New surgical maneuver to position the graft in a descemet stripping with automated endothelial keratoplasty surgery / Nova manobra cirúrgica para posicionar o enxerto em cirurgia de ceratoplastia endotelial com desnudamento automatizado da Descemet

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.

Trigeminal neuralgia after corneal transplantation - a case report / Neuralgia do trigêmeo pós-transplante de córnea - relato de caso

ABSTRACT Description of a patient with Fuchs endothelial dystrophy submitted to a corneal transplant, performed by Descemet membrane endothelial keratoplasty, which evolved with sudden, paroxysmal pain in the frontotemporal region, postoperatively. Due to the ophthalmologic picture of the patient, the attending physician believed in possible rejection of the graft, neglecting the complaint of pain. Even after a successful second transplant, performed due to primary failure, disabling pain persisted and the physician did not manage it. After years of investigation, consulting with several specialists, it was concluded the patient presented trigeminal neuralgia that had not been treated since the surgical procedure. In addition, it led to several psychosocial consequences. Therefore, it is essential to be aware trigeminal neuralgia is a possible outcome of corneal transplantation, and its symptoms should not be neglected by the attending physician, thus contributing to better management for transplanted patients.

RESUMO Descrição do relato de caso de uma paciente com distrofia endotelial de Fuchs submetida a transplante de córnea, realizado pela técnica DMEK, que evoluiu com quadro de dor súbita, paroxística, em região frontotemporal, no pós-operatório. Devido ao quadro oftalmológico da paciente, o médico assistente acreditava em possível rejeição do enxerto, negligenciando a dor. Mesmo após sucesso do segundo transplante, realizado devido à falência primária, as dores incapacitantes persistiam, e nenhuma conduta, por parte do médico, foi realizada. Após anos de investigação, mediante consultas com diversos especialistas, concluiu-se que a paciente apresentava um quadro de neuralgia do nervo trigêmeo que não tinha sido tratada desde a realização do procedimento cirúrgico. Além disso, apresentava uma série de consequências psicossociais. Portanto, torna-se imprescindível entender que a neuralgia do nervo trigêmeo é um possível desfecho do transplante de córnea, e seus sintomas não devem ser negligenciados por parte do médico assistente, contribuindo para melhores condutas para os pacientes transplantados.

Aplanamento corneano após DMEK associado a facoemulsificação em paciente com distrofia endotelial de Fuchs, ceratocone e catarata / Corneal flattening after simultaneous DMEK and phacoemulsification in patient with Fuchs endothelial dystrophy, keratoconus and cataract combined

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.

Descemet membrane endothelial keratoplasty in multifocal pseudophakic eyes / Ceratoplastia endotelial da membrana de Descemet em olhos pseudofácicos multifocais

ABSTRACT Purpose: This report describes the use of Descemet membrane endothelial keratoplasty for the management of endothelial decompensation after multifocal intraocular lens implantation. Methods: In this retrospective study, we reviewed and assessed the surgical outcomes of 9 patients (9 eyes) who underwent Descemet membrane endothelial keratoplasty after multifocal intraocular lens implantation. Results: Corneal edema occurred due to Fuchs endothelial corneal dystrophy (n=3), pseudophakic bullous keratopathy (n=3), Descemet's membrane detachment (n=2), and toxic anterior segment syndrome (n=1). The Descemet membrane endothelial keratoplasty surgeries were uneventful in all eyes, but rebubbling procedures were necessary in 2 eyes. One month after the surgery, all the corneas were clear. After 6 months, excluding 1 eye with amblyopia, the mean distance corrected visual acuity was 0.10 logMAR, with all eyes achieving 0.18 logMAR or better. Conclusions: This is the first report of Descemet membrane endothelial keratoplasty after multifocal intraocular lens implantation, and it suggests that good results can be achieved without multifocal intraocular lens exchange.

RESUMO Objetivo: Descrever o uso da ceratoplastia endotelial da membrana de Descemet para manejar descompensação endotelial após implante de lente intraocular multifocal. Métodos: Neste estudo retrospectivo, foram revisados e avaliados os resultados cirúrgicos de 9 olhos de 9 pacientes que foram submetidos a ceratoplastia endotelial da membrana de Descemet para manejar descompensação endotelial após implante de lente intraocular multifocal. Resultados: Descompensação endotelial ocorreu por distrofia endotelial de Fuchs (n=3), ceratopatia bolhosa do pseudofácico (n=3), descolamento da membrana de Descemet (n=2) e síndrome tóxica do segmento anterior (n=1). No ato per operatório de todos os olhos não houve intercorrência, com injeção de ar sendo necessário em dois olhos no pós-operatório por descolamento parcial do enxerto. Um mês após a cirurgia, todas as córneas estavam claras. Após seis meses, excluindo um olho com ambliopia, a acuidade visual média corrigida para longe foi de 0,10 logMAR, com todos os olhos atingindo 0,18 logMAR ou melhor. Conclusões: Este é o primeiro relato de ceratoplastia endotelial da membrana de Descemet após implante de lente intraocular multifocal, sugerindo que bons resultados podem ser alcançados sem a troca da lente intraocular multifocal.

Descemet membrane endothelial keratoplasty (DMEK): intraoperative and postoperative complications and clinical results / Queratoplastia endotelial da membrana de Descemet (DMEK): complicações intraoperatórias e pós-operatórias com resultados clínicos

ABSTRACT Purpose: To evaluate the complications and clinical results of Descemet membrane endothelial keratoplasty (DMEK) in patients with endothelial failure that occurred during the learning curve of a surgeon. Methods: Fifty eyes of 50 patients with DMEK and ≥6 months of follow-up were included. The patients were divided into the first 25 (group 1) and the second 25 (group 2) procedures performed by the surgeon. Best corrected visual acuity (BCVA), central corneal thickness (CCT), unfolding time of the Descemet membrane (DM) graft, and intraoperative and postoperative complications were compared between groups. Results: The differences in postoperative increase of BCVA (p=0.595) and decrease of CCT (p=0.725) in the two groups were not significant. The unfolding time of the DM was longer in group 1 than in group 2 (p=0.001). Primary graft failure occurred in three patients in group 1 and none in group 2. At the last visit, 42 (85.7%) of patients' corneas were clear, with significant difference between groups (p=0.584). A patient in group 1 with a history of pars plana vitrectomy, inferior iridectomy, and fluid as a tamponade experienced drop of the DM graft into the iridectomy space. All other intraoperative complications occurred in group 1. Conclusions: Occurrence of intraoperative and postoperative complications was increased in patients with coexisting ocular pathology or complicated endothelial dysfunction and during the surgeon's learning curve of DM endothelial keratoplasty procedures.

RESUMO Objetivo: Avaliar as complicações e os resultados clínicos da queratoplastia endotelial da membrana de Descemet (DMEK) em indivíduos com insuficiência endotelial, durante a curva de aprendizado de um cirurgião. Métodos: Cinquenta olhos de 50 pacientes submetidos ao procedimento queratoplastia endotelial da membrana de Descemet com pelo menos 6 meses de acompanhamento foram incluídos neste estudo. Os pacientes foram divididos em dois grupos: como os primeiros 25 casos do cirurgião (grupo 1) e como os 25 casos seguintes (grupo 2). A melhor acuidade visual corrigida (MAVC), a espessura corneana central (ECC), o tempo de desdobramento do enxerto da membrana de Descemet (MD), as complicações intraoperatórias e pós-operatórias foram apresentadas e comparadas entre os grupos. Resultados: Os grupos não diferiram estatisticamente em relação ao aumento pós-operatório de melhor acuidade visual corrigida (p=0,595) ou à diminuição da espessura corneana central (p=0,725). O tempo de desdobramento dos enxertos de membrana de Descemet no grupo 1 foi maior do que no grupo 2 (p=0,001). Falha do enxerto primário foi observada em 3 pacientes do grupo 1 e em nenhum do grupo 2. Na última visita, 42 (85,7%) das córneas dos pacientes estavam claras e não foram observadas diferenças estatisticamente significativas entre os grupos (p=0,584). Na cirurgia de um paciente do grupo 1, com história de vitrectomia pars plana (PPV) com iridectomia inferior e fluido como tamponamento, observou-se queda do enxerto de membrana de Descemet no local da iridectomia. Além disso, todas as demais complicações intraoperatórias ocorreram no grupo 1. Conclusões: As complicações intraoperatórias e pós-operatórias foram maiores em pacientes com coexistência de outra patologia ocular ou com disfunção endotelial complicada durante as curvas de aprendizado dos cirurgiões no procedimento queratoplastia endotelial da membrana de Descemet.

Descemet's membrane endothelial keratoplasty with a simplified technique and low complication rate: the samba technique / Ceratoplastia endotelial da membrana de Descemet com técnica simplificada e baixa taxa de complicação: a técnica de samba

ABSTRACT Purpose: We report a simplified Descemet's membrane endothelial keratoplasty (DMEK) technique that involves safe and effective preparation and introduction, correct orientation, and easy unfolding of the donor graft inside the recipient anterior chamber. Methods: In this retrospective study, we assessed the surgical outcomes of 26 eyes of 23 consecutive patients (mean age, 61.2 ± 11.4 yr; range, 39-82 yr) with Fuchs endothelial corneal dystrophy (n=19) or bullous keratopathy (n=7) who underwent the Samba technique, a simplified DMEK method, at the Sorocaba Ophthalmology Hospital, Sorocaba Eye Bank, Sorocaba, Brazil, between August 2011 and July 2012. Results: Of the 26 operated eyes, only two (7.7%) experienced partial graft detachment requiring rebubbling, and in those eyes, the graft was reattached successfully with one air bubble. There were no cases of primary graft failure, tissue loss, or pupillary block. All patients with good visual potential achieved a best-corrected visual acuity of 20/30 or better at 6 months, and 82.6% achieved a best-corrected visual acuity of 20/30 or better 1 month postoperatively. Conclusion: In this retrospective study, the Samba technique, a simplified DMEK procedure, was safe and effective, with an acceptably low rebubbling rate and no incidence of primary graft failure or pupillary block. Moreover, rapid and nearly complete visual recovery was achieved. This simplified DMEK technique can be adopted by corneal surgeons worldwide as a primary treatment for endothelial dysfunction with a less steep learning curve and low rate of postoperative complications.

RESUMO Objetivo: Relatar uma técnica simplificada de ceratoplastia endotelial da membrana de Descemet (DMEK) que envolve a preparação e a introdução seguras e eficazes, a orientação correta e o fácil desdobramento do enxerto doador dentro da câmara anterior receptora. Métodos: Neste estudo retrospectivo, foram revisados e avaliados os resultados cirúrgicos de 26 olhos de 23 pacientes consecutivos (idade média: 61,2 ± 11,4 anos, intervalo: 39 a 82 anos) com distrofia corneana endotelial de Fuchs (n=19) ou ceratopatia bolhosa (N=7) submetidos à técnica "Samba", método de DMEK simplificado, no Hospital Oftalmológico de Sorocaba, Banco de Olhos de Sorocaba, Sorocaba, Brasil, entre agosto de 2011 e julho de 2012. Resultados: Dos 26 olhos operados, apenas 2 olhos (7,7%) apresentaram descolamento parcial do enxerto que necessitou de nova injeção de ar na câmara anterior "re-bubble", e nesses olhos o enxerto foi posicionado com sucesso com o procedimento de "re-bubble". Nenhum dos 26 olhos apresentaram falência primária do enxerto ou perda de tecido, ou bloqueio pupilar. Todos os pacientes com bom potencial visual obtiveram a acuidade visual melhor corrigida de 20/30 ou melhor e 82,6% tinham acuidade visual melhor corrigida de 20/30 ou melhor com 1 mês de cirurgia. Conclusão: Neste estudo retrospectivo, a técnica de Samba, um procedimento de DMEK simplificado, mostrou-se segura e eficaz, com uma taxa de "re-bubble" aceitavelmente baixa e nenhuma incidência de falência primária ou complicação com bloqueio pupilar. Além disso, a recuperação visual rápida e completa foi rapidamente alcançada. Esta técnica DMEK simplificada pode ser adotada por cirurgiões de córnea em todo o mundo como um tratamento primário para disfunção endotelial com uma curva de aprendizado rápida e baixa taxa de complicações pós-operatórias.

Comparison of 20% sulfur hexafluoride with air for intraocular tamponade in Descemet membrane endothelial keratoplasty (DMEK) / Comparação de hexafluoreto de enxofre a 20% com ar para tamponamento intraocular na ceratoplastia endotelial de membrana Descemet (DMEK)

ABSTRACT Purpose: To compare the effect of 20% sulfur hexafluoride (SF6) with that of air on graft detachment rates for intraocular tamponade in Descemet membrane endothelial keratoplasty (DMEK). Methods: Forty-two eyes of patients who underwent DMEK by a single surgeon (A.S.J.) at Wilmer Eye Institute between January 2012 and 2014 were identified; 21 received air for intraocular tamponade and the next consecutive 21 received SF6. The main outcome measure was the graft detachment rate; univariate and multivariate analyses were performed. Results: The graft detachment rate was 67% in the air group and 19% in the SF6 group (p<0.05). No complete graft detachments occurred, and all partial detachments underwent intervention with injection of intraocular air. The percentages of eyes with 20/25 or better vision were not different between the groups (67% vs. 71%). Univariate analysis showed significantly higher detachment rates with air tamponade (OR, 8.50; p<0.005) and larger donor graft size (OR, 14.96; p<0.05). Multivariate analysis with gas but not graft size included showed that gas was an independent statistically significant predictor of outcome (OR, 6.65; p<0.05). When graft size was included as a covariate, gas was no longer a statistically significant predictor of detachment but maintained OR of 7.81 (p=0.063) similar to the results of univariate and multivariate analyses without graft size. Conclusion: In comparison with air, graft detachment rates for intraocular tamponade in DMEK were significantly reduced by 20% SF6.

RESUMO Objetivo: Comparar as taxas de descolamento do botão endotelial com o uso de gás hexafluoreto de enxofre a 20% (SF6) em relação ao ar para o tamponamento intraocular na ceratoplastia endotelial da membrana de Descemet (DMEK). Métodos: Quarenta e dois olhos foram operados com a técnica de DMEK por um único cirurgião (A.S.J.) no Wilmer Eye Institute entre janeiro de 2012 a 2014. Os primeiros 21 olhos receberam ar para o tamponamento intraocular após o enxerto do botão endotelial e os 21 olhos seguintes receberam SF6. O desfecho primário medido foi a taxa de descolamento do botão endotelial por análise univariada e multivariada. Resultados: A taxa de descolamento do botão endotelial foi de 67% no grupo que recebeu ar vs 19% no grupo que recebeu SF6 (p<0,05). Não houve nenhum descolamento total de botão e todos os parciais foram tratados com injeção de ar intraocular. Não houve diferença estatística significativa entre os grupos em relação a AV de 20/25 ou melhor (67% vs 71%). A análise univariada demonstrou maior taxa de descolamento com o tamponamento por ar intraocular (OR 8,50, p<0,005) e com botões doadores maiores (OR 14,96, p<0,05). Na análise multivariada, incluindo gás, mas não o tamanho do botão doador, o tipo de gás usado permaneceu sendo um fator preditivo independente e estatisticamente significativo para o desfecho primário, com OR de 6,65 (p<0,05). Porém, quando o tamanho do botão doador foi incluso como covariável, o gás perdeu a sua significância como preditor de descolamento, mantendo o OR de 7,81 (p=0,063), semelhante as análises univariada e multivariada excluindo o tamanho do botão doador. Conclusão: O uso de gás hexafluoreto de enxofre a 20% (SF6) para o tamponamento intraocular reduz a taxa de descolamento do botão endotelial quando comparado ao uso de ar no DMEK.

LASIK hipermetrópico pós-DSAEK (Descement Stripping Automated Endotelial Keratoplasty) / LASIK for hyperopia correction pos DSAEK(Descement Stripping Automated Endotelial Keratoplasty)

RESUMO O DSAEK (Descemet stripping automated endotelial Keratoplasty) é um dos procedimentos de escolha para tratamento das doenças que acometem o endotélio corneano. Apesar do sucesso terapêutico, o procedimento pode induzir uma hipermetropia residual. Em média a refração se estabiliza em um perído que varia de 6 a 12 meses após o transplante. O objetivo desse relato é descrever a evolução dessa opção terapêutica utilizada em um paciente de 54 anos portador de Distrofia de Fuchs. O paciente foi submetido ao transplante de córnea (DSAEK) e a remoção do cristalino no mesmo tempo cirúrgico o que resultou em hipermetropia residual. Após 3 anos de acompanhamento apresentava-se com a melhor visão corrigida de 20/20 (Snellen) no olho operado com uma refração de +3,25 -1,00 (5º). Optou-se por realização de LASIK (Laser assisted in situ Keratomileusis) hipermetrópico, obtendo um resultado visual satisfatório.

ABSTRACT DSAEK (Descemet stripping automated endothelial keratoplasty) is one of the options for corneal endothelium disease, which in some patients can result in a residual hyperopia after the procedure. Usually 6 to 12 months after corneal transplantation refraction is already stable. This report describes a therapeutic option used in a 54 years old patient with Fuchs' endothelial dystrophy submitted to cataract and corneal transplant that resulted in residual hyperopia, three years after the procedure the best corrected vision was 20/20 with a refraction of +3.25 -1.00 (5 º) treated with Hyperopic - LASIK (Laser-assisted In Situ Keratomileusis) with satisfactory visual result.

Comparison of Long-term Clinical Outcomes between Descemet's Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty in Patients with Bullous Keratopathy

PURPOSE: To compare 2-year clinical outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) in patients with bullous keratopathy. METHODS: A retrospective chart review was performed to obtain 2 years of follow-up data of DSAEK or PK at a single center from March 2009 to September 2012. The study comprised 15 eyes of DSAEK and 11 eyes of PK. Outcome measures included best-corrected visual acuity (BCVA), spherical and keratometric changes, central corneal thickness, endothelial cell density, intraocular pressure, and postoperative complications. Graft survival rate was assessed by Kaplan-Meier survival analysis. RESULTS: There were no differences in patient baseline characteristics between the two groups. At postoperative 2 years, better BCVA of 0.69 ± 0.51 logarithm of the minimum angle of resolution (logMAR) was found after DSAEK compared to 0.88 ± 0.48 logMAR after PK. Refractive cylinder in DSAEK and PK was −2.60 ± 1.53 and −6.00 ± 1.05 diopters (D), respectively, and keratometric cylinder was 3.27 ± 3.70 and 6.34 ± 3.51 D, respectively, at postoperative 2 years. The difference of mean spherical equivalents between postoperative 1 month and 2 years was 0.84 D after DSAEK and 2.05 D after PK. A hyperopic shift of 1.17 D was present after 2 years of DSAEK. The mean endothelial cell density at postoperative 2 years was 1,548 ± 456 cells/mm² for DSAEK and 1,052 ± 567 cells/mm² for PK, with a cell loss of 19.96% vs. 52.38%, respectively when compared to postoperative 1 month. No significant difference in central corneal thickness was found between DSAEK and PK (592 ± 75 vs. 563 ± 90 µm, respectively). Finally, the 2-year survival rate did not differ significantly between DSAEK and PK (93.3% vs. 81.8%, respectively, p = 0.344). CONCLUSIONS: Compared to PK, DSAEK provided more stable refractive errors with better visual outcome, lower endothelial cell loss, and a lower rate of graft rejection at postoperative 2 years in patients with bullous keratopathy.

Hipertensión ocular secundaria a endoqueratoplastia / Ocular hypertension secondary to endokeratoplasty

La queratoplastia endotelial no está exenta de complicaciones y hasta el momento ha demostrado ser un tratamiento efectivo para la disfunción endotelial. Se presenta una paciente femenina, blanca, de 76 años de edad, con antecedente patológico personal de hipertensión arterial controlada. Se le realizó queratoplastia endotelial con pelado de la descemet asistida con láser de excímero. Se obtuvo buena transparencia corneal y recuperación visual en ojo derecho. Al mes siguiente acudió a consulta y refirió dolor ocular intenso. En el examen oftalmológico presentaba edema palpebral, inyección cilioconjuntival, edema corneal ligero, cámara anterior muy estrecha y contacto iridocorneal en periferia temporal con cifras de presión ocular aumentada.

Endothelial keratoplasty is not complication-free and it has so far proved to be an effective treatment for endothelial dysfunction. This is a Caucasian female patient aged 76 years, who has personal pathological history of controlled blood hypertension. She underwent Descemet stripping with Excimer laser endothelial keratoplasty. Good corneal transparency and visual recovery in her right eye were achieved after surgery. One month later, she went to the ophthalmologist´s again and complained about intense ocular pain. The eye examination yielded palpebral edema, cilioconjunctival injection, mild corneal edema, very narrow anterior chamber, iridocorneal contact in temporal periphery and high ocular pressure figures.

In vivo ultrathin Descemet stripping automated endothelial keratoplasty with a low-energy and high-frequency femtosecond laser / In vivo Descemet stripping automated endothelial keratoplasty ultrafina com laser de femtosegundo de baixa energia e alta frequência

This case report describes the production of an ultrathin endothelial donor corneal lamella using a femtosecond laser with low energy and a high frequency. In addition, we report its use in vivo in an eye with pseudophakic bullous keratopathy. The outcomes were observed 3 months after surgery in terms of the change in endothelial donor lamella and full cornea thickness (including pachymetric mapping), visual acuity, and endothelial cell count.

Este relato de caso mostra a confecção de uma lamela corneana doadora endotelial ultrafina com o uso de um laser de femtosegundo de baixa energia e alta taxa de repetição, e sua utilização in vivo em um paciente com ceratopatia bolhosa do pseudofácico. O resultado final foi observado quanto a evolução da espessura da lamela endotelial doadora e de toda a córnea (incluindo mapa paquimétrico), da acuidade visual, e da contagem endotelial ao final de 3 meses de pós-operatório.

Effects of a Novel Push-through Technique Using the Implantable Collamer Lens Injector System for Graft Delivery during Endothelial Keratoplasty

PURPOSE: To investigate effects of a new push-through insertion method for donor lenticules using an injector system on endothelial viability ex vivo and in a clinical case series of endothelial keratoplasty. METHODS: An ex vivo delivery model was used with porcine corneoscleral rims. We compared the endothelial viability in a new push-through insertion method using the Visian Implantable Collamer Lens (ICL) injector versus that of standard forceps-assisted insertion for lenticule delivery. Twenty porcine corneal lenticules were divided into four groups by insertion method and wound size. Vital dye staining was performed and devitalized areas were semi-quantitatively assessed by digital imaging. In the clinical case series, Descemet's stripping endothelial keratoplasty (DSEK) using the push-through method was performed in seven patients and endothelial outcome was determined six months postoperatively. RESULTS: Mean devitalized areas for the push-through method were significantly lower than for forceps-assisted insertion through 3.2 mm incision (23.99 +/- 2.17% vs. 50.48 +/- 5.07%, p = 0.009) in the ex vivo model. Average endothelial cell counts of donor tissues of patients who underwent DSEK were 26.4% lower six months postoperatively. CONCLUSIONS: Push-through delivery of donor lenticules using the Visian ICL injector system appears to be less harmful to endothelial cells than conventional forceps-assisted delivery.

Effects of a Novel Push-through Technique Using the Implantable Collamer Lens Injector System for Graft Delivery during Endothelial Keratoplasty

PURPOSE: To investigate effects of a new push-through insertion method for donor lenticules using an injector system on endothelial viability ex vivo and in a clinical case series of endothelial keratoplasty. METHODS: An ex vivo delivery model was used with porcine corneoscleral rims. We compared the endothelial viability in a new push-through insertion method using the Visian Implantable Collamer Lens (ICL) injector versus that of standard forceps-assisted insertion for lenticule delivery. Twenty porcine corneal lenticules were divided into four groups by insertion method and wound size. Vital dye staining was performed and devitalized areas were semi-quantitatively assessed by digital imaging. In the clinical case series, Descemet's stripping endothelial keratoplasty (DSEK) using the push-through method was performed in seven patients and endothelial outcome was determined six months postoperatively. RESULTS: Mean devitalized areas for the push-through method were significantly lower than for forceps-assisted insertion through 3.2 mm incision (23.99 +/- 2.17% vs. 50.48 +/- 5.07%, p = 0.009) in the ex vivo model. Average endothelial cell counts of donor tissues of patients who underwent DSEK were 26.4% lower six months postoperatively. CONCLUSIONS: Push-through delivery of donor lenticules using the Visian ICL injector system appears to be less harmful to endothelial cells than conventional forceps-assisted delivery.

Endothelial keratoplasty: evolution and horizons / Transplante endotelial de córnea: evolução e horizontes

Endothelial keratoplasty has been adopted by corneal surgeons worldwide as an alternative to penetrating keratoplasty (PK) in the treatment of corneal endothelial disorders. Since the first surgeries in 1998, different surgical techniques have been used to replace the diseased endothelium. Compared with penetrating keratoplasty, all these techniques may provide faster and better visual rehabilitation with minimal change in refractive power of the transplanted cornea, minimal induced astigmatism, elimination of suture-induced complications and late wound dehiscence, and a reduced demand for postoperative care. Translational research involving cell-based therapy is the next step in work on endothelial keratoplasty. The present review updates information on comparisons among different techniques and predicts the direction of future treatment.

O transplante endotelial tem sido utilizado por cirurgiões de córnea em todo o mundo como uma alternativa ao transplante penetrante no tratamento das desordens do endotélio corneano. Desde as primeiras cirurgias em 1998, diferentes técnicas cirúrgicas tem sido utilizadas para substituir o endotélio doente. Comparadas ao transplante penetrante, estas técnicas oferecem uma reabilitação visual melhor e mais rápida com mínima alteração do poder refrativo da córnea transplantada, mínimo astigmatismo induzido, eliminação das complicações induzidas pela sutura e deiscência tardia da incisão, além de menor necessidade de cuidados pós-operatórios. Pesquisas translacionais envolvendo terapias celulares são o próximo passo em transplantes endoteliais. Este artigo contém uma fonte de dados atualizada comparando diferentes técnicas e futuros tratamentos.

Descemet membrane endothelial keratoplasty with a stromal rim in the treatment of posterior polymorphous corneal dystrophy.

A 20-year-old patient, diagnosed with posterior polymorphous corneal dystrophy, developed corneal edema for which he underwent Descemet membrane endothelial keratoplasty with a stromal rim (DMEK-S) in the right eye. No intra- or postoperative complications were noted. At the last follow-up 2 years and 9 months after the procedure, the best corrected visual acuity was 1.0 and endothelial cell density declined from 3533 cells/mm2 to 1012 cells/mm2. Despite the endothelial cell loss, DMEK-S appears to be a good alternative to other surgical techniques for the treatment of corneal endotheliopathies, and it may be of benefit to young patients.

Ceratoplastia endotelial com desnudamento da Descemet(DSEK) utilizando o dispositivo TAN EndoGlideTM: série de casos / Endothelial keratoplasty: Descemet stripping (DSEK) using TAN EndoGlideTM device: case series

OBJETIVO: Relatar os resultados da ceratoplastia endotelial com desnudamento da Descemet (DSEK) utilizando o dispositivo TAN EndoGlideTM para facilitar a introdução da membrana endotelial. MÉTODOS: Série de casos consecutivos, prospectiva. Foram incluídos 9 pacientes com edema corneano secundário à disfunção endotelial. Melhor acuidade visual corrigida, refração, astigmatismo ceratométrico, espessura corneana central, densidade das células endoteliais e complicações foram analisadas após seguimento de seis meses. RESULTADOS: Houve melhora do edema de córnea e da visão em 7 pacientes (77,78 por cento). A melhor acuidade visual corrigida ficou entre 20/40 e 20/200. A densidade endotelial média após 6 meses variou entre 1.305 céls/mm² e 2.346 céls/mm² com média de perda de 33,14 por cento. Desprendimento de parte do enxerto ocorreu em 1 olho (11,11 por cento), falência primária do transplante endotelial em 2 olhos (22,22 por cento). CONCLUSÃO: O dispositivo TAN EndoGlideTM facilita a introdução do enxerto na ceratoplastia endotelial com desnudamento da Descemet.

PURPOSE: To report the results of Descemet stripping endothelial keratoplasty (DSEK) using the TAN EndoGlideTM device to facilitate the insertion of the endothelial membrane. METHODS: Prospective clinical study that included nine patients presenting corneal edema secondary to endothelial dysfunction. Best corrected visual acuity, refraction, central corneal thickness, endothelial cell density and complications were analyzed after a six-month follow-up. RESULTS: There was a significant improvement in the corneal edema and visual acuity in 7 patients (77.78 percent). The best corrected visual acuity ranged between 20/40 and 20/200. The average density of endothelial cells in six months varied between 1,305 cells/mm² and 2,346 cells/mm² with an average loss of 33.14 percent cells. Detachment of part of the graft was observed in one eye (11.11 percent) and primary failure of the endothelial transplantation occurred in 2 eyes (22.22 percent). CONCLUSION: The device TAN EndoGlideTM facilitates the introduction of the graft in Descemet stripping endothelial keratoplasty.

One cornea for two patients: case report / Uma córnea para dois pacientes: relato de caso

Case reporting the use of one donor cornea for two transplantation procedures: deep anterior lamellar keratoplasty (DALK) in a case of an imminent corneal perforation caused by herpetic stromal necrosis, and Descemet stripping with endothelial keratoplasty (DSEK) in an eye with pseudophakic bullous keratopathy (PBK). Descemet's membrane (DM), denuded by stromal necrosis, served as the starting point for dissection plane and creation of the recipient bed for DALK. The next steps were excision of the diseased stroma along the edge of trephination, and transplantation of a 400-450 µm thick, manually dissected lamellar graft. The remaining posterior layers of the donor cornea, 100-150 µm thick, were used as a graft in the DSEK procedure for PBK. The integrity of the globe was saved, and best-corrected visual acuity (BCVA) of 20/40 was reached after DALK in the eye with an imminent corneal perforation. A subnormal central corneal thickness (CCT) of 430 µm did not interfere with corneal shape (43.50 x 45.50 D) and function. The graft remained attached and clear after DSEK in the eye with PBK, with BCVA of 20/30 and a CCT of 653 µm. One donor cornea can be used for two lamellar keratoplasties, DALK and DSEK. Although the described obstacles may prevent this approach from becoming widely used, it may prove useful when one is confronted with a need for an urgent anterior lamellar keratoplasty, a long list of cases for DSEK, and a shortage of donor corneas.

Relato de caso descrevendo o uso de uma córnea doadora para dois procedimentos de transplante: ceratoplastia anterior lamelar profunda (DALK) no caso de uma perfuração corneal iminente causada por necrose estromal por herpes vírus, e ceratoplastia com transplante de endotélio (DSEK) no olho com ceratopatia bolhosa em pseudofacia (PBK). A membrana de Descemet (DM), previamente desnudada pela necrose estromal, serviu como ponto de partida para o plano de dissecção e da criação do leito estromal para DALK. Os passos seguintes foram a excisão do estroma acometido até a borda da trepanação, transplante de um botão doador de aproximadamente 400-450 µm de espessura manualmente dissecado. As camadas posteriores restantes da córnea doadora, com a espessura de 100-150 µm, foram utilizadas para o procedimento DSEK no olho com PBK. A integridade do globo ocular foi mantida, e a acuidade visual melhor corrigida (BCVA) de 20/40 foi alcançada após DALK no olho com a perfuração corneal iminente. A espessura corneal central (CCT) de 430 µm abaixo da normal não interferiu com a curvatura anterior da córnea (43,50 x 45,50 D), nem com a sua função. O transplante de endotélio manteve-se tópico e transparente após DSEK no olho com a PBK, com uma BCVA de 20/30 e CCT de 653 µm. Uma córnea doadora pode ser utilizada para duas ceratoplastias lamelares, DALK e DSEK. Apesar de, devido os obstáculos descritos, pode não ser recomendada para o uso cotidiano, esta abordagem mostra-se útil nos casos da necessidade de uma ceratoplastia lamelar anterior de urgência, a longa lista para DESK e a falta de córneas doadoras.

A Comparison of Posterior Lamellar Keratoplasty Modalities: DLEK vs. DSEK

PURPOSE: To compare clinical outcomes after deep lamellar endothelial keratoplasty (DLEK) with Descemet stripping endothelial keratoplasty (DSEK) performed as initial cases by a single surgeon. METHODS: Sixteen patients with corneal endothelial were enrolled. Eight patients (8 eyes) underwent DLEK and 8 patients (8 eyes) DSEK. We measured uncorrected visual acuity, best corrected visual acuity (BCVA), manifest refraction, corneal endothelial count, interface opacity via Schiempflug imaging, and contrast sensitivity, as well as tracked postoperative complications over the first postoperative year. RESULTS: Primary graft failure occurred in two DLEK cases and one DSEK case, all of which were excluded for further analysis. The average 12-month postoperative BCVA was 20/70 in the DLEK group and 20/50 in the DSEK group, with the difference not statistically significant. No significant differences were identified between the 2 groups in terms of mean spherical equivalent and refractive astigmatism, although individuals in the DSEK group tended toward hyperopia. The average endothelial cell count at postoperative month 12 was 1849+/-494 in the DLEK group and 1643+/-417 cells/mm2 in the DSEK group, representing cell losses of 26.2% and 31.9%, respectively. No significant differences in endothelial cell count or endothelial cell loss were observed between groups. Early postoperative donor disc dislocation occurred in two eyes after DLEK and one eye after DSEK. Interface opacities and contrast sensitivities were similarly not significantly different between groups. CONCLUSIONS: No significant differences in any assessed clinical outcome were observed between individuals undergoing DLEK and DSEK, when performed as initial cases by a single surgeon.