The 9th Asia Cornea Society in conjunction with The 7th INASCRS Biennial Scientific Meeting 2024

Abstract Title
Descemet’s Membrane Endothelial Keratoplasty (DMEK) for Iatrogenic Damage to Descemet's Membrane Secondary to Nd:YAG Laser

Introduction & Objectives
Neodymium (Nd): yttrium aluminum garnet (YAG) laser capsulotomy is a relatively safe procedure, where a misdirected laser shot at the cornea is considered a minor issue that can just be observed. However, if such errors occur repeatedly, serious consequences may arise. The purpose of this study is to describe a case of advanced descemet’s membrane damage from an Nd:YAG laser procedure, managed with descemet's membrane endothelial keratoplasty (DMEK).

Methods
This is a case of an 83-year-old female who developed severe iatrogenic corneal pitting after an attempted Nd: YAG laser capsulotomy. Prednisolone acetate 1% (Pred Forte, Allergan) eye drops was administered four times a day for three months with no improvement. Corrected distance visual acuity (CDVA) was 20/100, with biomicroscope findings showing off-centered 2x2 mm dense posterior corneal scarring, disrupted Descemet’s membrane, and adjacent stromal edema. An in-the-bag trifocal diffractive intraocular lens with dense posterior capsule opacity was observed. Central corneal thickness (CCT) was measured at 665μm.

Results
DMEK was successfully performed with a 7.25mm descemetorrhexis and the implantation of a 7.0 mm graft. Rebubbling was done on the eleventh postoperative day due to an inferotemporal partial graft detachment. One month postoperatively, CDVA was 20/320, with corneal scarring still present but with a less edematous cornea and a thinner CCT of 514 μm. Three months postoperatively, a successful Nd: YAG capsulotomy was performed, resulting in an improved CDVA of 20/30 and a CCT of 484 μm.

Conclusion
DMEK is a feasible alternative to managing significant descemet’s membrane disruption secondary to Nd:YAG laser.

Keyword
DMEK, Nd:YAG laser, cornea, posterior capsular opacification

Abstract Title
Functional and Corneal Structural Outcomes of Corneal Collagen Cross-Linking (CXL) for Keratoconus at Dr. Sardjito General Hospital

Introduction & Objectives
Corneal collagen crosslinking (CXL) is a minimally invasive procedure used to minimize the progression of corneal ectatic disorders such as keratoconus. The purpose of this study was to evaluate the functional and corneal structural outcomes in Yogyakarta, Indonesian patients with keratoconus before and after corneal collagen crosslinking (CXL).

Methods
In this prospective cohort study, 36 eyes from 27 patients with mild to moderate keratoconus were examined. Epithelium-on corneal crosslinking were done at the Sardjito General Hospital, Yogyakarta, Indonesia. The best corrected visual acuity (BCVA), spheris, astigmatism, Kmax, Kmin, Kaverage, central corneal thickness (CCT), and intraocular pressure (IOP) were all evaluated. The follow-up time ranged from two weeks to six months after the procedure.

Results
BCVA results improved significantly from logMAR 1.158±0.38 to logMAR 0.924±0.38 at 2 weeks (p = 0.0003), logMAR 0.933±0.36 at 1.5 months (p <0.0001) and logMAR 0.794±0.35 at 6 months postoperatively (p < 0.0001). CXL significantly reduced astigmatism from -5.49±2.2 D to -4.81±2.17 D after 6 months (p = 0.0019). Following the procedure, there was a modest reduction of Kmax, Kmin, and Kaverage in keratoconus patients. The intraocular pressure and CCT did not differ significantly at different time points. No postoperative complications were discovered following the procedure.

Conclusion
CXL demonstrated early improvement in patient visual acuity and astigmatism, and it is regarded as a safe and efficient keratoconus treatment. Further research with larger sample sizes and longer follow-up periods are required to confirm these findings.

Keyword
corneal collagen cross-linking; keratoconus; visual outcome

Abstract Title
Management of Subluxated Traumatic Cataract After 17 Years of Neglected Blunt Trauma

Introduction & Objectives
Introduction : Traumatic lens damage can include subluxation, dislocation, and cataract formation. Lens subluxation is partially displaced lens but remains in the pupillary area. There are several procedures for managing this problem based on severity of zonular dialysis and capsular support, including intracapsular cataract extraction (ICCE) with an anterior chamber (AC) intraocular lens (IOL) using angle supported IOL or iris claw, and posterior chamber (PC) IOL with iris claw, scleral fixation, or iris sutured. An appropriate management can result a beneficial visual outcome. Objective : To report management of subluxated traumatic cataract after blunt trauma in rural area.

Methods
A case report study.

Results
A 28 year old male came with chief complaint of blurred vision since 17 years ago. Patient also complained of crossed eye on the left eye (LE) since 1 year ago. He had a history of blunt eye trauma 17 years ago on LE but left untreated. There was no systemic disease. Ophthalmology exam showed visual acuity of 1.0 on the right eye (RE) and close face finger counting on LE. Hirschberg test showed exotropia 15 degrees on LE. Anterior segment examination showed normal examination on RE and superotemporal lens subluxation and lens opacity on LE. Intraocular pressure on RE was 13.1 mmHg and 14.6 mmHg on LE. Patient was diagnosed with subluxated traumatic cataract with sensory deprivation exotropia on LE. Patient underwent ICCE with angle supported IOL.

Conclusion
Angle supported IOL can be a choice for management of moderate to severe subluxated traumatic cataracts in rural areas.

Keyword
subluxated traumatic cataract, angle supported intraocular lens, blunt trauma

Abstract Title
Clinical Outcomes Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) at Jakarta Eye Center One Year Follow-Up

Introduction & Objectives
to investigate the clinical outcomes over a 1-year follow-up period in patients who underwent DSAEK

Methods
This retrospective study conclude all patients who underwent DSAEK at Jakarta Eye Center (JEC) Hospitals in Menteng and Kedoya from 2018 to 2022.

Results
Out of the 191 patients who underwent The Descemet-stripping automated endothelial keratoplasty (DSAEK) at JEC Hospitals, 112 have been followed up for more than three months. The mean of patients' ages was 62.51 years and most of them were males. The DSAEK procedures only were performed on the majority of the patients 95,3% (182 patients), while combination procedures (DSAEK+Phacoemulsification+IOL) performed on 9 patients. Bullous keratopathy was the most common indication for DSAEK. Visual acuity tends to increase at postoperative follow-up 1 and 3 months postoperatively (0.1-0.4), and further improved at 1 year postoperative follow-up, where the majority of patients had a VA of 0.5 or more (55.4%). There was an increase in intraocular pressure (IOP) which peaked at 3 months postoperative follow-up (14.6 mmHg), but decrease at 1 year postoperative follow-up (13.5 mmHg). Graft rejection occurs mostly in male patients (16 patients)

Conclusion
Patients who underwent DSAEK had better visual acuity in 1 month, 3 months and 1 year postoperative follow up. It is usual for intraocular pressure to rise after DSAEK, main risk factor was previous glaucoma. Graft rejection or failure may be due to pre-existing iris damage scores associated

Keyword
endothelial keratoplasty, bullous keratopathy, Fuchs dystrophy, graft survival

Abstract Title
Corneal Transplantation From Brain-Dead Donors at Cho Ray Hospital From 2015 to 2020

Introduction & Objectives
To assess the efficacy and safety of corneal transplantation using corneas from brain-dead donors at Cho Ray Hospital during a period from 2015 to 2020. The main outcomes are the rate of graft survival and complications.

Methods
This retrospective case series study aimed to analyze the outcomes of corneal transplantation procedures from brain-dead donors performed at Cho Ray Hospital between 2015 and 2020. Medical records of all patients who underwent corneal transplantation during the study period were retrospectively examined. Patients with complete data sets were included in the analysis. The data collected included preoperative visual acuity, indications for surgery, graft survival status, postoperative complications, and visual acuity at 1-year and 3-year post-operation intervals.

Results
In this study, 17 eyes of 15 patients were recruited, with one patient undergoing surgeries on both eyes and the other receiving surgeries twice. The study had a 0.89 male to female ratio and a mean age of 54.41 years (range: 33-81). Corneal scars from infectious keratitis were the most common indication for transplantation (76.47%), followed by corneal dystrophy (17.65%). One case (5.88%) had graft failure from prior keratoplasty. All patients had severe vision loss preoperatively. At 1 year post-operation, 52.94% showed significant visual acuity improvement. At 3 years, 11.76% experienced vision decline to hand movement. No early complications occurred, but 29.41% had late complications, including infectious keratitis and secondary graft failure. Overall, 70.59% of grafts remained clear.

Conclusion
Corneal transplantation from brain-dead donors is effective. The main indication was infectious keratitis scars. The success rate was 70.59%, with a 29.41% rate of complications and graft failure.

Keyword
corneal transplantation, penetrating keratoplasty, brain-dead donors

Abstract Title
Corneal Specialist

Introduction & Objectives
Tue Khanh Vu, MD Corneal Specialist Tue Khanh Eye Clinics Ltd Co For the last decades in South East Asia countries, overnight Orthokeratology has been widely used to control myopic progression in children. Subsequently the ocular surface care and lens hygiene are utmost priority to prevent serious contact lens - induced complications. In order to examine the risk factors and carry out safe lens usage guidelines, regarding overnight orthokeratology lenses, a retrospective sequence of seri cases has been conducted. The clinical differentiate diagnosis of infectious and non-infectious infiltration is crutial because the microbilogical examination is not available in such clinics. The proper treatment plan in a timely manner directly contributes to the successful outcome.

Methods
Orthokeratology

Results

Conclusion

Keyword
Orthokeratology infiltration, Infectious infiltration, Non infectious infiltration

Abstract Title
A Decade of Changing Trends in Corneal Donors in Aotearoa (New Zealand) in the Era of COVID-19

Introduction & Objectives
To investigate the impact of the COVID-19 pandemic on corneal transplant trends and clinical outcomes in New Zealand (NZ) using the New Zealand National Eye Bank (NZNEB) database and Clinical Portal (CP). Building on established data, this study adds clinical information to evaluate the ramifications of the pandemic, including number of appointments, visual acuity (VA) at fixed time intervals, presentations to Emergency Eye Clinic, and any complication such as graft rejection.

Methods
The electronic records of the NZNEB were analysed for the period from January 2018- December 2022 for recipient demographics, clinical indications and type of corneal transplantation planned. The study received ethical approval from the Health and Disability Ethics Committee (EXP18674).

Results
The number of corneal grafts performed in New Zealand continued to rise by an average of 15% annually. The primary indication for corneal graft was regraft (32.4%) followed by keratoconus (29.6%). The mean number of follow-up appointments in the first year following transplantation was significantly lower during the pandemic compared to the previous decade (3.7 vs 5.2 P<000.1). VA improved after corneal graft in 97.3% of patients, with 92.4% retaining improved vision at 3 years. There was no significant increase in rate of graft rejection during the study period.

Conclusion
Despite the COVID-19 pandemic, NZ continued to increase its corneal transplantation services to meet rising demand. Although follow-up appointments were significantly reduced, this appears to have minimal impact on overall clinical outcome.

Keyword
Cornea COVID-19

Abstract Title
Outcomes of Sutureless (Yamane Technique) and Sutured Scleral Fixation in Patients With Inadequate Capsular Support: A Systematic Review

Introduction & Objectives
This study compare the postoperative surgical outcomes and other complications between sutureless (Yamane Technique) and sutured scleral fixated (SSF) intraocular lens (IOL) in patients with inadequate capsular support. The differences should be evaluated to develop the best practices.

Methods
A literature search was performed on PubMed, SCOPUS, and Google Scholar. Studies published between 2019 to 2023 were included. Uncorrected Visual Acuity (UCVA), Best Corrected Visual Acuity (BCVA), operating time, IOL tilt, astigmatism, refractive difference, corneal endothelial cell loss, and other complications compared between Yamane technique and SSF.

Results
10 studies with 551 eyes were included, 245 eyes were included in the SSF group and 306 eyes were included in the Yamane group. In this study, Yamane group had a shorter operating time than SSF group (p<0.001). While, there were no significant differences (p>0.05) in UCVA, BCVA, IOL tilt, astigmatism, refractive difference, corneal endothelial cell loss, and other complications included elevated IOP, cystoid macular edema, and vitreous hemorrhage.

Conclusion
We concluded that the surgical outcomes of both techniques were similar in postoperative visual acuity, IOL tilt, astigmatism, refractive difference, corneal endothelial cell loss, and other complications. The only significant difference between the two groups was operating time, Yamane technique was more efficient than SSF IOL.

Keyword
SSF, yamane technique, operating time

Abstract Title
Outcomes of Pre-Descemet's DALK in Keratoconus Patients: A Case Series

Introduction & Objectives
To report a series of 6 cases (6 patients) with keratoconus that underwent predescemetic deep anterior lamellar keratoplasty (DALK).

Methods
This study enrolled 6 keratoconus-affected eyes that underwent DALK. Several parameters from Scheimpflug corneal tomographer (Pentacam HR, Oculus, Germany) were recorded including thinnest corneal thickness (TCT), mean keratometry (Km front), keratometry max (Kmax front), index of surface variance (ISV), index of vertical asymmetry (IVA), keratoconus index (KI), and center keratoconus index (CKI). The outcome measured were postoperative best-corrected distance visual acuity (BCVA) at 1 and 6 months postoperatively.

Results
All patients were male aged 14 to 32 years old. Visual acuity at presentation was 1 patient with hand movement, 3 patients with 1 meter counting finger (CF), and 2 patients with 2 meters CF. Km front ranging from 45.5 to 66.3, Kmax front ranging from 57 to 81.5, ISV from 77 to 268, IVA from 0.42 to 2.36, KI from 1.03 to 2.14, and CKI from 0.97 to 1.27. At 1 month follow-up, 3 patients had VA of 3 CF, 1 patient had VA of 4 CF, 1 patient had VA of 6/60, and 1 patient had VA of 6/30. At the 6-month follow-up, 4 patients had VA of 6/30, 1 had VA of 6/18, and 1 had VA of 6/15.

Conclusion
These cases of predescemetic DALK in keratoconus provide clinical evidence that visual acuity improvement was notable during 1 month and 6 months. Longer follow-up is warranted to ensure graft survival as rejection may occur years after surgery.

Keyword
keratoconus, predescemetic, DALK

Abstract Title
Modified Safety-net Suture Technique in Complex Descemet Membrane endothelial keratoplasty

Introduction & Objectives
To report usefulness of modified safety-net suture technique to prevent intraoperative graft dislocation into the vitreous cavity during complex DMEK.

Methods
Modified safety-net DMEK underwent in 3 eyes of 3 patients with bullous keratoplasty complicated with large iris defect and scleral fixated IOL due to history of open globe injury. The tip of the 10-0 polypropylene suture needle was anchored into the barrel of the 30-gauge needle which was introduced into the anterior chamber from the opposite side. Either 3×5 mesh or 3×3 mesh of safety-net was created. An 8.0-mm donor roll was inserted into the anterior chamber, was unwrapped, and was lifted by air. At the end of the surgery, the safety-net was withdrawn. Intra- and postoperative complications, visual acuity, endothelial cell density (ECD), and central corneal thickness (CCT) were retrospectively analyzed.

Results
In all cases, the graft was kept in the pseudo-anterior chamber, and no posterior dislocations were observed. One eye required rebubbling for graft edge detachment. Visual acuity improved in 2 eyes, and visual acuity did not change in 1 eye. At 3 months postoperatively, mean ECD was 1987±313 /mm2 (unmeasurable in 1 eye), and mean CCT was 548±15 ㎛.

Conclusion
Both 3×5 mesh and 3×3 mesh of the safety-net suture technique is useful to prevent intraoperative graft dislocation into the vitreous cavity during complex DMEK in cases with prior open globe injury.

Keyword
complex DMEK, safety-net suture

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