Transcript Document

Postoperative Complications Following
Descemet-Stripping Automated
Endothelial Keratoplasty in Patients with
Prior Glaucoma Surgery
Melissa B Daluvoy MD, Ajoy S Virdi MD, Neelofar Ghaznawi MD,
Edwin S Chen MD, Kristin M Hammersmith MD,
Christopher J Rapuano MD
Cornea Service, Wills Eye Institute, Thomas Jefferson University Hospital,
Philadelphia, Pennsylvania, USA
The authors have no financial interest in the subject matter of this poster
Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)
has become the surgery of choice for endothelial dysfunction. This
procedure has well documented advantages over penetrating
keratoplasty but also has complications including graft dislocation,
graft failure or rejection, and elevation of intraocular pressure
1
(IOP) .
The presence of aqueous filtering or glaucoma drainage devices
(GDD) in the anterior chamber can create technical challenges with
graft placement, manipulation and achieving a complete air fill for
graft
2,3
adhesion .
To study post operative complications after
DSAEK in patients who had previous history of
glaucoma surgery including trabeculectomy and
glaucoma drainage devices.
• A retrospective chart review of clinical data of ten pseudophakic eyes
of nine patients who underwent DSAEK between 3/2006 and 9/2009
in the presence of previous glaucoma surgery was performed.
• Pre & post operative visual acuity (VA), IOP, and post operative
complications were recorded.
• No attempt was made to occlude the glaucoma filters or tubes
intraoperatively.
• Pre-op glaucoma medication regimens were reinstituted immediately
after surgery.
• Decision for further medical or surgical intervention was left to the
discretion of the managing surgeon and their consultants.
•
Nine of the 10 eyes had prior trabeculectomies and 1 had a prior GDD.
•
Two eyes (20%) required graft repositioning with an air bubble post operatively
for a displaced graft. One of these (10%) dislocated again and was replaced with
a penetrating keratoplasty; the other did well.
•
Three eyes (30%) required additional topical antiglaucoma medications.
•
Of those requiring additional topical medications, two (20%) went on to require
additional glaucoma surgery; one received a repeat trabeculectomy & the other
a GDD.
•
One eye (10%) had post operative cystoid macular edema (CME) which resolved
with one intravitreal Kenalog injection with no increase in IOP.
•
In total, 60% of eyes required a post-operative intervention as listed above.
•
All the complications were in patients who had prior trabeculectomies. The
patient with prior GDD had an uneventful post-operative course.
Pt
Eye Past Ocular History
Pre-Op
VA
Post-op Course
IOP
Post-op IOP
Post-op VA
1 mo 3 mo 6 mo 12mo
1 mo
3 mo
6mo
12mo
POD#5 graft
9 dislocated;POD#14 graft
dislocated; POD#21 PK
PK
PK
PK
PK
PK
PK
PK
PK
Uneventful
7
11
10
NA
NA
20/80
20/200
NA
NA
14
9
20/200
20/200
20/40
20/50
1
PBK; PDS; Trab (prior to
OS
2001); no medications
2
Fuchs’Dys; POAG; Trab; no 20/200
OD medications
3
Failed PK (Fuchs’); POAG;
OS Trab; no medications
POD#1
brimonidine
started
20/200 10
for wound leak
9
12
4
PBK; PXF; Trab (’95 & ’05);
OS Tube shunt (’07); no
medications
20/400
9 Uneventful
11
8
NA
NA
20/70
20/100
NA
NA
5
PBK; POAG; Trab; no
OS medications
CF 10ft
6 POD#3 graft dislocated
5
11
11
11
20/400
20/400
20/60
20/50
6
OD PBK; POAG; Trab (’05);
brimonidine TID,
PBK; PDS; Trab (86);
pilocarpine BID, timolol
OS 0.5% qam, brimatoprost
qHs
13 Uneventful
10
10
9
17
20/70
20/80
20/60
20/60
19
14
13
15
20/400
20/70
20/60
20/50
16
17
13
NA
20/400
20/100
20/100
NA
19
20
20
NA
20/200
20/100
20/100
NA
15
18
23
15
20/400
20/200
20/200 20/200
7
8
9
10
20/200
CF @
1 ft
CF 2ft
POD#1 brimonidine added
16 (IOP 40); POM#2 bleb
needling (IOP 25); Trab
(IOP 40)
POM#1 CME; IVK; resolved
12 by POM#4, no significant
IOP increase
PBK; POAG; Trab (’04);
OD revision for hypotony (’09); CF 4ft
no medications
PBK; POAG; Trab (’05);
OD Brimonidine BID, timolol
20/100 23 Uneventful
0.5% QD, latanoprost qHs
PBK; POAG; Trab; timolol
POM#3 brimonidine
CF
@
OS 0.5%BID, dorzolamide BID,
10
increased
(IOP
32);
POM#4
1 ft
brimonidine BID,
Tube shunt (IOP 27)
travoprost qhs
Pt: patient; VA: visual acuity; IOP: intraocular pressure; PBK: Pseudophakic bullous keratopahty; PDS :pigment dispersion syndrome; Trab: trabeculectomy; POD:
post-operative day; PK: penetrating keratoplasty; POAG: Primary open angle glaucoma; PXF: pseudoexfoliation; TID: three times daily; BID: twice daily; POM: postoperative month; QD: daily; CME: cystic macular edema; IVK: intravitreal Kenalog
Post-operative day #1 slit lamp photograph of patient #3
Post-operative month #3 slit lamp photograph of patient #3
• Graft displacement, graft failure, and poor IOP control are important
complications after DSAEK and may be expected to occur at a higher rate
in patients with pre-existing glaucoma surgery.
• In our small case series, the graft dislocation rate of 20% was within the
reported range of 1-34% in patients without previous glaucoma
1,4,5
surgery . However, one small study evaluating the outcomes of
DSAEK in 4 eyes with tube shunts in the anterior chamber showed no
3
effect on graft dislocations .
• In our study, 30% of patients required additional IOP lowering
medications and 20% went on to need additional glaucoma surgery. In a
previous study comparing patients with and without glaucoma, 38% of
eyes with prior glaucoma surgery required additional IOP lowering
6
medications and 19% needed surgery .
• Despite the obstacles that prior glaucoma surgery may present to the
DSAEK surgeon, this procedure can successfully be completed in patients
with prior glaucoma surgery.
• A larger series would help to determine more accurately the incidence of
these complications.
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