DSEK in Eyes with Double Glaucoma Tubes

Abstract

The management of endothelial keratoplasty in patients with corneal complications secondary to glaucoma tube implants is an increasingly more common clinical dilemma. We report 2 cases of visual acuity improvement and good intraocular pressure (IOP) control after Descemet's stripping endothelial keratoplasty (DSEK) in 2 patients with preexisting double glaucoma tubes and hand motion vision.Descemet's stripping endothelial keratoplasty is a new technique of transplantation of the posterior layer of the cornea used as an alternative to penetrating keratoplasty to treat endothelial dysfunction. This procedure provides faster healing, rapid visual recovery, and minimal refractive change.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar, 2Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence.J Cataract Refract Surg. 2006; 32: 411-418Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar The recipient cornea remains structurally intact and is more resistant to injury.4Elder M.J. Stack R.R. Globe rupture following penetrating keratoplasty; how often, why, and what can we do to prevent it?.Cornea. 2004; 23: 776-780Crossref PubMed Scopus (67) Google Scholar Descemet's stripping endothelial keratoplasty is performed through a small incision, decreasing the risk of intraoperative expulsive suprachoroidal hemorrhage, as well as ocular surface complications.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar, 2Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence.J Cataract Refract Surg. 2006; 32: 411-418Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar The challenges of this new technique are to fixate the donor tissue to the smooth posterior surface of the recipient stroma and to manage the immediate postoperative period. Complications reported are pupillary block, detachment of the graft, and graft failure.3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar In the cases presented, the authors used a previously described surgical technique.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar Additionally, to increase duration of full air tamponade, patients were kept supine for 1 to 1½ hours postoperatively.Case 1An 81-year-old woman presented with decreased vision in the left eye. She had a history of advanced open-angle glaucoma in both eyes, controlled after 2 trabeculectomies in the right eye and double glaucoma tube insertion in the left eye after previous unsuccessful procedures. Six weeks after tube implantation she developed choroidal detachment with hypotony, flat chamber, cornea-tube touch, and corneal decompensation in the left eye. After choroidal detachment resolution, corneal scarring and edema persisted. Central corneal thickness was 792 microns and vision was hand motions.Five months after tube implantation, she underwent uncomplicated DSEK with tube revision. On postoperative day 1, the graft was 100% attached with small residual air bubble in the anterior chamber, the tubes were well positioned, a central epithelial defect was noted, and the IOP was 36 mmHg. On postoperative day 7, the graft was clear and attached, and vision improved to 20/50. Five months after DSEK, best-corrected vision was 20/20 and the graft was clear and completely attached; IOP was well controlled (10 mmHg) and tubes were well positioned (Figure 1, available at http://aaojournal.org).Case 2An 85-year-old-man with advanced open-angle glaucoma in both eyes presented with a 6-week history of decreased vision in the left eye. Baseline vision was 20/20 in the right eye and 20/200 in the left eye. He had undergone numerous surgeries, including trabeculectomy in the right eye and 2 glaucoma tubes in the left eye. Six months after tube revision, he developed corneal decompensation. Central corneal thickness was 820 microns and vision was hand motions.Two years after tube implantation, he underwent uncomplicated DSEK with sphincterectomy, lysis of adhesions, and tube revision. On postoperative day 1, the graft was 100% attached with 60% air bubble in the anterior chamber and moderate corneal edema; tubes were well positioned and the IOP was 25 mmHg. On postoperative day 7, the graft cleared and vision improved to 20/400. Three months after DSEK, vision was 20/200, limited by advanced glaucoma, with 100% graft attachment; IOP was well controlled (15 mmHg) and tubes in stable position (Figure 2, available at http://aaojournal.org).Figure 2Slit-lamp photograph of the left eye of patient in case two 3 months after Descemet's stripping endothelial keratoplasty showing a clear graft. The aqueous drainage device plates can be observed temporally. Arrows point to the glaucoma tubes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The IOP in both patients was measured by Goldmann applanation tonometry. After DSEK, central corneal thickness increases secondary to addition of donor tissue lamella to the host posterior stroma. Corneal parameters affect the accuracy of Goldman tonometry and IOP values from thicker corneas are generally overestimed.5Herndon L.W. Measuring intraocular pressure-adjustments for corneal thickness and new technologies.Curr Opin Ophthalmol. 2006; 17: 115-119Crossref PubMed Scopus (92) Google Scholar Despite thicker corneas, these patients maintained good IOP (range, 10–15 mmHg), demonstrating functional drainage devices.Corneal endothelial decompensation is a known complication of multiple intraocular surgeries and cornea–tube touch in eyes with drainage devices. Penetrating keratoplasty has been the standard of care for these patients. However, penetrating keratoplasty has many drawbacks, including prolonged time for visual recovery, the need for contact lens in a large percentage of patients for correction of irregular astigmatism, ocular surface problems, and complications from sutures.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar, 2Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence.J Cataract Refract Surg. 2006; 32: 411-418Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar Descemet's stripping endothelial keratoplasty is emerging as a better alternative for endothelial dysfunction treatment. Nevertheless, in patients with double glaucoma tubes, this procedure is rendered more difficult. Revision of the glaucoma tubes, sphincterectomy, and lysis of adhesions are crucial to enhance the anterior chamber space and allow good Descemet's stripping, graft positioning, and bubble distribution. Our report demonstrates that DSEK can be done successfully and lead to good visual outcomes in eyes with preexisting double glaucoma tubes. The management of endothelial keratoplasty in patients with corneal complications secondary to glaucoma tube implants is an increasingly more common clinical dilemma. We report 2 cases of visual acuity improvement and good intraocular pressure (IOP) control after Descemet's stripping endothelial keratoplasty (DSEK) in 2 patients with preexisting double glaucoma tubes and hand motion vision. Descemet's stripping endothelial keratoplasty is a new technique of transplantation of the posterior layer of the cornea used as an alternative to penetrating keratoplasty to treat endothelial dysfunction. This procedure provides faster healing, rapid visual recovery, and minimal refractive change.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar, 2Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence.J Cataract Refract Surg. 2006; 32: 411-418Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar The recipient cornea remains structurally intact and is more resistant to injury.4Elder M.J. Stack R.R. Globe rupture following penetrating keratoplasty; how often, why, and what can we do to prevent it?.Cornea. 2004; 23: 776-780Crossref PubMed Scopus (67) Google Scholar Descemet's stripping endothelial keratoplasty is performed through a small incision, decreasing the risk of intraoperative expulsive suprachoroidal hemorrhage, as well as ocular surface complications.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar, 2Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence.J Cataract Refract Surg. 2006; 32: 411-418Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar The challenges of this new technique are to fixate the donor tissue to the smooth posterior surface of the recipient stroma and to manage the immediate postoperative period. Complications reported are pupillary block, detachment of the graft, and graft failure.3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar In the cases presented, the authors used a previously described surgical technique.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar Additionally, to increase duration of full air tamponade, patients were kept supine for 1 to 1½ hours postoperatively. Case 1An 81-year-old woman presented with decreased vision in the left eye. She had a history of advanced open-angle glaucoma in both eyes, controlled after 2 trabeculectomies in the right eye and double glaucoma tube insertion in the left eye after previous unsuccessful procedures. Six weeks after tube implantation she developed choroidal detachment with hypotony, flat chamber, cornea-tube touch, and corneal decompensation in the left eye. After choroidal detachment resolution, corneal scarring and edema persisted. Central corneal thickness was 792 microns and vision was hand motions.Five months after tube implantation, she underwent uncomplicated DSEK with tube revision. On postoperative day 1, the graft was 100% attached with small residual air bubble in the anterior chamber, the tubes were well positioned, a central epithelial defect was noted, and the IOP was 36 mmHg. On postoperative day 7, the graft was clear and attached, and vision improved to 20/50. Five months after DSEK, best-corrected vision was 20/20 and the graft was clear and completely attached; IOP was well controlled (10 mmHg) and tubes were well positioned (Figure 1, available at http://aaojournal.org). An 81-year-old woman presented with decreased vision in the left eye. She had a history of advanced open-angle glaucoma in both eyes, controlled after 2 trabeculectomies in the right eye and double glaucoma tube insertion in the left eye after previous unsuccessful procedures. Six weeks after tube implantation she developed choroidal detachment with hypotony, flat chamber, cornea-tube touch, and corneal decompensation in the left eye. After choroidal detachment resolution, corneal scarring and edema persisted. Central corneal thickness was 792 microns and vision was hand motions. Five months after tube implantation, she underwent uncomplicated DSEK with tube revision. On postoperative day 1, the graft was 100% attached with small residual air bubble in the anterior chamber, the tubes were well positioned, a central epithelial defect was noted, and the IOP was 36 mmHg. On postoperative day 7, the graft was clear and attached, and vision improved to 20/50. Five months after DSEK, best-corrected vision was 20/20 and the graft was clear and completely attached; IOP was well controlled (10 mmHg) and tubes were well positioned (Figure 1, available at http://aaojournal.org). Case 2An 85-year-old-man with advanced open-angle glaucoma in both eyes presented with a 6-week history of decreased vision in the left eye. Baseline vision was 20/20 in the right eye and 20/200 in the left eye. He had undergone numerous surgeries, including trabeculectomy in the right eye and 2 glaucoma tubes in the left eye. Six months after tube revision, he developed corneal decompensation. Central corneal thickness was 820 microns and vision was hand motions.Two years after tube implantation, he underwent uncomplicated DSEK with sphincterectomy, lysis of adhesions, and tube revision. On postoperative day 1, the graft was 100% attached with 60% air bubble in the anterior chamber and moderate corneal edema; tubes were well positioned and the IOP was 25 mmHg. On postoperative day 7, the graft cleared and vision improved to 20/400. Three months after DSEK, vision was 20/200, limited by advanced glaucoma, with 100% graft attachment; IOP was well controlled (15 mmHg) and tubes in stable position (Figure 2, available at http://aaojournal.org).The IOP in both patients was measured by Goldmann applanation tonometry. After DSEK, central corneal thickness increases secondary to addition of donor tissue lamella to the host posterior stroma. Corneal parameters affect the accuracy of Goldman tonometry and IOP values from thicker corneas are generally overestimed.5Herndon L.W. Measuring intraocular pressure-adjustments for corneal thickness and new technologies.Curr Opin Ophthalmol. 2006; 17: 115-119Crossref PubMed Scopus (92) Google Scholar Despite thicker corneas, these patients maintained good IOP (range, 10–15 mmHg), demonstrating functional drainage devices.Corneal endothelial decompensation is a known complication of multiple intraocular surgeries and cornea–tube touch in eyes with drainage devices. Penetrating keratoplasty has been the standard of care for these patients. However, penetrating keratoplasty has many drawbacks, including prolonged time for visual recovery, the need for contact lens in a large percentage of patients for correction of irregular astigmatism, ocular surface problems, and complications from sutures.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar, 2Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence.J Cataract Refract Surg. 2006; 32: 411-418Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar Descemet's stripping endothelial keratoplasty is emerging as a better alternative for endothelial dysfunction treatment. Nevertheless, in patients with double glaucoma tubes, this procedure is rendered more difficult. Revision of the glaucoma tubes, sphincterectomy, and lysis of adhesions are crucial to enhance the anterior chamber space and allow good Descemet's stripping, graft positioning, and bubble distribution. Our report demonstrates that DSEK can be done successfully and lead to good visual outcomes in eyes with preexisting double glaucoma tubes. An 85-year-old-man with advanced open-angle glaucoma in both eyes presented with a 6-week history of decreased vision in the left eye. Baseline vision was 20/20 in the right eye and 20/200 in the left eye. He had undergone numerous surgeries, including trabeculectomy in the right eye and 2 glaucoma tubes in the left eye. Six months after tube revision, he developed corneal decompensation. Central corneal thickness was 820 microns and vision was hand motions. Two years after tube implantation, he underwent uncomplicated DSEK with sphincterectomy, lysis of adhesions, and tube revision. On postoperative day 1, the graft was 100% attached with 60% air bubble in the anterior chamber and moderate corneal edema; tubes were well positioned and the IOP was 25 mmHg. On postoperative day 7, the graft cleared and vision improved to 20/400. Three months after DSEK, vision was 20/200, limited by advanced glaucoma, with 100% graft attachment; IOP was well controlled (15 mmHg) and tubes in stable position (Figure 2, available at http://aaojournal.org). The IOP in both patients was measured by Goldmann applanation tonometry. After DSEK, central corneal thickness increases secondary to addition of donor tissue lamella to the host posterior stroma. Corneal parameters affect the accuracy of Goldman tonometry and IOP values from thicker corneas are generally overestimed.5Herndon L.W. Measuring intraocular pressure-adjustments for corneal thickness and new technologies.Curr Opin Ophthalmol. 2006; 17: 115-119Crossref PubMed Scopus (92) Google Scholar Despite thicker corneas, these patients maintained good IOP (range, 10–15 mmHg), demonstrating functional drainage devices. Corneal endothelial decompensation is a known complication of multiple intraocular surgeries and cornea–tube touch in eyes with drainage devices. Penetrating keratoplasty has been the standard of care for these patients. However, penetrating keratoplasty has many drawbacks, including prolonged time for visual recovery, the need for contact lens in a large percentage of patients for correction of irregular astigmatism, ocular surface problems, and complications from sutures.1Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral cornea transplant.J Refract Surg. 2005; 21: 339-345PubMed Google Scholar, 2Price Jr, F.W. Price M.O. Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence.J Cataract Refract Surg. 2006; 32: 411-418Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 3Gorovoy M.S. Price Jr, F.W. New technique transforms corneal transplantation.Cataract Refract Surg Today. 2005; (Nov/Dec): 1-4Google Scholar Descemet's stripping endothelial keratoplasty is emerging as a better alternative for endothelial dysfunction treatment. Nevertheless, in patients with double glaucoma tubes, this procedure is rendered more difficult. Revision of the glaucoma tubes, sphincterectomy, and lysis of adhesions are crucial to enhance the anterior chamber space and allow good Descemet's stripping, graft positioning, and bubble distribution. Our report demonstrates that DSEK can be done successfully and lead to good visual outcomes in eyes with preexisting double glaucoma tubes.