Fig. 2. Slit-lamp observation of the representative patient before and after failed deep anterior lamellar keratoplasty (DALK) and additional penetrating keratoplasty (PK) (A). The corneal status after multiple failed PK at an initial visit to our clinic. Stromal neovascularization, opacity, and inferior circular persistent epithelial defect were noted (arrow). Total limbal stem cell deficiency was also noted (B). At 5 months after DALK with amniotic membrane transplantation, diffuse opacity was noted on the central cornea (C). At 10 months after DALK with amniotic membrane transplantation, deep stromal ulceration with extensive vascularization and opacity had progressed to the central cornea. The authors judged graft rejection after DALK and decided to perform additional PK (D). At 8 months after additional PK, the graft remained clear and the final bestcorrected visual acuity was 20 / 50.
