Early Outcomes of DSAEK in Pseudophakic Eyes with Anterior Chamber IOLs

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Early Outcomes of DSAEK in Pseudophakic Eyes with
Anterior Chamber IOLs

• Hong A, Boehlke CS,
• Afshari NA, Kim T
• Duke University Medical Center
• Authors have no financial interest

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Background

• DSAEK has significant advantages over standard
  penetrating keratoplasty in the management of
  corneal endothelial disorders
• Faster Visual Rehabilitation
• More predictable corneal power
• Preserves the structural integrity of the eye
• Decreased suture-related complications

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• This technique has gained widespread popularity
  for use in phakic and pseudophakic eyes with
  posterior chamber IOLs
• The role of DSAEK in eyes with anterior chamber
  IOLs (ACIOLs) remains unclear
• Generally considered a surgical contraindication
  due to higher risk of surgical complications and
  graft failure
• Reduced space in the anterior chamber
• Escape of air posteriorly through the peripheral
  iridectomy
• Greater potential for vitreous interference
• Possibly greater surgical manipulation of donor
  tissue
• May necessitate an IOL exchange (iris- or
  scleral-sutured IOL)

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Purpose

• To report on the early results of DSAEK in eyes
  with pre-existing ACIOLs
• To evaluate the visual outcomes, refractive
  changes, and complications in this patient
  population

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Methods

• Retrospective case study
• Nine eyes of 9 patients with ACIOLs that
  subsequently developed corneal edema requiring
  DSAEK were identified from May 2005 to February
  2008.
• The host Descemet membrane was stripped followed
  by insertion of a microkeratome-dissected donor
  endothelial graft that was delivered through a
  3-mm corneal incision. Donor adherence to the
  host cornea was maximized by air tamponade and
  graft interface venting incisions.
• Best spectacle-corrected visual acuity (BSCVA),
  manifest refraction, donor dislocation and graft
  failure rates were measured up to 12 months after
  DSAEK.

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Preoperative Clinical Data
Mean Age (yrs) 71.2 10.8 (range 53 to 84)
Male Female 72
Indications Pseudophakic bullous keratopathy 8
Recent failed penetrating keratoplasty 1
Fuchs corneal dystrophy 1
Preoperative comorbidities Chronic CME 1
Advanced Retinitis Pigmentosa 1
Open-angle glaucoma 6
Anterior chamber glaucoma tube 1
Pars plana glaucoma tube 1
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Refractive Outcomes
Preoperative Postoperative P-value
Mean spherical equivalent (D) 0.26 1.6 0.05 1.4 0.26
Mean refractive astigmatism (D) 2.4 1.7 1.6 1.5 0.50

Postoperative refractive status was obtained at 3 to 6 months D diopters n 8 Postoperative refractive status was obtained at 3 to 6 months D diopters n 8 Postoperative refractive status was obtained at 3 to 6 months D diopters n 8 Postoperative refractive status was obtained at 3 to 6 months D diopters n 8
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Visual Outcomes and Comorbidities
Patient No. Preoperative BSCVA Postoperative BSCVA Comorbidity
1 20/200 20/70 Chronic CME, glaucoma
2 20/200 20/40 Prior penetrating keratoplasty
3 20/200 20/50 Glaucoma, pars plana glaucoma tube
4 20/60 20/30 Glaucoma
5 20/200 20/50
6 Count Fingers 20/40 Glaucoma
7 20/400 20/60 Retinitis pigmentosa, AC glaucoma tube
8 20/200 20/60 Glaucoma
9 20/100 20/50
Mean 20/200 20/50 p0.0007
BSCVA best spectacle-corrected visual acuity AC anterior chamber Postoperative BSCVA obtained at 3 to 6 months BSCVA best spectacle-corrected visual acuity AC anterior chamber Postoperative BSCVA obtained at 3 to 6 months BSCVA best spectacle-corrected visual acuity AC anterior chamber Postoperative BSCVA obtained at 3 to 6 months BSCVA best spectacle-corrected visual acuity AC anterior chamber Postoperative BSCVA obtained at 3 to 6 months
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Complications
Complication No. of Patients ()
Donor dislocation, requiring repositioning 2 (22.2)
Primary graft failure, requiring repeat DSAEK 2 (22.2)
Pupillary block glaucoma 0 (0)

n 9 In one case, the donor tissue had first detached, was repositioned with repeat air injection, detached again and was regrafted
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Conclusions

• Average visual outcomes of DSAEK in eyes with
  ACIOLs may be comparable to vision after DSAEK
  with posterior chamber IOLs.
• Patients with ACIOLs may still be good candidates
  for DSAEK if they meet the ideal surgical
  criteria of a deep chamber, no vitreous
  interference, absent peripheral anterior
  synechiae, and the ability to maintain air
  tamponade for a prolonged period
• DSAEK in eyes with ACIOLs can result in excellent
  visual outcomes with rapid visual recovery and
  may eliminate the need for an IOL exchange