Keratoplasty advances

There is still room for DSAEK in the new era of endothelial keratoplasty

Dermot McGrath

Posted: Thursday, February 1, 2018

Recent advances in endothelial keratoplasty techniques, and particularly the arrival of Descemet membrane endothelial keratoplasty (DMEK), means that corneal surgeons today have no shortage of options when it comes to selecting the right procedure for particular indications, Sadeer Hannush MD told delegates attending the 8th EuCornea Congress in Lisbon.

Dr Hannush, Wills Eye Hospital, Philadelphia, Pennsylvania, United States, said that non-refractive corneal procedures could be broadly divided into five categories: ocular surface reconstruction, anterior lamellar keratoplasty, posterior lamellar keratoplasty (DSAEK and DMEK), penetrating keratoplasty and permanent keratoprosthesis surgery.

“The big advantage of endothelial keratoplasty for the indication of endothelial dystrophy and dysfunction, of course, is rapid visual rehabilitation. There are also other benefits, such as the absence of suture-related complications, decreased incidence of allograft rejection, an intact globe with resistance to traumatic wound dehiscence, predictable corneal toricity with minimal topographic change and a predictable small hyperopic refractive shift,” he said.

Dr Hannush said he has now performed almost 1,000 cases of Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) since his first procedure in October 2005.

“About one-third of these are endothelial grafts for endothelial dysfunction, usually in the presence of a posterior chamber implant. Another third are triple procedures (endothelial keratoplasty, cataract removal and IOL implantation). The final third are grafts in the presence of a co-morbidity (e.g. previous filtering surgery or tube shunt placement, ACIOL, or unicameral eye), which includes failed penetrating keratoplasty or even DMEK,” he said.

Although DMEK has evolved as the procedure of choice for corneal endothelial replacement in the setting of endothelial dystrophy and/or dysfunction, Dr Hannush believes that DSAEK still has a role to play in modern corneal practices.

“In many instances, especially in the presence of severe comorbidities, the surgeon may be able to more easily bring the case to a successful conclusion with DSAEK. This is especially true if the surgeon is not experienced in performing DMEK,” he said.

Looking at the outcomes after a decade of DSAEK procedures, Dr Hannush said it became apparent that postoperative visual acuity and graft survival were dependent on the type of surgery and the nature of the comorbidities.

“The results in all of our cases ultimately depend on the visual potential that the patient has both from a macula and optic nerve point of view at the time of surgery. Also, for patients with tube shunts, the prospects are not great. Endothelial cell loss tends to be very high in these patients and the five-year graft failure rate is around 75%,” he said.

Sadeer Hannush: