Graft Rejection in Descemet-Stripping Automated Endothelial Keratoplasty

Graft Rejection in Descemet-Graft Rejection in Descemet-Stripping Automated Endothelial Stripping Automated Endothelial

KeratoplastyKeratoplasty

Daniel D. Hayes, MDDaniel D. Hayes, MD11; Carolyn Y. Shih, MD; Carolyn Y. Shih, MD11; ; David C. Ritterband, MDDavid C. Ritterband, MD22; John A. Seedor, MD; John A. Seedor, MD22; ;

Ira J. Udell, MDIra J. Udell, MD11

1.1.Department of Ophthalmology, North Shore – Long Island Jewish Department of Ophthalmology, North Shore – Long Island Jewish Health System, Great Neck, NYHealth System, Great Neck, NY2.2.Department of Ophthalmology, New York Eye and Ear Infirmary, Department of Ophthalmology, New York Eye and Ear Infirmary, New York, NYNew York, NY

The authors have no financial interest in the subject matter of this The authors have no financial interest in the subject matter of this presentationpresentation

IntroductionIntroduction

Descemet-stripping automated endothelial Descemet-stripping automated endothelial keratoplasty (DSAEK) is rapidly becoming keratoplasty (DSAEK) is rapidly becoming the treatment of choice for endothelial the treatment of choice for endothelial disordersdisorders

Indications for DSAEK include Fuchs’ Indications for DSAEK include Fuchs’ endothelial dystrophy, pseudophakic and endothelial dystrophy, pseudophakic and aphakic bullous keratopathy, and failed aphakic bullous keratopathy, and failed penetrating keratoplasty (PK)penetrating keratoplasty (PK)

BackgroundBackground

DSAEK may have a lower rate of rejection DSAEK may have a lower rate of rejection compared to PKcompared to PK– Transplanted tissue is placed in the anterior chamber, Transplanted tissue is placed in the anterior chamber,

away from surface antibodies and antigen presenting away from surface antibodies and antigen presenting cellscells

– Fewer sutures may lead to fewer suture-related Fewer sutures may lead to fewer suture-related rejection episodesrejection episodes

– No direct contact between host stromal vessels and No direct contact between host stromal vessels and transplanted tissuestransplanted tissues

– Reduced immunogenicity of transplanted tissue due Reduced immunogenicity of transplanted tissue due to absence of epitheliumto absence of epithelium

PurposePurpose

To assess the rate of endothelial graft To assess the rate of endothelial graft rejection in DSAEKrejection in DSAEK

MethodsMethods

Retrospective chart review of all DSAEK’s Retrospective chart review of all DSAEK’s performed at 2 institutions (North Shore-Long Island performed at 2 institutions (North Shore-Long Island Jewish Health System and New York Eye and Ear Jewish Health System and New York Eye and Ear Infirmary) from January, 2006 to April, 2009Infirmary) from January, 2006 to April, 2009

Main outcome measure was endothelial graft Main outcome measure was endothelial graft rejection in patients with at least 6 months follow-uprejection in patients with at least 6 months follow-up

Endothelial graft rejection defined as presence of Endothelial graft rejection defined as presence of Keratic precipitates (KP) or Khodadoust line with Keratic precipitates (KP) or Khodadoust line with associated edemaassociated edema

ResultsResults

Cohort consists of 385 patientsCohort consists of 385 patients

Indications for surgery included Fuchs’ endothelial dystrophy, Indications for surgery included Fuchs’ endothelial dystrophy, aphakic and pseudophakic bullous keratopathy and failed PKaphakic and pseudophakic bullous keratopathy and failed PK

There have been 6 patients with endothelial graft rejection There have been 6 patients with endothelial graft rejection (1.56%)(1.56%)

5 were treated successfully 5 were treated successfully

1 failed and required a 21 failed and required a 2ndnd DSAEK DSAEK– This patient had a detachment of her DSAEK lenticle post-operatively, This patient had a detachment of her DSAEK lenticle post-operatively,

which subsequently spontaneously reattachedwhich subsequently spontaneously reattached

4 were using once daily topical steroids4 were using once daily topical steroids

2 were non-compliant with steroids2 were non-compliant with steroids

Patient CharacteristicsPatient CharacteristicsPatient 1Patient 1 Patient 2Patient 2 Patient 3Patient 3 Patient 4Patient 4

DiagnosisDiagnosis Fuchs’Fuchs’ Fuchs’ and Fuchs’ and PBKPBK

Fuchs’Fuchs’ PBKPBK

Time to Time to rejectionrejection

21 months21 months 1 month1 month 5 months5 months 20 months20 months

On drops?On drops? NoNo NoNo YesYes YesYes

Type of Type of dropdrop

N/AN/A N/AN/A Lotemax Lotemax QdayQday

PredForte PredForte QdayQday

TreatmentTreatment PredForte PredForte Q2hours and Q2hours and oral medroloral medrol

PredForte PredForte Q1hour and Q1hour and oral steroidsoral steroids

Lotemax Lotemax Q2hoursQ2hours

PredForte PredForte Q2hoursQ2hours

Time to Time to resolutionresolution

1 week1 week N/AN/A 1 week1 week 1 week1 week

OutcomeOutcome Cornea Cornea clearedcleared

Regraft Regraft (DSAEK)(DSAEK)

Cornea Cornea clearedcleared

Cornea Cornea clearedcleared

PBK=preudophakic bullous keratopathy, DSAEK=descemet-stripping automated endothelial keratoplasty

*2 additional patients had rejection episodes – medical records unavailable

Figure 1. Color photo of patient 2 showing acute rejection with edema and descemet-folds

Figure 2. Color photo of patient 3 showing inflammation, granular interface haze and subtle edema associated with acute rejection

Figure 3. Color photo of patient 4 showing acute rejection with Khodadoust line

ConclusionsConclusions

This is the second largest reported series evaluating This is the second largest reported series evaluating graft rejection in DSAEK graft rejection in DSAEK DSAEK has a low rate of endothelial graft rejection DSAEK has a low rate of endothelial graft rejection (1.56%) in this series(1.56%) in this seriesPreviously published rates of rejection are 6% of 118 Previously published rates of rejection are 6% of 118 eyes (7), 7.5% of 199 eyes (1), 9% of 598 eyes (3), 12% eyes (7), 7.5% of 199 eyes (1), 9% of 598 eyes (3), 12% of 26 eyes (4) and 14% of 21 eyes (2)of 26 eyes (4) and 14% of 21 eyes (2)Future study is needed to assess the long-term rate of Future study is needed to assess the long-term rate of graft rejection in DSAEK, the role of post-operative graft rejection in DSAEK, the role of post-operative steroid drops, and potential risk factors for rejection, as steroid drops, and potential risk factors for rejection, as well as to compare with the rate of rejection in PKwell as to compare with the rate of rejection in PK

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