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Descemet-Stripping Automated Endothelial Keratoplasty Technique in Patients with Anterior Chamber Intraocular Lenses
  1. Brian Groat,
  2. Michelle S Ying,
  3. David T Vroman,
  4. Luis E Fernández de Castro
  1. Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA

    Abstract

    Background: Descemet-Stripping Automated Endothelial Keratoplasty (DSAEK) is a relatively new, but proven procedure in treating endothelial dysfunction. Patients with aphakia or anterior chamber intraocular lenses (ACIOL) pose more of a challenge when performing DSAEK. We report a technique that can be used during DSAEK to address situations.

    Case Report: An 80-year-old white female with a history of intracpsular cataract extraction and a secondary ACIOL in her left eye was referred with pseudophakic bullous keratopathy and 3+ stromal edema. DSAEK was performed with two modifications: 1) occlusive pupilloplasty, and 2) a fixation suture to stabilize the donor tissue during the unfolding process. Her two-week postoperative visual acuity was 20/60.

    Video: The surgical video demonstrates the modified DSAEK technique. A 10-0 polypropylene suture was used to create the occlusive pupilloplasty with a slipknot. The endothelium and Descemet were stripped using a 90-degree scraper. The donor tissue was folded in a 60/40 taco fashion and inserted into the anterior chamber. To stabilize the graft while unfolding in a shallow anterior chamber, a fixation suture was placed in the inferior portion of the graft. Air was injected, and the tissue unfolded in good position with the Lindstrom roller, and finally the occlusive pupilloplasty was released.

    Comment: Currently, some patients with ACIOL are managed by performing an intraocular lens exchange with a scleral-sutured lens followed 6-8 weeks later by DSAEK. However, the two modifications described above allows DSAEK to be performed successfully in a single procedure with minimal additional surgical time.

    To view the full report and accompanying video please go to: http://bjo.bmj.com/cgi/content/full/91/6/714/DC1

    All videos from the BJO video report collection are available from: http://bjo.bmj.com/video/collection.dtl

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      Video Report

      Descemet-Stripping Automated Endothelial Keratoplasty Technique in Patients with Anterior Chamber Intraocular Lenses

      Brian Groat, Michelle S. Ying, David T. Vroman, Luis E. Fernández de Castro

      Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA

      Correspondence: David T. Vroman
      Email: vromandt{at}musc.edu
      Storm Eye Institute - MUSC 167 Ashley Avenue, Charleston, SC 29425, USA Tel: +00 1 843 792 8861; Fax: +00 1 843 7921166.

      Date of acceptance: April 6th 2007

      Self-sealing paracentesis incisions were made to create an occlusive pupilloplasty. The endothelium and Descemet were scored and then stripped. The donor tissue was then inserted. A fixation suture was placed to stabilize the graft while unfolding. Air was injected, and the tissue unfolded in good position. The occlusive pupilloplasty was then released.

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      Introduction

      Descemet-Stripping Automated Endothelial Keratoplasty (DSAEK) is a relatively new, but proven procedure in treating endothelial dysfunction. Previously, penetrating keratoplasty (PKP) was the standard procedure for patients with cornea endothelial disease including Fuchs' dystrophy and bullous keratopathy. Many studies have confirmed the advantages of DSAEK over PKP such as rapid visual recovery, lack of induced astigmatism and preserved globe strength. As a result, many surgeons believe DSAEK is the procedure of choice for patients with endothelial dysfunction.1-3

      There are certain situations which pose more of a challenge for the surgeon when performing DSAEK. These include patients with aphakia, anterior chamber intraocular lenses (ACIOL), tube shunts, and multiple peripheral iridectomies (PI). In all of these cases, it is difficult to elevate the pressure in the eye with an air bubble to allow the graft to adhere. Additionally, there may be problems in unfolding the donor tissue due to a shallow anterior chamber. We report a technique that can be used during DSAEK in patients with ACIOL or aphakia. 

      Case Report

      An 80-year-old white female was referred from an outlying facility for evaluation of decreased visual acuity and corneal edema in her left eye. She had an intracapsular cataract extraction in her left eye over 30 years ago, and a secondary ACIOL placed 17 years later. She reports enjoying very good vision for the past 11 years, but which began a slow decline in acuity over the past 2 years. Her best corrected visual acuity in our office was 20/150 in the left eye. On examination, she had pseudophakic bullous keratopathy with 3+ stromal edema, a well-positioned ACIOL, and a superotemporal peripheral iridectomy. Gonioscopy revealed an open angle and no peripheral anterior synechiae. After discussing treatment options with the patient, a DSAEK was performed with minor modifications to address the concerns about elevating the eye pressure with air in the anterior chamber and the relatively shallow anterior chamber due to the ACIOL. The two major modifications were: 1) occlusive pupilloplasty, and 2) a fixation suture to stabilize the donor tissue during the unfolding process. The surgery was uneventful and on postoperative day 1, the patient had a clear cornea with an attached graft. Her uncorrected visual acuity at this visit was 20/150 OS. Her two-week postoperative visual acuity was 20/60, and the patient remains very pleased with the result. 

      Technique

      Three limbal, self-sealing paracentesis incisions were made at the 1, 5, and 9-o'clock positions, and a 3.5 mm grooved, clear corneal incision was made at 3 o'clock. Viscoelastic material was injected to maintain the anterior chamber. Using a CIF-4 10-0 polypropylene suture, two passes were made through the superior and inferior portions of the iris to create the occlusive pupilloplasty. Care was taken not to engage the corneal stroma when exiting the wounds by guiding the tip of the needle out of the wound with a cannula. A single-throw slipknot was created, and the loop and knot were placed into the anterior chamber. A push-pull technique was used to retrieve the loop, and it was pulled through the 1 o'clock paracentesis. The suture loop was left exiting the main wound. The other end was then pulled through the opposite paracentesis incision at 5 o'clock. Tension on the loop and suture end at the 1 and 5 o'clock positions was applied to tighten the slipknot, and the occlusive pupilloplasty was completed.

      The endothelium and Descemet was scored using a blunt reverse Sinsky hook and then stripped using a 90-degree scraper. The viscoelastic was removed using irrigation and aspiration before the donor tissue was implanted. The donor tissue, which had previously been cut, was folded in a 60/40 taco fashion and inserted into the anterior chamber. To stabilize the graft while unfolding in a shallow anterior chamber, a fixation suture was placed in the inferior portion of the graft. Air was injected, and the tissue unfolded in good position requiring little manipulation with the Lindstrom roller. The eye was then pressurized by inserting air through a needle at the limbus. With the occlusive pupilloplasty, no air escaped to the back of the eye. A 100% air bubble was left in the eye for 12 minutes. Three drainage incisions were made in the cornea to drain fluid trapped in the interface. After 12 minutes, the air was replaced with balanced salt solution, leaving a 20% air bubble. The occlusive pupilloplasty was released by pulling on the loose end of the loop at the main wound. 

      Comment

      There are several surgeons who propose managing patients with ACIOL by performing an intraocular lens exchange with a scleral-sutured lens followed 6-8 weeks later by DSAEK.4 However, the two modifications described above allows DSAEK to be performed successfully in a single procedure with minimal additional surgical time. The occlusive pupilloplasty allows for the insertion of air at a high pressure to ensure good graft adherence without the fear of air escaping to the back of the eye and pushing the iris and ACIOL forward. This prevents pupillary block and disruption of the graft endothelium and also saves the patient from an extra lengthy procedure. There is a possibility that larger paracentesis incisions would need to be closed with a McCannel suture, but this has not been a problem in our cases to date.

      The fixation suture is placed to allow easy unfolding of donor tissue in a crowded anterior chamber. There is focal endothelial loss, but it will ensure that very little manipulation is needed after the unfolding. There are other techniques that can be used to fixate the donor tissue, but this has worked nicely in our cases.

      We believe DSAEK can be performed as a primary procedure in patients with ACIOL using the aforementioned modifications. The patients tolerate the procedure well and results have been good in the few cases we have performed. 

      Acknowledgement

      Supported in part by NIH/NEI EY-014793 (vision core) and an unrestricted grant to MUSC-SEI from Research to Prevent Blindness, New York, NY, USA. 

      Conflict of Interest Statement

      None of the authors have a proprietary interest in any product mentioned. 

      References

      1. Price FW, Price MO. Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral corneal transplant. J Refract Surg 2005;21:339-45.
      2. Price FW, Price MO. Descemet's stripping with endothelial keratoplasty (DSEK) in 200 eyes: early challenges and techniques to promote donor adherence. J Cataract Refract Surg 2006;32:411-418.
      3. Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea 2006;25:886-889.
      4. Kenyon KR, Gorovoy MS, Hamil MB, et al. New techniques change indications and outcomes of keratoplasty. Ocular Surgery News. March 15, 2006.

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