1. Use of a Novel Y- Suture Technique to Reduce Detachments in Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) Habeeb Ahmad, MD Martin Heur, MD, PhD Sam Yiu, MD Jonathon Song, MD Ronald Smith, MD *The authors have no financial interest in the subject matter of this poster

2. DSAEK vs. Penetrating Keratoplasty:  Avoids open sky surgery  Faster recovery time  Less sutures: reduced astigmatism, smoother anterior surface, less suture related complications  Improved tectonic stability  Reduced graft failure from ocular surface  Small refractive shift/Good visual outcomes Introduction: Advantages of DSAEK

3. The Rise of DSAEK 2006- 6,027 tissues provided for Endothelial Keratoplasty(EK) procedures  134% 2007- 14,159 tissues provided for Endothelial Keratoplasty procedures  30% 2008- 18,375 tissues provided for Endothelial Keratoplasty procedures 2007- 85% of all transplants for endothelial disease were EK surgical procedures 2008- Total transplants rose 5.7% (39,391  41,652) * Eye Bank Association of America Statistics Report 2008

4. DSAEK: Limitations in the Literature  Posterior Graft Dislocation (0-82%, average 14.5%)  Endothelial Cell Loss (1 year Postoperatively: 24 - 61%)  Primary Graft failure (0-29%)  Pupillary Block/Steroid Induced Glaucoma (0-15%)  Hyperopic Shift (0.7D - 1.5D, mean 1.1D) *Lee et al. Descemet’s Stripping Endothelial Keratoplasty: Safety & Outcomes. Ophthalmology 2009;116:1818-1830

5. Purpose To find a method to reduce/prevent lenticule detachments, particularly, in high risk patients including those with associated aphakia, glaucoma, blebs, tubes, iris abnormalities and vitreous in the AC. Ideal method would be: 1- Safe 2- Repeatable 3- Technically simple 4- Carry low risk of infection 5- Avoid gross manipulation of graft 6- Achieve anatomic and visual success 7- Reversible 8- Inexpensive

6. Retrospective review: 26 non-consecutive DSAEK procedures using Y- suture technique Timeframe: 2007- 2009 Performed by three surgeons at the university hospital setting Patient demographics: 25 Patients: 12 Males, 13 Females Ages: Range: 27 - 95 Mean Age: 69 Methods

7. Introduction to the Y-Suture Technique  3 Anchoring Sutures in Y Formation: Full thickness, Peripheral, Tangential, Used to tether small portion of lenticule  Performed after placing air bubble  Using 10.0 Nylon sutures  Knots are not buried  Removed after 1 week

8. Demographic Results

9. Color Slit Lamp Photo: 1 week after Y-Suture DSAEK

10. Results: Y-Suture DSAEK in High Risk Patients Fully Attached Grafts Dislocated Grafts Primary Graft Failure Graft Rejection Suture Related Complications 97% 0% 3%

11. Anterior Segment OCT of the only dislocation in the study group. Dislocation was a result of a severe hypotony with bleb leak Sutured graft with interface fluid Two months later: fully dislocated graft Repeat DSAEK after revision of bleb Graft remains well adhered months later Suture 1 2 4 3

12. DSAEK surgery when successful, results in excellent visual outcomes In high risk patients (glaucoma, previous dislocations, iris abnormalities, vitreous in AC), graft detachment can be significantly higher than typical patients limiting both surgical and visual success Use of the Y suture technique during DSAEK is an effective, safe, reproducible and inexpensive mean to reduce detachments in these high risk patients Conclusions