Descemet Stripping Automated Endothelial Keratoplasty Research Articles

Clinicopathologic Analyses of Failed Endothelial Keratoplasty (the Clinical Cases)

Purpose: To evaluate the clinicopathologic features of failed endothelial keratoplasty. Methods. In this study 11 patients (11 eyes) with recurrence of bullous keratopathy (BK) were included. Group 1 consisted of 4 patients who underwent repeat Descemet Stripping Automated Endothelial Keratoplasty (DSAEK), group 2 included 7 patients who underwent penetrating keratoplasty (PK) after failed Descemet Membrane Endothelial Keratoplasty (DMEK). Preoperative anterior segment optical coherence tomography (OCT), RTVue-100, Optovue, USA, was performed. Intraoperatively aqueous humour (AqH) samples were collected for multiplex cytokine analysis. During keratoplasty failed grafts/corneal buttons were obtained and then investigated histologically (hematoxylin/eosin staining, primary antibodies to pancytokeratin, vimentin, collagen III). Results. Recurrence of BK in all clinical cases manifests by the increase of inflammatory factors in AqH, corneal edema, neovascularization and remodeling to fibrosis. Glaucoma may induce DMEK/ DSAEK graft failure due to chronic local inflammation. In the clinical cases recurrence of BK was caused by peripheral and central graft detachment, rebubbling, graft upside-down orientation and donor corneal genetic disorders. Conclusions. Chronic local inflammation (including corneal morphological changes) in patients with BK recurrence is an indication for reoperation. The modification of keratoplasty — DMEK/DSAEK/PK — is determined according to slit-lamp and OCT images of the cornea. High-level risk of immune reaction (especially in cases of three and more times repeated keratolasty) is the reason for systemic corticosteroid and, sometimes, cytostatic therapy.

Netarsudil-Associated Reticular Epithelial Edema Directly Influenced by Endothelial Dysfunction in a Post-Endothelial Keratoplasty Patient

Purpose: The purpose of this report was to describe a case in which reticular epithelial edema secondary to topical netarsudil ophthalmic solution 0.2% occurred directly in relation to focal endothelial dysfunction in a post-endothelial keratoplasty eye. Methods: This was a case report. Results: A 76-year-old man with a complex ocular history was diagnosed with pseudophakic bullous keratopathy of the left eye. Topical netarsudil was prescribed to treat his glaucoma and to attempt improvement of his corneal edema. The corneal examination remained stable for many months, but the patient eventually underwent a Descemet stripping automated endothelial keratoplasty (DSAEK) for worsening corneal edema. One week later, the patient was observed to have 360-degree reticular epithelial edema around the periphery of the DSAEK graft. Given the lack of visual significance and need for continued glaucoma treatment, the patient was continued on netarsudil. The reticular epithelial edema later became restricted to areas outside the graft zone as the peripheral DSAEK graft endothelial cell function improved. Two months post-DSAEK, the patient developed a partial inferior endothelial graft rejection related to inadvertent cessation of topical steroid, with keratic precipitates, stromal edema, and new overlying reticular epithelial edema. On treatment and resolution of the DSAEK graft rejection, the overlying reticular epithelial edema also resolved. Conclusions: This case clearly demonstrates that netarsudil-associated reticular epithelial edema is highly likely to be related to endothelial cell dysfunction and that if endothelial cell dysfunction improves, the reticular epithelial edema will also improve, despite the continuation of netarsudil.

Scheimpflug Corneal Densitometry Patterns at the Graft-Host Interface in DMEK and DSAEK: A 12-Month Longitudinal Comparative Study.

To compare corneal densitometry (CD) patterns at the graft-host interface between Descemet Membrane Endothelial Keratoplasty (DMEK) and Descemet Stripping Automated Endothelial Keratoplasty (DSAEK). Corneal densitometry is a quantitative assessment that objectively evaluates corneal clarity and optical quality by measuring the light backscatter from the cornea. Fifty-one eyes that received DMEK or DSAEK surgery for corneal endothelium dysfunction were evaluated. The primary endpoint included CD patterns at the graft-host interface, which were assessed by the Pentacam HR device at the center point of the corneal horizontal meridian (CDcentral), and at six points on the central circumference of the cornea (with a total diameter of 4 mm) (CDI,II,III,IV,V,VI). Secondary endpoints included the best-corrected distance visual acuity (BCDVA), central corneal thickness (CCT), and graft thickness (GT). All of the evaluations were performed at follow-up appointments one, three, six and twelve months after the procedure. DMEK showed a significant overall CD reduction of -7.9 ± 8.5 grayscale unit (GSU) compared to DSAEK (p < 0.001). In addition, the DMEK group showed significantly lower CDCentral,I,II,III,IV,V,VI values at follow-up appointments one, three, six and twelve months after the procedure compared to the DSAEK group (p < 0.001). BCDVA, CCT and GT were in favor of the DMEK group with a mean value of 0.39 ± 0.35 LogMar, 552.2 ± 71.1 µm and 11.03 ± 1.4 µm, respectively (p < 0.001). CD patterns at the graft-host interface seem to be different depending on the endothelial keratoplasty procedure. This provides specific insight into CD changes in this critical region of surgery, which may provide a better understanding of the postoperative evolution of these patients.

Fuchs endothelial corneal dystrophy masking an underlying postrefractive surgery ectasia

Introduction: This article describes a case presenting Fuchs endothelial corneal dystrophy (FECD) masking an underlying postrefractive surgery ectasia. Patient and Clinical Findings: A 69-year-old woman presented in January 2022 with blurriness, halos, and glare in the left eye. Ocular history included a photorefractive keratectomy performed twice in her left eye in 2007 for hyperopic astigmatism. A diagnosis of asymptomatic Fuchs dystrophy was noted in 2010. She had acute decompensation of the cornea in the left eye because of FECD, and the first Descemet-stripping automated endothelial keratoplasty (DSAEK) with cataract surgery was performed in 2018. Diagnosis, Intervention, and Clinical Findings: The patient had a failed DSAEK graft in the left eye. A repeat DSAEK was performed in 2022, and 6 months postoperatively, the patient started showing signs of ectasia in the left eye. The authors believe the ectasia was preexisting but masked by the failed DSAEK graft and FECD and started showing after corneal deturgescence postoperatively. Conclusions: The presence of FECD and corneal ectasia can complicate diagnosis because of overlapping clinical and topographic features. This case highlights the importance of preoperative topography with epithelial/stromal thickness mapping in patients with a history of multiple refractive corneal procedures to consider the possibility of ectasia and prevent unforeseen outcomes and complications. Further research is necessary to determine standardized imaging techniques, particularly in cases of concurrent diseases.

Size and Shape Matter: Cell Viability of Preloaded Descemet Stripping Automated Endothelial Keratoplasty Grafts in Three Different Carriers.

The aim of this study was to examine endothelial cell loss (ECL) associated with preloaded Descemet stripping automated endothelial keratoplasty (DSAEK) grafts loaded into 3 carriers of different size and shape. Thirty-six donor corneas were prepared for DSAEK and loaded into an EndoGlide Ultrathin (control) (2.0 mm × 3.5 mm lumen, 4.5 mm/4.9 mm incision for scleral tunnel/clear corneal insertion), Descemet membrane endothelial keratoplasty EndoGlide (experimental) (1.1 mm × 1.7 mm lumen, 2.65 mm incision), or round glass Jones tube (experimental) (1.8 mm lumen, 3.0 mm incision). Control grafts were stored for 6 days in Optisol-GS and experimental grafts stored for 24 hours in Life4C before analysis using Calcein AM staining. Grafts were imaged and ECL was analyzed by FIJI segmentation. The statistical significance of ECL was determined using 1-way ANOVA and Tukey post hoc analysis. There were no significant differences in donor characteristics for grafts in each cohort. ECL for grafts loaded into the EndoGlide Ultrathin was 10.3% ± 2.3% (graft thickness: 60-189 μm, n = 9). ECL for grafts loaded into the Descemet membrane endothelial keratoplasty EndoGlide was 22.2% ± 7.1% (graft thickness: 38-63 μm, n = 9). ECL for thin grafts (34-60 μm, n = 9) loaded into the Jones tube was 24.0% ± 5.0%. ECL for thick grafts (92-119 μm, n = 9) loaded into the Jones tube was 34.2% ± 6.1% ECL ( P < 0.001). Combined regression analysis revealed that graft thickness is directly correlated to ECL ( P < 0.01). The size and shape of the carrier can influence the cell viability of preloaded DSAEK grafts. Compared with a larger carrier, smaller lumen carriers are associated with greater ECL. In smaller lumen carriers, ECL increases with increasing DSAEK graft thickness.

Preoperative surgeon evaluation of corneal endothelial status: the Viability Control of Human Endothelial Cells before Keratoplasty (V-CHECK) study protocol

IntroductionThe success of keratoplasty strongly depends on the health status of the transplanted endothelial cells. Donor corneal tissues are routinely screened for endothelial damage before shipment; however, surgical teams have...

Clinical outcomes of Descemet’s stripping endothelial keratoplasty using a manual or automated procedure at Undaan Eye Hospital Surabaya, Indonesia: with one-year follow up

Background: Endothelial keratoplasty (EK) is a selective lamellar corneal transplantation technique that replaces damaged endothelium while preserving the patient's corneal stroma. Donor graft preparation can be done using Descemet stripping endothelial keratoplasty (DSEK) or Descemet stripping automated endothelial keratoplasty (DSAEK). Research on EK in Indonesia is currently underreported, but it is crucial for developing strategies to treat corneal blindness in the future. This study aimed to present visual acuity, graft survival, and complications after DSEK or DSAEK at Undaan Eye Hospital Surabaya. Methods: This study involved 17 eyes, treated with DSEK or DSAEK surgery between 2017 and 2022. Patients with other ocular diseases and incomplete medical records were excluded. Best corrected visual acuity (BCVA) was documented before the surgery, and at 1 day, 1, 3, 6 months, and 1 year after. Data in this study were analyzed using multiple techniques, including Wilcoxon, Kaplan-Meier survival, and bivariate logistic regression analysis. Results: The postoperative mean BCVA significantly increased to 1.36 ± 0.57 logMAR (p=0.012) at 1 day, 1.02 ± 0.62 logMAR (p=0.002) at 1 month, 0.94 ± 0.66 logMAR (p=0.002) at 3 months, 0.72 ± 0.66 logMAR at 6 months (p=0.000), and 0.74 ± 0.74 logMAR (p=0.001) at 1-year compared to preoperative BCVA of 1.84 ± 0.39 logMAR. The graft could survive 100% within 1 day to 6 months and 76% within 1 year after surgery. Bivariate logistic regression showed donor origin had a statistically significant effect with p-value = 0.031 and odds ratio = 1.8, 95% confidence interval (CI) = 1.003 - 3.229. Corneal edema was the most common complication in the early and late postoperative periods. Conclusion: DSEK or DSAEK surgery is safe, effective, and viable. It shows good visual outcomes and becomes the most used EK treatment for corneal endothelial dysfunction.

Descemet Stripping Automated Endothelial Keratoplasty versus Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy: A National Registry-Based Comparison

To compare the outcome between posterior lamellar corneal transplant procedures for Fuchs endothelial corneal dystrophy, taking preoperative patient characteristics in consideration. Surgical methods compared were Descemet membrane endothelial keratoplasty (DMEK), Descemet stripping automated endothelial keratoplasty (DSAEK), and DSAEK with concomitant cataract surgery (phacoemulsification plus DSAEK). Registry-based study with propensity score matching. One thousand six hundred seventy-seven patients from all Swedish corneal transplantation units treated from 2012 through2019. All patients undergoing endothelial keratoplasty performed from 2012 through 2019 with completed 2-year follow-up data reported to The Swedish Corneal Transplant Register were included, totaling 1677 patients. Three comparable groups (DMEK, DSAEK, and phacoemulsification plus DSAEK) with 216 patients in each group were generated with propensity score matching based on preoperative visual acuity, age, sex, year of surgery, and preoperative risk factors such as inflammation, vascularization, and glaucoma. Best-corrected visual acuity (BCVA) at the 2-year follow-up, frequency of graft dislocation, graft rejection episodes, and graft failure within 2 years including primary graft failure. The preoperative corneal status was affected more severely in the DSAEK group before matching. In the matched groups, the median BCVA 2 years after surgery was 0.1 logarithm of the minimum angle of resolution (logMAR) in both the DMEK and the phacoemulsification plus DSAEK groups and 0.15 logMAR in the DSAEK group (P= 0.001). The frequency of graft dislocation was higher among the patients undergoing phacoemulsification plus DSAEK, but the frequency of graft failure and primary graft failure was higher in the DMEK group. Visual acuity improved in most patients (90%) with all 3 surgical methods. However, DMEK and phacoemulsification plus DSAEK reached higher levels of visual acuity 2 years after surgery, and phacoemulsification plus DSAEK was superior considering graft survival rate. All 3 surgical procedures showed both strengths and weaknesses, suggesting that the choice of surgical method should be individualized, taking into consideration not only the cornea, but each patient's complete medical status as well as the entire course of postoperative medical care. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Corneal transplantation at the beginning of the 21th century

Corneal transplantation (keratoplasty) is necessary when various disorders result in corneal opacities with severe visual loss that cannot be treated conservatively, or the regular structure and curvature of the cornea is distorted, and its function is lost. Among human transplantation, keratoplasty is the most successful surgical procedure. In recent decades, penetrating keratoplasties have been increasingly replaced by lamellar techniques, where only the abnormal layer of the cornea is transplanted. The anterior form is deep anterior lamellar keratoplasty (DALK), recommended mainly for keratoconus. The main forms of posterior lamellar keratoplasty are Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK). The indications are bullous keratopathy after cataract surgery with endothelial destruction and Fuchs endothelial dystrophy. Lamellar keratoplasty has several advantages over penetrating surgery. Postoperative visual acuity is better, wound healing, patient rehabilitation are faster and the course of any immune rejection is milder and can be better managed. Orv Hetil. 2023; 164(28): 1087-1093.

Association Between Indication for Descemet Stripping Automated Endothelial Keratoplasty and Rural Residency.

Residing in rural locations can be a barrier to health care access. This study investigated the impact of residing in rural and small town (RST) areas on Descemet stripping automated endothelial keratoplasty (DSAEK) indications and outcomes in Atlantic Canada. A retrospective cohort analysis examined consecutive DSAEKs performed in Nova Scotia between 2017 and 2020. Patient rurality was determined by the Statistical Area Classification system developed by Statistics Canada. Univariate and multivariate logistic regression models were used to assess for factors associated with DSAEK indication, including repeat keratoplasty, RST residence status, and travel time. Of 271 DSAEKs during the study period, 87 (32.1%) were performed on the eyes of RST residents. The median postoperative follow-up time was 1.6 years. Undergoing DSAEK for a previous failed keratoplasty was not associated with a higher odds of RST residency (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.19-1.16; P = 0.13) but was associated with travel time (OR, 0.78 for each increasing hour of travel; 95% CI, 0.61-0.99; P = 0.044). RST residency was not associated with the occurrence of graft failure (OR, 0.48; 95% CI, 0.17-1.17; P = 0.13). Residing in a rural area in Atlantic Canada was not associated with DSAEK graft failure. Repeat endothelial keratoplasty was associated with shorter travel time for corneal surgery but not rural residency status. Further research in this field could inform regional health strategies aimed at improving equity and accessibility to ophthalmology subspecialist care.

Ex-PRESS shunt combined with ab-interno peripheral iridectomy: A new surgical procedure for iridocorneal endothelial syndrome

PurposeIridocorneal endothelial (ICE) syndrome may cause refractory glaucoma due to progressive synechial closure or membrane formation at the anterior chamber angle. Filtration surgeries are often required but are associated with a higher rate of surgical failure or complications than other types of glaucoma. Herein, we report a new and effective surgical procedure for glaucoma secondary to ICE syndrome: Ex-PRESS shunt combined with ab-interno peripheral iridectomy using a small-gauge vitreous cutter. MethodsThree patients with ICE syndrome who underwent surgery were included. Intraoperatively, an ab-interno peripheral iridectomy was performed using a small-gauge vitreous cutter through a corneal incision in the superior-nasal or superior-temporal quadrants to create space for the insertion of Ex-PRESS shunt free from the iris tissue. The shunt was inserted under the scleral flap. The first patient underwent combined cataract surgery, whereas patients 2 (pseudophakia) and 3 (phakia) underwent Ex-PRESS alone. ResultsNo intraoperative complications were observed. The intraocular pressure remained stable until the final postoperative visits at approximately 7, 4, and 1 year in Cases 1, 2, and 3, respectively. Case 2, with mild preoperative corneal edema due to graft failure in Descemet's stripping automated endothelial keratoplasty (DSAEK), underwent reDSAEK 6 months postoperatively. Conclusions and importanceEx-PRESS shunt combined with ab-interno peripheral iridectomy using a small-gauge vitreous cutter may be a safe and effective surgical procedure in patients with ICE syndrome, regardless of the lens status.

Donor lamella thickness after ultrathin Descemet stripping automated endothelial keratoplasty and its relation to postoperative visual acuity and pre-operative lamella measures

BackgroundTo accurately measure ultrathin Descemet stripping automated endothelial keratoplasty (DSAEK) donor lamella thickness during the first postoperative year and to correlate this with pre-operative and other postoperative measurements.MethodsDonor lamella thickness in 41 eyes undergoing DSAEK for Fuchs endothelial dystrophy (FED) was measured using the Tomey Casia OCT directly after graft preparation and at 1 week and 1, 3, 6 and 12 months postoperatively. Visual acuity and endothelial cell density were measured as the secondary parameters.ResultsIndividual graft thickness profiles were shown to be fairly regular within the optically relevant area. There was a strong and highly significant correlation between the pre- and postoperative lamellar thicknesses at all time points (p < 0.0001). Compared with the measurements directly after preparation at the cornea bank, the lamella thickness decreased by 12% after 12 months. Between 1 and 12 months postoperatively, the lamella thickness (mean ± SD) changed from 112 ± 27 μm to 101 ± 21 μm. Best spectacle-corrected visual acuity (BSCVA) changed from 0.46 ± 0.30 logMAR pre-operatively through 0.36 ± 0.33 at 1 month to 0.13 ± 0.16 at 1 year postoperatively. The endothelial cell counts were comparable to those reported in previous studies.ConclusionsThickness profiles of individual grafts were fairly regular within the optically relevant area. A strong relationship between pre- and postoperative graft thicknesses was detected, and ultrathin DSAEK grafts prepared using methods similar to that applied in this study are expected to show a deswelling of around 12% during the first postoperative year. No correlation was detected between graft thickness and BSCVA.

Cost Drivers of Endothelial Keratoplasty: A Time-Driven Activity-Based Costing Analysis

To determine cost drivers of endothelial keratoplasty (EK) through evaluation of surgical costs and procedure length based on type of EK, use of preloaded grafts, and performance of simultaneous cataract surgery. This study was an economic analysis of EKs at a single academic institution using time-driven activity-based costing methodology (TDABC). EK surgical cases, including Descemet Membrane Endothelial Keratoplasty (DMEK) and Descemet Stripping Automated Endothelial Keratoplasty (DSAEK), at the University of Michigan Kellogg Eye Center from 2016 to 2018 were included in the analysis. Data and inputs were obtained via the electronic health record and from prior literature. Simultaneous cataract surgeries were included and separately categorized for analysis. EK expenses were determined with TDABC, a method for cost calculation that incorporates the time that key resources are used and each resource's associated cost rate. Main outcome measures included surgery length (in minutes) and day-of-surgery costs. There were 559 EKs included, 355 DMEK and 204 DSAEK. Fewer DSAEKs had simultaneous cataract extraction (47, 23%) than DMEK (169, 48%). Of the DMEKs, 196 (55%) utilized preloaded corneal grafts. DMEK cost $392.31 less [95% confidence interval ($251.05, $533.57), P < 0.0001] than DSAEK and required 16.94 fewer minutes [(14.16, 19.73), P < 0.0001]. DMEK cases that utilized preloaded corneal grafts cost $460.19 less [($316.23, $604.14), P < 0.0001] and were 14.16 minutes shorter [(11.39, 16.93), P < 0.0001]. In multivariate regression, preloaded graft use saved $457.19, DMEK (compared to DSAEK) saved $349.97, and simultaneous cataract surgery added $855.17 in day-of-surgery costs. TDABC cost analysis identified a day-of-surgery cost and surgical time reduction associated with the use of preloaded grafts for DMEK, DMEK compared to DSAEK, and isolated EK compared to EK combined with cataract surgery. This study provides an improved understanding of surgical cost drivers and margin incentivization, which may explain trends and indirectly influence patient care decisions in cornea surgery practices.

The Biologic Character of Donor Corneal Endothelial Cells Influences Endothelial Cell Density Post Successful Corneal Transplantation.

Corneal endothelial cell density (ECD) gradually decreases after corneal transplantation by unknown biologic, biophysical, or immunologic mechanism. Our purpose was to assess the association between donor corneal endothelial cell (CEC) maturity in culture and postoperative endothelial cell loss (ECL) after successful corneal transplantation. Prospective cohort study. This cohort study was conducted at Baptist Eye Institute, Kyoto, Japan, between October 2014 and October 2016. It included 68 patients with a 36-month follow-up period who had undergone successful Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty. Human CECs (HCECs) from remaining peripheral donor corneas were cultured and evaluated for maturity by surface markers (CD166+, CD44-/dull, CD24-, and CD105-) using fluorescence-activated cell sorting. Postoperative ECD was assessed according to the mature-differentiated HCEC contents: high-maturity group: > 70%, middle-maturity group: 10% to 70%, low-maturity group: < 10%. The successful rate of ECD maintained at 1500 cells/mm2 at 36 months postoperative was analyzed using the log-rank test. Endothelial cell density and ECL at 36 months postoperative. The 68 included patients (mean [standard deviation] age 68.1 [13.6] years, 47.1% women, 52.9% DSAEK). The high, middle, and low-maturity groups included 17, 32, and 19 eyes, respectively. At 36 months postoperative, the mean (standard deviation) ECD significantly decreased to 911 (388) cells/mm2 by 66% in the low-maturity group, compared with 1604 (436) by 40% and 1424 (613) cells/mm2 by 50% in the high and middle-maturity groups (P < 0.001 and P= 0.007, respectively) and the low-maturity group significantly failed to maintain ECD at 1500 cells/mm2 at 36 months postoperative (P < 0.001). Additional ECD analysis for patients who underwent DSAEK alone displayed a significant failure to maintain ECD at 1500 cells/mm2 at 36 months postoperative (P < 0.001). The high content of mature-differentiated HCECs expressed in culture by the donor peripheral cornea was coincident with low ECL, suggesting that a high-maturity CEC content predicts long-term graft survival. Understanding the molecular mechanism for maintaining HCEC maturity could elucidate the mechanism of ECL after corneal transplantation and aid in developing effective interventions. Proprietary or commercial disclosure may be found after the references.

A Comparison of the Corneal Thickness Following Descemet’s Stripping Automated Endothelial Keratoplasty and Descemet’s Membrane Endothelial Keratoplasty

Purpose To compare the central corneal thickness before and after Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet’s membrane endothelial keratoplasty (DMEK), and to evaluate the recipient corneal thickness following DSAEK. Methods The corneal thickness was compared between two groups of eyes following DMEK and DSAEK, performed by a single surgeon between 2015 and 2017. We evaluated the recipient corneal thickness and central corneal thickness pre- and postoperatively at 1, 3, and 6 months using anterior segment optical coherence tomography. Recipient corneal thickness was defined as the corneal thickness without graft thickness. Results We included DMEK and DSAEK eyes (n = 26 each), which were similar in terms of their etiologies. Preoperatively, there was no significant difference in the central corneal thickness between the groups (DSAEK, median [interquartile range]: 721 [606.5 to 847.8] µm; and DMEK: 690 [618 to 722.3] µm; p = 0.30). Despite the tendency of the central corneal thickness to be significantly greater (p < .01) at 6 months following DSAEK (619.5 [607.8 to 661.3] µm) compared with that following DMEK (497.5 [475.8 to 525.3] µm), there was no significant difference at 6 months between the recipient corneal thickness following DSAEK (488.5 [443.8 to 515] µm) and central corneal thickness following DMEK (p = 0.54). Conclusions DSAEK eyes display a similar tendency of stromal thinning as DMEK eyes.

Ten-Year Changes in Vision, Refractive Error, and Corneal Thickness After Descemet Stripping Automated Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy.

The goal of this study was to determine changes in best-corrected visual acuity (BCVA), refractive error, and central corneal thickness (CCT) during the first decade after Descemet stripping automated endothelial keratoplasty (DSAEK). Outcomes of all consecutive eyes undergoing DSAEK for Fuchs endothelial corneal dystrophy (FECD) were reviewed; eyes with untreatable comorbidities before DSAEK were excluded. DSAEK was performed through a temporal incision and all eyes were pseudophakic postoperatively. Changes in BCVA, manifest spherical equivalent, manifest cylinder (vector analysis), and CCT were assessed by using generalized estimating equation models. BCVA improved between 6 months (0.18 ± 0.12 logarithm of the minimum angle of resolution (logMAR); Snellen equivalent, 20/30) and 5 years (0.10 ± 0.10 logMAR; 20/25; n = 74, P < 0.001) and then remained stable at 10 years (0.09 ± 0.10 logMAR, n = 48, P = 0.22). There was a myopic shift of -0.20 ± 0.51 D between 6 months and 5 years (n = 65, P = 0.002) that remained stable at 10 years (-0.09 ± 0.44 D; 20/25; n = 34, P = 0.33). Manifest cylinder drifted with-the-rule between 6 months and 5 years (n = 65, P < 0.001) and between 5 and 10 years (n = 34, P < 0.001). CCT was stable between 6 months (672 ± 57 μm) and 5 years (677 ± 55 μm, n = 67, P = 0.47), but increased at 10 years (702 ± 60 μm, n = 39, P = 0.001). Excellent BCVA can be achieved during the first decade after DSAEK for FECD, although improvement seems to plateau after 5 years. Changes in manifest refractive error were not clinically significant. The gradual increase in CCT was consistent with longer-term changes found after other types of keratoplasty.

Effects of Descemet Stripping Automated Endothelial Keratoplasty on Corneal Densitometry of Cases with Long-Standing Pseudophakic Bullous Keratopathy.

To quantify the effects of Descemet stripping automated endothelial keratoplasty (DSAEK) on corneal clarity and densitometry of patients with long-standing pseudophakic bullous keratopathy (PBK) complicated with subepithelial fibrosis. Thirty-four eyes with PBK complicated with corneal edema for more than 6 months and subepithelial fibrosis were enrolled. All subjects underwent complete ophthalmic examination and corneal densitometry module of Pentacam HR, before and 1, 3, and 6 months after DSAEK. Thirteen patients were excluded due to postoperative complications or missed to follow-up visits. Finally, twenty-one patients' data were analyzed. Corneal densitometry measures significantly decreased in all three layers (anterior, central, and posterior) 3 and 6 months after surgery compared to preoperative values; however, the differences did not reach statistical significance in the 1st month. Moreover, densitometry measurements were significantly lower at month 6 compared to month 1, but not at month 3 compared to month 1. Corneal densitometry of the anterior layer was significantly higher than central and posterior layers in 2 mm and 6 mm zones preoperatively and at all postoperative visits. Corneal light backscatter of each three layers was not statistically different between 0-2 mm and 2-6 mm in all pre- and postoperative visits. Corneal densitometry in cases of PBK begins to improve after DSAEK in different layers in a slow and continued trend which takes up to 6 months for an effect to be seen. Interestingly, this improvement is possible even in complicated corneas with long-standing edema. Hence, corneal densitometry can be used as an objective method for quantification of the outcome of DSAEK in complicated cases of PBK.

IOCT-Assisted DSAEK Tamponade for Spontaneous Corneal Perforation with Secondary Bleb Formation in Pellucid Marginal Degeneration

Intraoperative optical coherence tomography (iOCT) is used extensively in complex anterior segment surgery, providing increased precision and thereby more safety and improved clinical outcomes. In lamellar keratoplasty, the successful application of iOCT has already been described [1]. For example, the iOCT can be used for defining the cutting depth of deep anterior lamellar keratoplasty (DALK) or for visualization of potential fluid in the interface in Descemet stripping automated endothelial keratoplasty (DSAEK) [2], [3], [4]. Moreover, for the correct corneal graft positioning in Descemet membrane endothelial keratoplasty (DMEK), a marker was previously required. The iOCT allows recognition of the corneal graft orientation and further observation of the unfolding process of the graft without the need for marking [1], [5].

Glaucoma-Related Risk Factors for Endothelial Cell Loss and Graft Failure After Descemet's Stripping Automated Endothelial Keratoplasty.

Previous trabeculectomy and medical or surgical glaucoma treatment after Descemet's stripping automated endothelial keratoplasty (DSAEK) were significantly associated with endothelial cell loss and graft failure. The pupillary block was a significant risk factor for graft failure. To evaluate the long-term risk factors associated with postoperative endothelial cell loss and graft failure after DSAEK in Japanese eyes, with special attention to glaucoma. This retrospective study involved 117 eyes of 110 consecutive patients with bullous keratopathy who had undergone DSAEK. The patients were classified into 4 groups: (1) no glaucoma group (n = 23 eyes), (2) primary angle closure disease group (n = 32 eyes), (3) glaucoma group that had previously undergone trabeculectomy (n = 44 eyes) (glaucoma with bleb), and (4) glaucoma group that had not previously undergone trabeculectomy (n = 18 eyes) (glaucoma without bleb). The cumulative 5-year graft survival rate was 82.1%. The cumulative 5-year graft survival rate among the 4 groups is as follows: no glaucoma (73%), primary angle closure disease (100%), glaucoma with bleb (39%), and glaucoma without bleb (80%). Multivariate analysis revealed that additional glaucoma medication and glaucoma surgery after DSAEK were independent risk factors for endothelial cell loss. Conversely, glaucoma with blebs and pupillary block were independent risk factors for graft failure after DSAEK. Previous trabeculectomy and medical or surgical glaucoma treatment after DSAEK were significantly associated with endothelial cell loss and graft failure. Pupillary block was a significant risk factor for graft failure.

Clinical Outcomes of the Intraocular Lens Injector and Busin Glide for Descemet Stripping Automated Endothelial Keratoplasty in Patients with Iridocorneal Endothelial Syndrome.

Purpose: To report the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) performed in iridocorneal endothelial (ICE) syndrome patients using the intraocular lens injector (injector), in comparison with those using the Busin glide. Methods: In this retrospective, interventional comparative study, we evaluated the outcomes of DSAEK performed using the injector (n = 12) or the Busin glide (n = 12) for patients with ICE syndrome. Their graft position and postoperative complications were recorded. Their best-corrected visual acuity (BCVA) and endothelial cell loss (ECL) were monitored over a 12-month follow-up period. Results: DSAEK was conducted successfully in the 24 cases. The BCVA improved from the preoperative 0.99 ± 0.61 to 0.36 ± 0.35 at 12 months after operation (p < 0.001), with no significant difference between the two groups (the injector group and the Busin group) (p = 0.933). ECL at 1 month after DSAEK was 21.80 ± 15.01% in the injector group, which was significantly lower than 33.69 ± 9.75% of the Busin group (p = 0.031). No surgery-related complications were observed in the 24 cases intraoperatively or postoperatively except that one case suffered from postoperative graft dislocation, without statistical difference between the two groups. Conclusions: At 1 month after surgery, the use of graft injector for delivering DSAEK-based endothelial graft may cause significantly less endothelial cell damage than the pull-through technique used in the application of Busin glide. The injector allows safe endothelial graft delivery without the need of anterior chamber irrigation, which increases the ratio of successful graft attachment.