title: Inadvertent donor button inversion during big-bubble deep anterior lamellar keratoplasty.
abstract: OBJECTIVE
  The aim of this study was to describe clinical outcomes and histopathologic findings in a case of repeat deep anterior lamellar keratoplasty (DALK) performed because of inadvertent inversion of the donor button at the time of primary surgery.
  
  
  METHODS
  A 34-year-old woman underwent big-bubble DALK for keratoconus in her right eye; 4 days postoperatively, slit-lamp examination revealed the presence of several inclusions in the interface, whereas anterior segment optical coherence tomography (AS-OCT) showed pathologically marked wrinkling of the posterior stroma; inadvertent intraoperative inversion of the graft was diagnosed and the interface inclusions were assumed to be of epithelial origin. Repeat surgery was performed: donor tissue was removed and submitted to histological examination, marking the external surface of the lamella; the recipient residual bed was carefully washed and a new lamellar graft was sutured into position. Three months postoperatively, the patient underwent a complete ophthalmologic examination, including best-spectacle corrected visual acuity testing, refraction, biomicroscopy, AS-OCT, and endothelial microscopy.
  
  
  RESULTS
  Histological examination confirmed that the donor button had been implanted with the epithelium facing the residual bed. Three months postoperatively, normal corneal curvature was visible at AS-OCT, the best-spectacle corrected visual acuity was 20/25, and the interface appeared perfectly clear. Endothelial cell density had not been substantially affected by the 2 surgical procedures.
  
  
  CONCLUSIONS
  Inadvertent inversion of donor tissue at the time of DALK is reported for the first time. Prompt exchange of the lamellar graft was instrumental in avoiding epithelial colonization of the interface, as well as in restoring excellent vision.
authors.affiliation: *Department of Ophthalmology, University of Magna Graecia, Catanzaro, Italy; †International Center for Ocular Physiopathology, the Veneto Eye Bank Foundation, Venice, Italy; ‡Department of Ophthalmology, Ospedale Privato "Villa Igea," Forlì, Italy; and §Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Scorcia
authors.forename: Franco D
authors.initials: FD
authors.lastname: Cosimo
authors.forename: Andrea
authors.initials: A
authors.lastname: Lucisano
authors.forename: Diego
authors.initials: D
authors.lastname: Ponzin
authors.forename: Giovanni
authors.initials: G
authors.lastname: Scorcia
authors.forename: Massimo
authors.initials: M
authors.lastname: Busin
mesh_terms: D000328:Adult; D003319:Corneal Stroma / Q000473:pathology*; D016039:Corneal Transplantation; D019573:Epithelium, Corneal / Q000473:pathology*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications; D007640:Keratoconus / Q000601:surgery*; D019300:Medical Errors; D012086:Reoperation; D014019:Tissue Donors; D041623:Tomography, Optical Coherence