Complications and clinical outcomes of descemet stripping automated endothelial keratoplasty with intraocular lens exchange.

PURPOSE: To evaluate complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with intraocular lens (IOL) exchange compared with DSAEK alone. DESIGN: Retrospective, interventional case series. METHODS: DSAEK was performed in 19 eyes in which the anterior chamber IOL was exchanged for a posterior chamber IOL (study group) and in 188 eyes in which the posterior chamber IOL was left in place (comparison group). The complications of graft dislocations, primary graft failure episodes, and pupillary block were recorded for all eyes. Six-month best spectacle-corrected visual acuity and mean central endothelial cell density were measured prospectively and then compared with preoperative values for all eyes. RESULTS: Dislocations occurred in 0 (0%) of 19 eyes in the study group and in 5 (3%) of 188 eyes in the comparison group (P = .47), with 0 primary graft failures and 0 pupillary block episodes in either group. Preoperative mean best spectacle-corrected visual acuity for those eyes without any underlying ocular comorbidities was 20/205 and 20/100 in the study and comparison groups, respectively (P = .18). Mean best spectacle-corrected visual acuity at 6 months improved to 20/48 in the study group and to 20/34 in the comparison group, a statistically significant difference (P = .01). Mean donor cell loss at 6 months was 33% in the study group and 26% in the comparison group (P = .18). CONCLUSIONS: Concurrent IOL exchange with DSAEK surgery does not increase the dislocation, primary graft failure, or pupillary block rates in the immediate postoperative period. Donor endothelial cell loss in DSAEK was not increased significantly by IOL exchange. Visual acuity was slightly worse after combined surgery than after DSAEK alone.

Descemet's stripping automated endothelial keratoplasty (DSAEK) using corneal donor tissue not acceptable for use in penetrating keratoplasty as a result of anterior stromal scars, pterygia, and previous corneal refractive surgical procedures.

PURPOSE: The purpose of this study was to evaluate outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using anterior stromal flawed (ASF) donor corneas that were unsuitable for use in full-thickness penetrating keratoplasty as a result of stromal scars, pterygia, or previous corneal refractive surgery and to compare results with DSAEK using standard tissue. METHODS: We conducted a review of our initial 42 (19 with 6-month follow up) consecutive DSAEK surgeries using ASF tissue compared with 357 (199 with 6-month follow up) time-matched controls using standard tissue. Intraoperative and perioperative complications, including dislocations and primary graft failures, were compared. Six-month best spectacle-corrected vision, incidence of rejection episodes, postoperative refractive astigmatism, keratometric values, pre- and postoperative topography-derived surface asymmetry index, and surface regularity index were compared. RESULTS: One surgeon-cut ASF tissue was perforated before surgery and was discarded. No surgeon-cut standard tissue was perforated. No intraoperative complications and no episodes of primary graft failure or pupillary block glaucoma occurred in either group. One (2.4%) postoperative graft dislocation and one (5.2%) graft rejection episode occurred in the study group. There were 10 (2.8%) dislocations and 8 (2.2%) graft rejection in the controls. A statistically similar significant improvement in best spectacle-corrected vision occurred in both groups. Corneal topography, pachymetry, and manifest astigmatism were not significantly different between groups. CONCLUSION: Postoperative results of DSAEK using donor tissue excluded from use in penetrating keratoplasty as a result of stromal flaws are equivalent to results using standard donor tissue. Central corneal thickness measurements should be performed before cutting to avoid tissue perforation. The use of ASF tissue for DSAEK will expand the cornea donor pool.

Endothelial keratoplasty: vision, endothelial survival, and complications in a comparative case series of fellows vs attending surgeons.

PURPOSE: To compare a 6-month postoperative vision, endothelial cell loss, and immediate postoperative complications in Descemet stripping automated endothelial keratoplasty (DSAEK) cases performed by an experienced corneal surgeon and his inexperienced fellows using an established technique. DESIGN: Retrospective analysis of prospectively gathered data in 327 consecutive DSAEK cases. METHODS: DSAEK cases performed by fellows vs attending surgeons during a concurrent period were compared for 6-month postoperative best spectacle-corrected visual acuity (BSCVA), endothelial cell loss, and immediate postoperative complications. This series represents the initial consecutive cases performed by 3 cornea fellows using a technique identical to that used by the attending. RESULTS: After DSAEK, average BSCVA improved from 20/80 to 20/37 in the attending cases and 20/74 to 20/36 in the fellow cases. There was no statistical difference in endothelial cell loss between groups (32% vs 35%). The dislocation rate was 2% in the attending group and 1% in the fellow group. There were no primary graft failures or cases of pupillary block in either group. CONCLUSIONS: This study demonstrates no difference in vision or endothelial cell loss after DSAEK when performed by an experienced corneal surgeon or inexperienced fellows. Postoperative complications also were similar. Results and complications of DSAEK performed by supervised novice fellows can equal those of an experienced DSAEK surgeon.

Endothelial keratoplasty for Fuchs' dystrophy with cataract: complications and clinical results with the new triple procedure.

PURPOSE: To report the immediate postoperative complications and the 6- and 12-month clinical results in a large series of cases undergoing the new triple-procedure Descemet's stripping automated endothelial keratoplasty (DSAEK) and concurrent cataract surgery. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Three hundred fifteen eyes of 233 patients with Fuchs' corneal dystrophy were evaluated for the complications of dislocation and iatrogenic primary graft failure (IPGF). Two hundred three eyes of 149 patients had 6-month postoperative data available for other outcome analysis. METHODS: A standardized technique of DSAEK with extensive use of cohesive viscoelastic was performed in all 315 eyes with Fuchs' dystrophy, and 225 of those eyes had cataract surgery concurrently. Of the 203 eyes with 6-month data, concurrent phacoemulsification with intraocular lens placement (triple procedure) was performed in 149 of those eyes. MAIN OUTCOME MEASURES: The complications of graft dislocation and IPGF were recorded for all eyes. Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive spherical equivalent (SE), and central donor endothelial cell density (ECD) were measured prospectively and then compared with preoperative values for the triple-procedure eyes. RESULTS: There were 4 dislocations (4%) among the 90 straight DSAEK cases and 4 dislocations (1.8%) among the 225 triple-procedure cases (P = 0.327). There was not a single case of IPGF in any of the 315 DSAEK cases. After the triple procedure, the BSCVA in eyes without comorbidity (n = 122) improved with 93% at 20/40 or better at 6 months and 97% at 20/40 or better at 12 months. Refractive SE at 6 months averaged 0.11+/-1.08 diopters (D), with 73% of eyes within 1 D of emmetropia and 95% within 2 D of emmetropia. The postoperative mean ECD was 1955 cells/mm(2) at 6 months (n = 125) and 1979 cells/mm(2) at 12 months (n = 89) and represented a 32% cell loss from that before surgery (P<0.001) for both postoperative time points. CONCLUSIONS: The new triple-procedure DSAEK combined with cataract surgery provides rapid visual recovery and allows selection of an appropriate intraocular lens. Dislocations are rare (1.8%) and primary graft failure did not occur.

Precut tissue for Descemet's stripping automated endothelial keratoplasty: vision, astigmatism, and endothelial survival.

PURPOSE: To report 6 and 12 month results using precut tissue for Descemet's stripping automated endothelial keratoplasty (DSAEK) and correlate donor characteristics with clinical outcomes. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: We reviewed 100 donor corneas precut for 100 eyes of 90 DSAEK patients. METHODS: Our first 100 consecutive cases of DSAEK with precut tissue were entered into a prospective protocol. Donor characteristics and the visual, refractive, topographic, and specular microscopy results at 6 and 12 months were analyzed. Correlation analysis comparing donor characteristics with clinical outcomes was performed. MAIN OUTCOME MEASURES: Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive astigmatism, topographic keratometry (K), and specular endothelial cell densities (ECD) were measured prospectively and then compared with preoperative values. Donor characteristics analyzed included death to preservation time, death to surgery time, precutting resection to surgery time, and graft thickness. RESULTS: Six months after DSAEK surgery, BSCVA improved from 20/83 to 20/38. (P<0.01). In eyes with no known comorbidity (n = 60), 92% had a vision of >/=20/40 at 6 months and 20% obtained > or =20/20. Astigmatism changed an average of 0.09 diopters (D) and K changed by +0.09 D, both of which were not significant and were stable to 12 months. The postoperative mean ECD (n = 65) was 1918 cells/mm(2) at 6 months, and represented a 31% cell loss from preoperatively (P<0.001). The mean ECD (n = 61) was 1990 cells/mm(2) at 12 months, and represented a 29% cell loss from preoperatively (P<0.001) with no significant change from 6 to 12 months (P = 0.172). Improvement of visual acuity from preoperative to postoperative in eyes without comorbidity was not correlated with any donor characteristic. Greater endothelial cell loss correlated with higher preoperative ECD levels (P<0.001) and with a trend toward longer precut resection to surgery times at both 6 months (P = 0.049) and 12 months (P = 0.051). CONCLUSIONS: Precut tissue by Eye Banks for use in DSAEK surgery provides an improvement in vision with no significant change in astigmatism. Donor endothelial cell loss from 6 to 12 months is stable and is comparable with reports involving tissue that is cut intraoperatively. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosures may be found after the references.

Endothelial keratoplasty: the influence of preoperative donor endothelial cell densities on dislocation, primary graft failure, and 1-year cell counts.

PURPOSE: The purpose of this study was to determine if an association exists between preoperative donor central endothelial cell density (ECD) and the complications of donor dislocation, iatrogenic primary graft failure (IPGF), and endothelial survival at 1 year after endothelial keratoplasty (EK) surgery. METHODS: A prospective, nonrandomized, interventional case study was conducted evaluating 629 consecutive EK procedures. The preoperative donor ECD was recorded for each case. The mean preoperative ECD of the group of EK cases with postoperative donor dislocation was compared with the mean ECD of the group of EK cases that did not suffer donor dislocation. The subset of eyes that underwent Descemet stripping automated endothelial keratoplasty (DSAEK) was also evaluated for dislocation, IPGF, and ECD at 1 year. RESULTS: There were 31 eyes that suffered a dislocation in the overall group of 629 eyes (4.9% dislocation rate). The mean preoperative ECD of the donor tissue in this dislocation group was 2769 cells per square millimeter (range = 2147-3454 cells/mm). The mean preoperative ECD of the donor tissue in the group that did not dislocate (n = 598) was 2818 cells per square millimeter (range = 2110-4209 cells/mm). There was no significant difference in preoperative ECD between these groups (P = 0.428). There was a subset of 350 cases of DSAEK, of which 9 cases dislocated (2.6% dislocation rate). The mean preoperative ECD of the donor tissue in this dislocation group was 2604 cells per square millimeter (range = 2323-3175 cells/mm), with 5 of the 9 dislocation donors with a preoperative ECD above 2500 cells per square millimeter. The mean preoperative ECD of the donor tissue in the group that did not dislocate (n = 341) was 2825 cells per square millimeter (range = 2110-4209 cells/mm). There was no significant difference in preoperative ECD between these groups (P = 0.069). There was no significant correlation between preoperative ECD and the ECD at 1 year after DSAEK (n = 90; Pearson correlation = 0.184; P = 0.082). There were no IPGFs in the entire series of 350 consecutive DSAEK cases, and therefore, no statistical analysis is possible for IPGF. CONCLUSIONS: Preoperative donor ECD was not associated with donor dislocation for any form of EK surgery. Tissue with donor cell counts below 2500 cells per square millimeter can attach, and tissue with donor cell counts above 2500 cells per square millimeter can detach. Higher preoperative donor ECD was not correlated with higher ECD at 1 year postoperatively. Surgeons' requests for donor tissue with an ECD above 2500 cells per square millimeter for DSAEK surgery for the purpose of avoiding dislocations, IPGF, or improving 1-year ECD are not supported by this data.

Descemet-stripping automated endothelial keratoplasty: six-month results in a prospective study of 100 eyes.

PURPOSE: To report 6-month results in a large, prospective study of Descemet-stripping automated endothelial keratoplasty (DSAEK). METHODS: A 5-mm scleral-limbal tunnel approach was created for placement of an automated microkeratome-prepared 8.0-mm endothelial graft after DSAEK in 150 consecutive cases between September 2005 and October 2006. Six-month follow-up data were available on 100 eyes. Intraoperative peripheral scraping was performed to promote adherence of the donor. Preoperative and postoperative visual acuity with and without spectacle correction (BSCVA and UCVA), refractive astigmatism, average topographic keratometry, surface asymmetry index, surface regularity index, and pachymetry were measured prospectively. RESULTS: After DSAEK surgery, average BSCVA improved from 20/86 to 20/38, and average UCVA improved from 20/155 to 20/73, which were both statistically significant (P < 0.05). Excluding 26 eyes with known retinal pathology: 97% of the 74 eyes had a vision of 20/40 or better at 6 months and 14% obtained 20/20 or better. Refractive astigmatism changed an average 0.06 D, and average topographic keratometry changed an average -0.13 D, which were not statistically significant. Surface regularity index and surface asymmetry index improved to normal levels of 0.67 and 1.03, respectively (P < 0.001 and P = 0.002). Pachymetry decreased significantly from 0.70 to 0.66 mm (P = .001). CONCLUSIONS: This large prospective study of DSAEK shows that this surgery provides a significant improvement in vision, corneal thickness, and surface regularity. It does not change refractive astigmatism or average topographic keratometry significantly. This newer technique of endothelial keratoplasty yields many of the benefits of its predecessors, deep lamellar endothelial keratoplasty and posterior lamellar keratoplasty, while improving the visual results.

Endothelial keratoplasty: improvement of vision after healthy donor tissue exchange.

OBJECTIVE: To report 3 cases of graft exchange by using a microkeratome-prepared donor tissue in place of a manually prepared donor tissue for inadequate postoperative visual acuity after deep lamellar endothelial keratoplasty and to discuss possible etiologies. METHODS: Prospective, observational case series. The patients were 3 consecutive patients who underwent endothelial graft replacement for unsatisfactory vision after initial deep lamellar endothelial keratoplasty. This is a review of clinical findings in 3 cases of endothelial keratoplasty that underwent graft exchange for unacceptable vision after deep lamellar endothelial keratoplasty. RESULTS: Two patients benefited from graft exchange by using a microkeratome-prepared donor in place of a manually prepared donor with improvement in best spectacle-corrected visual acuity and 1 did not because of recipient bed irregularities. Vision improved in this patient with penetrating keratoplasty. CONCLUSIONS: Endothelial keratoplasty results in rapid visual recovery and excellent vision. However, fewer eyes achieve 20/20 vision than with full-thickness penetrating keratoplasty. This report shows that some patients with suboptimal vision after endothelial keratoplasty felt to be caused by interface optical problems may benefit from either graft exchange or penetrating keratoplasty.

Endothelial cell loss after Descemet's stripping endothelial keratoplasty in a large prospective series.

PURPOSE: To report the donor endothelial cell loss in the first year after Descemet's stripping endothelial keratoplasty (DSEK) for the treatment of endothelial dysfunction. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Eighty eyes of 78 patients with corneal edema. METHODS: Eighty eyes with endothelial failure were entered into a prospective study of endothelial keratoplasty (EK). The donor central endothelial cell density (ECD) was recorded postoperatively at 6 months (n = 80) and 12 months (n = 80) and then compared with the preoperative eye bank measurements. The subsets of eyes with the donor prepared manually (DSEK; n = 19) and the donor prepared with a microkeratome (Descemet's stripping automated EK [DSAEK]; n = 61) were also evaluated and compared. MAIN OUTCOME MEASURES: Preoperative and postoperative central ECDs were prospectively evaluated and the cell loss calculated for each postoperative time point. RESULTS: The average and standard deviation ECD at 6 months was 1908+/-354 cells/mm(2), representing a mean cell loss from preoperative donor cell measurements of 34+/-12%. At 12 months, ECD was 1856+/-371 cells/mm(2) (35+/-13% cell loss). The 1% additional cell loss from 6 to 12 months was not significant (P = 0.233). In the subset of DSEK eyes (n = 19), the cell loss from preoperatively to 6 months was 34%, and at 12 months it was 39%. In the subset of DSAEK eyes (n = 61), the cell loss from preoperatively to 6 months was 34%, and at 12 months it was 34%. There was no statistical difference between the cell loss from DSEK and that from DSAEK at 6 months (P = 0.884) or at 12 months (P = 0.224). CONCLUSIONS: Descemet's stripping EK using our surgical technique has a mean donor endothelial cell loss of 34% at the 6-month postoperative examination, and this average cell loss remains relatively stable up to at least 1 year. We found no difference in cell loss between the DSEK and DSAEK techniques over this 1-year postoperative period.

Precut tissue in Descemet's stripping automated endothelial keratoplasty donor characteristics and early postoperative complications.

PURPOSE: To describe donor characteristics of eye bank-prepared precut tissue used in Descemet's stripping automated endothelial keratoplasty (DSAEK) and report any increase in immediate postoperative complications associated with its use. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: One hundred donor corneas deemed appropriate for transplant and 100 eyes undergoing DSAEK for endothelial dysfunction. METHODS: Precut donor tissue was evaluated in a prospective study of 100 consecutive cases of DSAEK surgery. Donor characteristics and the immediate postoperative complications of donor tissue dislocation and graft failure with the use of precut tissue were recorded and analyzed. MAIN OUTCOME MEASURES: Preoperative donor characteristics (age, time from death to preservation, time from death to implantation, time from cut to implantation, residual stromal bed thickness, pre- and postcut endothelial density), rate of dislocation, and rate of primary graft failure. RESULTS: Average donor age was 57.6+/-10.8 years, average time from death to preservation was 9.8+/-3.2 hours, average time from death to implantation was 94.5+/-33.5 hours, and average time from cut to implantation was 26.0+/-17.4 hours. The average residual stromal bed thickness was 169+/-36 microns. The average endothelial cell density (ECD) after cutting was 2709+/-292 cells/mm(2) (n = 100). In the subgroup of donors in whom pre-resection and postresection endothelial cell densities were available (n = 80), the average ECD before cutting was 2743+/-253 cells/mm(2) and the average ECD after cutting was 2644+/-257 cells/mm(2). This average cell loss of 3.7% was statistically significant (P<0.001). There was only 1 dislocation in this entire series of 100 eyes. There were no primary graft failures. CONCLUSION: The use of precut tissue in DSAEK had a low rate of early postoperative complications such as graft dislocation (1%) and primary graft failure (0%). A wide range of donor characteristics such as donor age, death to transplantation time, precutting to transplantation time, and donor lenticule thickness resulted in excellent adhesion of the tissue and clear grafts.

Endothelial keratoplasty a simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block.

PURPOSE: Endothelial keratoplasty is an exciting alternative to full-thickness penetrating keratoplasty for replacing the diseased endothelium, yet 3 of the major complications seen are dislocation of the donor tissue, primary graft failure (PGF), and pupillary block from the residual, supportive air bubble. Surgical strategies were developed to reduce the likelihood of occurrence of these complications in our first 200 consecutive Descemet's stripping automated endothelial keratoplasty (DSAEK) cases. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Two hundred eyes of 172 patients with corneal edema. METHODS: An institutional review board-approved, prospective protocol of endothelial keratoplasty was initiated. Four different surgeons performed DSAEK for the initial 200 consecutive cases using a technique of peripheral recipient bed scraping for donor edge adherence and leaving a residual supportive air bubble, which was freely mobile, and

A prospective study of endothelial cell loss during the 2 years after deep lamellar endothelial keratoplasty.

PURPOSE: To report the endothelial survival over a 2-year period after 2 techniques of deep lamellar endothelial keratoplasty (DLEK) in the treatment of endothelial dysfunction. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: One hundred eyes of 88 patients with corneal edema. METHODS: One hundred consecutive eyes with endothelial failure were entered into a prospective study of endothelial keratoplasty, and the donor central endothelial cell density (ECD) was recorded postoperatively at 6 months (n = 98), 12 months (n = 96), and 24 months (n = 85) and then compared with the preoperative eye bank measurements. The subsets of eyes with large-incision DLEK (n = 36) and small-incision DLEK (n = 62) were also evaluated and compared. MAIN OUTCOME MEASURES: Preoperative and postoperative central ECDs were prospectively evaluated and the cell loss calculated for each postoperative time point. RESULTS: The average (and standard deviation) ECD at 6 months was 2140+/-426 cells/mm(2), representing a mean cell loss from preoperative donor cell measurements of 25+/-15%. At 12 months, ECD was 2090+/-448 cells/mm2 (26+/-16% cell loss), and at 24 months, it was 1794+/-588 cells/mm2 (37+/-27% cell loss). The additional cell loss from 1 to 2 years was significant (P<0.001). In the subset of large-incision DLEK eyes (n = 36), the cell loss from preoperatively to 6 months was 23%; 12 months, 22%; and 24 months, 27%. In the subset of small-incision DLEK eyes (n = 62), the cell loss from preoperatively to 6 months was 25%; 12 months, 28%; and 24 months, 43%. The cell loss from small-incision DLEK surgery was significantly greater than that from large-incision DLEK surgery at the 12-month (P = 0.013) and 24-month (P<0.001) postoperative measurements. CONCLUSIONS: Although the initial cell loss from DLEK surgery is minimally changed from 6 to 12 months postoperatively, there is an acceleration of cell loss from 1 year to 2 years postoperatively. The small-incision DLEK technique, which involves folding of the donor tissue, results in a significantly higher endothelial cell loss at 1 and 2 years than that found after large-incision DLEK surgery, wherein the tissue is not folded.

Histology of dislocations in endothelial keratoplasty (DSEK and DLEK): a laboratory-based, surgical solution to dislocation in 100 consecutive DSEK cases.

PURPOSE: Laboratory studies were performed to evaluate the histologic differences between the recipient bed after deep lamellar endothelial keratoplasty (DLEK) surgery and Descemet's-stripping endothelial keratoplasty (DSEK) surgery. Relevant new surgical strategies to prevent dislocation in DSEK surgery were initiated in our first 100 consecutive clinical cases. METHODS: Ten pairs of cadaver eyes had a DLEK in 1 eye and a DSEK in the fellow eye, and the posterior stromal surface was analyzed by scanning electron microscopy at x50 magnification. Based on the findings in these cadaver eyes, our DSEK procedure was modified to include surgical roughening in the peripheral recipient bed in 100 consecutive eyes. One hundred percent of these eyes were followed for at least 60 days after surgery to determine the rate of donor dislocation. RESULTS: In all 10 pairs of cadaver eyes, the DSEK stromal interface showed a smoother surface than DLEK eyes, without the presence of cut stromal fibrils. The DLEK surface was less smooth than the DSEK eyes, but with the presence of uniformly cut fibrils over the entire surface. Subsequent surgical modifications to the DSEK procedure to include scraping and roughening of the recipient peripheral bed in humans resulted in only a 4% (4/100) dislocation rate of the donor tissue into the anterior chamber. One of these 4 dislocated donors was seen on the first postoperative day and was the only primary graft failure in the series. The other 3 cases were fully attached on the first postoperative day with no interface fluid, but they dislocated later on postoperative days 2, 3, and 4. CONCLUSION: The high rate of dislocation of the donor disc in DSEK may be caused by the absence of recipient stromal fibrils to initially bind to the donor stromal fibrils. Clinical success with a surgical technique of selectively scraping the peripheral recipient bed to promote donor edge adhesion (while leaving the central bed untouched for vision) may aid in the prevention of donor dislocation in DSEK surgery. Reduction of dislocation in DSEK surgery has also been associated with a reduced rate of iatrogenic primary graft failure (PGF) to 1%.