Antonio Moramarco

Purpose: The purpose of this study was to evaluate and compare clinical and visual outcomes, complications, and endothelial cell survival of different endothelial keratoplasty (EK) techniques—Descemet membrane endothelial keratoplasty (DMEK), preloaded DMEK (PL-DMEK), ultra-thin Descemet stripping automated endothelial keratoplasty (UT-DSAEK), and standard DSAEK—using real-world multicenter data. Methods: This retrospective multicenter cohort study included patients undergoing EK across 11 corneal centers in Italy. Clinical and visual outcomes were collected at baseline, 3, 6, and 12 months, and at last follow-up. Donor graft characteristics and their impact on postoperative outcomes were analyzed. Results: A total of 969 eyes were included. All EK techniques resulted in significant improvement in best-corrected visual acuity (BCVA). Although DMEK and PL-DMEK achieved better final BCVA, these groups had better baseline BCVA, and no significant differences in absolute BCVA recovery were observed among techniques, except for greater improvement with UT-DSAEK compared with DSAEK ( P = 0.020). Rebubbling rates were significantly higher in DMEK and PL-DMEK (34.3% and 31.7%) than in UT-DSAEK and DSAEK (16.0% and 16.9%; P < 0.05). Endothelial cell density loss was greater in DSAEK (57.8%) and UT-DSAEK (53.8%) compared with DMEK (46.8%) and PL-DMEK (42.3%) ( P < 0.001). Rejection rates did not differ significantly. Preservation media significantly influenced storage duration, BCVA, and pachymetry in analyses adjusted for baseline (ANCOVA P < 0.001), with Eusol, E-MEM + 6% dextran, and Tissue-C showing the most favorable outcomes. Conclusions: In this large multicenter real-world cohort, all EK techniques provided significant clinical benefit. Differences in visual outcomes, endothelial cell survival, and complication profiles support an individualized approach based on patient, donor, and surgical factors.

Purpose: To investigate whether corneal collagen cross-linking (CXL) is associated with measurable remodeling of extra-corneal tissues in KC, by comparing choroidal and scleral structural biomarkers between treatment-naïve and CXL-treated eyes. Methods: This is a single center, cross-sectional, observational study. Anterior scleral thickness (ST) was quantified using swept-source anterior segment optical coherence tomography (AS-OCT; CASIA2, Tomey, Japan). Ocular biomechanical parameters were measured with the Ocular Response Analyzer (ORA; Reichert, Germany). Subfoveal choroidal thickness (SFCT), peripapillary choroidal thickness (PPCT) were assessed with spectral-domain OCT (SPECTRALIS HRA-OCT, Heidelberg Engineering, Germany). Choroidal vascularity index (CVI) and total choroidal area (TCA) were computed using a validated semi-automated algorithm. A subgroup analysis compared treated and untreated fellow eyes in unilateral CXL cases. Results: 65 keratoconic eyes of 65 patients were recruited – 35 treatment-naïve versus 30 post–epithelium-off cross-linking (≥ 6 months post-treatment). CXL-treated eyes exhibited significantly greater Sub-Foveal Choroidal Thickness (SFCT) (421.1 ± 81.9 μm vs. 352.9 ± 81.9 μm; p = 0.016), mean Peripapillary Choroidal Thickness (PPCT) (238.0 ± 72.9 μm vs. 199.5 ± 65.3 μm; p = 0.038), and mean Total Choroidal Area (TCA) (1.45 ± 0.32 mm² vs. 1.29 ± 0.27 mm²; p = 0.046) compared with treatment-naïve eyes, whereas Choroidal Vascularity Index (CVI) and Scleral Thickness (ST) showed no significant differences ( p > 0.05). In unilateral cases, treated eyes demonstrated consistent increases in SFCT, TCA, and PPCT relative to fellow untreated eyes ( p < 0.05). PPE alterations occurred exclusively in the CXL group (16.7%). Multivariate regression analysis identified previous CXL as the only independent factor associated with increased SFCT (β = 0.340, p = 0.040). Conclusions: CXL appears to be associated with thicker choroids in keratoconic eyes, independent of biomechanical or scleral thickness variations. These findings support the hypothesis that CXL might be linked to subclinical remodeling of deeper ocular layers, potentially affecting choroidal-scleral fluid dynamics. Further prospective longitudinal studies with larger cohorts and multimodal assessment are warranted to clarify the mechanisms, time course, and long-term implications of choroidal changes following CXL.

Intraoperative optical coherence tomography (iOCT) has emerged as a pivotal technology in anterior segment surgery, particularly in cases limited by corneal opacity, edema, or altered anatomy. By providing real-time, cross-sectional imaging, iOCT enables surgeons to visualize otherwise hidden structures and to perform critical intraocular maneuvers with greater precision and safety. Its integration into the surgical microscope allows continuous monitoring of tissue–instrument interaction, transforming traditionally “blind” procedures into image-guided interventions. This review highlights the role of iOCT in endothelial keratoplasty, deep anterior lamellar keratoplasty (DALK), management of acute corneal hydrops, synechiolysis, glaucoma drainage device implantation, and ocular trauma. In endothelial procedures, iOCT helps confirm Descemet membrane removal, graft orientation, and resolution of interface fluid. In DALK, it facilitates accurate cannula placement, stromal depth assessment, and evaluation of leucoma extension to guide surgical strategy. During hydrops management, iOCT supports precise air/gas injection and compression suture placement. Additionally, it enhances safety in synechiolysis, shunt implantation, and repair of traumatic corneal injuries.

Background: The study aimed to assess the diagnostic and therapeutic management of infectious keratitis at a tertiary referral center, focusing on how microbiological analysis influences clinical outcomes. Methods: A retrospective review was conducted on 220 patients (221 eyes) with infectious keratitis treated between November 2021 and January 2025. Data collected included clinical presentation, microbiological findings, treatment approaches, and outcomes. Statistical analyses examined the relationships between microbiological results, improvements in visual acuity, and the need for rescue surgery. Results: Bacterial keratitis accounted for 64% of cases, followed by viral (20%), fungal (13%), and Acanthamoeba (3%). Microbiological testing was performed in 107 cases, with a culture positivity rate of 75.7%. Positive microbiological findings were significantly associated with better visual acuity (p = 0.019) and a reduced, though not statistically significant, need for rescue surgery. Use of contact lenses and ocular trauma were independent risk factors for culture positivity. Delayed referral (more than 15 days) was linked to longer treatment durations and a higher likelihood of surgical intervention (p < 0.001). Microbiological diagnosis correlates with improved visual outcomes and a decreased need for surgical procedures. Conclusion: Early referral and targeted therapy are essential for optimizing prognosis. The use of contact lenses and cases of ocular trauma should prompt early diagnostic sampling.

To describe a technique for managing acute corneal hydrops in eyes with keratoconus using dome stromal drainage with intracameral air injection under real-time three-dimensional (3D) microscope-integrated optical coherence tomography (OCT) guidance. We describe a retrospective case series of six eyes from six patients with keratoconus who developed acute corneal hydrops. All eyes underwent intracameral air injection with controlled dome puncture for stromal fluid drainage, without the use of sutures. The procedure was performed using a 3D visualization system that enables integrated and simultaneous viewing of the surgical field and intraoperative OCT scan (a 3D digitally assisted visualization system that displayed a split-screen view of the surgical field and OCT cross-sections simultaneously). Postoperative resolution of edema and improvement in clarity were documented. The resolution of corneal edema allowed for subsequent mushroom-shaped penetrating keratoplasty performed with a femtosecond laser in four eyes of four patients. All six eyes showed significant resolution of corneal edema within 2 to 4 weeks. Stromal clefts collapsed rapidly after drainage. In each case, the thick edema was reduced to a confined leucoma. No intraoperative or postoperative complications were observed. All four eyes that underwent a femtosecond laser-assisted mushroom-shaped penetrating keratoplasty showed optimal anatomical and functional success. Air-assisted dome drainage, combined with simultaneous 3D and OCT visualization, is a safe and effective technique for treating acute corneal hydrops. This technology enables real-time decision-making and enhances surgical precision, opening the door to advanced procedures that are otherwise limited by corneal opacity.

Background: Mushroom penetrating keratoplasty (MPK) is an alternative to traditional penetrating keratoplasty (PK) that offers improved graft survival and reduced immunological rejection. However, MPK grafts may still experience endothelial failure over time. This study evaluates the outcomes of non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK) as a surgical approach for endothelial decompensation following MPK. Methods: A monocentric, retrospective study was conducted at the Ophthalmology Department of Sant’Orsola-Malpighi Hospital, including patients who underwent nDSAEK for endothelial failure after MPK between 2022 and 2024. Pre- and postoperative best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell density (ECD) were assessed. Results: Eighteen eyes from 18 patients (mean age: 39.94 years) were included. Primary MPK indications were post-keratitis leucoma (77.7%), traumatic scarring (16.7%), and keratoconus (5.6%). At one year, mean BCVA improved significantly from 1.40 ± 0.42 logMAR to 0.46 ± 0.19 logMAR (p < 0.05), and mean CCT decreased from 721 ± 70.12 µm to 616 ± 52.80 µm (p < 0.05). The mean postoperative ECD was 1748 ± 100 cells/mm², with lower eye values requiring re-bubbling. No immunological rejection or graft failures were reported. Conclusions: nDSAEK is a promising treatment for MPK endothelial failure, demonstrating good visual and anatomical outcomes.

Recent research has highlighted the critical role of microbiota in organ transplant outcomes, particularly in the gut. However, the impact of ocular surface microbiota (OSM) on corneal transplantation remains largely unexplored. This piece examines the potential connection between OSM imbalances and corneal graftoutcomes, suggesting that microbial shifts could influence immune responses and transplant success. The OSM, though characterized by low microbial density, plays a critical role in local immune modulation and ocular surface homeostasis. Dysbiosis in this microbiota may compromise the immune privilege of the cornea, potentially increasing the risk of graft rejection. Looking at gut microbiota studies, where dysbiosis has been linked to graft failure, it is reasonable to hypothesize that similar mechanisms might be at play on the ocular surface. Disruptions in cornea’s immune tolerance pathways, such as anterior chamber-associated immune deviation (ACAID), may lead to pro-inflammatory responses that threaten graft survival. In addition, ocular surface diseases such as dry eye disease, microbial keratitis, and allergic conjunctivitis, already associated with OSM dysbiosis, may further exacerbate post-transplant complications. Despite the lack of direct studies linking OSM to corneal transplant outcomes, this opinion piece highlights the necessity for future research. Standardizing microbiota analysis methodologies and exploring therapeutic interventions, such as ocular probiotics, could open new roads for improving corneal transplant success and patient prognosis.