Deep Lamellar Endothelial Keratoplasty Surgery Research Articles

Outcomes of Repeat Endothelial Keratoplasty in Patients With Failed Deep Lamellar Endothelial Keratoplasty

To report the outcomes of repeat endothelial keratoplasty (EK) in patients with previous failed deep lamellar endothelial keratoplasty (DLEK). This retrospective interventional case series involved the review of clinical records of patients with failed DLEK surgery who underwent repeat EK surgery. Ten eyes of 9 patients (2 men and 7 women) were included. The mean age at initial DLEK surgery was 71.2 ± 8.0 years (range, 59-80 years), and the duration to repeat EK was 47 ± 14.3 months (range, 16-63 months). Removal of the failed DLEK donor disc was performed in 7 eyes (70%); in 3 eyes (30%), repeat EK was performed without removal of the failed donor disc. The mean follow-up after repeat EK surgery was 21.7 months (range, 3-44 months). Improvements in corneal clarity and visual acuity were obtained in all eyes. Mean preoperative logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) was 1.46 (20/577; range, 20/100 to counting fingers) and improved to 0.64 (20/87; range, 20/30 to 20/300) at the final follow-up (P = 0.03). Four eyes had limited BCVA secondary to ocular comorbidites, including age-related macular degeneration, cystoid macular edema, and advanced glaucomatous optic neuropathy. No significant postoperative complications were noted after repeat EK surgeries. Repeat EK in patients with late DLEK failure is effective in improving corneal clarity and is a viable alternative to penetrating keratoplasty (PK). Surgery may be performed with or without removal of the failed donor disc. Visual outcomes may be limited by the existence of ocular comorbidities.

Deep Lamellar Endothelial Keratoplasty: Up to 5-Year Follow-up

To evaluate the outcomes of small-incision deep lamellar endothelial keratoplasty (DLEK) for the treatment of endothelial dysfunction at up to 5 years of follow-up. Prospective, noncomparative case series. Sixty eyes of 55 consecutive patients who had corneal edema as a result of Fuchs' dystrophy, pseudophakic bullous keratopathy, bullous keratopathy secondary to glaucoma tube placement, failed graft, or deep endothelial scar. Patients underwent DLEK surgery at the Toronto Western Hospital. Best spectacle-corrected visual acuity (BSCVA), manifest refraction, corneal endothelial cell density (ECD), and postoperative complications. Data were available for 57, 49, 46, 23, and 7 eyes for examination at 1, 2, 3, 4, and 5 years, respectively. The mean spherical equivalent and refractive astigmatism were -0.18+/-1.62 diopters (D) and 1.67+/-1.36 D, respectively, at 1 year after surgery and remained stable at 2, 3, and 4 years after DLEK. Eliminating eyes with known significant macular or optic nerve disease, BSCVA of 20/188.5 before surgery improved to 20/56.9 at 1 year after surgery (P = 0.0002) and remained stable with BSCVA of 20/52.3, 20/46.2, and 20/56.8 at 2, 3, and 4 years, respectively, (P = 0.59, P = 0.31, P = 0.24, respectively). The number of patients who achieved 20/40 or better visual acuity, increased from a preoperative level of 13.5% to 44.1%, to 40%, to 48.4%, and to 50% at 1, 2, 3, and 4 years after surgery, respectively. The mean donor ECD before surgery was 2762+/-536 cells/mm2 and decreased by 43% at 1 year after surgery (1604+/-787 cells/mm2; P<0.0001), an additional yearly decrease by 14% (1257+/- 684 cells/mm2; P = 0.03), by 4% (1136+/-613 cells/mm2; P = 0.41), and by 1% (1064+/-515 cells/mm2; P = 0.68) was found at 2, 3, and 4 years, respectively. Complications included 4 graft dislocations, 2 primary graft failures, 5 rejections, and 12 secondary failures, with 27.5% graft failure at 4 years. Small-incision DLEK provides good and stable refractive and visual outcomes. The accelerated endothelial cell loss reported during the first 2 years after DLEK was shown to decrease and stabilize at low rates during the longer-term follow-up, which reduces the concern about progressive cell loss and secondary late endothelial failure. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Deep lamellar endothelial keratoplasty for bullous keratopathy

To investigate the efficacy, postoperative complications and management of deep lamellar endothelial keratoplasty (DLEK) in complex cases of severe bullous keratopathy. In the nonrandomized retrospective consecutive case series, fifteen cases (15 eyes) of severe and complex bullous keratopathy at Zhongshan Ophthalmic Center underwent DLEK in combination with other intraocular surgeries between October 2005 and March 2006. DLEK was combined with vitrectomy and ciliary sulcus sutured intraocular lens implantation in two patients, with vitrectomy and intraocular lens extraction in two patients and with vitrectomy and intraocular lens exchange in one patient Four patients with aphakic eyes underwent subsequent ciliary sulcus sutured intraocular lens implantation within 4 to 6 months after the DLEK donor tissue had been placed. The best spectacle corrected visual acuity (BSCVA), corneal astigmatism, curvature and endothelial cell density (ECD) were examined preoperatively and postoperatively. The graft-host interface was photographed by anterior segment optic coherent tomography (OCT). Repeated Measures Anova was applied for management of the data. On postoperative day 1, 13 grafts were well attached to the host except for one dislocation (re-located immediately and well attached). Fluid leakage between the graft-host interface occurred in one eye (absorbed on day 5). All the grafts remained clear during the follow-up. Five cases (33.3%) showed narrow gaps between the borders of graft and host. Bullous epithelial lesion reoccurred above the gap in two cases (13.3%), and disappeared during follow-up. BSCVA in 4 eyes (26.7%) was 0.4, in 3 eyes (20.0%) was 0.3, in 4 eyes (26.7%) was 0.2, and in 1 eye (6.7%) was 0.1 after DLEK. At 6, 9 and 12 months, the average corneal astigmatism were (2.80 +/- 0.70) D, (2.60 +/- 0.70) D and (2.20 +/- 0.60) D (F = 5.591, P = 0.090), average corneal curvature were (43.60 +/- 1.90) D, (44.10 +/- 1.30)D and (44.10 +/- 1.00) D (F =1.515, P = 0.237). The average central corneal thickness were (666.1 +/- 70.6) microm, (544.5 +/- 30.9) microm, (538.2 +/- 34.7) microm and (532.4 +/- 41.6) microm (F = 32.692, P = 0.000) at preoperatively, 6, 9 and 12 months postoperatively, respectively. The mean ECD was (1915.7 +/- 90.8) cells/mm2 postoperatively. DLEK surgery is an effective and safe procedure in severe and complex cases of bullous keratopathy,but it has to be successfully combined with other anterior segment surgeries. DLEK graft without sutures can tolerate subsequent other anterior segment surgeries at 4 to 6 months after placement of the donor tissue.

Comparison of Deep Lamellar Endothelial Keratoplasty and Penetrating Keratoplasty in Patients With Fuchs Endothelial Dystrophy

To evaluate and compare 1-year postoperative visual acuity, refractive results, endothelial cell density (ECD), and complications in a consecutive group of patients who underwent deep lamellar endothelial keratoplasty (DLEK) with those who underwent penetrating keratoplasty (PK) performed by 1 surgeon. We prospectively analyzed results of 20 consecutive patients with Fuchs dystrophy and pseudophakia who underwent small-incision DLEK surgery and retrospectively compared these results with those of 23 consecutive patients with Fuchs dystrophy and pseudophakia who underwent standard PK surgery during the same period. Main outcome measurements were best spectacle-corrected visual acuity (BSCVA); refractive, keratometric, and topographic astigmatism; topographic irregular astigmatism; absolute change in spherical equivalent; and ECD. Postoperative complications in the 2 groups were also analyzed. Preoperative BSCVA was significantly better in the DLEK group than the PK group (P = 0.013). Postoperative BSCVA was significantly better in the DLEK group than the PK group at 6 months (P = 0.025) and similar in each group at 12 months. Twelve-month postoperative refractive, keratometric, and topographic astigmatism was significantly less in the DLEK group than the PK group (P < 0.001). Surface asymmetry index and change in keratometric spherical equivalent was significantly less in the DLEK group than the PK group at 12 months postoperatively (P < 0.001). Preoperative ECD was significantly higher in the DLEK group (3072 +/- 307 cells/mm) than the PK group (2779 +/- 413 cells/mm). Twelve-month postoperative ECD was similar in the DLEK group (1293 +/- 469 cells/mm) compared with the PK group (1303 +/- 454 cells/mm; P = 0.949, not significant). Twelve-month percent endothelial cell loss was higher than reported in previous studies but was similar in the DLEK group (57.9%) compared with the PK group (53.1%). Twelve months postoperatively, all grafts were clear in the DLEK and PK groups. DLEK surgery resulted in more rapid vision recovery, significantly less regular and irregular astigmatism, and less change in spherical equivalent than PK surgery. Endothelial cell loss was significant in both groups but was not significantly different in the DLEK group from the PK group. DLEK surgery has significant advantages over PK surgery, but long-term ECD and graft survival in DLEK surgery should be studied.

Endothelial Keratoplasty Using Donor Tissue Not Suitable for Full-Thickness Penetrating Keratoplasty

To evaluate the use of corneal donor tissue deemed unsuitable for full-thickness penetrating keratoplasty (PK) for use in deep lamellar endothelial keratoplasty (DLEK) and to compare postoperative results to those of DLEK surgery using donor tissue that is suitable for PK. Small-incision DLEK surgery was performed using 39 donor corneas unsuitable for PK. Thirty-five donors had anterior scars or opacities, 3 donors had pterygia within the 8-mm zone, and 1 had prior LASIK. All donor preparation was completed by manual stromal dissection. The DLEK surgical and postoperative courses were reviewed. Preoperative and 6-month postoperative results of this study group were compared with a control group consisting of the first 55 consecutive small-incision DLEK patients receiving donor corneas that had no criteria excluding them from use in PK. Four eyes in the study group and 1 eye in the control group had the confounding variables of the presence of an anterior-chamber lens or surgical vitrectomy with macular disease in the recipient eye. There was no significant difference in preoperative measurements of best spectacle-corrected visual acuity (BSCVA; P = 0.372), donor endothelial cell density (ECD; P = 0.749), or corneal topography [surface regularity index (SRI), P = 0.485; or surface asymmetry index (SAI), P = 0.154] between the 2 groups. For the patients receiving corneas deemed unacceptable for PK, at 6 months after surgery, the vision (P = 0.002) and corneal topography measurements improved significantly from before surgery (SRI, P < 0.001; SAI, P < 0.001), and there was no significant change in refractive astigmatism (P = 0.240). There was a significant difference in the vision at 6 months postoperatively between the overall study group and the control group, with the mean vision of the study group at 20/56 and the control group at 20/43 (P = 0.015). If eyes with known cystoid macular edema (CME) and vitrectomy are removed from each group, there is no significant difference in vision at 6 months between the study group and the control group (P = 0.110), with the average BSCVA of those receiving donor corneas unsuitable for PK equal to 20/48 (range, 20/25-20/200) and the average vision for those receiving PK-acceptable donor tissue equal to 20/43 (range, 20/20-20/80). The 6-month average refractive astigmatism of the study group was 1.12 +/- 0.99 D (range, 0.00-4.00 D), and the average endothelial cell count was 2064 +/- 396 cells/mm(2) (range, 1208-2957 cells/mm(2)). There was no significant difference in 6-month postoperative endothelial cell count (P = 0.443), refractive astigmatism (P = 0.567), or corneal topography (SRI, P = 0.332; SAI, P = 0.110) in study patients who received corneas unsuitable for PK compared with control patients who received corneas suitable for PK. Endothelial keratoplasty such as DLEK surgery with manual donor preparation broadens the donor pool by enabling corneas that cannot be used for PK to be used for selective endothelial transplantation without deleterious postoperative results.

Influence of Final Corneal Thickness in Visual Acuity After Deep Lamellar Endothelial Keratoplasty

To determine if the final corneal thickness after deep lamellar endothelial keratoplasty (DLEK) is correlated in any way with visual performance. One hundred fifty-five consecutive eyes without macular disease underwent DLEK surgery and had pachymetry recorded at 6 months postoperatively. The eyes were grouped according to visual acuity, and pachymetry was correlated between groups: group 1 (20/20, 20/25, or 20/30), n = 38; group 2 (20/40 or 20/50), n = 79; group 3 (20/60, 20/70, or 20/80), n = 30; group 4 (20/100 or worse), n = 8. The mean pachymetry, SD, and range of pachymetry for each group are as follows: group 1, 0.571 +/- 0.080 mm (range, 0.408-0.784 mm); group 2, 0.598 +/- 0.080 mm (range, 0.437-0.816 mm); group 3, 0.605 +/- 0.099 mm (range, 0.454-0.945 mm); group 4, 0.607 +/- 0.120 mm (range, 0.410-0.781 mm). There was no significant correlation between vision and corneal thickness (P = 0.312). There was no statistical difference in pachymetry among all 4 groups (P = 0.323). The influence of pachymetry in visual acuity is not relevant (r = 0.03). The variance in corneal thickness in DLEK does not seem to influence visual results.

Evaluation of Deep Lamellar Endothelial Keratoplasty Surgery Using Scatterometry and Wavefront Analyses

To determine if postsurgical corneal interface abnormalities after deep lamellar endothelial keratoplasty (DLEK) cause increased light scattering or wavefront aberrations that may help to explain decreased best-corrected visual acuity in DLEK patients compared with penetrating keratoplasty (PK) patients. Prospective comparative case series. Clinically clear corneas of 4 eyes that had undergone DLEK surgery and 4 eyes that had PK were studied. Normal control data for light scattering was collected from 12 right eyes and 11 left eyes with normal corneas. Corneal light scattering was measured with a scatterometer designed at the Johns Hopkins Applied Physics Laboratory, and wavefront analysis was performed using standard methods with a Hartmann-Shack wavefront sensor. Corneal scattering measurements were normalized by taking the ratio of the subject's corneal light scattering to a reference material. A scattering index was calculated as the ratio of the normalized scattering for a given patient's cornea to the average scattering of normal corneas. Astigmatism and higher-order aberrations were analyzed using standard data output from wavefront analysis and Zernike polynomial decomposition. The mean scattering index was significantly higher after DLEK (1.78+/-0.29, mean+/-standard deviation [SD]) than after PK (1.03+/-0.27; P = 0.043). The higher-order root mean square (RMS) wavefront error was significantly higher after PK (0.71+/-0.11 microm, mean+/-SD) than after DLEK (0.44+/-0.12 microm; P = 0.029). Zernike polynomial decomposition of the wavefront aberrations revealed that regular corneal astigmatism was the most important aberration component for both PK and DLEK, but the PK patients had significantly more regular astigmatism (1.7+/-0.45 diopters [D], mean+/-SD) than did the DLEK patients (0.84+/-0.27 D; P = 0.029). Our data quantitatively support subclinical corneal haze as an explanation for the limited visual acuity after DLEK as compared with PK. Intraoperative or postoperative modifications to reduce stromal haze after DLEK may result in better visual acuity outcomes.

A Prospective Study of Endothelial Cell Loss during the 2 Years after Deep Lamellar Endothelial Keratoplasty

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. Prospective, noncomparative, interventional case series. One hundred eyes of 88 patients with corneal edema. 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. Preoperative and postoperative central ECDs were prospectively evaluated and the cell loss calculated for each postoperative time point. 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. 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.

Deep lamellar endothelial keratoplasty: early complications and their management

The authors reviewed the first 100 consecutive patients to reach the 6-month postoperative gate of a prospective series of patients undergoing deep lamellar endothelial keratoplasty (DLEK) for endothelial decompensation from Fuchs’ dystrophy or pseudophakic bullous keratopathy and no significant anterior corneal scarring. Two eyes were converted to penetrating keratoplasty at the time of DLEK surgery. Among 98 successfully completed DLEK procedures, four (4%) eyes had a dislocated disk on the first postoperative day which was repositioned without complication, four eyes (4%) experienced reversible endothelial rejection episodes, seven eyes (7%) required epithelial scraping for persistent epithelial irregular astigmatism, one patient (1%) experienced steroid-aggravated glaucoma, and one eye (1%) had primary graft failure. Eyes with postoperative disk location or endothelial rejection episodes had significantly fewer endothelial cells at 6 months than eyes that did not experience these complications (P = .003 and P = .027, respectively). There were no statistically significant differences in best-spectacle corrected vision (BSCVA) between eyes that experienced disk location or required epithelial scraping compared to those that did not, but there was a statistically significant reduction in BSCVA among eyes that experienced endothelial rejection episodes (P = .020). Disk replacement was successfully performed for the case of primary graft failure. There were no cases of endophthalmitis, microbial keratitis, persistent epithelial defects, late dislocation of the disk, or cataract progression. No patient required a contact lens or refractive modification of the cornea for residual refractive error. The authors conclude that the complications associated with DLEK are relatively uncommon and are easily resolved.—Michael D. Wagoner

Deep Lamellar Endothelial Keratoplasty

To report the early vision-threatening complications in a large series of deep lamellar endothelial keratoplasty (DLEK) procedures and discuss the management of these complications. The first 100 consecutive patients to reach the 6-month postoperative gate of a prospective, institutional review board-approved protocol for DLEK surgery were reviewed for intraoperative and postoperative complications. The method of treatment of these complications and the outcome of that treatment were recorded. Two eyes (2 of 100 = 2%) were converted to PK at the time of DLEK surgery. Of the 98 patients who had complete DLEK surgeries, 4 eyes (4 of 98 = 4%) were noted to have a dislocated disk on the first postoperative day. The dislocated disk in each case was repositioned in a short, often topical anesthesia technique, and all corneas cleared. One eye had primary graft failure (caused by surgeon error) resulting in disk dislocation. It was successfully replaced with another disk on postoperative day 1. Four patients (4 of 98 = 4%) experienced graft rejection of the donor disk from stopping steroids, but all grafts cleared with restarting of steroids. One patient required surgery for steroid-aggravated glaucoma. In the 5 cases of DLEK surgery in which the clear crystalline lens was left in place, no cataracts were induced at the 6-month postoperative gate. There were no infections, ulcerations, healing defects, or late dislocations. No patient required a contact lens, relaxing incision, or LASIK for residual refractive error. DLEK surgery is technically challenging, and yet complications from the surgery in our series were relatively rare and easily resolved. By eliminating sutures and high astigmatism, DLEK surgery avoids the usual complications often associated with transplant surgery.

Deep Lamellar Endothelial Keratoplasty: Visual Acuity, Astigmatism, and Endothelial Survival in a Large Prospective Series

To report the 6-month results for the treatment of endothelial dysfunction in a large, prospective series of deep lamellar endothelial keratoplasty (DLEK) procedures. Prospective, noncomparative, interventional case series. One hundred eyes of 88 patients with corneal edema from Fuchs' dystrophy and pseudophakia. A limbal, scleral, partial-depth incision provided access for a deep lamellar corneal pocket dissection. Two eyes were converted to penetrating keratoplasty (PK) at the time of DLEK surgery because of poor dissections. Of the 98 eyes that had completed DLEK surgeries, 36 eyes received a large-incision technique (9-mm scleral access incision) and 62 eyes received a small-incision technique (5-mm scleral access incision). A 7.5- to 8.0-mm posterior lamellar disc of recipient tissue then was excised and replaced through the pocket with a similar size donor disc containing healthy endothelium. A temporary air bubble in the anterior chamber was used for donor tissue adherence, and no surface corneal incisions or sutures were necessary. Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction (MR) astigmatism, and endothelial cell density (ECD) were evaluated prospectively. At 6 months after surgery, all 98 DLEK corneas were clear and the grafts were healed in good position. The mean BSCVA was 20/46, with a range between 20/20 and 20/400. The average MR astigmatism was 1.34+/-0.86 diopters (D), representing an average change in astigmatism from before surgery of +0.28+/-1.08 D (P = 0.013). The average ECD at 6 months was 2140+/-427 cells/mm2, representing a mean cell loss from preoperative donor cell measurements of 25%. The DLEK procedure, with its absence of corneal surface incisions and sutures, preserves the normal corneal topography, minimizes astigmatism, and provides a healthy donor endothelial cell count and function. The DLEK procedure represents a reasonable alternative to PK, and compared with historical PK data, offers superior refractive outcomes in the treatment of endothelial dysfunction.

Deep Lamellar Endothelial Keratoplasty: Surgery in Complex Cases With Severe Preoperative Visual Loss

This study was designed to report the use of deep lamellar endothelial keratoplasty (DLEK) in combination with other intraocular surgeries in the treatment of eyes with severe bullous keratopathy and visual loss. DLEK surgery was performed in six patients with severe bullous keratopathy and preoperative vision with a range of between count fingers and light perception only. DLEK was combined with vitrectomy and placement of a ciliary sulcus sutured intraocular lens in four patients and with cataract surgery in one patient. Two patients with vitreoretinal disease underwent pars plana vitrectomy within only 4 months after the DLEK donor tissue had been placed. Graft clarity, Snellen visual acuities, refractive astigmatism, endothelial cell counts, and corneal topography were prospectively measured at 6 and 12 months postoperatively. At 6 months after DLEK surgery, all grafts were clear and vision improved in all patients. Best spectacle-corrected visual acuity improved from count fingers level (or worse) before surgery to a range of 20/40 to 20/200 after surgery. Average refractive astigmatism at 6 months was 2.0 diopters (range, 0.50-4.00 diopters). The average postoperative endothelial cell count was 1,679 +/- 380 (range, 1,200-2,298) cells/mm at 6 months and 1,449 +/- 365 (range, 1,105-2,043) cells/mm at 12 months. Vitreoretinal surgery subsequent to graft placement did not affect corneal clarity or dislodge the grafted tissue. DLEK surgery can be used in cases with severe visual loss caused by bullous keratopathy with transfer of healthy donor endothelium, clearing of the central cornea, and restoration of useful vision. DLEK also can be successfully combined with other intraocular surgeries such as vitrectomy, intraocular lens exchange, and sutured intraocular lens surgery. The DLEK graft can tolerate subsequent intraocular surgery performed as early as 3 months after placement of the donor tissue.

Small-Incision Deep Lamellar Endothelial Keratoplasty (DLEK)

To evaluate the visual, topographic, and endothelial survival results in 25 consecutive patients who have received small-incision deep lamellar endothelial keratoplasty (DLEK) transplant surgery. DLEK surgery was performed in 25 patients with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy utilizing a 5-mm scleral access incision. Snellen visual acuities, refractive astigmatism, endothelial cell counts, and corneal topography were prospectively measured at preop and at 6 months after small-incision DLEK endothelial replacement surgery. Best spectacle-corrected visual acuity improved from an average of 20/90 (range 20/25 to 2'/200) before surgery to an average of 20/44 (range 20/25 to 20/200, P < 0.001) 6 months after surgery, with 56% of patients 20/40 or better at 6 months. Average refractive astigmatism at 6 months was 1.31 +/- 0.59 diopters (range 0.25 to 2.50 diopters), representing an average increase in astigmatism of 0.45 diopters from preop. Despite folding of the donor graft for placement into the recipient posterior lamellar bed, the average postoperative endothelial cell count at 6 months was 2122 +/- 510 cells/mm2 (range 1097 to 3202 cells/mm2) or an average 24% cell loss from donor eye preop measurements, a level of cell loss comparable to that reported after PK or after large-incision DLEK surgery. Small-incision DLEK surgery preserves the recipient corneal topography, resulting in very little change in astigmatism from preop. The excellent postoperative donor endothelial cell counts attest to the survival of donor endothelium despite folding of the graft for insertion. The small-incision DLEK technique may become the standard for endothelial replacement surgery in the future.

Stability of vision, topography, and endothelial cell density from 1 year to 2 years after deep lamellar endothelial keratoplasty surgery

To evaluate whether the visual, topographic, and endothelial cell count results observed 1 year after deep lamellar endothelial keratoplasty (DLEK) surgery remain stable up to 2 years after surgery. Prospective, noncomparative, interventional case series. Twenty eyes of 20 patients with corneal edema from Fuchs' endothelial dystrophy. Deep lamellar endothelial keratoplasty endothelial replacement surgery, with a 9.0-mm or 9.5-mm scleral access incision and a specialized intrastromal trephine, was performed. Snellen visual acuities, corneal topography, and endothelial cell counts were prospectively measured preoperatively and 1 year and 2 years after DLEK. Uncorrected and best spectacle-corrected visual acuity (BSCVA), refractive and topographic astigmatism, mean corneal curvature, topographic regularity and symmetry, and endothelial cell density. At 1 year postoperatively, BSCVA averaged 20/50 (range, 20/25-20/200), spherical equivalents (SE) averaged -0.194+/-1.521 diopters (D), manifest refraction (MR) astigmatism averaged 2.04+/-1.05 D (range, 0.0-4.0 D), topographic astigmatism averaged 2.3+/-1.1 D, mean corneal curvature was 43.2+/-1.8 D, the surface regularity index (SRI) averaged 1.16+/-0.41, and the surface asymmetry index (SAI) averaged 1.05+/-1.09. At 2 years postoperatively, BSCVA averaged 20/48 (range, 20/25-20/200), SE averaged -0.369+/-1.267 D, MR astigmatism averaged 1.76+/-0.66 D (range, 0.75-3.0 D), topographic astigmatism averaged 2.4+/-1.1 D, mean corneal curvature was 43.6+/-1.8 D, the SRI averaged 1.13+/-0.44, and the SAI averaged 0.76+/-0.59. There was no significant change in visual or topographic parameters between 1 year and 2 years postoperatively (P>0.05). Endothelial cell counts averaged 2335+/-468 cells/mm(2) at 1 year and 2151+/-457 cells/mm(2) at 2 years postoperatively (P = 0.041). Deep lamellar endothelial keratoplasty provides stable refractions, corneal topography, and endothelial cell densities as long as 2 years after surgery. The absence of corneal sutures in this technique seems to prevent the sutures in/sutures out changes in SE refractions and corneal topography sometimes seen after penetrating keratoplasty (PK). Deep lamellar endothelial keratoplasty is, therefore, an excellent alternative to PK for patients with endothelial dystrophies.

Rapid visual rehabilitation after endothelial transplants with deep lamellar endothelial keratoplasty (DLEK)

To evaluate the speed of visual recovery in 30 consecutive patients with Fuchs endothelial dystrophy who received deep lamellar endothelial keratoplasty (DLEK) transplant surgery.Best spectacle-corrected visual acuity (BSCVA) by manifest refraction and uncorrected visual acuity (UVA) were prospectively measured at preop, at 1 week, and at 1, 3, 6, 12, and 18 months after DLEK. The LogMAR of the postop vision was compared against each patient's preop vision. Visual results at 6 months were also compared against potential acuity meter (PAM) results in 27 patients. All eyes had reached at least the 6-month follow-up interval.Two of the first 32 eyes originally enrolled in the protocol were converted at surgery to standard penetrating keratoplasty (PK), and so DLEK data were obtained on 30 eyes for this report. Average BSCVA and UVA were better than preop vision at every time point, achieving statistical significance by 3 months (P < 0.05). Average preop BSCVA was 20/162 (range 20/40 to CF), improving to 20/63 at 3 months (range 20/25 to 20/200), 20/56 at 6 months, 20/51 at 1 year, and 20/46 at 18 months. Of the 27 patients who had PAM testing, 52% (14 of 27) had BSCVAs within 1 line of their PAM at 3 months, 63% (17 of 27) were within 1 line at 6 months, 71% (12 of 17) were within 1 line at 1 year, and 83% (10 of 12) were within 1 line at 18 months (P < 0.05 compared with preop from 3 months on).DLEK surgery preserves the normal corneal surface topography and allows rapid visual recovery of useful vision by 3 months. The visual acuity continues to improve over time.

Rapid visual rehabilitation after endothelial transplants with deep lamellar endothelial keratoplasty (DLEK).

To evaluate the speed of visual recovery in 30 consecutive patients with Fuchs endothelial dystrophy who received deep lamellar endothelial keratoplasty (DLEK) transplant surgery. Best spectacle-corrected visual acuity (BSCVA) by manifest refraction and uncorrected visual acuity (UVA) were prospectively measured at preop, at 1 week, and at 1, 3, 6, 12, and 18 months after DLEK. The LogMAR of the postop vision was compared against each patient's preop vision. Visual results at 6 months were also compared against potential acuity meter (PAM) results in 27 patients. All eyes had reached at least the 6-month follow-up interval. Two of the first 32 eyes originally enrolled in the protocol were converted at surgery to standard penetrating keratoplasty (PK), and so DLEK data were obtained on 30 eyes for this report. Average BSCVA and UVA were better than preop vision at every time point, achieving statistical significance by 3 months (P < 0.05). Average preop BSCVA was 20/162 (range 20/40 to CF), improving to 20/63 at 3 months (range 20/25 to 20/200), 20/56 at 6 months, 20/51 at 1 year, and 20/46 at 18 months. Of the 27 patients who had PAM testing, 52% (14 of 27) had BSCVAs within 1 line of their PAM at 3 months, 63% (17 of 27) were within 1 line at 6 months, 71% (12 of 17) were within 1 line at 1 year, and 83% (10 of 12) were within 1 line at 18 months (P < 0.05 compared with preop from 3 months on). DLEK surgery preserves the normal corneal surface topography and allows rapid visual recovery of useful vision by 3 months. The visual acuity continues to improve over time.

Deep lamellar endothelial keratoplasty (DLEK): pursuing the ideal goals of endothelial replacement.

Endothelial dysfunction is a leading cause of corneal vision loss and treatment requires surgical replacement with donor endothelium. Standard penetrating keratoplasty (PK) suffers from the inherent problems of surface corneal incisions and sutures and poor wound healing of vertical stromal wounds. This often results in high irregular astigmatism, unpredictable corneal power, and the risk of long-term visual loss from suture-induced vascularization, ulceration, rejection, and late wound rupture. This paper delineates five ideal goals of endothelial replacement, which include: (1) a smooth surface topography without significant change in astigmatism from preoperative to postoperative; (2) a highly predictable and stable corneal power; (3) a healthy donor endothelium that resolves all oedema; (4) a tectonically stable globe, safe from injury and infection; and (5) an optically pure cornea. Deep lamellar endothelial keratoplasty (DLEK) is a surgical method of endothelial replacement that is performed through a limbal scleral incision that leaves the surface of the recipient cornea untouched. The early results of this innovative surgery are discussed and compared to the results of PK in terms of fulfillment of the five ideal goals of endothelial replacement. With further refinement of interface creation, DLEK surgery may be the ideal method for endothelial replacement.