Transcript 角膜混濁を伴う白内障手術におけるスリット照明とICG

Clinical Outcomes of Descemet-Stripping Automated
Endothelial Keratoplasty for Bullous Keratopathy with
Pre-Existing Glaucoma
Tsutomu Inatomi, Hiroko Adachi, Kazuhiko Mori,
Hidetoshi Tanioka, Osamu Hieda, Shigeru Kinoshita
Kyoto Prefectural University of Medicine
Kyoto, JAPAN
Introduction
Primary causes of
bullous keratopathy
Post-DSAEK in glaucoma
N=101
2007-2010 at Kyoto Prefectural Univ. of Med.
DSAEK has now become a first-choice treatment for bullous keratopathy, resulting in a better visual
rehabilitation than that obtained by PK. The pie-chart graph on the left shows the percentage of
primary diseases treated by DSAEK at Kyoto Prefectural University of Medicine between 2007 and
2010. Laser-iridotomy-induced bullous keratopathy is a major cause of bullous keratopathy in
Japan. In this study, 14% of the cases were the result of repeated glaucoma surgeries. DSAEK is
now considered superior to PK for these type of cases for the control of intraocular pressure.
Purpose
To evaluate the clinical outcomes of DSAEK for bullous keratopathy in
patients with pre-existing glaucoma.
Subjects and Methods
1. Subjects
This study involved 48 eyes with bullous keratopathy, including 12
eyes with pre-existing glaucoma (Glaucoma group), 15 eyes that
had undergone laser iridotomy (LI group) for primary angle closure
glaucoma,12 eyes with pseudophakic bullous keratopathy (PBK
group), and 9 eyes with Fuch’s corneal dystrophy.
Patient age ranged from 61-80 years (mean age: 71.3±5.8 years).
2. Clinical design
3. Follow-up period
Retrospective clinical study
Follow-up ranged from 5-24 months (mean:13.5±8.8 months)
Preoperative Clinical Features
Type of Glaucoma
Number of Glaucoma Surgeries Received
Average number of glaucoma surgeries was 2.4.
Functional bleb after trabeculectomy existed in 67%
of the cases.
Anti-Glaucoma Medications Received
This chart illustrates the number of anti-glaucoma
medications received prior to DSAEK (average = 1.3).
Visual Field (Kozaki grade)
Of our cases, 50% were in the advanced stage of
glaucoma and 33% involved only a single eye.
Pre-DSAEK
Post-DSAEK
Surgical Procedure
A reversed Sinskey hook
was used to strip-away an
approximate 7-mm-diameter
area of the Descemet’s
membrane. An 8-mm precut corneal graft obtained
from SightLife (Seatle, USA)
was then placed on a Busin
glide, with the endothelial
side protected with a small
amount of viscoelastic
material. The graft was then
inserted though a 4-mm
temporal corneal incision.
An air bubble was then
injected into the anterior
chamber to promote the
graft attachment for 10
minutes.
Visual Acuity
Glaucoma group (N=12)
Comparison of Visual Acuity
PBK
N=12
3.0
LI
N=15
0.1
0.01
>0.7
>0.4
>0.1
2 eyes (17%)
5 eyes (42%)
9 eyes (75%)
※
2.0
1.5
※
1.0
※
※※
0.5
0.0
0.001
0.001
Fuchs’
N=9
※、※※ Scheffe's F test
2.5
BCVA (LogMAR)
Postoperative BCVA
1
Glaucoma
N=12
0.01
0.1
Preoperative BCVA
1
-0.5
Decimal VA
0.02
0.40
0.009
0.14
0.05
0.64
0.05
0.58
In all patients in the Glaucoma group, visual acuity was improved at 3 months after DSAEK.
The average postoperative visual acuity was 0.14 in the Glaucoma group, significantly lower
than the 0.64 in the LI group, 0.40 in the PBK group, and 0.58 in the Fuchs’ group.
Complications
Glaucoma group
(N=12)
Air misdirection to filtrating blebs
0
Partial graft detachment
1 (8%)
Complete graft dislocation
2 (16%)
Pupillary block
0
Primary failure
0
Air misdirection into the filtrating bleb leading to an inadequate air tamponade was not
observed in this study. Rates for partial detachment and graft dislocation were observed 8%
and 16%, respectively.
Rate of high IOP (%)
Rate of IOP Elevation after DSAEK ( >25mmHg )
50%
33%
13%
8%
Eyes:
n=12
n=12
n= 9
n= 15
This graph shows the rate (%) of intraocular pressure (IOP) elevation after DSAEK in the
various diseases. Six eyes (50% of the cases) of the glaucoma group showed high IOP, but
there was no statistically significant difference between the other groups. Statistical analysis
also demonstrated that the risk of postoperative high IOP was not associated with preoperative
clinical features such as the number of medications received, presence of filtrating bleb,
severity of the preoperative visual field, preoperative IOP, or patient age.
Corneal Endothelial Change
27.3%
Corneal Endothelial Density (cells/mm2)
3500
8.5%
20.5%
3000
31.9%
2500
Series
Other groups:
1 36 eyes
2902
2000
2654
Glaucoma group:
Series
2 12 eyes
1500
2111
2038
1998
1959
1000
1808
500
0
pre-cut post-cut
1M
3M
6M
9M
12M
Follow-up period (Months)
This graph shows the endothelial loss after DSAEK. Pre-cut versus postoperative endothelial
loss was 8.5% and 20.5%, respectively. A loss of 31.9% was observed after 1 month, but
there was no significant difference between the glaucoma group and the other groups.
Change of Visual Acuity after DSAEK
Failed graft
Postoperative BCVA
1
High IOP
Case 1
1
Needling
2
0.1
3
High IOP
4
5
Re-DSAEK 6
7
Case 6
0.01
8
9
Case 5
11
12
Case 4
0.001
Pre-OP
pre
1
3
6
9
12
15
18
21
24
Follow-up period (Months)
This graph shows the change of visual acuity after DSAEK. Four cases showed a notable loss
of vision after 6 months. In Case 1, vision recovered after re-DSAEK. Case 6 showed visual
loss due to the needling procedure. Two cases (Case 5 and Case 4) showed severe visual
loss due to the uncontrolled elevation of IOP and progressive visual field loss at the terminal
stage of glaucoma.
Elevation of IOP after DSAEK in 4 Cases
IOP (mmHg)
50
45
40
Needling
35
Case 5
30
25
20
Case 4
15
Case 1
10
Case 6
5
0
Pre-OP
術前
2
4
6
8
10
12
14
16
Follow-up period (Months)
18
20
22
24
This graph demonstrates the change of IOP in four cases that led to loss of vision. Three cases
showed high IOP spikes (>25mg) during the first postoperative month. One case (Case 6)
required the needling procedure to control the IOP at 5 months after DSAEK. Two cases (Case
4 and Case 5) showed poorly controlled IOP elevation that led to severe visual loss during the
mid-term postoperative period.
Conclusions
 DSAEK is effective for the recovery of corneal
endothelial function in patients with pre-existing
glaucoma, though the control of pre- and postoperative
intraocular pressure is essential for a good clinical
outcome.
 Adequate treatment for the expected elevation of IOP
after DSAEK is critical to prevent the progression of
visual loss in the advanced stage of glaucoma.