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Although the greatest and most durable post-CXL densitometry change was in the anterior layer, the degree of increased densitometry haze in the mid-stromal layer was most associated with and possibly predictive of improvement in CDVA, maximum K, and HOAs. The persistence of corneal haze at 6 months, measured by increased densitometry, might be a prognostic marker for CXL effectiveness.

A 17-year-old man had acute vision loss OS (visual acuity 20/40), having lost vision OD months before (20/400). There were cecocentral scotomas OU. Mitochondrial DNA testing revealed a T14484C mutation, suggestive of Leber hereditary optic neuropathy (LHON), which results in painless sequential vision loss. Acutely, there is hyperemia of the optic nerve, circumpapillary microangiopathy, and dilated, tortuous vasculature 1 ; the pathognomonic finding is nerve swelling without leakage on fluorescein angiography. Chronically, the optic nerve develops atrophy, sometimes with cupping.2 Optical coherence tomography angiography provides rapid, high-resolution visualization of retinal vasculature without dye injection, and is a novel imaging modality in LHON (figure).

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Purpose: To describe 2 insertion techniques, outcomes, and complications of preloaded, trifolded Descemet membrane endothelial keratoplasty (DMEK) cases using the DMEK EndoGlide inserter.Methods: This retrospective, consecutive case series analyzed the first 35 cases using the DMEK EndoGlide performed between October 2018 and October 2019 at a single center. Preloaded, trifolded DMEK tissues were delivered through a fluid-injected or pull-through technique. To inject the tissue, a burst of fluid was delivered into the lumen of the injector with a second instrument. Postoperatively, best-spectacle corrected visual acuity (BSCVA), pachymetry, graft survival, and complications were assessed.Results: Thirty-five eyes of 29 patients underwent DMEK alone (n = 11), with cataract surgery (n = 21), or with additional surgeries (n = 3). Of these, 19 (54.3%) grafts were injected. Video analysis revealed a median time of 3.5 minutes from graft insertion to opening for gas insertion. Median preoperative BSCVA of 0.398 logMAR improved to 0.097 logMAR (P = 0.02) at 9 months. Median pachymetry decreased from 619 mm to 551 mm (P = 0.03) at 9 months. Median donor endothelial cell count of 2890.5 cells/mm 2 reduced to 2123 cells/mm 2 (26.6% endothelial cell loss; P = 0.008) 6 months postoperatively. One (2.9%) graft failed due to inverted marking at the eye bank and subsequent reverse implantation.Conclusions: Pre-loaded, tri-folded tissues can be implanted with acceptable levels of endothelial cell loss. We describe a no-touch method of injecting pre-loaded, tri-folded tissue and highlight incorrect marking as a potential complication. This may not be identifiable intraoperatively due to lack of scroll formation.