Transcript Clinical Outcomes Of Descemet Stripping Automated Endothelial

Clinical Outcomes Of
Descemet Stripping Automated
Endothelial Keratoplasty
In A Series Of 218 Cases
Bryan Y Kim 1,
Shintaro Kanayama MD PhD 1, Tueng T Shen MD PhD 1, Thomas E Gillette MD 2
1 University
of Washington Department of Ophthalmology,
2 Eye Associates Northwest,
Seattle, WA
April 7, 2010
Financial Disclosure:
The authors have no financial interest in the subject matter of this poster.
Background / Purpose
BACKGROUND
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Descemet’s stripping automated endothelial keratoplasty (DSAEK) is the most widely
performed endothelial keratoplasty. (1)
Numerous benefits over penetrating keratoplasty (PKP) for treatment of corneal
endothelial disease including less induced astigmatism, shorter visual recovery, and
better tectonic support.
Few studies exist on outcomes of DSAEK performed with concurrent procedures
such as cataract phacoemulsification and intraocular lens implantation (PE/IOL) or
IOL exchange. (2,3,4)
PURPOSE
•
•
To report clinical outcomes of a large retrospective study of DSAEK and to compare
to existing published data.
To compare clinical outcomes of DSAEK performed with concurrent procedures to
DSAEK performed alone.
1. Lee WB et al. Descemet’s Stripping Endothelial Keratoplasty: Safety and Outcomes. Ophthalmology 2009;116:1818-1830.
2. Terry MA et al. Endothelial Keratoplasty for Fuchs’ Dystrophy with Cataract. Ophthalmology 2009;116:631-639.
3. Covert DJ, Koenig SB. New Triple Procedure: Descemet’s Stripping and Automated Endothelial Keratoplasty Combined with Phacoemulsification and Intraocular Lens Implantation.
Ophthalmology 2007;114:1272-1277
4. Shah AK et al. Complications and Clinical Outcomes of Descemet Stripping Automated Endothelial Keratoplasty With Intraocular Lens Exchange. Am J Ophthalmology 2010;149:390-397.
Methods
STUDY METHODS
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•
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Retrospective, nonrandomized case series of
218 consecutive DSAEK operations.
SURGICAL METHODS
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DSAEK technique
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Performed between April 2006 and April 2009
by a single surgeon (TEG) at an ambulatory
surgery center.
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Chart review performed with approval of and
in accordance with policies of institutional
review board of parent medical center.
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Statistical analysis
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Visual acuity measured by Snellen BCVA.
Pinhole VA used when manifest refraction not
available.
BCVA converted to logMAR for analysis.
Groups compared using Student’s T test,
ANOVA, and Chi-squared test with statistical
significance at P<0.05. For small n values,
Fisher’s exact test and randomization test for
goodness-of-fit were used.
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–
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Anesthesia by retrobulbar block and IV
sedation.
Anterior chamber entered through 5.0mm
temporal corneal incision and paracentesis.
6.5-8.5mm diameter descemetorhexis.
Graft dissected with Moria CB
microkeratome and trephinated to match
stripping area.
Graft inserted in 40/60 taco configuration,
placed into position, and unfolded with air.
Anterior chamber filled with air for 10
minutes to promote graft adhesion.
Air replaced by small bubble and incisions
made in host cornea as needed to drain
residual fluid.
Postoperatively, patient remained supine for
1 hour.
If performed, concurrent surgical
procedures (PE/IOL or IOL exchange)
were performed prior to DSAEK.
Results
Preoperative Clinical Data
No.
Demographics
Total DSAEK procedures
Age, yrs (mean ± SD)
Female:
Male:
Distinct Eyes
Distinct Patients
(%)
•
Most patients received DSAEK
for treatment of Fuch’s
dystrophy or pseudophakic
corneal edema.
•
“Pseudophakic/aphakic corneal
edema” includes 3 cases of
aphakic corneal edema.
•
“Other corneal edema” includes
1 Descemet’s detachment and
8 unspecified corneal edema.
218
72 ± 12, Range (5-95)
135
62%
83
38%
194
155
DSAEK Indication
Fuchs' dystrophy
Pseudophakic/aphakic corneal edema
PKP graft failure
Repeat DSAEK due to primary graft failure
Repeat DSAEK due to dislocated graft
Repeat DSAEK due to endothelial rejection
Other corneal edema
130
35
20
13
6
5
9
60%
16%
9%
6%
3%
2%
4%
Concurrent Procedures
PE/IOL
IOL Exchange
Other (iridotomy, vitrectomy, IOL scleral fixation)
None
88
16
3
111
40%
7%
1.4%
51%
Results
Overall Complications
Total Cases
Graft dislocation
Reposition only
Repeat DSAEK or PKP after dislocation
Total
Endothelial Rejection
Primary graft failure
Repeat DSAEK after primary graft failure
PKP after primary graft failure
Total
•
No.
218
(%)
4
8
12
1.8%
3.7%
5.5%
6
2.8%
14
7
21
6.4%
3.2%
9.6%
Comparative complication rates reported in a DSAEK outcomes literature review by
Lee et al.(1):
– Average graft dislocation rate: 14.5% (range 0-82%)
– Average endothelial rejection rate: 10% (range 0-45%)
– Average primary graft failure rate: 5% (range 0-29%)
1.
Lee WB et al. Ophthalmology 2009;116:1818-1830.
Results
Overall Visual Acuity Outcomes
LogMAR BCVA
Snellen BCVA
20/20 or better
1.8
20/40 or better
20/100 or better
20/200 or better
1.4
20/502
1.2
20/317
1.0
20/200
0.8
20/125
0.6
20/80
0.4
20/50
0.2
20/32
0.0
20/20
PreOp
1 Day
1 Week
1 Month
6 Months
Percentage of Patients with BCVA at:
20/796
Snellen Equivalent
Mean LogMAR BCVA
100%
1.6
80%
60%
40%
20%
0%
PreOp
1 Day
Post-op Period
LogMAR BCVA
Mean
SD
N
•
PreOp
0.79
0.58
215
1 Day
1.12
0.53
203
1 Week
0.82
0.56
206
1 Month 6 Months
0.43
0.40
0.34
0.32
181
162
Snellen BCVA
Mean
20/20 or better
20/40 or better
20/100 or better
20/200 or better
PreOp
20/124
0.5%
27%
64%
71%
Comparative VA outcomes reported by Lee et al.: (1)
– Mean VA over 3 to 21 month follow up periods ranged from 20/34 to 20/66.
– Percentage seeing 20/40 or better ranged from 38% to 100% (from 3 to 20 months)
1.
Lee WB et al. Ophthalmology 2009;116:1818-1830.
1 Week
Post-op Period
1 Day
20/262
2.4%
26%
47%
1 Month
1 Week
20/132
0.5%
21%
57%
68%
6 Months
1 Month 6 Months
20/54
20/50
1.1%
3.1%
43%
64%
79%
88%
87%
91%
Results
Comparison by Donor Graft Diameter
Demographics and Complications
7.50mm
No.
%
23
20
87%
3
13%
71 ±16 (range 33-90)
Demographics
No.
Female
Male
Age
Complications
Graft dislocation
Endothelial rejection
Primary DSAEK graft failure
Total
No.
2
4
6
Rate
9%
17%
26%
7.75mm
No.
%
17
7
41%
10
59%
70 ±8 (range 55-82)
No.
2
3
5
Rate
12%
18%
29%
8.00mm
No.
%
134
83
62%
51
38%
74 ±10 (range 43-95)
No.
4
4
12
20
8.25mm
No.
%
31
15
48%
16
52%
68 ±10 (range 47-84)
Rate
3%
3%
9%
15%
No.
1
1
2
4
8.50mm
%
9
8
89%
1
11%
68 ±24 (range 17-95)
Rate
3%
3%
6%
13%
No.
No.
2
1
3
Rate
22%
11%
33%
P Value
0.07
0.08
0.07
0.47
0.42
0.34
Visual Acuity
7.50mm
Visual Acuity
LogMAR mean BCVA
Standard deviation
Snellen mean BCVA
% 20/20 or better
% 20/40 or better
% 20/100 or better
% 20/200 or better
7.75mm
Preoperative
8.00mm
8.25mm
8.50mm
1.01
0.60
1.01
0.62
0.75
0.56
0.56
0.48
0.98
0.64
20/206
20/202
20/111
20/73
20/190
4%
57%
57%
18%
47%
53%
0.7%
30%
66%
75%
39%
84%
87%
22%
44%
56%
P Value
0.02
1.00
0.13
0.49
0.55
7.50mm
7.75mm
6 Month Postoperative
8.00mm
8.25mm
8.50mm
0.51
0.44
0.55
0.55
0.40
0.40
0.42
0.48
0.37
0.46
20/64
20/71
20/51
20/52
20/47
44%
75%
94%
50%
83%
83%
5%
65%
90%
92%
76%
86%
86%
83%
83%
83%
No significant difference in outcomes between graft diameters for:
• Complication rates
• 6 month postoperative BCVA
P Value
0.73
0.47
0.69
0.98
0.99
Results
Comparison of DSAEK for Fuch’s Dystrophy
With or Without Concurrent PE/IOL
Demographics and Complications
• 129 total DSAEK performed to
treat Fuchs’ dystrophy.
• 88 DSAEK performed with
concurrent PE/IOL (triple
procedure).
• 41 DSAEK performed alone.
• No significant difference of:
• Complication rates.
• Percentages of patients at
various VA’s at 6 months.
Demographics
No.
Female
Male
Age
Complications
Graft dislocation
Endothelial rejection
Primary graft failure
No.
2
3
4
Rate
2%
3%
5%
DSAEK alone
No.
%
41
27
66%
14
34%
76 ± 7 (range 58-90)
No.
P value
0.91
<0.001
Rate
2
4
5%
10%
0.59
0.55
0.26
Visual Acuity
Visual Acuity
No.
LogMAR mean BCVA
Standard deviation
• Significant difference:
• Mean BCVA of DSAEK
performed with PE/IOL
better than without at 6
months.
DSAEK w/ PE/IOL
No.
%
88
57
65%
31
35%
68 ± 10 (range 43-84)
Preoperative
DSAEK DSAEK
w/ PE/IOL Alone
88
0.41
0.29
41
0.57
0.33
Snellen mean BCVA
20/51
20/75
% 20/20 or better
% 20/40 or better
% 20/100 or better
% 20/200 or better
1.1%
56%
92%
95%
22%
83%
93%
P value
0.01
1.00
<0.001
0.17
0.55
6 Month Postoperative
DSAEK DSAEK
w/PEIOL
Alone
P value
72
0.26
0.22
31
0.36
0.22
20/36
20/46
7%
85%
96%
99%
71%
94%
97%
0.04
0.32
0.14
0.65
0.60
Results
Comparison of DSAEK
With or Without Concurrent IOL Exchange
• 16 DSAEK performed with
concurrent IOL exchange
• 15 due to pseudophakic
corneal edema
• 1 due to PKP graft failure
• 111 DSAEK performed alone
• Multiple indications
• No significant difference of:
• Complication rates
• Mean BCVA at 6 months.
• Percentages of patients at
most VA’s at 6 months.
• Significant difference:
• Higher percentage of
patients receiving DSAEK
alone had 20/40 VA or
better at 6 months.
Demographics and Complications
Demographics
No.
Female
Male
Age
DSAEK w/ IOL Exc
No.
%
16
6
38%
10
63%
82 ± 10 (range 64-95)
Complications
Graft dislocation
Endothelial rejection
Primary graft failure
No.
Rate
1
-
DSAEK alone
No.
%
111
70
63%
41
37%
74 ± 14 (range 5-95)
No.
6%
-
P value
0.07
0.01
Rate
9
3
15
8%
3%
14%
1.00
1.00
0.21
Visual Acuity
Visual Acuity
No.
LogMAR mean BCVA
Standard deviation
Snellen mean BCVA
% 20/20 or better
% 20/40 or better
% 20/100 or better
% 20/200 or better
DSAEK
w/ IOL Exc
Preoperative
DSAEK
Alone
16
1.09
0.64
111
1.06
0.57
20/249
20/228
56%
56%
8%
43%
54%
P value
0.86
1.00
0.60
0.33
0.88
6 Month Postoperative
DSAEK
DSAEK
w/ IOL Exc
Alone
P value
13
0.76
0.67
76
0.54
0.46
20/116
20/69
23%
77%
77%
51%
82%
86%
0.27
1.00
0.05
0.69
0.48
Conclusions
•
Overall DSAEK outcomes for our series of 218 eyes are comparable with
existing literature data.
•
Concurrent PE/IOL implantation does not lead to worse visual outcomes or
higher complication rates when compared to DSAEK alone.
•
Similarly, concurrent IOL exchange generally does not lead to worse visual
outcomes or higher complication rates compared to DSAEK alone.
•
Donor graft diameter from 7.5mm to 8.5mm does not have a significant
affect on visual outcomes or complication rates.
•
This study data strengthens the existing literature supporting DSAEK as an
effective treatment for corneal endothelial disease and further provides
evidence that PE/IOL and IOL exchange can safely and efficaciously be
performed concurrently with DSAEK.
References
•
Chen ES et al. Descemet-Stripping Endothelial Keratoplasty: Six-month Results in a Prospective Study of
100 Eyes. Cornea 2008;27:514-520.
•
Covert DJ, Koenig SB. New Triple Procedure: Descemet’s Stripping and Automated Endothelial Keratoplasty
Combined with Phacoemulsification and Intraocular Lens Implantation. Ophthalmology 2007;114:1272-1277
•
Gorovoy MS. Descemet-Stripping Automated Endothelial Keratoplasty..Cornea 2006;25:886-9.
•
Koenig SB, Covert DJ. Early Results of Small-Incision Descemet’s Stripping Endothelial Keratoplasty.
Ophthalmology 2007;114:221-26
•
Koenig SB et al. Visual Acuity, Refractive Error, And Endothelial Cell Density Six Months After Descemet
Stripping And Automated Endothelial Keratoplasty (DSAEK). Cornea 2007;26:670–4.
•
Lee WB et al. Descemet’s Stripping Endothelial Keratoplasty: Safety and Outcomes. Ophthalmology
2009;116:1818-1830.
•
Melles GR et al. Preliminary Clinical Results of Descemet Stripping Endothelial Keratoplasty. Am J
Ophthalmology 2008;145:222-227
•
Price FW, Price MO. Descemet’s Stripping with Endothelial Keratoplasty in 200 Eyes: Early Challenges and
Techniques to Enhance Donor Adherence. J Cataract Refract Surg 2006;32:411-418.
•
Shah AK et al. Complications and Clinical Outcomes of Descemet Stripping Automated Endothelial
Keratoplasty With Intraocular Lens Exchange. Am J Ophthalmology 2010;149:390-397.
•
Terry MA et al. Endothelial Keratoplasty for Fuchs’ Dystrophy with Cataract. Ophthalmology 2009;116:631639.
Acknowledgements
Special thanks to:
• Thomas E. Gillette, MD
• Tueng T. Shen, MD PhD
• Shintaro Kanayama, MD PhD
• Staff at Eye Associates Northwest
Author:
Bryan Y. Kim is a medical student at the University of
Washington School of Medicine and is pursuing
ophthalmology as a career.