Intraoperative optical coherence tomography-guided donor corneal tissue assessment and preparation

Purpose: To evaluate the role of intraoperative optical coherence tomography (i?OCT) in donor grading, selection, and preparation during different types of keratoplasty. Methods: Seventy?one consecutive donor corneas collected over 6 months, after clinical grading, were observed by an experienced corneal surgeon under an i?OCT equipped microscope. The donor preparation (manual/automated) for different types of keratoplasty procedures was also undertaken under i?OCT. Results: The mean central corneal thickness of optical and nonoptical grade tissues was 533 ± 19 and 662 ± 52 ?m, respectively. The i?OCT?based grading matched with clinical grading in 98.5% cases. Irregular thickness, anterior stromal hyperreflectivity, and previous scars were appreciated in 1.4, 1.4, and 7.04% donors, respectively. During Descemet stripping automated endothelial keratoplasty, i?OCT facilitated selection of appropriate microkeratome head for automated donor preparation in all cases, besides allowing manual dissection of partially dissected lenticule, identification of site of inadvertent perforation, and eccentric trephination in one case each. During Descemet membrane endothelial keratoplasty, i?OCT?based assessment of preexisting scar (five cases) guided careful tissue selection (2/5) and preparation. During predescemetic endothelial keratoplasty, precise needle advancement allowed successful type?1 bubble formation in all cases. All manually punched donors demonstrated an extra endothelial ledge, while those with automated preparation showed tapering donor margins. Conclusion: i?OCT might serve as a useful imaging tool for objective assessment of donor characteristics. The modality may complement clinical evaluation for donor grading, selection, and preparation.

Eye bank versus surgeon prepared Descemet stripping automated endothelial keratoplasty tissues: Influence on adhesion force in a pilot study

Purpose: To evaluate and compare the biomechanical properties of the eye bank?prepared and surgeon prepared Descemet stripping automated endothelial keratoplasty (DSAEK) tissues. Methods: In this laboratory study, corneal tissues for research were randomly allocated in the following groups: a) surgeon?cut DSAEK and b) eye bank?prepared (pre?cut and pre?loaded) DSAEK. Endothelial cell loss (ECL), immunostaining for tight junction protein ZO?1, elastic modulus, and adhesion force were investigated. Results: ECL was not found to be significantly different between surgeon?cut DSAEK (7.8% ±6.5%), pre?cut DSAEK (8.6% ±2.3%), and pre?loaded DSAEK (11.1% ±4.8%) (P = 0.5910). ZO?1 was expressed equally across all groups. Surgeon?cut DSAEK grafts showed a significantly higher elastic modulus compared to pre?cut and pre?loaded DSAEK groups (P = 0.0047 and P < 0.0001, respectively). Adhesion force was significantly greater in the surgeon?cut DSAEK compared to pre?cut (P < 0.0001) or pre?loaded DSAEK groups (P = 0.0101). Conclusion: The laboratory data on the biomechanics of DSAEK grafts suggests that surgeon?cut DSAEK grafts present higher elastic modulus and adhesion force compared to eye bank?prepared DSAEK grafts.

The outcome of 70/30 taco insertion through a 2.8 mm clear corneal incision in Descemet’s stripping automated endothelial keratoplasty - A retrospective analysis

Purpose: To assess the long?term outcome of graft insertion by taco technique through a 2.8?mm clear corneal incision in patients undergoing Descemet’s stripping automated endothelial keratoplasty (DSAEK). Methods: This is a retrospective interventional case series of 77 eyes of 75 patients who underwent DSAEK in a tertiary eye hospital. The DSAEK donor grafts were folded to an uneven 70/30 taco and held at a single point using Utrata forceps. All insertions were through a 2.8?mm clear corneal incision except the two aphakic patients requiring combined SFIOL implantation. All patients underwent a comprehensive eye examination preoperatively and were followed up to 6 years postoperatively. Visual outcomes, graft clarity, and complications of all and endothelial cell loss in 22 patients with available postop specular microscopy were analyzed. Results: Overall, 59 (76.6%) had clear grafts until the final follow?up. Visual acuity improved in 48 (62.3%) from an average of 1.3 to 0.8 logMAR (P = 0.0001). Vision was maintained in seven and worsened in four eyes. Grafts failed in 18 (23.3%) eyes: seven (9%) were primary failures, two post rejection, four done for failed PK did not clear, four due to worsening of preexisting glaucoma, and one noncompliant failed eventually. Average endothelial cell density reduction was 26.3% (mean preop donor 2419 to postop 1779 cells/mm2; P = 0.000). Conclusion: Our study shows good long?term clinical outcome of DSAEK using Taco technique through a 2.8?mm clear corneal incision in a tertiary hospital

Surgical management of post-Descemet stripping automated endothelial keratoplasty interface haze associated with interface deposits

We describe an effective technique for the management of graft杊ost interface haze associated with interface deposits after Descemet-stripping automated endothelial keratoplasty (DSAEK) with bimanual irrigation/aspiration. A Tan marginal dissector was used to separate the graft from the stroma in the nasal two-thirds of the graft杊ost interface. The aspiration handpiece was inserted in the interface through the nasal side-port corneal incision and a separate irrigation tip was placed in the anterior chamber (AC) through the temporal corneal paracentesis. Meticulous rinsing of the two-thirds of the interface area and the AC was performed. At the end of the procedure, air was injected into the AC to float the donor graft against the host stromal bed and facilitate graft adherence. Postoperative anterior segment optical coherence tomography and slit-lamp examination confirmed elimination of the interface haze杁eposits and a well-attached graft. An improvement in visual acuity was noted.

Repeat keratoplasty in failed Descemet stripping automated endothelial keratoplasty

Purpose: To evaluate the clinical factors associated with repeat Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty (PKP) in cases of failed DSAEK. Methods: Retrospective observational study of cases with failed DSAEK admitted to our center for a repeat keratoplasty over 5 years (January 2013–Decemeber 2017) was undertaken. Demographic and perioperative details of all cases and type of repeat keratoplasty were recorded. Logistic regression analysis was performed to analyze the factors affecting the type of repeat keratoplasty. Results: total of 94 eyes with failed DSAEK were evaluated. Repeat DSAEK was performed in 66% and PKP in 34% of cases. Significantly increased odds for requiring PKP were observed in association with stromal scarring [odds ratio (OR) = 2.9, P = 0.018)], trainee surgeons (OR = 4.05, P = 0.008), intraoperative complications (OR = 4.58, P = 0.003), scleral fixated intraocular lens or anterior chamber intraocular lens in situ (OR = 33.8, P < 0.001), secondary glaucoma (OR = 3.02, P = 0.015), peripheral anterior synechiae (OR = 8.6, P < 0.001), preoperative corneal thickness (OR = 1.01, P < 0001), time to primary surgery (OR = 1.03, P = 0.03), post-DSAEK host thickness (OR = 1.01, P < 0.001), and time interval from graft failure to regraft (OR = 1.18, P < 0.001). All eyes with congenital hereditary endothelial dystrophy, bee-sting-induced corneal decompensation, Axenfeld-Rieger syndrome, and multiple failed grafts underwent secondary PKP. All cases (nine eyes) that required surgical intervention for secondary glaucoma underwent secondary PKP (P < 0.001). Conclusion: Repeat DSAEK is feasible in up to two-third of cases of failed DSAEK. A PKP is required in one-third of cases, and various preoperative, intraoperative and postoperative factors are associated with unsuitability for repeat DSAEK.

Comparing Clinical Outcomes of Descemet's Membrane Stripping Automated Endothelial Keratoplasty Between Graft Insertion Methods

PURPOSE: To compare clinical outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) between different graft insertion methods. METHODS: The clinical records of 32 eyes of 30 DSAEK patients were retrospectively analyzed. Patients were divided into 2 groups according to graft insertion method. Group A: Taco-folding, group B: Tan-endoglide. The best corrected visual acuities (BCVA), intraocular pressures, astigmatism, endothelial cell count, central corneal thickness and complications were evaluated pre and post-operatively. RESULTS: The average follow-up period was 19 months (range 1-67). Postoperative log MAR visual acuity had significantly improved both from 1.63 (log MAR) to 0.69 and 0.53 at 12 months in each group (p = 0.035, p = 0.000). Mean endothelial cell survival of each group at 1 month postoperative were 75.8% (range 62.7-88.6) and 87.7% (range 70.2-97.9), respectively (p = 0.012). The differences of BCVA improvement and endothelial cell survival between the groups at 12 months were not significant (p = 0.393, p = 0.544). CONCLUSIONS: Both methods showed fast visual recovery. Using Tan-endoglide insertion resulted less endothelial cell loss at early post-operative period and showed less post-operative complication and graft failure.

The Correlations between Donor Endothelial Lenticule Thickness and Visual Prognosis in DSAEK

PURPOSE: To determine the correlations between donor endothelial lenticule thickness and visual prognosis in Descemet's stripping automated endothelial keratoplasty (DSAEK). METHODS: The present study included 22 patients (22 eyes), who underwent DSAEK surgery in our clinic due to endothelial decompensation. BCVA (log MAR) was compared at 1 month, 3 months and 6 months postoperatively between the thin lenticule group and thick lenticule group (> or =130 micrometer). RESULTS: The BCVA (log MAR) at 1 month postoperatively was 0.46 +/- 0.22 in the thin lenticule group, and 0.71 +/- 0.26 in the thick lenticule group, and significant statistical correlations between donor lenticule thickness and visual acuity were observed (p = 0.025). However, no significant correlations were observed at 3 months (p = 0.129) and 6 months (p = 0.141) postoperatively. CONCLUSIONS: The thin donor lenticule ( or =130 micrometer), however, there is no difference in visual acuity between the 2 groups at 3 and 6 months postoperatively.

A Case of Herpes Simplex Keratitis after Descemet Stripping Automated Endothelial Keratoplasty

PURPOSE: To report a case of herpes simplex keratitis after descemet stripping automated endothelial keratoplasty (DSAEK). CASE SUMMARY: A 66-year-old male underwent DSAEK in his right eye due to bullous keratopathy after cataract surgery. The corneal epithelium which was removed during surgery was healed, but the patient was experiencing pain and decreased visual acuity in his right eye 1 month after surgery. Increasing corneal epithelial defects and corneal edema were observed on slit-lamp examination. Therapeutic soft contact lenses and artificial tears were used for treatment but were not effective, thus amniotic membrane transplantation was performed. Three months after transplantation, the epithelial defect appeared as a geographic ulcer suspecting to be herpes simplex keratitis; therefore, ganciclovir ophthalmic ointment and oral acyclovir were administered. Six months after antiviral therapy, the epithelial lesion of herpes simplex keratitis completely disappeared, leaving only mild corneal opacity. CONCLUSIONS: If corneal epithelial defects are persistent after DSAEK in patients even with no past history of herpes simplex keratitis, herpes simplex keratitis should be considered in the differential diagnosis.

Long-Term Results of Descemet's Stripping Automated Endothelial Keratoplasty in Korea

PURPOSE: To evaluate the long-term results of Descemet's stripping automated endothelial keratoplasty in Korea (DSAEK). METHODS: Seven patients with bullous keratopathy who underwent DSAEK and who were followed-up for more than 18 months were reviewed retrospectively. Best corrected visual acuity, refraction, corneal thickness, and endothelial cell count were examined before and after surgery. RESULTS: The mean follow-up period was 19.9 +/- 2.9 months (18 to 24 months), and the mean age was 61.42 +/- 10.13 years (46 to 76 years). Six patients (85.7%) showed successful results after surgery. Best corrected visual acuity (logMAR) was significantly improved from 1.62 (median) to 1.15 (median) (p = 0.027) at one month after surgery and was maintained until the final follow-up period. There were no statistical differences in spherical ametropia or astigmatism before or 18 months after the operation. Graft failure was observed in one case, in which penetrating keratoplasty was performed 12 months after DSAEK. CONCLUSIONS: Long term results of DSAEK showed fast visual recovery, low ametropia and astigmatism. DSAEK may be a good option for the surgical management of corneal endothelial disease.