Simultaneous tectonic Descemet stripping endothelial keratoplasty and tectonic Bowman layer transplant for the management of corneal perforation

AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to tectonic penetrating keratoplasty(t-PKP).METHODS:Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included.The technique for DSEK was modified depending on individual requirements.The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture.Success was measured by the ability of this procedure to close a corneal perforation.RESULTS:All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period.Reinterventions were relatively common:2 cases required amniotic membrane transplant for persistent epithelial defects.One case required DSEK rebubbling.One case developed angle closure glaucoma requiring surgical peripheral iridectomy.CONCLUSION:Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.

Incidence of cystoid macular edema after Descemet's stripping automated endothelial keratoplasty

AIM： To determine the incidence of cystoid macular edema（CME） after Descemet＇s stripping automated endothelial keratoplasty（DSAEK）.METHODS： This study included all consecutive patients operated in a Spanish tertiary reference hospital over a period of four years. A total of 55 eyes from 47 patients matched the selection criteria. CME was diagnosed clinically at the slit-lamp and confirmed by optical coherence tomography. RESULTS： Six cases of CME were diagnosed postoperatively, which represented an incidence of 11%. Three patients had previously undergone DSAEK alone（7%; 3/41） and the other three, DSAEK combined with phacoemulsification（21%; 3/14）. Five out of six patients with CME responded to standard therapy.CONCLUSION： CME is a possible complication after DSAEK and can be treated with standard therapy. CME appears more frequently when DSAEK is combined with phacoemulsification and posterior chamber（PC） intraocular lens（IOL） implantation. Intraoperative damage to the corneal endothelial cells might play a role in the pathogenesis of CME. As long as the causes remain unclear, we recommend administering prophylaxis when risk factors are present or when combined surgery is planned.

Descemet stripping automated endothelial keratoplasty in phakic eyes:incision modification reducing cataract formation

AIM： To evaluate the efficacy of a technical modification to reduce the incidence of traumatic cataract induced by Descemet stripping automated endothelial keratoplasty（DSAEK） performed in phakic eyes. METHODS： A retrospective cohort study. The records of all patients with a clear crystalline lens and endothelial failure that underwent modified DSAEK at our insitution were reviewed. In this modification, in order to avoid inadvertent touch of the insertion forceps against the exposed crystalline lens while passing across the anterior chamber, the incision sites were shifted from the standard 9 and 3 o＇clock positions, superiorly to the 10 and 2 o＇clock position respectively. Formation of typically traumatic, anterior subcapsular cataract in these patients was compared to that observed in a cohort including all the patients with a clear crystalline lens and endothelial failure that underwent conventional DSAEK at our institution.RESULTS： The study group included 49 eyes following modified DSAEK and the control group included 35 eyes following DSAEK with conventional incision sites. Anterior subcapsular cataract occurring 4 mo or less postoperatively was identified in 2 of 49（4%） eyes in the study group and 7 of 35（20%） eyes in the control group. The rates of traumatic cataract were significantly higher in the control group in comparison to the study group（P=0.03, RR=4.9, 95%CI 1.08-22.1）.CONCLUSION： Traumatic cataract formation following phakic DSAEK may be avoided with a simple modification to the position of the incision sites.

Complications and outcomes of descemet stripping automated endothelial keratoplasty with artisan aphakia intraocular lens implantation

AIM： To evaluate the complications and outcomes of descemet stripping automated endothelial keratoplasty（DSAEK） combined with artisan aphakia intraocular lens（IOL） implantation in severely damaged eyes without capsular support.METHODS： DSAEK combined with artisan iris claw IOL implantation was performed on 29 eyes. All eyes were of abnormal structure due to complications from prior intraocular surgeries and ocular trauma. Ocular complications observed included graft dislocations, high intraocular pressure（IOP）, IOL dislocations, macular edema and hyphema. Best corrected visual acuity（BCVA）, IOP and mean central endothelial cell density（ECD） were recorded.RESULTS： Thirteen eyes had a history of ocular trauma, 10 eyes had an anterior chamber IOL, 16 eyes had prior vitrectomy. The iris was abnormal in 22 cases. Graft dislocation occurred in 5（17.2%） of 29 eyes. IOL dislocation occurred in 2 eyes（6.9%）. High IOP was found in 9 eyes and was controlled with treatment. The preoperative mean BCVA was 20/286. The 6 mo postoperative mean BCVA was 20/42. The average center ECD was 1965.3 cells/mm^2 at 6 mo, and the rate of the donor cell loss was 34.7%.CONCLUSION： DSAEK combined with artisan aphakia IOL implantation is an alternative option for resolving endothelial and lens disorders in aphakic eyes without capsular support. However, it should be performed cautiously for eyes with severe iris defects.

Corneal Endothelial Cell Loss in Femtosecond Laser-assisted Descemet＇s Stripping Automated Endothelial Keratoplasty： A 12-month Follow-up Study

Background：Descemet＇s stripping automated endothelial keratoplasty （DSAEK） surgery offers a more standardized approach and reliable method to create corneal grafts with an instrument such as a microkeratome.With the development of Descemet＇s membrane endothelial keratoplasty,an excellent clinical outcome is seen in the treatment of corneal endothelial dysfunctions,which indicates that thinner corneal graft results in better clinical outcome.With the recent development of the femtosecond laser,ultrathin corneal graft preparation has become possible.This study aimed to report corneal graft endothelial cell loss （ECL） in a large series of cases undergoing DSAEK with femtosecond laser-assisted corneal graft preparation within a 12-month period.Methods：This study was designed as a prospective,noncomparative,interventional case series.Totally 126 consecutive eyes with endothelial failure of 120 patients,who had corneal endothelial decompensation and underwent femtosecond-assisted DSAEK using the VisuMax femtosecond laser system,were included in the study.Central endothelial cell density （ECD） was recorded postoperatively at 2 weeks （n =126）,1 month （n =126）,3 months （n =110）,6 months （n =101）,and 12 months （n =71） and then compared with the preoperative eye bank measurements.Pre-and postoperative central ECDs were evaluated using Heidelberg retina tomography-Ⅲ confocal microscopy.ECL was calculated for each postoperative time point.Graft thickness was examined using anterior segment-optical coherence tomography.Results：Mean preoperative cell count was 3383 ± 350 cells/mm^2.Mean postoperative cell counts were 2382 ± 707 cells/mm^2,2179 ± 685 cells/mm^2,2074 ± 688 cells/mm^2,1884 ± 662 cells/mm^2,and 1723 ± 624 cells/mm^2 at 2 weeks,1,3,6,and 12 months,respectively;these represented the ECL of 29.7 ± 19.7%,35.4 ± 19.5%,38.6 ± 19.8%,44.3 ± 18.9%,and 48.9 ± 18.4% at the each corresponding time point.The mean corneal graft thickness after surgery was 142 ± 48 μm,118 ± 41 μm,108 ± 37 μm,100 ± 32 μm,and 99 ± 32 μm at each corresponding study visit,respectively.There was no correlation between corneal graft thickness and corneal ECL （R =0.039）.Conclusions：Corneal ECL remained relatively stable up to 12 months after femtosecond laser-assisted ultrathin DSAEK in a large case series.No correlation between cell loss and corneal graft thickness was found,which indicated that corneal graft preparation by the femtosecond laser was safe.ECL was faster within the first 6 months and relatively stable thereafter.

Ultrathin Descemet stripping automated endothelial keratoplasty versus Descemet membrane endothelial keratoplasty:a fellow-eye comparison

Background:To compare the visual outcome and patients’satisfaction after ultrathin Descemet stripping automated endothelial keratoplasty(UT-DSAEK)and Descemet membrane endothelial keratoplasty(DMEK)performed on fellow eyes of the same patients.Methods:In this retrospective study,the records of 18 pseudophakic patients affected by Fuchs endothelial dystrophy who underwent DMEK in one eye and UT-DSAEK in the fellow eye were reviewed.Best corrected visual acuity(BCVA),corneal pachymetry,keratometry,corneal aberrations,photopic and mesopic contrast sensitivity,and endothelial cell counts measured 12 months after surgery in either eye were analyzed and compared.The results of a satisfaction questionnaire were also reviewed.Results:Twelve months after surgery,BCVA was not significantly different in UT-DSAEK and DMEK eyes(0.10±0.04 and 0.07±0.07 logMAR,respectively);at both 4-and 6 mm optical zones total and posterior corneal higher order aberrations(HOAs),posterior astigmatism and total coma were significantly lower after DMEK;BCVA in both groups was significantly correlated mainly with anterior corneal aberrations;contrast sensitivity was higher after DMEK especially in mesopic conditions and at medium spatial frequencies;the endothelial cell density was similar,although slightly higher in the UT-DSAEK group(p=0.10).The satisfaction questionnaire showed that although patients were highly satisfied from both procedures,more than half of them preferred DMEK and reported a more comfortable and quicker postoperative recovery.Conclusions:DMEK and UT-DSAEK showed no evidence of difference in terms of postoperative BCVA,although DMEK had a better performance in terms of contrast sensitivity,posterior corneal aberrations and overall patient satisfaction.