Angeli Christy Yu

Purpose: To evaluate the long-term outcomes of superficial anterior lamellar keratoplasty (SALK) across a broad range of surgical indications. Methods: This is a retrospective interventional case series including consecutive eyes undergoing SALK, regardless of the indication. Outcomes included best spectacle-corrected visual acuity and refractive astigmatism at 6 months, 1 year, and annually through 5 years. Secondary outcomes included topographic astigmatism at 5 years, graft survival, and postoperative complications. Results: In total, 132 eyes from 132 patients were included, with a mean follow-up of 60.9 ± 48.5 months (60 and 12 eyes had 5-, and 10-year postoperative follow-up, respectively). Mean best spectacle-corrected visual acuity improved from 0.74 ± 0.50 logarithm of the minimum angle of resolution preoperatively to 0.10 ± 0.10 logarithm of the minimum angle of resolution 5 years postoperatively ( P < 0.001). Surgical indication was not associated with visual outcomes ( P = 0.815). Mean refractive astigmatism remained stable over time, measuring 2.65 ± 1.35 diopters (D) at 1 year, 2.00 ± 1.29 D at 3 years, and 2.52 ± 1.51 D at 5 years after surgery. Kaplan–Meier graft survival at 1, 3, 5, and 10 years was 93%, 92%, 86%, and 67%, respectively. Compared with corneal dystrophy, other indications showed lower risk of graft failure (HR: 0.32, 95% confidence interval: 0.14–0.78). Complications included graft dislocation (2.3%), epithelial ingrowth (1.5%), and interface infection (1.5%). Conclusions: SALK provides effective and sustained visual rehabilitation for anterior stromal corneal pathology unsuitable for phototherapeutic keratectomy yet not requiring deep anterior lamellar keratoplasty, with favorable long-term outcomes.

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Purpose: The aim of this study was to describe 3 keratoconic eyes referred for painless visual loss approximately 2 decades after penetrating keratoplasty, initially misdiagnosed as immunologic rejection but instead found to have detachment of a thin posterior corneal layer, which was successfully managed with deep anterior lamellar keratoplasty (DALK). Methods: This retrospective case series was conducted at Villa Igea, Ospedali Privati Forlì (Forlì, Italy). The main outcomes were best spectacle-corrected visual acuity, imaging findings, and endothelial cell density (ECD). Results: All patients presented with sectorial corneal edema extending into the host cornea, in the absence of intraocular inflammation. Anterior segment optical coherence tomography confirmed the extensive detachment of a thin posterior layer of the cornea, associated with ectatic thinning of the host stroma. Specular microscopy was possible in the nondetached area and showed a mean ECD of 1096 ± 235 cells/mm ² . To simultaneously address both the detachment and the recurring ectasia, each patient underwent a 9.0-mm DALK with complete preservation of the detached layer, thus also capping the ectatic portion of the recipient bed. Postoperatively, all corneas remained clear with no subsequent edema, best spectacle-corrected visual acuity improved to 20/30 or better, and average ECD showed minimal decline. Conclusions: Detachment of a thin posterior layer from the grafted cornea in post–penetrating keratoplasty keratoconic eyes may mimic endothelial rejection. Sectorial corneal edema extending beyond the graft–host junction should prompt consideration of a mechanical rather than an immunologic etiology. This case series highlights the possibility of successfully handling both the recurrent ectasia and the detachment with a 9.0-mm DALK.

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.

Purpose: To describe the surgical technique for 2-piece mushroom penetrating keratoplasty using the “pull-through” technique in infant eyes. Methods: Using a 250-μm microkeratome head, the donor cornea was split into anterior and posterior lamella, which were then punched to 8.0 to 8.5 and 6.0 mm, respectively. After partial trephination of the host cornea (depth = 250 μm, diameter = 7.5–8.0 mm), anterior stromal keratectomy was performed. Another partial-thickness trephination (6.0-mm diameter) was performed on the residual bed, which was then opened full thickness for about 1 o'clock hour at 12, 3, 6 and 9 o'clock positions. The donor anterior lamella was fixated with 4 cardinal sutures over the host residual bed that had been partially opened. Using corneal scissors, the central 6.0-mm trephination of the residual host cornea was completed full thickness and removed under the sutured donor anterior lamella. Descemet stripping automated endothelial keratoplasty microforceps were then inserted under the anterior lamella to grasp and deliver the donor posterior lamella into the anterior chamber through the pull-through technique. Suturing of the anterior lamella was completed with 12 additional interrupted stitches. Results: Surgery was performed in 7 eyes with Peters anomaly between 2 and 12 months. No intraoperative complications were recorded. All grafts were clear at the last follow-up. All patients were able to fix and follow. Conclusions: In infant eyes, fixation of a large anterior lamella over a smaller partially excised recipient cornea allows selective exchange of the centrally diseased host cornea under “semiclosed system” conditions, overcoming the threat of expulsion of intraocular structures posed by excessive vitreous pressure and possibly minimizing donor endothelial trauma.

Vitreoretinal surgery includes a group of highly complex microsurgical procedures that demand precision. Robotic systems can enhance surgical performance, particularly for novice surgeons, while ensuring patient safety through advanced sensing capabilities. Optical Coherence Tomography (OCT), commonly used for eye anatomy imaging, is typically implemented via microscopes or diagnostic devices. This paper introduces the GEYEDANCE system, a bilateral teleoperated microsurgery platform integrating OCT directly at the end-effector of its remote manipulator, offering multi-modal feedback. The system enables intraoperative global eye modelling and surface reconstruction by exploiting a neural network-based tool-to-tissue distance estimation module. Its performance was validated in the operating room using ex-vivo eyes, effectively simulating the surgical steps of various vitreoretinal procedures.

Background/aim To investigate the in vivo presence of a natural plane of separation at the pre-Descemet membrane (DM) level in post-penetrating keratoplasty (PK) eyes using confocal microscopy. Methods In vivo confocal microscopy was performed on the corneal stroma of 20 post-PK eyes and 20 keratoplasty-naive healthy control eyes. Patients were recruited from the cornea service of Ospedali Privati Forlì ‘Villa Igea’ between June 2022 and February 2024. The study adhered to the Declaration of Helsinki and was approved by the local ethics committee. Main outcome measures were stromal cell density (SCD) and the pattern of cell distribution. Results Posterior SCD was significantly higher in post-PK eyes compared with controls (387±96 vs 219±30 cell/mm², pConclusions A distinct pre-DM layer of keratocyte-like cells is present in post-PK eyes potentially contributing to the previously described natural plane of separation during repeat keratoplasties. Further studies are needed to clarify the origin and clinical implications of this finding.

While full-thickness penetrating keratoplasty (PK) has seen a decline in favor of partial-thickness techniques like endothelial keratoplasty (EK) and anterior lamellar keratoplasty (ALK), PK remains indicated for corneal disease involving the entire corneal thickness. Mushroom keratoplasty (MK) is a noteworthy modification of PK, designed to combine the refractive benefits of a large-diameter anterior lamellar graft with the graft survival advantage of limited replacement of the corneal endothelium. Leveraging the use of a microkeratome, the MK donor graft can be prepared by microkeratome dissection, thereby achieving a central interface compatible with 20/20 Snellen vision. This review explores the various surgical techniques, visual outcomes, graft survival rates, and complication rates associated with MK for various indications.