Descemet membrane endothelial keratoplasty in iridocorneal endothelial syndrome and posterior polymorphous corneal dystrophy

Corneal Collagen Cross-Linking for Late Onset Progressive Keratoconus in Iridocorneal Endothelial Syndrome

PURPOSE

The aim of this study was to report the first case of successful use of corneal collagen cross-linking (CXL) to halt the progression of keratoconus in a patient with concurrent iridocorneal endothelial (ICE) syndrome.

METHODS

A 30-year-old White man was referred to our subspecialty corneal clinic for further investigation of right corectopia. The patient was asymptomatic and was otherwise fit. Slit-lamp examination revealed a right oval-shaped pupil decentered superiorly, a transillumination defect at the 5-o'clock position, minimal gutta-like changes in the corneal endothelium, and few inferior peripheral anterior synechiae. Dilated fundoscopy was normal in both eyes, with healthy optic discs, maculae, and peripheral retinae. Specular microscopy and slit-lamp findings suggested ICE syndrome. Subsequent investigation with corneal tomography showed progressive signs of inferior corneal ectasia with steepening, and thinning in the right eye, consistent with keratoconus. The left eye was unremarkable.

RESULTS

Epithelium-off accelerated corneal CXL was performed in the affected eye. Early post-CXL follow-up (1 week) was unremarkable, and further follow-ups were arranged at 3, 6, 12, and 24 months, respectively. In subsequent reviews, the patient's vision and corneal tomography findings were stable.

CONCLUSIONS

We describe the first case of corneal CXL for progressive keratoconus with ICE syndrome. co-existing keratoconus and ICE syndrome can occur, and corneal cross-linking was used successfully in this case to halt keratoconus progression. However, further studies will need to establish the impact of epithelium-off corneal cross-linking, especially in more severely affected eyes.

Comparison of penetrating and endothelial keratoplasty in patients with iridocorneal endothelial syndrome: A registry study

BACKGROUND

To compare graft survival of endothelial keratoplasty (EK) versus penetrating keratoplasty (PK) in patients with iridocorneal endothelial (ICE) syndrome and identify ocular features associated with graft survival.

METHODS

Observational, prospective, cohort study. A total of 30 806 first grafts performed between 1985 and 2020 were identified through the Australian Corneal Graft Registry and included in this observational, prospective cohort study. A total of 196 eyes underwent a primary corneal graft for ICE syndrome. Kaplan-Meier graft survival plots and Chi-squared tests were performed to identify graft survival rates for EK and PK. A history of raised intraocular pressure (IOP) was also recorded and analysed. Graft survival of eyes with ICE syndrome were compared to that of other indications.

RESULTS

Grafts performed for ICE syndrome increased to 0.8% of all cases during the 2005 to 2020 period compared with 0.5% between 1985 to 2004 (χ2 =9.35, p = 0.002). From 2010, EK surpassed PK as the preferred graft type. Survival of primary grafts in eyes with ICE syndrome was lower than for other indications (log-rank = 56.62, p < 0.001). Graft survival was higher following PK than Descemet stripping (automated) endothelial keratoplasty (DS(A)EK) (log-rank = 10.56, p = 0.001). Graft survival was higher in eyes without a history of raised IOP compared to those with a reported history of raised IOP (log-rank = 13.06, p < 0.001).

CONCLUSIONS

ICE syndrome carries a poor prognosis for graft survival. DS(A)EK had a poorer prognosis than PK. A history of raised IOP is associated with higher risk of graft failure.

Spokewise iridotomy combined with Descemet stripping automated endothelial keratoplasty in iridocorneal endothelial syndrome

Purpose

Iridocorneal endothelial (ICE) syndrome is a progressive anterior segment disorder that can be tricky to treat. Keratoplasty is commonly used to treat corneal edema in ICE syndrome. However, glaucoma is an important risk factor affecting graft survival. To address this question, we designed a retrospective cohort study to evaluate the effect of Spokewise Iridotomy (SI) on Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) Grafts in Iridocorneal Endothelial (ICE) Syndrome.

Methods

This was a retrospective cohort study. A total of 29 patients were included; 31 eyes with ICE syndrome underwent DSAEK at Peking University Third Hospital between June 2015 and June 2022, including 11 eyes with combined SI during DSAEK. The aim was to explore the effect of SI on vision, glaucoma control, complications, peripheral anterior synechiae recurrence, endothelial cell count, and graft survival.

Results

The median follow-up time was 30.83 months (mo.) in the SI+Endothelial Keratoplasty (EK) group and 6.17 mo in the EK group. The 2-year cumulative survival rate of grafts in the SI+EK group was 100%, compared with the 6-month and 1-year cumulative survival rates of 80.2 and 63.2%, respectively, in the EK group (p = 0.043). The SI+EK group had a lower incidence of immediate postoperative complications (p = 0.005), fewer postoperative anti-glaucoma medications (AGMs) (p = 0.029), smaller peripheral anterior synechiae recurrence (p = 0.001), and significant visual acuity improvement (p < 0.05). More AGMs were used in failed grafts (p = 0.002).

Conclusion

SI can help control intraocular pressure, improve visual acuity, and increase graft survival after DSAEK in ICE syndrome patients.

Clinical Outcomes of the Intraocular Lens Injector and Busin Glide for Descemet Stripping Automated Endothelial Keratoplasty in Patients with Iridocorneal Endothelial Syndrome

Purpose: To report the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) performed in iridocorneal endothelial (ICE) syndrome patients using the intraocular lens injector (injector), in comparison with those using the Busin glide. Methods: In this retrospective, interventional comparative study, we evaluated the outcomes of DSAEK performed using the injector (n = 12) or the Busin glide (n = 12) for patients with ICE syndrome. Their graft position and postoperative complications were recorded. Their best-corrected visual acuity (BCVA) and endothelial cell loss (ECL) were monitored over a 12-month follow-up period. Results: DSAEK was conducted successfully in the 24 cases. The BCVA improved from the preoperative 0.99 ± 0.61 to 0.36 ± 0.35 at 12 months after operation (p < 0.001), with no significant difference between the two groups (the injector group and the Busin group) (p = 0.933). ECL at 1 month after DSAEK was 21.80 ± 15.01% in the injector group, which was significantly lower than 33.69 ± 9.75% of the Busin group (p = 0.031). No surgery-related complications were observed in the 24 cases intraoperatively or postoperatively except that one case suffered from postoperative graft dislocation, without statistical difference between the two groups. Conclusions: At 1 month after surgery, the use of graft injector for delivering DSAEK-based endothelial graft may cause significantly less endothelial cell damage than the pull-through technique used in the application of Busin glide. The injector allows safe endothelial graft delivery without the need of anterior chamber irrigation, which increases the ratio of successful graft attachment.

Descemet Membrane Endothelial Keratoplasty and Goniosynechialysis in Iridocorneal Endothelial Syndrome: Surgical Perspective and Long-Term Outcomes

PURPOSE

The purpose of this study was to report the long-term outcomes of Descemet membrane endothelial keratoplasty (DMEK) with goniosynechialysis in eyes with iridocorneal endothelial syndrome with an emphasis on the surgical technique.

METHODS

This was a retrospective series of 5 eyes of 5 patients undergoing a DMEK procedure at a tertiary eye care institute by a single surgeon. Modifications in the standard surgical technique, including the release of peripheral anterior synechiae, peripheral descemetorhexis, the release of adherent membranes, maneuvers in the anterior chamber with or without cataract extraction were logged. Long-term outcomes of the surgery in these patients are reported.

RESULTS

Five DMEK procedures were performed in 5 eyes of 5 patients. The average age of the patients was 48.2 ± 10.8 years, and the donor was 55.2 ± 3.2 years with a mean endothelial cell density (ECD) of 2784.6 ± 231 cells/mm 2 . After a mean follow-up period of 29.6 months (24-41 mo), all the 5 grafts remained clear; the mean BCVA at the last follow-up was 0.18 ± 0.17 logarithm of the minimum angle of resolution with a mean ECD of 1086.2 ± 338 cells/mm 2 with a 61.1% reduction in ECD. intra ocular pressure was normal in all the cases. None of the patients had graft detachments that required rebubbling, and all eyes had a clear graft at the last follow-up.

CONCLUSIONS

DMEK can be performed successfully in a case with iridocorneal endothelial syndrome with good visual outcomes with modifications to the surgical technique, including peripheral anterior synechiae release and minimizing surgical manipulation.

Comparison of Descemet Membrane Endothelial Keratoplasty for Iridocorneal Endothelial Syndrome and Fuchs Endothelial Dystrophy

PURPOSE

To evaluate the clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) for treating eyes with iridocorneal endothelial (ICE) syndrome and comparing the outcomes with those achieved after treating Fuchs endothelial dystrophy (FED).

DESIGN

Prospective interventional comparative case series.

METHODS

Sixty-three patients (68 eyes) with ICE syndrome or FED were enrolled at the Zhongshan Ophthalmic Center between March 10, 2014 and May 11, 2018. Eligible patients were divided into 2 groups: ICE group (eyes, 24; patients, 24) and FED group (eyes, 44; patients, 39). DMEK was performed in all cases. Corrected distance visual acuity (CDVA), endothelial cell loss (ECL), intraocular pressure (IOP), graft survival, and surgical complications were documented.

RESULTS

In the ICE and FED groups, the mean follow-up duration was 24.9 ± 5 months and 25.2 ± 7.7 months, respectively. At 1 year postoperatively, Kaplan-Meier survival analysis demonstrated 85.7% and 100% cumulative graft success rates (P = .017) in patients with ICE and FED, respectively. Postoperative CDVA level was comparable between the 2 groups through 12-month follow-up; thereafter CDVA was better in the FED group than in the ICE group (P < .001). Moreover, postoperative ECL was significantly higher in the ICE group than in the FED group throughout the follow-up period (P < .001). A discernable increase in structural abnormalities of the anterior chamber angle was observed in 2 eyes (8.3%) in the ICE group; however, no significant differences were observed in the incidence of principal complications between the 2 groups.

CONCLUSIONS

DMEK provides comparable short-term visual outcomes in the treatment of ICE to those observed in the treatment of FED, with higher postoperative ECL over FED.

Outcomes of Descemet stripping endothelial keratoplasty combined with near total iridectomy in iridocorneal endothelial syndrome

To report the outcomes of endothelial keratoplasty (EK) combined with near total iridectomy in the management of iridocorneal endothelial (ICE) syndrome with severely disorganised anterior segment. Three patients with ICE syndrome, who had a severely disorganised anterior segment underwent near total iridectomy, with/without cataract surgery, followed by EK at the same time. Mean age was 35 years. Prior to EK, the intraocular pressure (IOP) was in the range of 12-15 mm Hg. One patient (patient 2) had advanced disc damage prior to EK. Two eyes (patients 1 and 2) had a glaucoma drainage device, and in one, the IOP was controlled with two antiglaucoma medications. All grafts were clear, and IOP was well controlled till the last mean follow-up of 53 (range 30-72) months. The outcomes of EK with this surgical approach are favourable and should be considered in selective cases of ICE syndrome.

Atypical Case of Bilateral Chandler Syndrome With Recurrent Band Keratopathy

PURPOSE

To report a unique case of bilateral Chandler syndrome with recurrent band keratopathy.

METHODS

This is a retrospective observational case report.

RESULTS

A 39-year-old Asian man presented with progressive painless diminution of vision in both eyes for 6 years. Examination revealed diffuse corneal edema, hammered silver appearance of endothelium with guttae-like lesions, and corectopia in the right eye and mild corneal edema, central band keratopathy, and guttae-like lesions on the endothelium and peripheral anterior synechiae in the left eye. Routine specular microscopy, confocal microscopy, and pachymetry were performed. A clinical diagnosis of bilateral Chandler syndrome with band keratopathy was made. Superficial epithelial keratectomy with ethylenediaminetetraacetic acid (EDTA) chelation was performed in the left eye first, followed by Descemet-stripping automated endothelial keratoplasty in the right eye. Histopathological examination of the surgically excised Descemet membrane in the right eye showed multilayered endothelium with adhered epithelial cells consistent with Chandler syndrome. At 9-month follow-up, the right eye showed a clear cornea with an attached graft and the left eye revealed recurrence of central band keratopathy for which repeat EDTA chelation was successfully performed.

CONCLUSIONS

Recurrent band keratopathy coincident with endothelial dysfunction in iridocorneal endothelial syndrome can be repeatedly treated with EDTA chelation, whereas endothelial keratoplasty might be delayed until the time point of corneal decompensation.

Long-term clinical outcomes after Descemet Membrane Endothelial Keratoplasty (DMEK) in Irido-Corneal Endothelial Syndrome

Purpose

To evaluate the long-term clinical outcomes after Descemet Membrane Endothelial Keratoplasty (DMEK) in Irido-Corneal Endothelial Syndrome (ICE).

Observation

Four eyes of four patients diagnosed with ICE syndrome were treated with DMEK. Postoperatively, best corrected visual acuity (BCVA) and central endothelial cell density (ECD) were documented at 6, 12, 24 and 36 months for all the cases. All procedures were uneventful. Average follow-up time was 36 months. BCVA improved in all eyes. Mean BCVA improved significantly from 1.54 ± 0.71 log MAR preoperatively to 0.11 ± 0.14 logMAR at the final follow-up. Average donor ECD was 2895 ± 357 cells/mm² preoperatively and 1992 ± 321 cells/mm², 1816 ± 395 cells/mm², 1571 ± 299 cells/mm² and 1305 ± 246 cells/mm² at 6, 12, 24 and 36 months after DMEK surgery respectively. This represented an average endothelial cell loss (ECL) of 31.3%, 37.7%, 46.8% and 55.1% at 6, 12, 24 and 36 months respectively. Postoperative intraocular pressure (IOP) rise was seen in 3 eyes at 1 month which normalized under topical antiglaucoma medications.

Conclusion

DMEK is a relatively safe procedure providing favourable clinical outcomes in eyes with ICE syndrome. Since angle closure is progressive in these condition, regular IOP monitoring and glaucoma control is critical for long term survival of the graft.

Importance

Till date management of ICE syndrome has always been a great challenge due to its varied presentation and complex anatomical abnormalities. Replacing the endothelial cells in an irregular anterior chamber poses additional difficulty. Even well-trained DMEK surgeons find it difficult to appose the Descemet's Membrane (DM) in such a scenario and we in this article provide key surgical tips for successful long term management of these cases.

Successful pediatric DMEK facilitated by intracameral tissue plasminogen activator to mitigate anterior chamber fibrin reaction

Purpose

To report a case of a successful Descemet's membrane endothelial keratoplasty (DMEK) facilitated by the use of intracameral tissue plasminogen activator (tPA) in a 4-year old with posterior polymorphous corneal dystrophy (PPCD).

Observations

A 4-year old male was referred for bilateral corneal haze and blurry vision. Patient's exam and genetic testing were consistent with a diagnosis of PPCD. Patient was successfully treated with DMEK augmented by the use of intracameral tPA intraoperatively to combat the anterior chamber fibrin formation that can occur in DMEK.

Conclusions

To our knowledge, this case represents the youngest reported successful DMEK procedure and the first case describing the use of intracameral tPA intraoperatively to attenuate the anterior chamber fibrin formation that can occur in DMEK.

Iridocorneal endothelial syndrome in a patient with keratoconus - a case report

Background

To describe a case of a rare association of bilateral keratoconus and unilateral essential iris atrophy and to conduct a literature review of the current strategies of treatment of the corneal disease and glaucoma in patients with Iridocorneal Endothelial Syndrome (ICE).

Case presentation

We report a rare association of bilateral keratoconus and unilateral essential iris atrophy in a 38-year-old man. Diagnosis of bilateral keratoconus was confirmed by corneal topography. Slit-lamp examination showed extensive iris atrophy with corectopia and policoria in one eye. Corneal specular microscopy revealed an abnormal endothelium morphology in the same eye with extensive peripheral anterior synechiae and closure of the drainage angle at gonioscopy. Intraocular pressure was 26 mmHg, despite maximal topical therapy. Optic disc examination showed severe glaucomatous cupping. Surgery by glaucoma drainage device implantation was performed.

Conclusion

Essential iris atrophy is a rare clinical variant of ICE syndrome characterized by profound anatomical alterations of the anterior segment associated with corneal edema and secondary glaucoma. In these patients, selective keratoplasties have replaced penetrating keratoplasty to treat corneal decompensation and glaucoma drainage devices are preferred to conventional trabeculectomy for the treatment of secondary glaucoma.