Anterior segment reconstruction with artificial iris and Descemet membrane endothelial keratoplasty: a staged surgical approach

Intraoperative Complications ◽

Corneal Thickness ◽

Anterior Segment ◽

Descemet Membrane ◽

Artificial Iris ◽

Corneal Decompensation

PurposeTo describe a surgical approach that involves anterior segment reconstruction with CustomFlex Artificial Iris (CAI; HumanOptics, Erlangen, Germany) followed by Descemet membrane endothelial keratoplasty (DMEK) in complex eyes with corneal decompensation.MethodsRestrospective case series of eyes that underwent anterior segment restoration involving (1) synechiolysis of peripheral anterior synechiae and excision of iris remnants, (2) securing a well-fixated posterior chamber intraocular lens and (3) suture-fixated or capsular bag placement of CAI. All eyes then underwent DMEK using a pull-through technique with the DMEK EndoGlide (Network Medical Products, Ripon, UK). Main outcomes were successful anterior segment restoration and corneal clarity with central corneal thickness (CCT).ResultsFive eyes of five patients (median age 61 years, range 27–69 years; 60% female) underwent anterior segment reconstruction with CAI implantation (4 suture-fixated), followed by successful DMEK surgery (median 2 months later, range 1–5 months). There were no major intraoperative complications or primary graft failure, with one peripheral graft detachment that underwent a successful re-bubble at 1 week. All eyes had stable CAI implants and DMEK grafts remained clear at last follow-up with reduction in mean central corneal thickness (preoperative: 658±86 µm vs postoperative: 470±33 µm, p=0.005).ConclusionThis pilot study highlights a feasible approach of initial anterior segment reconstruction with CAI implantation, prior to DMEK, in eyes with significant anterior segment abnormalities such as iris damage or extensive peripheral anterior synechiae and corneal decompensation.

Outcomes after Descemet membrane endothelial keratoplasty over a period of 7 years at a tertiary referral center: endothelial cell density, central corneal thickness, and visual acuity

Graefe s Archive for Clinical and Experimental Ophthalmology ◽

10.1007/s00417-021-05152-w ◽

2021 ◽

Author(s):

Tarek Bayyoud ◽

Faik Gelisken ◽

Jens Martin Rohrbach ◽

Gunnar Blumenstock ◽

Karl Ulrich Bartz-Schmidt ◽

...

Keyword(s):

Visual Acuity ◽

Endothelial Cell ◽

Cell Density ◽

Corneal Thickness ◽

Descemet Membrane ◽

Group 2 ◽

Group 1

Abstract Purpose To better assess clinical trajectories of patients with or without ocular comorbidity after Descemet membrane endothelial keratoplasty. Background: To report on the outcomes of eyes with differing starting conditions following surgery. Design: Retrospective study at a University Eye Hospital. Participants: 361 eyes separated into group 1 (n=229; eyes with endothelial disease only) and group 2 (n=132; eyes with additional ocular comorbid conditions, such as herpetic eye disease 18/132 (13.6%), glaucoma 16/132 (12.1%), dry age-related macular degeneration 14/132 (10.6%), epiretinal membranes 10/132 (7.6%), and wet age-related macular degeneration 9/132 (6.8%)). Methods Consecutive eyes that underwent Descemet membrane endothelial keratoplasty over a follow-up period of up to 7 years at a tertiary referral center were reviewed. Main outcome measures were best-corrected visual acuity, postoperative complications, graft survival, central corneal thickness, and endothelial cell density. Results Postoperative best-corrected visual acuity at year 1 improved in both groups significantly (Wilcoxon signed rank test: group 1, p =.002; .63 to .23 logMAR; group 2, p <.001; 1.15 to .87 logMAR) with a group difference in favor of group 1 (p =.009, Mann-Whitney-Wilcoxon). A decrease of the endothelial cell density and central corneal thickness was noted at postoperative year 1 for both groups (paired t-tests (group 1, p <.001; group 2, p =.045) and paired t-tests (group 1, p <.001; group 2, p =.003). Complications were less common, and graft longevity was superior in group 1. Conclusion Eyes with different starting conditions might experience a visual improvement and benefit from surgery. Descemet membrane endothelial keratoplasty is a valid treatment for endothelial disorders in manifold of eyes. Further long-term studies are required.

Can we predict the refractive outcome after triple Descemet membrane endothelial keratoplasty?

European Journal of Ophthalmology ◽

10.1177/1120672118785282 ◽

2018 ◽

Vol 29 (2) ◽

pp. 165-170 ◽

Cited By ~ 2

Author(s):

Victor A Augustin ◽

Julia M Weller ◽

Friedrich E Kruse ◽

Theofilos Tourtas

Keyword(s):

Corneal Thickness ◽

Case Series ◽

Corneal Curvature ◽

Refractive Outcome ◽

Descemet Membrane ◽

Corneal Volume ◽

Posterior Corneal Curvature

Purpose: To analyze and correlate corneal parameters with refractive shift after Descemet membrane endothelial keratoplasty combined with cataract surgery (triple Descemet membrane endothelial keratoplasty). Methods: This single-center retrospective observational case series included 152 eyes of 152 consecutive patients undergoing triple Descemet membrane endothelial keratoplasty in the first eye for Fuchs endothelial corneal dystrophy. Patients were examined preoperatively, as well as at 3, 6, and 12 months after surgery. The main outcome measures were: refractive shift (predicted refractive outcome based on intraocular lens calculation compared to actual postoperative refractive outcome), central corneal thickness, corneal volume, anterior and posterior corneal curvature, and corneal densitometry. These parameters were analyzed and correlated with the refractive shift after surgery. Results: After 3 months from surgery, a mean refractive shift of +1.12 ± 1.10 D was observed and remained stable until the last follow-up at 12 months (+1.24 ± 1.07 D). Correlation analysis showed a weak but significant positive correlation between refractive shift and preoperative posterior curvature (rho = 0.314; p = 0.002) or preoperative posterior densitometry (rho = 0.227; p = 0.008). No correlation was found between refractive shift and preoperative central corneal thickness, corneal volume, anterior curvature, or anterior/mid-cornea densitometry. Conclusion: Changes of the posterior cornea may have an influence on the refractive shift. Patients with flatter posterior corneal curvature or higher posterior corneal density seem to exhibit a higher hyperopic shift. The weak correlations indicate a poor predictive value of any preoperative parameter used in our study.

Descemet Membrane Endothelial Keratoplasty: Intraoperative and Postoperative Imaging Spectral-Domain Optical Coherence Tomography

Case Reports in Ophthalmological Medicine ◽

10.1155/2015/506251 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4 ◽

Cited By ~ 4

Author(s):

Marcus Ang ◽

Adam M. Dubis ◽

Mark R. Wilkins

Keyword(s):

Optical Coherence Tomography ◽

Corneal Thickness ◽

Anterior Segment ◽

Spectral Domain ◽

Optical Coherence ◽

Descemet Membrane ◽

Postoperative Imaging ◽

Initial Adhesion

We describe a case report of using the same handheld spectral-domain anterior segment optical coherence tomography (ASOCT) for rapid intraoperative and postoperative imaging in a case of Descemet membrane endothelial keratoplasty (DMEK). A 67-year-old woman, with Fuchs dystrophy and corneal decompensation, underwent DMEK with intraoperative ASOCT imaging using the handheld Envisu spectral domain ASOCT system (Bioptigen, Inc., Morrisville, NC, USA). We found that this easy-to-use portable system with handheld probe allowed for rapid imaging of the anterior segment during donor manipulation to visualize the orientation of the DMEK donor, as well as to confirm the initial adhesion of the DMEK donor. Moreover, the same system may be used for postoperative monitoring of graft adhesion, corneal thickness, and stromal remodeling in the clinic with very high-definition images.

Descemet membrane suturing to manage recurrent graft detachment in a patient with Descemet membrane endothelial keratoplasty on failed penetrating keratoplasty

Therapeutic Advances in Ophthalmology ◽

10.1177/25158414211027705 ◽

2021 ◽

Vol 13 ◽

pp. 251584142110277

Author(s):

Zahra Ashena ◽

Thomas Hickman-Casey ◽

Mayank A. Nanavaty

Keyword(s):

Visual Acuity ◽

Penetrating Keratoplasty ◽

Anterior Segment ◽

Descemet Membrane ◽

Ocular Coherence Tomography ◽

Corrected Visual Acuity ◽

Intracameral Injection ◽

History Of

A 65-year-old patient with history of keratoconus, mild cataract and penetrating keratoplasty over 30 years ago developed corneal oedema subsequent of graft failure with best corrected visual acuity (BCVA) of counting fingers. He underwent a successful cataract surgery combined with a 7.25 mm Descemet’s Membrane Endothelial Keratoplasty (DMEK) with Sodium Hexafluoride (SF6) gas. His cornea remained oedematous inferiorly at 4 weeks, despite two subsequent re-bubbling due to persistent DMEK detachment inferiorly. This was managed by three radial full thickness 10-0 nylon sutures placed in the inferior cornea along with intracameral injection of air. Following this, his anterior segment ocular coherence tomography (OCT) confirmed complete attachment of the graft, and the sutures were removed 4 weeks later. Unaided visual acuity was 20/63 and BCVA was 20/32 after 8 months. DMEK suturing can be helpful in persistent DMEK detachments, which is refractory to repeated re-bubbling due to uneven posterior surface of previous PK.

Refractive outcome and tomographic changes after Descemet membrane endothelial keratoplasty in pseudophakic eyes with Fuchs’ endothelial dystrophy

International Ophthalmology ◽

10.1007/s10792-021-01850-w ◽

2021 ◽

Author(s):

Bishr Agha ◽

Nura Ahmad ◽

Daniel G. Dawson ◽

Thomas Kohnen ◽

Ingo Schmack

Keyword(s):

Corneal Thickness ◽

Corneal Astigmatism ◽

Corneal Densitometry ◽

Scheimpflug Imaging ◽

Fuchs Endothelial Dystrophy ◽

Posterior Corneal Astigmatism

Abstract Purpose To analyze refractive and topographic changes secondary to Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic eyes with Fuchs’ endothelial dystrophy (FED). Methods Eighty-seven pseudophakic eyes of 74 patients who underwent subsequent DMEK surgery for corneal endothelial decompensation and associated visual impairment were included. Median post-operative follow-up time was 12 months (range: 3–26 months). Main outcome measures were pre- and post-operative manifest refraction, anterior and posterior corneal astigmatism, simulated keratometry (CASimK) and Q value obtained by Scheimpflug imaging. Secondary outcome measures included corrected distance visual acuity (CDVA), central corneal densitometry, central corneal thickness, corneal volume (CV), anterior chamber volume (ACV) and anterior chamber depth (ACD). Results After DMEK surgery, mean pre-operative spherical equivalent (± SD) changed from + 0.04 ± 1.73 D to + 0.37 ± 1.30 D post-operatively (p = 0.06). CDVA, proportion of emmetropic eyes, ACV and ACD increased significantly during follow-up. There was also a significant decrease in posterior corneal astigmatism, central corneal densitometry, central corneal thickness and corneal volume over time (p = 0.001). Only anterior corneal astigmatism and simulated keratometry (CASimK) remained fairly stable after DMEK. Conclusion Despite tendencies toward a hyperopic shift, changes in SE were not significant and refraction remained overall stable in pseudophakic patients undergoing DMEK for FED. Analysis of corneal parameters by Scheimpflug imaging mainly revealed changes in posterior corneal astigmatism pointing out the relevance of posterior corneal profile changes during edema resolution after DMEK.

Outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes with failure of primary Descemet membrane endothelial keratoplasty (DMEK)

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2017-311834 ◽

2018 ◽

Vol 103 (5) ◽

pp. 599-603 ◽

Cited By ~ 2

Author(s):

Shmuel Graffi ◽

Pia Leon ◽

Yoav Nahum ◽

Shay Gutfreund ◽

Rossella Spena ◽

...

Keyword(s):

Intraoperative Complications ◽

Tertiary Care ◽

Case Series ◽

Care Hospital ◽

Visual Rehabilitation ◽

Descemet Membrane ◽

Graft Thickness ◽

Iol Exchange

AimTo evaluate the outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes after failure of primary Descemet membrane endothelial keratoplasty (DMEK).MethodsThis was a retrospective, non-comparative interventional case series done in a tertiary care hospital. The study group included 21 eyes of patients which underwent UT-DSAEK following the failure of primary DMEK. Outcome measures included best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) both recorded 6 and 12 months postoperatively as well as central graft thickness (CGT) measured 6 months after UT-DSAEK.ResultsWhen considering only eyes without comorbidities (17 of 21), 12 months after UT-DSAEK, BSCVA was ≥20/25 in 12/13 (92%) eyes and ≥20/20 in 4/13 (30%) eyes. Mean ECD loss rate was 38.9% at 12 months postoperatively (range 8%–57%). Six months postoperatively, CGT averaged at 81±34 µm (range 34–131 µm). No intraoperative complications were recorded. Postoperatively, one patient (no. 8) had graft wrinkles that were fixed 2 days following UT-DSAEK. Four patients have developed intraocular lens (IOL) opacification, and two of them underwent IOL exchange. No other postoperative complications were recorded.ConclusionsUT-DSAEK is instrumental in the management of primary DMEK graft failure, allowing visual rehabilitation which is comparable with that of repeat DMEK.

Corneal oedema with in situ implantable collamer lens: a challenging scenario for descemet membrane endothelial keratoplasty

BMJ Case Reports ◽

10.1136/bcr-2020-240709 ◽

2021 ◽

Vol 14 (5) ◽

pp. e240709

Author(s):

Vineet Pramod Joshi ◽

Pravin Krishna Vaddavalli

Keyword(s):

Posterior Chamber ◽

Cataract Formation ◽

Phakic Intraocular Lens ◽

Implantable Collamer Lens ◽

Air Bubble ◽

Descemet Membrane ◽

Corneal Decompensation

A 27-year-old woman had foggy vision and photophobia since 10 months after implantation of implantable collamer lens (ICL STAAR Surgical AG, Nidau, Switzerland) with evidence of corneal decompensation and no cataract formation. Descemet membrane endothelial keratoplasty in phakic eyes is challenging, considering presence of posterior chamber phakic intraocular lens (IOL), decreasing the space available in anterior chamber to manoeuvre the graft. Need of inferior peripheral iridotomy in presence of central hole technology in ICL depends on the dynamics of full chamber air bubble. At 8 months, vision had improved to 20/20 and normal IOP with well-attached graft, stable phakic IOL and clear lens.

Epithelial downgrowth after Descemet membrane endothelial keratoplasty

European Journal of Ophthalmology ◽

10.1177/1120672120912413 ◽

2020 ◽

pp. 112067212091241

Author(s):

Viet Nhat Hung Le ◽

Florian Wabnig ◽

Bjoern Bachmann ◽

Claus Cursiefen

Keyword(s):

Anterior Segment ◽

Corneal Edema ◽

Visual Axis ◽

Corneal Incision ◽

Descemet Membrane ◽

Clear Corneal Incision ◽

Close Observation ◽

Histopathologic Evaluation

Purpose: To describe a patient with epithelial downgrowth after Descemet membrane endothelial keratoplasty. Methods: Case report. Results: A 73-year-old woman underwent triple Descemet stripping automated endothelial keratoplasty for cataract and corneal edema secondary to Fuchs endothelial dystrophy in the left eye elsewhere. Three years later, Descemet membrane endothelial keratoplasty was performed at our department due to graft failure. One month after the operation, her vision improved to 20/32 and maintained stable. At the 14-month visit, her visual acuity decreased, and a routine examination revealed epithelial downgrowth at the posterior surface of the cornea and partly beneath the graft, accompanied by presumed graft rejection. Therefore, repeat Descemet membrane endothelial keratoplasty with epithelial scraping and intracameral injection of 5-fluorouracil was indicated. She recovered 20/25 vision by 1 month after the surgery. However, small sheet-like epithelial downgrowth recurred 1 month later. The epithelial downgrowth was limited to the peripheral margin of the Descemet membrane endothelial keratoplasty graft and did not affect the visual axis. Epithelial downgrowth showed “islands” with connection between epithelial downgrowth and clear corneal incision on anterior segment optical coherence tomography images. Histopathologic evaluation of the removed Descemet membrane endothelial keratoplasty graft confirmed conjunctival epithelium as the source. Under close observation at the current 4-year follow-up, the epithelial downgrowth remained stable and localized and her vision increased to 20/20. Conclusion: Epithelial downgrowth can occur after Descemet membrane endothelial keratoplasty. The limited progression of epithelial downgrowth in this patient suggests that this condition after Descemet membrane endothelial keratoplasty even in the recurrence stage may cause less damage than expected and may only need to be observed closely if no progression occurs.