Comparison of Descemet

1
Comparison of Descemets Stripping Endothelial
Keratoplasty to Descemets Membrane Endothelial
KeratoplastyOne Surgeons Initial 16 Cases

• Jeffrey J. Ing, MD, FACS, (Delta Eye Medical
  Group, Loma Linda University School of Medicine,
  Department of Ophthalmology)
• Thanh T. Nguyen, OD (Delta Eye Medical Group)
• Art W. Giebel, MD (Pacific Cataract and Laser
  Institute, Loma Linda University School of
  Medicine, Department of Ophthalmology)
• The authors have no financial interest in the
  subject matter of this poster.

2
Purpose

• To compare one surgeons initial experience with
  Descemets stripping endothelial
  keratoplasty/Descemets stripping automated
  endothelial keratoplasty (DSEK/DSAEK), to his
  initial experience with Descemets membrane
  endothelial keratoplasty (DMEK)

Methods
We retrospectively reviewed charts on one
surgeons initial 16 eyes that had DSEK/DSAEK
(5/05-8/06) with his initial 16 eyes that had
DMEK (8/08-1/09). Preoperative and 7-14 month
post-operative Snellen acuities (converted to
LogMAR) and endothelial cell densities (ECD) were
recorded.
3
DSEK/DSAEK

• DSEK tissue was harvested with hand cut lamellar
  dissection or precut DSAEK by eye bank using a
  microkeratome.
• DSEK/DSAEK cases posterior lamellar corneal
  tissue was inserted using utrata forceps the
  tissue was unfolded and an air bubble was placed
  into the eye to position the tissue.

DSEK/DSAEK graft
4
DMEK

• DMEK cases the Descemets endothelial complex
  (DEC) was harvested manually while submerged in
  preservation media (SCUBA technique).
• The DEC was injected into the eye (2.75-3.5 mm
  incision) air bubbles were used to unfold and
  position the DEC.

Minuteman sign w/microbubble
DMEK, hours after procedure performed
5
Results
DSEK or DSAEK Pre -Snellen Pre-LogMAR 7-14mo Snellen 7-14 mo LogMAR
1 20/60 0.48 20/80- 0.60
2 20/50 0.40 20/40- 0.30
3 20/50 0.40 20/40cc 0.30
4 20/40- 0.30 20/30 0.18
5 20/60- 0.48 20/50 0.40
6 20/100-cc 0.70 20/50- 0.40
7 20/100 0.70 20/70 0.54
8 20/HM gt1.3 20/400 1.30
9 20/60-cc 0.48 20/100- 0.70
10 20/50 0.40 20/80 AR 0.60
11 20/30- 0.18 20/40- 0.30
12 20/HMsc gt1.3 20/30 0.18
13 20/200 1.00 20/100- 0.70
14 20/70cc 0.54 20/30-cc 0.13
15 20/70- 0.54 Deceased Deceased
16 20/100cc 0.70 20/50 0.40
Average gt20/87 gt0.64 20/44 0.34

• Eyes with other pathology were excluded from
  average visual acuity analysis.
• DSEK The average preoperative acuity was 20/87
  (0.64 logMAR). The average 7-14 month
  postoperative acuity was 20/44 (0.34 logMAR).

Manifest refraction acuities were recorded unless
otherwise noted with habitual correction (cc),
without correction (sc), autorefractor (AR).
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Results
DMEK Pre- Snellen Pre-LogMAR 7-14mo Snellen 7-14 LogMAR
1 20/200sc 1.00 20/20 0.00
2 20/200cc 1.00 20/30 0.13
3 20/400cc 1.30 20/25 0.10
4 20/100sc 0.70 20/25 0.10
5 20/50 0.40 20/25 0.10
6 20/400 PH 1.30 20/25 0.10
7 20/60 0.48 20/25 0.10
8 20/70-cc 0.54 20/40 0.30
9 20/50cc 0.40 20/20 0.00
10 20/60/- 0.48 20/30 0.13
11 20/50cc 0.40 20/30 0.13
12 20/60 0.48 20/30 0.13
13 20/70 0.54 20/30 0.13
14 20/400cc 1.30 20/50 0.40
15 20/100 0.70 20/40 0.30
16 20/20- 0.00 Failed n/a
Average 20/123 0.79 20/24 0.08

• Eyes with other pathology were excluded from
  average visual acuity analysis.
• DMEK The average pre-operative acuity was 20/123
  (0.79 logMAR), the average 7-14 month
  postoperative acuity was 20/24 (0.08 logMAR).

Manifest refraction acuities were recorded unless
otherwise noted with habitual correction (cc),
without correction (sc), pin-holed (PH) 4-6
month data input due to no 7-14 month follow-up
data available. DMEK 16 had localized non
resolving corneal edema preoperative, failed and
was excluded from postoperative visual acuity
analysis
7
Results

• Average endothelial cell density decreased by 47
  for DSEK/DSAEK and by 42 for DMEK at the 7-16
  month interval.

DSEK Donor ECD 7-14mo ECD Decrease
1 2832 n/a n/a
2 3048 n/a n/a
3 2778 2163 22
4 3448 2074 40
5 2949 n/a n/a
6 4060 n/a n/a
7 3129 n/a n/a
8 3260 867 73
9 2865 1881 34
10 3040 n/a n/a
11 3174 n/a n/a
12 2798 967 65
13 2985 n/a n/a
14 3050 n/a n/a
15 3052 Deceased n/a
16 3017 n/a n/a
    Average 47
DMEK Donor ECD 7-14mo ECD Decrease
1 3262 1000 69
2 2964 2502 16
3 3108 2157 31
4 2780 1122 60
5 3003 1331 56
6 3322 2387 28
7 2994 805 73
8 3115 2312 26
9 3155 1958 38
10 3258 910 72
11 2748 1579 43
12 3077 2719 12
13 3067 1613 47
14 2865 1222 57
15 2985 2103 30
16 3135 Failed n/a
Average 42
4-6 month data input due to no 7-14 month
follow-up data available.
8
Results

• In DSEK one donor tissue was wasted due to damage
  during hand cut lamellar dissection.
• In DMEK one donor tissue was wasted due to
  unfolding difficulty.

Descemets endothelial complex after injection
into the anterior chamber. Endothelium Is on the
outside of the DEC roll
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Discussion

• Caveats of Study
• Retrospective Design
• Current DSAEK techniques have improved over older
  DSEK techniques and the learning curve is
  significantly shortened with precut tissue.
• Endothelial cell density (ECD) measurements
• Single measurement (not averaged)
• Manual counting by different technicians
• Difficulty measuring post DSEK/DSAEK ECD

10
Learning Curve our opinion

• It is the opinion of the authors that DMEK is
  still evolving as a technique. DMEK has a steep
  learning curve. Taking a course and practice in
  the lab with donor tissue improves results. Some
  of the maneuvers needed for DMEK are different
  from anything else done in ocular surgery.
  However, previous experience with endothelial
  keratoplasty Descemets stripping and bubble
  management make the learning curve easier. DMEK
  may be less equipment intensive and the incision
  size can be smaller.

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Conclusion

• On average DMEK eyes had better post-operative
  vision than DSEK/DSAEK eyes.
• There was insufficient endothelial cell data for
  the DSEK/DSAEK eyes to allow a good comparison
  with DMEK data.

12
References

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   microkeratome-dissected and manually dissected
   donor tissue. Ophthalmology 2006113(11)1936-42.
3. Terry MA. Endothelial keratoplasty history,
   current state, and future directions. Cornea
   200625(8)873-8.
4. Perlman EM. Endothelial keratoplasty. Med Health
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6. Giebel AW, Price FW, Jr., Ing JJ, "Minimizing
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   DMEK." AAO.PAAO Conference, San Francisco,
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7. Price MO, Giebel AW, Fairchild KM, Price FW, Jr.
   Descemet's membrane endothelial keratoplasty
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   Ophthalmology 2009116(12)2361-8.