Endothelial Keratoplasty DSAEKting from the Inside - PowerPoint PPT Presentation


Title: Endothelial Keratoplasty DSAEKting from the Inside


1
Endothelial Keratoplasty DSAEK-ting from the
Inside
  • Paul Phillips M.D.
  • Sightline Laser and Ophthalmic Associates
  • University of Virginia Dept of Ophthalmology

Humphries Tech Lecture 9-12-09
2
Goals of EK Talk
  • Discuss normal physiology of endothlium and
    endothelial failure
  • Historical perspective
  • Briefly discuss the development of endothelial
    keratoplasty
  • Discuss techniques of DSAEK in more detail
  • Discuss outcomes and normal post-operative
    course.

3
Healthy Eye With Normal Endothelial Cell Function
Epithelial Cell Layer
Stroma
Cornea
Endothelial Cell Layer
Crystalen Lens (Cataract)
4
Diseased Endothelium from Fuchs Dystrophy
Resulting in Microcystic Corneal Edema
Epithelial Cell Layer
Microcystic edema
Stroma edema
Cornea
Endothelial Cell Layer
Crystalen Lens (Cataract)
5
Corneal Transplantation
Could not a small piece of cornea be excised
with a trephine, the size of a small bristle or a
large quill and would it not heal with a
transparent scar? - 1760 - Erasmus Darwin

1731-1802
  • Corneal transplantation has been used to treat
    corneal disease for over 100 years.
  • The first successful full thickness human
    transplant performed by a private practice
    physician, Eduard Zirm, in 1905.1,2

6
Over 50 of corneal transplants in the United
States are performed primarily to treat
endothelial dysfunction.
Endothelium
(Eye Bank Association of America, Statistical
Report, 2005)
7
Penetrating Keratoplasty
Trephination cuts
B
A
Open eye post trephination
D
C
Donor cornea with healthy endothelium trephine
The donor is sutured into area of central
trephination
8
PK Surgery Full Thickness Surgery
Donor tissue sutured into recipient
Recipient tissue removed
Central trephine cut made
Sutures create an irregular surface with
astigmatism and blurring
Full thickness block of tissue removed just to
get to the endothelium
Smooth Surface with only endothelial disease
9
Optically purebut often high astigmatism
  • Beautifully clear graft, 20/20 vision, minimal
    astigmatism.
  • After sutures out at one year, vision is still
    20/20, but
  • MR -3.00-5.00X16020/20

10
Additional Problems Associated with PKs
  • Suture related problems
  • Immune reactions
  • Suture infiltrates/Ulcerations
  • Rejection episodes
  • Infections
  • Wound integrity related problems
  • Early and Late wound dehiscence
  • Mild trauma leads to rupture even years after PK

11
Suture related complications
Pt. 1
  • Patient 1 Exposed suture 1 ½ years after PK
    leading to ulceration and rejection episode

Pt. 2
  • Patient 2 Endophthalmitis from retained suture
    fragment 2 years after PK

12
Wound integrity related complications
Pt. 1
  • Patient 1 Expulsive Hemorrhage From mild
    blunt trauma five years after PK

Pt. 2
  • Patient 2 Rupture with vitreous loss 3 years
    after PK. Fell at home (blunt trauma).

13
Solution to Problems with P.K.
  • Eliminate corneal sutures
  • No suture problems
  • Eliminate corneal surface incisions
  • Faster wound healing, smoother topography,
    stronger and more stable eye.

14
Endothelial Keratoplasty
  • The selective transplantation of the endothelium
  • Multiple names and acronyms for small changes
  • PLK Posterior Lamellar Keratoplasty (Melles,
    1999)
  • DLEK Deep Lamellar Endothelial Keratoplasty
    (Terry, 2001)
  • DSEK Descemets Stripping Endothelial
    Keratoplasty (Price, 2005)
  • DSAEK Descemets Stripping with Automated
    Endothelial Keratoplasty (Gorovoy, 2006)
  • DMEK Descemets Membrane Endothelial
    Keratoplasty (Melles, 2006)

Case report only, has not been validated in a
larger study.
15
Deep Lamellar Endothelial KeratoplastyDLEK
Recipient tissue removed
Scleral incision, deep corneal pocket, and
endothelium trephined with Terry Trephine or
cut with Cindy Scissors
Endothelium removed with posterior stromal disc
Donor tissue placed into recipient
Endothelium replaced with no sutures, supported
by air bubble in anterior chamber. Surface
remains smooth with no astigmatism
16
DSAEK Surgery
A
B
Sick endothelium
Incision
Donor Cornea
5mm Incision Made
Diseased descemets stripped
D
Cornea clears as it is thinned by the new
endothelium
Graft held in position with air bubble
17
DSAEK for Fuchs Dystrophy
The new endothelium of the DSAEK graft rapidly
deterges the stroma as demonstrated here by OCT
of the anterior segment preoperatively and at
days 1 and 5 days postoperatively.
18
Complications
725 DSAEK case performed at Devers Eye Institute
as of 8/1/09
Dislocations in DSAEK (N19)
2.6
Primary Graft Failure in DSAEK (N1)
  • 0.1

Pupillary Block in DSAEK (N1)
0.1
19
DSAEK Visual Results Prospective study, 6 months
post-op (n100)
  • Visual acuity (mean BSCVA)
  • All eyes (n100) 20/38
  • Eyes without measurable retinal disease (n74)
    20/30
  • Percent of eyes 20/40 (or better) 97
  • Percent of eyes 20/25 (or better) 38
  • Percent of eyes 20/20 (or better) 14

Chen, Terry, Shamie, et al Cornea 2007
20
DSAEK Current Results (July 2007) Prospective
study, 1 year post-op (n 100)
  • Astigmatism Less than 0.06 D change from pre-op
    measurements (p.68)

Terry MA, et al. Endothelial survival following
DSAEK surgery in a large prospective study.
(Terry et al Ophthalmology, 2007, in press)
21
Typical Post Operative Course
  • Visits
  • Day 1, Week 1, Month 1, Q2-3 months and Year 1.
  • If no steroids, Q6 months
  • If steroids are continued, Q3 month visits for
    second year can be tapered to Q4-6 month visits
    the following year.
  • Immediate Post op
  • Eye patched and shielded
  • Supine positioning for 1 hour followed by supine
    positioning at all times except bathroom use and
    to eat.
  • Pain meds (rarely needed)

22
Typical Post Operative Course
  • Post Op Day 1
  • Patch removed.
  • Vision is usually between finger counting and
    20/80
  • IOP check only if complaints of pain or signs of
    microcystic edema (signs of increase iop) (avoid
    trauma to graft if possible)
  • Slit Lamp Exam
  • Wound check
  • Surface (if significant epi defect, bandage
    contact lens placed)
  • Graft Position (Attached/Detached?
    Centered/Decentered?)
  • Signs of interface fluid (if localized, will
    resolve)
  • AC reaction
  • IOL position (especially if triple procedure or
    IOL exchange)

23
Typical Post Operative Course
  • POD 1 continued
  • Patient instructed on meds
  • Prednisolone 1 QID (tapered over course of
    12molonger if necessary)
  • Flouroquinolone QID
  • Topical NSAID (If triple procedure or IOL
    exchange)
  • Lubricating ointment QHS
  • Patient activity instructions
  • NO RUBBING, NO RUBBING, NO RUBBING!
  • Supine positioning 2 hours every 2 hours for
    entire day.
  • Sleep with eye shield for two weeks

24
Typical Post Operative Course
  • POD1 continued
  • Warning signs discussed
  • Usual signs of infection (redness, pain,
    discharge, photophobia, decreased vision)
  • Signs of dislocation Painless dramatic drop in
    vision
  • Patient is instructed to call (but not to panic)
  • Repositioning or rebubbling can take place in a
    non-emergent fashion within 1-2 weeks.
  • At Devers most dislocation occurred at
    POD1-POD4 and have not occurred later than 1
    week.
  • Week 1
  • Vision improves 20/100-20/40
  • Patient begin to realize benefit (many begin to
    inquire about surgery on their other eye
  • Check Wound, IOP, Surface, Interface (fluid
    usually resolved if present on POD1)
  • If vision slow to recover, encourage patient
    (significant variability in vision at this time)
  • Continue meds

25
Typical Post Operative Course
  • Month 1
  • Vision 20/60-20/20
  • Refract if patient anxious to improve vision
    (advise patient that change in refraction may
    occur)
  • Full exam, consider dilation especially if
    triple or other combined procedure or if VA
    lower than expected
  • Patient advised on signs of rejection RSVP
  • Redness, Sensitivity to light, Vision decrease,
    Pain
  • Subsequent follow up as noted above
  • Refraction generally stable at 2-3 months
  • While on Steroids, IOP checks are imperative
  • Steroid response usually does not occur within
    first few weeks, but can occur at any time there
    after.
  • If steroid response, we first add IOP lowering
    meds or consider SLT/LTP, if no improvement,
    decrease steroid dose or strength.

26
Thank You.
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Endothelial Keratoplasty DSAEKting from the Inside

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Title: Endothelial Keratoplasty DSAEKting from the Inside


1
Endothelial Keratoplasty DSAEK-ting from the
Inside
  • Paul Phillips M.D.
  • Sightline Laser and Ophthalmic Associates
  • University of Virginia Dept of Ophthalmology

Humphries Tech Lecture 9-12-09
2
Goals of EK Talk
  • Discuss normal physiology of endothlium and
    endothelial failure
  • Historical perspective
  • Briefly discuss the development of endothelial
    keratoplasty
  • Discuss techniques of DSAEK in more detail
  • Discuss outcomes and normal post-operative
    course.

3
Healthy Eye With Normal Endothelial Cell Function
Epithelial Cell Layer
Stroma
Cornea
Endothelial Cell Layer
Crystalen Lens (Cataract)
4
Diseased Endothelium from Fuchs Dystrophy
Resulting in Microcystic Corneal Edema
Epithelial Cell Layer
Microcystic edema
Stroma edema
Cornea
Endothelial Cell Layer
Crystalen Lens (Cataract)
5
Corneal Transplantation
Could not a small piece of cornea be excised
with a trephine, the size of a small bristle or a
large quill and would it not heal with a
transparent scar? - 1760 - Erasmus Darwin

1731-1802
  • Corneal transplantation has been used to treat
    corneal disease for over 100 years.
  • The first successful full thickness human
    transplant performed by a private practice
    physician, Eduard Zirm, in 1905.1,2

6
Over 50 of corneal transplants in the United
States are performed primarily to treat
endothelial dysfunction.
Endothelium
(Eye Bank Association of America, Statistical
Report, 2005)
7
Penetrating Keratoplasty
Trephination cuts
B
A
Open eye post trephination
D
C
Donor cornea with healthy endothelium trephine
The donor is sutured into area of central
trephination
8
PK Surgery Full Thickness Surgery
Donor tissue sutured into recipient
Recipient tissue removed
Central trephine cut made
Sutures create an irregular surface with
astigmatism and blurring
Full thickness block of tissue removed just to
get to the endothelium
Smooth Surface with only endothelial disease
9
Optically purebut often high astigmatism
  • Beautifully clear graft, 20/20 vision, minimal
    astigmatism.
  • After sutures out at one year, vision is still
    20/20, but
  • MR -3.00-5.00X16020/20

10
Additional Problems Associated with PKs
  • Suture related problems
  • Immune reactions
  • Suture infiltrates/Ulcerations
  • Rejection episodes
  • Infections
  • Wound integrity related problems
  • Early and Late wound dehiscence
  • Mild trauma leads to rupture even years after PK

11
Suture related complications
Pt. 1
  • Patient 1 Exposed suture 1 ½ years after PK
    leading to ulceration and rejection episode

Pt. 2
  • Patient 2 Endophthalmitis from retained suture
    fragment 2 years after PK

12
Wound integrity related complications
Pt. 1
  • Patient 1 Expulsive Hemorrhage From mild
    blunt trauma five years after PK

Pt. 2
  • Patient 2 Rupture with vitreous loss 3 years
    after PK. Fell at home (blunt trauma).

13
Solution to Problems with P.K.
  • Eliminate corneal sutures
  • No suture problems
  • Eliminate corneal surface incisions
  • Faster wound healing, smoother topography,
    stronger and more stable eye.

14
Endothelial Keratoplasty
  • The selective transplantation of the endothelium
  • Multiple names and acronyms for small changes
  • PLK Posterior Lamellar Keratoplasty (Melles,
    1999)
  • DLEK Deep Lamellar Endothelial Keratoplasty
    (Terry, 2001)
  • DSEK Descemets Stripping Endothelial
    Keratoplasty (Price, 2005)
  • DSAEK Descemets Stripping with Automated
    Endothelial Keratoplasty (Gorovoy, 2006)
  • DMEK Descemets Membrane Endothelial
    Keratoplasty (Melles, 2006)

Case report only, has not been validated in a
larger study.
15
Deep Lamellar Endothelial KeratoplastyDLEK
Recipient tissue removed
Scleral incision, deep corneal pocket, and
endothelium trephined with Terry Trephine or
cut with Cindy Scissors
Endothelium removed with posterior stromal disc
Donor tissue placed into recipient
Endothelium replaced with no sutures, supported
by air bubble in anterior chamber. Surface
remains smooth with no astigmatism
16
DSAEK Surgery
A
B
Sick endothelium
Incision
Donor Cornea
5mm Incision Made
Diseased descemets stripped
D
Cornea clears as it is thinned by the new
endothelium
Graft held in position with air bubble
17
DSAEK for Fuchs Dystrophy
The new endothelium of the DSAEK graft rapidly
deterges the stroma as demonstrated here by OCT
of the anterior segment preoperatively and at
days 1 and 5 days postoperatively.
18
Complications
725 DSAEK case performed at Devers Eye Institute
as of 8/1/09
Dislocations in DSAEK (N19)
2.6
Primary Graft Failure in DSAEK (N1)
  • 0.1

Pupillary Block in DSAEK (N1)
0.1
19
DSAEK Visual Results Prospective study, 6 months
post-op (n100)
  • Visual acuity (mean BSCVA)
  • All eyes (n100) 20/38
  • Eyes without measurable retinal disease (n74)
    20/30
  • Percent of eyes 20/40 (or better) 97
  • Percent of eyes 20/25 (or better) 38
  • Percent of eyes 20/20 (or better) 14

Chen, Terry, Shamie, et al Cornea 2007
20
DSAEK Current Results (July 2007) Prospective
study, 1 year post-op (n 100)
  • Astigmatism Less than 0.06 D change from pre-op
    measurements (p.68)

Terry MA, et al. Endothelial survival following
DSAEK surgery in a large prospective study.
(Terry et al Ophthalmology, 2007, in press)
21
Typical Post Operative Course
  • Visits
  • Day 1, Week 1, Month 1, Q2-3 months and Year 1.
  • If no steroids, Q6 months
  • If steroids are continued, Q3 month visits for
    second year can be tapered to Q4-6 month visits
    the following year.
  • Immediate Post op
  • Eye patched and shielded
  • Supine positioning for 1 hour followed by supine
    positioning at all times except bathroom use and
    to eat.
  • Pain meds (rarely needed)

22
Typical Post Operative Course
  • Post Op Day 1
  • Patch removed.
  • Vision is usually between finger counting and
    20/80
  • IOP check only if complaints of pain or signs of
    microcystic edema (signs of increase iop) (avoid
    trauma to graft if possible)
  • Slit Lamp Exam
  • Wound check
  • Surface (if significant epi defect, bandage
    contact lens placed)
  • Graft Position (Attached/Detached?
    Centered/Decentered?)
  • Signs of interface fluid (if localized, will
    resolve)
  • AC reaction
  • IOL position (especially if triple procedure or
    IOL exchange)

23
Typical Post Operative Course
  • POD 1 continued
  • Patient instructed on meds
  • Prednisolone 1 QID (tapered over course of
    12molonger if necessary)
  • Flouroquinolone QID
  • Topical NSAID (If triple procedure or IOL
    exchange)
  • Lubricating ointment QHS
  • Patient activity instructions
  • NO RUBBING, NO RUBBING, NO RUBBING!
  • Supine positioning 2 hours every 2 hours for
    entire day.
  • Sleep with eye shield for two weeks

24
Typical Post Operative Course
  • POD1 continued
  • Warning signs discussed
  • Usual signs of infection (redness, pain,
    discharge, photophobia, decreased vision)
  • Signs of dislocation Painless dramatic drop in
    vision
  • Patient is instructed to call (but not to panic)
  • Repositioning or rebubbling can take place in a
    non-emergent fashion within 1-2 weeks.
  • At Devers most dislocation occurred at
    POD1-POD4 and have not occurred later than 1
    week.
  • Week 1
  • Vision improves 20/100-20/40
  • Patient begin to realize benefit (many begin to
    inquire about surgery on their other eye
  • Check Wound, IOP, Surface, Interface (fluid
    usually resolved if present on POD1)
  • If vision slow to recover, encourage patient
    (significant variability in vision at this time)
  • Continue meds

25
Typical Post Operative Course
  • Month 1
  • Vision 20/60-20/20
  • Refract if patient anxious to improve vision
    (advise patient that change in refraction may
    occur)
  • Full exam, consider dilation especially if
    triple or other combined procedure or if VA
    lower than expected
  • Patient advised on signs of rejection RSVP
  • Redness, Sensitivity to light, Vision decrease,
    Pain
  • Subsequent follow up as noted above
  • Refraction generally stable at 2-3 months
  • While on Steroids, IOP checks are imperative
  • Steroid response usually does not occur within
    first few weeks, but can occur at any time there
    after.
  • If steroid response, we first add IOP lowering
    meds or consider SLT/LTP, if no improvement,
    decrease steroid dose or strength.

26
Thank You.
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