Transcript The Evolution of Lamellar Grafting Techniques Over 25 Years

DSAEK in Eyes With Severe
Pre-operative Visual Acuity
Loss.
Paul Phillips, MD1,2, Mark A. Terry, MD2,3, Neda Shamie, MD2, Anand
Shah, MD2, and Daniel Friend3
1. Sightline Ophthalmic Associates, Pittsburgh, PA
2. Devers Eye Institute, Portland, OR
3. Lions Eye Bank of Oregon Vision Research Laboratory, Portland, OR
Financial interest statement:
Mark A. Terry, MD has a financial interest in the specialized DSAEK instruments used in this study.
Funding for this project was supplied by The Lions Eye Bank of Oregon.
Introduction
Endothelial Keratoplasty (EK) is a technique for the
selective replacement of diseased corneal endothelium.
Descemet’s Stripping Automated EK (DSAEK) has
become the most commonly used technique of EK today
for the treatment of endothelial dysfunction.
Previous studies have demonstrated the benefit of
EK in the form of deep lamellar endothelial keratoplasty
(DLEK) for eyes with severe vision loss (VA<20/400)1,2.
To date, no study has evaluated outcomes of the
treatment of these eyes with DSAEK.
The specific goal of this study was to determine
whether acceptable outcomes could be achieved in this
severe vision loss group in the form of low complications,
dislocations, primary graft failures (PGF), endothelial cell
loss and late endothelial failures.
Methods
Data collection:
Eyes with severe pre-operative vision loss (SVL)(<20/400) (n=43)
were retrospectively analyzed and compared with a time match
control group (>/=20/400) (n=538).
Patients were evaluated at 1month for:
-Intra-operative complications
-Post-operative dislocations
-Primary graft failure (PGF)
Patients were evaluated at 6 months and 12 months for:
-Best spectacle visual acuity (BSCVA)
-Endothelial cell density (ECD)
-Late endothelial failure
Data Analysis
-These parameters were evaluated for statistical significance by ChiSquare independent sample T tests, using SPSS 12.0.
Results
Pre-Operative Comorbidities: Study vs. Control
Comorbidities*
SVL
Control
p-value
65%
27%
0.000
* Optic neuropathy, retinal pathology, iritis, ICE syndrome, HSV, surface disease
Post-Operative Vision
Severe Vision Loss Group (BSCVA)
Follow up time point
Average
Improved Vision
>/= 20/40
6mo
20/122
96%
35%
(n=23)
(20/20-20/2000)
(n=22)
(n=8)
12mo
20/108
88%
35%
(n=17)
(20/25-HM)
(n=15)
(n=6)
Control Group (BSCVA)
Follow up time point
Average
Improved Vision
>/= 20/40
6mo
20/35
82%
83%
(n=361)
(20/10 -20/400)
(n=295)
(n=300)
12mo
20/24
84%
85%
(n=257)
(20/10 – 20/2000)
(n=215)
(n=219)
Results
VA of SVL eyes: with comorbidities vs. no comorbidities
Severe Vision Loss Group (BSCVA)
No Comorbidity
With Comorbidity
P Value
Pre-Operative
20/4050
(CF)
20/3050
(CF)
0.359
6mo
20/50
20/155
0.007
(n=23)
(n=5)
(n=18)
12mo
20/39
20/147
(n=17)
(n=4)
(n=13)
0.220
BSCVA was better in the “no comorbidity” group, but only statistically significant at 6mo
Results
Complications
*Operative Complication
Dislocation
PGF
SVL
Control
p-value
5%
1%
0.031
(n=2)
(n=5)
7%
2%
(n=3/43)
(n=11/538)
0
1
0.042
n/a
* Excessive manipulation or damage of corneal tissue, iris damage, loss of donor tissue, compromise
of filtering bleb and other.
Results
Endothelial Health
SVL
Control
p-value
Pre-op ECD
2793
2755
6mo ECD
(% Cell Loss)
1640
(35%)
2004
(26.9%)
0.013
12mo ECD
(% Cell Loss)
1587
(36.2%)
2005
(27.6%)
0.019
Late Endothelial Failure
5.8%
0.3%
0.000
(Eyes with at least one year f/u)
(n=2/36)
(n=1/362)
Results
Example Patient
Figure 1a: Pre-op EK for Bullous
Keratopathy from trauma
BSCVA: CF
Figure 1b: 3yrs post-op EK for
Bullous Keratopathy from trauma
BSCVA: 20/30
Discussion
When compared to a time matched control group, vision in the SVL group
was more limited.
– This limitation in vision may be due to a higher rate of comorbidities, but may
also be limited by inherent chronic stromal changes, as there was not a
significant difference in final acuities between eyes with and without
comorbidities at one year in the SVL group.
While there was not a higher incidence of PGF in SVL group, there were
higher rates of dislocation and intra-operative complications.
– We believe that the dislocation (7%) and intra-operative complication (5%) rates
in the SVL group are acceptable, however these rates may be higher than the
control group due to the more complex nature of surgery in these eyes.
Post-operative endothelial cell loss is also higher in the SVL group, with
increased rates of late endothelial failure.
– We believe that rates of ECD loss (36.2%) and late endothelial failure (5.8%) are
acceptable, but may possibly be higher due to increased intra-operative trauma
and significant comorbidities, such as the presence of glaucoma, filtering tubes
and trabeculectomies.
– In the future, data from a greater number of eyes with SVL, with long term followup, will help to clarify the true difference in outcomes in this population.
Discussion
Despite a significantly higher rate of comorbid
conditions in the severe vision loss (SVL) study
group, DSAEK was performed in these eyes with
relatively:
- Low intra-operative complications
- Low dislocation rates
- Low primary graft failure rates
- Improved vision
- Reasonable preservation of endothelium and
rates of late endothelial failure