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ABSTRACT Primary graft failure (PGF) is a known complication following penetrating keratoplasty (PKP). The usual approach to treat this complication is to repeat a penetrating keratoplasty. Here, we report a case of Descemet's membrane endothelial keratoplasty (DMEK) for the treatment of PGF after PKP. A patient that underwent PKP, developed PGF with persistent graft edema and very poor visual acuity despite aggressive steroid use and a proof anti-viral treatment. Three months after the initial surgery, a DMEK was performed under the PKP graft. There was progressive early corneal clearing and, by the end of the first month, the patient already had no corneal edema. Uncorrected visual acuity (UCVA) improved to 20/40 and best corrected visual acuity (BCVA) to 20/20. DMEK may be an alternative to a second PKP for the treatment of PGF. This technique is a less invasive option when compared to the standard PKP procedure.
RESUMO A falência primária do enxerto é uma complicação conhecida que pode ocorrer após o transplante penetrante de córnea. O tratamento usual dessa complicação é com um novo transplante penetrante. Apresentamos um caso em que foi usado o transplante endotelial de membrana de Descemet (DMEK - do inglês Descemet membrane endo-thelial keratoplasty) para o tratamento da falência primária após o transplante penetrante. Uma paciente submetida a transplante penetrante evoluiu com falência primária do enxerto a despeito do uso intenso de corticoide tópico e uma prova terapêutica de antivirais. Três meses após a cirurgia inicial, foi optado pela realização do transplante endotelial de membrana de Descemet sob o transplante penetrante. Houve um clareamento precoce e progressivo do enxerto com melhora importante da visão. Após um mês, a visão sem correção era de 20/40 melhorando para 20/20 com refração. O transplante endotelial de membrana de Descemet pode ser uma alternativa a um novo transplante penetrante como tratamento da falência primária.
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Purpose: We aimed to determine whether Descemet抯 membrane (DM) scrolling occurs primarily along the vertical or horizontal axis and establish whether oval trephination along the axis of least scrolling can reduce the grade of the scroll. Methods: The longest limbus?to?limbus axis on 28 sclerocorneal discs was taken as the horizontal axis. The horizontal (n = 7) or (right angles to it) vertical (n = 6) axis was marked on DM before peeling it off. The direction and grade of scrolling was observed. Narrow strips (3�mm wide) were then cut along the two axes (n = 4 each) and the scrolling pattern was observed. Ellipses (7 � 9 mm) of DM were punched along the two axes (n = 6 each) and the scrolls graded. Immunofluorescent staining for elastin on horizontal and vertical tissue sections from three DM samples was performed. The intensity and thickness of elastin staining were measured. Results: Twenty?four (85.72%) DM samples showed scrolling along the horizontal axis, none showed scrolling along the vertical axis, and four (14.28%) samples showed a spiral scroll, regardless of which axis was marked (grade 3.7 and 3.6). Vertically oval discs showed significantly reduced scrolling (grade 1.2) compared to horizontally oval discs (grade 3.5). Narrow strips of DM showed a similar scrolling pattern. Immunohistology showed no difference in any of the parameters examined along the two axes or from the center to the periphery. Conclusion: DM scrolls primarily along the horizontal axis. Vertically oval DM samples show minimal scrolling, which can be an advantage in DMEK. Differential scrolling is not determined by the distribution of elastin.
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The comorbidity of keratoconus with Fuchs� endothelial dystrophy with cataract is a rare clinical combination. We present an amalgamation of surgical techniques to manage the above clinical conditions and its complications in single setting. The modified triple procedure, namely, the phacoemulsification, pinhole pupilloplasty, and pre-Descemet抯 endothelial keratoplasty (PDEK) in the order of description is followed in single sitting. Lens removal by phacoemulsification, correction of irregular astigmatism by pinhole pupilloplasty (pinhole optics), and exchanging the endothelial layer for PDEK forms the main segments of the triple procedure. This combination of techniques may decrease the risk of multiple surgeries and its related complications. Moreover, it will allow the patient for faster visual rehabilitation by improving the uncorrected visual acuity and visual quality.
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Purpose: To analyze the visual outcome and complications of Descemet stripping endothelial keratoplasty (DSEK) with their management in 256 eyes at a tertiary eye care center in southern India. Methods: This is a retrospective interventional study of 62 months duration conducted at a tertiary eye care center in southern India. Two hundred and fifty?six eyes of 205 patients were included in the study after obtaining written informed consent from the patients. All cases of DSEK were performed by a single experienced surgeon. In all cases, donor dissection was performed manually. A Sheet’s glide was inserted through the temporal corneal incision and donor button was placed on the Sheet’s glide with the endothelial side down. The lenticule was separated and inserted into the anterior chamber by pushing the lenticule into the anterior chamber using Sinskey’s hook. Any complication, either intraoperative or postoperative, was recorded and managed either medically or by appropriate surgical means. Results: The mean best corrected visual acuity (BCVA) before surgery was CF?1 m, which improved to 6/18 after surgery. Intraoperative donor graft perforation during dissection was seen in 12 cases, thin lenticule in three eyes, and repeated artificial Anterior Chamber (AC) collapse in three eyes. Dislocation of lenticule was the most common complication seen in 21 eyes, which was managed by graft repositioning and rebubbling. Eleven cases had minimal separation of the graft and seven cases had interface haze. Pupillary block glaucoma was seen in two cases that resolved with partial release of bubble. Surface infiltrate was seen in two cases, which was managed with topical antimicrobial agents. Primary graft failure was seen in two cases. Conclusion: DSEK is a promising alternative to penetrating keratoplasty for corneal endothelial decompensation, but it also has its own merits and limitations, and most often, merits overweigh limitations.
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ABSTRACT Purpose: The aim of this study was to investigate the association of anatomical outcomes and medications of patients with systemic diseases who underwent Descemet membrane endothelial keratoplasty with donor factors. Methods: Sixty nondiabetic donors of endothelial grafts and 60 patients who underwent operation by a single surgeon were included in this retrospective study. The patients' data, including the presence of diabetes mellitus and hypertension, antidiabetic-antihypertensive medications, and intracameral tamponades and anatomical outcomes, were recorded. The donor data were obtained from eye bank records. Results: Eighteen patients had type 2 diabetes mellitus (30%) and 34 had hypertension (56.6%). Among the patients with diabetes mellitus, 13 were receiving a single-agent antidiabetic drug, 4 were receiving dual oral antidiabetic therapy, and 1 was receiving insulin therapy. Among the hypertensive patients, 11 had monotherapy and 23 had dual antihypertensive therapy. Postoperatively, 35 patients (58.3%) had an endothelial attachment, 8 (13.3%) received reinjection, 7 (11.7%) required re-Descemet membrane endothelial keratoplasty, and 10 (16.7%) underwent penetrating keratoplasty. The mean donor age was 51.2 ± 14.1 years. The most common cause of donor death was cardiopulmonary arrest (36/60 cases; 60.0%). Regression analysis revealed that the presence of diabetes mellitus significantly disrupted graft attachment (p=0.034), while the presence of hypertension, antidiabetic and antihypertensive medication use, and the type of tamponade used in the patients, and the age, sex, cause of death, and specular endothelial cell count of donors were not statistically significantly associated with graft attachment (p>0.05). Conclusion: In this study, the anatomical outcomes of Descemet membrane endothelial keratoplasty surgery were affected by recipient and donor factors. The presence of diabetes mellitus in the recipient significantly negatively affected graft attachment.
RESUMO Objetivo: Investigar a associação de desfechos ana tômicos com doenças sistêmicas e medicamentos em casos submetidos à ceratoplastia endotelial da membrana de Descemet e fatores relativos aos doadores. Métodos: Foram incluídos neste estudo retrospectivo enxertos obtidos de doadores não diabéticos e 60 casos operados por um único cirurgião. Foram registrados os dados dos casos, incluindo a presença de diabetes mellitus e hipertensão, medicamentos antidiabéticos e anti-hipertensivos, tamponamentos intracamerais e desfechos anatômicos. Os dados dos doadores foram obtidos dos prontuários do banco de olhos. Resultados: Dezoito casos tinham diabetes mellitus tipo 2 (30%) e 34 tinham hipertensão (56,6%). Entre os casos de diabetes mellitus, 13 estavam em uso de uma medicação antidiabética de agente único, 4 estavam em terapia antidiabética oral dupla e 1 estava em insulinoterapia. Entre os hipertensos, 11 estavam em monoterapia e 23 em terapia anti-hipertensiva dupla. No pós-operatório, 35 pacientes (58,3%) submeteram-se a uma fixação endotelial, enquanto 8 casos (13,3%) receberam reinjeção, 7 casos (11,7%) necessitaram de ceratoplastia endotelial da membrana de Descemet e 10 casos (16,7%) foram submetidos a uma ceratoplastia penetrante. A média de idade dos doadores foi de 51,2 ± 14,1 anos. A causa mais comum de morte do doador foi parada cardiorrespiratória (36/60 casos; 60,0%). A análise de regressão revelou que a presença de diabetes mellitus causa distúrbios significativos na fixação do enxerto (p=0,034), enquanto a presença de hipertensão, o uso de medicamentos antidiabéticos e anti-hipertensivos, o tipo de tamponamento usado, a idade, o sexo, a causa da morte e a contagem de células endoteliais especulares dos doadores não demonstraram associações estatisticamente significativas com a fixação do enxerto (p>0,05). Conclusões: Os resultados anatômicos da cirurgia de ceratoplastia endotelial da membrana de Descemet são afetados por fatores do receptor e do doador. A presença de diabetes mellitus no receptor teve um significativo impacto negativo na fixação do enxerto.
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Purpose: To evaluate the gonioscopic changes in patients receiving Descemet’s stripping endothelial keratoplasty (DSEK) without pre?existing ocular hypertension (OHT) and to report its correlation with post?surgery OHT, graft survival, and visual outcomes. Methods: Adult patients who underwent DSEK surgery from April 2014 to March 2018 with at least 2 years of follow?up were analyzed in this retrospective study. Demographic details, indication of DSEK, necessary anterior and posterior segment findings, and the post?DSEK OHT details were documented. Results: A total of 58 patients (23 males and 35 females) with a mean age of 61.44 ± 8.8 years were included in the study. The most common etiology for DSEK surgery was pseudophakic bullous keratopathy in 47 eyes (81.03%). A total of 22.41% (13/58) eyes showed elevated intra?ocular pressure (IOP) following DSEK surgery. The most common cause of IOP elevation was steroid?induced OHT in seven eyes (12.06%). Gonioscopy examination revealed areas of peripheral anterior synechiae (PAS) in 17 (29.3%) eyes. OHT was found in 4/17 (23.5%) eyes having PAS. Three of these cases required trabeculectomy + goniosynechiolysis (GSL), and the fourth case required GSL alone to control IOP. These four cases also required repeat DSEK for failed grafts. The mean pre?operative best corrected visual acuity was 1.62 logMAR (range 1.17–1.77), which gradually improved to 0.79 logMAR (range 0.3–1.77) after 2 years (p < 0.00001). Conclusion: PAS was found to be an important factor associated with post?DSEK ocular hypertension in our study. OHT in PAS cases required definitive surgical treatments to control IOP. It adversely affected the graft survival and in turn affected visual outcomes also.
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Purpose: This study aims to assess the preferred surgical technique of Descemet membrane endothelial keratoplasty (DMEK) among corneal surgeons in India, and barriers in performing DMEK surgeries amongst the non?DMEK surgeons. Methods: An online, questionnaire-based, cross-sectional survey was conducted among members of the Cornea Society of India (CSI) (n = 500). Responses on their surgical experience, preferred technique, complications, and outcome of DMEK were collected and analyzed. Barriers in performing DMEK surgeries were assessed amongst the non?DMEK surgeons. Results: A total of 100 responses were obtained and response rate for the survey was 20%. DMEK was performed by 55% of the participants of whom only 40% had formal training in this technique. Surgical video-based learning was the most often used self-training method for others. Lack of training was the most common reason for not performing DMEK by the non-DMEK surgeons. Descemet stripping endothelial keratoplasty (DSEK) was the most common endothelial keratoplasty (EK) performed by both DMEK and non-DMEK surgeons. High volume (>50 cases) DMEK surgeries were reported by limited surgeons (n = 6). Nearly all the DMEK surgeons prepared the donor tissue by themselves on the day of the surgery, and majority felt that unrolling the graft in the anterior chamber was the most difficult surgical step. Nearly 80% of the DMEK surgeons were more comfortable with DSEK or Descemet stripping automated endothelial keratoplasty (DSAEK) when compared to DMEK. Conclusion: DMEK practice in India needs improvement with increased accessibility to DMEK training programs, wet lab facilities, and better support from eye banks
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Purpose: To evaluate the outcomes of trabeculectomy, graft survival, and risk factors for failure in post penetrating keratoplasty (PK) and Descemet’s stripping endothelial keratoplasty (DSEK) eyes. Methods: We reviewed charts of eyes that underwent trabeculectomy for post keratoplasty glaucoma PK [25 eyes] and DSEK [14 eyes] between 1993 and 2019. The demographics, clinical features, and surgical outcomes were evaluated. Success of trabeculectomy was defined as complete when the intraocular pressure (IOP) was >5 and ?21 mmHg without antiglaucoma medications (AGM) and qualified with AGM. Clear and compact graft was considered for graft success. Results: Median (interquartile range [IQR] preoperative IOP in post?PK eyes and post?DSEK eyes was comparable, 32 (28–38) vs. 31.5 (25–36) mmHg, P = 0.38). Median number of preoperative AGMs was comparable (P = 0.78). Median postoperative follow?up was longer in post?PK, compared with post?DSEK, 2.5 (1.3–3.3) vs. 1 (0.3–2.9) years (P = 0.05). Kaplan–Meier survival estimates for complete and qualified success of trabeculectomy at 3 years were 23.7% and 73.3%, respectively, for PK and 45.8% and 71.6%, respectively, for DSEK. Kaplan–Meier survival estimates for graft survival were 91.8% up to 3 years for PK and 100% until 2 years and 77.8% at 3 years for DSEK. Higher IOP prior to trabeculectomy was a risk factor for failure of trabeculectomy (P = 0.03) and older age was a risk factor for graft failure (P = 0.05) in PK eyes. Number of prior corneal surgeries (P = 0.05) was associated with failure of trabeculectomy and graft failure in post?DSEK eyes. Conclusion: Trabeculectomy had moderate qualified success in post?PK and DSEK eyes at 3 years. Higher pretrabeculectomy IOP and higher number of prior corneal surgeries were significantly associated with failure of trabeculectomy in PK and DSEK eyes, respectively
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Introducción: La distrofia corneal endotelial de Fuchs se trata de un trastorno degenerativo específico, bilateral y progresivo del endotelio corneal, es la más frecuente pero no siempre es diagnosticada en sus etapas iniciales en las consultas de oftalmología general. Objetivo: Describir el comportamiento clínico de pacientes con distrofia corneal endotelial de Fuchs en la provincia Camagüey. Métodos: Se realizó un estudio observacional, descriptivo, transversal en el Centro Oftalmológico del Hospital Universitario Manuel Ascunce Domenech en la provincia Camagüey desde noviembre 2019 hasta junio 2021. El universo de estudio estuvo constituido por todos los pacientes que asistieron durante el periodo de estudio y la muestra la conformaron 19 pacientes (38 ojos) quienes cumplieron con los criterios de inclusión y exclusión. Las variables estudiadas fueron edad, sexo, color de la piel, agudeza visual con corrección, asociación con glaucoma, paquimetría, biomicroscopía del segmento anterior, microscopía endotelial, microscopía confocal, estadio de la enfermedad y tipo de tratamiento aplicado. Resultados: Predominaron los pacientes entre 40 y 59 años de edad, el sexo femenino y color blanco de la piel. Sobresalió la visión útil, los valores de paquimetría altos y asociados al glaucoma. Se constató la presencia de guttas, edema corneal, bajo conteo celular con polimorfismo y polimegatismo. El estadio 2 estuvo en 47,4 % y el tratamiento médico se aplicó en el 97,4 %. Conclusiones: La distrofia aparece con más frecuencia después de los 40 años de edad, en sexo femenino y color blanco de piel. Predominó la visión útil, valores altos de paquimetrías y asociación con glaucoma. En la biomicroscopía del segmento anterior predominaron las guttas y el edema estromal y la microscopía endotelial y confocal se caracterizaron en su mayoría por el bajo conteo celular, las guttas, polimorfismo y polimegatismo. Prevaleció el estadio 2 y el tratamiento médico.
Introduction: Fuchs endothelial corneal dystrophy is a specific, bilateral and progressive degenerative disorder of the corneal endothelium, it is the most frequent but it is not always diagnosed in its initial stages in general ophthalmology consultations. Objective: To describe the clinical behavior of patients with Fuchs endothelial corneal dystrophy in Camagüey province. Methods: A cross-sectional descriptive observational study was carried out at the Ophthalmological Center of the Manuel Ascunce Domenech University Hospital in Camagüey in the period from November 2019 to June 2021. The study universe consisted of all the patients who attended during the study period and the sample was made up of 19 patients (38 eyes) who met the inclusion and exclusion criteria. The variables studied were age, sex, skin color, corrected visual acuity, association with glaucoma, pachymetry, anterior segment biomicroscopy, endothelial microscopy, confocal microscopy, disease stage, and type of treatment applied. Results: Patients between 40 and 59 years of age, female sex, and white skin color predominated. Useful vision stood out, high pachymetry values and associated with glaucoma, the presence of guttas, corneal edema, low cell count with polymorphism, and polymegatism was confirmed. Stage 2 was 47.4% and medical treatment was applied in 97.4%. Conclusions: Dystrophy appears more frequently after 40 years of age, in females and white skin persons. Useful vision, high pachymetry values, and association with glaucoma prevailed. In the biomicroscopy of the anterior segment, guttas and stromal edema predominated, and endothelial and confocal microscopy were mostly characterized by low cell count, guttas, polymorphism, and polymegatism. Stage 2 and medical treatment prevailed.
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ABSTRACT Objective: To describe a new surgical maneuver to position the graft in a Descemet Stripping with Automated Endothelial Keratoplasty (DSAEK) surgery. Methods: Case series. Results: This technique allows a correct repositioning of the graft in a minimally invasive way. Conclusion: This new surgical maneuver was successful in manipulating the graft in DSAEK surgery and therefore might be effective and safe.
RESUMO Objetivo: Descrever uma nova manobra cirúrgica para posicionar o enxerto em uma cirurgia de ceratoplastia endotelial automatizada com desnudamento da Descemet. Métodos: Série de casos. Resultados: A técnica permitiu o correto reposicionamento do enxerto de forma minimamente invasiva. Conclusão: Esta nova manobra cirúrgica foi bem-sucedida para manipular o enxerto na cirurgia ceratoplastia endotelial automatizada com desnudamento da Descemet e, portanto, pode ser eficaz e segura.
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Humanos , Endotelio Corneal/trasplante , Queratoplastia Endotelial de la Lámina Limitante Posterior/instrumentación , Queratoplastia Endotelial de la Lámina Limitante Posterior/métodos , Agujas , Colgajos Quirúrgicos , Técnicas de Sutura , Procedimientos Quirúrgicos Mínimamente Invasivos , Córnea/cirugía , Enfermedades de la Córnea/cirugía , Lámina Limitante Posterior/cirugía , Pérdida de Celulas Endoteliales de la Córnea/prevención & control , Rechazo de Injerto/prevención & controlRESUMEN
As an ideal surgical method for treating corneal endothelial decompensation, endothelial keratoplasty has been widely applied.It has many advantages, but there are also complications during graft preparation, intraoperative operation and postoperative recovery.The two common types of corneal endothelial keratoplasty, Descemet-stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty, were taken as examples in this article to introduce the treatment of complications during graft preparation, such as graft perforation and graft tear, intraoperative complications, for instance, difficulty in expanding graft and graft inversion, postoperative complications including graft detachment, high intraocular pressure, etc.The incidence of complications at different stages of endothelial keratoplasty, influencing factors and treatment methods were reviewed to provide a reference for clinicians to diagnose and treat complications of endothelial keratoplasty at various stages.
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Objective:To explore the long-term influence of donor central graft thickness (CGT) and donor graft size on corneal endothelial cell density (ECD) after Descemet stripping automated endothelial keratoplasty (DSAEK).Methods:An observational case series study was conducted.One hundred and forty-four eyes of 134 patients who underwent DSAEK in Peking University Third Hospital from January 2013 to December 2017 with at least 24-month follow-up were enrolled.Preoperative donor ECD was evaluated by specular microscopy, and ECD was determined by in vivo confocal microscopy at 1, 3, 6, 12, and 24 months postoperatively.Donor CGT was measured by anterior segment optical coherence tomography.According to the 3-month postoperative donor CGT, the subjects were divided into thinner graft group (45 eyes with CGT<100 μm), medium-thick graft group (66 eyes with CGT≥100-<150 μm) and thicker graft group (33 eyes with CGT≥150 μm). According to the donor trephination size, the subjects were divided into smaller graft group (31 eyes with trephination size≥7-<8 mm) and larger graft group (113 eyes with trephination size≥8-<9 mm). The changes of the donor CGT and corneal endothelial cell loss rate were compared at different time points after surgery.The relationships between 24-month postoperative ECD and donor ECD, donor graft size and donor CGT were analyzed.This study adhered to the Declaration of Helsinki.The study protocol was approved by the Ethics Committee of Peking University Third Hospital (No.IRB00006761-2008025). Written informed consent was obtained from each subject prior to any medical examination. Results:The donor CGT was 129.0 (90.8, 160.8), 115.5 (93.0, 146.0), 115.5 (89.0, 151.0), 112.5 (94.3, 146.8) and 114.0 (89.0, 144.5) μm at 1, 3, 6, 12 and 24 months after surgery, showing a statistically significant difference ( H=37.369, P<0.001). There was a statistically significant difference between 1-month and 3-month postoperative CGT ( P<0.001). There was no statistically significant difference in the endothelial cell loss rate among the three different donor CGT groups and between the two different donor graft size groups at any postoperative time points (all at P>0.05). Spearman correlation analysis showed that the 24-month postoperative ECD was strongly positively correlated with the preoperative donor ECD( rs=0.783, P<0.001), which was not associated with donor graft size and donor CGT ( rs=0.141, P=0.093; rs=-0.044, P=0.600). Conclusions:Larger postoperative ECD is correlated with larger preoperative ECD of donor graft.Lower long-term corneal endothelial cell loss rate after DSAEK is associated with thinner and larger diameter of donor graft.
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ABSTRACT Objective To identify preoperative clinical characteristics of patients undergoing femtosecond laser-assisted anterior lamellar keratoplasty who failed to achieve optimal postoperative visual outcomes. Methods In this single-center, retrospective case series, patients who underwent femtosecond laser-assisted anterior lamellar keratoplasty between 2013 and 2018 were included if they required graft revision, subsequent corneal procedure, or additional postoperative visits for a femtosecond laser-assisted anterior lamellar keratoplasty-related issue. Visual outcomes assessed included best-corrected visual acuities and postoperative corneal astigmatism. Results Eight eyes of eight patients meeting the above criteria were included. Mean patient age was 64.5 years (range, 21 to 89 years). Mean included preoperative best-corrected visual acuities was one logarithm of the minimum angle of resolution (range, 0.3 logarithm of the minimum angle of resolution to counting fingers). Indications for femtosecond laser-assisted anterior lamellar keratoplasty included anterior stromal scarring due to viral keratitis (two cases), bacterial keratitis (one case), chronic epithelial defect (one case), Avellino dystrophy (one case), trauma (one case), and chronic endothelial failure (two cases). Six patients had history of prior intraocular surgeries including phacoemulsification (four cases), pars plana vitrectomy (one case), endothelial keratoplasty (two cases), and trabeculectomy (one case). Mean included best-corrected visual acuities at most recent follow-up was one logarithm of the minimum angle of resolution (range zero logarithm of the minimum angle of resolution to hand movements) representing improvement or stability in six of eight patients. Visually significant corneal astigmatism was present in four of eight patients. Post-femtosecond laser-assisted anterior lamellar keratoplasty procedures included graft repositioning, arcuate keratotomy, phacoemulsification, and regraft. Conclusion While femtosecond laser-assisted anterior lamellar keratoplasty offers a less-invasive treatment option compared to penetrating keratoplasty, intraoperative and postoperative management can be complex. Femtosecond laser-assisted anterior lamellar keratoplasty in patients with history of prior endothelial keratoplasty or ongoing ocular comorbidities should be pursued with caution.
RESUMO Objetivo Identificar as características clínicas pré-operatórias de pacientes submetidos à ceratoplastia lamelar anterior assistida por laser de femtossegundo que não alcançaram resultados visuais pós-operatórios ideais. Métodos Nesta série de casos retrospectiva em um único centro, os pacientes submetidos à ceratoplastia lamelar anterior assistida por laser de femtossegundo entre 2013 e 2018 foram incluídos se precisassem de revisão do enxerto, procedimento corneano subsequente ou visitas pós-operatórias adicionais por uma intercorrência relacionada à ceratoplastia lamelar anterior assistida por laser de femtossegundo. Os resultados visuais avaliados incluíram melhor acuidade visual corrigida e astigmatismo pós-operatório da córnea. Resultados Oito olhos de oito pacientes que atenderam aos critérios descritos foram incluídos. A idade média dos pacientes foi de 64,5 anos (variação de 21 a 89). A melhor acuidade visual corrigida pré-operatória média foi de um logaritmo do mínimo ângulo de resolução (variação de 0,3 logaritmo do mínimo ângulo de resolução para contagem de dedos). As indicações para ceratoplastia lamelar anterior assistida por laser de femtossegundo incluíram cicatriz do estroma anterior devido à ceratite viral (dois casos), ceratite bacteriana (um caso), defeito epitelial crônico (um caso), distrofia de Avellino (um caso), trauma (um caso) e insuficiência endotelial crônica (dois casos). Seis pacientes tinham história de cirurgias intraoculares anteriores, incluindo facoemulsificação (quatro casos), vitrectomia via pars plana (um caso), ceratoplastia endotelial (dois casos) e trabeculectomia (um caso). O mínimo ângulo de resolução médio no acompanhamento mais recente foi de um logaritmo do mínimo ângulo de resolução (variação de zero logaritmo do mínimo ângulo de resolução para movimentos das mãos), representando melhora ou estabilidade em seis de oito pacientes. Astigmatismo corneano visualmente significativo estava presente em quatro de oito pacientes. Os procedimentos pós-ceratoplastia lamelar anterior assistida por laser de femtossegundo incluíram reposicionamento do enxerto, ceratotomia arqueada, facoemulsificação e enxerto. Conclusão Embora a ceratoplastia lamelar anterior assistida por laser de femtossegundo ofereça uma opção de tratamento menos invasiva em comparação com a ceratoplastia penetrante, o manejo intra e pós-operatório pode ser complexo. A ceratoplastia lamelar anterior assistida por laser de femtossegundo em pacientes com história de ceratoplastia endotelial anterior ou comorbidades oculares correntes deve ser avaliada com cautela.
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Humanos , Trasplante de Córnea/métodos , Córnea/cirugía , Complicaciones Posoperatorias , Refracción Ocular , Estudios Retrospectivos , Queratoplastia Penetrante , Resultado del Tratamiento , Cirugía Laser de Córnea/métodos , Terapia por Láser/métodos , Queratitis , Rayos LáserRESUMEN
Resumo Descrição de relato de caso de paciente com ceratocone (KC), Distrofia Endotelial de Fuchs (DEF) e catarata concomitantes com descompensação corneana submetido a Ceratoplastia Lamelar Posterior pela técnica Descemet's Membrane Endothelial Keratoplasty (DMEK) associado a facoemulsificação com implante de lente intraocular (LIO). Observou-se aplanamento corneano significativo no pós-operatório e acuidade visual final sem correção de 20/25 . Destaca-se a possibilidade do DMEK como alternativa à Ceratoplastia Penetrante (Penetrating Keratoplasty - PK) em casos de DEF e KC associados. Aplanamento corneano pode ocorrer neste grupo de pacientes, o que pode resultar em imprevisibilidade refracional no cálculo do poder da LIO ao se optar por facectomia combinada. Neste relato, apesar da modificação da curvatura corneana após cirurgia combinada de DMEK com facectomia, a acuidade visual final sem correção foi satisfatória, demonstrando a possibilidade de sucesso desta abordagem na coexistência de DEF, KC e Catarata. Entretanto, a possibilidade de mudança significativa na curvatura corneana deve ser considerada em pacientes com KC, edema de córnea secundário a DEF e catarata, na decisão de cirurgia simultânea ou em dois tempos.
Abstract This is a case report of a patient with concomitant Keratoconus (KC), Fuchs Endothelial Dystrophy (FED) and cataract with corneal decompensation submitted to Posterior Lamellar Corneal surgery (Descemet's Membrane Endothelial Keratoplasty - DMEK) associated with phacoemulsification with intraocular lens (IOL) implantation. Corneal flattening and uncorrected visual acuity of 20/25 was observed in the postoperative period. We reasure the viability of DMEK as an alternative to Penetrating Keratoplasty (PK) in cases of associated DEF and KC associated. Changes in corneal curvature may occur in this group of patients and lead to the possibility of refractive unpredictability in IOL calculation when performing a combined cataract surgery. Despite unexpected corneal flattening, satisfactory final visual acuity was achieved, demonstrating the possibility of success of this approach in the coexistence of the three conditions. Nonetheless, the possibility of corneal curvature changes should be considered in patients with KC and corneal decompensation due to FED in decision making, regarding simultaneous or sequential surgical approach.
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Tomografía/métodos , Distrofia Endotelial de Fuchs/cirugía , Facoemulsificación/métodos , Queratoplastia Endotelial de la Lámina Limitante Posterior/métodos , Queratocono/cirugía , Lentes IntraocularesRESUMEN
ABSTRACT Here, we describe the result of a Descemet's membrane endothelial keratoplasty for acute corneal hydrops in a 45-year-old female with keratoconus, who presented with severe visual loss in her OS. The patient's best-corrected visual acuity was 20/80 in the right eye and hand motion in the OS. Slit-lamp examination revealed an extensive tear of the Descemet's membrane and stromal corneal edema in the OS. We opted for Descemet membrane endothelial keratoplasty. Twelve months postoperatively, the patient had a best-corrected visual acuity of 20/50 in the OS.
RESUMO Trata-se de uma paciente do sexo feminino, de 45 anos, portadora de ceratocone, submetida a uma ceratoplastia endotelial com membrana Descemet após apresentar um quadro de perda de visão severa devido a uma hidrópsia corneana aguda no olho esquerdo. Inicialmente, a acuidade visual corrigida da paciente era de 20/80 no olho direito e de movimento de mãos no olho esquerdo. Após exame de biomicroscopia que detectou uma extensa rotura da membrana de Descemet e edema estromal, optamos por tratar esse caso com o ceratoplastia endotelial com membrana Descemet. Doze meses após o procedimento cirúrgico, percebeu-se uma melhora do edema corneano, não havia sinais de rejeição do botão óptico e a acuidade visual corrigida da paciente era de 20/50 no olho afetado.
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Edema Corneal , Trasplante de Córnea , Lámina Limitante Posterior , Queratoplastia Endotelial de la Lámina Limitante Posterior , Endotelio Corneal , Agudeza Visual , Edema Corneal/cirugía , Edema Corneal/etiología , Lámina Limitante Posterior/cirugía , EdemaRESUMEN
RESUMEN La queratopatía bullosa pseudoafáquica o edema corneal crónico pseudoafáquico del paciente operado por cataratas con implante de lente intraocular es un proceso en el que la córnea se edematiza y pierde su función óptica, con síntomas dolorosos e irritativos de lagrimeo, ojo rojo, probabilidad de inflamación y ulceración corneal por infección secundaria. Se observan en esta afección multicausal dos grupos de pacientes. En uno de ellos el daño estructural corneal y ocular ha sido excesivo y no existe expectativa de mejora visual. El otro grupo aún conserva la potencialidad de recuperación de la agudeza visual. En el intento de solucionar esta afección se han empleado diversos tratamientos con fundamentos diferentes y resultados acordes con el desarrollo técnico y científico en que fueron aplicados. Es propósito de esta actualización describir y adecuar las posibilidades que los oftalmólogos puedan aplicar como terapéutica en sus respectivos niveles de actuación(AU)
ABSTRACT Pseudophakic bullous keratopathy or chronic pseudophakic corneal edema in patients undergoing cataract surgery with intraocular lens implantation is a process in which the cornea edematizes and loses optical function, with painful and irritating lacrimation symptoms, red eye, probable inflammation and corneal ulceration due to secondary infection. Sufferers of this multicausal condition are divided into two groups: In one of them structural corneal and ocular damage has been extreme and no visual improvement is expected, whereas in the other visual acuity recovery is still possible. In an attempt to heal this condition various treatments have been used with different rationales and results according to the scientific and technological development of the setting where they were applied. The present update is aimed at describing and adjusting the possible therapies that ophthalmologists may use in their respective fields of activity(AU)
Asunto(s)
Humanos , Edema Corneal/etiología , Trasplante de Córnea/efectos adversos , Implantación de Lentes Intraoculares/métodosRESUMEN
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.
RESUMEN
Purpose: To study the outcomes of rebubbling for graft detachment after Descemet's stripping endothelial keratoplasty (DSEK) or Descemet's stripping automated endothelial keratoplasty (DSAEK). Methods: From 2260 eyes that underwent DSEK or DSAEK from July 2008 to June 2015, 80 eyes of 80 patients developed graft detachment and were retrospectively reviewed. Host-related, surgery-related and donor-related factors that have a bearing on graft adhesion were looked at retrospectively, and eventual outcomes after rebubbling procedure were studied. Results: Successful attachment was observed in 77 (96.25%) eyes and clear grafts were achieved in 55 (68.75%) eyes, while 25 (31.25%) eyes had graft failure. The uncorrected and best-corrected distance visual acuities significantly improved from 1 month to 3 months post-operatively and remained stable till 12 months of follow-up. Three lenticules that failed to attach with the first rebubbling procedure underwent a second rebubbling, two underwent a repeat DSEK with good outcomes and four underwent penetrating keratoplasty. On evaluating possible risk factors for graft failure, lower donor endothelial cell density was found to be a significant factor (P = 0.03). The median graft survival following rebubbling was 30 months. Conclusion: Rebubbling procedure in detached grafts after DSEK or DSAEK can reattach the lenticule in 96% of eyes in immediate post-operative period and the majority of the grafts remained clear on long-term follow-up with a median graft survival period of 2.5 years.
RESUMEN
PURPOSE: To report a patient with a pseudophakic bullous keratopathy (PBK) who underwent Descemet's membrane stripping endothelial keratoplasty (DSEK) with manual preparation of the donor corneal graft.CASE SUMMARY: A 61-year-old female presented with visual disturbance in her right eye. Five months prior, she was treated with phacoemulsification and intraocular lens exchange surgery of the right eye, and a very severe corneal edema was revealed by slit-lamp examination. We diagnosed PBK and planned DSEK with manual preparation of a donor corneal graft because of the non-availability of a microkeratome or a femtosecond laser. After making the corneal graft using an artificial anterior chamber, crescent knife and cornea dissector, the keratoplasty proceeded using the graft. Three months after surgery, her graft was well-maintained on the right eye. The patient's visual acuity was 0.3, and the corneal endothelial cell count was 1,844/mm².CONCLUSIONS: Manual preparation of the donor corneal graft for DSEK is suitable as a second choice treatment method when the availability of surgical devices is limited.