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Retrospective comparison of staged versus
combined cataract surgery and Descemets-strippin
g endothelial keratoplasty (DSEK) in patients
with Fuchs Dystrophy Christine Garcia, MS2,1
Omar Krad, MD,2 Amy Lin, MD2 Loyola
University Chicago, Stritch School of Medicine,
Maywood, IL,1 Department of Ophthalmology, Loyola
University Health System,2 Maywood, IL
Introduction
Objectives
Results contd
Conclusion
which will specifically include more combined
cataract and DSEK surgery cases. This will make
group 2 stronger, and contribute to the overall
goal of fifty patients in each group. Using the
data obtained thus far, general surface analysis
showed a trend in which patients who underwent
combined CEIOL and DSEK surgeries had a 29.7
greater improvement in visual acuity than
patients who underwent staged surgeries (Table
1). Also, of the 28 patients who underwent staged
procedures, five had a graft dislocation treated
with a repositioning, whereas two of the five
patients who underwent simultaneous procedures
had the same complication. This will be studied
further to possibly indicate which surgical
protocol has better visual outcomes and less
post-operative complications. Data collection
continues in order to increase the power of the
study. When complete, a t-test will be performed
to analyze any differences in the visual acuities
and central corneal thicknesses between the two
groups.
Fuchs endothelial dystrophy is a progressive
hereditary corneal disease characterized by
deterioration of the endothelium and overlying
Descemets membrane (Figure 1). Patients with
Fuchs dystrophy may develop loss of vision from
corneal and stromal edema and excrescences of the
Descemets membrane (corneal guttata). Because
the visual disturbances are not typically seen
until after age fifty, patients frequently have
coexisting visually significant cataracts. The
recently developed procedure indicated for
patients with Fuchs dystrophy, Descemets
Stripping Endothelial Keratoplasty (DSEK), can be
performed in a combined surgery following
cataract extraction with intraocular lens
placement (CEIOL) or in a staged fashion with
DSEK following CEIOL. To date there is no
significant evidence that one method of
performing the cataract and DSEK surgeries,
staged or combined, is more advantageous, but
there have been a few studies completed that
indicate possible benefits of each protocol.
Covert and Koenig (2007) specified that combined
surgeries would enable the patient to undergo a
single surgery with an overall shorter recovery
time. However, according to Yoo et al. (2008)
more surgical working space and better stability
of the anterior chamber after recovery from
cataract surgery could offer more beneficial
conditions for performing DSEK, namely greater
ease of DSEK donor graft tissue insertion and
positioning. This may minimize the damage to the
endothelial cells in the donor graft, with less
likelihood of graft dislocation or failure.
There is also the possibility of avoiding DSEK
altogether should there be adequate visual
recovery from cataract surgery. A Chicago area
multi-center retrospective comparison of visual
acuity and central corneal thickness was
performed to determine which surgical protocol,
staged versus combined, produces better clinical
outcomes.

• Report the outcomes of staged cataract extraction
  by phacoemulsification technique with IOL
  placement followed by DSEK (group 1) compared
  with the outcomes of combined cataract extraction
  with IOL placement and DSEK (group 2)
• Evaluate advantages and disadvantages to
  performing staged versus combined
  phacoemulsification and DSEK procedure.
• Determine the percentage of patients who were
  scheduled for staged phacoemulsification and DSEK
  procedures, but did not undergo DSEK because of
  favorable visual outcome and corneal appearance
  after cataract surgery.
• Report the criteria (indications) for performing
  cataract surgery and/or DSEK in a large
  metropolitan area.

At this time, the study is in progress. With
the multi-center nature of the project, data
continues to be collected. Thus far however, the
trend seems to show better visual outcomes in
patients who had combined cataract and DSEK
surgeries, but a smaller percentage of cases with
complications (graft dislocation) in the patients
who had staged cataract and DSEK surgeries.
Further analysis of the incoming data may
contribute to either approval or disapproval of
these trends. Evaluation of patients who
did not undergo DSEK because of significant
visual improvement after cataract surgery is
inconclusive with the data at hand. The
definitive reasons that the four post-CEIOL
patients were still awaiting DSEK surgeries in
the same eye were not charted. It was unclear
whether or not the DSEK surgeries in these
patients were postponed due to favorable visual
outcome or another clinical indication. A
considerable obstacle found with the
retrospective study was incomplete charting and
number of subjects who fit the inclusion/exclusion
criteria. The incoming data will be beneficial,
however, in order to make more significant
conclusions comparing the staged versus combined
procedures.  

Figure 1 Histopathology of the posterior cornea
in Fuchs' dystrophy. The thickened Descemet's
membrane with nodular excrescences (guttata) is
seen. Endothelial cells are sparse.
Table 1 Pre-operative and post-operative best
spectacle-corrected visual acuity (BSCVA) in
patients with staged or combined cataract and
DSEK surgeries. Post-operative BSCVA is at 12
months or the latest post-operative data
available within one year. Lower logMAR values
indicate better vision. Graft dislocations.
References
Results
Covert, D.J., Koenig, S.B. 2007. New triple
procedure Descemets stripping and automated
endothelial keratoplasty combined with
phacoemulsification and intraocular lens
implantation. Ophthalmology. 114(7)1272-1277.
Krachmer, J.H., Palay, D.A. Cornea Atlas. 2nd
ed. Elsevier Inc., 2006. p 176. Price, M.O.,
Price, F.W. 2007. Descemets stripping
endothelial keratoplasty. Current Opinion in
Ophthalmology. 18290-294.   Terry, M., Shamie,
N., Chen, E., Hoar, K., Friend, D. 2008.
Endothelial Keratoplasty A simplified technique
to minimize graft dislocation, iatrogenic graft
failure, and pupillary block. Ophthalmology.
115(7)1179-1186.   Yoo, S.H., Kymionis, G.D.,
Deobhakta, A.A., Ide, T., Manns, F., Culbertson,
W.W., OBrien, T.P., Alfonso, E.C. 2008.
One-year results and anterior segment optical
coherence tomography findings of Descemet
stripping automated endothelial keratoplasty
combined with phacoemulsification.
Ophthalmology. 126(8)1052-1055. Acknowledgemen
ts This work was supported by the Richard A.
Perritt Charitable Foundation.
Retrospective chart review was carried out for
patients identified to have both cataracts and
Fuchs endothelial dystrophy. The multi-center
study included review of 28 eyes from 28 patients
who underwent staged CEIOL followed by DSEK
(group 1) and 5 eyes from four patients that
underwent a combined CEIOL and DSEK surgery
(group 2). Visual outcomes were compared using
logMAR visual acuity and central corneal
thickness measurements before and after the
surgeries at post-operative months 1, 3, 6, and
12. At the present time, more data is being
gathered from University of Chicago and Wheaton
Eye Clinic,