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Reinert U, Seitz B, Munteanu C, Daas L. [Impact of the ratio between graft and host corneal size on immune rejection, re-bubbling rate and postoperative endothelial cell loss in 457 eyes after Descemet membrane endothelial keratoplasty (DMEK)]. DIE OPHTHALMOLOGIE 2024:10.1007/s00347-024-02030-8. [PMID: 38639889 DOI: 10.1007/s00347-024-02030-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/10/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The aim of this study was to assess the impact of the ratio between the graft and host corneal size (RGH) on postoperative complications, such as immune reactions, re-bubbling rate and endothelial cell loss (ECL) after Descemet membrane endothelial keratoplasty (DMEK). PATIENTS AND METHODS Retrospectively, 457 patient eyes were included which had undergone surgery between 2016 and 2019 in the Department of Ophthalmology, Saarland University Medical Center in Homburg/Saar using DMEK or triple DMEK, diagnosed as Fuchs' endothelial dystrophy (n = 431), pseudophakic bullous keratopathy (n = 9) and others (n = 17). The follow-up period extended until the end of 2020. Main outcome measures included immune reaction (IR), re-bubbling rate and the postoperative endothelial cell loss (ECL) at 6 weeks, 6 months and 12 months and whether these measures depended on the RGH. RESULTS The RGH in this study ranged from 0.35 to 0.62 (0.46 ± 0.04). There were 33 (7.2%) postoperative IRs (DMEK n = 25; triple DMEK n = 8). The average RGH without IR (0.46 ± 0.04) was significantly (p = 0.038) smaller than in the group with IR (0.47 ± 0.05). Re-bubbling was necessary in 159 of 457 (34.8%) patient eyes. The RGH in patient eyes with re-bubbling (0.47 ± 0.04) was significantly (p = 0.014) higher than that in eyes without re-bubbling (0.45 ± 0.04). The mean preoperative endothelial cell count (ECD) was 2603 ± 251 cells/mm2 (min: 2161, max: 3500 cells/mm2). It was shown that a larger RGH had no positive influence on endothelial cell loss (r = 0.001; p = 0.974). CONCLUSION Our results suggest that a larger graft diameter compared to host corneal size is associated with an increased rate of immune reactions and a higher re-bubbling rate after DMEK. Otherwise, a larger RGH had no positive influence on endothelial cell loss after DMEK. Accordingly, the graft size for DMEK should not be unnecessarily large, especially in eyes with Fuchs' endothelial dystrophy.
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Affiliation(s)
- Ursula Reinert
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland.
| | - Berthold Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland
| | - Cristian Munteanu
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland
| | - Loay Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland
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Parekh M, Wallace AG, Airaldi M, Ruzza A, Ferrari S, Romano V, Ahmad S. Performance outcomes from a DMEK peeling and preparation wet lab. BMJ Open Ophthalmol 2024; 9:e001540. [PMID: 38272533 PMCID: PMC10824027 DOI: 10.1136/bmjophth-2023-001540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
OBJECTIVE To evaluate the Descemet membrane endothelial keratoplasty (DMEK) preparation performance of trainee surgeons in an ex vivo human donor cornea DMEK wet lab simulation setting. METHODS Human donor corneoscleral rims unsuitable for transplantation were obtained from Moorfields Lions Eye Bank. At the wet lab, graft stripping was performed by scoring the peripheral endothelium. The trypan blue positive cells (TBPC) and cell density (cells/mm2-reticule count) were counted manually before and after stripping. The procedural time, peripheral and central tears and complete peel-off were also recorded and analysed. RESULTS Eight trainee surgeons attended the wet lab each attempting three DMEKs. Between the first and last attempts a significant decrease was seen in the procedural time (17.6 min vs 10.6 min (p<0.05)) and the TBPC % (12.9% vs 3.8% (p<0.05)). The percentage of tears peripherally and centrally also reduced between the first and the last trials (50% vs 13% (p=0.2226) and 38% vs 0% (p=0.1327)). A significant correlation was found between longer peeling times and higher TBPC % (p<0.001) with a 0.7% endothelial mortality increase for each additional minute required to complete the peel. CONCLUSIONS DMEK wet labs provide a controlled risk-free learning opportunity for trainee surgeons to improve confidence and competence. Wet labs improve the success rate of DMEK graft preparation as well as flatten the learning curve. This emphasises the importance of continued support for the expansion of this valuable learning resource, promoting wider uptake of DMEK surgery.
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Affiliation(s)
- Mohit Parekh
- Schepens Eye Research Institute of Massachusetts Eye and Ear, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | | | - Matteo Airaldi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Stefano Ferrari
- Fondazione Banca degli Occi del Veneto, Mestre, Venice, Italy
| | - Vito Romano
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Sajjad Ahmad
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Institute of Ophthalmology, University College London, London, UK
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Borgia A, Coco G, Airaldi M, Romano D, Pagano L, Semeraro F, Menassa N, Gadhvi KA, Kaye SB, Romano V. Role of Direct Supervision in the Learning Curve of Descemet Membrane Endothelial Keratoplasty Surgery. Cornea 2024; 43:52-58. [PMID: 37098113 DOI: 10.1097/ico.0000000000003278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/26/2023] [Indexed: 04/27/2023]
Abstract
PURPOSE The aim of this study was to compare complication rates of Descemet membrane endothelial keratoplasty (DMEK) performed by directly supervised and nondirectly supervised corneal fellows. METHODS This study was a retrospective, comparative case series of DMEK surgeries performed by novice surgeons (less than 15 DMEK cases) with or without direct direct expert supervision. Patients who underwent surgery for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy with a minimum follow-up of 12 weeks were included. Data on patients' demographics, surgical details, surgeon level, intraoperative and postoperative complications, and rate of rebubbling were collected. RESULTS In this study, 41 nondirectly supervised and 48 directly supervised DMEK surgeries were included. At 6 months, 67.4% of eyes achieved a best-corrected visual acuity of ≤0.3 logMAR with no significant difference between groups ( P = 0.95). Intraoperative complications occurred in 22% of cases in the nondirect supervision group and 4.2% in the direct supervision group ( P = 0.02). Postoperative complications occurred in 9.8% of cases in the nondirect supervision group and 6.2% of cases in the direct supervision group ( P = 0.7). The rebubbling rate was comparable in the 2 groups (34.1% vs. 33.3%, P = 1.0). Five cases (12.2%), all from the nondirect supervision group, required secondary keratoplasty ( P = 0.02). The overall complication rate was significantly higher in the nondirect supervision group (31.7% vs. 10.4%, P = 0.03). CONCLUSIONS Functional success can be achieved in directly supervised or nondirectly supervised DMEK surgery. However, nondirectly supervised DMEK surgery may associate with higher rates of complications.
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Affiliation(s)
- Alfredo Borgia
- Eye Unit, Humanitas-Gradenigo Hospital, Turin, Italy
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Giulia Coco
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Matteo Airaldi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Italy
| | - Davide Romano
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Italy
- Eye Unit, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom; and
| | - Luca Pagano
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Francesco Semeraro
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Italy
| | - Nardine Menassa
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Kunal A Gadhvi
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Stephen B Kaye
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Vito Romano
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Italy
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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Zilles M, Flockerzi E, Daas L, Weinstein I, Hamon L, Seitz B. Impact of cleanroom status on the reasons for discarding organ-cultured corneal transplants in a modern eye bank - More donor corneas thanks to astronaut suit? Acta Ophthalmol 2023. [PMID: 38131522 DOI: 10.1111/aos.16611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/10/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE This study investigated the influence of cleanroom conditions on the discard rates of donor corneas in a German university eye bank. METHODS Discard rates were analysed from 2017 to 2020 at the LIONS Cornea Bank at Saarland University Medical Center. 1941 corneas from 971 donors were included. 1262 corneas (65.1%) were stored in a class D cleanroom from 2017 to 2019 and processed in a cleanroom class A sterile bank (group 1). 679 corneas (34.9%) were continuously stored in a class B cleanroom and processed in a class A cleanroom safety cabinet in the same room from 2019 to 2020 (group 2). The target parameter of this work was the number of contamination-related discards. Although they cannot be influenced by the spatial conditions, the discards due to insufficient endothelial quality, serology, contraindications, scars and technical causes were also recorded. Statistical analysis was performed using SPSS and various testing procedures. RESULTS In group 1, significantly more corneas were discarded due to positive serology (6.9%|3.8%, p = 0.020). There was no significant change between both groups for either contamination or the other reasons for discard. CONCLUSION Optimization of hygiene standards from cleanroom class D to B did not reduce contamination. Serology, endothelial quality, medical contraindications and the presence of scars cannot be influenced by cleanroom conditions.
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Affiliation(s)
- Marco Zilles
- Department of Ophthalmology, University Hospital of the Saarland (UKS), Homburg, Germany
| | - Elias Flockerzi
- Department of Ophthalmology, University Hospital of the Saarland (UKS), Homburg, Germany
| | - Loay Daas
- Department of Ophthalmology, University Hospital of the Saarland (UKS), Homburg, Germany
| | - Isabel Weinstein
- Department of Ophthalmology, University Hospital of the Saarland (UKS), Homburg, Germany
| | - Loic Hamon
- Department of Ophthalmology, University Hospital of the Saarland (UKS), Homburg, Germany
| | - Berthold Seitz
- Department of Ophthalmology, University Hospital of the Saarland (UKS), Homburg, Germany
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Berg K, Safi T, Seitz B, Daas L. Non-invasive endothelial cell density measurement of in toto pre-stripped DMEK-roll - impact of pre- and intraoperative endothelial cell loss on postoperative midterm clinical outcome. Eye (Lond) 2023; 37:2956-2962. [PMID: 36813996 PMCID: PMC10516950 DOI: 10.1038/s41433-023-02450-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 01/13/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND/OBJECTIVES To measure the endothelial cell density (ECD) of the in toto pre-stripped endothelial Descemet membrane lamellae (EDML) and to describe the impact of pre- and intraoperative endothelial cell loss (ECL) on postoperative midterm clinical outcome. SUBJECTS/METHODS The ECD of 56 Corneoscleral Donor Discs (CDD) was first measured with an inverted specular microscope (t0pre). The measurement was then repeated non-invasively after the preparation of the EDML (t0post). DMEK was performed the next day using these grafts. Follow-up examinations took place 6 weeks, 6 months and 1 year postoperatively where the ECD was assessed. In addition, the impact of ECL 1 (during preparation) and ECL 2 (during surgery) on the ECD, visual acuity (VA) and pachymetry at 6 months and 1 year was investigated. RESULTS The average ECD (in cells/mm²) at time points t0pre, t0post, 6 weeks, 6 months & 1 year was 2584 ± 200, 2355 ± 207, 1366 ± 345, 1091 ± 564 and 939 ± 352. The average logMAR VA and pachymetry (in µm) was 0.50 ± 0.27 and 597 ± 63, 0.23 ± 0.17 and 535 ± 54, 0.16 ± 0.12 and 535 ± 54, 0.06 ± 0.08 and 512 ± 37, respectively The ECL 1 (9% on average) had no significant impact on the main outcome measures after 6 months and 1 year (p > 0.11). The ECL 2 correlated significantly with the ECD and the pachymetry at 1 year postop (p < 0.02). CONCLUSION Our results indicate that the non-invasive ECD measurement of the prestripped EDML roll before its transplantation is feasible. Despite significantly decreasing ECD up to 6 months postoperatively, visual acuity further improved and thickness further decreased up to 1 year postoperatively.
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Affiliation(s)
- Kolja Berg
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany.
| | - Tarek Safi
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany
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Stuhlmacher ES, Suffo S, Munteanu C, Seitz B, Daas L. Assessing the Learning Curve for DMEK Using Post-Procedural Clinical Outcomes-Comparison of Four Different Surgeons during Two Different Periods. J Clin Med 2023; 12:jcm12030811. [PMID: 36769458 PMCID: PMC9917538 DOI: 10.3390/jcm12030811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/11/2023] [Accepted: 01/18/2023] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Evaluating the learning curve of individual surgeons for Descemet Membrane Endothelial Keratoplasty (DMEK) and Triple-DMEK and assessing outcome with experience. METHODS The first 41 and the last 41 surgeries of each of the four surgeons were retrospectively included. Surgery duration and graft preparation time were recorded. Corrected distance visual acuity (CDVA, logMAR) and central corneal thickness (CCT, µm) were collected preoperatively after 6 and 12 months, as well as postoperative complications, e.g., re-bubbling or repeat penetrating keratoplasty. RESULTS Surgical duration for Triple-DMEK and DMEK decreased significantly by 21 min and 14 min between the two periods (p < 0.001; p < 0.001). Graft preparation time decreased significantly from 13.3 ± 5.2 min (95%CI 12.8-14.3) in period 1 to 10.7 ± 4.8 min (95%CI 10.2-11.4) in period 2 (p = 0.002). The postoperative changes in CDVA and CCT over both periods were not significant (p = 0.900; p = 0.263). The re-bubbling rate decreased significantly from 51.2% in period 1 to 26.2% in period 2 (p < 0.001). The repeat penetrating keratoplasty (PKP) was 7.3% in period 1 and 3.7% in period 2 (p = 0.146). Re-DMEK was necessary in 6.1% in period 1 and 4.9% in period 2 (p = 0.535). Several parameters showed significant differences between the surgeons in both periods (surgical duration: period 1: p < 0.001, period 2 p < 0.001; graft preparation: period 1: p < 0.001, period 2 p < 0.001). CONCLUSION Significant decrease in surgery duration, graft preparation time, and the re-bubbling rate can be attributed to gained individual experience.
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Aljundi W, Abdin A, Suffo S, Seitz B, Daas L. Descemet Membrane Endothelial Keratoplasty (DMEK) in Previously Vitrectomized Eyes: Complications and Clinical Outcomes. Klin Monbl Augenheilkd 2021; 238:1101-1107. [PMID: 34311490 DOI: 10.1055/a-1517-4518] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the results and complications of Descemet membrane endothelial keratoplasty (DMEK) in previously vitrectomized eyes. DESIGN Retrospective study of 35 eyes that had undergone DMEK, due to Fuchs endothelial corneal dystrophy (FECD), at our department with a follow-up after 6 months postoperatively. We compared the intraoperative procedure, complications, and results of DMEK between 14 previously vitrectomized pseudophakic eyes (group 1) and a control group of 21 pseudophakic non-vitrectomized eyes (group 2). RESULTS The unfolding time (in minutes) was significantly longer in group 1 than in group 2 (10.5 ± 6.4 vs. 3.2 ± 1.5, p < 0.01). A single re-bubbling was needed in 8 patients in group 1 (57.1%) and in 3 patients in group 2 (14.2%) (p < 0.01). Repeated re-bubbling (≥ 1 time) was performed in only 5 patients of group 1 (35.7%). There was significant postoperative improvement in best-corrected visual acuity (BCVA, in LogMAR) in both groups (p = 0.04 in group 1 and p < 0.01 in group 2). The central corneal thickness (CCT, in µm) did not differ significantly between the two groups preoperatively (p = 0.4) or postoperatively (p = 0.1). However, the CCT decreased significantly postoperatively in both groups (p < 0.01 in both groups). The postoperative endothelial cell density (ECD in cell/mm²) was significantly lower in group 1 than in group 2 (p = 0.03). CONCLUSION DMEK in previously vitrectomized eyes presents a surgical challenge, which requires special, and sometimes unpredictable, intraoperative maneuvers, but good functional and morphological results can be achieved. The use of the endothelial Descemet membrane lamellae (EDML) of older donors might be recommended to facilitate the intraoperative unfolding process.
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Affiliation(s)
- Wissam Aljundi
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Alaadin Abdin
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Shady Suffo
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Berthold Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Loay Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
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Abstract
Wir berichten über einen Fuchs-Endotheldystrophie-Patienten mit drei „Descemet Membrane Endothelial Keratoplasty“ (DMEK) bei rezidierendem Transplantatversagen mit Intraokulardruckerhöhung und cystoides Makulaödem. Bei der dritten DMEK wurde Herpes im Vorderkammeraspirat nachgewiesen und eine adäquate Therapie eingeleitet. Bei der 6 Monaten-Kontrolle blieb die Hornhaut klar, der Visus betrug 0,8, der Intraokulardruck lag im Normbereich und das Makulaödem bildete sich zurück. Entweder wurde eine latente Herpes simplex Virus(HSV)-Infektion des Patienten reaktiviert oder eine befallene Spender-Lamelle transplantiert mit Spender-zu-Wirt-zu-Spender „Ping-Pong“ Übertragung.
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Affiliation(s)
- C Matar
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, Kirrberger Str. 100, 66424, Homburg/Saar, Deutschland.
| | - B Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, Kirrberger Str. 100, 66424, Homburg/Saar, Deutschland
| | - L Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, Kirrberger Str. 100, 66424, Homburg/Saar, Deutschland
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Pujari A, Saluja G, Bhaskaran K, Modaboyina S, Asif MI, Agarwal T, Sharma N, Titiyal JS. Animal and cadaver human eyes for residents' surgical training in ophthalmology. Surv Ophthalmol 2021; 67:226-251. [PMID: 33992664 DOI: 10.1016/j.survophthal.2021.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/24/2021] [Accepted: 05/03/2021] [Indexed: 11/19/2022]
Abstract
In ophthalmology residency programs surgical training plays a vital role in creating confident and skillful surgeons. As almost all ophthalmic surgery needs microscope training, creating a well-taught environment for hand-eye coordination, ocular tissue handling, and anticipation of complications is essential. Wet lab training with animal or cadaver human eyes offers diverse possibilities. We conducted a thorough literature search on various databases to identify the existing literature on wet labs. The results revealed constructive efforts for training novice surgeons in all surgical ophthalmology subspecialties. Wet lab models were initially used only to practice cataract surgery; however, now various complex ocular procedures can be practiced. Ocular surface, corneal, iris, lenticular, scleral, vitreoretinal, extraocular, eyelid, and other adnexal surgeries were reproduced and mastered in many ways. Importantly, with repeated surgical practice, residents gained an increasing level of confidence with enhanced surgical accuracy. In addition, we propose a few novel techniques of various other procedures.
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Affiliation(s)
- Amar Pujari
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
| | - Gunjan Saluja
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Karthika Bhaskaran
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Sujeeth Modaboyina
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Mohamed Ibrahime Asif
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar Agarwal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jeewan S Titiyal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Safi T, Seitz B, Berg K, Schulz K, Langenbucher A, Daas L. Reproducibility of Non-Invasive Endothelial Cell Loss Assessment of the Pre-Stripped DMEK Roll After Preparation and Storage. Am J Ophthalmol 2021; 221:17-26. [PMID: 32795433 DOI: 10.1016/j.ajo.2020.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To present a novel, reproducible, and noninvasive method to quantify endothelial cell loss (ECL) of pre-stripped endothelial Descemet membrane lamellae (EDML) caused by its preparation and storage for 5 days. DESIGN Prospective laboratory investigation. METHODS Thirty EDML were stripped from corneoscleral discs and placed in a well plate containing organ culture medium 1 without dextran. An additional 5 corneoscleral discs were also placed in the same medium and served as a control group. Endothelial cell density (ECD) was measured without any additional manipulation by using spectral microscopy following an extensive protocol by which 3 clear images from the center and periphery were used for each measurement, and each measurement was repeated 5 times. ECD was measured before and directly after preparation and on days 1, 2, and 5 of storage. RESULTS The average ECD of the 30 corneoscleral discs, which later underwent stripping, was 2,292 ± 308 cells/mm2 vs 2,129 ± 222 cells/mm2 for the 5 corneoscleral discs of the control group. The ECL of the control group was significantly lower than that of the EDML group (P < .0001), reaching ±2% versus 11 ± 5%, respectively, on day 0; 3% ± 4% versus 19 ± 10%, respectively, on day 1; 2% ± 2% versus 22% ± 11%, respectively on day 2; and 4% ± 3% versus 23% ± 9%, respectively, on day 5. Reproducibility of the results on all measurement days was good, with Cronbach alpha values ranging from 0.85 to 0.98. CONCLUSIONS A highly reproducible, noninvasive method was presented for measuring the ECD of the EDML. Prestripped EDML lose a significant amount of cells, up to 11%, due to the preparation process and up to 23% after 5 days of storage. Therefore, shipping them after several days of storage to be used in a DMEK surgery cannot be recommended.
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Seitz B, Daas L, Flockerzi E, Suffo S. [Descemet membrane endothelial keratoplasty DMEK - Donor and recipient step by step]. Ophthalmologe 2020; 117:811-828. [PMID: 32561987 DOI: 10.1007/s00347-020-01134-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In 2020 Descemet membrane endothelial keratoplasty (DMEK) has become the gold standard in Germany for the treatment of corneal endothelial diseases; however, the widespread use of DMEK was initially limited due to problems with donor preparation and the difficulty of correctly and gently unfolding the endothelial Descemet membrane (EDM) in the anterior chamber. Following the situational donor selection, the safe single-handed donor preparation of the cornea without tearing or even rupturing the EDM, including the indispensable peripheral semicircular orientation marking. Also presented is a step by step atraumatic loading of the glass cartridge, the introduction of the EDM roll into the anterior chamber, and its safe step by step unfolding based on (1) the sequential use of jets of fluid, (2) repeated tapping on the peripheral/central cornea, (3) controlled flattening of the anterior chamber, (4) use of air bubbles of defined size and finally, the fixation of the EDM in correct orientation to the back of the host cornea with a gas bubble. Since every wrong step with DMEK can have far-reaching consequences for patient and surgeon, this step by step pragmatic approach should minimize the incidence of donor tissue damage and failure in patient maneuvers.
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Affiliation(s)
- Berthold Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland.
| | - Loay Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - Elias Flockerzi
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - Shady Suffo
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
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Triple Descemet membrane endothelial keratoplasty for Haab striae with endothelial decompensation in congenital glaucoma. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.jcro.2019.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Schmidt I, Schlötzer-Schrehardt U, Langenbucher A, Eppig T, Hager T, Zimpfer A, Seitz B. Ultrastructural findings in graft failure after Descemet membrane endothelial keratoplasty (DMEK) and new triple procedure. Medicine (Baltimore) 2019; 98:e15493. [PMID: 31083187 PMCID: PMC6531070 DOI: 10.1097/md.0000000000015493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate factors that influence graft failure after Descemet membrane endothelial keratoplasty (DMEK) based on transmission electron microscopy results.Retrospective observational case series.This single center study included 16 eyes of 16 patients with penetrating keratoplasty (n = 14) or repeat DMEK (n = 2) following graft failure after DMEK. The main outcome measures were ultrastructural changes in the explanted graft on transmission electron microscopy, best-corrected visual acuity, and central corneal thickness.The mean preoperative and postoperative best-corrected visual acuity was 1.01 ± 0.54 logMAR and 0.56 ± 0.37 logMAR. The mean central corneal preoperative and postoperative thickness was 667 ± 187 μm and 511 ± 42 μm. Visual acuity and central corneal thickness improved significantly (P = .001/P = .003) after repeat surgery. Electron microscopy showed that 3 of 14 corneas showed upside down transplantation, and 3 corneas had pigmented cells or pigment granules at the Descemet-stroma interface. Further, 9 of 16 specimens showed a posterior collagenous layer deposited onto the Descemet membrane (average thickness 5.1 ± 6.2 μm; ranged 0.65-20 μm); this did not correlate significantly with the time between the original and repeat keratoplasty. Of 16 original grafts, 7 showed ultrastructural anomalies of the Descemet membrane, but one excised cornea showed no Descemet membrane pathologies.The majority of eyes with graft failure after DMEK showed ultrastructural changes in the Descemet membrane. It is crucial to assess donor tissue quality and to conduct graft marking before surgery to avoid immediate or delayed graft failure after DMEK. Nevertheless, repeat keratoplasty provided significant improvement in central corneal thickness and visual acuity.
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Affiliation(s)
- Isabell Schmidt
- Department of Ophthalmology, Saarland University Medical Center UKS Homburg/Saar
| | | | | | - Timo Eppig
- Institute of Experimental Ophthalmology, Saarland University
| | - Tobias Hager
- Department of Ophthalmology, Saarland University Medical Center UKS Homburg/Saar
| | - Annette Zimpfer
- Department of Pathology, Saarland University Medical Center UKS, Homburg/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center UKS Homburg/Saar
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Abdin A, Daas L, Pattmöller M, Suffo S, Langenbucher A, Seitz B. Negative impact of dextran in organ culture media for pre-stripped tissue preservation on DMEK (Descemet membrane endothelial keratoplasty) outcome. Graefes Arch Clin Exp Ophthalmol 2018; 256:2135-2142. [DOI: 10.1007/s00417-018-4088-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/14/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022] Open
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Flockerzi E, Maier P, Böhringer D, Reinshagen H, Kruse F, Cursiefen C, Reinhard T, Geerling G, Torun N, Seitz B. Trends in Corneal Transplantation from 2001 to 2016 in Germany: A Report of the DOG-Section Cornea and its Keratoplasty Registry. Am J Ophthalmol 2018; 188:91-98. [PMID: 29410297 DOI: 10.1016/j.ajo.2018.01.018] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 01/14/2018] [Accepted: 01/16/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this retrospective panel study was to provide an overview of absolute numbers and of trends in the types of and indications for corneal transplantation in Germany from 2001 to 2016. METHODS A questionnaire about absolute numbers, types of transplantation, and indications was sent to 111 ophthalmologic departments in Germany, out of which 94 (85%) provided their data. RESULTS Since the year 2001, the number of corneal transplantations has increased by 1.5-fold, from 4730 penetrating keratoplasties (PKPs) in 2001 to 7325 penetrating and lamellar keratoplasties in 2016. The shift from penetrating to lamellar procedures began in 2006. In 2014, lamellar procedures (231 [4%] anterior and 2883 [49%] posterior lamellar keratoplasties) surpassed PKPs (2721, 47%) for the first time. Main indications for keratoplasty in Germany (2016) are Fuchs endothelial corneal dystrophy (46%), pseudophakic corneal decompensation (bullous keratopathy, 13%), repeated keratoplasty after graft failure (11%), keratoconus (8%), and corneal scarring (6%; others: 16%). The number of Descemet membrane endothelial keratoplasties (DMEKs) was 12 times higher (3850, 53%) than Descemet stripping automated endothelial keratoplasties (DSAEKs, 319, 4.4%) in 2016. The proportion of deep anterior lamellar keratoplasties (DALKs) never exceeded 6% (269 in 2011). CONCLUSIONS The number of keratoplasties in Germany has increased from 2001 to 2016. Since 2014, posterior lamellar keratoplasties have surpassed PKPs. There was a constant increase of DMEKs, with a 12-fold higher number compared to DSAEKs in 2016. The shorter recovery time after DMEK seems to contribute to the trend toward earlier operative intervention in corneal endothelial diseases.
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