Descemet stripping automated endothelial keratoplasty (DSAEK) is a lamellar corneal surgical technique for the selective replacement of abnormal corneal endothelium. The main indication for DSAEK is diseased corneal endothelium, as found in Fuchs endothelial dystrophy and pseudophakic bullous keratopathy.^1-3 Quick visual rehabilitation, fewer induced refractive errors, minimal postoperative discomfort, and corneal integrity and biomechanical tensile strength are among the reasons for DSAEK gaining popularity.^4-7

Backround: We describe a modified method for deepitheliazation prior to corneal cross linking (CXL). The technique may overcome the current corneal pachymetric limitation parameter (over 400 microns) that is necessary for the safety of the procedure without affecting the overall benefits. Methods: In a series of two patients, with inferior topographic steepening and regional thinning (less than 400 microns corresponding to the area of corneal steepening), CXL after customized epithelial removal was performed. Results: There were no intra- or postoperative adverse events seen by the nine month follow up examination. Stabilization of the corneal ectasia was observed up to nine months post-costumized pachymetric-guided epithelial removal. Conclusion: The technique of customized pachymetric-guided epithelial removal is easy to perform and may overcome the limitations of the preoperative corneal pachymetry expanding the application of the procedure in patients with regional corneal thinning.

Purpose: To describe complications associated with femtosecond laser-assisted flap creation in LASIK surgery. The management and visual outcomes of femtosecond laser complications related to flap creation in LASIK patients are also described. Methods: All eyes that underwent LASIK with the IntraLase femtosecond laser from September 2003 to June 2006 at a university-based refractive center were included in this retrospective, noncomparative, interventional case series and IntraLase-related LASIK complications are described. All flaps were made with the 15- and 30-kHz IntraLase femtosecond laser. Results: Included in the study were 4772 eyes, of which 44 (0.92%) eyes had direct or indirect complications due to flap creation. Thirty-two eyes had indirect complications (diffuse lamellar keratitis [DLK] and transient light sensitivity)—20 (0.42%) eyes developed DLK (stage 1 to 2) and 12 (0.25%) eyes had transient light sensitivity syndrome. Twelve (0.25%) eyes had direct femtosecond laser flap-related complications—8 (0.17%) eyes had premature breakthrough of gas through the epithelium within the flap margins, 3 (0.06%) eyes had incomplete flaps due to suction loss, and 1 (0.02%) eye had irregular flap due to previous corneal scar. Conclusions: Less than 1% of eyes had direct or indirect complications due to femtosecond laser flap creation. Laser in situ keratomileusis complications specifically related to the IntraLase femtosecond laser did not cause loss of best spectacle-corrected visual acuity in any eyes. [ J Refract Surg. 2009;25:979–984.]

Purpose: To qualitatively assess the endothelial damage on Descemet-stripping automated endothelial keratoplasty (DSAEK) donor tissue resulting from a gentian violet marking pen. Methods: An in vitro model was used, by using corneoscleral rims, DSAEK quality corneal donor tissue, and a gentian violet marking pen. After making a mark on the stromal side of a microkeratome-prepared DSAEK corneal button to confirm appropriate orientation of the donor tissue after insertion into the anterior chamber, the corneal tissue was returned to Optisol GS solution for 1 hour. A vital dye assay was used to identify devitalized and necrotic endothelial cells with alizarin red S and trypan blue. Results: Corneal donor tissue evaluated with the gentian violet marking pen showed positive trypan blue staining, limited to the area marked with the gentian violet ink. Conclusions: Marking the DSAEK donor stromal surface with a gentian violet marker damages the endothelium. Surgeons should limit the size of the mark or use an insertion technique that avoids confusion about orientation of the donor cornea.