Three Year Visual and Endothelial Density Outcomes after Endothelial Keratoplasty

Three Year Visual Three Year Visual and Endothelial and Endothelial

Density Outcomes Density Outcomes after Endothelial after Endothelial

KeratoplastyKeratoplasty

AuthorsAuthors

Sabah Ali Shah, M.S.Sabah Ali Shah, M.S.Albany Medical College, MS-4Albany Medical College, MS-4

Abraham Sleem, MDAbraham Sleem, MDAlbany Medical College, PGY-4Albany Medical College, PGY-4

Robert L. Schultze, MDRobert L. Schultze, MDDirector, Cornea and Refractive Surgery, Albany, NYDirector, Cornea and Refractive Surgery, Albany, NYDisclosure: The authors have no

financial/conflicting interests to disclose

Purpose / IntroductionPurpose / Introduction

• PurposePurpose: To report changes in best spectacle-corrected visual : To report changes in best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) up to 3 years acuity (BSCVA) and endothelial cell density (ECD) up to 3 years after DLEK.after DLEK.

• Introduction: Introduction: This case series reviews longer-term outcomes on This case series reviews longer-term outcomes on patients undergoing Deep Lamellar Endothelial Keratoplasty. While patients undergoing Deep Lamellar Endothelial Keratoplasty. While this procedure has largely been replaced by Descemet’s Stripping this procedure has largely been replaced by Descemet’s Stripping Automated Endothelial Keratoplasty, the cases in this series Automated Endothelial Keratoplasty, the cases in this series represent the primary surgeon’s (RLS) early learning curve on a represent the primary surgeon’s (RLS) early learning curve on a relatively invasive corneal procedure. relatively invasive corneal procedure.

MethodsMethods• 14 eyes underwent deep lamellar endothelial 14 eyes underwent deep lamellar endothelial

keratoplasty (DLEK) by one surgeon (RLS).keratoplasty (DLEK) by one surgeon (RLS).• BSCVA and ECC were obtained pre-operatively and BSCVA and ECC were obtained pre-operatively and

annually for 3 years. annually for 3 years. • All donor tissue came from the Lions Eye Bank in All donor tissue came from the Lions Eye Bank in

Albany, NYAlbany, NY• Pre-operative donor endothelial cell density was Pre-operative donor endothelial cell density was

determined at the procuring the Eye Bank and post-determined at the procuring the Eye Bank and post-operative measurements were determined in office 1, 2, operative measurements were determined in office 1, 2, and 3 years postoperatively.and 3 years postoperatively.– SP4000 noncontact specular microscope, Konan Medical Corp.SP4000 noncontact specular microscope, Konan Medical Corp.

Surgical TechniqueSurgical Technique• DLEK procedure using a Moria artificial DLEK procedure using a Moria artificial

anterior chamber and LSK-ONE anterior chamber and LSK-ONE microkeratome for donor preparationmicrokeratome for donor preparation

• ““350” or “300” head used 350” or “300” head used

Slit lamp photo showing smooth interface after DLEK

ResultsResults• BSCVA after DLEK improved from an average of BSCVA after DLEK improved from an average of

20/127 20/127 pre-operatively to pre-operatively to 20/47, 20/40, 20/32 20/47, 20/40, 20/32 at at years 1, 2, and 3 post-operatively, respectively years 1, 2, and 3 post-operatively, respectively (p=0.005 at year one). (p=0.005 at year one).

• Average ECC decreased from Average ECC decreased from 2859±465 2859±465 pre-pre-operatively to operatively to 1302±698 (54.1% loss), 914 ±554 1302±698 (54.1% loss), 914 ±554 (68.7% loss), and 920±696 (68.4% loss) (68.7% loss), and 920±696 (68.4% loss) at years at years 1, 2 and 3 post-operative, respectively 1, 2 and 3 post-operative, respectively (p<0.01 (p<0.01 at year one)at year one)

Preop vs. Postop Best Spectacle Preop vs. Postop Best Spectacle Corrected Visual AcuityCorrected Visual Acuity

p>0.05p=0.0005

Preop vs. Postop Endothelial Preop vs. Postop Endothelial Cell CountCell Count

p=0.0001

Endothelial Cell Loss In Other Endothelial Cell Loss In Other StudiesStudies

Author/StudyAuthor/Study ## 1 Yr Post-op1 Yr Post-op 2 Yrs Post-op2 Yrs Post-op 3 Yrs Post-op3 Yrs Post-op

Mashor et. al 60 43% 57% 61%

Terry 78 29% 46%

Terry et. al. 36 45% 72%

Our StudyOur Study 1414 51.40%51.40% 69%69% 68.40%68.40%

Mashor RS, Kaiserman I, Kumar N, Sansanayudh W, Rootman DS. Deep Lamellar Endothelial Keratoplasty Up to a 5-Year Follow-up. Ophthalmology 2010;117:680-6.Terry MA, Endothelial Keratoplasty: Clinical Outcomes in the Two Years following Deep Lamellar Endothelial Keratoplasty (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc 2007;105:530-63.Terry MA, Wall JM, Hoar KL, Ousley PJ. A Prospective Study of Endothelial Cell Loss during the 2 Years after Deep Lamellar Endothelial Keratoplasty. Ophthalmology 2007;114:621-9.

BSCVA in Other StudiesBSCVA in Other Studies

Author/Study # Pre-Op 1 Yr Post-op 2 Yrs Post-op 3 Yrs Post-op

Mashor et. al 60 20/189 20/57 20/52 20/46

Terry 107 20/83 20/42 20/39

Our StudyOur Study 1616 20/12720/127 20/4720/47 20/4020/40 20/3220/32

Mashor RS, Kaiserman I, Kumar N, Sansanayudh W, Rootman DS. Deep Lamellar Endothelial Keratoplasty Up to a 5-Year Follow-up. Ophthalmology 2010;117:680-6.Terry MA, Endothelial Keratoplasty: Clinical Outcomes in the Two Years following Deep Lamellar Endothelial Keratoplasty (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc 2007;105:530-63.

Factors Thought to Influence Factors Thought to Influence Endothelial Cell SurvivalEndothelial Cell Survival• Progressive cell loss in the second year post –op may be due to the Progressive cell loss in the second year post –op may be due to the

delayed effect on central ECC caused by folding and added delayed effect on central ECC caused by folding and added manipulation of the tissue in small-incision DLEKmanipulation of the tissue in small-incision DLEK

– Mashor RS, Kaiserman I, Kumar N, Sansanayudh W, Rootman DS. Deep Lamellar Endothelial Keratoplasty Up to a 5-Year Follow-up. Ophthalmology 2010;117:680-6.

• Insertion techniques: small incision causes higher rate of cell loss as Insertion techniques: small incision causes higher rate of cell loss as opposed to larger incisionopposed to larger incision

– Terry MA, Wall JM, Hoar KL, Ousley PJ. A Prospective Study of Endothelial Cell Loss during the 2 Years after Deep Lamellar Endothelial Keratoplasty. Ophthalmology 2007;114:621-9.

• ACIOLs may accelerate the rate of endothelial cell loss in DLEK ACIOLs may accelerate the rate of endothelial cell loss in DLEK patients. patients.

– Chen ES, Terry MA, Neda S, Friend DJ. Endothelial Keratoplasty: Endothelial Cell Loss After Deep Lamellar Endothelial Keratoplast y With Retention of an Open-Loop Anterior Chamber Intraocular Lens. Cornea 2010;29:162-6

• Patients that have undergone DLEK have Patients that have undergone DLEK have significant improvement in BSCVA at 1 significant improvement in BSCVA at 1 year. year.

• BCVA and ECC do not show statistically BCVA and ECC do not show statistically significant change after the first year.significant change after the first year.

• Our cell loss was in agreement with other Our cell loss was in agreement with other published studiespublished studies

ConclusionsConclusions

DiscussionDiscussion• Incision size and insertion technique may Incision size and insertion technique may

contribute to differences in endothelial cell loss.contribute to differences in endothelial cell loss.

• May provide a better alternative to traditional PK May provide a better alternative to traditional PK for the treatment of endothelial dysfunctionfor the treatment of endothelial dysfunction

• DLEK has been mostly abandoned in favor of DLEK has been mostly abandoned in favor of DSAEK, although they show similar ECL and DSAEK, although they show similar ECL and BSCVA. BSCVA.

– Bahar I, Sansanayudh W, Levinger E, Kaiserman I, Srinivasan S, Rootman D. Posterior lamellar keratoplasty—comparison of deep lamellar endothelial keratoplasty and Descemet stripping automated endothelial keratoplasty in the same patients: a patient’s perspective. Br J Ophthalmol 2009 93: 189-190.