Suture pull-through insertion techniques for Descemet stripping automated endothelial keratoplasty in Chinese phakic eyes: outcomes and complications

Glaucoma drainage device implantation and cyclophotocoagulation in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty

AIM

To compare the surgical outcomes of glaucoma drainage device implantation (GDI) and trans-scleral neodymium:YAG cyclophotocoagulation (CPC) in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty (DSAEK).

METHODS

This retrospective study on observational case series enrolled 29 patients who underwent DSAEK and posterior anti-glaucoma surgery (15 with GDI and 14 with CPC). The main outcome measures were intraocular pressure (IOP), glaucoma surgery success rate (defined as IOP of 6-21 mm Hg without additional anti-glaucoma operation), number of glaucoma medications, endothelial graft status, and best-corrected visual acuity (BCVA).

RESULTS

The mean follow-up time was 34.1 and 21.0mo for DSAEK or glaucoma surgeries, both for the GDI and CPC groups. Both groups showed significant IOP reduction after glaucoma surgery. The GDI group presented a significantly higher success rate in IOP control than the CPC group (60% vs 21.4%, P=0.03). Both procedures significantly decreased the number of glaucoma medications (P=0.03). Forty percent and 57% of cases in the GDI and the CPC group, respectively, experienced endothelial graft failure during follow-up (P=0.36). Significantly worse BCVA after surgery was observed in the CPC group but not in the GDI group.

CONCLUSION

Both GDI and CPC significantly decrease IOP in eyes with glaucoma after DSAEK. GDI is preferable to CPC in refractory glaucoma cases after DSAEK, as it manifests a significantly higher success rate for IOP control, similar endothelial graft failure rate, and relatively preserves BCVA than CPC.

Spontaneous Reattachment of a Detached Sutured Descemet-Stripping Automated Endothelial Keratoplasty Graft

Introduction

This is a case report of a spontaneous reattachment of Descemet-stripping automated endothelial keratoplasty (DSAEK). This graft was primarily sutured, and 20% sulfur hexafluoride (SF6) was injected into the anterior chamber, followed by graft detachment and spontaneous reattachment, 3 months later.

Case Presentation

A 78-year-old male presented with DSAEK graft detachment, which was the patient's second DSAEK (the first also did not adhere). During the second surgery, the DSAEK graft was sutured and 20% SF6 was injected intraoperatively. Graft reattachment occurred without any intervention or repositioning 3 months after the 2nd DSAEK surgery.

Conclusion

Spontaneous DSEAK late graft reattachment is possible, particularly in the setting of an anchoring suture. In some patients, waiting can be an option that can spare the patient the possible risks of graft repositioning, rebubbling, or repeating the DSAEK. Suturing the DSAEK graft primarily may have served as an anchor to keep the graft approximate and aid in attachment. A graft suture can be considered in the setting of a previously failed DSAEK due to DSAEK graft detachment.

Spokewise iridotomy combined with Descemet stripping automated endothelial keratoplasty in iridocorneal endothelial syndrome

Purpose

Iridocorneal endothelial (ICE) syndrome is a progressive anterior segment disorder that can be tricky to treat. Keratoplasty is commonly used to treat corneal edema in ICE syndrome. However, glaucoma is an important risk factor affecting graft survival. To address this question, we designed a retrospective cohort study to evaluate the effect of Spokewise Iridotomy (SI) on Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) Grafts in Iridocorneal Endothelial (ICE) Syndrome.

Methods

This was a retrospective cohort study. A total of 29 patients were included; 31 eyes with ICE syndrome underwent DSAEK at Peking University Third Hospital between June 2015 and June 2022, including 11 eyes with combined SI during DSAEK. The aim was to explore the effect of SI on vision, glaucoma control, complications, peripheral anterior synechiae recurrence, endothelial cell count, and graft survival.

Results

The median follow-up time was 30.83 months (mo.) in the SI+Endothelial Keratoplasty (EK) group and 6.17 mo in the EK group. The 2-year cumulative survival rate of grafts in the SI+EK group was 100%, compared with the 6-month and 1-year cumulative survival rates of 80.2 and 63.2%, respectively, in the EK group (p = 0.043). The SI+EK group had a lower incidence of immediate postoperative complications (p = 0.005), fewer postoperative anti-glaucoma medications (AGMs) (p = 0.029), smaller peripheral anterior synechiae recurrence (p = 0.001), and significant visual acuity improvement (p < 0.05). More AGMs were used in failed grafts (p = 0.002).

Conclusion

SI can help control intraocular pressure, improve visual acuity, and increase graft survival after DSAEK in ICE syndrome patients.

Clinical Outcomes of the Intraocular Lens Injector and Busin Glide for Descemet Stripping Automated Endothelial Keratoplasty in Patients with Iridocorneal Endothelial Syndrome

Purpose: To report the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) performed in iridocorneal endothelial (ICE) syndrome patients using the intraocular lens injector (injector), in comparison with those using the Busin glide. Methods: In this retrospective, interventional comparative study, we evaluated the outcomes of DSAEK performed using the injector (n = 12) or the Busin glide (n = 12) for patients with ICE syndrome. Their graft position and postoperative complications were recorded. Their best-corrected visual acuity (BCVA) and endothelial cell loss (ECL) were monitored over a 12-month follow-up period. Results: DSAEK was conducted successfully in the 24 cases. The BCVA improved from the preoperative 0.99 ± 0.61 to 0.36 ± 0.35 at 12 months after operation (p < 0.001), with no significant difference between the two groups (the injector group and the Busin group) (p = 0.933). ECL at 1 month after DSAEK was 21.80 ± 15.01% in the injector group, which was significantly lower than 33.69 ± 9.75% of the Busin group (p = 0.031). No surgery-related complications were observed in the 24 cases intraoperatively or postoperatively except that one case suffered from postoperative graft dislocation, without statistical difference between the two groups. Conclusions: At 1 month after surgery, the use of graft injector for delivering DSAEK-based endothelial graft may cause significantly less endothelial cell damage than the pull-through technique used in the application of Busin glide. The injector allows safe endothelial graft delivery without the need of anterior chamber irrigation, which increases the ratio of successful graft attachment.

Update on Pediatric Corneal Diseases and Keratoplasty

Managing pediatric corneal disorders is challenging as the prognosis of pediatric keratoplasty depends on several factors. Advancements in the genetic basis of congenital corneal diseases and investigations in congenital corneal conditions provide a better understanding of pediatric corneal conditions. Surgeons performing keratoplasty in children now have a choice of various techniques. Evolving surgical techniques of anterior lamellar and endothelial keratoplasties has expanded the management interventions in these pediatric corneal morbidity conditions; however, considerable concerns still exist in association with corneal transplantation in infants and children. Outcomes in pediatric keratoplasty depend upon the preoperative indications, the timing of surgical intervention, intraoperative and postoperative factors including the patient/care givers' compliance. Factors such as low scleral rigidity, higher rate of graft failure, need for frequent examinations under anesthesia, and difficulty in optimal visual acuity assessment still remain a considerable challenge in pediatric scenarios. In children, deprivation amblyopia as a result of the corneal opacification can adversely affect visual development, causing dense amblyopia. Outcomes to surgical interventions for management of corneal opacification in children is further compromised by the pre-existing amblyopia apart from the concerns of refractive outcome of the graft. Graft rejection, graft infection, amblyopia, and glaucoma continue to be serious concerns. In recent years both anterior and posterior lamellar keratoplasty techniques are being increasingly performed in pediatric eyes, which offer advantages in the form of lower risk of graft rejection. The timing of surgery, careful case selection, cautious intraoperative approach, and optimal postoperative management can improve the anatomical and functional outcome in difficult cases.

The clinical outcomes of keratoplasty in irreversible corneal decompensation secondary to Axenfeld-Rieger syndrome

PURPOSE

To evaluate the clinical outcomes of penetrating keratoplasty (PK) and Descemet's stripping automated endothelial keratoplasty (DSAEK) in eyes with irreversible corneal decompensation secondary to Axenfeld-Rieger syndrome (ARS).

METHODS

In this retrospective case series, a total of four eyes undergoing PK and seven eyes undergoing DSAEK, including one eye requiring one repeat DSAEK, between 2014 and 2021 were enrolled. Postoperative complications, graft survival, glaucoma treatment before and after keratoplasty, visual outcomes, and endothelial cell density were recorded.

RESULTS

The mean follow-up duration was 34.4 ± 16.8 months. Before keratoplasty, the mean BCVA was 2.0 ± 0.4 LogMAR, and the mean IOP was 21.7 ± 8.1 mmHg. A total of 63.6% of eyes (7/11) received glaucoma treatment, including five eyes with glaucoma surgeries. After keratoplasty, 27.3% of eyes (3/11) exhibited secondary graft failure. The mean BCVA reached a maximum of 0.7 ± 0.5 LogMAR at 8.9 ± 7.5 months, with no significant difference between the PK and DSAEK groups (P₁ = 1.00, P₂ = 0.12). Four eyes with previous glaucoma surgeries exhibited markedly high IOP. A total of 72.7% of eyes (8/11) required additional glaucoma treatments. The mean endothelial cell loss (ECL) rates at 1, 6, 12 and 24 months were 43%, 49%, 63% and 54%, respectively, with no significant difference between the PK and DSAEK groups (P₁ = 0.64, P₂ = 1.00, P₃ = 0.57, and P₄ = 0.44).

CONCLUSION

Both PK and DSAEK can successfully treat corneal decompensation secondary to ARS, resulting in similar outcomes with regard to IOP control, BCVA and ECL. IOP control is essential for postoperative management, especially for eyes with previous glaucoma surgeries.

Pediatric endothelial keratoplasty: a systematic review and individual participant data meta-analysis

BACKGROUND

Recently, endothelial keratoplasty (EK) has been increasingly considered the first intervention in pediatrics with isolated corneal endothelial dysfunction. This systematic review aims to investigate the current evidence about the advantages, disadvantages, technical challenges, and clinical outcomes of EK in the pediatric group.

METHOD

All the English literature relevant to pediatric EK was searched in PubMed, Embase, Scopus, and Cochrane databases with appropriate keywords. Relevant data were pooled to conduct an individual participant data meta-analysis.

RESULTS

Of 1646 articles found initially, 35 articles were finally eligible to be included in our study. A total of 154 eyes of 107 patients underwent Descemet's stripping automated endothelial keratoplasty (DSAEK). Congenital hereditary endothelial dystrophy (CHED) was the most reported indication for pediatric DSAEK (108 eyes). Descemet's membrane endothelial keratoplasty (DMEK) was performed in 2 eyes of 2 cases, one with PPCD and another one in a patient with Kearns-Sayre syndrome. Owing to some specific anatomical and physiological pediatric characteristics, some modifications in a standard procedure were suggested. The average follow-up period was 23.80 ± 20.18 months (3 months to 8.5 years). Seventy-six eyes who had a mean best-corrected visual acuity (BCVA) of 1.36 ± 0.70 (0.49 to 3) logMAR preoperatively found mean BCVA of 0.51 ± 0.33 (0.04 to 2) logMAR postoperatively. Graft dislocation was the most reported complication (26 eyes). The rate of other complications was low. Endothelial cell loss was reported from 8.3 to 63.7% after pediatric EK with follow-up duration from 3 months to 8.3 years.

CONCLUSION

EK procedures, despite some technical challenges, are feasible surgical techniques with acceptable visual and anatomical outcomes in the management of pediatrics with corneal endothelial dysfunction and minimal stromal involvement.

Graft detachments in endothelial keratoplasty

Graft detachment is the most common complication of endothelial keratoplasty. With the ongoing advancements in the field of endothelial keratoplasty, our understanding of risk factors of graft detachments and its management has been evolving. Various prevention measures have been described in literature including presoaking the donor graft, anterior chamber tamponade, venting incisions, sutures to prevent dislocation of graft. Management of a detached graft involves secondary interventions such as rebubbling, suturing and regrafts. In this review, we discuss graft detachment in different types of endothelial keratoplasty techniques including Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty; with emphasis on incidence, risk factors, preventive measures and their management.

Treatment of corneal endothelial damage in a rabbit model with a bioengineered graft using human decellularized corneal lamina and cultured human corneal endothelium

Objective

We aimed to investigate the functionality of human decellularized stromal laminas seeded with cultured human corneal endothelial cells as a tissue engineered endothelial graft (TEEK) construct to perform endothelial keratoplasty in an animal model of corneal endothelial damage.

Methods

Engineered corneal endothelial grafts were constructed by seeding cultured human corneal endothelial cell (hCEC) suspensions onto decellularized human corneal stromal laminas with various coatings. The functionality and survival of these grafts with cultured hCECs was examined in a rabbit model of corneal endothelial damage after central descemetorhexis. Rabbits received laminas with and without hCECs (TEEK and control group, respectively).

Results

hCEC seeding over fibronectin-coated laminas provided an optimal and consistent endothelial cell count density and polygonal shape on the decellularized laminas, showing active pump fuction. Surgery was performed uneventfully as standard Descemet stripping automated endothelial keratoplasty (DSAEK). Corneal transparency gradually recovered in the TEEK group, whereas haze and edema persisted for up to 4 weeks in the controls. Histologic examination showed endothelial cells of human origin covering the posterior surface of the graft in the TEEK group.

Conclusions

Grafting of decellularized stroma carriers re-surfaced with human corneal endothelial cells ex vivo can be a readily translatable method to improve visual quality in corneal endothelial diseases.

Keratometric measurements and IOL calculations in pseudophakic post-DSAEK patients

Background

To compare different K readings in pseudophakic patients post-Descemet’s stripping automated endothelial keratoplasty (DSAEK) and evaluate corresponding prediction errors in intraocular lens (IOL) power calculations.

Methods

Subjects that underwent cataract surgery and DSAEK surgery at least 3 and 6 months prior, respectively, and IOL implantation in the capsular bag were included in this study. Manifest refraction and IOL information were recorded. A Scheimpflug keratometer (Pentacam) was used for corneal measurements, including the mean anterior and posterior radii of curvature, simulated keratometer (SimK), true net power (TNP), and equivalent K reading (EKR) at the 4.0-mm zone. Conventional keratometry was acquired using the IOLMaster (K_Master). The four K measurements were evaluated for calculating the predicted refraction.

Results

The study included 20 eyes from 19 subjects. The ratio of the posterior to the anterior corneal radius was 74.1 ± 3.24%. Comparison of the four keratometric methods (K_Master, SimK, EKR, and TNP) revealed statistically significant differences among all the methods besides K_Master and SimK. Of the four IOL calculation methods(K_Master, SimK, EKR and TNP method),the arithmetic prediction error of the K_Master, SimK, and EKR methods featured nonsignificant differences from zero(p = 0.07, 0.19 and 0.84 respectively); the EKR method calculated the highest percentage of eyes with IOLs within the prediction error.

Conclusions

IOL calculations in post-DSAEK eyes using K_Master, SimK, and EKR can yield small refractive errors after surgery. The EKR (4.0-mm diameter) method was found to be the most accurate.

Corneal Endothelial Cell Loss in Femtosecond Laser-assisted Descemet's Stripping Automated Endothelial Keratoplasty: A 12-month Follow-up Study

Background:

Descemet's stripping automated endothelial keratoplasty (DSAEK) surgery offers a more standardized approach and reliable method to create corneal grafts with an instrument such as a microkeratome. With the development of Descemet's membrane endothelial keratoplasty, an excellent clinical outcome is seen in the treatment of corneal endothelial dysfunctions, which indicates that thinner corneal graft results in better clinical outcome. With the recent development of the femtosecond laser, ultrathin corneal graft preparation has become possible. This study aimed to report corneal graft endothelial cell loss (ECL) in a large series of cases undergoing DSAEK with femtosecond laser-assisted corneal graft preparation within a 12-month period.

Methods:

This study was designed as a prospective, noncomparative, interventional case series. Totally 126 consecutive eyes with endothelial failure of 120 patients, who had corneal endothelial decompensation and underwent femtosecond-assisted DSAEK using the VisuMax femtosecond laser system, were included in the study. Central endothelial cell density (ECD) was recorded postoperatively at 2 weeks (n = 126), 1 month (n = 126), 3 months (n = 110), 6 months (n = 101), and 12 months (n = 71) and then compared with the preoperative eye bank measurements. Pre- and postoperative central ECDs were evaluated using Heidelberg retina tomography-III confocal microscopy. ECL was calculated for each postoperative time point. Graft thickness was examined using anterior segment-optical coherence tomography.

Results:

Mean preoperative cell count was 3383 ± 350 cells/mm². Mean postoperative cell counts were 2382 ± 707 cells/mm², 2179 ± 685 cells/mm², 2074 ± 688 cells/mm², 1884 ± 662 cells/mm², and 1723 ± 624 cells/mm² at 2 weeks, 1, 3, 6, and 12 months, respectively; these represented the ECL of 29.7 ± 19.7%, 35.4 ± 19.5%, 38.6 ± 19.8%, 44.3 ± 18.9%, and 48.9 ± 18.4% at the each corresponding time point. The mean corneal graft thickness after surgery was 142 ± 48 μm, 118 ± 41 μm, 108 ± 37 μm, 100 ± 32 μm, and 99 ± 32 μm at each corresponding study visit, respectively. There was no correlation between corneal graft thickness and corneal ECL (R = 0.039).

Conclusions:

Corneal ECL remained relatively stable up to 12 months after femtosecond laser-assisted ultrathin DSAEK in a large case series. No correlation between cell loss and corneal graft thickness was found, which indicated that corneal graft preparation by the femtosecond laser was safe. ECL was faster within the first 6 months and relatively stable thereafter.

Clinical outcomes after Descemet's stripping endothelial keratoplasty using donor corneas from children younger than 3 years

Importance

There is limited literature on paediatric donors in endothelial keratoplasty.

Background

This study investigated the efficacy of and appropriate paediatric donor age for Descemet’s stripping endothelial keratoplasty (DSEK).

Design

Retrospective and observational case series.

Participants

Thirty‐eight consecutive patients underwent DSEK with paediatric donor corneas.

Methods

The age of the donors ranged from 32 weeks gestation (premature neonate) to 3 years old. All donor consents were obtained from the parents. The causes of donor death included traffic accident, congenital heart disease and neonatal respiratory distress syndrome.

Main Outcome Measures

The outcome measures included best‐corrected visual acuity, endothelial cell loss and complications.

Results

Best‐corrected visual acuity at last follow‐up was >20/40 in 28 of 38 eyes (73.7%). The mean preoperative endothelial cell density of donor corneas was 4682 ± 520 cells/mm². The mean endothelial cell density of grafts was 3977 ± 556 cells/mm² at 18 months postoperatively. Three lenticules from premature neonate donors exhibited severe contraction postoperatively. The edge of six lenticules from donors <1‐year‐old exhibited contraction in the early postoperative period and gradually flattened spontaneously. Graft detachment occurred in one patient.

Conclusions and Relevance

DSEK with paediatric donor corneas can achieve good clinical outcomes. The corneal lenticules from 1‐ to 3‐year‐ old donors are suitable for DSEK while those from donors <1‐year‐old are less suitable due to the possibility of severe postoperative graft contraction.

Clinical outcome of Descemet stripping automated endothelial keratoplasty in 18 cases with iridocorneal endothelial syndrome

PurposeTo evaluate the clinical outcome of Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with iridocorneal endothelial (ICE) syndrome.Patients and methodsA retrospective case series study was conducted. Eighteen consecutive Chinese patients with 20 DSAEK grafts were enrolled. Participants were evaluated by anterior segment optical coherence tomography and confocal microscopy. Postoperative complications, graft survival, endothelial cell counts, corneal thickness, and anterior chamber depth were analysed. A Log-rank test in a Kaplan-Meier analysis and a Cox proportional hazard regression were used to analyse potential risk factors of graft failure.ResultsThe mean follow-up duration was 19.0±8.6 months. The donors' endothelial cell density (ECD) (cells/mm²) values at 1, 3, 6, 12, 18, and 24 months were 3342.2±287.0, 1897.6±745.4, 1793.6±755.7, 1618.1±604.3, 1421.9±650.8, 1265.1±844.1, and 1148.2±1217.8, respectively. Eleven of the 20 grafts exhibited secondary graft failure, with a mean estimated graft survival of 23.4 months. Immediate postoperative complications (air bubble ventilation for elevated intraocular pressure or rebubbling for graft detachment) were more common in eyes exhibiting graft failure (P=0.040). Postkeratoplasty glaucoma surgery emerged as a risk factor of graft failure, with a hazard ratio of 5.174. Eyes with a poor prognosis showed statistically greater central corneal thickness at 1 month, greater graft thickness at 3 months, and a shallower anterior chamber at 6 and 12 months.ConclusionsThe long-term outcome of DSAEK in eyes with ICE syndrome is relatively poor. Immediate postoperative complications, postkeratoplasty glaucoma surgery, thicker corneal parameters, and a shallow anterior chamber were all associated with graft failure.