Transcript Surgery for Diabetic Eye Disease: The State of the Art

Special considerations for
DSEK in monocameral eyes
R. E. Fintelmann, MD
S. Hannush, MD
I. Raber, MD
B. Ayres, MD
No financial interests to disclose regarding this presentation
Purpose
• To outline the challenges of DSEK in eyes with
direct communication between the anterior
chamber and vitreous cavity.
• To outline techniques to manage these
challenges.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
Monocameral eyes
Any eye that has a communication between
the anterior and posterior segment.
– Eyes with an ACIOL
– Eyes with a sulcus PCIOL after Yag
Capsulotomy
– Eyes with a subluxated PCIOL with an
opening in the posterior capsule
– Eyes with a big Iridectomy
– Aphakia
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
Challenges facing surgeon
• Sequestering of viscoelastic can lead to
incomplete removal before the insertion of the
button.
• Communication between the anterior and
posterior segment can lead to misdirection of air
leading to vitreous prolapse.
• Air migrates easily into the posterior segment
making tamponade of the endothelial button
difficult.
• Endothelial Button can dislocate into the
posterior segment.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
Special considerations
1. Consider avoiding viscoelastic altogether
during scoring and stripping, opting for
irrigation to maintain the chamber.
2. Consider constricting the pupil early
during the procedure to limit migration of
BSS or air into the posterior segment
during the procedure.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
3. Anticipate and be prepared to
manage any vitreous herniation
during the procedure.
4. Balance the potential advantages
of replacing an ACIOL with an insulcus or sutured PCIOL1 against
the challenges of explanting an
ACIOL through a limbal incision
(bleeding, etc).
– Suturing a PCIOL
– Iris clipped Artisan lens2
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
5. If leaving an ACIOL in place,
consider using a non-folding
insertion technique to avoid the
challenges of limited working
space.
6. Consider a temporary anchoring
suture in an aphakic eye with
significant risk of posterior tissue
subluxation3.
7. Coloring the button with Trypan
blue can aid in visualization of
the button after implantation3.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
9. Anticipate the larger amount of
air required for tissue
tamponade, in the event of
posterior air migration.
10.Learn to distinguish the different
reflex of air posterior versus
anterior to an IOL.
11.Avoid unnecessary irrigation,
aspiration or air removal that
may invite vitreous forward.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
12. Postoperative air bubble management
is different than with usual EK.
– True pupillary block is extremely rare.
– Appositional angle closure secondary to
disproportionately greater amounts of air
posteriorly is not uncommon.
– Familiarity with reducing appositional angle
closure postoperatively is essential.
13. Consider the role of topical NSAIDS if
not usually used in EK.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
Conclusions
• EK is effective in the management of corneal
endothelial dystrophy and dysfunction in
monocameral eyes.
• A background in basic endothelial keratoplasty
before attempting more complex cases is
helpful.
• Several special considerations are helpful in
accomplishing successful surgery.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD
Bibliography
1. Wylegala E, Tarnawska D. Management of
2.
3.
pseudophakic bullous keratopathy by combined
Descemet-stripping endothelial keratoplasty and
intraocular lens exchange. J Cataract Refract Surg
2008;34(10):1708-14.
Lake DB, Rostron CK. Management of anglesupported intraocular lens and iridectomy in
Descemet-stripping endothelial keratoplasty. Cornea
2008;27(2):223-4.
Price MO, Price FW, Jr., Trespalacios R. Endothelial
keratoplasty technique for aniridic aphakic eyes. J
Cataract Refract Surg 2007;33(3):376-9.
Robert E. Fintelmann, MD, S. Hannush, MD
I. Raber, MD, B. Ayres, MD