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Moderator
Jimmy Y Hu, MD, ABO
Panelists
Rawan s Alshabeeb, MD
Viewing Papers
Expand a paper title to the right to view the paper abstract and authors. Use the video link to jump to that poster in the session.
Presenting Author
Ryan S. Huang, MD, MSc
Co-Authors
Manokamna Agarwal (MD), Michael Mimouni (MD), Clara Chan (MD, FRCSC)
Purpose
To evaluate the outcomes of cyanoacrylate tissue adhesive (CTA) in the management of corneal perforation and severe thinning based on underlying etiology.
Methods
This retrospective cohort study included eyes undergoing CTA application for corneal perforation or thinning treated at a tertiary care center. Eligible cases were categorized into infectious, immune-mediated, ocular surface disease (OSD), neurotrophic, or trauma-related etiologies. The primary outcomes were need for repeat CTA applications and progression to penetrating keratoplasty (PK). Kaplan-Meier survival analysis was conducted to evaluate time to PK. Multivariable logistic regression was performed to examine associations between etiology and outcomes, adjusting for relevant clinical covariates.
Results
Among 174 eyes, 62 (35.6%) were infectious, 15 (8.6%) immune-mediated, 22 (12.6%) OSD, 46 (26.4%) neurotrophic, and 29 (16.7%) trauma. The cohort was predominantly male (56.9%), with a mean age of 66.1±18.7 years. Over a median follow-up of 5.0 months, an average of 1.7±0.8 CTA applications were performed per eye, highest in neurotrophic cases (2.0±0.8; p=0.038). Overall, 58 eyes (33.3%) progressed to PK. Trauma cases had the most favorable PK-free survival (log-rank p=0.033). In multivariable regression, trauma were less likely to progress to PK (OR=0.19; 95%CI=0.05-0.74; p=0.016), whereas neurotrophic cases were more likely (OR=1.65; 95%CI=1.06-3.80; p=0.031) compared to infectious cases.
Conclusion
Rates of repeat gluing and progression to PK varied by the underlying etiology of corneal perforation and thinning. Incorporating etiology into prognostication and management decisions may help identify patients at highest risk for early surgical intervention and support more tailored treatment strategies.
Presenting Author
Jumanah Qedair, MBBS
Purpose
Corneal transplant rejection poses a significant challenge for patients undergoing high-risk penetrating keratoplasty (HR-PKP). We systematically reviewed the literature to evaluate the efficacy of combining topical tacrolimus with steroids in reducing graft failure rates.
Methods
A systematic review and meta-analysis were conducted according to PRISMA guidelines and registered with PROSPERO (ID: CRD42024585962). PubMed, Web of Science, and CENTRAL/Cochrane databases were searched from inception to September 2024. Meta-analyses were conducted using weighted means, proportions, and log odds ratios (OR) with a random-effects model. A two-tailed p-value of <0.05 was considered statistically significant.
Results
Five homogeneous comparative studies (n = 274 HR-PKP patients) were included. The tacrolimus-plus-steroids (n = 138) and steroids-alone (n = 136) groups were well-matched in baseline characteristics: weighted mean age (54.0 vs. 52.6 years, p = 0.90), sex distribution (p = 0.68), and underlying diagnoses with keratoconus being the most common (29.7% vs. 25.6%, p = 0.68). Follow-up durations were comparable as well (20.1 vs. 20.2 months, p = 0.98). After undergoing HR-PKP, patients in the tacrolimus-plus-steroids group showed significantly reduced graft failure odds by 75.0% (OR: 0.25 [95% CI: 0.13 – 0.43]) compared to patients in the steroids-alone group (p = 0.01).
Conclusion
While preserving graft viability in HR-PKP patients remains challenging, adjunctive topical tacrolimus combined with steroids demonstrates a clinically meaningful reduction in graft failure risk. Larger long-term studies are warranted to validate these findings.
Presenting Author
Sami Can Yücel, FEBO
Co-Authors
Nilay kandemir Besek (MD), Gülay Yalç?nkaya çak?r (FEBO), Sibel Ahmet (FEBO, FRCSEd, MD), Seda Liman Uzun (FRCSEd), Ahmet Kirgiz (FEBO), Dilan Colak (FEBO)
Purpose
To evaluate the 10-year visual and anatomical outcomes of deep anterior lamellar keratoplasty (DALK) and to investigate the impact of etiology on anatomical success.
Methods
This retrospective study included 73 eyes of 73 patients who underwent DALK for keratoconus, herpetic or trauma-related corneal scarring. Pre- and postoperative uncorrected (UDVA) and corrected distance visual acuities (CDVA) were recorded at 6 months, 1, 3, 5, 7, and 10 years postoperatively. Refractive values, complications, the need for secondary surgeries, and demographic data were evaluated. A linear mixed model was used to analyze longitudinal changes in visual acuity, while the relationship between etiology and graft survival was assessed with the Chi-square test. The association between postoperative air injection and graft survival was evaluated.
Results
The mean age was 33.6 ± 14.8 years. Linear mixed-effects modeling showed significant improvement in CDVA (?=-0.062 logMAR/year, 95% CI -0.070 to -0.053, p<0.001) and UDVA (?=-0.059, 95% CI -0.067 to -0.050; p<0.001). At 10 years, graft rejection occurred in 5 eyes (7.1%) (4 herpetic scarring, 1 keratoconus). During follow-up, cataract surgery was performed in 9 eyes (12.9%), and repeat DALK was required in 1 eye (1.4%). There was a significant association between etiology and graft survival (p<0.001), with the lowest survival noted in eyes with herpetic scarring. No association was found between postoperative anterior chamber air injection and survival (p=0.79).
Conclusion
DALK provides significant and sustained improvements in visual acuity with high anatomical success rates over a 10-year follow-up. However, etiology plays a critical role in graft survival, underscoring the importance of careful patient selection and close postoperative monitoring, particularly in high-risk etiologies.
Presenting Author
Samar A. Alswailem, MD
Purpose
To evaluate current surgical techniques, outcomes, and complications of deep anterior lamellar keratoplasty (DALK) among cornea surgeons in the region.
Methods
A cross-sectional study using a validated online questionnaire was distributed to board-certified corneal surgeons with over five years of DALK experience. Responses from 52 surgeons were analyzed.
Results
Most respondents (73.1%) performed ≤10 DALKs annually, primarily for corneal ectasia (87.8%). Manual near Descemet membrane dissection was preferred (40.5%), followed by the big bubble technique (24.2%). The average significant bubble success rate was 51–75%. Spontaneous bubble rupture occurred in <5% of cases for most surgeons. Perforation during surgery was reported by 73.5%, with a <5% incidence. Air tamponade and Descemet stripping were standard. Most surgeons (60.8%) considered DALK visual outcomes comparable to penetrating keratoplasty.
Conclusion
Despite technical variability and complications, DALK is widely practiced in the region, with favorable outcomes and manageable risks.
Presenting Author
Öznur Bekmez, MD
Co-Authors
Emine Esra Karaca (MD), Yonca Asfuro?lu (MD, FEBO), Ozlem Evren Kemer (MD)
Purpose
The aim of this study was to evaluate the surgical indications, outcomes, and postoperative complications of patients who underwent emergency tectonic and therapeutic keratoplasty.
Methods
A total of 69 patients (72 eyes) who underwent tectonic or therapeutic keratoplasty at our hospital between 2021 and 2024 were retrospectively analyzed. Data collected included age, sex, systemic comorbidities, etiology (infectious vs. non-infectious), surgical indications (melting, perforation, descemetocele), graft size, type of keratoplasty (lamellar vs. penetrating), pre- and postoperative visual acuity (LogMAR), anatomical and functional success, time from diagnosis to surgery, adjunctive preoperative treatments [amniotic membrane transplantation (AMT), cyanoacrylate application], and postoperative complications (glaucoma, anterior synechiae, cataract, endophthalmitis).
Results
Tectonic keratoplasty was performed in 81.9% of patients, while 18.1% underwent therapeutic keratoplasty (50% patch graft, 50% PK). Infectious causes were present in 32%. In the tectonic group, surgical indications included perforation (61%), melting (28.8%), and descemetocele (10.2%). The mean time from diagnosis to surgery was 14.7±12.3 days. Adjunctive treatments were cyanoacrylate in 15.3% and AMT in 56.9%. Anatomical success was 91.6%, functional success 59.7%, and 12-month graft stability 62%. Repeat keratoplasty was needed in 30.6%. The most frequent complications were glaucoma (23.9%), anterior synechiae (12.7%), cataract (11.3%), and endophthalmitis (2.8%).
Conclusion
Despite limited donor tissue and high complication risks, emergency keratoplasty is a key option to preserve ocular integrity in vision-threatening infections and non-traumatic perforations. While surgical success is high, long-term follow-up is vital, and adjunctive treatments like cyanoacrylate and AMT may enhance outcomes.
Presenting Author
David Cui, MD
Co-Authors
Priya Mathews (MD, MPH), Esen Akpek (MD)
Purpose
To evaluate the current indications and clinical outcomes for penetrating keratoplasty (PK) in the United States.
Methods
Patients from the IRIS® Registry (Intelligent Research in Sight) without a history of prior keratoplasty who underwent PK from October 2015 to December 2017. Corneal graft survival, transplant-specific outcomes, and postoperative complications were evaluated for all patients based on International Classification of Disease code. Best-corrected visual acuity (BCVA) was evaluated at 1 year and 5 years. Graft survival and BCVA were stratified based on reported presumed surgical indication. Risk factors for corneal graft failure were evaluated using multivariable analysis.
Results
A total of 4,061 patients were included (mean age at surgery 60.2 years, 51.5% female, 60.6% White). At 5 years, the highest rates of graft failure were observed in patients with complications of ocular prosthetic device (42.9%), trauma/perforation (31.4%), and corneal edema (23.2%), while the lowest rate was seen in corneal ectasia (8.5%). Overall graft survival rate at 5 years was 81.1%. Among surgical indications, the highest rates of visual acuity worse than 20/70 were seen in corneal edema (91.3%), corneal opacities (90.9%), trauma/perforation (87.1%), and the lowest in corneal ectasia (67.2%). Half (53.4%) of all patients had improved BCVA more than 2 lines after 5 years.
Conclusion
Compared to previous literature, there is decreased PK surgical indication for corneal ectasia, and decreased graft survival for the entire cohort. While PK in corneal ectasia patients was associated with increased graft survival and better long-term BCVA in this study, worse outcomes are observed compared to previous literature outcomes.
Presenting Author
Ryan S. Huang, MD, MSc
Co-Authors
Manokamna Agarwal (MD), Michael Mimouni (MD), Clara Chan (MD, FRCSC)
Purpose
To evaluate the effectiveness of concomitant tarsorrhaphy in promoting epithelial healing in neurotrophic corneas undergoing penetrating keratoplasty (PK).
Methods
This was a retrospective chart review of eyes with neurotrophic keratopathy (NK) that underwent PK with concomitant permanent or temporary tarsorrhaphy at two tertiary academic centers between January 2017 and June 2025. The primary outcomes were time to complete epithelial healing and the proportion of eyes with full resolution of epithelial defects. Secondary outcomes included change in best-corrected visual acuity (BCVA) from preoperative baseline to the final follow-up visit. Comparative statistical analyses were conducted using t-tests, chi-square tests, and Kruskal-Wallis tests where appropriate. A two-sided p-value of <0.05 was considered statistically significant.
Results
A total of 85 eyes (mean age 68.5 ± 14.2 years; 61.2% male) were included, with a mean follow-up duration of 25.6 ± 21.3 months. Indications for tarsorrhaphy included NK-related persistent epithelial defects, corneal melt or perforation, post-infectious scarring, and prior graft failure. Most tarsorrhaphies were performed laterally (84.7%), and the majority were permanent (60 eyes, 70.6%), while 25 (29.4%) were temporary. Following tarsorrhaphy, epithelial defects completely resolved in 75 eyes (88.2%). The mean time to epithelial closure was 13.7 ± 4.1 days. Visual acuity significantly improved from a mean baseline BCVA of 2.23 ± 0.34 logMAR to 1.75 ± 0.60 at final follow-up (p=0.01).
Conclusion
Concomitant tarsorrhaphy in NK eyes undergoing PK achieved high rates of epithelial closure, typically within two weeks, and was associated with significant visual improvement. These findings support routine use of tarsorrhaphy in eyes at high risk for delayed epithelial healing.
Presenting Author
Muhammad A. Ahad, FRCSEd, MRCOphth, PhD
Purpose
To assess the efficacy and safety of topical insulin eye drops in promoting epithelial healing following lamellar keratoplasty (LKP) for keratoconus.
Methods
In this prospective, randomized controlled trial, 72 eyes of 72 patients undergoing LKP were randomized to receive either conventional therapy (CT: topical steroid, antibiotic, and lubricant) or conventional therapy plus topical insulin (CTI: 1 IU/ml insulin every 6 hours). Epithelial defects were documented intraoperatively with fluorescein staining and monitored at 24, 48, 72, and 96 hours using slit-lamp photography. Defect area was quantified with ImageJ software. Primary endpoint was complete epithelial healing at 96 hours. Secondary endpoints included rate of epithelial defect reduction and adverse events.
Results
At 96 hours, complete epithelial healing was achieved in 88.9% of eyes in the CTI group compared with 61.1% in the CT group (p=0.01). Median time to full re-epithelialization was shorter in the CTI group (3.2 ± 0.7 days) versus CT (4.5 ± 1.1 days). Daily reduction in epithelial defect area was significantly faster with insulin therapy (p<0.001). No insulin-related adverse events were reported.
Conclusion
Topical insulin eye drops significantly accelerate corneal epithelial healing after lamellar keratoplasty with a favorable safety profile. These findings suggest that insulin drops may serve as a cost-effective adjunct to improve graft epithelialization and early postoperative outcomes.
Presenting Author
Sunayana Narasimha Murthy, MBBS, MS
Co-Authors
Rohit Shetty (FRCS), Gairik Kundu (MD), Yathish Shivanna (DOMS, DNB), Vibha Singh (MBBS, MS)
Purpose
This study aimed to look at outcomes including demographics, clinical characteristics, and long-term outcomes of therapeutic penetrating keratoplasty (TPK) performed using Artificial intelligence(AI) in a tertiary eye care hospital
Methods
Case records of 1046 therapeutic transplants that were performed between 2013 and 2022 were retrospectively analyzed, and outcomes were measured until 3 years of follow-up. Information on demographics, presentation characteristics, keratoplasty indications, micro-organism, and secondary surgical interventions was studied. The final outcome was classified in terms of therapeutic, anatomical, and functional outcomes. An AI models was then built to look at these risk factors.The area under the curve (AUC), sensitivity (se), specificity (sp) and accuracy (ac) along with other metrics were evaluated.
Results
The median age of the recipients was 58 years with 72% men. The most common indications for TPK were advanced microbial keratitis including perforated infectious ulcer ,nonhealing ulcers and graft infections. AI model detected mixed infections with concomitant fungal and bacterial followed by fungal infections(Asp Flavus) as important factors for adverse outcomes.Other risk factors included greater distance to eye hospital with higher risk for missed follow ups.Therapeutic success was achieved in 72% at the end of 6 month. At 3 years 15 % retained a clear graft either after a primary therapeutic keratoplasty. The clinical risk factors model had an ac,se, sp of 82%, 73% and 86% respectively.
Conclusion
Therapeutic keratoplasty although effective in eradicating infection and providing anatomical integrity, needs timely intervention, and can aid in achieving the best functional outcome. Understanding key factors including type of infection, socio-economic factors can play an effective role in optimizing outcomes.
Presenting Author
Elizabeth K Kiros, MD, MPH
Co-Authors
Priya Mathews (MD, MPH), David Cui (MD), Divya Srikumaran (MD), Esen Akpek (MD), Charles Li (BA), Xuan Peng (MS)
Purpose
To evaluate the current indications and clinical outcomes for Repeat Penetrating Keratoplasty (PK) in the United States.
Methods
This was a retrospective cohort study of patients from the IRIS® Registry (Intelligent Research in Sight) with a history of prior keratoplasty who underwent repeat penetrating keratoplasty (PK) between October 2015 and December 2017. Corneal graft survival, transplant-specific outcomes, and postoperative complications were identified using International Classification of Diseases (ICD) codes. Best-corrected visual acuity (BCVA) was assessed at 1 year and 5 years postoperatively, and both graft survival and BCVA were stratified by the reported presumed surgical indication. Risk factors for corneal graft failure were evaluated using multivariable regression analysis.
Results
We analyzed 569 eyes undergoing repeat PK. Mean age was 62.3 ± 14.9 years, and 51.5% were female. The most common indications were prior graft failure (40.4%), corneal edema (30.2%), and corneal opacity (23.4%). Five year graft survival was 67.5% overall, lowest for trauma or perforation (60.6%) and corneal edema (65.8%), and highest for ectasia or keratoconus (83.1%). In ectasia or keratoconus, 91.7% achieved BCVA of 20/200 or better at 5 years. Glaucoma was the most common early postoperative event (15.1% within 1 month).
Conclusion
Compared with prior reports, repeat PK in this IRIS Registry cohort showed lower overall graft survival. Outcomes were best for ectasia or keratoconus, with better long term survival and vision, while trauma, perforation, corneal edema, and prior graft failure had poorer outcomes.
Presenting Author
Gavin Li, MD
Co-Authors
Ayren Li (None), Esen Akpek (MD)
Purpose
With the advent of endothelial keratoplasty, the indications for penetrating keratoplasty (PK) have shifted substantially over the past two decades. As a result, many PKs are now performed in eyes at high risk for graft failure. This review evaluates the outcomes of repeat penetrating keratoplasty in this evolving context.
Methods
We systematically searched MEDLINE (PubMed) and registry/grey-literature sources for large-scale studies on outcomes after repeat PK. The PubMed strategy combined MeSH and free-text terms for PK, regraft/repeat keratoplasty, and outcomes. Eligible designs were registry, national, population-based, multicenter, or claims-based cohorts reporting PK-specific outcomes. We excluded small cohort studies (<100 repeat PKs), case reports, reviews, and editorials. From included studies, outcomes were extracted at prespecified annual time points and stratified by preoperative diagnosis and by first repeat PK versus multiple repeat PKs.
Results
This review included 29 studies (14,445 eyes) spanning 1975-2020. The most frequent primary indications were bullous keratopathy (25.8%), keratoconus (12.9%), and corneal scarring (9.1%). Common indications for regrafting included endothelial decompensation (36.4%), allograft rejection (21.1%), and primary graft failure (11.7%).For first regrafts, survival varied from 53.5-98.0% at one year to 18.3-80.0% at five years. Five-year survival ranged from 20.0-62.5% for second regrafts and 40.0-66.7% for 3+ regrafts. Final functional outcomes were limited; aggregated best-corrected visual acuity better than 20/40 was achieved in 25.3% of eyes, and better than 20/200 in 42.7% of eyes.
Conclusion
Long-term outcomes of repeat penetrating keratoplasty yield low graft survival and poor functional vision, with outcomes declining further after multiple regrafts. These results underscore the high-risk nature of regrafting and the necessity of developing alternative therapies for high-risk cases.
