Postoperative Complications Following Descemet-Stripping Automated Endothelial Keratoplasty in Patients with Prior Glaucoma Surgery

1
Postoperative Complications Following
Descemet-Stripping Automated Endothelial
Keratoplasty in Patients with Prior Glaucoma
Surgery

• Melissa B Daluvoy MD, Ajoy S Virdi MD, Neelofar
  Ghaznawi MD,
• Edwin S Chen MD, Kristin M Hammersmith MD,
• Christopher J Rapuano MD
• Cornea Service, Wills Eye Institute, Thomas
  Jefferson University Hospital, Philadelphia,
  Pennsylvania, USA
• The authors have no financial interest in the
  subject matter of this poster

2
Introduction

• Descemets Stripping Automated Endothelial
  Keratoplasty (DSAEK) has become the surgery of
  choice for endothelial dysfunction. This
  procedure has well documented advantages over
  penetrating keratoplasty but also has
  complications including graft dislocation, graft
  failure or rejection, and elevation of
  intraocular pressure (IOP)1. The presence of
  aqueous filtering or glaucoma drainage devices
  (GDD) in the anterior chamber can create
  technical challenges with graft placement,
  manipulation and achieving a complete air fill
  for graft adhesion2,3.

3
Purpose

• To study post operative complications after
  DSAEK in patients who had previous history of
  glaucoma surgery including trabeculectomy and
  glaucoma drainage devices.

4
Methods

• A retrospective chart review of clinical data of
  ten pseudophakic eyes of nine patients who
  underwent DSAEK between 3/2006 and 9/2009 in the
  presence of previous glaucoma surgery was
  performed.
• Pre post operative visual acuity (VA), IOP, and
  post operative complications were recorded.
• No attempt was made to occlude the glaucoma
  filters or tubes intraoperatively.
• Pre-op glaucoma medication regimens were
  reinstituted immediately after surgery.
• Decision for further medical or surgical
  intervention was left to the discretion of the
  managing surgeon and their consultants.

5
Results

• Nine of the 10 eyes had prior trabeculectomies
  and 1 had a prior GDD.
• Two eyes (20) required graft repositioning with
  an air bubble post operatively for a displaced
  graft. One of these (10) dislocated again and
  was replaced with a penetrating keratoplasty the
  other did well.
• Three eyes (30) required additional topical
  antiglaucoma medications.
• Of those requiring additional topical
  medications, two (20) went on to require
  additional glaucoma surgery one received a
  repeat trabeculectomy the other a GDD.
• One eye (10) had post operative cystoid macular
  edema (CME) which resolved with one intravitreal
  Kenalog injection with no increase in IOP.
• In total, 60 of eyes required a post-operative
  intervention as listed above.
• All the complications were in patients who had
  prior trabeculectomies. The patient with prior
  GDD had an uneventful post-operative course.

6
Results
Pt Eye Past Ocular History Pre-Op Pre-Op Post-op Course Post-op IOP Post-op IOP Post-op IOP Post-op IOP Post-op VA Post-op VA Post-op VA Post-op VA
VA IOP 1 mo 3 mo 6 mo 12mo 1 mo 3 mo 6mo 12mo
1 OS PBK PDS Trab (prior to 2001) no medications 20/200 9 POD5 graft dislocatedPOD14 graft dislocated POD21 PK PK PK PK PK PK PK PK PK
2 OD FuchsDys POAG Trab no medications 20/200 7 Uneventful 11 10 NA NA 20/80 20/200 NA NA
3 OS Failed PK (Fuchs) POAG Trab no medications 20/200 10 POD1 brimonidine started for wound leak 9 12 14 9 20/200 20/200 20/40 20/50
4 OS PBK PXF Trab (95 05) Tube shunt (07) no medications 20/400 9 Uneventful 11 8 NA NA 20/70 20/100 NA NA
5 OS PBK POAG Trab no medications CF 10ft 6 POD3 graft dislocated 5 11 11 11 20/400 20/400 20/60 20/50
6 OD PBK POAG Trab (05) brimonidine TID, CF _at_ 1 ft 13 Uneventful 10 10 9 17 20/70 20/80 20/60 20/60
7 OS PBK PDS Trab (86) pilocarpine BID, timolol 0.5 qam, brimatoprost qHs CF 2ft 16 POD1 brimonidine added (IOP 40) POM2 bleb needling (IOP 25) Trab (IOP 40) 19 14 13 15 20/400 20/70 20/60 20/50
8 OD PBK POAG Trab (04) revision for hypotony (09) no medications CF 4ft 12 POM1 CME IVK resolved by POM4, no significant IOP increase 16 17 13 NA 20/400 20/100 20/100 NA
9 OD PBK POAG Trab (05) Brimonidine BID, timolol 0.5 QD, latanoprost qHs 20/100 23 Uneventful 19 20 20 NA 20/200 20/100 20/100 NA
10 OS PBK POAG Trab timolol 0.5BID, dorzolamide BID, brimonidine BID, travoprost qhs CF _at_ 1 ft 10 POM3 brimonidine increased (IOP 32) POM4 Tube shunt (IOP 27) 15 18 23 15 20/400 20/200 20/200 20/200
Pt patient VA visual acuity IOP intraocular
pressure PBK Pseudophakic bullous keratopahty
PDS pigment dispersion syndrome Trab
trabeculectomy POD post-operative day PK
penetrating keratoplasty POAG Primary open
angle glaucoma PXF pseudoexfoliation TID
three times daily BID twice daily POM
post-operative month QD daily CME cystic
macular edema IVK intravitreal Kenalog
7
Results
Post-operative day 1 slit lamp photograph
of patient 3
8
Results
Post-operative month 3 slit lamp
photograph of patient 3
9
Conclusions

• Graft displacement, graft failure, and poor IOP
  control are important complications after DSAEK
  and may be expected to occur at a higher rate in
  patients with pre-existing glaucoma surgery.
• In our small case series, the graft dislocation
  rate of 20 was within the reported range of
  1-34 in patients without previous glaucoma
  surgery1,4,5. However, one small study
  evaluating the outcomes of DSAEK in 4 eyes with
  tube shunts in the anterior chamber showed no
  effect on graft dislocations3.
• In our study, 30 of patients required additional
  IOP lowering medications and 20 went on to need
  additional glaucoma surgery. In a previous study
  comparing patients with and without glaucoma, 38
  of eyes with prior glaucoma surgery required
  additional IOP lowering medications and 19
  needed surgery6.

10
Conclusions

• Despite the obstacles that prior glaucoma surgery
  may present to the DSAEK surgeon, this procedure
  can successfully be completed in patients with
  prior glaucoma surgery.
• A larger series would help to determine more
  accurately the incidence of these complications.

11
References

• Shih CY, Ritterband DC, et al. Visually
  significant and nonsignificant complications
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  keratoplasty(DSAEK) in patients with glaucoma
  drainage devices. Cornea. 2009 Oct28(9)959-62.
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