EK 2016 ASCRS Complications and Controversiesascrs16.expoplanner.com/handouts_ascrs/001424... · – Rudolph: Ophthalmolgy 119; 3: 528-534 – DMEK: LESS HOA than DSAEK • More SA

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EK: Complications and Controversies

Michael J. Taravella, MD Director: Cornea and Refractive

Surgery University of Colorado

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Why DMEK?

•  Quicker visual recovery •  Lower rejection rate

– Less stroma? •  Potential for better BCVA

–  Interface – HOA

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EK: Aberrometry

•  Corneal higher-order aberrations after Descemet’s Membrane Endothelial Keratoplasty – Rudolph: Ophthalmolgy 119; 3: 528-534 – DMEK: LESS HOA than DSAEK

•  More SA in DSAEK group •  Both better than PKP

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Why not DMEK?

•  Steep learning curve •  High rate of damage to endothelium and

loss of graft in preparation during learning curve – Up to 8-10% loss (learning curve)

•  High re-bubble rate •  If totally detached; unlike DSAEK; cannot re-bubble

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Why Now?

•  Many eye banks are beginning to offer pre-prepared tissue (just like DSAEK)

•  Eliminates one learning curve and source of loss of graft/tissue

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Which EK? •  If complex; choose DSAEK

– AC IOL – One chamber eye – Previous vitrectomy*** – Tube shunt present – Previous PKP (failure or rejection)

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Case Selection: DMEK •  Pseudophakic Bullous Keratopathy

–  May need larger graft** •  Fuch’s dystrophy •  Combined procedure (Cataract/EK)

– Dilate with Tropicamide 1% and Phenylephrine 2.5%

–  NOT CYCLOGYL!

– SMALLER CAPSULORHEXIS – MIOSTAT PRIOR TO INSERTION OF GRAFT

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Should you block? •  Pros

– Anesthesia/Akinesia – Consider Sub-tenon’s

•  Cons – Cannot monitor LP during air fill – Consider Topical

•  Proparacaine 1% on surface, Xylocaine gel after prep •  Intracameral 1% lidocaine •  2 or 4% lidocaine on surface •  Traction sutures to hold eye in place

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When should you perform a PI?

•  Always! •  Especially DMEK

–  Inferior as possible (6 o’clock) – Avoid bleeding – FUGO BLADE

•  Use Viscoelastic •  Plasma blade •  Controlled size and location

–  Small size avoids diplopia

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FUGO BLADE PI

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Which gas? •  Air Ok for DSAEK

–  32 gauge retina needle; small gauge avoids back leakage

–  90-95% bubble if tube present; if one chamber eye

•  Consider posterior infusion technique for one chamber eye

•  Keeps bubble in AC – Can check IOP to keep physiologic pressure

•  tonopen on the table for glaucoma patients

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SF6 •  Use for DMEK •  95% bubble

– Check patient at end of procedure (Light perception)

– Check at Slit lamp one hour post procedure – Fluid should cover PI

•  Isoexpansive mixture –  15-20% Air/SF6 mixture

•  Decreases re-bubble rate

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Methods of insertion: DSAEK (Ultrathin tissue < 100 microns)

•  Insert over a Sheet’s glide •  Busin Glide •  Tan (Angiotech) Endoglide

– Probably not Forceps for ultrathin tissue

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SHEETS GLIDE

•  ADVANTAGES: Easy to insert •  Easy to Deploy •  Must have incision about 5 to 5.5 mm •  ?Endothelial Trauma?

– About 12% loss from insertion

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DMEK GRAFT INSERTION

•  Modified Glass Jones Tube •  IOL Cartridge

– Current: B&L injector – Spring Removed !!

•  Suture incision immediately

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SIZE OF DONOR

•  Considerations: – Larger donors = more endothelial cells – Smaller donor disc = easier to deploy

•  Guidelines – W-W minus 3 – DSAEK : 8.0-8.25 – DMEK: 8.0-8.25

•  ** if PBK consider larger graft (up to 9.0)

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DSAEK/DMEK complications (Depth, Deployment, Dislocation)

•  Failure to Insert properly •  Failure to Deploy

– Soft eye, AC depth •  Insert Upside Down •  Dislocation

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Hyperacute rejection

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Shallow AC

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Inversion Management Technique

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Inverted Graft •  S on stromal surface •  STEPS to Re-invert

1.  Leave graft in eye 2.  Leave air lying above graft 3.  Bent needle on air to catch edge of graft 4.  Pull needle back, graft will flip over around air bubble 5.  Inject air through needle to re-deploy

Shah VC. Reorientation of inverted endothelial graft during Descemet stripping automated endothelial keratoplasty Cornea2012 Sep;31(9):1075-7

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Insert Upside Down (DMEK)?

•  Confirm double scroll configuration on insertion – Eidolon portable slit lamp (Price)

•  Gentle irrigation maneuvers to flip •  “S” stamp?

– Yes! – Helpful once deployed – Confusing if on part of graft that is curled

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DMEK: Inserting Donor Tissue

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Case Video: Graft ejection

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Suture immediately after insertion BUT AVOID BLEEDING!!

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Bubble management •  For any EK

– Make sure bubble is UNDER THE GRAFT – Cannula or needle against iris –  Inflate slowly and monitor graft position –  32 Gauge retina needle helpful in preventing

“back leak” of air – Full (90-95%) fill for 1 chamber eye, tube shunt,

and DMEK •  Monitor LP and IOP (tonopen) for glaucoma patients

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Video Place Bubble in Right Spot!

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DMEK: Final Air Fill

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Lens management

•  AC IOL? – Must decide if stable or requires replacement – Advantage: less OR time if you can leave in

place – Disadvantage: less space for deployment, risk

traumatic insertion and IOL touch –  If very large PI; may need to suture to make

PI smaller and prevent air from going behind iris

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Insertion over an AC IOL

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Advanced technique

•  Consider removal of AC IOL •  Replace with Glued IOL

– Requires more OR time – Scleral flaps –  IOL helps to separate AC from PC – Less traumatic insertion of donor

•  Consider Posterior placement of infusion – Helps prevent air from going posterior

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DSAEK and Glued IOL technique

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Dislocation

•  Diagnosis: Slit lamp exam, Visante OCT – DSAEK: if partially attached (>75%) will attach

eventually – DMEK: if partially attached; will NOT

eventually reattach

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Visante OCT: complete graft dislocation

62 year old Post-op day 1

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Timing to re-bubble

•  DSAEK: not urgent; easier if graft partially attached

•  DMEK: as soon as possible •  Technique

– Minor OR: prep eye and lids – Lid speculum – 32 gauge needle – At slit lamp?

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Re-bubble: How many times?

•  Primary graft failure? – Traumatic insertion? – Endothelial viability?

•  3 strikes your out – 1 or 2 times if endothelial viability questioned

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ASCRS 2016 Film 116

•  Ergonomic Technique for Rebubbling DMEK Grafts at the Slitlamp Using IV Extension Tubing – Producer: Mark Terry

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Donor Issues

•  Inspect Donor •  Review Donor Information Sheet

– How large is stromal bed? •  Determines maximum trephine size

–  Irregular cut? •  Usually noted on prep sheet from eye bank

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Rejection in DSAEK/DMEK •  DSAEK: incidence uncertain (<12%) @ 2 years •  DMEK: < 1% (Price, et al) @ 2 years •  Rejection in DSAEK/DMEK

–  Less inflammation and AC reaction –  Unexplained corneal edema with minimal KP –  Harder to recognize

•  Long term steroid use for DMEK/DSAEK? –  Consider FML BID –  Restasis?

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Topical Steroids in EK

•  Long term steroid use for DMEK/DSAEK? •  Prednisolone Acetate 1% Taper over 3

months •  Lotemax: if steroid responder

– Consider FML BID – Restasis?

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