Cornea Clinic Interactive Part 3.ppt

PART III

INCIDENCE OF PK1 PK/10.000 People Required in 1

Year

ITALY = 6,000 PKs/Year

• Impaired Corneal Curvature (i.e. Keratoconus)

• Impaired Corneal Transparency & Decompensated Endothelium

(i.e. Bullous Keratopathy)

• Impaired Corneal Transparency & Normal Endothelium

(i.e. Corneal Scars)

MAIN INDICATIONS

Impaired Corneal Curvature

KERATOCONUS

MAIN INDICATIONS

Impaired Corneal Transparency & Decompensated Endothelium

BULLOUS KERATOPATHY (Fuchs or Postoperative)

MAIN INDICATIONS

Impaired Corneal Transparency & Normal Endothelium

SCARS s/p KERATITIS (viral, bacterial, ecc.)

MAIN INDICATIONS

Impaired Corneal Transparency & Normal EndotheliumCORNEAL DYSTROPHIES AND DEGENERATIONS

MAIN INDICATIONS

Impaired Corneal Transparency & Normal Endothelium

SCARS s/p TRAUMA

MAIN INDICATIONS

• KERATOCONUS = 40-45%

• DECOMPENSATED ENDOTHELIUM = 30-35%

• NORMAL ENDOTHELIUM = 20-25%

MAIN INDICATIONS (up to 2005)

• KERATOCONUS = 30-35%

• DECOMPENSATED

ENDOTHELIUM = 40-45%• NORMAL ENDOTHELIUM = 20-25%

MAIN INDICATIONS (2015)

• RECOVERY OF TRANSPARENCY

• RECOVERY OF NORMAL CURVATURE

• RECOVERY OF BOTH

PENETRATING KERATOPLASTY

PK (from’60s)

One Solution for ALL !!!

KPL IN THE XX CENTURY

LK (up to ’50s)

Hand Dissection

“Bad” Interface

Poor Vision (<20/40)

KPL IN THE XX CENTURY

PK = the “GOLD STANDARD”Operating Microscope

Endothelial Function/Viscoprotection

Suturing Material/Technique

Trephines/Punches

Lasers

KPL IN THE XX CENTURY

Healing > 1 Year Suture Removal after 1 y VA Limitated by Distortion

(Sutures in Place)

Final Astigmatism after Suture Removal 4 D in 20% of Cases

KPL IN THE XX CENTURY “Perfect Disc in a Perfectly

Round Hole”

“TOP HAT” PK

Busin, Arch. of Ophthalmol. 2003

Top Hat

Mushroom

Zig-Zag

FEMTO-SHAPED PK

Stromal Dissection May Be Compatible with 20/20 VA (LASIK !!!)

Corneal Layers Can Stick to Each Other without

Sutures (Melles 1998)

NEW INFORMATION & KPL

Infections Dystrophies Degenerations Post-Surgical (PRK) Others

DISEASED STROMA

Primary Corneal Edema (Fuchs) Post-Surgical BK PK FailureEndothelial Dystrophies ICE Syndrome Others

DISEASED ENDOTHELIUM

Traumata Infections (HSV) Macular Dystrophy Others

COMBINATIONS

“NEW” KERATOPLASTYCorneal Disease

Healthy Endothelium

Diseased Endothelium

Anterior LK

(Mushroom)

Posterior LK

(PK)

DISSECTION:

Manual

Pneumatic (“Big Bubble”)

Microkeratome

Femtosecond Laser

NEW INFORMATION & KPL

Difficult

Non Reproducible

Interface of Poor Optical Quality (20/20 Vision

Only if Very DEEP !!!)

CORNEAL DISSECTION

MANUAL:

Learning Curve

Non Reproducible (30-90%)

20/20 is the RULE (DM or Dua’s Layer)

CORNEAL DISSECTION

PNEUMATIC:

MICROKERATOME: Easy Use and Relatively

Reproducible

Relatively Imprecise

Interface of Excellent Optical Quality (20/20 Vision is the RULE !!!)

CORNEAL DISSECTION

FEMTOSECOND LASER: Expensive but

Precise Optical Quality

of Interface ???

CORNEAL DISSECTION

FEMTOSECOND LASER:

Does NOT Cut through

Opacities !!!

CORNEAL DISSECTION

“NEW” KERATOPLASTYCorneal Disease

Healthy Endothelium

Diseased Endothelium

Anterior LK

(Mushroom)

Posterior LK

(PK)

A STAGED STRATEGY1/3 ANT. STROMA (≤ 200 m) (Healthy Endothelium)

SALK (SUPERFICIAL ANTERIOR LK)

ANTERIOR LK

2/3 ANT. STROMA (≤ 350-400 m) (Healthy Endothelium)

DALK (DEEP ANTERIOR LK)

A STAGED STRATEGYANTERIOR LK

100% STROMA (Healthy Endothelium)

“BIG BUBBLE”

A STAGED STRATEGYANTERIOR LK

PREOP OCT

CHOICE OF PROCEDURE

ANTERIOR LK

PREOP OCT

CHOICE OF PROCEDURE

ANTERIOR LK

PREOP OCT

CHOICE OF PROCEDURE

ANTERIOR LK

+/- Sutures

1-Month Healing

Minimal Postop Refr. Error

SALK Compares to LASIKANTERIOR LK

Sutures

1-Year Healing

20% High Astigmatism

DALK Compares to PKANTERIOR LK

SALK (SUPERFICIAL ANTERIOR LAMELLAR KERATOPLASTY)

• Subepithelial Scarring (s/p PRK)• Subepithelial Irregularity (Bowman’s Dystrophy, s/p Superficial Keratitis)• Superficial Stromal Opacities (Granular

Dystrophy, Lattice Dystrophy)

SUPERFICIAL ANTERIOR LK (SALK)

TISSUE REMOVAL = 130-200 mNEW LAMELLA = 90-130 m

SALK3 years post-SALK BSCVA = 20/20Ref. = +3.00 sph. -2.00 cyl. @ 170°

HSV Keratitis 1 year s/p SALK UCVA = 20/100BSCVA = 20/25(-1.00 sf. –1.25 cil. @ 175°)

SALKHSV Keratitis pre SALKUCVA = 20/200BSCVA = 20/200

IRREGULAR ASTIGMATISM

DEEP ANTERIOR LK (DALK)

TISSUE REMOVAL = 200-300 mNEW LAMELLA = 300-350 m

DALK (DEEP ANTERIOR LAMELLAR KERATOPLASTY)

Various Etiology (s/p Infection, s/pTraumas, Dystrophies) Scarring Limited to 2/3 of Anterior Stroma NORMAL CORNEAL THICKNESS !!!

DALKLattice Dystrophy preop VA = 20/50

Lattice Dystrophy postop VA = 20/20

DALKLattice Dystrophy pre DALK

Lattice Dystrophy post DALK

“BIG BUBBLE” (DALK)

TISSUE REMOVAL = 99% StromaNEW LAMELLA = w/o Endoth.

IRREGULAR ASTIGMATISM

Keratoconus VA = 20/4002 Years post-DALKVA = 20/20 !!!

DALK

1m Postop VA 20/25 (+1.00 sph.-2.25

cyl. @ 20°)

“SMALL BUBBLE” DALK

DALK

Infl. Infiltrate

Scar Tissue

Adhesions

Risk of Perforation

Descemet Involvment

Opacity of Residual Bed

SMALL Grafts

LOWER

Rejection Rate

HIGHER Refractive Error

LARGE Grafts

HIGHER

Rejection Rate

LOWER Refractive Error

CONVENTIONAL PK

ENDOTHELIAL MIGRATION

Imaizumi T.Imaizumi T. (1990)

Groh MJGroh MJ et al. et al. (1999, 2000)

Kruse et al. (2011)

CONVENTIONAL PK

ENDOTHELIAL MIGRATION

FROM HIGHER TO

LOWER DENSITY

FROM GRAFT INTO HOST (ABK, PBK, FUCHS, etc.)

ENDOTHELIAL MIGRATION

FROM HIGHER TO

LOWER DENSITY

FROM HOST INTO GRAFT (KC, INFECTIONS, etc.)

“MUSHROOM” PKConcept:“Minimal Endothelial Replacement”

r = 3 mm S = 32

S = r2

r = 6 mm S = 62

“MUSHROOM” PKAREA OF RESIDUAL HEALTHY ENDOTHELIUM

(62 ) – (32 )

36 – 9

27 mm2

>75% !!!

“MUSHROOM” PK

ANTERIOR LK = “HAT”(thickness = 250 m; diameter = 9-9.5 mm)

POSTERIOR LK = “STEM”

(thickness = 300 m; diameter = 5-6 mm)

MUSHROOM PK FULL-THICKNESS

OPACITY

HEALTHY ENDOTHEL.

CORNEA OF UNEVEN THICKNESS (NEOVESSELS !!!)

100% STROMA + SCAR (Healthy Endothelium)

“MUSHROOM” PK

A STAGED STRATEGYANTERIOR LK

ADVANTAGES:LK Wound HealingPK EffectOptimal RefractionEndothelial Spare

2-Piece “MUSHROOM” PK

Survival Analysis (K-M) 1 y 2 y 5 y

Overall 98.3% 97.5% 95.3%Low Risk 100% 98.5% 96.3%High Risk 96.1% 96.1% 93.9%

GRAFT SURVIVAL

Rejection RateHigh Risk 2/71 (2.8%)Low Risk 4/109 (3.7%)

GRAFT SURVIVAL

Endothelial Rejection

Previous Case (2 Years postop), Resolved with Steroids

GRAFT SURVIVAL

Endothelial Repopulation?

Day 0 Month 6 Month 12

GRAFT SURVIVAL

“MUSHROOM” PK

CASE 1 (2004):35-year-old Males/p Perforating Injury OS10 months postopUCVA = 20/200BSCVA = 20/20(-2.50 sf –1.00 cil @ 20°)

“MUSHROOM” PK

CASE 2 (2008):39-year-old Females/p Amoebic K OS5 Years postopUCVA = 20/200BSCVA = 20/22.5(-3.50 sf –4.00 cil @ 70°)

“MUSHROOM” PK

CASE 3 (2007):9-year-old girss/p HZK OS4 Years postopUCVA = 20/40BSCVA = 20/25(+0.50 sf –3.50 cil @ 40°)

“MUSHROOM” PK

CASE 4 (2010):16-year-old Males/p HSK OS2 Years postopUCVA = 20/50BSCVA = 20/20(-1.50 sf –2.75 cil @ 155°)

• Primary Corneal Edema (Fuchs)• Post-Surgical BK• PK Failure•Endothelial Dystrophies• ICE Syndrome• Others

CONVENTIONAL PK SURGERY

POSTERIOR LK

Tillet (’50s)

Barraquer (’60s)

NEW ORLEANS (USA) 1984-86

Dr. H.E Kaufman, Dr. M.B.McDonald and Cornea Fellows

Kaufman 1980Epikeratophakia for Aphakia

“THE LIVING CONTACT LENS”

ANTERIOR “ONLAY” LK

SUBSTITUTIVE (“INLAY”)ADDITIVE (“ONLAY”)

LAMELLAR KERATOPLASTY

POSTERIOR “ONLAY” LK CONCEPT

1

4

2

3

1. Peeling of Descemet + endothelium

2. Tunnel approach

3. Preparation of posterior donor lamella (endothelium + deep stroma)

4. Suturing to the bare posterior stromal surface

ENDOKERATOPLASTY: A NEW SURGICAL TECHNIQUE FOR THE REPLACEMENT OF DISEASED CORNEAL ENDOTHELIUM

Massimo Busin1, M.D., Thomas Mönks2, M.D., Robert Arffa3, M.D.1 University of Bonn, Germany, 2 Surgical Eye Center Viktoriahaus, Krefeld, Germany, 3 Allegheny General Hospital, Pittsburgh, Pennsylvania

MATERIALS AND METHODS

Donor lenticules were prepared as follows: Approximately 80% of the anterior stroma of the donor corneas was removed with a microkeratome(Storz, Heidelberg, Germany) and a 6mm button was trephined. In five eyes a 4mm limbal incision was made and the central endothelium and Descemets membrane were removed. In four eyes a donor lenticulewas then sutured to the posterior surface of the central cornea, using four to five prolene 10-0 mattress sutures. The fifth eye did not receive any lenticule and served as control. All animals were examinded 1, 3, 5, 7, and 14 days after surgery and clinical pictures were taken. On the fourteenth day they were killed and the excised corneas submitted for histologic evaluation.

INTRODUCTION

To date, penetrating keratoplasty (PK) is the only available surgicaltreatment for endothelial decompensation. Although epithelium and stroma are not primarily affected, this procedure involves full-thickness transplantation, leading to unsatisfactory refractive results ina relatively high number of patients. A new surgical technique aimed at replacing exclusively the diseased endothelium is presented by means of a rabbit model.

RESULTS

Despite the technical difficulty of handling very thin corneaslike therabbit ones, it was possible in all animals used in this experiment study to perform endokeratoplasty as theoretically designed. By two weeks all of the corneas with endokeratoplasty-lenticules demonstrated substantial clearing, while the scraped cornea did not. On histology only a small proportion of the endothelial cells were present onthe donor lenticules.

CONCLUSION

Endokeratoplasty exhibits potential for endothelial transplantationand merits further study. Possible advantages of this procedure overconventional PK surgery include:

1) reduced postoperative corneal distortion in the absence of a full-thickness surgical wound;2) increased safety secondary to the use of a short tunnel approach3) reduced immunogenicity (no epithelium is transplanted).Improved handling of the donor lenticule and use of an alternateanimalmodel, e.g. primates, may improve endothelial cell transfer.

This study was supported in part by a grant from the Medical EyeBank of Western Pennsylvania, Pittsburgh, Pennsylvania.

Fig. 1:Schematic representation of endokeratoplastysurgery: a) Edematous cornea; b) Removal of Endotheliumfrom the center of the recipient cornea (arrows); c) Insertionof the endokeratoplasty-lenticule through a scleral tunnel;d) Suturing in place of the endokeratoplasty-lenticule.

Fig. 2:Endokeratoplasty surgery in a rabbit model: A) Removal of Descemts membrane and endothelium fromthe recipient central cornea; B) Entering the anterior chamberwith a 4mm keratome; C) Preparation of a 10-0 prolene mattress suture to fixate the endokeratoplasty-lenticule;D) Mattress suture led through the recipient cornea at the 6 oclock position.

Fig. 3:Postoperative results: A) Rabbit cornea with endokerato-plasty-lenticule fixated with four 10-0 prolene mattress sutures. The slit-lamp examination reveals tight contact between donor lenticule and recipient cornea as well as only moderate corneal edema; B) Control cornea exhibiting marked edema in the central area denudes of the endothelium.

a

b

c

d

POSTERIOR “ONLAY” LK (ENDOKERATOPLASTY)

Busin et al. OPHTHALMOLOGY, 1996 (Suppl.)

DLEK (Melles 1998)

SUTURELESS POSTERIOR INLAY LK

(D)eep (L)amellar (E)ndothelial (K)eratoplasty

DSEK (2002)

SUTURELESS POSTERIOR ONLAY LK

(D)escemet (S)tripping (E)ndothelial (K)eratoplasty

DSAEK (2004)

(D)escemet (S)tripping (A)utomated (E)ndothelial

(K)eratoplasty

SUTURELESS POSTERIOR ONLAY LK

DMEK (2006)

(D)escemet (M)embrane (E)ndothelial (K)eratoplasty

SUTURELESS POSTERIOR INLAY LK

U(ltra)T(hin)-DSAEK (BUSIN, 2009)

SUTURELESS POSTERIOR ONLAY LK

TODAY GOLD STANDARD

FOR SURGICAL TREATMENT OF ENDOTHELIAL

DECOMPENSATION

DSAEK

2010 statistical report

1.429 20056.122 200614.159 200717.468 200818.221 200919.159 2010

USA

1000/5.300 (2010)

ITALY

DSAEK – VISUAL OUTCOME

BSCVA ≥ 0.538% to 100%at 3-6 months72.96% at 1 month*81.13% at 3 mos*

*Personal Data, Excluding Co-Morbidities

Post-PK VA in ABK/PBK Patients

DSAEK – VISUAL OUTCOME

BSCVA ≥ 1.00% to 71%**30.19% at 6 mos*50%% at 6 mos*50%% at 6 mos*

**UT-DSAEK Neff et al, *UT-DSAEK Personal Data*Personal Data, Excluding Co-Morbidities

DSAEK – GRAFT SURVIVAL

ECL at 1 Year Average = 41% (29-61%) DSAEK = 23%*UT = 29%*

*UT-DSAEK Personal Data*DSAEK Personal Data

0102030405060708090

100

1 Year 2 Years 3 Years

Endothelial Cell Loss (ECL) in % after DSAEK

DSAEK – COMPLICATIONS

Detachment Rate Average = 14.5% (0-82%) DSAEK = <5%*UT = <1%*

*UT-DSAEK Personal Data*DSAEK Personal Data

A DOUBLE CHAMBER

MAY BE A VERY

SUBTLE FINDING !!!

DSAEK – COMPLICATIONS

DSAEK – COMPLICATIONS

GRAFT ATTACHMENT

NO AQUEOUS IN THE INTERFACE !!!

GRAFT ATTACHMENT Air Tamponade

(Squeezes out Aqueous)

Price’s Venting Incisions (Evacuate Aqueous)

DSAEK COMPLICATIONS

GRAFT ATTACHMENT

100% Possible !!!

DSAEK–GRAFT ATTACHMENT

“Closed System” Fast Visual Rehabilitation Better UCVA and BSCVA Reduced Astigmatism/

Other Aberrations Rare Complications

IDEAL KERATOPLASTY

DSAEK PROSRARE LATE

COMPLICATIONS !!! INTACT INNERVATION

IMMUNOLOGIC PREVILEGE

NO SUTURE RELATED COMPLICATIONS

Patients with BSCVA ≥ 1.0DMEK vs DSAEK

DSAEK = 0% to 33%*

DMEK = 20% to 45%*DSAEK Personal Data

Postoperative Refractive ErrorDMEK vs DSAEK

DSAEK = Hyperopic Shift (1 D)

DMEK = Neutral

Graft Rejection Rate in Fuchs’

DSAEK = 2% - 18%

DMEK = < 1% (13%)

DSAEK vs DMEK

DMEK vs DSAEK

MEMBRANE

Vs

LAMELLA

DMEK

Easy & Reproducible

No Waste of Tissue

Allow Alternatives (DSAEK!!!)

IDEAL TECHNIQUE

DMEK

Preparation

Delivery into AC

Positioning

Attachment

SURGICAL CHALLENGES

DMEK Waste of Tissue

up to 16%

Detachment Rate up to 63%

Primary Graft Failure up to 8%

DMEK

4 DAYS POSTOP

EK IN THE USAIn 2011:

DSAEK n ± 21,000

DMEK n = 343

EK IN THE USAIn 2012:

DSAEK n ± 25,000

DMEK n = 744

EK IN THE USAIn 2013:

DSAEK n = 23,465

DMEK n = 1,522

EK IN THE USAIn 2014:

DSAEK n = 23,100

DMEK n = 2,865

IDEAL CASE:

FUCHS &

INTACT PC

DMEK

SAFETYDSAEK

POOR VISUALIZATIONPOOR VISUALIZATIONDSAEK vs DMEK

DANGER OF LUXATION DSAEK vs DMEK

DSAEK & ACIOLDSAEK vs DMEK

DSAEK & IOL EXCHANGEDSAEK vs DMEK

DSAEK & ACIOL in PCDSAEK vs DMEK

DMEK CONSHIGH SURGICAL SKILLS REQUIRED (NO AVERAGE SURGEON!!!) PROLONGED SURGICAL TIME

COMPLICATION RATE HIGHER

NOT SUITABLE FOR ALL EYES

DMEK CONSNOT FOR EVERY

SURGEON !!!

NOT FOR EVERY EYE !!!

55-Year Old Patient with Fuchs’

Dystrophy + Cataract BSCVA

preop: 20/100 BSCVA 1 m postop: 20/20

Thin Endothelial Grafts (DMEK-Like)

Ease of Preparation (Microkeratome)

Ease of Delivery (DSAEK-Like)

DMEK vs DSAEKIDEAL GRAFT FOR EK

DSAEK vs DMEKIS THE

INTERFACE THE TRUE PROBLEM

???

RECENT DSAEK Grafts Thinner Than

131 µm Lead to Improved Visual Outcomes up to 75% VA 20/20 (Neff et al. 2010)

U(ltra)T(hin)-DSAEK (BUSIN, 2009)

SUTURELESS POSTERIOR ONLAY LK

UT-DSAEKSURGICAL TECHNIQUESame As DSAEKExcept for:

Graft Preparation

Graft Delivery

Prospective Study (Ophthalmology, June 2013)

Preop BSCVA ≤ 6/10

ULTRATHIN (UT) DSAEK

ISSUE # 1BSCVA ≥ 10/10 in Eyes with 10/10 Potential

BSCVA post UT-DSAEK in Eyes with 10/10 Potential

UT-DSAEK DMEK10/10= 20/20 39% 41%

8/10= 20/25 71% 80%6/10= 20/30 95% 98%

ECL 34% 36%Data for Fuchs or PBK indications only, w/o comorbidities

1 Year UT-DSAEK vs DMEK

ISSUE # 2SPEED OF

VISUAL RECOVERY

BSCVA preop DMEK 0.51± 0.44

logmar±3/10

BSCVA preop UT-DSAEK 0.76 ± 0.49 logmar ±1.5/10

BSCVA preop DMEK 0.51± 0.44

logmar±3/10

BSCVA preop PHAKIC

UT-DSAEK 0.55 ± 0.43

logmar ±2,8/10

ISSUE # 2

Why not 100% BSCVA

of 10/10 ???

DSAEK/UT-DSAEK/DMEKPOSSIBLE CAUSES INTERFACE ? GRAFT THICKNESS ? HOA ? RECIPIENT CORNEA !

Patients with BSCVA ≥ 10/10

≥10/10 = 20% to 45% <10/10 = 55% to 80%

DMEK

DSAEK/UT-DSAEK/DMEKPOSSIBLE CAUSES INTERFACE ? GRAFT THICKNESS ? HOA ? RECIPIENT CORNEA !

DSAEK/UT-DSAEK/DMEK

BSCVA = 9/10CGT= 61 µm

6 mos Postop UT-DSAEK

INTERFACE/THICKNESS

DSAEK/UT-DSAEK/DMEK

BSCVA = 4/10CGT= 127 µm

12 mos Postop DSAEK

INTERFACE/THICKNESS

DSAEK/UT-DSAEK/DMEK

BSCVA = 10/10CGT= 61 µm

9 mos Postop re-DSAEK (UT-DSAEK)

INTERFACE/THICKNESS

Corneal higher-order aberrations after Descemet's membrane endothelial keratoplasty.Rudolph M1, Laaser K, Bachmann BO, Cursiefen C, Epstein D, Kruse FE.Ophthalmology. 2012 Mar;119(3):528-35

DMEK/DSAEK/PK

Pentacam Analysis !!!

DSAEK/UT-DSAEK/DMEK

High Order AberrationsUT-DSAEK = Planar Graft !!!

315 251

92 95

92 95

Thin, Regular Shape

Thick, Irregular Shape

160 318

DSAEK/UT-DSAEK/DMEK

IMPROPER PUNCHING

!!!

DSAEK/UT-DSAEK/DMEK

DSAEK/UT-DSAEK/DMEK

DMEK Graft Variables ECC Diameter ???

DSAEK/UT-DSAEK/DMEKDS(A)EK Graft Variables ECC Diameter STROMA (Thickness, Regularity, Orientation)

DSAEK/UT-DSAEK/DMEK

BSCVAUT-DSAEK >> DSAEK !!!UT-DSAEK ≥ DMEK !!!

DSAEK/UT-DSAEK/DMEK

(Historical Controls)

Thick, Regular Shape !!!

DSAEK/UT-DSAEK/DMEK

204 197

9 mos Postop DSAEKVA = 10/10

OD UT-DSAEK VA = 12/10

OS DSAEK VA = 6/10

UT-DSAEK/DSAEK

OD UT-DSAEK VA = 12/10

OS DSAEK VA = 6/10

UT-DSAEK/DSAEK

OS UT-DSAEK VA = 16/10

OD DMEK VA = 10/10

UT-DSAEK/DMEK

OS UT-DSAEK VA = 16/10

OD DMEK VA = 10/10

UT-DSAEK/DMEK

UT-DSAEK/DMEK

UT-DSAEK vs DMEK = PD-DALK vs DALK

DSAEK/UT-DSAEK/DMEK

DSAEK/UT-DSAEK/DMEK

RECIPIENT CORNEA

c dDIFFERENT PREOPERATIVE

CONDITION !!!

ISSUE # 3IMMUNOLOGIC

REJECTION

IMMUNOLOGIC REJECTIONLow-Risk Eyes n = 237High-Risk Eyes n = 48

Previous Graft(s) n = 39Corneal Vascul. n = 6Herpetic Endothelit. N = 3

UT-DSAEK Imm. Rej.

POSTOPERATIVE TREATMENT

Topical Dexamethasone 0.1%Tapered off over a 5-month Period (from 2-Hourly to qd) qd Lifelong (unless Contraindicated)

For Eyes at High Risk 1.0-1.5 mg/Kg Prednisone p.o. Tapered off over a 2-

month Period

Endothelial Rejection in 4/162 Eyes (2.47%)

Low Risk n=3/142(2.1%)High Risk n=1/21 (4.8%)

All Cases Resolved with Steroidal Treatment !!!

UT-DSAEK Imm. Rej.

DSAEK* UT DMEK

1 Year 6% 2.5% 1%

2 Years 10% 2.5% 1%

*Fuchs Indications Only

DSAEK/UT-DSAEK/DMEK Cumulative Probability (K-M)

COMPLICATIONS UT-DSAEK DMEK*

Air Re-injection 3% 17-77%

Primary Failure 1% 9%Rejection1yr 2.5% 0-13%

Tissue Loss 1% 0-13%Data for Fuchs or PBK indications only

CONCLUSIONSDMEK vs

GOOD (UT)DSAEK !!!

CONCLUSIONSOutcomes of UT-DSAEK Compare

Favorably with Those of Conventional

DSAEK and Do Not Differ

Substantially from Those of DMEK

50μ54μ

UT-DSAEK

365μ204μDSAEK

32μ52μ DMEK

UT-DSAEK/DMEK

DMEK 2.0

UT-DSAEK/DMEK

DMEK 2.0StandardizationSubstantial Advantages

UT-DSAEK/DMEKDMEK 2.0

SimplifyReduce TraumaEliminate Primary Failure

(UPSIDE DOWN!!!)

UT-DSAEK/DMEK

DMEK 2.0TOTAL

CONTROL !!!

DMEK 2.0

Step #1: TRI-FOLDING

DMEK 2.0

Step #2: CL TRANSFER

DMEK 2.0

Step #3: LOADING A-B

Endothelium

Descemet

DMEK 2.0

Step #3: LOADING C-D

DMEK 2.0

Step #4: POSITIONING

DMEK 2.0

Step #5: PULL-THROUGH

DMEK 2.0

Step #5: PULL-THROUGH

DMEK 2.0Results 6 Mos Post-DMEK20 Consecutive Uneventful

DMEKVA≥20/25 in 16/20 Eyes

DMEK 2.0Forceps Trauma

50 µm

EACH BITE = 0.03mm2 = 50-75 Cells

DMEK 2.0Results 6 Mos Post-DMEK20 Consecutive Uneventful

DMEKECL ≤ 12% !!!

Requests of Course Electronic Copies to Be

E-mailed to: mbusin@yahoo.com