Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results - PowerPoint PPT Presentation

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Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results

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Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir S MEHTA, FRCS ... – PowerPoint PPT presentation

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Title: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results


1
Descemet Stripping Automated Endothelial
Keratoplasty with a Graft Insertion Device
Technique and Early Results
  • Dr Wei-Boon KHOR, MRCS(Ed),
  • Dr Jodhbir S MEHTA, FRCS(Ed),
  • Prof Donald TH TAN, FRCS(G)
  • Singapore National Eye Centre (SNEC)
  • and Singapore Eye Research Institute (SERI)
  • WB Khor has no financial interests.
  • Jodbir Mehta and Donald Tan have financial
    interests
  • in the EndoGlide (Network Medical Products)

Singapore Eye Research Institute
2
Introduction
  • Descemet Stripping Automated Endothelial
    Keratoplasty (DSAEK) is a form of selective
    corneal lamellar transplant surgery with many
    advantages over penetrating keratoplasty (PK)
  • However, there is concern over the degree of
    endothelial cell loss in DSAEK
  • a recent review reported an average loss of 37
    (range 25-54) at 6 months, and 42 (range
    24-61) at 12 months1
  • Graft insertion through a small incision with the
    current taco-fold technique may be a major
    cause of endothelial cell damage
  • New inserters are now emerging which are designed
    to minimize surgical trauma and reduce loss in
    endothelial cell density (ECD)

1. Lee, W.B., et al., Descemet's stripping
endothelial keratoplasty safety and outcomes a
report by the American Academy of Ophthalmology.
Ophthalmology, 2009. 116(9) p. 1818-30.
3
Purpose
  • This poster describes the use of the EndoGlide
    (Network Medical Products, North Yorkshire, UK),
    a new graft insertion device for use during DSAEK
  • We also report the early clinical results of the
    Singapore National Eye Centre (SNEC) EndoGlide
    Trial
  • The SNEC EndoGlide Trial is an IRB-approved
    prospective clinical trial aimed at evaluating
    the use of the EndoGlide in 100 eyes

4
The EndoGlide
Glide Introducer
Glide Capsule
Glide Capsule
Preparation Base
Glide Introducer
  • The EndoGlide consists of three components the
    Glide Capsule, the Glide Introducer, and the
    Preparation Base

Diagram on the left is courtesy of Network
Medical Products.
5
Central Ridge
  • A central ridge within the Glide Capsule (Figure
    A) enables automatic coiling of the donor tissue
    into a double-coil configuration when pulled
    into the chamber
  • Double-coiled graft outlined from the front
    (Figure B) and the top (Figure C) the
    endothelial surface is on the inside of the
    double-coil
  • The Capsule can hold a double-coiled graft
    without endothelium to endothelium touch
  • accomodates a graft of up to 10 mm in diameter
    and 250 um in thickness

A
B
C
6
Surgical Technique
  • Microkeratome lamellar dissection of the donor
    cornea is performed and then trephined to the
    desired diameter
  • Figure D Leading edge of the posterior lenticule
    can be inked on the stromal edge for easy
    visualization
  • Figure E The internal lumen of the Glide Capsule
    is lubricated with balanced salt solution (BSS)
  • Figure F Both anterior cap and posterior donor
    lenticule are gently separated with BSS and then
    transferred (endothelial side up) onto the
    Preparation Base

D
E
F
7
Forceps introduced here
  • Figure G Straight forceps are introduced through
    the anterior opening of the Capsule to grasp the
    leading edge of the graft
  • Figure H As the graft is drawn into the Capsule,
    it rolls into the double-coil configuration when
    the lateral edges of the donor encounter the
    central internal ridge
  • Figure I The graft is drawn completely into the
    Capsule

G
H
I
8
  • Figure J The purple Glide Introducer is inserted
    into the posterior opening of the Capsule and
    locked into place
  • The assembled EndoGlide is removed from the
    Preparation Base and inverted for insertion
  • Figure K The anterior glide surface of the
    EndoGlide is inserted into the eye through a
    4.5mm scleral tunnel and advanced fully in the AC
  • Figure L Through a nasal paracentesis, forceps
    are passed over the glide surface and used to
    grasp the stromal edge of the graft

J
K
L
9
  • Figure M The graft is simply pulled out of the
    EndoGlide and into the AC
  • Figure N Within the AC, the graft will uncoil,
    endothelial surface down. Moderate BSS flow from
    a pre-placed AC maintainer will facilitate
    unfolding. Gentle movements of the graft with the
    forceps will also aid in the full uncoiling
    process
  • Figure O Whilst still holding the graft with
    forceps, the EndoGlide is removed and a small air
    bubble is injected beneath the graft to float it
    against the recipient stromal surface
  • The surgery is then completed in the usual manner

M
N
O
10
Results
  • The EndoGlide has been used in 26 eyes of 26
    patients so far (performed by 2 surgeons DTHT
    and JSM)
  • Diagnosis
  • - 11 Pseudophakic/Aphakic Bullous Keratopathy
  • - 9 Fuchs Endothelial Dystrophy
  • - Others Post-Laser PI Bullous Keratopathy,
    Descemet Detachment, PPMD, Failed DSAEK
  • Procedures performed - 12 DSAEK
  • - 11 Phaco-DSAEK
  • - 3 DSAEK IOL exchange
  • Median donor diameter 8.75 mm (range 8.25-9.5)
  • Mean donor thickness 187 microns (SD32)

11
  • We found that coiling of the graft and graft
    insertion were easily achieved in all cases
  • For donor coiling, the use of a BSS cannula or
    Sinskey hook to gently stroke up the stromal
    edges of the graft was useful to achieve a
    perfect double-coil configuration
  • Immediate post-op results
  • No primary iatrogenic graft failures
  • No donor dislocations
  • 13 patients have completed 6 months follow-up
    (and 4 have completed 1 year follow-up)
  • Best corrected VA range from 6/7.5 to 6/45
  • No patient has lost any lines of vision
  • Mean ECD 2528 (SD 337) at 6 months
  • Mean ECD loss 17.6 at 6 months

12
Discussion
  • The EndoGlide enables graft insertion through a
    4.5mm incision with ease, minimal graft
    manipulation, and with full control of the graft
    at all times during DSAEK
  • Early results show that it is safe in clinical
    use no immediate endothelial complications such
    as primary graft failure or graft dislocation so
    far
  • Initial 6 months ECD results are promising, but
    more patients and longer follow-up times are
    required to determine the long-term ECD loss with
    EndoGlide use

Comments? Email ltkhor.wei.boon_at_singhealth.com.sggt
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