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

Jan 21, 2016

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Page 1: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

Descemet Stripping Automated Descemet Stripping Automated Endothelial Keratoplasty with a Endothelial Keratoplasty with a

Graft Insertion Device : Graft Insertion Device :

Technique and Early ResultsTechnique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir S MEHTA, FRCS(Ed), Dr Jodhbir S MEHTA, FRCS(Ed),

Prof Donald TH TAN, FRCS(G)Prof Donald TH TAN, FRCS(G)

Singapore National Eye Centre (SNEC)Singapore National Eye Centre (SNEC)and Singapore Eye Research Institute (SERI)and Singapore Eye Research Institute (SERI)

WB Khor has no financial interests.WB Khor has no financial interests.Jodbir Mehta and Donald Tan have financial interestsJodbir Mehta and Donald Tan have financial interests

in the EndoGlide (Network Medical Products)in the EndoGlide (Network Medical Products)

Singapore National Eye CentreSingapore National Eye Centre Singapore Eye Research InstituteSingapore Eye Research Institute

Page 2: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

IntroductionIntroduction► 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.

Page 3: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

PurposePurpose► This poster describes the use of the EndoGlide This poster describes the use of the EndoGlide

((Network Medical Products, North Yorkshire, UK), Network Medical Products, North Yorkshire, UK), a new graft insertion device for use during DSAEKa new graft insertion device for use during DSAEK

► We also report the early clinical results of the We also report the early clinical results of the Singapore National Eye Centre (SNEC) EndoGlide Singapore National Eye Centre (SNEC) EndoGlide TrialTrial

► The SNEC EndoGlide Trial is an IRB-approved The SNEC EndoGlide Trial is an IRB-approved prospective clinical trial aimed at evaluating the prospective clinical trial aimed at evaluating the use of the EndoGlide in 100 eyesuse of the EndoGlide in 100 eyes

Page 4: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

The EndoGlideThe EndoGlide

► The EndoGlide consists of three components – the Glide Capsule, the Glide Introducer, and the Preparation Base

Glide Capsule Glide Introducer

Preparation BaseGlide IntroducerGlide Introducer

Glide CapsuleGlide Capsule

Diagram on the left is courtesy of Network Medical Products.

Page 5: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

► 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

Central RidgeCentral Ridge

Page 6: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

Surgical TechniqueSurgical Technique► Microkeratome lamellar dissection of Microkeratome lamellar dissection of

the donor cornea is performed and the donor cornea is performed and then trephined to the desired then trephined to the desired diameterdiameter

► Figure D: Leading edge of the Figure D: Leading edge of the posterior lenticule can be inked on posterior lenticule can be inked on the stromal edge for easy the stromal edge for easy visualizationvisualization

► Figure E: The internal lumen of the Figure E: The internal lumen of the Glide Capsule is lubricated with Glide Capsule is lubricated with balanced salt solution (BSS)balanced salt solution (BSS)

► Figure F: Both anterior cap and Figure F: Both anterior cap and posterior donor lenticule are gently posterior donor lenticule are gently separated with BSS and then separated with BSS and then transferred (endothelial side up) onto transferred (endothelial side up) onto the Preparation Basethe Preparation Base

D

E

F

Page 7: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

► Figure G: Straight forceps are Figure G: Straight forceps are introduced through the anterior introduced through the anterior opening of the Capsule to opening of the Capsule to grasp the leading edge of the grasp the leading edge of the graftgraft

► Figure H: As the graft is drawn Figure H: As the graft is drawn into the Capsule, it rolls into the into the Capsule, it rolls into the double-coil configuration when double-coil configuration when the lateral edges of the donor the lateral edges of the donor encounter the central internal encounter the central internal ridgeridge

► Figure I: The graft is drawn Figure I: The graft is drawn completely into the Capsule completely into the Capsule

G

H

I

Forceps introduced hereForceps introduced here

Page 8: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

► Figure J: The purple Glide Figure J: The purple Glide Introducer is inserted into the Introducer is inserted into the posterior opening of the Capsule posterior opening of the Capsule and locked into place and locked into place

► The assembled EndoGlide is The assembled EndoGlide is removed from the Preparation removed from the Preparation Base and Base and invertedinverted for insertion for insertion

► Figure K: The anterior glide Figure K: The anterior glide surface of the EndoGlide is surface of the EndoGlide is inserted into the eye through a inserted into the eye through a 4.5mm scleral tunnel and 4.5mm scleral tunnel and advanced fully in the ACadvanced fully in the AC

► Figure L: Through a nasal Figure L: Through a nasal

paracentesis, forceps are paracentesis, forceps are passed over the glide surface passed over the glide surface and used to grasp the stromal and used to grasp the stromal edge of the graft edge of the graft

J

K

L

Page 9: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

► Figure M : The graft is simply pulled out Figure M : The graft is simply pulled out of the EndoGlide and into the ACof the EndoGlide and into the AC

► Figure N : Within the AC, the graft will Figure N : Within the AC, the graft will uncoil, endothelial surface down. uncoil, endothelial surface down. Moderate BSS flow from a pre-placed Moderate BSS flow from a pre-placed AC maintainer will facilitate unfolding. AC maintainer will facilitate unfolding. Gentle movements of the graft with the Gentle movements of the graft with the forceps will also aid in the full uncoiling forceps will also aid in the full uncoiling processprocess

► Figure O: Whilst still holding the graft Figure O: Whilst still holding the graft with forceps, the EndoGlide is removed with forceps, the EndoGlide is removed and a small air bubble is injected and a small air bubble is injected beneath the graft to float it against the beneath the graft to float it against the recipient stromal surface recipient stromal surface

► The surgery is then completed in the The surgery is then completed in the usual mannerusual manner

M

N

O

Page 10: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

ResultsResults► 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 (SD+32)

Page 11: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

► 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

Page 12: Descemet Stripping Automated Endothelial Keratoplasty with a Graft Insertion Device : Technique and Early Results Dr Wei-Boon KHOR, MRCS(Ed), Dr Jodhbir.

DiscussionDiscussion► The EndoGlide enables graft insertion through a The EndoGlide enables graft insertion through a

4.5mm incision with ease, minimal graft 4.5mm incision with ease, minimal graft manipulation, and with full control of the graft at all manipulation, and with full control of the graft at all times during DSAEKtimes during DSAEK

► Early results show that it is safe in clinical use; no Early results show that it is safe in clinical use; no immediate endothelial complications such as immediate endothelial complications such as primary graft failure or graft dislocation so farprimary graft failure or graft dislocation so far

► Initial 6 months ECD results are promising, but Initial 6 months ECD results are promising, but more patients and longer follow-up times are more patients and longer follow-up times are required to determine the long-term ECD loss with required to determine the long-term ECD loss with EndoGlide useEndoGlide use

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