Purpose: The purpose of this paper is to report the clinical manifestations, diagnostic evaluation, management and outcomes of microsporidial keratitis in post-keratoplasty eyes. Methods: This is a retrospective review of three patients diagnosed with microsporidial stromal keratitis in post-keratoplasty eyes between January 2012 and December 2021 at a tertiary referral center (Ospedali Privati Forlì “Villa Igea”, Forlì, Italy). Results: All patients presented with fine multifocal granular infiltrates following keratoplasty for a presumed herpetic keratitis. No microorganisms were isolated from the corneal scrapings and no clinical response was observed with broad-spectrum antimicrobial therapy. In all cases, confocal microscopy demonstrated spore-like structures. The histopathologic examination of the excised corneal buttons confirmed the diagnosis of microsporidial stromal keratitis. Following therapeutic keratoplasty and treatment with an initial high dose and extended taper of topical fumagillin, clinical resolution was achieved in all eyes. The Snellen visual acuities at the final follow-up were 20/50, 20/63 and 20/32. Conclusions: Prior to definitive surgery, confocal microscopy can be employed for the in vivo detection of pathogenic microorganisms such as Microsporidium. In post-keratoplasty eyes, therapeutic keratoplasty and an initial high dose of topical fumagillin with extended taper can allow the resolution of microsporidial stromal keratitis with a satisfactory visual prognosis.

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.