%, thickness increased by 30.80±20.85% and one-third of glucose was utilised during the preservation phase. Alizarin red showed hexagonality of the cells. Cell apoptosis was not observed and expression of ZO-1 was noted on the preserved tissues. In study B, 25% ECD loss was observed after 6 months. BSCVA improved to 20/25 or better within 3 months after DSAEK. Mean surgical time recorded was 21 min.ConclusionsThis paper describes the development, design, laboratory and clinical validation of a 3D printed SSG which helps to store and deliver posterior lenticules, therefore allowing transportation of quality-controlled precut tissues.

PurposeTo evaluate the outcomes of a 9-mm deep anterior lamellar keratoplasty (DALK) use of Moria pre-calibrated trephine to optimize pneumatic dissection.DesignProspective, noncomparative, interventional case series. Par2cipants: A total of 1118 consecutive eyes with stromal disease, with at least 1 postoperative examination 1 month after complete suture removal.MethodsStandardized DALK was performed by fellows and senior surgeons: (1) deep trephination of the recipient bed 450 to 550 mm in depth and 9 mm in diameter; (2) pneumatic dissection; (3) debulking of approximately 80% of the anterior stroma; (4) removal of the deep stroma (bubble roof) from a central 6-mm optical zone; and (5) transplanta5on of a 9-mm anterior corneal lamella cut by microkeratome-assisted dissection (400-mm head) and sutured with a double running 10–0 nylon suture. Success rate, best spectacle-corrected visual acuity (BSCVA) and refractive astigmatism (RA) were evaluated.ResultsLarge diameter DALK was successfully performed in 1079 of 1118 eyes (97%). Pneumatic dissection was successful in 396 of 489 eyes (81%) with keratoconus without scarring, in 164 of 315 eyes (52%) with keratoconus with scarring, in 69 of 87 eyes (79%) with other DALK indications not associated with stromal scarring and in 190 of 276 eyes (69%) with other DALK indications associated with stromal scarring. Mean logMAR BSCVA was 0.10± 0.16. Mean RA was 2.7± 1.4 D. RA was greater than 4.5 D but less than 6 D in 51 eyes (5%) while RA was greater than 6 D in 15 eyes (1%). The 5- and 10-year cumulative probability for stromal rejection was 2% at 5 years and 3% and for graft survival was 99% and 98%, respectively.ConclusionThe use of Moria pre-calibrated trephine optimizes pneumatic dissection during large diameter DALK, which provides visual outcomes superior to those reported for PK with excellent 10-year survival regardless of surgical indication

CaseA 58-year-old female was referred to our clinic for corneal scarring in the left eye. She previously underwent ipsilateral rotational autokeratoplasty (IRA) for herpetic keratitis in 2001. Day to day visual acuity was 0.74 logMAR and best corrected visual acuity was 0.40 logMAR. Slit lamp exam showed significant stromal scarring in the visual axis. The peripheral cornea was otherwise clear. Deep anterior lamellar keratoplasty (DALK) using the stromal peeling technique described by Bovone et al was attempted. The donor was prepared with a microkeratome (Moria SA, Antony, France) with a 400 µm head. A 9.0 mm adjustable depth vacuum trephine (Moria SA, Antony, France) was applied to the cornea to a depth of 450 microns. After repeated attempts to open a pre-descemetic plane with no success, the surgery was electively converted to a 2-piece microkeratome-assisted mushroom keratoplasty with 9 mm anterior lamella secured with 16 interrupted 10–0 nylon sutures and a 6 mm posterior lamella. At 6 months postoperatively, the graft was clear. Unaided visual acuity was 0.50logMAR improving to 0.10logMAR with correction. Topographic astigmatism with sutures in situ was 5.4D. The postoperative course was otherwise uneventful. The apparent absence of a pre-descemetic plane in an old IRA adds evidence that formation of this plane is dependent on the allogeneic stimulation of host keratocytes. Our working theory is that host keratocytes migrate to the pre-descemet layer of an allogeneic PK graft, thereby allowing stromal peeling in post-PK eyes along a natural pre-descemetic plane of separation.

This is a report of two cases in which tissue that had undergone radial keratotomy (RK) was utilized for double-pass ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). Postoperative slit-lamp examination, visual acuity, anterior segment optical coherence tomography, and specular microscopy were available 30 months after surgery. Both corneas from a donor, who had undergone RK several years before his demise, and were otherwise suitable for endothelial keratoplasty were prepared for UT-DSAEK using double-pass dissection using first a 300 mm microkeratome head and then a 130μm microkeratome head (ALTK system, Moria, Antony, France). After the second cut, the tissue was punched to 9.0 mm and transplanted in two eyes with endothelial decompensation according to standard technique. As early as 3 months after surgery, both patients had 20/25 best-corrected visual acuity, which remained stable for the following 27 months. Postoperative endothelial cell loss was 34% and 57% at 2.5 years. In conclusion, post-RK donor tissue can be used for UT-DSAEK.