Descemet-Stripping Automated Endothelial Keratoplasty.

PURPOSE: To evaluate the speed of visual recovery in 16 consecutive patients with corneal endothelial dysfunction who received Descemetstripping automated endothelial keratoplasty (DSAEK). METHODS: This is a retrospective study of a novel method for smallincision endothelial transplantation (DSAEK). Endothelial replacement was accomplished with Descemet stripping of the recipient and insertion of a posterior donor tissue that had been prepared with a microkeratome. Best spectacle-corrected visual acuity (BSCVA) by manifest refraction, endothelial counts, and dislocation rates were measured up to 12 months after DSAEK. RESULTS: Sixteen consecutive patients underwent uncomplicated DSAEK. Three patients had known optic nerve or macular disease precluding vision better than 20/200. Of the remaining 14 patients, 11 had BSCVA of 20/40 by postoperative week 12 (7 by week 6). The remaining 2 were 20/50 by weeks 6 and 12. All 14 patients were 20/40 or better at 1 year. One patient had a primary graft failure, and surgery was repeated with 20/40 BSCVA at 1 year. The dislocation rate was 25%. The average cell count between 7 and 10 months was 1714. The average pachymetry was 682. CONCLUSION: DSAEK surgery allows rapid, excellent BSCVAvisual recovery. The rate of visual recovery is more rapid than usually found with penetrating keratoplasty.

Donor tissue characteristics in preparation of DMEK grafts.

PURPOSE: The aim of the study was to determine donor tissue characteristics that contribute to longer peeling times or tissue tears during peeling during Descemet membrane endothelial keratoplasty (DMEK) graft preparation. METHODS: The data analyzed included donor age, gender, postmortem tissue age, contralateral eye data, peel time, and peel complications of 116 consecutive DMEK donor tissues, which were prepared by a single surgeon with the submerged cornea using backgrounds away (SCUBA) technique. RESULTS: The mean peel time was 10.1 ± 3.3 minutes (range, 6-24 minutes). Tears were noted in 7 cases (6%) and occurred more commonly with longer peel times. Three of the torn grafts had either peripheral tears or small, noncentral buttonholes or horseshoe tears and were successfully transplanted, for a transplant rate of 97%. However, the host stroma in these cases took longer to clear postoperatively. The donor gender and postmortem day of peeling did not have any statistical significance for the peeling time or tear rate (P > 0.05). Interestingly, tissue from donors older than 65 years had slightly faster peel times, but this difference did not reach statistical significance (≤65 = 11.0 ± 4 minutes; >65 = 9.3 ± 3.1 minutes; P = 0.07) and had equal rates of graft tears (6%). Most importantly, however, there was a strong correlation between peel times for the 2 eyes from the same donor (r = 0.78, P = 0.03), and the risk of a tear during peeling in the second eye was much greater if the first graft also had a tear during preparation (odds ratio = 7.2, P = 0.02). CONCLUSIONS: Exclusion of the contralateral eye tissue when there was difficulty in graft peeling for the first eye may prove to be a unique quality of DMEK donor tissue.

DMEK Complications.

PURPOSE: The aim of this study was to describe the incidence and management of the complications of Descemet membrane endothelial keratoplasty (DMEK) surgery performed by a single surgeon. METHODS: This is a retrospective case series. The clinical records of 72 consecutive patients (75 eyes) who underwent a DMEK with a minimum of 1-month postoperative follow-up were reviewed for adverse outcomes. The surgeon's first 50 operated eyes over a 4-month period were excluded from this study. RESULTS: All the eyes included were pseudophakic with endothelial failure resulting from either Fuchs dystrophy, pseudophakic bullous keratopathy, or a failed Descemet stripping automated endothelial keratoplasty. All the eyes had a total resolution of corneal edema. Donor tissue peeling was unsuccessful in 2 of 75 cases. Primary failure occurred in 2 of 75 cases; a repeated DMEK provided successful visual rehabilitation in both cases. Rebubbling was performed in 2 of 75 eyes, which was unsuccessful in both cases. Peripheral donor scrolls/contractions occurred in 17 of 75 eyes, and all were asymptomatic with 14 of 17 eyes (82%) located in the inferior quadrants. There were no cases of pupillary block glaucoma, inverted donors, or free-floating donors. Preliminary best spectacle-corrected visual acuity was 20/25 at postoperative month 3 with corresponding excellent endothelial counts (mean of 2112 cells per square millimeter in 22 patients with 6 months of follow-up). CONCLUSIONS: The safety and rate of operative complications of DMEK are approaching that of Descemet stripping automated endothelial keratoplasty.

The effect of donor age on penetrating keratoplasty for endothelial disease: graft survival after 10 years in the Cornea Donor Study.

OBJECTIVE: To determine whether the 10-year success rate of penetrating keratoplasty for corneal endothelial disorders is associated with donor age. DESIGN: Multicenter, prospective, double-masked clinical trial. PARTICIPANTS: A total of 1090 participants undergoing penetrating keratoplasty at 80 sites for Fuchs' dystrophy (62%), pseudophakic/aphakic corneal edema (34%), or another corneal endothelial disorder (4%) and followed for up to 12 years. METHODS: Forty-three eye banks provided corneas from donors aged 12 to 75 years, using a randomized approach to assign donor corneas to study participants without respect to recipient factors. Surgery and postoperative care were performed according to the surgeons' usual routines. MAIN OUTCOME MEASURES: Graft failure defined as a regraft or, in the absence of a regraft, a cloudy cornea that was sufficiently opaque to compromise vision for 3 consecutive months. RESULTS: In the primary analysis, the 10-year success rate was 77% for 707 corneas from donors aged 12 to 65 years compared with 71% for 383 donors aged 66 to 75 years (difference, +6%; 95% confidence interval, -1 to +12; P = 0.11). When analyzed as a continuous variable, higher donor age was associated with lower graft success beyond the first 5 years (P<0.001). Exploring this association further, we observed that the 10-year success rate was relatively constant for donors aged 34 to 71 years (75%). The success rate was higher for 80 donors aged 12 to 33 years (96%) and lower for 130 donors aged 72 to 75 years (62%). The relative decrease in the success rate with donor ages 72 to 75 years was not observed until after year 6. CONCLUSIONS: Although the primary analysis did not show a significant difference in 10-year success rates comparing donor ages 12 to 65 years and 66 to 75 years, there was evidence of a donor age effect at the extremes of the age range. Because we observed a fairly constant 10-year success rate for donors aged 34 to 71 years, which account for approximately 75% of corneas in the United States available for transplant, the Cornea Donor Study results indicate that donor age is not an important factor in most penetrating keratoplasties for endothelial disease.

Chronic keratitis with intrastromal epithelioid histiocytes: a new finding in Muckle-Wells syndrome.

PURPOSE: To report a new corneal finding in Muckle-Wells syndrome (MWS) and its subsequent treatment. METHODS: The medical chart of a 45-year-old woman with a history of MWS was reviewed. She presented with progressive bilateral stromal edema and scarring that had been worsening over the past year. The left eye, which had more severe stromal scarring and a best spectacle-corrected visual acuity (BSCVA) of hand motion, had a history of cataract removal with lens implantation, argon laser trabeculoplasty, and trabeculectomy 2 years previously for open-angle glaucoma. The right eye had also undergone argon laser trabeculoplasty and trabeculectomy and had a BSCVA of 20/100. RESULTS: The patient underwent penetrating keratoplasty in the more severely affected left eye. Nine months postoperatively the patient had a BSCVA of 20/40 in the eye that had undergone transplantation. The pathologic specimen demonstrated a chronic keratitis with focal calcification of Bowman layer, localized Descemet membrane breaks, marked endothelial loss, and pronounced intrastromal epithelioid histiocytes without evidence of amyloidosis. CONCLUSIONS: To the best of our knowledge, this case highlights a new association with MWS. Epithelioid histiocytes have been demonstrated in other parts of the body in patients with MWS including the skin and joints, which is sometimes accompanied by amyloidosis.

Descemet stripping automated endothelial keratoplasty for spontaneous descemet membrane detachment in a patient with osteogenesis imperfecta.

PURPOSE: To report the first use of Descemet stripping automated endothelial keratoplasty (DSAEK) for spontaneous Descemet membrane detachment in a patient with osteogenesis imperfecta (OI), keratoconus, and acute bullous keratopathy. METHODS: A case report of a 25-year-old man with OI and symptomatic unilateral bullous keratopathy secondary to spontaneous Descemet membrane detachment is described. The patient presented with acute loss of vision in his right eye and was noted on slit-lamp examination to have a totally detached and taut Descemet membrane, spanning the anterior chamber. This diagnosis was confirmed with an anterior segment OCT (Visante; Carl Zeiss Meditec, Dublin, CA). RESULTS: After an attempt to reattach the Descemet membrane with air bubbling was unsuccessful, the patient underwent successful DSAEK. Seven months postoperatively, his best spectacle-corrected visual acuity was 20/50 compared with his other eye, which was 20/40. There were some central folds in the donor noted immediately postoperatively that have persisted. CONCLUSIONS: To the best of our knowledge, this case is the first documented spontaneous Descemet membrane detachment in a patient with OI and probable keratoconus treated successfully with DSAEK. Unlike in classical keratoconus hydrops, medical management is unlikely to resolve a total Descemet membrane detachment. This unusual Descemet membrane detachment was tightly stretched across the anterior chamber without any obvious tear, making simple air or gas bubble apposition impossible. Attempts to tear the Descemet membrane and then bubble led to significant folds. DSAEK was successful in removing the detached Descemet membrane and replacing it with the donor tissue.

Dislocation of the donor graft to the posterior segment in descemet stripping automated endothelial keratoplasty.

PURPOSE: To report a series of dislocations of the donor graft into the posterior segment associated with Descemet stripping endothelial keratoplasty (DSAEK) and to identify possible risk factors for dislocation and clinical outcomes. DESIGN: Retrospective case series. METHODS: Cases of donor graft dislocation into the posterior segment associated with endothelial keratoplasty were identified from the clinical experience of 7 surgeons. Observations included the preoperative surgical history of each eye, preoperative and postoperative visual acuity, management of the complication, and the postoperative clinical course. No identified cases were excluded from this series. RESULTS: Eight posterior graft dislocations were associated with DSAEK surgery. Each eye had a history of vitrectomy. Five eyes had sutured posterior chamber intraocular lenses, 1 eye had a sulcus intraocular lens, and 2 eyes were aphakic. Each eye required repeat grafting, and in 6 of 8 eyes, pars plana vitrectomy was used to remove the dislocated graft. Final visual acuities ranged from 20/30 to no light perception. CONCLUSIONS: Graft dislocation into the posterior segment is a rare complication of DSAEK surgery that can lead to permanent vision loss. It has occurred in eyes that have undergone previous vitrectomy and complicated intraocular lens placement or were aphakic. As is the case with a dropped lens nucleus during cataract extraction, visual acuities after a dropped DSAEK graft range from very good to no light perception. Better postoperative results seem to be associated with prompt removal of the posteriorly dislocated graft.

Long-term results of Descemet stripping automated endothelial keratoplasty.

PURPOSE: To report the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: A retrospective case series was conducted on 51 patients who underwent DSAEK 5 years ago. DSAEK was performed for Fuchs corneal dystrophy, pseudophakic or aphakic bullous keratopathy, or failed penetrating keratoplasty (PKP). Best spectacle-corrected visual acuity (BSCVA), endothelial cell counts (ECC), and current graft status were ascertained for the eyes included in the study. Episodes of rejection and need for repeat transplantation were also analyzed. RESULTS: Forty-seven of 51 eyes had clear grafts at the most recent postoperative visit. There were 4 graft failures treated with repeat DSAEK, and regrafts are also clear to date. One eye had an episode of rejection that was successfully treated with topical steroids. CONCLUSIONS: Long-term results of DSAEK were excellent. Grafts were clear despite lower than normal endothelial cell counts. To our knowledge, this is the longest running study of DSAEK outcomes to date.

Laser-assisted in situ keratomileusis or photorefractive keratectomy after descemet stripping automated endothelial keratoplasty.

PURPOSE: To report the outcomes of laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: A retrospective case series was conducted on 5 postoperative unilateral DSAEK cases that underwent LASIK or PRK. DSAEK was performed for Fuchs corneal dystrophy and pseudophakic bullous keratopathy. Postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and current graft status were ascertained for the 5 eyes included in the study. RESULTS: All eyes had clear grafts at the most recent postoperative visit. Three eyes underwent LASIK, and 2 eyes had PRK 11 to 17 months after DSAEK. UCVA ranged from 20/80 to 20/200 before refractive surgery (BSCVA: 20/20 to 20/30). Postoperative UCVA improved to 20/20-20/40, and BSCVA was unchanged at 20/20 to 20/30. No patient lost vision. CONCLUSIONS: Refractive error after DSAEK may be safely treated with LASIK or PRK. PRK is equally as effective as LASIK. All grafts remain clear, and all the eyes have significantly improved UCVA.

Spontaneous reattachment of Descemet stripping automated endothelial keratoplasty lenticles: a case series of 12 patients.

PURPOSE: To review 12 cases of postoperative detachment and spontaneous reattachment of Descemet stripping automated endothelial keratoplasty (DSAEK) lenticles. DESIGN: Retrospective, observational case series. METHODS: This was a review of patients undergoing DSAEK at 7 institutions. Patients who had a significant detachment of their DSAEK lenticle during the postoperative period were identified and divided into 2 groups. Significant detachment was defined as either complete central interface fluid with bare peripheral attachment (group 1) or a free-floating lenticle in the anterior chamber (group 2). Patients who subsequently had a spontaneous reattachment of the lenticle were identified, with data regarding surgical technique and intraoperative and postoperative complications collected for analysis. RESULTS: Our cohort consisted of 12 eyes of 12 patients who met the definition of significant postoperative detachment with subsequent spontaneous reattachment. Four patients had complete central detachment with peripheral attachment (group 1), whereas 8 patients had a free-floating lenticle (group 2). Ten of the 12 patients had a successful outcome as defined as an attached and clear DSAEK lenticle. In our study, reattachment was seen as early as 5 days and as late as 7 months after surgery, with reattachment in 9 of 12 patients by day 25. CONCLUSIONS: Spontaneous reattachment of detached DSAEK lenticles may occur during the postoperative period. The decision of when to bring the patient back for a rebubble ultimately must be made on a case-by-case basis.

Epithelial downgrowth after Descemet stripping automated endothelial keratoplasty.

PURPOSE: To report the clinical and histological findings of a single patient who developed late epithelial downgrowth of donor origin after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: A 70-year-old woman underwent uneventful DSAEK for Fuchs dystrophy in the right eye. The donor had a thickened graft edge for 2 clock hours laterally. She recovered 20/40 vision by 3 months after operation and was maintained on daily prednisolone acetate drops. Three years postoperatively, a routine examination revealed signs of an asymptomatic epithelial downgrowth exhibited by synechiae and ectropion uvea at the area of the thickened donor edge. Six months later, a faint retrocorneal membrane limited to the donor periphery and contiguous with the thick edge was noted. Visual acuity and intraocular pressure remained unchanged. She was followed for the next 15 months, without intervention until the retrocorneal membrane grew centrally, resulting in graft edema. The iris synechiae remained unchanged. Repeat DSAEK, without iridectomy, was performed with confirmation of epithelial downgrowth of donor origin. Six months postoperatively, the patient has done well without sequela of residual downgrowth. RESULTS: Histopathological evaluation showed epithelial downgrowth, emanating from thickened donor edge onto the posterior graft surface. The anterior donor surface (interface) was devoid of downgrowth. X and Y DNA analysis confirmed the downgrowth of male origin (donor) in this female patient. CONCLUSIONS: Donor-derived epithelial downgrowth can occur after DSAEK. Although it can result in graft failure, it behaves much less aggressively than expected and observation may be indicated until symptomatic graft edema occurs. Repeat DSAEK, not penetrating keratoplasty, may be curative.

Late repeat Descemet-stripping automated endothelial keratoplasty.

PURPOSE: To report the outcomes of 2 patients who underwent repeat Descemet-stripping automated endothelial keratoplasty (DSAEK) 13 and 23 months after their primary surgeries. METHODS: Two patients underwent repeat DSAEK for late graft failure at approximately 1 and 2 years, respectively. The operative procedure involved removing the failed graft and replacing it with new donor tissue. RESULTS: The postoperative visual recovery was similar to the visual outcomes of primary DSAEK surgery, with both patients achieving 20/30 or better best spectacle-corrected visual acuity within 3 months. There were no signs of interface scarring after surgical removal of the failed donor disc. CONCLUSIONS: Late repeat DSAEK can result in rapid visual recovery without interface scarring.

Descemet-stripping automated endothelial keratoplasty.

PURPOSE: To evaluate the speed of visual recovery in 16 consecutive patients with corneal endothelial dysfunction who received Descemet-stripping automated endothelial keratoplasty (DSAEK). METHODS: This is a retrospective study of a novel method for small-incision endothelial transplantation (DSAEK). Endothelial replacement was accomplished with Descemet stripping of the recipient and insertion of a posterior donor tissue that had been prepared with a microkeratome. Best spectacle-corrected visual acuity (BSCVA) by manifest refraction, endothelial counts, and dislocation rates were measured up to 12 months after DSAEK. RESULTS: Sixteen consecutive patients underwent uncomplicated DSAEK. Three patients had known optic nerve or macular disease precluding vision better than 20/200. Of the remaining 14 patients, 11 had BSCVA of 20/40 by postoperative week 12 (7 by week 6). The remaining 2 were 20/50 by weeks 6 and 12. All 14 patients were 20/40 or better at 1 year. One patient had a primary graft failure, and surgery was repeated with 20/40 BSCVA at 1 year. The dislocation rate was 25%. The average cell count between 7 and 10 months was 1714. The average pachymetry was 682. CONCLUSION: DSAEK surgery allows rapid, excellent BSCVA visual recovery. The rate of visual recovery is more rapid than usually found with penetrating keratoplasty.