Transcript Descemet’s stripping automated endothelial keratoplasty by

Descemet’s stripping automated
endothelial keratoplasty by novice
endothelial keratoplasty surgeons
Jason W. Much, M.D.1
Paul M. Phillips, M.D.1,2
Leslie A. Olsakovsky, M.D.1
The authors have no financial interest in the subject matter of this poster.
1. University of Virginia Department of Ophthalmology, Charlottesville, VA
2. Sightline Ophthalmic Associates, Sewickley, PA
Purpose
• To report 6-month postoperative outcomes
from two cornea surgeons performing their
first solo DSAEK cases while strictly adhering
to a well-described, previously published
technique1
Methods
• Consecutive, prospective series of the first cases performed between
September 2008 and August 2009
• Surgeon 1 (PMP) is in private practice (fellowship-trained in DSAEK)
• Surgeon 2 (LAO) is in academic practice (fellowship-trained in cornea
and traditional penetrating keratoplasty)
• Surgical technique strictly followed as described by Mark Terry1
In brief:
– Peripheral scraping of recipient bed for 360 degrees
– 5mm scleral tunneled wound with folded (40:60) insertion
– Surface sweeping maneuvers used to remove interface fluid
– Freely floating air bubble left in the anterior chamber at end of case
• All tissue was pre-cut by the Portland Eye Bank
Baseline patient characteristics
N
71 eyes of 62 patients
Mean age (yrs)
70.6
Gender
19 male : 43 female
Diagnosis
57 Fuchs (80%)
10 PBK/ABK/surgically-induced corneal
edema (14%)
2 failed PK (3%)
1 ICE syndrome
1 Reiger's anomaly/Descemet’s tear
38 eyes (54%) underwent concomitant cataract extraction
Graft sizes used: 8mm (n=49); 8.5mm (n=17); 7.5mm (n=3); 7mm (n=2)
Results
Mean BCVA
(all eyes)
Pre-op
6-months
P
20/96
20/38
<0.0001
20/79
20/34
<0.0001
Mean BCVA
(excluding
comorbidities*)
Endothelial
cell density
2770 + 340
2263 + 310 <0.0001
(cells/mm2)
Average visual acuity gain over 4 Snellen lines
Endothelial cell loss rate = 18.3%
*macular disease, amblyopia, end-stage glaucoma
Results
• Complications
– The dislocation rate was 4.2%
– All dislocations were successfully repositioned
– Two patients had posterior pressure intraoperatively which led to
significant graft manipulation and post-op anterior synechiae formation
– There were no cases of pupillary block and no cases of primary graft
failure (all grafts were clear at 1 and 6 months)
– At 6 months, 21 eyes (30%) had an intraocular pressure > 24mmHg or a
rise in intraocular pressure of > 10mmHg above pre-op values
• No eyes required glaucoma surgery by the 6 month follow up
– 5 eyes developed interface haze
• Surgeon comparisons
– There was no statistical difference between surgeon 1 or surgeon 2 in
visual acuity results, endothelial cell loss rate or intraocular pressure
rise at 6 months
– Surgeon 1 had a lower dislocation rate (2.1%) than Surgeon 2 (8.7%)
though this did not reach statistical significance (P=0.24)
Results - complications
Interface haze 6 months post-op
but with good final vision
(BCVA at 1 year = 20/30-)
Dislocated graft 1 day post-op
(note ACIOL, trabeculectomy bleb,
and large superior iridectomy)
Graft repositioned without
complication and cornea cleared
(BCVA at 1 month = 20/50-)
Clear DSAEK grafts 6 months post-op
Fuch’s dystrophy
Reiger’s anomaly
Conclusion
• The dislocation rate is better than the average
rate reported in the literature (14%; range 0-82%)
though not as low as that reported by Terry (05%)2
• The 6-month rate of endothelial cell loss is better
than that reported in the literature (average 37%;
range 25-54%) 1-8
• There was a significant rate of steroid response
glaucoma at 6 months consistent with previous
reports9-11
Conclusion
• The novice endothelial keratoplasty surgeon
can achieve encouraging early postoperative
results with few complications by carefully
adhering to a specific surgical technique with
minimal graft trauma
• Our results show that the initial learning curve
may not be as steep as previously thought
References
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Terry MA, Shamie N, Chen ES, et al. Endothelial keratoplasty: a simplified technique to minimize graft dislocation,
iatrogenic graft failure, and pupillary block. Ophthalmology 2008;115:1179-1186.
Lee WB, Jacobs DS, Musch DC, et al. Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the
American Academy of Ophthalmology. Ophthalmology 2009;116:1818-1830.
Terry MA. Endothelial keratoplasty: a comparison of complication rates and endothelial survival between precut tissue
and surgeon-cut tissue by a single DSAEK surgeon. Transactions of the American Ophthalmological Society
2009;107:184-191.
Chen ES, Terry MA, Shamie N, et al. Endothelial keratoplasty: vision, endothelial survival, and complications in a
comparative case series of fellows vs attending surgeons. American Journal of Ophthalmology 2009;148:26-31.e2.
Shih CY, Ritterband DC, Rubino S, et al. Visually significant and nonsignificant complications arising from Descemet
stripping automated endothelial keratoplasty. American Journal of Ophthalmology 2009;148:837-843.
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