Abstract

1
Long-Term Endothelial Outcome Following Deep
Lamellar Endothelial Keratoplasty
Dr Rajesh Fogla. DNB, FRCS, MMed. Apollo
Hospitals, Hyderabad, India

• Abstract
• Purpose To analyze long term endothelial
  outcome in patients undergoing deep lamellar
  endothelial keratoplasty (DLEK) procedure for
  endothelial dysfunction   
• Methods 10 eyes of 10 patients were included in
  this study. Through a 5.5mm scleral incision, a
  deep lamellar pocket was created across the
  cornea, followed by excision of 8.0mm disc of
  posterior lamellar corneal tissue. Same size
  lamellar donor disc was prepared and placed in
  position without the need of suture fixation.
  Long term endothelial outcome was analyzed in
  these eyes.   
• Results Best spectacle corrected visual acuity
  (BSCVA) was 20/40 (range 20/20 to 20/120) at 36
  months follow up. Average refractive astigmatism
  at last follow up was 1.36 1.42 diopters
  (range, 0 to 4 diopters). Preoperative average
  donor endothelial cell density was 2541 286
  cells/mm2. Postoperatively at one month 2055
  344 cells/mm2 , at one year 1736 466 cells/mm2
  , at 2 years 1474 438 cells/mm2 , and 3 years
  1284 324 cells/mm2 . Preoperative average
  pachymetry was noted to be 801.4 211.3 microns,
  improving to 553 90.4 microns at last follow
  up. 
• Conclusion Endothelial cell loss following deep
  lamellar endothelial keratoplasty is comparable
  to full thickness keratoplasty at long term
  follow up.

www.corneaclinic.com Financial interest -
None
2
Introduction

• Endothelial keratoplasty A new method of
  lamellar corneal surgery which allows selective
  replacement of dysfunctional endothelium.
• Various surgical techniques have evolved in the
  past decade.1
• Encouraging results, namely early visual
  recovery, and minimal refractive change in
  corneal parameters have led to worldwide
  acceptance of this corneal surgery.
• Endothelial keratoplasty involves greater
  manipulation of the donor tissue when compared to
  full thickness corneal grafts. Various degrees of
  endothelial cell loss following Endothelial
  Keratoplasty have been reported in literature 2-5
• This poster presents long term endothelial
  outcome in our initial patients who underwent
  small incision DLEK procedure.

3
Materials and Methods

• 10 eyes of 10 patients, Male Female (4 6)
• Mean age 59.3 9 years (Range 44 to 78 years)
• Indications for DLEK surgery
• Pseudophakic bullous keratopathy 7 eyes
• Fuchs endothelial dystrophy 3 eyes (combined
  with phacoemulsification with foldable
  intraocular lens implantation surgery via a
  superior scleral incision)
• Surgical technique as described by Terry et
  al.2,3(5.5mm scleral incision, deep lamellar
  pocket created across the cornea, followed by
  excision of 8.0mm disc of posterior lamellar
  corneal tissue. Same size lamellar donor disc
  prepared and placed in position without the need
  of suture fixation)

4
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5
Results

• Post-op average BSCVA 20/40 (Range,20/20
  20/120) at last follow up, compared to preop
  average BSCVA of 20/200 (Range, 20/40 hand
  movements,HM)
• Average Astigmatism 1.36 1.42 (Range, 0 - 4
  diopters) at last follow up
• Average Keratometry readings
• Operated eye 43.64 1.09
  diopters ( 42.47 45.32),
• Unoperated fellow eye 43.96 1.39 diopters
  (41.9 46)
• Pachymetry readings average preop 801.4 211.3
  microns improving to 553 90.4 microns at last
  follow up.

6
Endothelial changes - small incision DLEK
procedure
7
3rd Year follow up post small incision DLEK
Case 6
8
Endothelial changes following small incision DLEK
procedure
Eyes 1 month 12 months 24 months 36 months
Melles GJ 4 Am J Ophthalmol (2004) 15 NA 1859 477 1385 451 1047 425
Terry MA 5 Ophthalmology (2007) (Large small incision DLEK) 100 NA 2090 448 (26) 1794 588 (37)
Terry MA 5 Ophthalmology (2007) (Small Incision DLEK) 62 2020 (28) 1622 (43)
Fogla 10 2055 344 (19.1 loss) 1736 466 (31.6) 1474 438 (42) 1284 324 (50.5)
Post PK endothelial cell loss approximately
overall loss of 33 at one year, 52 by 3rd year,
and 59 by 5th year. Bourne et al.6-8 Cornea
2001 (560 569), Ophthalmology 1998 (1885
1865), Am J Ophthalmol 1994 (185 196)
9
Conclusions

• Small incision DLEK surgery resulted in good
  visual recovery with minimal induced astigmatism
  due to absence of surface incisions and sutures
• Mean endothelial cell loss of 19 is seen
  immediately post surgery and can be attributed to
  intra-op surgical trauma to the donor tissue
• Endothelial cell loss at one year is
  approximately 31 ie further 12 loss from
  immediate postoperative values
• Endothelial cell loss continues at an approximate
  rate of 10 per eye at 2nd and 3rd year follow up
  in our study
• Endothelial changes over three year period
  following small incision DLEK is similar to
  changes observed following full thickness
  penetrating keratoplasty

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References

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   keratoplasty Endothelial Keratoplasty. Int
   Ophthalmol Sep 2007
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   Endothelial Keratoplasty (DLEK) 6 months results
   in first prospective clinical study. Cornea 2005
   24 59 - 65
3. Fogla R. Initial results of small incision DLEK.
   Am J Ophthalmol, 2006141346-351.
4. Melles G et al. Endothelial cell density after
   posterior lamellar keratoplasty (Melles
   techniques) 3 years follow-up. Am J Ophthalmol.
   2004138211-7.
5. Terry MA et al. A prospective study of
   endothelial cell loss during the 2 years after
   deep lamellar endothelial keratoplasty.
   Ophthalmology. 2007114631-9
6. Bourne WM et al. Corneal endothelium five years
   after transplantation. Am J Ophthalmol. 1994
   118185-96
7. Bourne WM et al. Cellular changes in transplanted
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8. Bourne WM et al. Ten-year postoperative results
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   Oct1051855-65