Descemet Stripping with Automated Endothelial Keratoplasty for Bullous Keratopathies Secondary to Argon Laser Iridotomy-Preliminary Results and Usefulness of Double-Glide Donor Insertion Technique

Busin Glide-Assisted Pull-Through Insertion of Artificial Corneal Endothelium (EndoArt)

Background

Currently, the push-in technique through the corneal tunnel using a blunt-tip spatula is used to insert an artificial corneal endothelium (EndoArt) into the anterior chamber (AC). The device is useful for patients with bullous keratopathy; however, it may be difficult to manipulate the very thin implant through hazy cornea. Unlike DMEK graft, it cannot be stained and the F-mark is faint. So, visualizing and orienting the implant is a real challenge especially through a hazy cornea and inadequate AC visualization. Therefore, alternative EndoArt implantation techniques are needed in patients with advanced endothelial dysfunction to avoid complications.

Purpose

To report an alternative technique for EndoArt implantation using a Busin glide.

Technique

The EndoArt was loaded onto the Busin glide with the concave side of the EndoArt facing upward and was then pulled/pushed into the Busin glide opening. After the Descemet's membrane and endothelium were detached and removed in a circular fashion in a patient with advanced corneal endothelial decompensation, the Busin glide was inserted into the corneal incision, and the EndoArt was slowly pulled into the AC using retractor forceps. Finally, the air was injected into the AC.

Conclusion

The Busin glide-assisted pull-through technique smoothly and securely inserted the EndoArt into the AC without upside-down attachment. This alternative technique can be useful for patients with a history of repeat intraocular surgeries or trauma with severe corneal edema to avoid potential complications such as epithelial implantation cysts or downgrowth.

Size and Shape Matter: Cell Viability of Preloaded Descemet Stripping Automated Endothelial Keratoplasty Grafts in Three Different Carriers

PURPOSE

The aim of this study was to examine endothelial cell loss (ECL) associated with preloaded Descemet stripping automated endothelial keratoplasty (DSAEK) grafts loaded into 3 carriers of different size and shape.

METHODS

Thirty-six donor corneas were prepared for DSAEK and loaded into an EndoGlide Ultrathin (control) (2.0 mm × 3.5 mm lumen, 4.5 mm/4.9 mm incision for scleral tunnel/clear corneal insertion), Descemet membrane endothelial keratoplasty EndoGlide (experimental) (1.1 mm × 1.7 mm lumen, 2.65 mm incision), or round glass Jones tube (experimental) (1.8 mm lumen, 3.0 mm incision). Control grafts were stored for 6 days in Optisol-GS and experimental grafts stored for 24 hours in Life4C before analysis using Calcein AM staining. Grafts were imaged and ECL was analyzed by FIJI segmentation. The statistical significance of ECL was determined using 1-way ANOVA and Tukey post hoc analysis.

RESULTS

There were no significant differences in donor characteristics for grafts in each cohort. ECL for grafts loaded into the EndoGlide Ultrathin was 10.3% ± 2.3% (graft thickness: 60-189 μm, n = 9). ECL for grafts loaded into the Descemet membrane endothelial keratoplasty EndoGlide was 22.2% ± 7.1% (graft thickness: 38-63 μm, n = 9). ECL for thin grafts (34-60 μm, n = 9) loaded into the Jones tube was 24.0% ± 5.0%. ECL for thick grafts (92-119 μm, n = 9) loaded into the Jones tube was 34.2% ± 6.1% ECL ( P < 0.001). Combined regression analysis revealed that graft thickness is directly correlated to ECL ( P < 0.01).

CONCLUSIONS

The size and shape of the carrier can influence the cell viability of preloaded DSAEK grafts. Compared with a larger carrier, smaller lumen carriers are associated with greater ECL. In smaller lumen carriers, ECL increases with increasing DSAEK graft thickness.

Graft rejection episodes after keratoplasty in Japanese eyes

We aimed to investigate the clinical characteristics and risk factors for graft rejection after keratoplasty in Japanese patients. We enrolled 730 cases (566 patients) of penetrating keratoplasty (PK, N = 198), Descemet's stripping automated endothelial keratoplasty (DSAEK, N = 277), non-Descemet's stripping automated endothelial keratoplasty (nDSAEK, N = 138), and Descemet membrane endothelial keratoplasty (DMEK, N = 117). The incidence, clinical characteristics, and possible risk factors for graft rejection were analyzed. Graft rejection occurred in 65 cases (56 patients, 8.9%). The incidence rate of rejection was highest with PK (3.45/100 person-years), followed by DSAEK (2.34), nDSAEK (1.55), and DMEK (0.24). Cox regression analysis revealed keratoplasty type, younger age, indications (such as failed keratoplasty and infection), and steroid eyedrop use as possible risk factors. In the multivariate model adjusting baseline characteristics, PK and DSAEK had significantly higher hazard ratios (HRs) than DMEK (HR = 13.6, 95% confidence interval [CI] [1.83, 101] for PK, 7.77 [1.03, 58.6] for DSAEK). Although not statistically significant, the HR estimate of nDSAEK to DMEK (HR = 7.64, 95% CI [0.98, 59.6]) indicated higher HR in nDSAEK than in DMEK. DMEK is the favorable option among the four surgical procedures to avoid graft rejection after keratoplasty.

Specifying Risk of Intraocular Lens Opacification After Endothelial Keratoplasty for Different Intraocular Lens Models: A Retrospective Monocentric Cohort Study

PURPOSE

The aims of this study were to calculate the specific risk of opacification for different intraocular lens (IOL) models and to determine whether differences exist, even between lenses made of similar acrylic materials.

METHODS

This is a retrospective cohort study of all patients who underwent endothelial keratoplasty (EK), either after or in conjunction with cataract surgery, from June 2009 to October 2020 at Fundación Jiménez Díaz Hospital.

RESULTS

Three hundred seventy-two eyes of 308 patients with a median follow-up of 856 days [interquartile range (IQR): 384-1570] were included, of which 128 IOLs were hydrophobic, 120 hydrophilic, and 124 unknown. 12.9% of IOLs opacified after a median of 466 days (IQR: 255-743). Visual acuity (VA) was significantly lower in the opacified IOL group [0.51 (IQR: 0.36-1.13)] compared with the nonopacified group [0.22 (IQR: 0.11-0.65)] ( P < 0.001). IOL explantation and exchange was performed in 10 eyes, in which VA improved markedly, from 1.75 (IQR: 0.99-3.00) to 0.60 (IQR: 0.36-0.86) ( P = 0.004). IOL material and opacification events were not independent ( P < 0.001). Significant differences were found between the Akreos ADAPT AO and MI60P models and the Asphina 409M model ( P = 0.022). No significant differences were found in the opacification ratio for hydrophilic IOLs in the clinical diagnosis ( P = 0.11), the type of EK ( P = 0.25), the rebubbling rate ( P = 0.44), or the tamponade used ( P = 0.36).

CONCLUSIONS

Hydrophilic lenses should be avoided in patients at risk of requiring EK. It is important to know the probability of opacification of each IOL model to balance risk and benefits when planning an EK procedure because not all lenses opacify equally. Opacification is an unwanted event with a negative impact on VA, making IOL explantation and exchange the only viable treatment, although one that is not without risks.

Novel Technique for Descemetorhexis Under Ophthalmic Viscosurgical Devices and Air

PURPOSE

The aim of this study was to describe a novel technique for descemetorhexis that combines the advantages of stable anterior chamber (AC) associated with ophthalmic viscosurgical devices and optimal surgical visualization seen with air to overcome the issues of poor Descemet membrane (DM) visibility or AC instability when each is used alone.

METHODS

This study is a description of a new surgical approach.

RESULTS

We describe a new technique for performing descemetorhexis. The simultaneous presence of cohesive ophthalmic viscosurgical device and air in the AC offers optimal DM visualization and guarantees a stable AC during this surgical step. It does not require an additional incision for an AC maintainer.

CONCLUSIONS

The described technique may facilitate the surgical step of descemetorhexis, offering improved AC stability and better visualization of the DM. It may reduce early postoperative graft detachment due to the presence of residues of the recipient's diseased DM.

Long-term outcomes of Descemet stripping automated endothelial keratoplasty for bullous keratopathy after argon laser iridotomy

PURPOSE

To report the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) for bullous keratopathy secondary to argon laser iridotomy (BK-ALI).

STUDY DESIGN

Retrospective chart review.

METHODS

Forty-five eyes from 41 consecutive patients with BK-ALI who underwent DSAEK from July 2007 to December 2013 were retrospectively analyzed. Best spectacle-corrected visual acuity (BCVA), endothelial cell density (ECD), and any complications were investigated over a 10-year postoperative period.

RESULTS

The mean BCVA improved from 0.80 logMAR before DSAEK to 0.28 logMAR at 6 months after DSAEK; the mean values showed an additional slight improvement between 6 months and 10 years after the surgery (P < .01). The mean ECD decreased from 2864 cells/mm² at baseline to 2269 cells/mm² (20.8% loss) at 6 months post-DSAEK, and this decreasing trend continued throughout the 10 years after DSAEK (P < .01). The mean ECD was 1148 cells/mm² (59.9% loss) after 5 years, and 568 cells/mm² (80.2% loss) after 10 years. No graft deaths were observed throughout the 10-year period (5-year follow-up rate 60.0%, 10-year follow-up rate 20.0%).

CONCLUSIONS

The 10-year outcomes of DSAEK for BK-ALI were excellent with a high graft survival rate.

Clinical Evaluation of the NS Endo-Inserter, a Novel Donor Inserter for Descemet's Stripping Automated Endothelial Keratoplasty

Purpose

This study investigated the clinical outcomes achieved with a newly developed donor inserter (NS Endo-Inserter [NSI], HOYA Co., Ltd., Tokyo, Japan) for Descemet's stripping automated endothelial keratoplasty (DSAEK) in Japanese eyes with bullous keratopathy secondary to argon laser iridotomy (BK-ALI). The NSI device utilizes pressure flow to push the DSAEK donor tissue into the anterior chamber.

Methods

Six eyes of 6 patients (1 male, 5 females; mean age, 78.5 years) with BK-ALI were enrolled. Donor tissue was pushed into the anterior chamber using the NSI. Intraoperative complications, graft dislocation, and iatrogenic primary graft failure were recorded for all eyes. Six-month postoperative central donor endothelial cell densities (ECD) were measured prospectively and compared with preoperative values, along with 6-month best corrected visual acuity (BCVA).

Results

In all cases, donor loading onto the NSI spatula and donor insertion into the anterior chamber using the NSI was smooth and successful; no intraoperative complications were noted. There were no cases of graft dislocation or IPGF. Postoperative ECD was 2,187.2 cells/mm² (mean loss, 14.8%) and mean BCVA increased from 0.27 decimal to 0.8 at 6 months.

Conclusion

In this small preliminary case series, clinical outcomes for patients with BK-ALI undergoing DSAEK using the NSI were comparable or better than those achieved with conventional DSAEK insertion techniques.

Descemet stripping automated endothelial keratoplasty performed by trainees

PURPOSE

To assess the surgical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) performed by trainees.

STUDY DESIGN

Retrospective, case control comparative study.

METHODS

This study compared cases performed by trainees with those performed by an experienced surgeon. First 10 cases of DSAEK performed by trainees with more than 6 months follow-up periods were recruited. The surgical outcomes of DSAEK performed by the trainees (Trainee group) were compared with disease-matched pairs of cases performed by an experienced surgeon (Experienced group). Graft clarity, best spectacle-corrected visual acuity, corneal endothelial cell density, and incidence of intra- or post-operative complications were studied.

RESULTS

Forty-one pairs were recruited. The graft clarity rate was not different between the Trainee and Experienced groups, with 95.1% and 97.6%, respectively, maintaining clear grafts at 12 months postoperatively. Trainee best spectacle corrected visual acuity was significantly worse at 6 and 12 months postoperatively compared with the Experienced group, and percent decreases in corneal endothelial density was more in the Trainee group at 3 months following surgery (P = 0.0029). While intra- or late post-operative complication rates were similar in both groups, incidences of early post-operative complications such as double chamber formation or pupillary block were observed more frequently in the Trainee group than in the Experienced group (P = 0.049).

CONCLUSION

DSAEK can be performed relatively safely by training physicians with careful preparation and supervision by attending physicians. However, careful case selection and education on management of air injected in the anterior chamber seemed to be a key to long-term success.

Corneal endothelial cell dysfunction: etiologies and management

A transparent cornea is essential for the formation of a clear image on the retina. The human cornea is arranged into well-organized layers, and each layer plays a significant role in maintaining the transparency and viability of the tissue. The endothelium has both barrier and pump functions, which are important for the maintenance of corneal clarity. Many etiologies, including Fuchs’ endothelial corneal dystrophy, surgical trauma, and congenital hereditary endothelial dystrophy, lead to endothelial cell dysfunction. The main treatment for corneal decompensation is replacement of the abnormal corneal layers with normal donor tissue. Nowadays, the trend is to perform selective endothelial keratoplasty, including Descemet stripping automated endothelial keratoplasty and Descemet’s membrane endothelial keratoplasty, to manage corneal endothelial dysfunction. This selective approach has several advantages over penetrating keratoplasty, including rapid recovery of visual acuity, less likelihood of graft rejection, and better patient satisfaction. However, the global limitation in the supply of donor corneas is becoming an increasing challenge, necessitating alternatives to reduce this demand. Consequently, in vitro expansion of human corneal endothelial cells is evolving as a sustainable choice. This method is intended to prepare corneal endothelial cells in vitro that can be transferred to the eye. Herein, we describe the etiologies and manifestations of human corneal endothelial cell dysfunction. We also summarize the available options for as well as recent developments in the management of corneal endothelial dysfunction.

Development of a Donor Tissue Holding Technique for Descemet's Membrane Endothelial Keratoplasty Using a 25-Gauge Graft Manipulator

Purpose

To report a modified surgical technique called the “donor tissue holding technique for Descemet's membrane endothelial keratoplasty (DMEK)” using a newly developed 25-gauge graft manipulator.

Methods

Six consecutive patients exhibiting endothelial dysfunction were enrolled and treated by DMEK. In brief, after insertion of a DMEK donor into the anterior chamber, the edge of the roll was grasped using a graft manipulator and this grasp was maintained throughout the centering and opening of the roll (holding technique). The following parameters were evaluated in comparison to the previous 10 consecutive DMEK cases in which the no touch technique was used: time of graft unfolding, incidence of intra-/postoperative complications, and best spectacle-corrected visual acuity (BCVA) and endothelial cell density (ECD) 6 months after the procedure.

Results

In both technique groups, neither intra- nor postoperative complications were noted in any case. No differences were observed between the two groups in postoperative BCVA (p = 0.88). Also, no differences were observed between the two groups in postoperative ECD (holding technique group: 2,108.3 cells/mm², no touch technique group: 1,491.7 cells/mm²) (p = 0.08) Most notably, the time of graft unfolding prior to filling with air was significantly reduced in the holding technique group (305.5 s) compared to that of the no touch technique group (1,310.0 s; p = 0.01).

Conclusions

This donor tissue holding technique enabled rapid and safe DMEK in a reproducible manner, even in Asian eyes with shallow anterior chambers with high vitreous pressure.

A 10-year review of underlying diseases for endothelial keratoplasty (DSAEK/DMEK) in a tertiary referral hospital in Japan

Purpose

To report a 10-year review of endothelial keratoplasty (EK) procedures, Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK), and underlying diseases at a tertiary referral hospital in Japan.

Study design

A single-center, retrospective case series.

Methods

We retrospectively reviewed all medical records of bullous keratopathy (BK) surgically treated by EK (DSAEK/DMEK) at Kanazawa University Hospital from January 2007 to December 2016. Changes or modifications to the annual number of EK procedures and underlying diseases were analyzed.

Results

During this period, 320 EK procedures (DSAEK: 288 cases, DMEK: 32 cases) were performed on 250 patients. Total annual EKs gradually increased from 19 to 45 cases between 2007 and 2016. The annual number of DSAEKs was stable, although the proportion of DSAEKs to other procedures decreased significantly as re-DSAEKs and DMEKs increased. BK after argon laser iridotomy (ALI) was the leading cause in 2007, followed by Fuchs' endothelial dystrophy (FED) and failed penetrating keratoplasty. In 2016, BK after trabeculectomy (TLE) was most prevalent, followed by failed DSAEK, failed penetrating keratoplasty, and pseudophakic BK. The decreased ALI and FED, and increased BK after TLE and failed DSAEK were statistically significant.

Conclusion

The distribution of EK procedures (DSAEK/DMEK) and underlying diseases changed over 10 years at a tertiary referral hospital in Japan. The proportion of re-DSAEK and DMEK increased among all EK procedures. Most significantly, among the underlying diseases, decreased ALI and FED and increased TLE and failed DSAEK were observed. Extended multicenter analysis may further elucidate the changes in EK procedures and the causes of BK in Japan.

Endothelial cell loss and graft survival after penetrating keratoplasty for laser iridotomy-induced bullous keratopathy

PURPOSE

To assess corneal endothelial cell loss after penetrating keratoplasty (PK) treatment for laser iridotomy (LI)-induced bullous keratopathy (BK).

METHODS

A retrospective study conducted on consecutive patients who underwent PK between March 2000 and December 2011. Patients who had undergone more than 24 months of follow-up were included. Patients who underwent PK were subcategorized into two groups based on their diagnosis of BK prior to PK; PK was performed to treat either LI-BK or non LI-BK. The cell density of the central corneal endothelium and the graft survival were evaluated during follow-up.

RESULTS

Corneal endothelial cell density decreased in a similar fashion in both the LI-BK and non LI-BK patients, though the cell density decreased significantly faster in the LI-BK group than in the non LI-BK group throughout the 108 months of the study (p = 0.026). The mean cell loss at 36 months for the LI-BK group was 57.7% vs. 63.2% for the non LI-BK, 76.9% vs. 70.1% at 72 months, and 85.6% vs. 72.0% at 108 months. No eye among 21 eyes in the LI-BK group (0%) had failed grafts, whereas 4 of 25 eyes in the non LI-BK group (16.0%) had failed grafts at 60 months (p = 0.114).

CONCLUSIONS

The outcome of PK for BK secondary to LI was no worse than the outcome of PK for other types of BK. However, our long-term follow-up after PK showed that cell density decreased faster in the LI-BK group than in the non LI-BK, suggesting that cell loss might be involved in the existence of LI prior to PK.

Wheel Spokes Technique for Endothelial Keratoplasty for Extremely Mydriatic Bullous Keratopathy Eyes without Capsular Support

We describe a new technique to prevent an endothelial donor graft from dropping into the vitreous cavity during non-Descemet stripping automated endothelial keratoplasty (nDSAEK) for extremely mydriatic bullous keratopathy (BK) eyes without capsular support. The patient was a 79-year-old woman who underwent nDSAEK for an extremely mydriatic BK eye with an incomplete barrier between the anterior and posterior chambers. She had undergone argon laser iridotomy for acute glaucoma at the age of 59 years and cataract surgery 3 years later. The pupil was extremely mydriatic as a result of iris sphincter muscle damage associated with an acute glaucoma attack and cataract surgery. After cataract surgery, the dislocated intraocular lens (IOL) sometimes touched the corneal endothelium. Despite simultaneous surgery to remove the dislocated IOL and lens capsule, vitrectomy, and intrascleral IOL fixation, her corneal endothelial decompensation progressed to BK. During nDSAEK, three 9-0 Prolene suture threads were placed through the recipient's cornea, limbus-to-limbus, resembling wheel spokes, to prevent the graft from dropping into the vitreous cavity. With the aid of these pre-placed sutures, the graft was inserted safely and was well attached to the host's posterior cornea by air tamponade without suturing. The wheel spokes technique prevented the endothelial graft from dropping during intraoperative manipulation, suggesting that nDSAEK is possible even in an extremely mydriatic aphakic BK eye without capsule support.

Modified Descemet's Stripping Automated Endothelial Keratoplasty: The Use of Ophthalmic Viscoelastic Devices in Hypotonic Eyes That Had Undergone Glaucoma Filtering Surgeries

Purpose

Descemet's stripping automated endothelial keratoplasty (DSAEK) is more difficult in hypotonic eyes with filtering bleb, due to the difficulties in elevating the intraocular pressure (IOP). We report a new method that uses ophthalmic viscoelastic devices (OVDs) to achieve good graft adhesion.

Case Presentation

We performed modified DSAEK surgery on 2 eyes of 2 patients, who had previously undergone a trabeculectomy. Both eyes had functioning filtering blebs; the IOP was lower than 10 mmHg without medication. After the graft was inserted into the anterior chamber, the conjunctiva was penetrated, apart from the bleb, using a 30 G needle, and Healon V® was injected into the bleb until the encapsulated space was filled completely. Air was subsequently injected into the anterior chamber to promote the graft attachment to the back surface of the cornea. The IOP was elevated above 40 mmHg in both eyes 1 h after surgery and then decreased to less than 30 mmHg over the subsequent 3 h period. The implanted graft showed good adhesion and no dislocation.

Conclusions

Our novel DSAEK procedure that adds one step of OVD injection into the filtering bleb may be useful for hypotonic eyes that had undergone filtering surgeries.

Spontaneous reattachment of dislocated endothelial graft after non-Descemet stripping automated endothelial keratoplasty: a case report

Background

Graft detachment is a complication of non-Descemet stripping automated endothelial keratoplasty (nDSAEK). We report a case of spontaneous reattachment of an extensively dislocated graft after nDSAEK.

Case presentation

A 54-year-old male underwent penetrating keratoplasty (PKP) for keratoconus in his left eye in 2001. Following graft opacity due to rejection, a second PKP was implemented in May 2014. The graft was kept in good condition after the reoperation and yet, visual acuity (VA) declined due to cataract. PEA+IOL was then performed in May 2015. Because edema appeared in the graft 6 months after the PEA+IOL, nDSAEK was carried out in May 2016. Although the donor graft well attached immediately after the nDSAEK, the graft was almost completely dislocated 3 h later except a temporal part. Air was reinjected into the anterior chamber on the following day and the detachment was resolved. Despite of the treatment, about 1/5 of the graft remained detached and the detachment deteriorated to 3/4 of the graft 9 days later. Because the patient could not decide whether to undergo another operation immediately, we decided to follow him up first and found that the partially detached graft reattached spontaneously 1 month later during the follow-up. Although the cornea had a mild edema remaining in the superior temporal area, his BCVA improved to 1.0. Three months later, the graft remained in position and the cornea kept its transparency.

Conclusions

Spontaneous reattachment was observed during the follow-up in a case that had shown a comparatively extensive graft dislocation after nDSAEK.

Comparison of the Endosaver with noninjector techniques in Descemet's stripping endothelial keratoplasty

Purpose:

Minimal loss of corneal endothelial cells during corneal transplantation is a major target but remains a point of controversy among specialists. Hence, the available method to best achieve this continues to stir progress in the field. The aim of this study is to evaluate the use of the Endosaver injector device for graft insertion in Descemet's stripping endothelial keratoplasty (DSEK) and compare the visual outcomes and endothelial cell survival between the Endosaver injector and Goosey grasping forceps insertion techniques.

Methods:

This was a retrospective, interventional, consecutive case series undertaken at the University of Southampton Eye Department to assess outcomes of DSEK using the Endosaver injector device compared to noninjector DSEK insertion. Postoperative specular microscopy alongside manifest refraction at 6 and 12 months was evaluated and compared. Mann–Whitney U-test was employed for the statistical analysis of data.

Results:

Both the Endosaver and Goosey forceps groups showed an improvement in best corrected visual acuity. No significant statistical difference was found in preoperative and postoperative best-corrected visual acuity between the Endosaver and non-Endosaver insertion groups. Mean preoperative endothelial cell count was 2660 (±130) for the Endosaver group and 2608 (±66) for the non-Endosaver group. Postoperative endothelial counts at 6 and 12 months showed a significant difference between the Endosaver: 2104 (±199)–1896 (±226) and the non-Endosaver: 1492 (±207)–1314 (±224) (P < 0.005) groups, respectively.

Conclusion:

The Endosaver injection device is associated with less trauma to endothelium during graft insertion due to the minimal touch technique employed. A smaller insertion wound of 4.0 mm compared to noninjector cases enabled a more stable system during surgery with no or minimal anterior chamber shallowing. The combination of a stable host with minimal endothelial graft handling and subsequent trauma potentially leads to higher endothelial cell counts when the Endosaver injection device is used compared to forceps insertion.

Evaluation of Visual Quality in Patients With Fuchs Endothelial Corneal Dystrophy

Fuchs endothelial corneal dystrophy (FECD) is a bilateral corneal endothelial dystrophy characterized by the deposition of extracellular matrix (guttae), thickening of Descemet membrane, and progressive loss of corneal endothelial cells. Progressive endothelial cellular loss leads to corneal edema and impairs visual function. In eyes with FECD, corneal edema begins in the central cornea and expands into the periphery. FECD is the most common dystrophic reason for corneal transplantation in many countries. Some patients with FECD report visual discomfort despite the absence of corneal edema. Intraocular forward light scatter impairs patients' quality of vision (QOV), and corneal guttae associated with FECD may cause intraocular light scatter and glare, which can be extremely debilitating despite the absence of edema. We recently investigated the effect of the severity of corneal guttae on QOV in patients with mild FECD. It was shown that corneal guttae increased forward light scatter that negatively affected QOV in eyes with mild FECD without severe corneal edema. Therefore, quantification of corneal guttae would be useful to determine surgical indications for eyes with mild FECD. This review discusses QOV in patients with FECD.

Evaluation of factors affecting visual acuity after Descemet stripping automated endothelial keratoplasty

PURPOSE

To elucidate the factors affecting visual acuity after Descemet stripping automated endothelial keratoplasty (DSAEK).

METHODS

We reviewed consecutive patients who underwent primary DSAEK for corneal endothelial dysfunction at Inouye Eye Hospital from January 2010 through January 2015 and who had a follow-up of at least 6 months. Fifty-four eyes of 49 patients (24 men and 25 women) were enrolled; the mean age was 72.5 ± 8.7 years. Medical charts were retrospectively examined for best spectacle-corrected visual acuity (BSCVA), intraocular pressure, keratometric value, keratometric cylinder, grade of preoperative corneal edema, preoperative graft thickness, and endothelial cell density (ECD) before and at 1, 3, 6, 12, and 24 months after surgery. A multiple regression analysis was used to evaluate the factors associated with BSCVA at 3, 6 months, and 1 year after surgery. Explanatory variables included age, sex, preoperative factors (BSCVA, degree of corneal edema, donor ECD, and graft thickness), and factors at each time point (keratometric value, keratometric cylinder, and intraocular pressure).

RESULTS

The mean logarithms of the minimum angle of resolution (logMAR) BSCVA preoperatively and at 1, 3, 6, and 12 months after surgery were 1.03 ± 0.49, 0.42 ± 0.26, 0.29 ± 0.21, 0.24 ± 0.20, and 0.22 ± 0.20, respectively. Multiple regression analysis showed that preoperative BSCVA alone was significantly associated with BSCVA at 3, 6, and 12 months.

CONCLUSION

A better preoperative BSCVA was associated with a better BSCVA after DSAEK, which suggests that DSAEK should be considered earlier than stromal changes such as subepithelial fibrosis occurrence.

Descemet Membrane Endothelial Keratoplasty: Preliminary Results of a Donor Insertion Pull-through Technique Using a Donor Mat Device

PURPOSE

To evaluate a novel technique of Descemet membrane endothelial keratoplasty (DMEK) donor insertion using the EndoGlide pull-through device.

DESIGN

Prospective, interventional cases series.

METHODS

We performed DMEK using the EndoGlide technique with a protoype donor carrier device (Descemet Mat, or D-Mat) in 30 patients by a single surgeon (including learning curve). Clinical data and donor and recipient characteristics were tracked from our prospective Singapore Corneal Transplant Registry. Main outcome measures were intraoperative complications and the incidence of postoperative graft detachment and primary graft failures within 3 months from surgery.

RESULTS

In our preliminary study of 30 eyes in 30 patients (73% female, mean age 64.5 ± 8.3 years), we observed 3 cases (10%) of partial donor detachment requiring rebubbling and 1 (3%) primary donor failure. Twenty of 30 eyes (66.7%) achieved ≥20/25 3-month best spectacle-corrected visual acuity. Six-month endothelial cell loss reduced from 65% ± 13% to 48% ± 11% (P = .02) comparing the first and last 15 cases. With the exception of 1 case with excessive fibrin formation, we did not experience any further intraoperative complications related to donor tissue insertion, incomplete tissue unfolding, donor tissue malposition, or incorrect orientation.

CONCLUSION

Our study suggests that the described technique allows for donor control and insertion in the correct orientation with the endothelium facing down. Further studies are required to confirm if this DMEK donor insertion technique can lead to reduced endothelial cell loss and better graft survival.

Visualization of precut DSAEK and pre-stripped DMEK donor corneas by intraoperative optical coherence tomography using the RESCAN 700

BACKGROUND

To report the feasibility of intraoperative spectral domain optical coherence tomography (OCT) using the RESCAN 700 for the visualization and evaluation of precut Descemet's stripping automated endothelial keratoplasty (DSAEK) and prestripped Descemet's membrane endothelial keratoplasty (DMEK) donor tissue.

METHODS

Precut DSAEK (n = 11), prestripped DMEK (n = 4) preserved in a viewing chamber were examined by intraoperative OCT. Wholly intact donor corneas for penetrating keratoplasty (PK) (n = 8) were also examined as controls. The obtained images were analyzed qualitatively for characteristics of each type of donor.

RESULTS

For each type of donor, characteristic images were consistently obtained by intraoperative OCT in both the front and back views through the viewing chamber. In wholly intact donors for PK, appearance of normal corneal curvature and stromal texture with high reflectivity of epithelium and endothelium cell layers were clearly visualized. In precut DSAEK donors, precut lines were characteristically visualized in addition to the intact donor cornea images. In prestripped DMEK donors, identical OCT images to the intact donor cornea were noted when observed from the anterior surface. However, peripheral partial detachments of Descemet's membrane were characteristically observed in all prestripped DMEK donors when viewed from the back of the viewing chamber.

CONCLUSION

Rapid visualization and rough evaluation of donor tissues for PK, precut DSAEK and prestripped DMEK donor corneas by intraoperative OCT was consistently possible through the viewing chamber. Therefore, this device may be used as an alternative of AS-OCT when the eyebank does not have their own AS-OCT. Although the peripheral detachment in DMEK donors are quite common and clinically non-problematic in DMEK donor quality and subsequent DMEK surgeries, it may be useful to distinguish between wholly intact PK donors and prestripped DMEK donors, enabling to prevent mix-ups of donors, especially when several different types of keratoplasties are scheduled in a same day in one operating theater.

Factors associated with graft survival and endothelial cell density after Descemet's stripping automated endothelial keratoplasty

Postoperative endothelial cell loss leads to graft failure after corneal transplantation, and is one of the important issues for long-term prognosis. The objective of this study was to identify clinical factors affecting graft survival and postoperative endothelial cell density (ECD) after Descemet’s stripping automated endothelial keratoplasty (DSAEK). A total of 198 consecutive Japanese patients (225 eyes) who underwent DSAEK were analysed using Cox proportional hazard regression and multiple linear regression models. The candidate factors included recipient age; gender; diagnosis; pre-existing iris damage state, scored based on its severity; the number of previous intraocular surgeries; graft ECD; graft diameter; simultaneous cataract surgery; surgeons experience; intraoperative iris damage; postoperative rebubbling; and graft rejection. Eyes with higher pre-existing iris damage score and more number of previous intraocular surgery had a significantly higher risk of graft failure (HR = 8.53; P < 0.0001, and HR = 2.66; P = 0.026, respectively). Higher pre-existing iris damage score, lower graft ECD, and smaller graft diameter were identified as significant predisposing factors for lower postoperative ECD. The results show that iris damage status before DSAEK may be clinically useful in predicting the postoperative course. Avoiding intraoperative iris damage, especially in eyes with low ECD can change the prognosis of future DSAEK.

How Much Progress Has Been Made in Corneal Transplantation?

To assess the benefits of component lamellar corneal surgery, we investigated the surgical outcomes of deep anterior lamellar keratoplasty (DALK) for keratoconus and Descemet stripping automated endothelial keratoplasty (DSAEK) for laser iridotomy-induced bullous keratopathy (LI-BK). The results were compared with the surgical outcomes of penetrating keratoplasty (PKP). Seventy-nine eyes with keratoconus treated with DALK and 81 eyes with LI-BK treated with DSAEK were studied, and the graft clarity rate, best spectacle-corrected visual acuity, endothelial cell density (ECD), and surgical complications were compared with 273 eyes with keratoconus and 98 eyes with LI-BK all treated with PKP. Keratoconus eyes showed excellent visual outcomes with DALK and PKP, but graft survival was higher for PKP (100%, 98.9%, and 96.3% vs. 98.6%, 90.6%, and 86.1%, at 1, 3, and 5 years after surgery, respectively; P < 0.0001). There were no significant differences in the ECD up to 1 year after surgery. Greater ECD decline was observed for PKP at 3 and 5 years after surgery. Descemet membrane microperforation was observed in 49 eyes treated with DALK. Postoperative complications in eyes treated with PKP were increased incidence of immunological rejection and secondary glaucoma compared with eyes treated with DALK. LI-BK graft survival rates were excellent in both groups (DSAEK: 89.6% and 86.1%; PKP: 100% and 98.6%, 1- and 2-year rates, respectively; P = 0.17). Best spectacle-corrected visual acuity was better in the DSAEK group, and ECD showed a higher rate of decrease with DSAEK than with PKP. DALK and DSAEK considerably improved surgical outcomes in eyes with keratoconus and those with LI-BK, respectively. However, several key areas require further work, including development of safe surgical methods in DALK and prevention of early postoperative ECD loss in DSAEK.

Case series and techniques of Descemet's Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury

BACKGROUND

To evaluate clinical outcomes of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for severe bullous keratopathy that develop as a late complication of endothelial injury to the baby during forceps delivery at birth.

CASE PRESENTATIONS

Four eyes (four patients; mean age, 51.5 years) with severe bullous keratopathy as a late complication of forceps delivery at birth were enrolled. All patients had amblyopia from childhood due to cloudy cornea. Nontheless, DSAEK was indicated in these patients for the irritation and severe light sensation caused by apparent bullous change of the injured cornea. All patients underwent DSAEK and two patients had simultaneous cataract surgery. Intraoperative and postoperative complications were recorded. Postoperative donor endothelial-cell densities (ECDs) were measured prospectively at six and 12 months and compared with preoperative values. Best corrected visual acuity (BCVA) was measured at 6 and 12 months postoperatively. All cases required corneal epithelial removal; two cases with simultaneous cataract surgeries required lens anterior capsule staining by trypan blue and illumination of the cornea for visualization. There were no cases of graft dislocation or primary graft failure. Mean BCVA improved from 0.06 to 0.15 at 6 months and to 0.38 at 12 months. Postoperative ECD was 2270 cells/mm(2) (mean loss, 24.4 %) at 6 months and 2130 (mean loss, 29.1 %) at 12 months. Postoperative intraocular pressure elevation was observed in two cases, and a rejection episode occurred in one case at 4 months postoperatively.

CONCLUSIONS

In this case series, the clinical outcome of DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance, which was comparable to uncomplicated cases. Cataract and DSAEK surgery was safely performed using techniques including epithelial removal, lens anterior capsule staining and illuminating the cornea, which enabled better visualization of the anterior chamber.

Effects of corneal irregular astigmatism on visual acuity after conventional and femtosecond laser-assisted Descemet's stripping automated endothelial keratoplasty

PURPOSE

To compare short-term outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using a graft prepared with either a femtosecond laser or a microkeratome.

METHODS

Thirty-eight patients underwent DSAEK with grafts prepared with either a femtosecond laser (f-DSAEK; 21 eyes) or a microkeratome (m-DSAEK; 17 eyes). Visual acuity, endothelial cell density, regular astigmatism and irregular astigmatism were compared between the two groups preoperatively and at 1, 3, and 6 months post-operatively. Fourier analysis was conducted to calculate astigmatism of the anterior and posterior surfaces, and total cornea, using anterior segment optical coherence tomography (AS-OCT).

RESULTS

Visual acuity (logMAR) improved from 1.20 ± 0.60 to 0.43 ± 0.25 after m-DSAEK (P < 0.001) and from 1.20 ± 0.57 to 0.77 ± 0.33 after f-DSAEK (P = 0.0028) at 6 months following DSAEK. Visual acuity after m-DSAEK was significantly better than after f-DSAEK at 1, 3, and 6 months (P < 0.05). AS-OCT corneal images revealed greater irregularities on the posterior surfaces of f-DSAEK grafts compared to m-DSAEK grafts. Irregular astigmatism of the total cornea and the posterior surface was significantly larger after f-DSAEK than after m-DSAEK, although there was no significant difference in irregular astigmatism of the anterior surface at 6 months. Postoperative visual acuity was significantly correlated with the postoperative irregular astigmatism of the total cornea (r = 0.6657 and P < 0.001) and the anterior (r = 0.416, P = 0.016) and posterior surfaces (r = 0.7046, P < 0.001).

CONCLUSIONS

Visual outcomes after f-DSAEK were poor compared to conventional m-DSAEK due to an increase in irregular astigmatism caused by posterior surface irregularities.

The use of endoillumination probe-assisted Descemet membrane endothelial keratoplasty for bullous keratopathy secondary to argon laser iridotomy

Purpose

To report the first case of Descemet membrane endothelial keratoplasty (DMEK) for bullous keratopathy (BK) secondary to argon laser iridotomy (ALI).

Patient

A 71-year-old woman presented with decreased visual acuity in her right eye due to BK secondary to ALI that was performed 10 years prior.

Results

Phacosurgery was performed first, followed by successful DMEK 4 months later. A DMEK shooter was used for donor insertion, which allowed for a stable anterior chamber during donor insertion, even when the anterior chamber was quite shallow. Also, removal of edematous epithelial cells and endoillumination probe-assisted DMEK was quite useful to visualize DMEK graft on the background of the dark brown iris seen in Asian eyes. The patient’s best corrected visual acuity rapidly increased from 20/200 to 25/20 after 1 month, with complete resolution of corneal edema.

Conclusion

We reported the first successful DMEK case for BK secondary to ALI. The use of a DMEK shooter for donor insertion and endoillumination assistance to visualize the DMEK graft was a useful technique for BK secondary to ALI.

Three-year outcome of Descemet stripping automated endothelial keratoplasty for bullous keratopathy after argon laser iridotomy

PURPOSE

The aim of this study was to evaluate the 3-year outcome of Descemet stripping automated endothelial keratoplasty (DSAEK) for the treatment of bullous keratopathy secondary to argon laser iridotomy (ALI).

METHODS

A total of 22 consecutive patients (22 eyes) with ALI who underwent DSAEK were retrospectively analyzed. Best spectacle-corrected visual acuity (BSCVA), endothelial cell density, and complications were investigated over 3 years postoperatively. The outcome of DSAEK was also compared between the ALI group and 21 other patients with Fuchs endothelial dystrophy (FED) or pseudophakic bullous keratopathy (PBK) (FED/PBK group).

RESULTS

The median BSCVA improved from logarithm of the minimum angle of resolution 1.40 before DSAEK to 0.30 at 6 months, 0.30 at 12 months, 0.22 at 24 months, and 0.15 at 36 months after surgery. The median endothelial cell loss was 20.3% at 6 months, 18.4% at 12 months, 32.5% at 24 months, and 46.5% at 36 months. Comparison of the ALI group with the FED/PBK group showed no significant difference in the BSCVA or endothelial cell density. Rejection affected 9.1% of the ALI group versus 0% of the FED/PBK group (P = 0.49), the graft dislocation rate was 0% versus 9.5% (P = 0.23), and posterior synechiae were found in 31.8% versus 4.8% (P = 0.046).

CONCLUSIONS

The 3-year outcome of DSAEK for bullous keratopathy after ALI was excellent. However, caution should be exercised in patients with a history of ALI to avoid posterior synechiae after DSAEK.

Endothelial keratoplasty with infant donor tissue

Here we report a case of endothelial keratoplasty with infant donor tissue obtained after brain death. A 52-year-old man with endothelial dysfunction of unknown cause in the right eye underwent non-Descemet stripping automated endothelial keratoplasty (nDSAEK) with tissue from an infant donor (2 years). Intraoperative and postoperative complications were recorded. Best corrected visual acuity and donor central endothelial cell density were recorded preoperatively and postoperatively. Infant donor tissue preparation with a microkeratome set at 300 μm was successful; the donor tissue was extremely elastic and soft compared with adult tissue. The central endothelial cell density of the infant donor tissue was as high as 4,291 cells/mm². No complications were observed during donor tissue (8.0 mm in diameter) insertion with the double-glide technique (Busin glide with intraocular lens sheet glide) or any of the other procedures. Best corrected visual acuity improved from 1.7 logMAR (logarithm of the minimum angle of resolution; 0.02 decimal visual acuity) preoperatively to 0.2 logMAR (0.6) after 6 months and 0.1 logMAR (0.8) after 1 year. The central endothelial cell density after 6 months was 4,098 cells/mm² (representing a 4.5% cell loss from preoperative donor cell measurements), and the central endothelial cell density after 1 year was 4,032 cells/mm² (6.0% decrease). Infant donor tissue may be preferably used for DSAEK/nDASEK, since it may not be suitable for penetrating keratoplasty or Descemet membrane endothelial keratoplasty.

Comparison of a donor insertion device to sheets glide in Descemet stripping endothelial keratoplasty: 3-year outcomes

PURPOSE

To compare 3-year endothelial cell loss and graft survival following Descemet stripping automated endothelial keratoplasty (DSAEK) using the EndoGlide (AngioTech, Reading, Pennsylvania, USA/Network Medical Products, North Yorkshire, UK) donor insertion device compared to donor insertion using the Sheets glide technique.

DESIGN

Retrospective comparative case series.

METHODS

Study involved consecutive patients who underwent DSAEK with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy at a single tertiary center. Clinical data with outcomes and donor and recipient characteristics were obtained from our ongoing prospective cohort from the Singapore Corneal Transplant Study. Main outcome measures were percent endothelial cell loss and graft survival up to 3 years.

RESULTS

Overall percent endothelial cell loss was significantly lower in the EndoGlide group (100 eyes) compared to the Sheets glide group (119 eyes) at 1 year (16.3% ± 16.6% vs 29.5% ± 22.2%, P < .001), 2 years (23.8% ± 17.8% vs 35.7% ± 22.9%, P = .001), and 3 years (29.7% ± 20.9% vs 38.5% ± 24.1%, P = .015) postoperatively. Overall graft survival was greater in the EndoGlide compared to Sheets glide group up to 3 years postoperatively (97.9% vs 86.5%, log-rank P value = .005). In eyes with Fuchs endothelial dystrophy, endothelial cell loss was significantly lower in the EndoGlide group (3-year: 28.2% ± 17.9% vs 43.4% ± 27.1%, P = .032). In eyes with pseudophakic bullous keratopathy, the EndoGlide group had a superior graft survival compared to Sheets glide (log-rank P = .031).

CONCLUSION

Endothelial cell loss was lower using a donor insertion device during DSAEK, compared to using the Sheets glide technique for DSAEK, in Asian eyes with Fuchs endothelial dystrophy, and resulted in better graft survival in eyes with pseudophakic bullous keratopathy.

Descemet's stripping and non-Descemet's stripping automated endothelial keratoplasty for microcornea using 6.0 mm donor grafts

Background

The purpose of this paper is to report our experience of Descemet’s stripping and non-Descemet’s stripping automated endothelial keratoplasty (DSAEK/nDSAEK) for microcorneas using 6.0 mm donor grafts.

Methods

Three eyes of two patients (a 56-year-old woman and a 59-year-old woman) with microcornea and suffering from bullous keratopathy were treated with either DSAEK or nDSAEK. A small donor graft (6.0 mm) was inserted into the anterior chamber using a double glide (Busin glide and intraocular lens sheet glide) donor insertion technique. Both patients were followed for at least 12 months. Clinical outcomes, including intraoperative and postoperative complications, visual acuity, and endothelial cell density were evaluated.

Results

In all three cases (100%), no intraoperative complications were noted. In one case with a flat keratometry value (32.13 D), a partial donor detachment was noted one day postoperatively, but it was reattached by rebubbling. In another case, rejection was noted 8 months postoperatively, but treatment with systemic corticosteroids was successful. A clear cornea remained in all three cases (100%), with best-corrected visual acuity greater than 20/100 (mean 20/50) at 12 months. Mean postoperative endothelial cell counts were 2,603 ± 18 cells/mm² at 6 months (7.4% decrease from preoperative donor cell counts) and 1,799 ± 556 cells/mm² at 12 months (36.5% decrease).

Conclusion

We report for the first time the successful use of a small donor graft (6.0 mm) for DSAEK/nDSAEK in cases of microcornea. Additional stud ies using a large number of patients are required to evaluate fully the potential advantages and drawbacks of small diameter donor grafts for microcornea.

Non-Descemet's stripping automated endothelial keratoplasty for bullous keratopathy secondary to iridoschisis

Purpose

To report a case of bullous keratopathy secondary to iridoschisis treated by non-Descemet’s stripping automated endothelial keratoplasty (nDSAEK).

Case report

A 79-year-old woman was referred to our hospital with loss of vision in the left eye. Slit lamp examination of her left eye showed a shallow anterior chamber with cataract and schisis in the inferior quadrant of iris stroma. Bullous keratopathy secondary to iridoschisis was diagnosed. Cataract surgery with iridectomy succeeded to deepen the anterior chamber and remove the floating iris leaf, although corneal edema remained. Four days later, nDSAEK was performed, which resolved corneal edema and restored visual acuity.

Conclusion

The two-step surgery of cataract surgery plus iridectomy followed by nDSAEK may be an effective strategy for treating bullous keratopathy secondary to iridoschisis.

Suture pull-through insertion techniques for Descemet stripping automated endothelial keratoplasty in Chinese phakic eyes: outcomes and complications

Purpose

To investigate the outcomes and complications of suture pull-through insertion techniques for Descemet stripping automated endothelial keratoplasty (DSAEK) in Chinese phakic eyes.

Patients and Methods

Retrospective case series. Included in the study were all Chinese patients with phakic eyes who underwent DSAEK at Peking University Third Hospital from August 2008 to August 2011. All ocular diseases of the patients were recorded. Distance visual acuity (DVA), near visual acuity (NVA), intraocular pressure (IOP), anterior chamber depth (ACD), central corneal thickness (CCT), and corneal endothelial cell density (ECD) were compared prior to and 12 months after DSAEK. The DSAEK success rate, endothelial cell loss (ECL), complications, and prognosis were analyzed. All patients had at least 12 months of follow up.

Results

Twenty-one eyes of 16 patients were included (11 males and 5 females). Ages ranged from 2 to 47 years with an average age of 29.8 years. The average follow up was 15.4 months (ranging from 12 to 36 months). Diagnoses included 7 eyes (4 patients) with corneal endothelial dystrophy and 14 eyes (12 patients) with bullous keratopathy. Presurgical DVA and NVA (LogMAR) were 1.7±0.7 and 1.2±0.4; postsurgical DVA and NVA were 0.8±0.6 and 0.7±0.5; Z = −3.517, −2.764; P<0.001 and P = 0.006 respectively. Presurgical IOP was 15.8±3.7 mm Hg; postsurgical IOP was 15.2±2.6 mm Hg; Z = −0.505, P = 0.614. Presurgical ACD was 3.00±0.74 mm; postsurgical ACD was 2.72±0.59 mm; Z = −0.524, P = 0.600. Donor ECD was 2992±163 cells/mm², ECD was 1836±412 cells/mm² with a 12-month postsurgical ECL of 39%. Success rate was 86%. Surgery complications included pupillary block-induced hypertension in 5 eyes (24%), graft detachment in 3 eyes (14%), and graft dislocation in 1 eye (5%).

Conclusions

DSAEK on Chinese phakic eyes can significantly improve DVA and NVA by preserving the patient’s own crystalline lens. DSAEK is an optional surgery for patients who need to preserve accommodative function. More attention should be given to postsurgical pupillary block-induced hypertension.

In vivo laser confocal microscopy after Descemet's membrane endothelial keratoplasty

OBJECTIVE

To investigate the in vivo corneal changes in patients with bullous keratopathy who underwent Descemet's membrane endothelial keratoplasty (DMEK) with the use of in vivo laser confocal microscopy.

DESIGN

Single-center, retrospective clinical study.

PARTICIPANTS

Five eyes of 4 patients (3 men, 1 women; mean age, 61.3 ± 9.6 years) with bullous keratopathy who had undergone successful DMEK were enrolled in this study.

TESTING

In vivo laser confocal microscopy was performed before and 1, 3, and 6 months after DMEK.

MAIN OUTCOME MEASURES

Selected confocal images of corneal layers were evaluated qualitatively and quantitatively for the degree of haze and the density of deposits. Subepithelial haze, donor-recipient interface haze, donor-recipient interface particles, and host stromal needle-shaped materials were graded on a scale of 4 categories (grade 0 = none, grade 1 = mild, grade 2 = moderate, grade 3 = severe) at each time point. Time trends of the outcomes were graphically displayed and evaluated with Mantel-Haenszel trend test.

RESULTS

The following were observed preoperatively in all patients: slight corneal epithelial edema, moderate subepithelial haze, keratocytes in a honeycomb pattern, and tiny needle-shaped materials in the stroma. After DMEK, moderate subepithelial haze persisted during the follow-up period. Needle-shaped materials had a tendency to decrease after DMEK. Most notably, donor-recipient interface haze and donor-recipient interface particles were barely noticeable after DMEK as early as 1 month postoperatively.

CONCLUSIONS

In vivo laser confocal microscopy can identify subclinical corneal abnormalities after DMEK, such as subepithelial haze, host stromal needle-shaped materials, and minimum donor-recipient interface haze/particles. These abnormalities seemed subtle compared with Descemet stripping automated endothelial keratoplasty; this may explain the superior postoperative visual acuity after DMEK. Further studies with this technology in a large number of patients and long-term follow-up are needed to fully understand the long-term corneal changes after DMEK.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

A sliding technique to load thin endothelial donor lamella onto Busin glide for Descemet-stripping automated endothelial keratoplasty

We describe a modified technique for loading donor corneal endothelial lamella onto a Busin glide^® without causing wrinkles, as part of the procedure of Descemet-stripping automated endothelial keratoplasty. Briefly, after punching out a composite of the donor-endothelial lamella and a microkeratome-dissected cap, several drops of dispersive ophthalmic viscosurgical device are placed onto the endothelial surface. The Busin glide surface is then wetted with several drops of balanced salt solution. After the composite is transferred onto the Busin glide, hydrodissection of the potential space between the donor-endothelial lamella and the microkeratome-dissected cap is carefully performed to enable smooth detachment of these two lamellae. Whereas simply dragging the donor-endothelial lamella directly onto the glide can cause wrinkling or folding of the donor lamella, this technique enables smooth detachment of the composite without wrinkle or fold formation, and results in less endothelial cell damage.

No-Touch Technique and a New Donor Adjuster for Descemet's Stripping Automated Endothelial Keratoplasty

Purpose

One difficulty with Descemet's stripping automated endothelial keratoplasty (DSAEK) is air management during surgery and donor endothelial lamella centering. We evaluated the no-touch technique for donor centering and the use of a newly developed DSAEK donor adjuster.

Methods

We evaluated the records of 12 consecutive patients (mean age 75.3 years) with bullous keratopathy who had undergone DSAEK. In all cases, the no-touch technique was attempted first. When the no-touch technique failed, a DSAEK donor adjuster with a 30-gauge cannula resembling a curved reverse Sinskey hook was used for donor centering. The adjuster allows air injection during donor centering.

Results

The no-touch technique using simple corneal surface massage to center the graft was successful in 4 cases (33.3%), while 4 cases required ocular tilting (33.3%) in addition to corneal surface massage. The no-touch technique was ineffective in 4 cases (33.3%), but the donor adjuster was used successfully and easily for these patients. Comparing the endothelial cell loss rate between the no-touch technique group and the donor adjuster group, there was no significant difference at 6 months.

Conclusions

The no-touch technique was useful for better control of DSAEK donor centering in most cases. When the no-touch technique was ineffective, the DSAEK donor adjuster was uniformly successful.

Descemet stripping automated endothelial keratoplasty for microcornea

PURPOSE

Our aim was to evaluate the surgical technique and postoperative results of Descemet stripping automated endothelial keratoplasty (DSAEK) for bullous keratopathy in eyes with microcornea.

METHODS

Two patients with microcornea (8.8 mm in case 1 and 9.3 mm in case 2) and bullous keratopathy after cataract surgery or after laser iridotomy were treated by DSAEK. A donor lamella with a smaller diameter (7.5 mm) was inserted into the anterior chamber using the double-glide donor insertion technique (Busin glide with intraocular lens sheet glide).

RESULTS

No intraoperative or postoperative complications occurred. Corrected visual acuity improved from counting fingers to 0.222 logMAR in case 1 and from 1.000 to 0.155 logMAR in case 2 over 6 months. Corneal endothelial cell loss was 6.5 % in case 1 and 1.9 % in case 2.

CONCLUSIONS

DSAEK was useful for bullous keratopathy in patients with microcornea. However, surgery should be done with meticulous care, and modification of the diameter of the donor lamella and of the donor insertion technique may be required.

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.

Surgical outcome of Descemet's stripping automated endothelial keratoplasty for bullous keratopathy secondary to argon laser iridotomy

BACKGROUND: To report the 6-month clinical outcome of Descemet's stripping automated endothelial keratoplasty (DSAEK) for bullous keratopathy (BK) secondary to argon laser iridotomy (ALI), and compare the results with those of DSAEK for pseudophakic bullous keratopathy (PBK) or Fuchs' endothelial dystrophy (FED). METHODS: A total of 103 patients (54 with ALI, 28 with PBK, 21 with FED) undergoing DSAEK were retrospectively analyzed. Simultaneous cataract surgery was performed in 37 patients with ALI and 13 with FED. Preoperative ocular conditions, best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction (SE), induced astigmatism, keratometric value, endothelial cell density (ECD), and complications were determined over 6 months postoperatively. RESULTS: Mean axial length in the ALI group (21.8 ± 0.8 mm) was significantly shorter than that in the FED (P = 0.02) or PBK groups (P = 0.003). Severe corneal stromal edema (n = 6), advanced cataract (n = 10), posterior synechia (n = 3), poor mydriasis (n = 5), and Zinn zonule weakness (n = 1) were found only in the ALI group. A significant improvement was observed in postoperative BSCVA in all groups. No significant difference was observed in BSCVA, SE, induced astigmatism, keratometric value, ECD, or complications among the three groups. CONCLUSIONS: Descemet's stripping automated endothelial keratoplasty for BK secondary to ALI showed rapid postoperative visual improvement, with similar efficacy and safety to that observed in DSAEK for PBK or FED.

Chandelier illumination for use during descemet stripping automated endothelial keratoplasty in patients with advanced bullous keratopathy

We demonstrate a technique that uses chandelier illumination during Descemet stripping automated endothelial keratoplasty (DSAEK) in cases of severe bullous keratopathy. A chandelier illumination fiber inserted through the corneal side port provides sclerotic scattering-like illumination from the sclerocorneal margin and endoillumination from the anterior chamber, resulting in excellent visibility for Descemet stripping and intraocular manipulation without obstruction from a hazy cornea. In cases complicated by dense cataract, the chandelier fiber can be inserted transconjunctivally into the pars plana, providing sufficient retroillumination to perform phacoemulsification with intraocular lens implantation combined with Descemet stripping for a DSAEK triple procedure. Because of the powerful illumination and hands-free nature of the chandelier fiber, the Descemet membrane can be visualized clearly and stripped as 1 sheet without inadvertent complications. We have developed a new 25-gauge illuminated anterior chamber maintainer comprising a 25-gauge infusion cannula through which a 29-gauge chandelier fiber probe passes. Because of the resulting bright illumination and adequate irrigation flow, excellent visibility with stable anterior chamber maintenance can be concurrently obtained for Descemet stripping, endothelial graft insertion, and subsequent intraocular manipulations without the need for biological staining or ophthalmic viscosurgical products, even in patients with severe corneal haze. This technique and new device facilitates safe and simple intraocular manipulation during DSAEK and encourages surgeons to perform DSAEK in challenging cases.

Examination of human meibum collection and extraction techniques

PURPOSE

To compare various meibum collection methods and extraction techniques.

METHODS

Sixty subjects, all successful contact lens wearers, were seen on two visits. Meibum was collected from the lower lid of the right eye with a glass microcapillary tube, and with a Dacron swab, cytology microbrush, or spatula from the left eye. Extraction with 2:1 chloroform:methanol was done either immediately or after data collection was complete. Individual samples were divided into four equal aliquots for analysis of total lipids, cholesterol, and inorganic phosphates by assay-based techniques. Effects of collection method, extraction, and dry eye status were examined using repeated measures analysis of variance and logistic regression.

RESULTS

Total lipids showed significance for collection device (p < 0.0001) but not for extraction technique (p = 0.13) or dry eye status (p = 0.97). Dacron swab collection was associated with more total lipid on average than each other collection device (p < 0.0001). The cholesterol assay showed significance of collection device (p < 0.0001) and extraction technique (p = 0.0002) but not dry eye status (p = 0.55). Spatula collection was associated with more cholesterol on average than each other collection device (p < 0.0001). For inorganic phosphates, immediate extraction (p < 0.0001), cytology microbrush collection (p < 0.0001), and non-dry eye status (p = 0.03) were associated with the greater likelihood of detection.

CONCLUSIONS

Dacron swab collection was associated with the highest average amount of total lipid detected, whereas spatula collection and immediate extraction was associated with the highest average amount of cholesterol detected. Cytology microbrush collection with immediate extraction on non-dry eye subjects was associated with the highest probability of detection of inorganic phosphates.