Background/Aims To explore the outcomes of conjunctival flap (CF) followed by keratoplasty in patients with severe infectious keratitis (IK) unresponsive to medical treatment. Methods This is a retrospective monocentric study including 29 eyes of 29 patients with IK resistant to antibiotic treatment associated with stromal ulcer deepening to ≥50% of corneal thickness. All eyes underwent Gundersen’s CF procedure and penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK) or mushroom keratoplasty (MK), at least 4 months thereafter. Outcome measures included corrected distance visual acuity (CDVA), endothelial cell count (ECC), graft survival and complications. Results IK healed in all eyes following CF. The mean time interval between CF and keratoplasty was 16.3±16.1 months. 55% of patients underwent PK, 35% MK and 10% DALK. Mean follow-up duration was 39.6±34.3 months. At the last available follow-up, a CDVA≥20/200 was obtained in 50%, 33.3% and 70% of cases, respectively after PK, DALK and MK. Mean annual endothelial cell loss was 24.5% following PK and 10.7% following MK. Overall, graft failure occurred in 75% of cases after PK, 100% after DALK and 20% after MK. The most frequent complications were endothelial decompensation without immunological rejection (34.5%, after 31.1±25.1 months) and graft rejection (17.2%, after 10.2±7.9 months, all in the PK group). Conclusion CF surgery followed by staged keratoplasty represents an alternative therapeutic approach to avoid high-risk keratoplasty ‘a chaud’ in cases of severe IK.

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.

To evaluate and compare the clinical outcomes of keratoconic patients who received deep anterior lamellar keratoplasty (DALK) in one eye and mushroom penetrating keratoplasty (MK) in the fellow eye. Retrospective interventional case series based on prospectively collected data. Keratoconic patients who underwent keratoplasty at the department of ophthalmology of "Villa Igea," Ospedali Privati Forlì (Forlì, Italy) between July 2006 and December 2023. Patients underwent DALK in one eye and converted MK from intended DALK in the fellow eye. The primary outcomes were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism, and endothelial cell density (ECD). Kaplan-Meier curves were drawn for both DALK and MK to compare the cumulative probability of obtaining a BSCVA < 0.3 LogMAR (Snellen 20/40) within the end of follow-up. We included 46 keratoconic patients that underwent DALK in one eye and MK in the fellow eye. Mean follow-up was 5.4 ± 2.1 years (up to 10 years). During the first two years after surgery, BSCVA was significantly better in the DALK group (0.08 ± 0.11 vs 0.15 ± 0.20 LogMAR, P = .05); however, no significant differences between the 2 groups were found at later follow-up times. At 5 years, BSCVA values were 0.08 ± 0.10 and 0.12 ± 0.18 LogMAR, respectively for DALK and MK (P = .305). The 5-year probability of retaining a BSCVA < 0.3 LogMAR was 85.1% and 83.0%, respectively for DALK and MK (P = .791). Three years postoperatively, refractive astigmatism was significantly lower for DALK (at 5 years, 2.37 ± 1.21 D vs 2.97 ± 1.13 D; P= .04); however, the percentage of eyes with astigmatism higher than 4.5 D did not significantly differ between DALK (n = 3) and MK (n = 2) (P > .99). Five years postoperatively, ECD was 1837 ± 625 cells/mm² for DALK and 1083 ± 378cells/mm² for MK (P < .001). At 1 year, mean ECL was 20.3% for DALK and 35.4% for MK (P = .008). Thereafter, mean annual ECL was 1.4% for DALK and 5.9% for MK (P = .021). This study allowed direct intra-patient comparison between DALK and MK. Compared with MK, our findings showed for DALK better BSCVA during the first 2 years after surgery, lower refractive astigmatism from 3 years postoperatively on, and higher ECD at all time points.

In this study, we describe a case of graft dislocation into the vitreous cavity after Descemet stripping automated endothelial keratoplasty (DSAEK), and review the risk factors and complications of posterior dislocation. A 70-year-old female with disruption of the iris–lens diaphragm experienced DSAEK graft dislocation into the vitreous cavity during air re-bubbling at 1 week postoperatively. The corneal opacity hindered adequate visualization of the vitreous cavity for the immediate retrieval of the graft. Five days after re-bubbling, vitrectomy and corneal tissue removal was performed using a temporary Eckardt keratoprosthesis, and penetrating keratoplasty was subsequently performed. Two weeks after graft removal, a retinal detachment occurred. Silicon oil was used as a tamponade to reattach the retina. Three months after the last procedure, the retina was attached, and the cornea was clear. Posterior dislocation of DSAEK graft is a rare complication. A disrupted iris–lens diaphragm and previous vitrectomy are the main risk factors. Severe vision loss is more likely to occur when corneal tissue removal is delayed. In cases of delayed removal, it is advisable to take precautions to prevent possible retinal detachment.

Purpose: The aim of this study was to compare the outcomes of 2-piece mushroom keratoplasty (MK) between eyes at high risk and eyes at low risk of immunologic rejection. Methods: This is a retrospective interventional case series including 475 eyes from 475 patients who underwent 2-piece MK, of whom 146 (30.7%) were classified as high risk of rejection (group 1) and 329 (69.3%) as low risk (group 2). Outcome measures included corrected distance visual acuity, endothelial cell count, endothelial cell loss, graft survival rate, and postoperative complications. Results: There was no significant difference in endothelial cell count between groups at 10 years after transplantation (754.7 ± 316.7 [95% CI: 695.1–956.6] vs. 892.3 ± 298.8 [95% CI: 757.8–969.4] cells/mm ² , P = 0.088, respectively). Although corrected distance visual acuity was better in the low-risk group at 1 year (0.37 ± 0.30 [95% CI: 0.32–0.42] vs. 0.25 ± 0.23 [95% CI: 0.23–0.28], P < 0.001) and 5 years (0.20 ± 0.26 [95% CI: 0.15–0.27] vs. 0.14 ± 0.21 [95% CI: 0.10–0.17], P = 0.044), this difference was no longer statistically significant at 10 years (0.25 ± 0.34 [95% CI: 0.13–0.39] vs. 0.18 ± 0.25 [95% CI: 0.12–0.24] logMAR, P = 0.269, respectively). Postoperative complication rates were comparable, except for infections, which occurred more frequently in group 1 (7.5% vs. 1.5%, P < 0.001). Graft survival rates at 10 years were 80.3% for group 1 (n = 24) and 90.7% for group 2 (n = 50) ( P = 0.153). Conclusions: Two-piece MK provides consistent long-term outcomes in both high-risk and low-risk eyes, showing comparable visual, endothelial, and survival results. These findings highlight the potential of MK to reduce the impact of preoperative immunologic risk and expand its role in complex corneal transplantation.

Topic: This was a review of the available literature on blepharoptosis after modern phacoemulsification cataract surgery with intraocular lens (IOL) implantation. Clinical Relevance: Blepharoptosis is a frequently underestimated complication of ocular surgery. Methods: This review followed PRISMA guidelines and was prospectively registered in PROSPERO (CRD420261348501). A literature search was conducted in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials, from database inception to February 2026. Studies evaluating postoperative ptosis after modern phacoemulsification with IOL implantation were included. Extracted data focused on the incidence of ptosis and associated risk factors. Results: 8 studies, including a total of 863 eyes, met the inclusion criteria. 5 studies reported the exact incidence of ptosis, whereas the remaining studies only compared preoperative and postoperative marginal reflex distance 1 (MRD1). Among studies reporting incidence, rates ranged from 0% to 10.7%, with 4 of the 5 studies (674/702 eyes, 96%) reporting incidences ≤4.1%. None of the studies comparing preoperative and postoperative MRD1 measurements found a statistically significant difference. Lower preoperative levator palpebrae superioris function and higher preoperative MRD1 were identified as potential risk factors. Conversely, surgical duration and lid speculum type were not consistently associated with ptosis. Studies using exclusively topical anesthesia reported either no ptosis or no significant change in MRD1. Conclusions: Postoperative ptosis after modern cataract surgery has a low but not negligible incidence. Preoperative eyelid characteristics and the type of anesthesia may influence its occurrence. Postoperative ptosis should be routinely discussed during preoperative counselling.