Descemet Stripping Automated Endothelial Keratoplasty for Bullous Keratopathy With an Irregular Posterior Surface

Descemet Membrane Endothelial Keratoplasty in Corneal Endothelial Decompensation After a Forceps-Induced Corneal Birth Injury: Case Series and Technique

PURPOSE

The aim of this study was to describe the efficacy of Descemet membrane endothelial keratoplasty (DMEK) in patients with corneal endothelial decompensation secondary to a forceps-induced corneal birth injury.

METHODS

This was a retrospective, noncomparative, interventional case series. Four eyes of 4 patients (1 female and 3 males; mean age, 64.0 ± 4.7 years) with corneal endothelial decompensation due to forceps-induced corneal birth injury were included. DMEK was performed in all cases, using a combined technique, including the use of intraoperative optical coherence tomography, vital staining of Descemet membrane of both host and donor, removal of scarred Descemet membrane with side-port forceps and vitreous cutter to smoothen the posterior corneal surface, epithelial peeling, and illumination for visualization. The examination included preoperative and postoperative ophthalmologic examinations: best-corrected visual acuity (converted to logarithm of the minimum angle of resolution [logMAR]), intraocular pressure, endothelial cell density (ECD), and central corneal thickness.

RESULTS

No postoperative complications were noted, and corneal transparency was maintained during follow-up (mean follow-up period, 32.0 ± 27.0 months; range, 3-71 months). The mean best-corrected visual acuity was 0.52 ± 0.35 logMAR preoperatively and 0.15 ± 0.09 logMAR at the last visit. The mean postoperative ECD was 1632 ± 631 cells/mm 2 (mean ECD at baseline, 3167 cells/mm 2 ). Central corneal thickness decreased from 640 ± 67 μm preoperatively to 576 ± 58 μm postoperatively.

CONCLUSIONS

This study suggests that DMEK can be performed uneventfully in eyes with a forceps-induced corneal birth injury. The combination of surgical techniques may be an effective approach for DMEK.

A Comparison of the Corneal Thickness Following Descemet's Stripping Automated Endothelial Keratoplasty and Descemet's Membrane Endothelial Keratoplasty

PURPOSE

To compare the central corneal thickness before and after Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK), and to evaluate the recipient corneal thickness following DSAEK.

METHODS

The corneal thickness was compared between two groups of eyes following DMEK and DSAEK, performed by a single surgeon between 2015 and 2017. We evaluated the recipient corneal thickness and central corneal thickness pre- and postoperatively at 1, 3, and 6 months using anterior segment optical coherence tomography. Recipient corneal thickness was defined as the corneal thickness without graft thickness.

RESULTS

We included DMEK and DSAEK eyes (n = 26 each), which were similar in terms of their etiologies. Preoperatively, there was no significant difference in the central corneal thickness between the groups (DSAEK, median [interquartile range]: 721 [606.5 to 847.8] µm; and DMEK: 690 [618 to 722.3] µm; p = 0.30). Despite the tendency of the central corneal thickness to be significantly greater (p < .01) at 6 months following DSAEK (619.5 [607.8 to 661.3] µm) compared with that following DMEK (497.5 [475.8 to 525.3] µm), there was no significant difference at 6 months between the recipient corneal thickness following DSAEK (488.5 [443.8 to 515] µm) and central corneal thickness following DMEK (p = 0.54).

CONCLUSIONS

DSAEK eyes display a similar tendency of stromal thinning as DMEK eyes.

Corneal higher-order aberrations in corneal endothelial decompensation secondary to obstetric forceps injury

Forceps corneal injuries during infant delivery cause Descemet membrane (DM) breaks, that cause corneal astigmatism and corneal endothelial decompensation. The aim of this study is to characterise corneal higher-order aberrations (HOAs) and corneal topographic patterns in corneal endothelial decompensation due to obstetric forceps injury. This retrospective study included 23 eyes of 21 patients (54.0 ± 9.0 years old) with forceps corneal injury, and 18 healthy controls. HOAs and coma aberrations were significantly larger in forceps injury (1.05 [0.76-1.98] μm, and 0.83 [0.58-1.69], respectively) than in healthy controls (0.10 [0.08-0.11], and 0.06 [0.05-0.07], respectively, both P < 0.0001). Patient visual acuity was positively correlated with coma aberration (r_s = 0.482, P = 0.023). The most common topographic patterns were those of protrusion and regular astigmatism (both, six eyes, 26.1%), followed by asymmetric (five eyes, 21.7%), and flattening (four eyes, 17.4%). These results indicate that increased corneal HOAs are associated with decreased visual acuity in corneal endothelial decompensation with DM breaks and corneal topography exhibits various patterns in forceps injury.

Regular and irregular astigmatism of bullous keratopathy using Fourier harmonic analysis with anterior segment optical coherence tomography

Bullous keratopathy (BK) is known to present with corneal edema and Descemet's folds, which can cause corneal astigmatism. However, no report quantitatively evaluated BK astigmatism by separating it into regular and irregular astigmatism. This study investigated the regular and irregular astigmatism of the anterior and posterior corneal surface with Fourier harmonic analysis and anterior segment optical coherence tomography. Preoperative data from 43 eyes of 41 BK patients who received corneal endothelial transplantation were compared with the data from 43 eyes of 43 subjects without corneal disease. Anterior and posterior cylinder power, central corneal thickness (CCT) and thinnest corneal thickness were significantly greater in BK. With Fourier harmonic analysis, BK eyes were found to have significantly larger anterior and posterior regular astigmatism, asymmetry component and higher-order irregularity. Asymmetry component and higher-order irregularity that accounted for the posterior irregular astigmatism increased as CCT increased in BK. Higher-order irregularity in the posterior cornea also positively correlated with worsening best corrected visual acuity. Subgroup analysis found significant correlations between CCT and posterior higher-order irregularity for intraocular surgery and laser iridotomy, but not Fuchs endothelial corneal dystrophy. This study has significance in that it revealed the characteristics of the corneal posterior irregular astigmatism of BK.

Obstetrical forceps-induced Descemet membrane tears

Obstetrical forceps-induced Descemet membrane tears (FIDMT) are usually encountered during complicated forceps-assisted deliveries. The condition may lead to significant visual debilitation in young children and is frequently ignored due to its low incidence. Undue stretch on the Descemet's membrane during the process of forceps-assisted delivery results in their vertical/oblique tear (s), which usually leads to corneal edema in early neonatal life. On its resolution, these residual tears result in visually disabling astigmatism that can lead to dense and recalcitrant amblyopia. Slit-lamp examination, anterior segment optical coherence tomography, specular microscopy, confocal microscopy, and corneal topography and tomography can be employed for its accurate diagnosis. While these can be prevented by improved perinatal care, once diagnosed, they mandate prompt refractive correction and amblyopia therapy to prevent disabling visual deterioration in affected children. In adulthood, medical and surgical management may be planned for symptomatic patients based on coexistent amblyopia as this is the major factor guiding visual prognosis. There is limited comprehensive literature in this regard, and the present review discusses the pathogenesis, clinical features, and recent developments in investigations, management, and outcomes of FIDMT during the last three decades.

Repeat Descemet Membrane Endothelial Keratoplasty for Failed Primary Descemet Membrane Endothelial Keratoplasty at a Referral Center for Keratoplasty in Spain: DIMOEK Study

PURPOSE

To analyze the clinical results of repeat Descemet membrane endothelial keratoplasty (re-DMEK) for failed primary DMEK graft at a referral center for keratoplasty in Spain.

DESIGN

Retrospective, interventional, comparative case series.

METHODS

From a single-center, single-surgeon series of 189 consecutive DMEK surgeries, 14 (7.41%) were re-DMEK eyes. The primary outcome was best-corrected visual acuity change (ΔBCVA, logarithm of minimal angle of resolution [logMAR]) from baseline (before first DMEK) to last follow-up. Secondary outcomes were ΔBCVA from baseline at 3, 6, and 12 months postoperatively, endothelial cell loss (%ECL), rebubbling rate, and re-DMEK graft failure. Outcomes were compared with an age-matched control group of 18 successful primary DMEK eyes.

RESULTS

After re-DMEK (median follow-up time 14.5 [42.5] months), mean BCVA improved from 0.55 (0.42) logMAR (Snellen 20/71 [20/53]) at baseline to 0.09 (0.26) logMAR (Snellen 20/25 [20/36]; P = .037). ΔBCVA from baseline was statistically significant at months 3 (P = .028), 6 (P = .023), and 12 (P = .012), and ΔBCVA was significant observed between months 6 and 12 (P = .028). BCVA differences between patient groups were statistically nonsignificant at 3 (P = .397), 6 (P = .468), and 12 months (P = .647). Mean %ECL in re-DMEK eyes with follow-up ≥12 months was 48.2 (15.1%), and the rebubbling rate was 28.6%; differences between groups were statistically nonsignificant for both variables (P = .580 and P = .669, respectively). Three re-DMEK eyes developed graft failure, all achieving final BCVA ≤0.30 logMAR (Snellen ≥20/40) after tertiary keratoplasty.

CONCLUSIONS

Repeat DMEK produces significant, continuous visual improvement after failed primary DMEK. Although visual outcomes and %ECL were comparable to primary DMEK, there was a relatively high rate of graft failure after re-DMEK.

Descemet membrane endothelial keratoplasty for endothelial decompensation after previous radial keratotomy

Purpose

To report Descemet membrane endothelial keratoplasty (DMEK) for endothelial decompensation in an eye with previous radial keratotomy.

Observations

A history of radial keratotomy may hasten endothelial dysfunction. Previously reported surgical treatments include penetrating kerotoplasty and Descemet stripping automated endothelial keratoplasty.

Conclusions and Importance

DMEK may be successfully used in post-RK eyes with good recovery of visual acuity and patient satisfaction.

Evaluation of Anterior and Posterior Corneal Irregularity After Descemet Membrane Endothelial Keratoplasty

PURPOSE

To investigate the changes in anterior and posterior corneal irregularity after Descemet membrane endothelial keratoplasty (DMEK).

METHODS

This retrospective study included 27 eyes of 23 patients who underwent DMEK and 27 eyes of age-matched healthy controls. Corneal irregularity indexes, surface regularity of height (SR_H), and higher-order aberrations were evaluated in 4- and 6-mm diameters of the cornea, preoperatively and postoperatively, using anterior segment optical coherence tomography.

RESULTS

The best spectacle-corrected visual acuity (logarithm of the minimum angle of resolution) improved from 1.01 ± 0.54 preoperatively to 0.08 ± 0.11 at 6 months postoperatively. Anterior SR_H was significantly lower at 6 months postoperatively [from 1.86 ± 0.73 to 1.20 ± 0.34 (P < 0.01) (4-mm) and from 2.29 ± 0.62 to 1.64 ± 0.42 (P < 0.01) (6-mm)]. Posterior SR_H showed a significant decrease from 6.87 ± 4.19 to 2.18 ± 0.51 (4-mm) and from 5.21 ± 2.60 to 2.44 ± 0.38 (6-mm) at 6 months postoperatively (P < 0.001). The SR_H was positively correlated with best spectacle-corrected visual acuity (anterior 4 mm: R = 0.524; anterior 6 mm: R = 0.477; posterior 4 mm: R = 0.655; posterior 6 mm: R = 0.655, P < 0.001) and with higher-order aberrations for 4-mm and 6-mm diameters (R = 0.511 and R = 0.325, P < 0.001, respectively).

CONCLUSIONS

The SR_H reflects corneal irregularity and is correlated with the visual outcome after DMEK, which may be very helpful to corneal surgeons as an index indicating the severity before DMEK, and the quality of visual function after DMEK.

Case series and techniques of Descemet's Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury

BACKGROUND

To evaluate clinical outcomes of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for severe bullous keratopathy that develop as a late complication of endothelial injury to the baby during forceps delivery at birth.

CASE PRESENTATIONS

Four eyes (four patients; mean age, 51.5 years) with severe bullous keratopathy as a late complication of forceps delivery at birth were enrolled. All patients had amblyopia from childhood due to cloudy cornea. Nontheless, DSAEK was indicated in these patients for the irritation and severe light sensation caused by apparent bullous change of the injured cornea. All patients underwent DSAEK and two patients had simultaneous cataract surgery. Intraoperative and postoperative complications were recorded. Postoperative donor endothelial-cell densities (ECDs) were measured prospectively at six and 12 months and compared with preoperative values. Best corrected visual acuity (BCVA) was measured at 6 and 12 months postoperatively. All cases required corneal epithelial removal; two cases with simultaneous cataract surgeries required lens anterior capsule staining by trypan blue and illumination of the cornea for visualization. There were no cases of graft dislocation or primary graft failure. Mean BCVA improved from 0.06 to 0.15 at 6 months and to 0.38 at 12 months. Postoperative ECD was 2270 cells/mm(2) (mean loss, 24.4 %) at 6 months and 2130 (mean loss, 29.1 %) at 12 months. Postoperative intraocular pressure elevation was observed in two cases, and a rejection episode occurred in one case at 4 months postoperatively.

CONCLUSIONS

In this case series, the clinical outcome of DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance, which was comparable to uncomplicated cases. Cataract and DSAEK surgery was safely performed using techniques including epithelial removal, lens anterior capsule staining and illuminating the cornea, which enabled better visualization of the anterior chamber.

Effects of corneal irregular astigmatism on visual acuity after conventional and femtosecond laser-assisted Descemet's stripping automated endothelial keratoplasty

PURPOSE

To compare short-term outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using a graft prepared with either a femtosecond laser or a microkeratome.

METHODS

Thirty-eight patients underwent DSAEK with grafts prepared with either a femtosecond laser (f-DSAEK; 21 eyes) or a microkeratome (m-DSAEK; 17 eyes). Visual acuity, endothelial cell density, regular astigmatism and irregular astigmatism were compared between the two groups preoperatively and at 1, 3, and 6 months post-operatively. Fourier analysis was conducted to calculate astigmatism of the anterior and posterior surfaces, and total cornea, using anterior segment optical coherence tomography (AS-OCT).

RESULTS

Visual acuity (logMAR) improved from 1.20 ± 0.60 to 0.43 ± 0.25 after m-DSAEK (P < 0.001) and from 1.20 ± 0.57 to 0.77 ± 0.33 after f-DSAEK (P = 0.0028) at 6 months following DSAEK. Visual acuity after m-DSAEK was significantly better than after f-DSAEK at 1, 3, and 6 months (P < 0.05). AS-OCT corneal images revealed greater irregularities on the posterior surfaces of f-DSAEK grafts compared to m-DSAEK grafts. Irregular astigmatism of the total cornea and the posterior surface was significantly larger after f-DSAEK than after m-DSAEK, although there was no significant difference in irregular astigmatism of the anterior surface at 6 months. Postoperative visual acuity was significantly correlated with the postoperative irregular astigmatism of the total cornea (r = 0.6657 and P < 0.001) and the anterior (r = 0.416, P = 0.016) and posterior surfaces (r = 0.7046, P < 0.001).

CONCLUSIONS

Visual outcomes after f-DSAEK were poor compared to conventional m-DSAEK due to an increase in irregular astigmatism caused by posterior surface irregularities.

Anterior-segment optical coherence tomography investigation of corneal deturgescence and epithelial remodeling after DSAEK

PURPOSE

The aim of this study was to evaluate via Fourier-domain anterior-segment optical coherence tomography 3-dimensional corneal, epithelial, and graft thickness changes after Descemet stripping automated endothelial keratoplasty (DSAEK).

METHODS

Sixteen eyes were investigated preoperatively and up to 6 months postoperatively for preoperative and postoperative central corneal thickness (CCT), minimum corneal thickness, central graft thickness (CGT), and for epithelial topographic thickness variability. An age-matched and gender-matched control group of 32 healthy eyes was used for comparison.

RESULTS

In the DSAEK group, the preoperative CCT was 582.32 ± 45.24 (550-615) μm. One-month postoperatively, the CCT was 736.26 ± 34.52 (713-771) μm, and the CGT was 210.42 ± 34.52 (145-243) μm. Three months postoperatively, the CCT was 641.39 ± 38.75 (569-684) μm, and the CGT was 171.23 ± 27.54 (119-185) μm. The preoperative center epithelial thickness was 55.74 ± 9.29 (45-74) μm, the minimum was 32.53 ± 14.30 (13-53) μm, the maximum was 76.00 ± 11.32 (64-105) μm, and the topographic thickness variability was 10.84 ± 4.09 (5.90-18.80) μm. Three months postoperatively, the center epithelial thickness was 47.21 ± 5.45 (43-56) μm, the minimum was 35.11 ± 4.70 (30-41) μm, the maximum was 58.11 ± 6.51 (49-65) μm, and the topographic variability was 4.77 ± 1.48 (2.90-6.50) μm. The average differences were -8.53, +4.53, and -17.89 μm for the center, minimum, and maximum (P < 0.001, <0.001, and <0.001). Similar results were obtained 3 and 6 months postoperatively.

CONCLUSIONS

We present a near-term postoperative investigation of the corneal and epithelial thickness changes after DSAEK for bullous keratopathy, by in vivo, clinical anterior-segment optical coherence tomography. Epithelial thickness recovery and normalization and corneal deturgescence were noted as early as in the first postoperative month.