1. JENNIFER NOTTAGE, MD VERINDER NIRANKARI, MD CORNEA SERVICE, UNIVERSITY OF MARYLAND (JMN AND VSN) CORNEA SERVICE, EYE CONSULTANTS OF MARYLAND,BALTIMORE, MD (VSN) THE AUTHORS HAVE NO FINANCIAL INTERESTS Endothelial Keratoplasty in Eyes with Previous Penetrating Corneal Transplants

2. Background Of the 30,000 corneal transplants that are performed yearly in the US, 10-40% are regrafts Penetrating Keratoplasty (PK)  Prolonged visual recovery  Post -0p astigmatism  Suture-related complications  Poorer survival in regrafts  Corneal neurosensory deprivation Endothelial Keratoplasty (EK)  Faster visual recovery  Less refractive variation  Maintained structural integrity of the eye  Larger area of endothelium transplanted  Decreased number of post-op visits

3. Background Previous Studies: Price and Price 2006  7 eyes of 7 patients  BCVA improved in 6/7 patients  One graft detachment Covert and Koenig 2007  7 eyes of 7 patients  BCVA improved in 6/7 patients  3 pt with graft dislocation  2 pt with iatrogenic donor failure

4. Purpose To evaluate techniques, outcomes, and complication of endothelial keratoplasty (EK) in eyes with previous penetrating corneal transplant (PK) Pre-opPost-op

5. Study Design Retrospective study Two surgical sites, one surgeon (VSN) Consecutive surgical cases of EK after failed PK All patients had experienced endothelial decomposition after previously having clear corneal transplants

6. Data Obtained Pre-op Data: Sex Age Eye Diagnosis before last PK Months since previous PK Best vision since most recent PK Cause of PK failure Concomitant eye conditions Prior surgical procedures Surgical/Post-op Data: Horizontal corneal diameter Complications BCVA after EK Endothelial cell count at 3 months and 1 year Pachymetry at 3 months and 1 year Follow-up duration

7. Surgical Technique 5mm scleral tunnel created 1mm behind limbus Precut corneal button: placed endothelial side up on a Hessburg trephine, cut at 8mm Paracentesis created, BSS placed into the AC 5mm Corneal scleral tunnel dissected into clear cornea using 2.75mm keratome No descmets stripping was done in any cases Precut cornea placed endo up on the surgical field Viscoelastic placed onto the endo Cornea folded 60/40, grasped with Ogawa forceps and placed into the anterior chamber 3 interrupted 10-0 nylon sutures placed to close the incision Air bubble inserted into the AC to unfold the cornea Cornea centered and more air is placed to obtain a 100% air bubble Homatropine gtts placed After 10 minutes, 50% of air remove and replaced with BSS Subconjunctival antibiotic and steroid injection Pt remains flat for 30 minutes after the conclusion of the case

8. Results 27 eyes of 25 patients underwent EK in eyes with previous graft rejections (18 eyes) and endothelial failure (9 eyes) 14 female, 11 males 11 OD, 16 OS Average age= 50.5 year old Reason for initial PK  Fuchs’ dystrophy: 14  Corneal Scar: 8  Pseudophakic Bullous Keatopathy: 2  Keratoconus: 2  Stromal Corneal Dystrophy: 1 Visual acuity  Improved from an average pre-op VA of 20/400 (range from 20/80 to CF) to an average post-op VA of 20/60 (range from 20/40 to 20/200)  Minimum of 1 year follow-up  Only one patient did not have visual improvement following the EK

9. Results Endothelial Cell Density  Results at one year:  Average endothelial cell loss in our study was 37% at one year  Average endothelial cell loss in primary EK is 38% at one year  Average endothelial cell loss in primary PK is 20% at one year Cell densityPachymentry Graft2717505 Host1972628

10. Results 1/27 eyes (3.7%) had a graft dislocation at 1 week 26/27 (96.3%) grafts remained clear at the last follow-up appointment Pre-opPost-op

11. Conclusion Endothelial Keratoplasty in eyes with Penetrating Keratoplasty graft failure is a viable alternative to a repeat full thickness corneal transplant Pre-opPost-op

12. References Covert DJ, Koenig SB. Descemet Stripping and Automated Endothelial Keratoplasty (DSAEK) in Eyes With Failed Penetrating Keratoplasty. Cornea. July 2007;26(6):692-6. Price FW, Price MO. Endothelial Keratoplasty to Restore Clarity to a Failed Penetrating Graft. Cornea. Sept 2006; 25(8):895-9. Terry MA. Endothelial Keratoplasty: A Comparison of Complication Rates and Endothelial Survival between Precut Tissue and Surgeon-Cut Tissue by a Single DSAEK Surgeon. Trans Am Ophthalmol Soc. 2009 Dec;107:184-91. Flowers CW, Chanq KY, McLeod SD, et al. Changing indications for Penetrating Keratoplasty, 1989-1993. Cornea. 1995;14:583-8. Cosar CB, Sridhar MS, Cohen EJ, et al. Indications for penetrating keratoplasty and associated procedures, 1996-2000. Cornea. 2002;21:148-51. Thompson RW Jr, Price MO, Bowers PJ, et al. Long-term graft survival after penetrating keratoplasty. Ophthalmology. 2003. 110:1396-1402. Maeno A, Naor J, Lee HM, et al. Three decades of corneal transplantation: indications, and patient characteristics. Cornea. 2000;19:7-11. Inoue K, AmanoS, Oshika T, et al. A 10-year review of penetrating keratoplasty. Jpn J Ophthalmol. 2000;44:139-145. Magurie MG, Stark WJ, Gottsch JD, et al. Risk factors for corneal graft failure and rejection in the collaborative corneal transplantation studies. Colaborative Corneal Transplantation Studies Research Group. Ophthalmology. 1994;101:1536-47. PriceFW Jr, Price MO. Descemet’s stripping with endothelial keratoplasty (DSEK) in 50 eyes: a refractive neutral corneal transplant. J Refract Surg. 2005;21:339-45. MacEwen CJ, Khan ZU, Anderson E, et al. Corneal re-graft: indications and outcome. Ophthalmic Surg. 1988;19:706-12. Rapuano CJ, Cohen EJ, Brady SE, et al. Indication for and outcomes of repeat penetrating keratoplasty. Am J Ophthalmol. 1990;109:689-95. Patel NP, Kim T, Rapuano CJ, et al. Indications for and outcomes for repeat penetrating keratoplasty, 1989-1995. Ophthalmology. 2000;107:719-24. Price MO, Gorovoy M, Benetz BA, et al. Descemet’s Stripping Automated Endothelial Keratoplasty Outcomes Compared With Penetrating Keratoplasty from the Cornea Donor Study. Ophthalmology. Dec 2009; epub ahead of print.