Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange

Anterior chamber intraocular lens removal combined with triple DMEK: Quadruple DMEK for bullous keratopathy

PURPOSE

To present the outcomes of a patient with anterior chamber intraocular lens (ACIOL) related endothelial decompensation who underwent Descemet membrane endothelial keratoplasty (DMEK) and cataract surgery with intraocular lens (IOL) implantation in the capsular bag (so-called triple DMEK) combined with ACIOL removal (quadruple DMEK) in both eyes.

METHODS

Case report.

RESULTS

A 58-year-old female patient was referred due to decreased visual acuity within the last 18 months. She had a history of iris-claw ACIOL implantation 17 years before. The corrected distance visual acuity (CDVA) was 20/40 in both eyes. Due to low endothelial cell density and increased corneal thickness, ACIOL removal combined with triple DMEK (as quadruple DMEK) was performed for both eyes. Despite a graft detachment that was successfully managed with re-bubbling in the first eye, both eyes showed an increase in the CDVA (20/25 and 20/32, respectively) without any other significant complications in the follow-up of the patient. The corneas of both eyes were clear postoperatively.

CONCLUSION

This case report demonstrated that quadruple DMEK may provide feasible management for chronic endothelial cell decompensation secondary to iris-claw ACIOL implantation.

Efficacy and safety of UT-DSAEK combined with Carlevale's sutureless scleral fixation IOL

PURPOSE

To evaluate a novel surgical combination of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and sutureless scleral fixation for Carlevale intraocular lens (SSF-Carlevale IOL) implantation to manage corneal endothelial decompensation when there is a concomitant need for secondary IOL fixation.

METHODS

Clinical data collected from 10 eyes of 9 patients with bullous keratopathy (BK) who underwent combined UT-DSAEK and SSF-Carlevale IOL implantation in a single procedure were retrospectively analyzed. Anterior chamber IOL (4 cases), aphakia (4 cases, 1 of which associated with PEX), and previous trauma (2 cases) were the conditions responsible for BK. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell density (ECD), central corneal thickness (CCT), graft thickness (GT) and complications were recorded over a 12-month follow-up period.

RESULTS

In 90% (9/10) of eyes graft clarity was maintained during follow-up. The mean CDVA improved significantly (p < 0.0001) from 1.78 ± 0.76 logMAR preoperatively to 0.53 ± 0.3 logMAR at 12 months. ECD on average decreased from 2575 ± 125.3 cells/mm2 (donor tissue) to 1697 ± 133.3 cells/mm2 in 12 months. The mean CCT decreased from 870 ± 200 µm to 650 µm ± 9 at 12 months (ANOVA, p = 0.0005).

CONCLUSIONS

Combined UT-DSAEK and SSF-Carlevale IOL implantation was associated with good corneal graft survival and IOP control, with few complications. These findings suggest that this surgical approach is a practical option for patients requiring both treatment for corneal endothelial dysfunction and secondary IOL implantation.

Outcomes of Secondary Intraocular Lens Implantation and Descemet Stripping Endothelial Keratoplasty-Comparing Staged Versus Combined Surgical Approach

PURPOSE

The aim of this study was to compare the outcomes of staged versus combined surgical approach for secondary intraocular lens (IOL) implantation and Descemet stripping endothelial keratoplasty (DSEK).

METHODS

This is a retrospective review of 124 eyes from 124 patients who underwent either staged or combined secondary IOL implantation in addition to DSEK over a 5-year period at 2 academic tertiary referral centers, between January 1, 2014, and October 1, 2019. Corrected distance visual acuity (CDVA), presence of graft detachment, primary graft failure (PGF), and cystoid macular edema were documented and analyzed.

RESULTS

The CDVA for the 1- to 2- month follow-up period was significantly better in the staged group compared with the combined group ( P = 0.011). By the postoperative 6- to 9-month follow-up period, there was no significant difference in the CDVA between the groups ( P = 0.591). There was no significant difference in the incidence of PGF or graft detachment between the 2 groups ( P > 0.05). In addition, there was no significant difference in the CDVA or rate of postoperative complications between the different methods of IOL fixation.

CONCLUSIONS

The short-term visual outcomes were significantly better in eyes that underwent staged secondary IOL implantation and DSEK versus the combined surgical approach, although the difference was no longer present at 6 to 9 months. There was no difference in the rate of PGF or graft detachment between the 2 groups.

Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens

Purpose

To assess the incidence of glaucoma after combined Descemet's stripping endothelial keratoplasty (DSEK) and retropupillary fixated iris-claw intraocular lens (IOL) implantation in the patients with bullous keratopathy (BK) who required secondary IOL or IOL exchange.

Methods

In this retrospective case series, medical records of 22 patients who underwent combined DSEK and retropupillary fixated iris-claw IOL implantation were evaluated. Preoperative vision, intraocular pressure (IOP), postoperative IOP at different time periods, and intraoperative and postoperative complications were analyzed.

Results

A total of 22 eyes of 22 patients (7 females and 15 males) were analyzed. The median age was 62 years, and the median duration of the postoperative follow-up was 106.5 days. The corrected distance visual acuity improved from a median of 1.85 logMAR to 1.68 logMAR. None of the patients had intraoperative complications. Three patients (13.6%) had dislocation of the donor tissue on the 1^st postoperative day and were successfully rebubbled. Six eyes (27.3%) had graft failure and required penetrating keratoplasty. Eleven eyes (50%) had a sustained rise in the IOP, of which 2 (9.09%) had ocular hypertension and 9 eyes (40.9%) progressed to glaucoma.

Conclusions

DSEK combined with retropupillary fixated iris-claw lens is a good surgical option for the management of aphakic/pseudophakic BK in patients who require secondary IOL or IOL exchange. Regular IOP monitoring after the surgery is an essential, as there is a risk of IOP rise and glaucoma in the postoperative period. Clinicians should be vigilant and control the IOP to prevent glaucoma progression.

Visual Outcome of Combined Descemet Stripping Endothelial Keratoplasty and Sutured Scleral Fixated Intraocular Lens in Endothelial Decompensation with Coexistent Aphakia or Intra Ocular Lens Subluxation

Purpose To elucidate visual outcome of patients after combined Descemet stripping endothelial keratoplasty (DSEK) with scleral fixated intra ocular lens (SFIOL) implantation in patients of endothelial decompensation with coexistent aphakia or lens subluxation.

Materials and Methods A prospective interventional study of combined DSEK with sutured SFIOL in the patients who have undergone surgery at our center over 6-month follow-up period. Preoperative visual acuity and slit lamp findings were documented. Postoperative follow-up was done at days 1, 3, and 7 subsequently, months 1 and 3, and thereafter monthly till the sixth month.

Results Mean age of the patients was 60.47 years. Six patients had aphakic bullous keratopathy, while 11 patients had pseudophakic bullous keratopathy with subluxated posterior chamber IOL (PCIOL). Preoperative visual acuity ranged from hand movements close to face (LogMar 2.4) with accurate projection of rays to 1/60 (LogMar 2) due to existing corneal edema and aphakia. Postoperatively uncorrected visual acuity at 6 months improved up to 6/36 (LogMar 0.8) in all cases. There was gradual improvement in corneal clarity and compactness during the follow-up. A good donor tissue endothelial count and an adequate IOP control were vital prognostic factors for the successful outcome.

Conclusion This novel surgical merger reduces the complications of lenticule dislocation into vitreous and repeated surgeries and shows results akin to when performed in a staged manner.

Descemet-stripping automated endothelial keratoplasty with intrascleral haptic-fixated intraocular lens in a sequential vs simultaneous approach

PURPOSE

To compare the outcomes of Descemet-stripping automated endothelial keratoplasty (DSAEK) with intrascleral haptic-fixated intraocular lens (IOL) in a sequential and simultaneous approach.

SETTING

Tertiary eyecare center.

DESIGN

Prospective randomized comparative study.

METHODS

Patients with aphakic or complicated pseudophakic bullous keratopathy visiting a tertiary eyecare center were included in the study. A total of 40 patients were randomized into 2 groups of 20 each. Group 1 had subjects who underwent scleral-fixated IOL (SF IOL) implantation by intrascleral haptic fixation technique, followed by DSAEK (sequential procedure) with an interval of at least 3 months. Group 2 (simultaneous) had subjects who underwent DSAEK with SF IOL as a combined procedure. Graft survival, endothelial cell loss (ECL), corrected distance visual acuity (CDVA), and need for any intervention such as rebubbling were evaluated for both the groups at the end of 6 months.

RESULTS

At 6 months, the sequential group had significantly better CDVA of 0.62 ± 0.17 logMAR compared with 0.87 ± 0.19 logMAR in the simultaneous group (P = .002). Group 1 had significantly better overall cumulative graft survival (100% vs 60%, P = .002), significantly lower ECL (P = .006), lesser mean central corneal thickness (P = .03), and significantly thinner donor lenticule (P = .009). Rebubbling rate was significantly higher in Group 2 (P = .025). The mean hyperopic shift was significantly more in Group 2 (P = .02).

CONCLUSION

The sequential procedure of SF IOL followed by DSAEK has better visual outcomes and graft survival when compared with simultaneous procedure in cases of aphakic or complicated pseudophakic bullous keratopathy.

Endothelial keratoplasty with anterior chamber intraocular lens versus secondary posterior chamber intraocular lens

AIM

To describe the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with an anterior chamber intraocular lens (ACIOL) compared to secondary posterior chamber (PC) IOL.

METHODS

This was a retrospective comparative cohort study. The clinical data of 82 eyes from 82 consecutive patients with pseudophakic (PBK) or aphakic bullous keratopathy (ABK) who either underwent DSAEK with retained or secondary ACIOL (n=23) or DSAEK with IOL exchange and/or secondary PCIOL (retropupillary iris-claw IOL, n=25; intrascleral-fixated IOL, n=29; or sulcus IOL, n=5) were analysed. The main outcome measures were graft survival and complications up to 5 years.

RESULTS

The graft survival in the secondary PCIOL group was superior than the ACIOL group over 5 years (year 1, 100.0% vs 100.0%; year 3, 94.7% vs 75.0%; year 5, 91.1% vs 60.6%, p=0.022). The presence of an ACIOL was a significant risk factor associated with graft failure (HR, 4.801; 95% CI, 1.406 to 16.396, p=0.012) compared to a secondary PCIOL. There was no significant difference in the rate of graft detachment and elevated intraocular pressure between the groups. There were five cases (9.3%) of IOL subluxation or dislocation in the retropupillary iris-claw and intrascleral-fixated IOL groups.

CONCLUSIONS

Eyes that underwent DSAEK with ACIOL in situ had poorer long-term graft survival compared with those with secondary PCIOL. Intraocular lens exchange was not associated with a higher complication rate. In ABK or PBK eyes with ACIOL, we recommend performing IOL exchange and/or secondary PCIOL implantation combined with endothelial keratoplasty.

Corneal transplantation after failed grafts: Options and outcomes

Corneal transplantation is the most commonly performed human tissue transplantation procedure worldwide. Because of the large number of transplants, corneal graft failure has become one of the most common indications for corneal transplantation. The relatively recently developed lamellar transplant techniques have brought about specific potential complications leading to graft failure that may require different approaches to repeat transplantation other than penetrating keratoplasty. On the other hand, these new lamellar techniques also provide novel ways of rescuing failed penetrating grafts, with potential advantages over successive penetrating keratoplasties, such as reduced intraoperative risks and faster visual rehabilitation. We summarize the incidence and risk factors of graft failure for penetrating and lamellar (stromal and endothelial) corneal transplants and discuss the various surgical alternatives currently available to rescue such failed grafts, with a focus on the reported outcomes and limitations.

Descemet membrane endothelial keratoplasty for corneal decompensation caused by a phakic anterior chamber intraocular lens implantation

PURPOSE

To describe the clinical outcomes of Descemet membrane endothelial keratoplasty combined with phacoemulsification/posterior chamber intraocular lens implantation (triple procedure) for treatment of corneal decompensation induced by a phakic anterior chamber intraocular lens (AC IOL) implantation.

METHODS

Ten patients (10 eyes) with corneal decompensation due to phakic AC IOL implantation that had undergone the triple procedure were included in this study. Among the 10 eyes, 5 eyes underwent explantation of AC IOL prior to the transplantation, and then underwent the triple procedure. The remaining 5 eyes with a phakic AC IOL in situ underwent the triple procedure with concurrent explantation of AC IOL. Corrected distance visual acuity (CDVA), subjective refraction, endothelial cell density (ECD), and complications were documented.

RESULTS

The triple procedure was performed across all eyes without any adverse events. The average CDVA improved from 1.32 ± 0.24 preoperatively to 0.15 ± 0.05 logarithm of the minimum angle of resolution (logMAR), which represents an improvement in Snellen equivalent from 20/400 (0.05) preoperatively to 20/28 (0.71) at 12 months after surgery. At 12 months, all eyes reached a CDVA of 20/32 (0.63) or better, and 50% of eyes reached a CDVA of 20/25 (0.8) or better. The mean donor ECD±SD was 2868.7 ± 67.9 cells/mm², which decreased to 1724.1 ± 84.6 cells/mm² at 12 months, representing 39.9% of endothelial cell loss. Patients did not experience any severe adverse events.

CONCLUSION

The triple procedure is a safe and effective option for corneal decompensation induced by a phakic AC IOL implantation, helping achieve a satisfactory visual rehabilitation with few complications.

Glued Intraocular Lens Combined with Endothelial Keratoplasty: A Case Report

In an aphakic eye with corneal edema, performing Descemet's stripping automated endothelial keratoplasty (DSAEK) combined with implantation of intraocular lens can be a challenge. This case report describes a surgical technique for postsurgical aphakia with endothelial decompensation in a 42-year-old female with Marfan syndrome and subluxated lens. This technique comprised implanting DSAEK with fibrin glue-assisted sutureless posterior chamber intraocular lens. The donor lenticels were formed on a 60-kHz femtosecond laser platform (IntraLase^®). Two partial-thickness scleral flaps and sclerotomies were created, and then, the Descemet's membrane was scored and stripped. A posterior chamber intraocular lens was implanted, and its haptics was pulled out through the sclerotomies and tucked beneath the flaps. The flaps were then apposed with fibrin glue. The donor lenticule was introduced to the anterior chamber and unfolded. Air tamponade was used to stabilize and center it. This technique significantly improved the uncorrected and best-corrected visual acuities of the patient, and no donor dislocations were reported. This case corroborates the findings of few similar cases that have found combined use of glued intraocular lens with DSAEK to be beneficial in such cases.

Endothelial keratoplasty in eyes with a retained angle-supported intraocular lens

PURPOSE

To describe the outcomes of endothelial keratoplasty (EK) for bullous keratopathy in eyes with a retained angle-supported anterior chamber intraocular lens (acIOL).

METHODS

Among 263 consecutive EK procedures, 7 DMEK and 11 DSAEK procedures were identified in eyes with an acIOL and included in the present retrospective case series. Pre- and postoperative status including ocular history, anatomical outcome and complications as well as best-corrected visual acuity was evaluated.

RESULTS

Ocular history included complicated cataract surgery (n = 11), ocular trauma (n = 4) and primary intracapsular cataract extraction (n = 3). Surgery-related complications included primary graft failure (n = 1), graft detachment (n = 1), endophthalmitis (n = 1) and allograft rejection (n = 1). A clear cornea at the final examination (14 ± 4 months) was observed in 14/18 (78%), while the visual outcome was limited due to significant ocular comorbidity in 9 out of 14 uncomplicated procedures.

CONCLUSION

The presented short-term outcomes suggest that both DMEK and DSAEK are feasible in eyes with an angle-supported acIOL yielding an acceptable graft survival rate in the first postoperative year.

Association between transient interface fluid on intraoperative OCT and textural interface opacity after DSAEK surgery in the PIONEER study

PURPOSE

The aim of this study was to examine the association between transient interface fluid (TIF) and textural interface opacity (TIO) after Descemet stripping automated endothelial keratoplasty (DSAEK) surgery using intraoperative optical coherence tomography (iOCT) in the PIONEER (Prospective Intraoperative and Perioperative Ophthalmic ImagiNg with Optical CoherEncE TomogRaphy) study.

METHODS

All consecutive eyes that underwent DSAEK between October 2011 and September 2013 from the PIONEER intraoperative and perioperative OCT study were included. iOCT images were captured after lenticule apposition with complete air fill and after air-fluid exchange. Postoperative day 1 OCT images were obtained. Outcome variables included the presence of TIO at the graft-host junction and the presence of intraoperative and postoperative interface fluid on OCT.

RESULTS

Seventy-six eyes from 69 patients who underwent DSAEK with iOCT were included. The mean age of the patients was 71 years (range 31-90). The 2 most common indications for surgery were Fuchs dystrophy (63%) and pseudophakic bullous keratopathy (24%). In 18 of 76 (23.7%) eyes, TIF was visible on iOCT post air-fluid exchange. Of these eyes, 14 developed TIO. TIO was observed in 18 of 76 (23.7%) eyes. TIF on iOCT was associated with a significantly higher rate of postoperative TIO (odds ratio = 47.25; P < 0.0001). Sixteen of the 18 eyes that had TIF on iOCT had had resolution on the postoperative day 1 OCT. There was no significant difference in the mean graft thickness between eyes with TIF on iOCT and those without (P = 0.58).

CONCLUSIONS

Eyes with TIF on iOCT are more likely to develop TIO in the postoperative period. It is believed that the process of gap closure results in TIO, possibly secondary to precipitated solutes, retained viscoelastic, or lamellar irregularities caused by delayed adhesion or uneven matching of lamellar fibrils.

Outcomes of descemet stripping automated endothelial keratoplasty in patients with an anterior chamber versus posterior chamber intraocular lens

PURPOSE

The aim of this study was to assess the implications of a retained anterior chamber intraocular lens (ACIOL) during Descemet stripping automated endothelial keratoplasty (DSAEK) and to compare the outcomes in this group with those in patients who underwent DSAEK and had a posterior chamber intraocular lens (PCIOL).

METHODS

This is a retrospective cohort study conducted in a tertiary medical center, which compares patients who underwent DSAEK and had a retained ACIOL with patients who underwent DSAEK and had a PCIOL regarding operative and postoperative complications, visual acuity, endothelial cell density, and long-term graft survival.

RESULTS

Eleven eyes with an ACIOL and 50 eyes with a PCIOL met the study criteria. No significant differences were found between the groups in terms of operative complications, change in visual acuity, graft survival, and endothelial cell loss.

CONCLUSIONS

DSAEK in the setting of an ACIOL produced similar results to those of uncomplicated PCIOL cases. Although further studies are needed to gain more accurate information on this subject, it seems that DSAEK can be performed while retaining an ACIOL with favorable results.

Descemet's stripping automated endothelial keratoplasty with anterior chamber intraocular lenses: complications and 3-year outcomes

PURPOSE

To describe outcomes and complications following Descemet's stripping automated endothelial keratoplasty (DSAEK) in eyes with pseudophakic bullous keratopathy (BK) while retaining the anterior chamber intraocular lenses (ACIOL).

METHODS

We included consecutive patients who underwent DSAEK for BK at a single tertiary centre from 1 January 2008 to 1 April 2010, from our prospective cohort (Singapore Corneal Transplant Study). We compared eyes with BK, which underwent DSAEK while retaining ACIOL (n=18), to those with DSAEK alone with the posterior chamber intraocular lenses left in place as a comparison group (n=114). Main outcome measures were endothelial cell (EC) loss and graft survival.

RESULTS

The percentage EC loss at 1 year was 31.9±21.3% in the DSAEK with ACIOL group compared to 24.5±21.2% in the DSAEK group (p=0.516); however, this figure was significantly greater in the DSAEK with ACIOL group at 3 years compared to the DSAEK group (55.3±29.2% vs 33.3±20.8%; p=0.01 respectively). Graft survival was also significantly poorer in the DSAEK ACIOL group compared to the DSAEK group over 3 years (log rank p=0.002).

CONCLUSIONS

We found that although eyes with BK and ACIOL that underwent DSAEK while retaining the ACIOL suffered EC loss which was not significantly greater at 1 year, EC loss and graft survival were significantly poorer compared to DSAEK controls at 3 years postoperatively.

Intrascleral fibrin glue intraocular lens fixation combined with Descemet-stripping automated endothelial keratoplasty or penetrating keratoplasty

PURPOSE

To evaluate the outcomes of intrascleral haptic fixation of an intraocular lens (IOL) with fibrin glue combined with penetrating keratoplasty (PKP) or Descemet-stripping automated endothelial keratoplasty (DSAEK) for aphakic or pseudophakic bullous keratopathy (BKP).

SETTING

Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

DESIGN

Case series.

METHODS

Eyes with BKP had combined PKP or DSAEK with fibrin glue-assisted intrascleral posterior chamber (PC) IOL fixation; PKP was performed in eyes with a corneal scar and DSAEK in eyes without a scar. The parameters evaluated were corrected distance visual acuity (CDVA), anterior segment biomicroscopy, intraocular pressure, central corneal thickness (CCT), and IOL status. Intraoperative events and postoperative complications were recorded.

RESULTS

The study evaluated 11 patients (11 eyes). Intrascleral fixation of a PC IOL with PKP or DSAEK was successfully performed in all eyes; PKP was performed in 6 eyes (54.54%) and DSAEK in 5 eyes. The mean CDVA improved from 1.95 logMAR ± 0.29 (SD) to 0.40 ± 0.16 logMAR (P<.001). The mean CCT was 0.741 ± 0.71 mm preoperatively and 0.579 ± 0.20 mm postoperatively (P<.001). There were no cases of intraoperative or postoperative IOL decentration or other complications.

CONCLUSIONS

Fibrin glue-assisted intrascleral fixation of a PC IOL combined with DSAEK or PKP was a safe, effective method to manage BKP with aphakia or malpositioned IOLs. The IOL fixation was strong enough to sustain the manipulation required for corneal procedures.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Endothelial keratoplasty with pars plana air-fluid exchange in the absence of an intact lens-iris diaphragm

The author reports the use of pars plana air-fluid exchange in promoting adhesion of the donor endothelial graft to the host cornea during Descemet's membrane stripping with endothelial keratoplasty in the absence of an intact lens-iris diaphragm. A three-port pars plana 25-gauge core vitrectomy is performed, followed by the insertion of the endothelial graft into the anterior chamber with a glide. After the limbal incision and the paracentesis site are sutured, the air-fluid exchange is done from the vitreous cavity toward the anterior chamber until the eye is completely filled with air. The air infusion pressure is maintained at 30 mm Hg for 10 minutes. The endothelial graft is centered with a roller. The pars plana cannulas are removed, and the scleral incisions seal spontaneously. This technique ensures that the anterior chamber is completely filled with air at the end of case and provides fine control of the intraocular pressure throughout the surgery.

Endothelial keratoplasty: a revolution in evolution

Endothelial keratoplasty (EK) is continually evolving both in surgical technique and clinical outcomes. Descemet's stripping endothelial keratoplasty (DSEK) has replaced penetrating keratoplasty (PK) as the treatment of choice for corneal endothelial dysfunction. It is safe and predictable and offers early visual rehabilitation. Newer iterations include Descemet's membrane endothelial keratoplasty, Descemet's membrane automated endothelial keratoplasty, and other hybrid techniques. Early data on these newer EK techniques suggests that they provide significantly better visual outcomes compared to DSEK. Initial 5-year survival data indicates that EK is at least comparable to PK, and more widespread survival data is anticipated. Further work is needed to simultaneously optimize visual outcomes, refractive predictability, and endothelial cell survival, as well as surgical techniques of donor preparation and insertion.

Descemet's Stripping-Automated Endothelial Keratoplasty for Traumatic Aniridia and Aphakia

This Interventional case reports a challenging case of descemet's stripping-automated endothelial keratoplasty (DSAEK) in a young male patient with traumatic aniridia, aphakia, and corneal edema. Surgery was planned in two stages; first was implantation of aniridia intraocular lens (AIOL), few months later, DSAEK procedure was performed. Successful outcome of both procedures was achieved as measured by the stability of the AIOL, clarity of the cornea, attachment of the lenticule, and improvement in vision. Aniridia implant supports a sufficient amount of air in the anterior chamber especially if the posterior segment is well formed, while providing the required lens power to improve vision. DSAEK procedure challenges that include iris defects and aphakia may be overcome by stepwise planning of the procedure.

[Complications after endothelial keratoplasty: three years of experience]

OBJECTIVE

To study the complications after Descemet's stripping automated endothelial keratoplasty (DSAEK).

METHODS

Retrospective study of 75 eyes in 67 patients with Fuchs' endothelial dystrophy or bullous keratopathy operated on in the Instituto de Oftalmología La Arruzafa from March, 2007 until March, 2010. Phacoemulsification and IOL implantation was involved in 30 cases. All surgical and post-surgical complications, as well as the endothelial cell density were recorded.

RESULTS

Graft detachment was the most common complication: 17 cases (22.5%); 16 of them resolved with reintroduction of air in the anterior chamber. The rate of detachment in cases without capsular support (8 eyes) increased up to 50%. Five cases had primary graft failure and, in 2 cases, a medium term failure was observed. Only one case of endothelial rejection was observed (1.3%). Five eyes (6.5%) developed a pupillary block, but of them were solved with the aspiration of the air. In one eye (1.3%), a posterior capsule rupture was observed during the phacoemulsification. This case ended with a retinal detachment. The endothelial cell loss was 42.75%.

CONCLUSIONS

DSAEK is an effective surgical technique to resolve the corneal oedema due to endothelial failure; however, complications are not uncommon. Graft detachment is the most common complication, but is usually resolved with re-bubbling. There is an evident learning curve and the surgical trauma to the endothelium is the most important factor that influences the endothelial cell loss.

Early outcomes of descemet stripping automated endothelial keratoplasty in pseudophakic eyes with anterior chamber intraocular lenses

PURPOSE

To evaluate complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty in eyes with preexisting anterior chamber intraocular lenses.

DESIGN

Retrospective review.

METHODS

Thirty-one patients who underwent Descemet stripping automated endothelial keratoplasty and who had a preexisting anterior chamber intraocular lens were identified from May 2006 through March 2009. Patient follow-up ranged from a minimum of 1 month up to 30 months. Preoperative and postoperative best spectacle-corrected visual acuity, manifest refraction, comorbid conditions, and complications were recorded. Endothelial cell loss, graft dislocation, graft failure rates were calculated.

RESULTS

The mean age at surgery was 78 ± 9 years (range, 53 to 91 years). All eyes had pseudophakic bullous keratopathy, except 1 patient who had a failed penetrating keratoplasty graft. Excluding those patients with severely limited visual potential because of noncorneal pathologic features, the mean best spectacle-corrected visual acuity improved significantly from 20/200 to 20/400 before surgery to 20/63 at 3 months (P < .0001), 20/60 at 6 months (P = .0006), 20/50 at 12 to 15 months (n = 10; P = .004), and 20/40 between 23 and 30 months (n = 8; median, 25 months; P = .007). The preoperative mean spherical equivalent was -0.3 ± 1.8 diopters compared with -0.15 ± 1.5 diopters after surgery (P = .78). The graft dislocation rate was 13%, and the graft failure rate was 16%. For those patients with endothelial cell density data available, the average endothelial cell loss was 48% at a mean of 14 months.

CONCLUSIONS

Although Descemet stripping automated endothelial keratoplasty surgery in patients with an anterior chamber intraocular lens remains a controversial topic, the visual and anatomic outcomes from this limited study support this approach as a surgical option in selected cases.

Complications and clinical outcomes of descemet stripping automated endothelial keratoplasty with intraocular lens exchange

PURPOSE

To evaluate complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with intraocular lens (IOL) exchange compared with DSAEK alone.

DESIGN

Retrospective, interventional case series.

METHODS

DSAEK was performed in 19 eyes in which the anterior chamber IOL was exchanged for a posterior chamber IOL (study group) and in 188 eyes in which the posterior chamber IOL was left in place (comparison group). The complications of graft dislocations, primary graft failure episodes, and pupillary block were recorded for all eyes. Six-month best spectacle-corrected visual acuity and mean central endothelial cell density were measured prospectively and then compared with preoperative values for all eyes.

RESULTS

Dislocations occurred in 0 (0%) of 19 eyes in the study group and in 5 (3%) of 188 eyes in the comparison group (P = .47), with 0 primary graft failures and 0 pupillary block episodes in either group. Preoperative mean best spectacle-corrected visual acuity for those eyes without any underlying ocular comorbidities was 20/205 and 20/100 in the study and comparison groups, respectively (P = .18). Mean best spectacle-corrected visual acuity at 6 months improved to 20/48 in the study group and to 20/34 in the comparison group, a statistically significant difference (P = .01). Mean donor cell loss at 6 months was 33% in the study group and 26% in the comparison group (P = .18).

CONCLUSIONS

Concurrent IOL exchange with DSAEK surgery does not increase the dislocation, primary graft failure, or pupillary block rates in the immediate postoperative period. Donor endothelial cell loss in DSAEK was not increased significantly by IOL exchange. Visual acuity was slightly worse after combined surgery than after DSAEK alone.

Endothelial keratoplasty: DSEK/DSAEK or DMEK--the thinner the better?

PURPOSE OF REVIEW

Endothelial keratoplasty has been adopted worldwide as an alternative to penetrating keratoplasty in the treatment of corneal endothelial disorders. Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) may be the current standard, whereas Descemet membrane endothelial keratoplasty (DMEK), that is, isolated transplantation of Descemet membrane, may allow further improvement of clinical outcome.

RECENT FINDINGS

DSEK/DSAEK may still have three major challenges: suboptimal visual acuity and relatively slow visual rehabilitation, limited accessibility due to required investments in equipment or the purchase of predissected tissue, and a drop in donor endothelial cell density in the early postoperative phase. Although DMEK may allow much quicker and (near) complete visual rehabilitation as well as easier logistics in donor preparation, the surgical technique may initially require more training to obtain consistent outcomes.

SUMMARY

Compared with DSEK/DSAEK, DMEK may have higher clinical potential with 75% of cases reaching 20/25 or better (> or =0.8) within 1-3 months. Furthermore, preparation of isolated Descemet grafts does not require large investments and may increase overall donor tissue availability. Hence, corneal surgeons may consider 'to make the switch' from DSEK/DSAEK to DMEK.

Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology

OBJECTIVE

To review the published literature on safety and outcomes of Descemet's stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea.

DESIGN

Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives.

RESULTS

The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection (mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from -0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%).

CONCLUSIONS

The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.