To evaluate myofibroblast differentiation as an etiology of haze at the graft-host interface in a cat model of Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK).
DSAEK was performed on 10 eyes of 5 adult domestic short-hair cats. In vivo corneal imaging with slit lamp, confocal, and optical coherence tomography (OCT) were performed twice weekly. Cats were sacrificed and corneas harvested 4 hours, and 2, 4, 6, and 9 days post-DSAEK. Corneal sections were stained with the TUNEL method and immunohistochemistry was performed for α-smooth muscle actin (α-SMA) and fibronectin with DAPI counterstain.
At all in vivo imaging time-points, corneal OCT revealed an increase in backscatter of light and confocal imaging revealed an acellular zone at the graft-host interface. At all post-mortem time-points, immunohistochemistry revealed a complete absence of α-SMA staining at the graft-host interface. At 4 hours, extracellular fibronectin staining was identified along the graft-host interface and both fibronectin and TUNEL assay were positive within adjacent cells extending into the host stroma. By day 2, fibronectin and TUNEL staining diminished and a distinct acellular zone was present in the region of previously TUNEL-positive cells.
OCT imaging consistently showed increased reflectivity at the graft-host interface in cat corneas in the days post-DSAEK. This was not associated with myofibroblast differentiation at the graft-host interface, but rather with apoptosis and the development of a subsequent acellular zone. The roles of extracellular matrix changes and keratocyte cell death and repopulation should be investigated further as potential contributors to the interface optical changes.
To report the 6-month clinical outcome of Descemet’s stripping automated endothelial keratoplasty (DSAEK) for bullous keratopathy (BK) secondary to argon laser iridotomy (ALI), and compare the results with those of DSAEK for pseudophakic bullous keratopathy (PBK) or Fuchs’ endothelial dystrophy (FED).
A total of 103 patients (54 with ALI, 28 with PBK, 21 with FED) undergoing DSAEK were retrospectively analyzed. Simultaneous cataract surgery was performed in 37 patients with ALI and 13 with FED. Preoperative ocular conditions, best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction (SE), induced astigmatism, keratometric value, endothelial cell density (ECD), and complications were determined over 6 months postoperatively.
Mean axial length in the ALI group (21.8 ± 0.8 mm) was significantly shorter than that in the FED (P = 0.02) or PBK groups (P = 0.003). Severe corneal stromal edema (n = 6), advanced cataract (n = 10), posterior synechia (n = 3), poor mydriasis (n = 5), and Zinn zonule weakness (n = 1) were found only in the ALI group. A significant improvement was observed in postoperative BSCVA in all groups. No significant difference was observed in BSCVA, SE, induced astigmatism, keratometric value, ECD, or complications among the three groups.
Descemet’s stripping automated endothelial keratoplasty for BK secondary to ALI showed rapid postoperative visual improvement, with similar efficacy and safety to that observed in DSAEK for PBK or FED.
Descemet’s stripping automated endothelial keratoplasty; Argon laser iridotomy; Fuchs’ dystrophy; Pseudophakic bullous keratopathy; Posterior lamellar keratoplasty
Purpose. To report the use of femtosecond laser-assisted in situ keratomileusis (LASIK) in the treatment of hyperopia subsequent to Descemet stripping-automated endothelial keratoplasty (DSAEK). Methods. Interventional case report. Results. A 66-year-old woman with Fuchs endothelial dystrophy developed bullous keratopathy after cataract surgery in her right eye. She underwent DSAEK with a significant postoperative hyperopic shift in her refraction. Thirteen months after DSAEK, she underwent wavefront-guided, femtosecond laser-assisted LASIK (IntraLase, Inc., Irvine, CA/AMO, Inc., IL, USA). Pretreatment unaided visual acuity was 20/120, and best-corrected visual acuity was 20/20 with a refraction of +3.25/−0.50 × 170. One year after laser refractive correction, unaided visual acuity was 20/20 with a refraction of +0.25/−0.75 × 160. Conclusion. To our knowledge, this is the first paper on the successful treatment of hyperopic shift related to DSAEK with wavefront-guided, femtosecond laser-assisted LASIK.
The purpose of this paper is to report our experience of Descemet’s stripping and non-Descemet’s stripping automated endothelial keratoplasty (DSAEK/nDSAEK) for microcorneas using 6.0 mm donor grafts.
Three eyes of two patients (a 56-year-old woman and a 59-year-old woman) with microcornea and suffering from bullous keratopathy were treated with either DSAEK or nDSAEK. A small donor graft (6.0 mm) was inserted into the anterior chamber using a double glide (Busin glide and intraocular lens sheet glide) donor insertion technique. Both patients were followed for at least 12 months. Clinical outcomes, including intraoperative and postoperative complications, visual acuity, and endothelial cell density were evaluated.
In all three cases (100%), no intraoperative complications were noted. In one case with a flat keratometry value (32.13 D), a partial donor detachment was noted one day postoperatively, but it was reattached by rebubbling. In another case, rejection was noted 8 months postoperatively, but treatment with systemic corticosteroids was successful. A clear cornea remained in all three cases (100%), with best-corrected visual acuity greater than 20/100 (mean 20/50) at 12 months. Mean postoperative endothelial cell counts were 2,603 ± 18 cells/mm2 at 6 months (7.4% decrease from preoperative donor cell counts) and 1,799 ± 556 cells/mm2 at 12 months (36.5% decrease).
We report for the first time the successful use of a small donor graft (6.0 mm) for DSAEK/nDSAEK in cases of microcornea. Additional stud ies using a large number of patients are required to evaluate fully the potential advantages and drawbacks of small diameter donor grafts for microcornea.
microcornea; Descemet’s stripping; non-Descemet’s stripping; automated endothelial keratoplasty; small donor grafts
To report the outcomes of DSAEK surgery performed in pediatric patients.
Noncomparative interventional case series.
Subjects and methods
All pediatric patients (age up to 16 years) undergoing Descemet automated stripping endothelial keratoplasty (DSAEK) at our Institution since January 2008 have been enrolled in a prospective study. A standard DSAEK, involving delivery of an 8.5–9.5 mm graft by Busin glide, was performed under general anesthesia in 19 eyes of 11 pediatric patients (congenital hereditary endothelial dystrophy n = 13; congenital glaucoma n = 2; posterior polymorphous dystrophy n = 2, and failed penetrating keratoplasty n = 2). Slit-lamp examination, refraction and visual acuity as well as endothelial cell density were evaluated preoperatively as well as 1, 3, 6, 12, and 18 months postoperatively.
All surgical procedures were uneventful. Graft detachment occurred in 4 cases and was managed successfully with repeat air injection. All corneas cleared within a week from surgery. Follow-up was 3–18 months. At last follow-up examination, best-corrected visual acuity (BCVA) was better than 20/40 in 8 of the 13 cases of patients old enough to assess vision. A graft rejection episode was seen in 1 case within 3 months from surgery but was reverted with steroidal treatment. No graft failures were observed.
DSAEK is an appropriate surgical intervention for children with corneal endothelial failure. In contrast to penetrating keratoplasty (PK), DSAEK is performed under “closed system” conditions, thus minimizing intraoperative risks. Finally, healing is much faster than with PK and all sutures can be removed within 2–4 weeks from surgery, thus allowing fast visual recovery and prompt starting of amblyopia treatment.
DSAEK; Corneal endothelial failure; Pediatric patients
To report a case of corneal graft failure due to epithelial ingrowth after an uneventful combined Descemet stripping automated endothelial keratoplasty (DSAEK) and phacoemulsification cataract surgery with intraocular lens implant treated successfully with a repeat DSAEK.
A 77-year-old male patient underwent combined DSAEK and phacoemulsification with intraocular lens implant implantation for Fuchs’ endothelial dystrophy plus cataract in the right eye. The donor cornea was cut on the Moria ALTK system and introduced using a suture pull-through technique. After an episode of endothelial rejection, the graft failed, with signs suggesting epithelial ingrowth. It was stripped from the host cornea using a Descemet’s membrane stripper, and a Simcoe irrigation-aspiration cannula was used to remove all traces of interface material. The excised lenticule was examined histologically using a hematoxylin and eosin stain.
The patient regained and maintained excellent visual acuity with no sign of recurrence of epithelial ingrowth. Histopathological evaluation of the donor tissue of the first graft showed epithelial ingrowth on the stromal surface of the graft and very few endothelial cells, in keeping with the diagnosis of graft failure.
Epithelial ingrowth is a possible cause of endothelial graft failure, but histologically proven cases are rare. Surgical intervention can achieve successful clearance, with the potential for cure and an excellent outcome.
epithelial ingrowth; Descemet stripping automated endothelial keratoplasty; graft failure
One difficulty with Descemet's stripping automated endothelial keratoplasty (DSAEK) is air management during surgery and donor endothelial lamella centering. We evaluated the no-touch technique for donor centering and the use of a newly developed DSAEK donor adjuster.
We evaluated the records of 12 consecutive patients (mean age 75.3 years) with bullous keratopathy who had undergone DSAEK. In all cases, the no-touch technique was attempted first. When the no-touch technique failed, a DSAEK donor adjuster with a 30-gauge cannula resembling a curved reverse Sinskey hook was used for donor centering. The adjuster allows air injection during donor centering.
The no-touch technique using simple corneal surface massage to center the graft was successful in 4 cases (33.3%), while 4 cases required ocular tilting (33.3%) in addition to corneal surface massage. The no-touch technique was ineffective in 4 cases (33.3%), but the donor adjuster was used successfully and easily for these patients. Comparing the endothelial cell loss rate between the no-touch technique group and the donor adjuster group, there was no significant difference at 6 months.
The no-touch technique was useful for better control of DSAEK donor centering in most cases. When the no-touch technique was ineffective, the DSAEK donor adjuster was uniformly successful.
Descemet's stripping automated endothelial keratoplasty; No-touch technique; Donor adjuster
Subepithelial fibrosis (SEF) and the transdifferentiation of keratocytes into fibroblasts or myofibroblasts (Fbs/MFbs) have been detected in the cornea of individuals with bullous keratopathy. We examined the anterior cornea of bullous keratopathy patients for such changes after Descemet’s stripping automated endothelial keratoplasty (DSAEK). Twenty-two individuals who underwent unilateral DSAEK at Yamaguchi University Hospital were enrolled in the study. The subjects were divided into groups A (n = 10) and B (n = 12) with a preoperative duration of stromal edema of less than or at least 12 months, respectively. The structure of the anterior stroma was examined by in vivo laser confocal microscopy at various times after surgery. SEF was detected in 1 (10.0%) and 11 (91.7%) cases in groups A and B, respectively, before surgery as well as in 0 (0%) and 7 (58.3%) cases, respectively, at 6 months after DSAEK. Fb/MFb transdifferentiation was detected in 0 (0%) and 8 (66.7%) cases in groups A and B, respectively, before surgery as well as in 0 and 1 (8.3%) case, respectively, at 6 months postsurgery. Anterior stromal scattering (ASS) was detected in 10 (100%) and 12 (100%) cases in groups A and B, respectively, before surgery as well as in 0 (0%) and 6 (50.0%) cases, respectively, at 6 months after DSAEK. Changes in anterior stromal structure apparent before surgery were thus also detected in bullous keratopathy patients after DSAEK. SEF and ASS persisted for more than 6 months in a substantial proportion of individuals with a preoperative duration of stromal edema of at least 12 months.
To investigate a correlation between the severity of histologic changes of Descemet’s membrane in patients with Fuchs’ endothelial dystrophy and the postoperative best-corrected visual acuity following Descemet’s membrane stripping endothelial keratoplasty (DSAEK).
In a retrospective study design, a histologic grading system was created based on common characteristics observed histologically among 92 DSAEK specimens sent to the UW Eye Pathology Laboratory with a clinical diagnosis of Fuchs’ dystrophy from three separate corneal surgeons. Cases were graded as mild, moderate, or severe based on four characteristics including guttae dispersion, presence of a laminated Descemet’s membrane, presence of embedded guttae, and density of guttae. Regression models were built to study the relationship between preoperative visual acuity, histological findings and best corrected visual acuity six months, 1 year, and 2 years after DSAEK surgery.
No correlation was found between the severity of histologic changes of Descemet’s membrane and preoperative visual acuity. A correlation exists, however, between the preoperative visual acuity and final visual acuity. Cases with a laminated Descemet’s membrane but no embedded guttae (n=8) appear less responsive to DSAEK surgery. Otherwise, the severity of histologic changes of Descemet’s membrane observed in patients with Fuchs’ corneal dystrophy following DSAEK did not show a statistically significant correlation with final visual acuity.
Our analysis fails to show an inverse relationship between the severity of histologic changes of Descemet’s membrane and the best-corrected visual acuity of ≥ 20/40 following DSAEK for Fuchs’ endothelial dystrophy. However, in a subset of Fuchs’ dystrophy patients, those who develop a laminated Descemet’s membrane without embedded guttae, the visual recovery following DSAEK is less than expected. The laminated architecture of Descemet’s membrane without embedded guttae may facilitate the separation between the layers of Descemet’s and, thus, incomplete removal of the recipient’s Descemet’s membrane during DSAEK, which may then limit the postoperative visual outcome.
To investigate the contribution ocular aberrations have on visual performance by quantifying improvements in best-corrected visual acuity (VA) and contrast sensitivity (CS) obtained with higher-order aberration (HOA) correction after penetrating (PK), deep anterior lamellar (DALK), or Descemet's stripping automated endothelial keratoplasty (DSAEK).
Sixteen eyes were evaluated from 14 subjects who underwent PK (n = 5), DALK (n = 6), or DSAEK (n = 5) greater than 1 year prior to study enrollment. Ocular aberrations were measured and an adaptive optics system was used to correct ocular lower-order aberration (LOA) and HOA. VA and CS were measured for each subject with LOA or full-aberration correction. CS was measured at each of three spatial frequencies: 4, 8, and 12 cycles/deg.
All keratoplasty groups had more aberration than that of a normal myopic population and experienced significant VA gains with full-aberration correction (P < 0.0013). PK subjects had better VA than that of DSAEK subjects with LOA correction (logMAR VA 0.03 ± 0.05 vs. 0.25 ± 0.05; P = 0.0870). After HOA correction this trend persisted (P = 0.1734). DSAEK subjects also experienced less VA benefit from full-aberration correction than that of PK and DALK subjects. All keratoplasty groups demonstrated similar CS benefits from full-aberration correction despite differing higher-order root-mean-square magnitudes.
PK eyes had better logMAR VA than that of DSAEK eyes with LOA correction, whereas DALK eyes performed intermediate between the two. When full correction was applied, the same trend persisted. The findings suggest that factors other than aberration contribute to decrements in VA with DSAEK compared with PK.
Correction of lower- and higher-order aberrations using adaptive optics does not improve visual performance equally across post-keratoplasty groups. Results suggest that other factors, such as scatter or neural adaptation, play a role in visual acuity and contrast sensitivity.
To investigate the outcomes and complications of suture pull-through insertion techniques for Descemet stripping automated endothelial keratoplasty (DSAEK) in Chinese phakic eyes.
Patients and Methods
Retrospective case series. Included in the study were all Chinese patients with phakic eyes who underwent DSAEK at Peking University Third Hospital from August 2008 to August 2011. All ocular diseases of the patients were recorded. Distance visual acuity (DVA), near visual acuity (NVA), intraocular pressure (IOP), anterior chamber depth (ACD), central corneal thickness (CCT), and corneal endothelial cell density (ECD) were compared prior to and 12 months after DSAEK. The DSAEK success rate, endothelial cell loss (ECL), complications, and prognosis were analyzed. All patients had at least 12 months of follow up.
Twenty-one eyes of 16 patients were included (11 males and 5 females). Ages ranged from 2 to 47 years with an average age of 29.8 years. The average follow up was 15.4 months (ranging from 12 to 36 months). Diagnoses included 7 eyes (4 patients) with corneal endothelial dystrophy and 14 eyes (12 patients) with bullous keratopathy. Presurgical DVA and NVA (LogMAR) were 1.7±0.7 and 1.2±0.4; postsurgical DVA and NVA were 0.8±0.6 and 0.7±0.5; Z = −3.517, −2.764; P<0.001 and P = 0.006 respectively. Presurgical IOP was 15.8±3.7 mm Hg; postsurgical IOP was 15.2±2.6 mm Hg; Z = −0.505, P = 0.614. Presurgical ACD was 3.00±0.74 mm; postsurgical ACD was 2.72±0.59 mm; Z = −0.524, P = 0.600. Donor ECD was 2992±163 cells/mm2, ECD was 1836±412 cells/mm2 with a 12-month postsurgical ECL of 39%. Success rate was 86%. Surgery complications included pupillary block-induced hypertension in 5 eyes (24%), graft detachment in 3 eyes (14%), and graft dislocation in 1 eye (5%).
DSAEK on Chinese phakic eyes can significantly improve DVA and NVA by preserving the patient’s own crystalline lens. DSAEK is an optional surgery for patients who need to preserve accommodative function. More attention should be given to postsurgical pupillary block-induced hypertension.
To describe a new slit‐lamp technique for draining interface fluid to manage complete donor disc detachments following Descemet's stripping (automated) endothelial keratoplasty (DSEK/DSAEK).
Interventional case series. Five DSEK/DSAEK patients presented on the first postoperative day with complete detachment of the donor lenticule. Slit‐lamp biomicroscopy showed interface fluid preventing attachment of the donor disc to the host stromal bed. A new slit‐lamp technique is described to drain the interface fluid. This technique involved completely filling the anterior chamber with an air bubble using a 30‐gauge needle on a 3 ml syringe. Following this, a 0.12 forceps was used to open the inferior mid‐peripheral corneal drainage slit to drain the interface fluid.
This technique was successful in draining the interface fluid in all five patients, leading to immediate complete reattachment of the donor disc.
Donor disc detachments following DSEK/DSAEK can be successfully managed by this slit‐lamp technique of draining the interface fluid.
To report a case of bullous keratopathy secondary to iridoschisis treated by non-Descemet’s stripping automated endothelial keratoplasty (nDSAEK).
A 79-year-old woman was referred to our hospital with loss of vision in the left eye. Slit lamp examination of her left eye showed a shallow anterior chamber with cataract and schisis in the inferior quadrant of iris stroma. Bullous keratopathy secondary to iridoschisis was diagnosed. Cataract surgery with iridectomy succeeded to deepen the anterior chamber and remove the floating iris leaf, although corneal edema remained. Four days later, nDSAEK was performed, which resolved corneal edema and restored visual acuity.
The two-step surgery of cataract surgery plus iridectomy followed by nDSAEK may be an effective strategy for treating bullous keratopathy secondary to iridoschisis.
iridoschisis; bullous keratopathy; non-Descemet’s stripping automated endothelial keratoplasty
To analyze the visual results of Descemet stripping automated endothelial keratoplasty (DSAEK) in the first consecutive 10 cases.
Materials and Methods:
Retrospective, non-randomized, non-comparative interventional case series. Ten eyes of 10 patients with endothelial dysfunctions of different etiology, scheduled for DSEAK, were included in this study. Indications, operative problems, and postoperative complications were noted. Best-corrected visual acuity, refractive and keratometric astigmatism, and central corneal thickness were analyzed for each patient after a minimum follow-up of 10 months.
In a median follow-up of 12 months (range 10–16 months), visual outcomes were satisfactory. Preoperative diagnosis included five eyes of psuedophakic bullous keratopathy and two eyes of repeated failed corneal grafts and one bullous keratopathy secondary to anterior chamber phakic IOL implantation. Two eyes with Fuchs dystrophy and cataract had combined DSAEK and phacoemulsification and IOL implantation. One patient had known glaucomatous optic nerve precluding vision better than 20/150. Of the remaining nine patients, four eyes had BSCVA of 20/40 or better by postoperative 6 months (3 by 3 months). The average pachymetry was 646.9 μm. One patient had total graft dislocation and one needed trabeculectomy. None of the patients developed graft rejection or graft failure. None of patients needed to convert to penetrating keratoplasty.
DSAEK is safe and effective procedure in patients with endothelial dysfunctions with encouraging surgical and visual outcomes.
Bullous keratopathy; Descemet stripping automated endothelial keratoplasty; Fuchs dystrophy; microkeratome
To report the technique of combining the two different polarization filters to detect the flap edge of the corneoscleral tissue before trephining the Descemet's stripping automated endothelial keratoplasty (DSAEK) tissue.
A human DSAEK donor tissue was prepared with mechanical microkeratome and the tissue on the cutting block was brought under the microscope. The liner, circular, or the combination of these two polarization filters was placed between the tissue and the microscope. The tissue images were taken with digital camera under either of 3 settings.
The combination of circular and linear polarization filters enabled us to recognize the edge of the flap more easily than others.
This simple system with polarization filters was effective in clear visualization of the flap edge during DSAEK tissue preparation. These features may significantly enhance safety of various surgical procedures, in addition to DSAEK tissue preparation.
DSAEK; polarization filter; edge; flap; circular; linear.
To compare postoperative complications after Descemet stripping with automated endothelial keratoplasty (DSAEK) in patients with and without glaucoma.
For this retrospective study a series of 298 DSAEK cases performed at the Doheny Eye Institute were taken, we compared postoperative complications in eyes with glaucoma on medication (55) or with previous glaucoma surgeries (64) with a time-matched group of all other DSAEK cases (179, control).
With a mean follow-up of 1.85 ± 1.12 years, the complication rates were 12.8%, 11.1%, and 26.8% for postoperative graft detachment, graft failure, and IOP elevation, respectively. Graft detachment was an independent risk factor for graft failure (odds ratio OR = 12.35, 95% confidence interval CI [5.46–27.90], P < 0.001). Graft detachment was not associated with either history of glaucoma or glaucoma surgery (P > 0.05). Glaucoma on medication had no increased risks of graft failure compared to normal eyes (P = 0.38). However, increased risk of failure was seen in eyes with prior incisional glaucoma surgeries (OR = 4.26, 95% CI [1.87–9.71], P < 0.001). Medically managed glaucoma has increased risks of postoperative IOP elevation (OR = 2.39, 95% CI [1.25–4.57], P = 0.013), whereas surgically managed glaucoma has no significant elevation (P = 0.23). Elevation of IOP was not significantly correlated with graft failure (P = 0.21).
DSAEK is the preferred treatment for corneal endothelial dystrophy. We observed that having glaucoma or glaucoma surgery is not associated with graft detachment. A history of glaucoma surgery and postoperative graft detachment appeared to be important risk factors for graft failure. And more studies are indicated to study long-term IOP evolution in post-DSAEK patients and its association with graft survival.
DSAEK; Cornea transplant; Glaucoma; Trabeculoplasty; Tube shunt; Drainage device; Intraocular pressure; Graft failure
To assess repeatability of the Zhongshan Assessment Program (ZAP) software measurement of Anterior Segment Optical Coherence Tomography (ASOCT) images and correlate with graft trephine diameter following Descemet Stripping Automated Endothelial Keratoplasty (DSAEK)
Retrospectively evaluated interventional case series. 121 consecutive eyes undergoing DSAEK over a 26 month period underwent ASOCT imaging 1month after their surgery. ASOCT images were processed using ZAP software which measured the graft and cornea parameters including anterior and posterior graft arc length and cord length, posterior cornea arc length (PCAL) and anterior chamber width.
The graft measurements showed good repeatability on ASOCT using ZAP with high intra class coefficient and small variation in the coefficient of variation. On ASOCT, the mean recipient PCAL was 12.99+/−0.69mm and the anterior chamber width was 11.16+/−0.57mm. The mean Graft anterior arc length was 9.69+/−0.66mm and the mean Graft anterior cord length was 8.92+/−2.94mm. The mean graft posterior arc length was 9.24+/−0.75mm and the mean graft posterior cord length was 8.15+/−0.57mm. Graft posterior arc length (rho=0.788, p< 0.001) correlated best with intra-operative graft trephine diameter. The mean ratio of posterior graft arc length to PCAL was 0.712 +/− 0.056.
We have validated the repeatability of the ZAP software for DSAEK graft measurements from ASOCT images and shown that the graft arc length parameters calculated from the ASOCT images correlate well with the intra-operative graft trephine diameter. This software may help surgeons determine the optimal DSAEK graft size based on pre-operative ASOCT measurements of the recipient eye.
To report a case of progressive fibrotic contraction of the posterior lamellar graft after initially successful Descemet's stripping automated endothelial keratoplasty (DSAEK).
Retrospective report of clinical data and histopathological analysis of excised corneal tissue.
A 63-year-old woman underwent uncomplicated DSAEK in her left eye due to endothelial dystrophy. During the first months after surgery, her visual acuity was 0.3, and a semilunar contraction gradually appeared at the edge of the graft. Over the following months, the fibrotic changes progressed and visual acuity decreased, with no improvement after uncomplicated cataract surgery. A successful penetrating keratoplasty was performed, and the excised corneal button with an attached posterior lamellar graft was histologically examined. The affected part of the graft consisted of a thickened fibrocellular tissue positive for glycosaminoglycans and smooth muscle actin.
The present case demonstrates asymmetric fibrotic contraction of a DSAEK graft.
Anti-smooth muscle actin; Cornea; Endothelial keratoplasty; Transplantation
The purpose of this study was to compare endothelial cell counts after Descemet’s stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty in Asian eyes.
This was a retrospective study of patients from our prospective Singapore Corneal Transplant Study cohort who received corneal transplantation in 2006–2008. We compared eyes that underwent DSAEK or penetrating keratoplasty for Fuchs’ endothelial dystrophy or pseudophakic and aphakic bullous keratopathy. Clinical data, and donor and recipient characteristics were recorded. Of 241 patients who met our inclusion criteria, 68 underwent DSAEK and 173 underwent penetrating keratoplasty. The main outcome measure was endothelial cell loss at 1 year. Secondary outcome measures were graft survival and visual outcomes at 1-year follow-up.
There were no significant differences in baseline characteristics of patients between the treatment groups. Percent endothelial cell loss at 1-year follow-up was greater in penetrating keratoplasty eyes (40.9% ± 2.9%) compared with DSAEK eyes (22.4% ± 2.3%; P < 0.001). DSAEK-treated eyes had significantly superior uncorrected visual acuity (mean difference = 0.42 ± 0.0059; P < 0.001) and best spectacle-corrected visual acuity (mean difference = 0.14 ± 0.032; P < 0.001) as compared with penetrating keratoplasty-treated eyes. Penetrating keratoplasty-treated eyes had worse astigmatism as compared with DSAEK-treated eyes (−3.0 ± 2.1 versus −1.7 ± 0.8; P < 0.001). Graft survival at 1 year was comparable in both groups, ie, 66/68 (97.0%) DSAEK-treated eyes versus 158/173 (92.0%) of penetrating keratoplasty-treated eyes had clear grafts (P = 0.479).
We report lower percent endothelial cell loss comparing DSAEK and penetrating keratoplasty at 1-year follow-up in Asian eyes, with comparable graft survival rates in both groups.
Descemet’s stripping automated endothelial keratoplasty; endothelial cell count; penetrating keratoplasty
Descemet’s stripping automated endothelial keratoplasty (DSAEK) has been shown to have superior refractive and visual results compared with penetrating keratoplasty, but higher rates of primary graft failure (PGF). This paper presents donor and surgical risk factors for PGF in DSAEK cases in Asian eyes.
Retrospective case-control study.
All consecutive patients who underwent DSAEK at a tertiary referral teaching hospital from March 2006–December 2008.
Donor details analyzed were: age of donor, cause of donor death, death to harvesting time, donor storage time, distribution distance of tissue, preoperative endothelial cell count. Surgical factors analyzed were: donor diameter, donor thickness, and method of donor insertion. These risk factors in cases of PGF were compared with patients with successful DSAEK as the control group.
Main outcome measure
A total of 124 DSAEK procedures were performed. Six DSAEK procedures (five eyes of five patients; one eye with two failures) resulted in PGF (4.8%). Significant risk factors were found for PGF to include graft insertion using a folding technique (odds ratio [OR], 34.03; 95% confidence interval [CI], 3.75–314.32; P = 0.0017) and a small donor diameter (OR, 39.94; 95% CI, 2.18–732.17; P = 0.013).
The results of this study suggest that in Asian eyes with shallow anterior chambers, surgical trauma relating to the technique of donor insertion, and the use of a small donor are major risk factors for PGF following DSAEK.
DSAEK; PGF; penetrating keratoplasty
Optical coherence tomography has already been proven to be useful for pre- and post-surgical anterior eye segment assessment, especially in lamellar keratoplasty procedures. There is no evidence for intraoperative usefulness of optical coherence tomography (OCT). We present a case report of the intraoperative donor disc attachment assessment with spectral-domain optical coherence tomography in case of Descemet stripping automated endothelial keratoplasty (DSAEK) surgery combined with corneal incisions. The effectiveness of the performed corneal stab incisions was visualized directly by OCT scan analysis. OCT assisted DSAEK allows the assessment of the accuracy of the Descemet stripping and donor disc attachment.
Descemet membrane; keratoplasty; optical coherence tomography
To assess outcomes 1 year after Descemet’s stripping automated endothelial keratoplasty (DSAEK) in comparison with penetrating keratoplasty (PKP) from the Specular Microscopy Ancillary Study (SMAS) of the Cornea Donor Study.
Multicenter, prospective, nonrandomized clinical trial.
A total of 173 subjects undergoing DSAEK for a moderate risk condition (principally Fuchs’ dystrophy or pseudophakic/aphakic corneal edema) compared with 410 subjects undergoing PKP from the SMAS who had clear grafts with at least 1 postoperative specular image within a 15-month follow-up period.
The DSAEK procedures were performed by 2 experienced surgeons per their individual techniques, using the same donor and similar recipient criteria as for the PKP procedures in the SMAS performed by 68 surgeons at 45 sites, with donors provided from 31 eye banks. Graft success and complications for the DSAEK group were assessed and compared with the SMAS group. Endothelial cell density (ECD) was determined from baseline donor, 6-month (range, 5–7 months), and 12-month (range, 9–15 months) postoperative central endothelial images by the same reading center used in the SMAS.
Main Outcome Measures
Endothelial cell density and graft survival at 1 year.
Although the DSAEK recipient group criteria were similar to the PKP group, Fuchs’ dystrophy was more prevalent in the DSAEK group (85% vs. 64%) and pseudophakic corneal edema was less prevalent (13% vs. 32%, P<0.001). The regraft rate within 15 months was 2.3% (DSAEK group) and 1.3% (PKP group) (P = 0.50). Percent endothelial cell loss was 34±22% versus 11±20% (6 months) and 38±22% versus 20±23% (12 months) in the DSAEK and PKP groups, respectively (both P<0.001). Preoperative diagnosis affected endothelial cell loss over time; in the PKP group, the subjects with pseudophakic/aphakic corneal edema experienced significantly higher 12-month cell loss than the subjects with Fuchs’ dystrophy (28% vs. 16%, P = 0.01), whereas in the DSAEK group, the 12-month cell loss was comparable for the 2 diagnoses (41% vs. 37%, P = 0.59).
One year post-transplantation, overall graft success was comparable for DSAEK and PKP procedures and endothelial cell loss was higher with DSAEK.
To compare the 3-year incidence of de novo ocular hypertension (OHT) after Descemet stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK). For DSAEK, to evaluate predictors for OHT and 2-year outcomes after OHT development.
This was a review of the prospective Singapore Corneal Transplant Study at a single tertiary referral center. Consecutive DSAEKs and PKs for Fuchs’ endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK) in eyes without pre-existing glaucoma were analyzed. OHT incidence after DSAEK and PK were compared using Kaplan–Meier survival analysis, and OHT risk factors identified using Cox proportional regression. OHT was defined: intraocular pressure (IOP) ≥ 24 mmHg or ≥ 10 mmHg from baseline. Secondary outcomes 2 years after OHT development in DSAEK were rates of glaucoma medical therapy failure, IOP success, graft failure and rejection, and best-spectacle corrected visual acuity (BSCVA).
There were 108 (96.4%) DSAEKs and 216 (96%) PKs. The 1-, 2- and 3-year de novo OHT incidence was not significantly different between DSAEK (36.1%, 47.2%, 47.2%, respectively) and PK (35.7%, 44.9%, 45.8%, respectively; P = 0.914). OHT incidence did not differ in subgroup analyses of multiple clinical variables (P > 0.1). OHT predictors after DSAEK were: fellow eye glaucoma (hazard ratio [HR] 3.20, P = 0.004), age <60 years (HR 2.41, P = 0.016), concurrent goniosynechiolysis (HR 3.29, P = 0.021), post-graft complications or procedures (HR 2.85, P = 0.006). Two years after OHT onset, 29.7% of DSAEKs failed glaucoma medical therapy requiring trabeculectomy. Complete and qualified IOP success was achieved in 23.5% and 76.5%, respectively. Graft failure developed in 9.8% and graft rejection in 5.9%. At 6 months, 1, and 2 years from OHT onset, 86.3%, 88.3%, and 92.1% achieved BSCVA 20/40, respectively.
DSAEK and PK have comparable OHT risks. A significant 30% of DSAEK eyes with OHT require filtration surgery. Effective IOP control and good graft and visual outcomes are achieved with treatment.
DSAEK; glaucoma; ocular hypertension; risk factors
To report the mid-term outcomes of graft suturing in a patient with lenticule dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK).
A 78-year old woman was found to have graft dislocation involving the nasal half of the cornea after uneventful DSAEK. Graft repositioning, refilling the anterior chamber with air, and placement of four full-thickness 10/0 nylon sutures over the detached area were performed two weeks after the initial surgery. The sutures were removed 6 weeks later. Serial specular microscopy and anterior segment optical coherence tomography were performed. At 18 months, there was good lenticule apposition and a clear graft.
Anchoring sutures seem to be effective for management of graft detachment following DSAEK.
Corneal Transplantation; Descemet Stripping Automated Endothelial Keratoplasty
To report four cases of Descemet stripping automated endothelial keratoplasty (DSAEK) in the presence of previous glaucoma filtering surgery.
Observational case series.
Review of clinical data of four patients who underwent DSAEK successfully performed in the presence of previous glaucoma filtering surgery with endothelial survival rates comparable with larger series previously published and good postoperative IOP control.
The endothelial cell loss was 36% and 39% mean cell loss at 6 months and 1 year postoperatively. The intraocular pressure remained well controlled within target levels in all patients. No complications were reported in any of the 4 cases.
Corneal endothelial failure can be successfully managed with DSAEK in glaucoma patients with previous filtering surgery with good endothelial survival rates and good IOP control.
DSAEK; endothelial failure; glaucoma