PART III
INCIDENCE OF PK1 PK/10.000 People Required in 1
Year
ITALY = 6,000 PKs/Year
• Impaired Corneal Curvature (i.e. Keratoconus)
• Impaired Corneal Transparency & Decompensated Endothelium
(i.e. Bullous Keratopathy)
• Impaired Corneal Transparency & Normal Endothelium
(i.e. Corneal Scars)
MAIN INDICATIONS
Impaired Corneal Curvature
KERATOCONUS
MAIN INDICATIONS
Impaired Corneal Transparency & Decompensated Endothelium
BULLOUS KERATOPATHY (Fuchs or Postoperative)
MAIN INDICATIONS
Impaired Corneal Transparency & Normal Endothelium
SCARS s/p KERATITIS (viral, bacterial, ecc.)
MAIN INDICATIONS
Impaired Corneal Transparency & Normal EndotheliumCORNEAL DYSTROPHIES AND DEGENERATIONS
MAIN INDICATIONS
Impaired Corneal Transparency & Normal Endothelium
SCARS s/p TRAUMA
MAIN INDICATIONS
• KERATOCONUS = 40-45%
• DECOMPENSATED ENDOTHELIUM = 30-35%
• NORMAL ENDOTHELIUM = 20-25%
MAIN INDICATIONS (up to 2005)
• KERATOCONUS = 30-35%
• DECOMPENSATED
ENDOTHELIUM = 40-45%• NORMAL ENDOTHELIUM = 20-25%
MAIN INDICATIONS (2015)
• RECOVERY OF TRANSPARENCY
• RECOVERY OF NORMAL CURVATURE
• RECOVERY OF BOTH
PENETRATING KERATOPLASTY
PK (from’60s)
One Solution for ALL !!!
KPL IN THE XX CENTURY
LK (up to ’50s)
Hand Dissection
“Bad” Interface
Poor Vision (<20/40)
KPL IN THE XX CENTURY
PK = the “GOLD STANDARD”Operating Microscope
Endothelial Function/Viscoprotection
Suturing Material/Technique
Trephines/Punches
Lasers
KPL IN THE XX CENTURY
Healing > 1 Year Suture Removal after 1 y VA Limitated by Distortion
(Sutures in Place)
Final Astigmatism after Suture Removal 4 D in 20% of Cases
KPL IN THE XX CENTURY “Perfect Disc in a Perfectly
Round Hole”
“TOP HAT” PK
Busin, Arch. of Ophthalmol. 2003
Top Hat
Mushroom
Zig-Zag
FEMTO-SHAPED PK
Stromal Dissection May Be Compatible with 20/20 VA (LASIK !!!)
Corneal Layers Can Stick to Each Other without
Sutures (Melles 1998)
NEW INFORMATION & KPL
Infections Dystrophies Degenerations Post-Surgical (PRK) Others
DISEASED STROMA
Primary Corneal Edema (Fuchs) Post-Surgical BK PK FailureEndothelial Dystrophies ICE Syndrome Others
DISEASED ENDOTHELIUM
Traumata Infections (HSV) Macular Dystrophy Others
COMBINATIONS
“NEW” KERATOPLASTYCorneal Disease
Healthy Endothelium
Diseased Endothelium
Anterior LK
(Mushroom)
Posterior LK
(PK)
DISSECTION:
Manual
Pneumatic (“Big Bubble”)
Microkeratome
Femtosecond Laser
NEW INFORMATION & KPL
Difficult
Non Reproducible
Interface of Poor Optical Quality (20/20 Vision
Only if Very DEEP !!!)
CORNEAL DISSECTION
MANUAL:
Learning Curve
Non Reproducible (30-90%)
20/20 is the RULE (DM or Dua’s Layer)
CORNEAL DISSECTION
PNEUMATIC:
MICROKERATOME: Easy Use and Relatively
Reproducible
Relatively Imprecise
Interface of Excellent Optical Quality (20/20 Vision is the RULE !!!)
CORNEAL DISSECTION
FEMTOSECOND LASER: Expensive but
Precise Optical Quality
of Interface ???
CORNEAL DISSECTION
FEMTOSECOND LASER:
Does NOT Cut through
Opacities !!!
CORNEAL DISSECTION
“NEW” KERATOPLASTYCorneal Disease
Healthy Endothelium
Diseased Endothelium
Anterior LK
(Mushroom)
Posterior LK
(PK)
A STAGED STRATEGY1/3 ANT. STROMA (≤ 200 m) (Healthy Endothelium)
SALK (SUPERFICIAL ANTERIOR LK)
ANTERIOR LK
2/3 ANT. STROMA (≤ 350-400 m) (Healthy Endothelium)
DALK (DEEP ANTERIOR LK)
A STAGED STRATEGYANTERIOR LK
100% STROMA (Healthy Endothelium)
“BIG BUBBLE”
A STAGED STRATEGYANTERIOR LK
PREOP OCT
CHOICE OF PROCEDURE
ANTERIOR LK
PREOP OCT
CHOICE OF PROCEDURE
ANTERIOR LK
PREOP OCT
CHOICE OF PROCEDURE
ANTERIOR LK
+/- Sutures
1-Month Healing
Minimal Postop Refr. Error
SALK Compares to LASIKANTERIOR LK
Sutures
1-Year Healing
20% High Astigmatism
DALK Compares to PKANTERIOR LK
SALK (SUPERFICIAL ANTERIOR LAMELLAR KERATOPLASTY)
• Subepithelial Scarring (s/p PRK)• Subepithelial Irregularity (Bowman’s Dystrophy, s/p Superficial Keratitis)• Superficial Stromal Opacities (Granular
Dystrophy, Lattice Dystrophy)
SUPERFICIAL ANTERIOR LK (SALK)
TISSUE REMOVAL = 130-200 mNEW LAMELLA = 90-130 m
SALK3 years post-SALK BSCVA = 20/20Ref. = +3.00 sph. -2.00 cyl. @ 170°
HSV Keratitis 1 year s/p SALK UCVA = 20/100BSCVA = 20/25(-1.00 sf. –1.25 cil. @ 175°)
SALKHSV Keratitis pre SALKUCVA = 20/200BSCVA = 20/200
IRREGULAR ASTIGMATISM
DEEP ANTERIOR LK (DALK)
TISSUE REMOVAL = 200-300 mNEW LAMELLA = 300-350 m
DALK (DEEP ANTERIOR LAMELLAR KERATOPLASTY)
Various Etiology (s/p Infection, s/pTraumas, Dystrophies) Scarring Limited to 2/3 of Anterior Stroma NORMAL CORNEAL THICKNESS !!!
DALKLattice Dystrophy preop VA = 20/50
Lattice Dystrophy postop VA = 20/20
DALKLattice Dystrophy pre DALK
Lattice Dystrophy post DALK
“BIG BUBBLE” (DALK)
TISSUE REMOVAL = 99% StromaNEW LAMELLA = w/o Endoth.
IRREGULAR ASTIGMATISM
Keratoconus VA = 20/4002 Years post-DALKVA = 20/20 !!!
DALK
1m Postop VA 20/25 (+1.00 sph.-2.25
cyl. @ 20°)
“SMALL BUBBLE” DALK
DALK
Infl. Infiltrate
Scar Tissue
Adhesions
Risk of Perforation
Descemet Involvment
Opacity of Residual Bed
SMALL Grafts
LOWER
Rejection Rate
HIGHER Refractive Error
LARGE Grafts
HIGHER
Rejection Rate
LOWER Refractive Error
CONVENTIONAL PK
ENDOTHELIAL MIGRATION
Imaizumi T.Imaizumi T. (1990)
Groh MJGroh MJ et al. et al. (1999, 2000)
Kruse et al. (2011)
CONVENTIONAL PK
ENDOTHELIAL MIGRATION
FROM HIGHER TO
LOWER DENSITY
FROM GRAFT INTO HOST (ABK, PBK, FUCHS, etc.)
ENDOTHELIAL MIGRATION
FROM HIGHER TO
LOWER DENSITY
FROM HOST INTO GRAFT (KC, INFECTIONS, etc.)
“MUSHROOM” PKConcept:“Minimal Endothelial Replacement”
r = 3 mm S = 32
S = r2
r = 6 mm S = 62
“MUSHROOM” PKAREA OF RESIDUAL HEALTHY ENDOTHELIUM
(62 ) – (32 )
36 – 9
27 mm2
>75% !!!
“MUSHROOM” PK
ANTERIOR LK = “HAT”(thickness = 250 m; diameter = 9-9.5 mm)
POSTERIOR LK = “STEM”
(thickness = 300 m; diameter = 5-6 mm)
MUSHROOM PK FULL-THICKNESS
OPACITY
HEALTHY ENDOTHEL.
CORNEA OF UNEVEN THICKNESS (NEOVESSELS !!!)
100% STROMA + SCAR (Healthy Endothelium)
“MUSHROOM” PK
A STAGED STRATEGYANTERIOR LK
ADVANTAGES:LK Wound HealingPK EffectOptimal RefractionEndothelial Spare
2-Piece “MUSHROOM” PK
Survival Analysis (K-M) 1 y 2 y 5 y
Overall 98.3% 97.5% 95.3%Low Risk 100% 98.5% 96.3%High Risk 96.1% 96.1% 93.9%
GRAFT SURVIVAL
Rejection RateHigh Risk 2/71 (2.8%)Low Risk 4/109 (3.7%)
GRAFT SURVIVAL
Endothelial Rejection
Previous Case (2 Years postop), Resolved with Steroids
GRAFT SURVIVAL
Endothelial Repopulation?
Day 0 Month 6 Month 12
GRAFT SURVIVAL
“MUSHROOM” PK
CASE 1 (2004):35-year-old Males/p Perforating Injury OS10 months postopUCVA = 20/200BSCVA = 20/20(-2.50 sf –1.00 cil @ 20°)
“MUSHROOM” PK
CASE 2 (2008):39-year-old Females/p Amoebic K OS5 Years postopUCVA = 20/200BSCVA = 20/22.5(-3.50 sf –4.00 cil @ 70°)
“MUSHROOM” PK
CASE 3 (2007):9-year-old girss/p HZK OS4 Years postopUCVA = 20/40BSCVA = 20/25(+0.50 sf –3.50 cil @ 40°)
“MUSHROOM” PK
CASE 4 (2010):16-year-old Males/p HSK OS2 Years postopUCVA = 20/50BSCVA = 20/20(-1.50 sf –2.75 cil @ 155°)
• Primary Corneal Edema (Fuchs)• Post-Surgical BK• PK Failure•Endothelial Dystrophies• ICE Syndrome• Others
CONVENTIONAL PK SURGERY
POSTERIOR LK
Tillet (’50s)
Barraquer (’60s)
NEW ORLEANS (USA) 1984-86
Dr. H.E Kaufman, Dr. M.B.McDonald and Cornea Fellows
Kaufman 1980Epikeratophakia for Aphakia
“THE LIVING CONTACT LENS”
ANTERIOR “ONLAY” LK
SUBSTITUTIVE (“INLAY”)ADDITIVE (“ONLAY”)
LAMELLAR KERATOPLASTY
POSTERIOR “ONLAY” LK CONCEPT
1
4
2
3
1. Peeling of Descemet + endothelium
2. Tunnel approach
3. Preparation of posterior donor lamella (endothelium + deep stroma)
4. Suturing to the bare posterior stromal surface
ENDOKERATOPLASTY: A NEW SURGICAL TECHNIQUE FOR THE REPLACEMENT OF DISEASED CORNEAL ENDOTHELIUM
Massimo Busin1, M.D., Thomas Mönks2, M.D., Robert Arffa3, M.D.1 University of Bonn, Germany, 2 Surgical Eye Center Viktoriahaus, Krefeld, Germany, 3 Allegheny General Hospital, Pittsburgh, Pennsylvania
MATERIALS AND METHODS
Donor lenticules were prepared as follows: Approximately 80% of the anterior stroma of the donor corneas was removed with a microkeratome(Storz, Heidelberg, Germany) and a 6mm button was trephined. In five eyes a 4mm limbal incision was made and the central endothelium and Descemets membrane were removed. In four eyes a donor lenticulewas then sutured to the posterior surface of the central cornea, using four to five prolene 10-0 mattress sutures. The fifth eye did not receive any lenticule and served as control. All animals were examinded 1, 3, 5, 7, and 14 days after surgery and clinical pictures were taken. On the fourteenth day they were killed and the excised corneas submitted for histologic evaluation.
INTRODUCTION
To date, penetrating keratoplasty (PK) is the only available surgicaltreatment for endothelial decompensation. Although epithelium and stroma are not primarily affected, this procedure involves full-thickness transplantation, leading to unsatisfactory refractive results ina relatively high number of patients. A new surgical technique aimed at replacing exclusively the diseased endothelium is presented by means of a rabbit model.
RESULTS
Despite the technical difficulty of handling very thin corneaslike therabbit ones, it was possible in all animals used in this experiment study to perform endokeratoplasty as theoretically designed. By two weeks all of the corneas with endokeratoplasty-lenticules demonstrated substantial clearing, while the scraped cornea did not. On histology only a small proportion of the endothelial cells were present onthe donor lenticules.
CONCLUSION
Endokeratoplasty exhibits potential for endothelial transplantationand merits further study. Possible advantages of this procedure overconventional PK surgery include:
1) reduced postoperative corneal distortion in the absence of a full-thickness surgical wound;2) increased safety secondary to the use of a short tunnel approach3) reduced immunogenicity (no epithelium is transplanted).Improved handling of the donor lenticule and use of an alternateanimalmodel, e.g. primates, may improve endothelial cell transfer.
This study was supported in part by a grant from the Medical EyeBank of Western Pennsylvania, Pittsburgh, Pennsylvania.
Fig. 1:Schematic representation of endokeratoplastysurgery: a) Edematous cornea; b) Removal of Endotheliumfrom the center of the recipient cornea (arrows); c) Insertionof the endokeratoplasty-lenticule through a scleral tunnel;d) Suturing in place of the endokeratoplasty-lenticule.
Fig. 2:Endokeratoplasty surgery in a rabbit model: A) Removal of Descemts membrane and endothelium fromthe recipient central cornea; B) Entering the anterior chamberwith a 4mm keratome; C) Preparation of a 10-0 prolene mattress suture to fixate the endokeratoplasty-lenticule;D) Mattress suture led through the recipient cornea at the 6 oclock position.
Fig. 3:Postoperative results: A) Rabbit cornea with endokerato-plasty-lenticule fixated with four 10-0 prolene mattress sutures. The slit-lamp examination reveals tight contact between donor lenticule and recipient cornea as well as only moderate corneal edema; B) Control cornea exhibiting marked edema in the central area denudes of the endothelium.
a
b
c
d
POSTERIOR “ONLAY” LK (ENDOKERATOPLASTY)
Busin et al. OPHTHALMOLOGY, 1996 (Suppl.)
DLEK (Melles 1998)
SUTURELESS POSTERIOR INLAY LK
(D)eep (L)amellar (E)ndothelial (K)eratoplasty
DSEK (2002)
SUTURELESS POSTERIOR ONLAY LK
(D)escemet (S)tripping (E)ndothelial (K)eratoplasty
DSAEK (2004)
(D)escemet (S)tripping (A)utomated (E)ndothelial
(K)eratoplasty
SUTURELESS POSTERIOR ONLAY LK
DMEK (2006)
(D)escemet (M)embrane (E)ndothelial (K)eratoplasty
SUTURELESS POSTERIOR INLAY LK
U(ltra)T(hin)-DSAEK (BUSIN, 2009)
SUTURELESS POSTERIOR ONLAY LK
TODAY GOLD STANDARD
FOR SURGICAL TREATMENT OF ENDOTHELIAL
DECOMPENSATION
DSAEK
2010 statistical report
1.429 20056.122 200614.159 200717.468 200818.221 200919.159 2010
USA
1000/5.300 (2010)
ITALY
DSAEK – VISUAL OUTCOME
BSCVA ≥ 0.538% to 100%at 3-6 months72.96% at 1 month*81.13% at 3 mos*
*Personal Data, Excluding Co-Morbidities
Post-PK VA in ABK/PBK Patients
DSAEK – VISUAL OUTCOME
BSCVA ≥ 1.00% to 71%**30.19% at 6 mos*50%% at 6 mos*50%% at 6 mos*
**UT-DSAEK Neff et al, *UT-DSAEK Personal Data*Personal Data, Excluding Co-Morbidities
DSAEK – GRAFT SURVIVAL
ECL at 1 Year Average = 41% (29-61%) DSAEK = 23%*UT = 29%*
*UT-DSAEK Personal Data*DSAEK Personal Data
0102030405060708090
100
1 Year 2 Years 3 Years
Endothelial Cell Loss (ECL) in % after DSAEK
DSAEK – COMPLICATIONS
Detachment Rate Average = 14.5% (0-82%) DSAEK = <5%*UT = <1%*
*UT-DSAEK Personal Data*DSAEK Personal Data
A DOUBLE CHAMBER
MAY BE A VERY
SUBTLE FINDING !!!
DSAEK – COMPLICATIONS
DSAEK – COMPLICATIONS
GRAFT ATTACHMENT
NO AQUEOUS IN THE INTERFACE !!!
GRAFT ATTACHMENT Air Tamponade
(Squeezes out Aqueous)
Price’s Venting Incisions (Evacuate Aqueous)
DSAEK COMPLICATIONS
GRAFT ATTACHMENT
100% Possible !!!
DSAEK–GRAFT ATTACHMENT
“Closed System” Fast Visual Rehabilitation Better UCVA and BSCVA Reduced Astigmatism/
Other Aberrations Rare Complications
IDEAL KERATOPLASTY
DSAEK PROSRARE LATE
COMPLICATIONS !!! INTACT INNERVATION
IMMUNOLOGIC PREVILEGE
NO SUTURE RELATED COMPLICATIONS
Patients with BSCVA ≥ 1.0DMEK vs DSAEK
DSAEK = 0% to 33%*
DMEK = 20% to 45%*DSAEK Personal Data
Postoperative Refractive ErrorDMEK vs DSAEK
DSAEK = Hyperopic Shift (1 D)
DMEK = Neutral
Graft Rejection Rate in Fuchs’
DSAEK = 2% - 18%
DMEK = < 1% (13%)
DSAEK vs DMEK
DMEK vs DSAEK
MEMBRANE
Vs
LAMELLA
DMEK
Easy & Reproducible
No Waste of Tissue
Allow Alternatives (DSAEK!!!)
IDEAL TECHNIQUE
DMEK
Preparation
Delivery into AC
Positioning
Attachment
SURGICAL CHALLENGES
DMEK Waste of Tissue
up to 16%
Detachment Rate up to 63%
Primary Graft Failure up to 8%
DMEK
4 DAYS POSTOP
EK IN THE USAIn 2011:
DSAEK n ± 21,000
DMEK n = 343
EK IN THE USAIn 2012:
DSAEK n ± 25,000
DMEK n = 744
EK IN THE USAIn 2013:
DSAEK n = 23,465
DMEK n = 1,522
EK IN THE USAIn 2014:
DSAEK n = 23,100
DMEK n = 2,865
IDEAL CASE:
FUCHS &
INTACT PC
DMEK
SAFETYDSAEK
POOR VISUALIZATIONPOOR VISUALIZATIONDSAEK vs DMEK
DANGER OF LUXATION DSAEK vs DMEK
DSAEK & ACIOLDSAEK vs DMEK
DSAEK & IOL EXCHANGEDSAEK vs DMEK
DSAEK & ACIOL in PCDSAEK vs DMEK
DMEK CONSHIGH SURGICAL SKILLS REQUIRED (NO AVERAGE SURGEON!!!) PROLONGED SURGICAL TIME
COMPLICATION RATE HIGHER
NOT SUITABLE FOR ALL EYES
DMEK CONSNOT FOR EVERY
SURGEON !!!
NOT FOR EVERY EYE !!!
55-Year Old Patient with Fuchs’
Dystrophy + Cataract BSCVA
preop: 20/100 BSCVA 1 m postop: 20/20
Thin Endothelial Grafts (DMEK-Like)
Ease of Preparation (Microkeratome)
Ease of Delivery (DSAEK-Like)
DMEK vs DSAEKIDEAL GRAFT FOR EK
DSAEK vs DMEKIS THE
INTERFACE THE TRUE PROBLEM
???
RECENT DSAEK Grafts Thinner Than
131 µm Lead to Improved Visual Outcomes up to 75% VA 20/20 (Neff et al. 2010)
U(ltra)T(hin)-DSAEK (BUSIN, 2009)
SUTURELESS POSTERIOR ONLAY LK
UT-DSAEKSURGICAL TECHNIQUESame As DSAEKExcept for:
Graft Preparation
Graft Delivery
Prospective Study (Ophthalmology, June 2013)
Preop BSCVA ≤ 6/10
ULTRATHIN (UT) DSAEK
ISSUE # 1BSCVA ≥ 10/10 in Eyes with 10/10 Potential
BSCVA post UT-DSAEK in Eyes with 10/10 Potential
UT-DSAEK DMEK10/10= 20/20 39% 41%
8/10= 20/25 71% 80%6/10= 20/30 95% 98%
ECL 34% 36%Data for Fuchs or PBK indications only, w/o comorbidities
1 Year UT-DSAEK vs DMEK
ISSUE # 2SPEED OF
VISUAL RECOVERY
BSCVA preop DMEK 0.51± 0.44
logmar±3/10
BSCVA preop UT-DSAEK 0.76 ± 0.49 logmar ±1.5/10
BSCVA preop DMEK 0.51± 0.44
logmar±3/10
BSCVA preop PHAKIC
UT-DSAEK 0.55 ± 0.43
logmar ±2,8/10
ISSUE # 2
Why not 100% BSCVA
of 10/10 ???
DSAEK/UT-DSAEK/DMEKPOSSIBLE CAUSES INTERFACE ? GRAFT THICKNESS ? HOA ? RECIPIENT CORNEA !
Patients with BSCVA ≥ 10/10
≥10/10 = 20% to 45% <10/10 = 55% to 80%
DMEK
DSAEK/UT-DSAEK/DMEKPOSSIBLE CAUSES INTERFACE ? GRAFT THICKNESS ? HOA ? RECIPIENT CORNEA !
DSAEK/UT-DSAEK/DMEK
BSCVA = 9/10CGT= 61 µm
6 mos Postop UT-DSAEK
INTERFACE/THICKNESS
DSAEK/UT-DSAEK/DMEK
BSCVA = 4/10CGT= 127 µm
12 mos Postop DSAEK
INTERFACE/THICKNESS
DSAEK/UT-DSAEK/DMEK
BSCVA = 10/10CGT= 61 µm
9 mos Postop re-DSAEK (UT-DSAEK)
INTERFACE/THICKNESS
Corneal higher-order aberrations after Descemet's membrane endothelial keratoplasty.Rudolph M1, Laaser K, Bachmann BO, Cursiefen C, Epstein D, Kruse FE.Ophthalmology. 2012 Mar;119(3):528-35
DMEK/DSAEK/PK
Pentacam Analysis !!!
DSAEK/UT-DSAEK/DMEK
High Order AberrationsUT-DSAEK = Planar Graft !!!
315 251
92 95
92 95
Thin, Regular Shape
Thick, Irregular Shape
160 318
DSAEK/UT-DSAEK/DMEK
IMPROPER PUNCHING
!!!
DSAEK/UT-DSAEK/DMEK
DSAEK/UT-DSAEK/DMEK
DMEK Graft Variables ECC Diameter ???
DSAEK/UT-DSAEK/DMEKDS(A)EK Graft Variables ECC Diameter STROMA (Thickness, Regularity, Orientation)
DSAEK/UT-DSAEK/DMEK
BSCVAUT-DSAEK >> DSAEK !!!UT-DSAEK ≥ DMEK !!!
DSAEK/UT-DSAEK/DMEK
(Historical Controls)
Thick, Regular Shape !!!
DSAEK/UT-DSAEK/DMEK
204 197
9 mos Postop DSAEKVA = 10/10
OD UT-DSAEK VA = 12/10
OS DSAEK VA = 6/10
UT-DSAEK/DSAEK
OD UT-DSAEK VA = 12/10
OS DSAEK VA = 6/10
UT-DSAEK/DSAEK
OS UT-DSAEK VA = 16/10
OD DMEK VA = 10/10
UT-DSAEK/DMEK
OS UT-DSAEK VA = 16/10
OD DMEK VA = 10/10
UT-DSAEK/DMEK
UT-DSAEK/DMEK
UT-DSAEK vs DMEK = PD-DALK vs DALK
DSAEK/UT-DSAEK/DMEK
DSAEK/UT-DSAEK/DMEK
RECIPIENT CORNEA
c dDIFFERENT PREOPERATIVE
CONDITION !!!
ISSUE # 3IMMUNOLOGIC
REJECTION
IMMUNOLOGIC REJECTIONLow-Risk Eyes n = 237High-Risk Eyes n = 48
Previous Graft(s) n = 39Corneal Vascul. n = 6Herpetic Endothelit. N = 3
UT-DSAEK Imm. Rej.
POSTOPERATIVE TREATMENT
Topical Dexamethasone 0.1%Tapered off over a 5-month Period (from 2-Hourly to qd) qd Lifelong (unless Contraindicated)
For Eyes at High Risk 1.0-1.5 mg/Kg Prednisone p.o. Tapered off over a 2-
month Period
Endothelial Rejection in 4/162 Eyes (2.47%)
Low Risk n=3/142(2.1%)High Risk n=1/21 (4.8%)
All Cases Resolved with Steroidal Treatment !!!
UT-DSAEK Imm. Rej.
DSAEK* UT DMEK
1 Year 6% 2.5% 1%
2 Years 10% 2.5% 1%
*Fuchs Indications Only
DSAEK/UT-DSAEK/DMEK Cumulative Probability (K-M)
COMPLICATIONS UT-DSAEK DMEK*
Air Re-injection 3% 17-77%
Primary Failure 1% 9%Rejection1yr 2.5% 0-13%
Tissue Loss 1% 0-13%Data for Fuchs or PBK indications only
CONCLUSIONSDMEK vs
GOOD (UT)DSAEK !!!
CONCLUSIONSOutcomes of UT-DSAEK Compare
Favorably with Those of Conventional
DSAEK and Do Not Differ
Substantially from Those of DMEK
50μ54μ
UT-DSAEK
365μ204μDSAEK
32μ52μ DMEK
UT-DSAEK/DMEK
DMEK 2.0
UT-DSAEK/DMEK
DMEK 2.0StandardizationSubstantial Advantages
UT-DSAEK/DMEKDMEK 2.0
SimplifyReduce TraumaEliminate Primary Failure
(UPSIDE DOWN!!!)
UT-DSAEK/DMEK
DMEK 2.0TOTAL
CONTROL !!!
DMEK 2.0
Step #1: TRI-FOLDING
DMEK 2.0
Step #2: CL TRANSFER
DMEK 2.0
Step #3: LOADING A-B
Endothelium
Descemet
DMEK 2.0
Step #3: LOADING C-D
DMEK 2.0
Step #4: POSITIONING
DMEK 2.0
Step #5: PULL-THROUGH
DMEK 2.0
Step #5: PULL-THROUGH
DMEK 2.0Results 6 Mos Post-DMEK20 Consecutive Uneventful
DMEKVA≥20/25 in 16/20 Eyes
DMEK 2.0Forceps Trauma
50 µm
EACH BITE = 0.03mm2 = 50-75 Cells
DMEK 2.0Results 6 Mos Post-DMEK20 Consecutive Uneventful
DMEKECL ≤ 12% !!!
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E-mailed to: [email protected]
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