New continuous air pumping technique to improve clinical outcomes of descemet-stripping automated endothelial keratoplasty in asian patients with previous ahmed glaucoma valve implantation.

Chang-Min Liang,Ming-Cheng Tai,Yi-Hao Chen,Da-Wen Lu,Jiann-Torng Chen

doi:10.1371/journal.pone.0072089

Abstract

BackgroundTo evaluate the outcomes of Descemet-stripping automated endothelial keratoplasty (DSAEK) with the use of continuous air pumping technique in Asian eyes with previous Ahmed glaucoma valve implantation.MethodsThe DSAEK procedure was modified in that complete air retention of the anterior chamber was maintained for 10 min using continuous air pumping at 30 mm Hg. The primary outcome measurement was graft survival, and postoperative clinical features including, rate of graft detachment, endothelial cell count, intraocular pressure (IOP), surgical time and cup/disc ratio were also recorded.ResultsA total of 13 eyes of 13 patients which underwent modified DSAEK and 6 eyes of 6 patients which underwent conventional DSAEK were included. There was a significant difference in graft survival curves between two groups (P = 0.029); the 1-year graft survival rates were estimated as 100% and 66.7% for patients with modified DSAEK and those with traditional DSAEK, respectively. The rate of graft detachment were 0% and 33.3% for the modified DSAEK and conventional DSAEK groups, respectively (P = 0.088). The significantly lowered surgical time for air tamponade was noted in the modified DSAEK group compared to that in the conventional DSAEK group [median (IQR): 10.0 (10.0, 10.0) min vs. 24.5 (22.0, 27.0) min; P<0.001] Postoperatively, patients in the modified DSAEK group had significantly lower IOP as compared to the conventional DSAEK group [12.0 (11.0, 15.0) mm Hg vs. 16.0 (15.0, 18.0) mm Hg; P = 0.047]. Modified DSAEK patients had higher endothelial cell counts as compared to conventional DSAEK patients [2148.0 (1964.0, 2218.0) vs. 1529.0 (713.0, 2014.0)], but the difference did not reach statistical significance (P = 0.072).ConclusionsNew continuous air pumping technique in DSAEK can be performed safely and effectively in patients with prior GDDs placement who have corneal failure.

Highlights

[3] Advantages of Descemet-stripping automated endothelial keratoplasty (DSAEK) over penetrating keratoplasty (PKP) include rapid healing and visual recovery, smaller incision and a stronger wound after healing, better visual acuity, and lower risk of graft failure. [3,5,6] Though a relatively new procedure, excellent long-term outcomes have been reported. [7,8,9] Letko et al [10] reviewed a consecutive series of 1050 primary DSAEK procedures and reported that in cases of unacceptable visual acuity after primary DSAEK repeat endothelial keratoplasty can improve vision in select patients
Despite the advantages of DSAEK, the procedure is more challenging in patients with prior glaucoma surgery, and in particular in those with tube shunt placement. [3,12,13,14] Potential complications in patients with prior tube shunts include the tube interfering with the placement of the graft, the tube providing a potential route for air to escape, inadequate air tamponade, possible graft detachment and papillary block glaucoma, and air migrating behind the pupil. [12]
The purpose of this study is to report the clinical outcomes of the modified DSAEK in Asian patients with glaucoma and prior Ahmed tube placement using anterior segment optical coherence tomography (AS-OCT) as an assessment tool

Summary

Introduction

Patients who have had poor glaucoma control with frequent acute attacks and long-term high intraocular pressure (IOP) usually develop irreversible endothelial compromise and chronic corneal edema. [1] Implantation of glaucoma drainage devices (GDDs) have assumed an important role in the surgical treatment of complicated and refractory glaucoma. [2] patients with GDDs are at further risk for developing corneal endothelial failure, and corneal transplantation has been the only successful option to preserve vision. [2] Full-thickness penetrating keratoplasty (PKP) is commonly performed for visual rehabilitation; drawbacks of the procedure include prolonged visual recovery, risk of wound dehiscence and infection, development of secondary glaucoma, and high rates of graft failure. [3].Endothelial keratoplasty has been developed an alternative to PKP for the treatment of corneal endothelial decompensation. [4] Recently, Descemet’s stripping automated endothelial keratoplasty (DSAEK) has been developed, and is rapidly becoming the procedure of choice in patients with corneal disease. [3] Advantages of DSAEK over PKP include rapid healing and visual recovery, smaller incision and a stronger wound after healing, better visual acuity, and lower risk of graft failure. [3,5,6] Though a relatively new procedure, excellent long-term outcomes have been reported. [7,8,9] Letko et al [10] reviewed a consecutive series of 1050 primary DSAEK procedures and reported that in cases of unacceptable visual acuity after primary DSAEK repeat endothelial keratoplasty can improve vision in select patients. [2] Full-thickness penetrating keratoplasty (PKP) is commonly performed for visual rehabilitation; drawbacks of the procedure include prolonged visual recovery, risk of wound dehiscence and infection, development of secondary glaucoma, and high rates of graft failure. [3] Advantages of DSAEK over PKP include rapid healing and visual recovery, smaller incision and a stronger wound after healing, better visual acuity, and lower risk of graft failure. The purpose of this study is to report the clinical outcomes of the modified DSAEK in Asian patients with glaucoma and prior Ahmed tube placement using anterior segment optical coherence tomography (AS-OCT) as an assessment tool. To evaluate the outcomes of Descemet-stripping automated endothelial keratoplasty (DSAEK) with the use of continuous air pumping technique in Asian eyes with previous Ahmed glaucoma valve implantation

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