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Retrospective comparison of staged versus combined cataract surgery
and Descemet’s-stripping endothelial keratoplasty (DSEK) in patients with Fuchs’ Dystrophy
Christine Garcia, MS2,1 Omar Krad, MD,2 Amy Lin, MD2
Loyola University Chicago, Stritch School of Medicine, Maywood, IL,1 Department of Ophthalmology, Loyola University Health System,2 Maywood, IL
Introduction
Fuchs’ endothelial dystrophy is a
progressive hereditary corneal disease
characterized by deterioration of the endothelium
and overlying Descemet’s membrane (Figure 1).
Patients with Fuchs’ dystrophy may develop loss of
vision from corneal and stromal edema and
excrescences of the Descemet’s membrane
(“corneal guttata”). Because the visual
disturbances are not typically seen until after age
fifty, patients frequently have coexisting visually
significant cataracts. The recently developed
procedure indicated for patients with Fuchs’
dystrophy, Descemet’s Stripping Endothelial
Keratoplasty (DSEK), can be performed in a
combined surgery following cataract extraction with
intraocular lens placement (CEIOL) or in a staged
fashion with DSEK following CEIOL.
To date there is no significant evidence that
one method of performing the cataract and DSEK
surgeries, staged or combined, is more
advantageous, but there have been a few studies
completed that indicate possible benefits of each
protocol. Covert and Koenig (2007) specified that
combined surgeries would enable the patient to
undergo a single surgery with an overall shorter
recovery time. However, according to Yoo et al.
(2008) more surgical working space and better
stability of the anterior chamber after recovery from
cataract surgery could offer more beneficial
conditions for performing DSEK, namely greater
ease of DSEK donor graft tissue insertion and
positioning. This may minimize the damage to the
endothelial cells in the donor graft, with less
likelihood of graft dislocation or failure. There is
also the possibility of avoiding DSEK altogether
should there be adequate visual recovery from
cataract surgery.
A Chicago area multi-center retrospective
comparison of visual acuity and central corneal
thickness was performed to determine which
surgical protocol, staged versus combined,
produces better clinical outcomes.
Objectives
1. Report the outcomes of staged cataract extraction
by phacoemulsification technique with IOL
placement followed by DSEK (group 1) compared
with the outcomes of combined cataract extraction
with IOL placement and DSEK (group 2)
2. Evaluate advantages and disadvantages to
performing staged versus combined
phacoemulsification and DSEK procedure.
3. Determine the percentage of patients who were
scheduled for staged phacoemulsification and
DSEK procedures, but did not undergo DSEK
because of favorable visual outcome and corneal
appearance after cataract surgery.
4. Report the criteria (indications) for performing
cataract surgery and/or DSEK in a large
metropolitan area.
Results cont’d
which will specifically include more combined
cataract and DSEK surgery cases. This will make
group 2 stronger, and contribute to the overall goal
of fifty patients in each group.
Using the data obtained thus far, general
surface analysis showed a trend in which patients
who underwent combined CEIOL and DSEK
surgeries had a 29.7% greater improvement in
visual acuity than patients who underwent staged
surgeries (Table 1). Also, of the 28 patients who
underwent staged procedures, five had a graft
dislocation treated with a repositioning, whereas
two of the five patients who underwent
simultaneous procedures had the same
complication. This will be studied further to possibly
indicate which surgical protocol has better visual
outcomes and less post-operative complications.
Data collection continues in order to increase the
power of the study. When complete, a t-test will be
performed to analyze any differences in the visual
acuities and central corneal thicknesses between
the two groups.
Figure 1: Histopathology of the posterior cornea in Fuchs' dystrophy.
The thickened Descemet's membrane with nodular
excrescences (guttata) is seen. Endothelial cells are sparse.
Results
Retrospective chart review was carried out for
patients identified to have both cataracts and Fuchs’
endothelial dystrophy. The multi-center study included
review of 28 eyes from 28 patients who underwent
staged CEIOL followed by DSEK (group 1) and 5 eyes
from four patients that underwent a combined CEIOL
and DSEK surgery (group 2). Visual outcomes were
compared using logMAR visual acuity and central
corneal thickness measurements before and after the
surgeries at post-operative months 1, 3, 6, and 12. At
the present time, more data is being gathered from
University of Chicago and Wheaton Eye Clinic,
Table 1: Pre-operative and
post-operative best
spectacle-corrected visual
acuity (BSCVA) in patients with
staged or combined cataract
and DSEK surgeries. Postoperative BSCVA is at 12
months or the latest postoperative data available within
one year. Lower logMAR
values indicate better vision.
**Graft dislocations.
Conclusion
At this time, the study is in progress. With
the multi-center nature of the project, data
continues to be collected. Thus far however, the
trend seems to show better visual outcomes in
patients who had combined cataract and DSEK
surgeries, but a smaller percentage of cases with
complications (graft dislocation) in the patients
who had staged cataract and DSEK surgeries.
Further analysis of the incoming data may
contribute to either approval or disapproval of
these trends.
Evaluation of patients who did not undergo
DSEK because of significant visual improvement
after cataract surgery is inconclusive with the data
at hand. The definitive reasons that the four postCEIOL patients were still awaiting DSEK surgeries
in the same eye were not charted. It was unclear
whether or not the DSEK surgeries in these
patients were postponed due to favorable visual
outcome or another clinical indication.
A considerable obstacle found with the
retrospective study was incomplete charting and
number of subjects who fit the inclusion/exclusion
criteria. The incoming data will be beneficial,
however, in order to make more significant
conclusions comparing the staged versus
combined procedures.
References
Covert, D.J., Koenig, S.B. 2007. “New triple procedure: Descemet’s stripping and automated endothelial
keratoplasty combined with phacoemulsification and intraocular lens implantation.” Ophthalmology.
114(7):1272-1277.
Krachmer, J.H., Palay, D.A. Cornea Atlas. 2nd ed. Elsevier Inc., 2006. p 176.
Price, M.O., Price, F.W. 2007. “Descemet’s stripping endothelial keratoplasty.” Current Opinion in
Ophthalmology. 18:290-294.
Terry, M., Shamie, N., Chen, E., Hoar, K., Friend, D. 2008. “Endothelial Keratoplasty: A simplified
technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block.” Ophthalmology.
115(7):1179-1186.
Yoo, S.H., Kymionis, G.D., Deobhakta, A.A., Ide, T., Manns, F., Culbertson, W.W., O’Brien, T.P., Alfonso,
E.C. 2008. “One-year results and anterior segment optical coherence tomography findings of Descemet
stripping automated endothelial keratoplasty combined with phacoemulsification.” Ophthalmology.
126(8):1052-1055.
Acknowledgements: This work was supported by the Richard A. Perritt Charitable Foundation.