Clinical Evaluation of Non Descemet-Stripping Automated Endothelial Keratoplasty

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Clinical Evaluation of Non Descemet-Stripping
Automated Endothelial Keratoplasty

• Akira Kobayashi MD, PhD, Hideaki Yokogawa MD,
• Kazuhisa Sugiyama MD, PhD,
• Department of Ophthalmology, Kanazawa University
  Graduate School of Medical Science, Kanazawa,
  Japan.

Financial DisclosureAll authors declares no
financial interest.
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Background

• Descemets stripping endothelial keratoplasty
  (DSAEK) has been a revolutionary change in the
  treatment of endothelial disorders, aviding the
  need for the more invasive penetrating
  keratoplasty.
• Recently, we eliminated Descemet stripping for
  non-Fuchs type bullous keratopathies and called
  the modified procedure non-Descemet Stripping
  Automated Endothelial Keratoplasty (nDSAEK). 1, 2

1. Kobayashi A, Yokogawa H, Sugiyama K.
Non-Descemet stripping automated endothelial
keratoplasty for endothelial dysfunction
secondary to argon laser iridotomy. Am J
Ophthalmol 2008146543-549. 2. Kobayashi A,
Yokogawa H, Sugiyama K. In vivo laser confocal
microscopy after non-Descemet stripping automated
endothelial keratoplasty. Ophthalmology 2009 in
press.
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Purpose

• To report clinical outcomes of non-Descemets
  stripping automated endothelial keratoplasty
  (nDSAEK) as treatment for non-Fuchs type
  endothelial dysfunction.

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Methods

• Ten eyes (ten patients, three men, seven women
  mean age, 73.56.6 years meanSD) with bullous
  keratopathy were treated with endothelial
  keratoplasty without recipient Descemets
  stripping(nDSAEK). Nine patients had previous
  argon laser iridotomy for angle closure glaucoma
  attack the remaining patient had developed
  bullous keratopathy after endotheliitis. Best
  corrected visual acuity (BCVA), astigmatism and
  donor central endothelial cell density (ECD) were
  recorded preoperatively and at six months
  postoperatively. Intra- and postoperative
  complications were also recorded.

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Table 1. Demographic data and clinical outcomes
of the 10 patients with bullous keratopathy
enrolled in this study.
Case Sex/Age(years) Eye Surgery Clinical diagnosis Complications Donor insertion technique Initial BCVA and manifest refraction BCVA and manifest refraction six months postoperatively Max BCVA (postoperative days reached Max BCVA) Endothelial cell density (/mm2), Preop/ six months postop (cell loss rate )
1 F/66 OS nDSAEK BK after ALI Iris prolapse during donor insertion Pull-through (Busin glide) 20/40 (-3.5 D cylinder -0.5D 40) 20/20 (-3.25 D) 20/20 (187) 3455/ 1966 (42.2)
2 M/71 OD nDSAEKPEAIOL BK after ALI None Pull-through (double glide) 20/63 (-6.0 D ) 20/25 (cylinder -1.0 D 90) 20/20 (340) 3072 / 2898 (5.7)
3 F/83 OS nDSAEKPEAIOL BK after ALI Donor dislocation requiring re-bubbling Pull-through (double glide) 20/40 (0.5 D cylinder -1.75 D 88 ) 20/32 (-1.0 D cylinder -1.5 D 90) 20/32 (96) 2582/1964 (23.9)
4 F/74 OS nDSAEKPEAIOL BK after ALI Subclinical rejection (POD26) Pull-through (double glide) 20/32 (-3.5 D) 20/20 (-0.5 D cylinder 1.0 D 55) 20/16 (312) 3273/2433 (25.7)
5 F/67 OD nDSAEKPEAIOL BK after ALI None Pull-through (double glide) Hand motion (unmeasurable ) 20/32 (-2.5 D cylinder -0.5 D 90) 20/25 (277) 2889/1701 (41.1)
6 F/76 OD nDSAEKPEAIOL BK after ALI None Pull-through (double glide) 20/63 (-12.0 D cylinder -2.0 D 90) 20/25 (-3.5 D cylinder -1.0 D 10 ) 20/20 (334) 2823/1589 (43.7)
7 M/76 OD nDSAEKPEAIOL BK after ALI None Pull-through (double glide) 20/25 (0.5 D cylinder -1.75 D 115) 20/20 (-0.75 D cylinder -0.25 D 90 ) 20/20 (130) 3016/2570 (14.8)
8 F/63 OD nDSAEKPEAIOL BK after ALI None Pull-through (cartridge) 20/63 (2.5 D cylinder -2.0 D 79) 20/16 (-0.5 D cylinder -1.5 D 50) 20/16 (186) 2849/2066 (27.5)
9 M/78 OS nDSAEK endotheliitis None Pull-through (cartridge) Hand motion (unmeasurable ) 20/20 (-1.5 D cylinder -1.0 D 70) 20/20 (186) 3720/3095 (16.8)
10 F/81 OS nDSAEK BK after ALI None Pull-through (double glide) 20/400 (1.5-1.555) 20/25 (2.5 D cylinder -2.25 D 45) 20/25 (221) 2666/2008 (24.7)
Abbreviations OD, right eye OS, left eye BK,
bullous keratopathy D, dioptor ALI, argon laser
iridotomy nDSAEK, non-Descemets stripping
automated endothelial keratoplasty PEA,
phacoemulcification and aspiration IOL,
intraocular lens implantation. unmeasurable due
to severe bullous keratopathy
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Double-glide technique (The video is
downloadable from AJO.com 1)
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25-gauge DSAEK forceps grasped the donor lamella
from the Busin glide.
A temporal clear corneal incision (5.0 mm) is
made.
IOL glide insertion to prevent iris prolapse.
Donor endothelial lamella loaded onto Busin
glide.
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The donor lamella was left to unfold
spontaneously under continuous irrigation.
The IOL glide was pulled away from the anterior
chamber.
Air was injected to attach the donor lamella to
the posterior stromal surface.
Then, the donor lamella was pulled into the
anterior chamber.
1.Kobayashi A, Yokogawa H, Sugiyama K.
Non-Descemet stripping automated endothelial
keratoplasty for endothelial dysfunction
secondary to argon laser iridotomy. Am J
Ophthalmol 2008146543-549. 2.Kobayashi A,
Yokogawa H, Sugiyama K. Descemet stripping with
automated endothelial keratoplasty for bullous
keratopathies secondary to argon laser
iridotomy--preliminary results and usefulness of
double-glide donor insertion technique.Cornea
200827 Suppl 1S62-9.
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Results 1

• Visual Acuity All ten patients (100) reached
  better than 20/32 BCVA within six months after
  nDSAEK. Four patients (40.0) reached more than
  20/20, and one patient (10.0) reached 20/16
  within six months. Within one year, seven
  patients (70.0) reached more than 20/20, and two
  (20.0) reached 20/16.
• Astingmatism Mean induced astigmatism in
  measurable cases at six months postoperatively
  was 0.67D?0.45D (range, 0.25D to 1.5D).

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Results 2

• Complications Postoperatively, one patient
  experienced donor dislocation requiring
  re-bubbling.
• Endothelial cell counts Postoperative ECD after
  six months ranged from 1589 to 3095 cells/mm2
  (mean, 2229.4?501.0 cells/mm2), a 26.5 reduction
  compared with donor counts (mean, 3034.5?356.9
  cells/mm2).

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Case 7, 76M BK after argon laser iridotomy
ECD after 6M2570/mm2 (14.8?)
Postope BCVA20/20-0.75Dcyl-0.25DAx90
Preope BCVA 20/250.5Dcyl-1.75DAx115
Case 8, 63F BK after argon laser iridotomy
ECD after 6M2066/mm2 (27.5?)
Preope BCVA 20/63
Postope BCVA20/16-0.5D cyl -1.5D Ax50
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Summary
nDSAEK resulted in

• minimal induced astigmatism (0.67D0.45D ).
• excellent visual acuity (seven patients (70.0)
  reached better than 20/20, and two patients
  (20.0) reached 20/16. )
• less endothelial cell loss (26.5 reduction after
  6 months) using double-glide technique, which is
  extremely useful for narrow angle eyes such as
  Asian eyes.

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Conclusions

• This modified endothelial keratoplasty technique
  (nDSAEK) for treatment of non-Fuchs type
  endothelial dysfunction produced excellent
  clinical outcomes such as reduced endothelial
  cell loss, good visual acuity and minimal induced
  astigmatism.
• Further studies using a large number of patients
  and with long-term follow-up after nDSAEK are
  needed to fully understand the benefits of this
  procedure.