Corneal Deturgescence after Descemet Stripping Automated Endothelial Keratoplasty Evaluated by Visante Anterior Segment Optical Coherence Tomography

doi:10.1016/j.ajo.2009.01.016

American Journal of Ophthalmology

Volume 148, Issue 1, July 2009, Pages 32-37.e1

https://doi.org/10.1016/j.ajo.2009.01.016 Get rights and content

Purpose

To evaluate postoperative corneal deturgescence after Descemet stripping endothelial keratoplasty (DSAEK) using the Visante anterior segment optical coherence tomography (OCT) system (Carl Zeiss Meditec Inc, Dublin, California, USA).

Design

Retrospective case series.

Methods

We included 21 eyes (9 males and 12 females; mean age ± standard deviation, 76.3 ± 12 years). The Visante OCT system was used to determine the central and peripheral endothelial keratoplasty graft thickness and total central and peripheral corneal thickness.

Results

Central graft thickness decreased from the first day (243.3 ± 92 μm) to the last visit (147.8 ± 44 μm; P = .0001). The rate of central graft thinning slowed during the following intervals: during the first week (47 μm), at 1 week to 1 month (40 μm), and at 1 to 6 months (25 μm), with a mild increase at 6 to 9 months (5 μm). Peripheral graft thickness continued to decrease from postoperative day 1 (318.5 ± 99 μm) to the last visit (196.7 ± 50 μm; P = .0001). There was a decrease in total central corneal thickness from day 1 (903.8 ± 179 μm) to the last visit (671 ± 93 μm; P = .0001). All patients were imaged with the Visante OCT at the first 4 defined postoperative intervals; however, only 9 eyes were imaged at the last interval of 6 to 9 months.

Conclusions

After DSAEK, there is a greater thinning of the central graft compared with the peripheral graft. The central cornea thickness decreases and peripheral corneal thickness increases. Central corneal graft deturgescence stabilizes by 6 months after surgery.

Section snippets

Methods

We retrospectively reviewed the clinical and anterior segment OCT data of patients before and after DSAEK during the period from July 3, 2006 through July 31, 2007. We included 15 eyes with the diagnosis of Fuchs endothelial dystrophy and 6 eyes with bullous keratopathy. Twelve patients were female and 9 were male. The mean age ± standard deviation was 76.3 ± 12 years. DSAEK alone was performed in 12 eyes and DSEAK with phacoemulsification and posterior chamber intraocular lens implantation was

Clinical Results

All eyes had clinical follow-up and anterior segment OCT measurements at all defined intervals to the 3- to 6-month postoperative period; however, only 9 (43%) of 21 eyes had clinical follow-up and anterior segment OCT measurements at the last period of 6 to 9 months. The range of preoperative BSCVA was between hand movements and 20/50. The range of postoperative BSCVA was between counting fingers at 4 feet and 20/20. Eleven eyes improved 2 lines or more of BSCVA, 4 eyes improved 1 line of

Discussion

In the current study, we evaluated corneal deturgescence after DSAEK by using anterior segment OCT. Our results show that there is a difference in the deturgescence rate between the central and peripheral endothelial keratoplasty graft. The deturgescence rate of the central endothelial keratoplasty graft peaks during the first week in comparison with the peripheral endothelial keratoplasty graft, which peaks between 1 week and 1 month . Although OCT measurements were performed in only 9 (43%)

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Multivariate model of refractive shift in Descemet stripping automated endothelial keratoplasty
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There are more references available in the full text version of this article.

Cited by (60)

Precut Post–Laser In Situ Keratomileusis / Photorefractive Keratectomy Donor Corneas for Use in Endothelial Keratoplasty: Potential Impact of Postcut Morphology on Visual Outcomes
2018, American Journal of Ophthalmology
To evaluate the accuracy, complication rates, cut quality, and degree of induced hyperopic shift of eye bank–prepared post–laser in situ keratomileusis (LASIK)/photorefractive keratectomy (PRK) donor corneas compared to those of non-post-LASIK/PRK donor corneas.
The cut accuracy and failure rates of all post-LASIK/PRK donor cornea tissue processed for use in Descemet stripping automated endothelial keratoplasty (DSAEK) from January 2012 through December 2016 were compared to control cornea donor tissue. Corneas were analyzed for regularity and morphology of cut using anterior segment optical coherence tomography images. Using a mathematical model, the hyperopic shifts induced by post-LASIK/PRK donor lenticules were compared to the control corneas.
During the study period, 733 post-LASIK/PRK and 10 437 non-post-LASIK/PRK donor corneas were processed for DSAEK. Cut accuracy and quality were similar (P > .05), but there was an increased tissue wastage rate of 5.0% compared to 2.2% (P < .000001). For tissue < 100 μm in central thickness (P = .0001), and for tissue between 100 and 150 μm in central thickness (P = .0023), the difference between central and peripheral thickness when comparing the post-LASIK/PRK and control corneas was statistically significant. These differences resulted in a 1.96 diopter (D), 1.60 D, and 2.35 D hyperopic shift when using donor corneas 100 μm, 125 μm, and 150 μm thick, respectively, from post-LASIK/PRK donors compared to 1.11 D, 0.38 D, and 1.96 D from control donors.
Eye bank technicians and surgeons should be aware of the increased risk of tissue wastage when cutting post-LASIK/PRK corneas compared to non-post-LASIK/PRK donors. Surgeons should also be aware of the theoretical increase in hyperopic shift when using post-LASIK/PRK donor corneas compared to non-post-LASIK/PRK donors when cut to less than 150 μm.
NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
Practical assessment of DSAEK in the management of endothelial decompensation following penetrating keratoplasty
2017, Journal Francais d'Ophtalmologie
Rapporter nos résultats anatomiques et fonctionnels ainsi que les complications éventuelles des six premières Descemet's stripping endothelial keratoplasty (DSAEK) effectuées sur indication de décompensation de kératoplastie transfixiante (KT).
Il s’agit d’une étude monocentrique rétrospective et observationnelle, à propos des 6 patients ayant bénéficié d’une DSAEK secondairement à une KT antérieure décompensée, entre janvier 2015 et juillet 2016. Les données recueillies sont : caractéristiques démographiques (âge, sexe), comorbidités ophtalmologiques, indication initiale de la KT, délai entre la KT et la DSAEK. La meilleure acuité visuelle corrigée (MAVC) préopératoire et à 1, 3 et 6 mois postopératoires a été recueillie en échelle de Monoyer et Parinaud et convertie en log MAR pour l’analyse statistique. Les épaisseurs centrales respectives du greffon et de la cornée mesurées en OCT ainsi que les complications postopératoires ont été également recueillies.
La durée moyenne de suivi était de 7,2 mois (3–10). Le délai moyen depuis la KT était de 7,7 ans. L’âge moyen des patients était de 67,5 ans (32–87). L’indication initiale de la KT était une dystrophie de Fuchs (3/6), une décompensation du pseudophake (1/6), une plaie cornéenne (1/6) et une dystrophie cornéenne autre (1/6). Il s’agissait pour tous les patients de la première KT. Il s’agissait dans un cas, d’une chirurgie combinée phaco-DSAEK. Les complications observées étaient un décollement précoce du greffon traité par injection d’air intracamérulaire dans un cas et un œdème maculaire cystoïde dans un autre cas. L’épaisseur cornéenne centrale moyenne est passée de 780 μm à j7 à 656 μm à 6 mois. L’épaisseur moyenne du greffon est passée de 154 μm à j7 à 122 μm à 6 mois. La MAVC préopératoire moyenne était de 1,52 log MAR (1,0–1,7), comparée à la MAVC postopératoire moyenne qui était de 1,5 log MAR (1,1–3) à 1 mois, de 1,15 log MAR (0,5–1,7) à 3 mois et de 1,1 log MAR (0,7–1,7) à 6 mois (données disponibles pour 4 patients à 6 mois). La récupération d’acuité visuelle a été limitée dans 2 cas, malgré une clarté cornéenne rétablie (comorbidités associées).
Les résultats obtenus sont comparables avec ceux de la littérature. L’arrivée en fin de vie de nombreuses greffes transfixiantes permettra à l’avenir d’avoir des effectifs d’étude plus importants.
La réalisation d’une DSAEK sur des yeux préalablement greffés par KT est une bonne alternative à une nouvelle KT en cas de décompensation endothéliale du greffon. La possibilité d’une greffe lamellaire postérieure permet une récupération visuelle plus rapide, avec une conservation du dioptre cornéen antérieur et un taux de complications moindre.
To report our anatomical and functional results as well as possible complications of the first six Descemet's stripping endothelial keratoplasties (DSAEK) performed in our department for endothelial decompensation after penetrating keratoplasty (PK)
This was a retrospective and observational monocentric study of six patients with DSAEK after prior PK between January 2015 and July 2016. The data collected were: demographic characteristics (age, sex), ophthalmological comorbidities, initial indication for PK, delay between PK and DSAEK. Best corrected visual acuity (BCVA) preoperatively and at 1, 3 and 6 months postoperatively were collected in Monoyer's and Parinaud scale and converted to log MAR for statistical analysis. The central cornea and graft thickness measured on OCT as well as postoperative complications were also collected.
Mean follow-up duration was 7.2 months [3–10]. The average time after PK was 7.7 years. The mean age of the patients was 67.5 years [32–87]. The initial indication for PK was Fuchs dystrophy (3/6), pseudophakic bullous keratopathy (1/6), corneal laceration (1/6) and other corneal dystrophy (1/6). The authors report one case a combined phaco-DSAEK surgery. The complications observed were: an early graft detachment treated by an additional air bubble injection (1/6) and cystoid macular edema in one other case. The average central corneal thickness decreased from 780 μm at day 7 postoperatively to 656 μm at 6 months. The average thickness of the graft decreased from 154 μm at day 7 to 122 μm at 6 months. The mean preoperative BCVA was 1.52 log MAR [1.0–1.7], compared to the mean postoperative BCVA which was 1.5 log MAR [1.1–2.3] at 1 month, 1.15 log MAR [0.5–1.7] at 3 months and 1.1 log MAR [0.7–1.7] at 6 months (data available for 4 patients at 6 months). The recovery of visual acuity was limited in 2 cases, despite corneal clarity restored in all our patients.
Our results can be compared to those described in literature. As more penetrating keratoplasty grafts reach the end of their lives, this will allow for more powerful studies.
DSAEK on eyes previously treated with PK is a good alternative to a new PK in the case of endothelial decompensation of the graft. The possibility of a posterior lamellar graft allows for faster visual recovery, with preservation of the anterior corneal power and a lower rate of complications.
Effect of donor graft characteristics on clinical outcomes in Descemet stripping automated endothelial keratoplasty (DSAEK)
2017, Journal Francais d'Ophtalmologie
L’objectif de notre étude était d’évaluer l’évolution des greffons cornéens lamellaires après greffe endothéliale par Descemet stripping automated endothelial keratoplasty (DSAEK) et l’influence de leurs caractéristiques sur les résultats cliniques et fonctionnels.
Il s’agit d’une étude prospective, dans laquelle ont été inclus 74 patients opérés de greffe endothéliale par technique de DSAEK. Les greffons cornéens provenaient de l’établissement français du sang et ont été livrés dans un milieu de conservation contenant un agent de déturgescence (Corneajet^® ou Stemalpha 3^®). La pachymétrie du greffon cornéen était mesurée ex vivo par pachymétrie ultrasonique avant la dissection puis après la 1^e ou la 2^e découpe, le cas échéant. L’acuité visuelle corrigée en logMAR, la pachymétrie totale et du greffon, mesurées en OCT du segment antérieur (Spectralis^® HRA + SDOCT, Heidelberg engineering, Inc., Heidelberg, Allemagne) et la densité cornéenne (Pentacam^®, Oculus, Inc., Wetzlar, Allemagne) étaient relevées chez le patient en préopératoire, à j5, M1, M3, M6, M9 et M12.
Au total, 74 greffons cornéens, issus de donneurs âgés de 69,7 ± 13,3 ans en moyenne [37 à 92 ans] ont été greffés chez 67 patients âgés de 70,3 ± 12,1 ans. La pachymétrie prédissection était statistiquement plus élevée en cas de durée courte de déturgescence (r = −0,383, p = 0,001). Pour une même durée de déturgescence, la pachymétrie prédissection était statistiquement plus élevée dans le milieu Stemalpha 3^® (691 ± 89 μm pour le Corneajet^® vs. 760 ± 100 μm pour le Stemalpha 3^®, p = 0,01), avec une même pachymétrie finale (168 ± 31 μm vs. 166 ± 25 μm, p = 0,833). La pachymétrie du greffon et la pachymétrie cornéenne totale diminuaient significativement entre la mesure préopératoire et M12 (168 ± 29 μm vs. 92 ± 57 μm, p = 0,0008 et 665 ± 124 μm vs. 566 ± 73 μm, p = 0,027 respectivement). La densité endothéliale préopératoire (2938 ± 418 cellules/mm²) n’était pas corrélée à l’acuité visuelle postopératoire. Il existe une corrélation positive entre l’acuité visuelle à j5 et l’âge du donneur (r = 0,3, p = 0,04). L’acuité visuelle postopératoire était corrélée positivement à l’acuité visuelle préopératoire (p < 0,05). La densitométrie cornéenne était statistiquement supérieure à la densitométrie normale en postopératoire. La densité cornéenne à M1 était corrélée de manière positive au temps écoulé depuis le prélèvement sur le donneur (r = 0,373, p = 0,043). Il n’existait pas de différence significative entre les sous-groupes de plus ou de moins de 130 μm. Sept patients ont subi un échec de greffe sans qu’aucun facteur de risque de greffe ne ressorte de manière statistiquement significative.
Le milieu de conservation influence la pachymétrie prédissection sans conséquence sur les résultats cliniques. Dans notre étude, l’acuité visuelle préopératoire et l’âge du donneur sont corrélés à l’acuité visuelle après DSAEK.
Bien que le jeune âge du donneur soit lié à une meilleure acuité visuelle à j5, les autres caractéristiques du donneur n’ont pas d’influence sur les résultats cliniques.
The purpose of our study was to evaluate the progression of lamellar corneal grafts after endothelial keratoplasty by Descemet stripping automated endothelial keratoplasty (DSAEK) and the effect of their characteristics on the clinical and functional results.
This was a prospective study in which 74 patients who had undergone endothelial keratoplasty by DSAEK were included. The corneal grafts were obtained from a French tissue bank and were delivered in a preservation medium containing a deturgescent agent (Corneajet^® or Stemalpha 3^®). Pachymetry of the corneal graft was measured ex vivo by ultrasonic pachymetry prior to dissection, then after the 1st or 2^nd cut as necessary. Corrected visual acuity in logMAR, total graft pachymetry, measured by anterior segment OCT (Spectralis^® HRA + SDOCT, Heidelberg engineering, Inc., Heidelberg, Germany) and corneal density (Pentacam^®, Oculus, Inc., Wetzlar, Germany) were obtained for each patient preoperatively, at D5, M1, M3, M6, M9 and M12.
Overall, 74 corneal grafts, from donors of mean age 69.7 ± 13.3 years (37 to 92 years) were transplanted into 67 patients aged 70.3 ± 12.1 years. Predissection pachymetry was statistically significantly thicker in the case of short deturgescence time (r = −0.383, P = 0.001). For the same deturgescence time, predissection pachymetry was statistically significantly thicker in the Stemalpha 3^® medium (691 ± 89 μm for Corneajet^® vs. 760 ± 100 μm for Stemalpha 3^®, P = 0.01), with the same final pachymetry (168 ± 31 μm vs. 166 ± 25 μm, P = 0.833). Graft pachymetry and total corneal pachymetry decreased significantly between the preoperative measurement and M12 (168 ± 29 μm vs. 92 ± 57 μm, P = 0.0008 et 665 ± 124 μm vs. 566 ± 73 μm, P = 0.027 respectively). Preoperative endothelial cell density (2938 ± 418 cells/mm²) did not correlate with postoperative visual acuity. There was a positive correlation between visual acuity at D5 and donor age (r = 0.3, P = 0.04). Postoperative visual acuity correlated positively with preoperative visual acuity (P < 0.05). Corneal densitometry was statically higher than normal postoperative densitometry. Corneal density at M1 correlated positively with time since obtaining the donor tissue (r = 0.373, P = 0.043). There was no significant difference between the sub-groups of over or under 130 μm. Seven patients experienced graft failure with no statistically significant graft risk factor.
The preservation medium affects predissection pachymetry with no consequence on clinical results. In our study, preoperative visual acuity and donor age were correlated with visual acuity after DSAEK.
Although donor age was associated with better visual acuity at D5, the other donor characteristics had no effect on clinical results.
Determinants of visual quality after endothelial keratoplasty
2016, Survey of Ophthalmology
Endothelial keratoplasty is now favored over full-thickness penetrating keratoplasty for corneal decompensation secondary to endothelial dysfunction. Although endothelial keratoplasty has evolved as surgeons strive to improve outcomes, fewer patients than expected achieve best corrected visual acuity of 20/20 despite healthy grafts and no ocular comorbidities. Reasons for this remain unclear, with theories including anterior stromal changes, differences in graft thickness and regularity, induced high-order aberrations, and the nature of the graft-host interface. Newer iterations of endothelial keratoplasty such as thin manual Descemet stripping endothelial keratoplasty, ultrathin automated Descemet stripping endothelial keratoplasty, and Descemet membrane endothelial keratoplasty have achieved rates of 20/20 acuity of approximately 50%, comparable to modern cataract surgery, and it may be that a ceiling exists, particularly in the older age group of patients. Establishing the relative contribution of the factors that determine visual quality following endothelial keratoplasty will help drive further innovation, optimizing visual and patient-reported outcomes while improving surgical efficacy and safety.
Effect of Graft Thickness on Visual Acuity after Descemet Stripping Endothelial Keratoplasty: A Systematic Review and Meta-Analysis
2016, American Journal of Ophthalmology
Citation Excerpt :
One study did not report a correlation but found better vision in a group with thinner grafts (categorical analysis).4 Of the individual studies that found a statistically significant relationship, several had methodological limitations, such as unexplained outliers with high leverage (eyes with very poor BCVA that would otherwise be incompatible with a healthy visual system and healthy graft),15,17 very small sample sizes,30,36 or incongruent data reporting.20,25 One study reported greater improvement in visual acuity with thinner grafts, but did not address whether eyes with thinner grafts had better visual outcomes,25 and we interpreted 1 study as assessing the relationship between improvement in BCVA and improvement in corneal thickness in the postoperative period.23
To assess the relationship between graft thickness and best-corrected visual acuity (BCVA) after Descemet stripping endothelial keratoplasty (DSEK).
Systematic review and meta-analysis.
PubMed, EMBASE, Web of Science, and conference abstracts were searched for studies published up to October 2015 with standard systematic review methodology. Eligibility criteria included studies evaluating graft thickness in primary DSEK and visual outcomes. There were no restrictions to study design, study population, or language. Correlation coefficients were pooled using random-effects models.
Of 480 articles and conference abstracts, 31 met inclusion criteria (2214 eyes) after full-text review. Twenty-three studies assessed correlations between BCVA and graft thickness, and 8 studies used different statistical methods. All associations were reported dimensionless. Studies generally had small sample sizes and were heterogeneous, especially with respect to data and analysis quality (P = .02). Most studies did not measure BCVA in a standardized manner. The pooled correlation coefficient for graft thickness vs BCVA was 0.20 (95% CI, 0.14–0.26) for 17 studies without data concerns; this did not include 7 studies (815 eyes) that used different statistical methods and did not find significant associations.
There is insufficient evidence that graft thickness is clinically important with respect to BCVA after DSEK, with meta-analysis suggesting a weak relationship. Although well-designed longitudinal studies with standardized measurements of visual acuity and graft thickness are necessary to better characterize this relationship, current evidence suggests that graft thickness is not important for surgical planning.
Comparison of anterior and posterior topographic analysis between 3 imaging systems
2015, Journal of Cataract and Refractive Surgery
To evaluate and compare (anterior and posterior) corneal parameters obtained by use of 3 corneal topography devices.
Tertiary referral eye center, Singapore.
Prospective observational study.
Corneal measurements were obtained from 30 normal eyes and 40 eyes after Descemet-stripping automated endothelial keratoplasty (DSAEK) with use of the spectral-domain AS-OCT device, Scheimpflug device, and time-domain AS-OCT device. The posterior area analyzed, anterior and posterior keratometric values, keratometric power, and pachymetry were compared.
The spectral-domain AS-OCT device was able to capture the highest posterior area analyzed (86.2% ± 6.7%) compared with the Scheimpflug device (56.8% ± 11.9%) and the time-domain AS-OCT device (68.8% ± 12.3%) (P < .001). Intra-class coefficients (ICC) indicated strong agreement between devices in anterior keratometry (ICCs between 0.9 to 1.0) in both normal and DSAEK eyes. Agreement was poor to moderate for normal eyes (ICCs between 0.6 to 0.9) but poor in DSAEK eyes (ICCs between 0.60 to 0.7). For corneal pachymetry, agreement was moderate to strong for normal eyes (ICCs between 0.8 to 1.0) but showed poor to moderate agreement in DSAEK eyes (ICCs between 0.5 to 0.8). Vector analysis plots for mean astigmatism values showed greater differences between devices in anterior values compared with posterior values in both groups.
Although the agreement between imaging systems was good for anterior corneal topography, posterior corneal topography had moderate agreement in normal eyes and poor agreement in eyes after endothelial keratoplasty.

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Mario A. Di Pascuale, MD, is an Ophthalmology resident at the University of Texas Southwestern Medical Center in Dallas, Texas. He received his medical degree from Universidad Central of Venezuela, Caracas, Venezuela, in 1996. Dr Di Pascuale did his initial residency training in Ophthalmology at the Universidad Central of Venezuela. He did a fellowship in Ocular Surface Disease at Ocular Surface Center, Miami, Florida. Afterwards, Dr Di Pascuale completed a fellowship in Cornea, External Disease, and Refractive Surgery at the University of Texas Southwestern Medical Center. His current work interests are corneal lamellar transplantation, corneal imaging, dry eye, ocular surface reconstruction, and refractive surgery.

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Original articleCorneal Deturgescence after Descemet Stripping Automated Endothelial Keratoplasty Evaluated by Visante Anterior Segment Optical Coherence Tomography

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Clinical Results

Discussion

Ophthalmology

J Cataract Refract Surg

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Endothelial cell loss after Descemet stripping endothelial keratoplasty in a large prospective series

Ophthalmology

Original article
Corneal Deturgescence after Descemet Stripping Automated Endothelial Keratoplasty Evaluated by Visante Anterior Segment Optical Coherence Tomography