DSAEK%20in%20Eyes%20With%20Severe%20Pre-operative%20Visual%20Acuity%20Loss.

1
DSAEK in Eyes With Severe Pre-operative Visual
Acuity Loss.

• Paul Phillips, MD1,2, Mark A. Terry, MD2,3, Neda
  Shamie, MD2, Anand Shah, MD2, and Daniel Friend3

1. Sightline Ophthalmic Associates, Pittsburgh,
PA 2. Devers Eye Institute, Portland, OR 3.
Lions Eye Bank of Oregon Vision Research
Laboratory, Portland, OR
Financial interest statement Mark A. Terry, MD
has a financial interest in the specialized DSAEK
instruments used in this study. Funding for this
project was supplied by The Lions Eye Bank of
Oregon.
2
Introduction

• Endothelial Keratoplasty (EK) is a technique
  for the selective replacement of diseased corneal
  endothelium. Descemets Stripping Automated EK
  (DSAEK) has become the most commonly used
  technique of EK today for the treatment of
  endothelial dysfunction.
• Previous studies have demonstrated the benefit
  of EK in the form of deep lamellar endothelial
  keratoplasty (DLEK) for eyes with severe vision
  loss (VAlt20/400)1,2. To date, no study has
  evaluated outcomes of the treatment of these eyes
  with DSAEK.
• The specific goal of this study was to
  determine whether acceptable outcomes could be
  achieved in this severe vision loss group in the
  form of low complications, dislocations, primary
  graft failures (PGF), endothelial cell loss and
  late endothelial failures.

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Methods

• Data collection
• Eyes with severe pre-operative vision loss
  (SVL)(lt20/400) (n43) were retrospectively
  analyzed and compared with a time match control
  group (gt/20/400) (n538).
• Patients were evaluated at 1month for
• -Intra-operative complications
• -Post-operative dislocations
• -Primary graft failure (PGF)
• Patients were evaluated at 6 months and 12
  months for
• -Best spectacle visual acuity (BSCVA)
• -Endothelial cell density (ECD)
• -Late endothelial failure
• Data Analysis
• -These parameters were evaluated for
  statistical significance by Chi-Square
  independent sample T tests, using SPSS 12.0.

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Results
Pre-Operative Comorbidities Study vs. Control
SVL Control p-value
Comorbidities 65 27 0.000
Optic neuropathy, retinal pathology, iritis, ICE syndrome, HSV, surface disease Optic neuropathy, retinal pathology, iritis, ICE syndrome, HSV, surface disease Optic neuropathy, retinal pathology, iritis, ICE syndrome, HSV, surface disease Optic neuropathy, retinal pathology, iritis, ICE syndrome, HSV, surface disease
Post-Operative Vision
Severe Vision Loss Group (BSCVA) Severe Vision Loss Group (BSCVA) Severe Vision Loss Group (BSCVA) Severe Vision Loss Group (BSCVA)
Follow up time point Average Improved Vision gt/ 20/40
6mo (n23) 20/122 (20/20-20/2000) 96 (n22) 35 (n8)
12mo (n17) 20/108 (20/25-HM) 88 (n15) 35 (n6)
Control Group (BSCVA) Control Group (BSCVA) Control Group (BSCVA) Control Group (BSCVA)
Follow up time point Average Improved Vision gt/ 20/40
6mo (n361) 20/35 (20/10 -20/400) 82 (n295) 83 (n300)
12mo (n257) 20/24 (20/10 20/2000) 84 (n215) 85 (n219)
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Results
VA of SVL eyes with comorbidities vs. no
comorbidities
Severe Vision Loss Group (BSCVA) Severe Vision Loss Group (BSCVA) Severe Vision Loss Group (BSCVA) Severe Vision Loss Group (BSCVA)
No Comorbidity With Comorbidity P Value
Pre-Operative 20/4050 (CF) 20/3050 (CF) 0.359
6mo (n23) 20/50 (n5) 20/155 (n18) 0.007
12mo (n17) 20/39 (n4) 20/147 (n13) 0.220
BSCVA was better in the no comorbidity group,
but only statistically significant at 6mo
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Results
Complications
SVL Control p-value
Operative Complication 5 (n2) 1 (n5) 0.031
Dislocation 7 (n3/43) 2 (n11/538) 0.042
PGF 0 1 n/a
Excessive manipulation or damage of corneal tissue, iris damage, loss of donor tissue, compromise of filtering bleb and other. Excessive manipulation or damage of corneal tissue, iris damage, loss of donor tissue, compromise of filtering bleb and other. Excessive manipulation or damage of corneal tissue, iris damage, loss of donor tissue, compromise of filtering bleb and other. Excessive manipulation or damage of corneal tissue, iris damage, loss of donor tissue, compromise of filtering bleb and other.
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Results
Endothelial Health
SVL Control p-value
Pre-op ECD 2793 2755
6mo ECD ( Cell Loss) 1640 (35) 2004 (26.9) 0.013
12mo ECD ( Cell Loss) 1587 (36.2) 2005 (27.6) 0.019
Late Endothelial Failure (Eyes with at least one year f/u) 5.8 (n2/36) 0.3 (n1/362) 0.000
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Results
Example Patient
Figure 1b 3yrs post-op EK for Bullous
Keratopathy from trauma BSCVA 20/30
Figure 1a Pre-op EK for Bullous Keratopathy from
trauma BSCVA CF
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Discussion

• When compared to a time matched control group,
  vision in the SVL group was more limited.
• This limitation in vision may be due to a higher
  rate of comorbidities, but may also be limited by
  inherent chronic stromal changes, as there was
  not a significant difference in final acuities
  between eyes with and without comorbidities at
  one year in the SVL group.
• While there was not a higher incidence of PGF in
  SVL group, there were higher rates of dislocation
  and intra-operative complications.
• We believe that the dislocation (7) and
  intra-operative complication (5) rates in the
  SVL group are acceptable, however these rates may
  be higher than the control group due to the more
  complex nature of surgery in these eyes.
• Post-operative endothelial cell loss is also
  higher in the SVL group, with increased rates of
  late endothelial failure.
• We believe that rates of ECD loss (36.2) and
  late endothelial failure (5.8) are acceptable,
  but may possibly be higher due to increased
  intra-operative trauma and significant
  comorbidities, such as the presence of glaucoma,
  filtering tubes and trabeculectomies.
• In the future, data from a greater number of eyes
  with SVL, with long term follow-up, will help to
  clarify the true difference in outcomes in this
  population.

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Discussion

• Despite a significantly higher rate of comorbid
  conditions in the severe vision loss (SVL) study
  group, DSAEK was performed in these eyes with
  relatively
• - Low intra-operative complications
• - Low dislocation rates
• - Low primary graft failure rates
• - Improved vision
• - Reasonable preservation of endothelium and
  rates of late endothelial failure