Dislocation of the DSEK Donor Graft into the Posterior Segment An Intraoperative Complication in DSEK Surgery - PowerPoint PPT Presentation

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Dislocation of the DSEK Donor Graft into the Posterior Segment An Intraoperative Complication in DSEK Surgery

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Title: Dislocation of the DSEK Donor Graft into the Posterior Segment An Intraoperative Complication in DSEK Surgery


1
Dislocation of the DSEK Donor Graft into the
Posterior SegmentAn Intraoperative Complication
in DSEK Surgery
  • Mark M Fernandez MD, Mark S Gorovoy MD, George OD
    Rosenwasser MD, Terry Kim MD, Alan N Carlson, MD,
    and Natalie A Afshari MD
  • Financial Disclosures
  • Dr. Gorovoy has a relationship with Harvey
    Instruments
  • Dr. Rosenwasser is a paid lecturer for Allergan,
    Vistacon and Inspire
  • Dr. Afshari has a research grant from Reseach to
    Prevent Blindness
  • Drs. Fernandez, Kim and Carlson report no
    financial interests

2
Introduction
Anterior chamber OCT showing a well adhered DSEK
graft
  • Descemets stripping endothelial keratoplasty
    (DSEK) is rapidly becoming the preferred
    treatment for corneal edema due to endothelial
    dysfunction
  • DSEK surgery is also being conducted in eyes with
    prior vitrectomy
  • We present a series of DSEK graft dislocations
    into the posterior segment

3
Methods
  • Four cases of intraoperative DSEK graft
    dislocation into the posterior segment were
    identified
  • The surgical management, and the final outcome of
    each eye are discussed

A DSEK graft dislocated posteriorly
4
Case 1
  • A 59 year old woman with a sutured sulcus
    intraocular lens and history of pars plana
    vitrectomy underwent DSEK surgery for
    decompensation of her fourth full thickness
    corneal graft
  • As the donor graft unfolded within the anterior
    chamber, it slipped through a hole in the
    posterior capsule and entered the posterior
    segment
  • Attempts to float the graft using irrigation were
    unsuccessful, so incisions were closed
  • Seven days later she underwent pars plana
    vitrectomy to remove the graft from the posterior
    segment as well as full thickness penetrating
    keratoplasty

5
Case 2
  • A 62 year old man with Fuchs dystrophy underwent
    DSEK surgery three months after
    phacoemulsification with anterior vitrectomy and
    sulcus intraocular lens placement
  • The donor graft was inserted into the anterior
    chamber and unfolded uneventfully filtered air
    was inserted into the anterior chamber and the
    DSEK graft could no longer be visualized
  • A superotemporal sclerotomy was made by a
    vitreoretinal surgeon the donor graft was seen
    laying on the surface of the macula and was
    removed. It was then repositioned in the
    anterior chamber
  • The graft remained attached postoperatively, but
    it did not clear. Two months later, repeat DSEK
    surgery was performed

6
Case 2 Two months after repeat DSEK, the new
donor graft is well-adhered. A healed scleral
incision is seen superotemporally
7
Case 3
  • A 63 year old man with a failed penetrating
    keratoplasty, aphakia, only remnants of an iris
    rim, and prior pars plana vitrectomy underwent
    secondary scleral sutured posterior intraocular
    lens placement, followed by a DSEK one month
    later
  • During DSEK surgery, the graft dislocated
    posteriorly around the sutured posterior chamber
    intraocular lens during unfolding with the
    irrigator/aspirator (see supplemental video)
  • Using the IA handpiece, the graft was maneuvered
    around the sutured posterior chamber IOL into the
    anterior chamber and repositioned
  • Post-op day one revealed a dislocated donor
    graft. The patient underwent a penetrating
    keratoplasty two weeks later

8
Case 4
  • A 79 year old woman with history of traumatic
    open globe, pars plana vitrectomy,
    trabeculectomy, Ahmed valve, sutured posterior
    chamber lens and a failed large diameter corneal
    graft underwent DSEK surgery
  • Upon opening, the globe began to collapse. Air
    was used to maintain the anterior chamber. The
    graft was inserted and the globe was refilled
    with balanced salt solution
  • Air was injected to unfurl the graft. Despite
    attempts to hold it in the anterior chamber, the
    graft slipped between the lens implant and
    ciliary body into the posterior segment
  • A pars plana vitrectomy was performed nine days
    later to remove the graft. Two months after, a
    penetrating keratoplasty was performed

9
The gray-colored donor graft is held in place
centrally with a Sinskey hook while air is
inserted into the anterior chamber
The graft is seen within the anterior chamber
moments before it slips into the posterior segment
Shortly after, the graft has dislocated into the
posterior segment and is no longer visible
10
Results Patient and Intraoperative Risk Factors
  • All eyes had undergone anterior or pars plana
    vitrectomy between three months and several years
    prior to surgery
  • All eyes had undergone complicated intraocular
    lens placement prior to DSEK surgery All IOLs
    were in the posterior chamber. Three were
    sutured and one was a sulcus IOL
  • In two cases, the graft dislocated as it unfolded
    within the anterior chamber
  • In two cases, dislocation occurred after
    injection of sterile air within the anterior
    chamber

11
Results Surgical Management
  • Of the four cases reported, one eye underwent
    successful repeat DSEK and the other three
    underwent successful PK following graft removal
  • In two cases the misplaced graft was subsequently
    repositioned and remained at least partially
    attached. Both grafts failed and were repeated
    within two months
  • In one case the graft was retrieved using the IA
    handpiece. In three cases a vitreoretinal
    surgeon was consulted to remove the graft
  • Satisfactory visual results were attained after
    the complication was addressed in each case

12
Conclusions
  • Dislocation of donor grafts to the posterior
    segment is a rare complication of DSEK surgery
    that appears to require repeat corneal grafting,
    however good final results can be obtained
  • This complication must be considered in the
    preoperative planning of DSEK surgery in
    vitrectomized eyes, especially those with other
    risk factors for posterior dislocation like
    aphakia, pseudophakia with open posterior
    capsule, and sutured IOL
  • Although access to a vitreoretinal surgeon for
    the removal of posterior segment grafts is ideal,
    in some circumstances the problem can be
    addressed using tools available for anterior
    segment surgery
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