Pre-loaded DMEK Tissue Shahzad Mian, M.D., University of Michigan Lauren Johnson, Eversight Director Training & Education
Pre-loadedDMEKTissueShahzad Mian,M.D.,UniversityofMichigan
LaurenJohnson,EversightDirectorTraining&Education
DMEKvs.DSEK
DSEKDMEK
Tissueadditive Tissueneutral
EndothelialKeratoplasty
Endothelialdysfunction/cornealedema
01,0002,0003,0004,0005,0006,0007,000
2012 2013 2014 2015 2016
Tran
splants
Year
DescemetMembraneEndothelialKeratoplasty
DMEK• Overthepast3years,therehasbeenasharpincrease
inthenumberofDMEKsurgeriesbeingperformed
2015EyeBankingStatisticalReport.EyeBankAssociationofAmerica.2016.WashingtonDC.
103.5%
88.2%
63.8%
37.6%
Hamzaoglu EC,Straiko MD,Mayko ZM,SálesCS,TerryMA.Ophthalmology.
2015;122(11):2193-9.
N=200;First100casesofeachprocedure
(retrospectivecaseseries).
DMEK– improvedvisualacuity
DMEK– Reducedrejectionrisk
Anshu A,PriceMO,PriceFW.Ophthalmology.2012;119(3):536-40.
DMEK• DMEKstillonlyaccountsfor23%ofallEKproceduresperformedintheUS
0
5,000
10,000
15,000
20,000
25,000
2012 2013 2014 2015 2016
Tran
splants
Year
EndothelialKeratoplasty (EK)
DMEK DSAEK
DMEK
• DMEKisatechnicallydifficultsurgery–Newsurgicalmaneuvers–DMEKgrafttissueisveryfragile•Minimizemanipulation
Sowhydon’twedoDMEKoneverycase?
DMEK
• Optimaltissuedelivery– Prestrippedandpretrephined• Eye-bankpreparationofprestripped tissuehasaidedinacceptanceandincreasedconversiontoDMEK– SimilartoprecutDSAEKnearlyadecadeago
DMEK
• Optimaltissuedelivery–Prestrippedandpretrephined–Preloaded• Containertype• Trypan staining
PURPOSE
• Todeterminetheendothelialsafetyofpre-stainingDMEKgraftswithTrypanBluepriortopreloading
WolleM,DeMillD,WoodwardM,Mian,S.TheEndothelialSafetyofUsingPreloadedDescemetMembraneEndothelialKeratoplasty Graft.Cornea (inpress)
METHODS• Twentysevencadavericcorneas• PreparedforDMEKusingastandardizedtechnique– ExperiencedDMEKeyebanktechnician
METHODS• Twentysevencadavericcorneas
• PreparedforDMEKusingastandardizedtechnique
• LoadedinStraiko ModifiedJonesTubeinjector(GuntherWeissScientificGlass,Portland,OR)– FilledwithOptisolGS
METHODS
• Twentysevencadavericcorneas
• PreparedforDMEKusingastandardizedtechnique
• LoadedinStraikoModifiedJonesTubeinjector
• Storedwithsiliconecapscoveringeachend
METHODS• Corneasdividedintothreegroupsofnine
– Group1—Preloadedprestained DMEKGraft(psDMEK)• Pre-stainedwithTrypan Blue0.06%(DORCInternational) for3minutespriortopreloadingandstorageinthemodifiedjonestubefor24hours
– Group2—PreloadedDMEKGraft(pDMEK)• Directlypreloadedintheinjectorpriortostoragefor24hours
– Group3—ImmediatelyInjectedDMEKGraft(Control)• Immediatelyinjectedintovitaldye
RESULTS
RESULTS• AppearanceofpreloadedandprestainedDMEKtissueafter24hoursofstorage
RESULTS
Table1.EndothelialCellLoss(%)*PreloadedprestainedDMEK Grafts(Group 1)
PreloadedDMEK Grafts(Group 2)
ImmediatelyInjectedDMEKGrafts-Control(Group3)
Average(SD) 16.78(7.11) 20.16(7.52) 18.47(6.36)Range 6.86—32.27 12.81—33.29 10.27—30.50p-value 0.67 0.57 REF
CONCLUSION
• DMEKtissuecanbestoredinOptisolGSwithintheStraiko ModifiedJonesTubefor24hourswithoutincreasedECL
• Prestaining DMEKtissuewithTrypan Blue0.06%priortopreloadingdoesnotresultinincreasedECL
• DMEKGraftsretainsufficientbluecolorationafter24hours
SurgicalTechnique
PURPOSE
• Pilotstudytoassessfeasibilityandefficacyofpre-loadedcornealdonorgraftsforDescemetMembraneEndothelialKeratoplasty
Methods
• Prospectivestudy• Eyebankpre-stripped,pre-stained,pre-trephineddonortissue
• Outcomemeasures– Primaryendpoints:ratesofdetachment,primarygraftfailure,rebubbling
– Secondaryendpoint:specularmicroscopyat3months
RESULTS• 14eyesof13patients• Followup:7weeks(1weekto3months)• PrimaryEndpoints– Detachment:4/14(28.6%)– Rebubble:1/14(7.1%)– Primarygraftfailure:0/14
• SecondaryEndpoints– Specularat3months:– MeanECD2530(-11.4%)
Complications
• CME:1/14(ERM)• Pupillaryblock:1/14
Summary
• Pre-stripped,pre-stained,pre-loadedDMEK(p3DMEK)maybeasafeandefficaciousalternative
TrainingResources
www.eversightvision.org/onlinetraining
Journalarticles,tissueprepoptions,demonstrationvideosandmore
Questions?