Descemet’s stripping automated endothelial keratoplasty by novice endothelial keratoplasty surgeons Jason W. Much, M.D. 1 Paul M. Phillips, M.D. 1,2 Leslie A. Olsakovsky, M.D. 1 The authors have no financial interest in the subject matter of this poster. 1.University of Virginia Department of Ophthalmology, Charlottesville, VA 2.Sightline Ophthalmic Associates, Sewickley, PA

Purpose To report 6-month postoperative outcomes from two cornea surgeons performing their first solo DSAEK cases while strictly adhering to a well-described, previously published technique 1

Methods Consecutive, prospective series of the first cases performed between September 2008 and August 2009 Surgeon 1 (PMP) is in private practice (fellowship-trained in DSAEK) Surgeon 2 (LAO) is in academic practice (fellowship-trained in cornea and traditional penetrating keratoplasty) Surgical technique strictly followed as described by Mark Terry 1 In brief: – Peripheral scraping of recipient bed for 360 degrees – 5mm scleral tunneled wound with folded (40:60) insertion – Surface sweeping maneuvers used to remove interface fluid – Freely floating air bubble left in the anterior chamber at end of case All tissue was pre-cut by the Portland Eye Bank

Baseline patient characteristics N71 eyes of 62 patients Mean age (yrs)70.6 Gender19 male : 43 female Diagnosis57 Fuchs (80%) 10 PBK/ABK/surgically-induced corneal edema (14%) 2 failed PK (3%) 1 ICE syndrome 1 Reiger's anomaly/Descemet’s tear 38 eyes (54%) underwent concomitant cataract extraction Graft sizes used: 8mm (n=49); 8.5mm (n=17); 7.5mm (n=3); 7mm (n=2)

Results Pre-op6-monthsP Mean BCVA (all eyes) 20/9620/38< Mean BCVA (excluding comorbidities*) 20/7920/34< Endothelial cell density (cells/mm 2 ) < Average visual acuity gain over 4 Snellen lines Endothelial cell loss rate = 18.3% *macular disease, amblyopia, end-stage glaucoma

Results Complications – The dislocation rate was 4.2% – All dislocations were successfully repositioned – Two patients had posterior pressure intraoperatively which led to significant graft manipulation and post-op anterior synechiae formation – There were no cases of pupillary block and no cases of primary graft failure (all grafts were clear at 1 and 6 months) – At 6 months, 21 eyes (30%) had an intraocular pressure > 24mmHg or a rise in intraocular pressure of > 10mmHg above pre-op values No eyes required glaucoma surgery by the 6 month follow up – 5 eyes developed interface haze Surgeon comparisons – There was no statistical difference between surgeon 1 or surgeon 2 in visual acuity results, endothelial cell loss rate or intraocular pressure rise at 6 months – Surgeon 1 had a lower dislocation rate (2.1%) than Surgeon 2 (8.7%) though this did not reach statistical significance (P=0.24)

Results - complications Interface haze 6 months post-op but with good final vision (BCVA at 1 year = 20/30-) Dislocated graft 1 day post-op (note ACIOL, trabeculectomy bleb, and large superior iridectomy) Graft repositioned without complication and cornea cleared (BCVA at 1 month = 20/50-)

Clear DSAEK grafts 6 months post-op Fuch’s dystrophyReiger’s anomaly

Conclusion The dislocation rate is better than the average rate reported in the literature (14%; range 0-82%) though not as low as that reported by Terry (0- 5%) 2 The 6-month rate of endothelial cell loss is better than that reported in the literature (average 37%; range 25-54%) 1-8 There was a significant rate of steroid response glaucoma at 6 months consistent with previous reports 9-11

Conclusion The novice endothelial keratoplasty surgeon can achieve encouraging early postoperative results with few complications by carefully adhering to a specific surgical technique with minimal graft trauma Our results show that the initial learning curve may not be as steep as previously thought

References 1.Terry MA, Shamie N, Chen ES, et al. Endothelial keratoplasty: a simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block. Ophthalmology 2008;115: Lee WB, Jacobs DS, Musch DC, et al. Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology. Ophthalmology 2009;116: Terry MA. Endothelial keratoplasty: a comparison of complication rates and endothelial survival between precut tissue and surgeon-cut tissue by a single DSAEK surgeon. Transactions of the American Ophthalmological Society 2009;107: Chen ES, Terry MA, Shamie N, et al. Endothelial keratoplasty: vision, endothelial survival, and complications in a comparative case series of fellows vs attending surgeons. American Journal of Ophthalmology 2009;148:26-31.e2. 5.Shih CY, Ritterband DC, Rubino S, et al. Visually significant and nonsignificant complications arising from Descemet stripping automated endothelial keratoplasty. American Journal of Ophthalmology 2009;148: 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 2010;117: Bahar I, Kaiserman I, Levinger E, et al. Retrospective contralateral study comparing descemet stripping automated endothelial keratoplasty with penetrating keratoplasty. Cornea 2009;28: Lombardo M, Terry MA, Lombardo G, et al. Analysis of posterior donor corneal parameters 1 year after Descemet stripping automated endothelial keratoplasty (DSAEK) triple procedure. Graefes Archive for Clinical & Experimental Ophthalmology 2010;248: Vajaranant TS, Price MO, Price FW, et al. Visual acuity and intraocular pressure after Descemet's stripping endothelial keratoplasty in eyes with and without preexisting glaucoma. Ophthalmology 2009;116: Jones R, Rhee DJ. Corticosteroid-induced ocular hypertension and glaucoma: a brief review and update of the literature. Current Opinion in Ophthalmology 2006;17: Tripathi RC, Parapuram SK, Tripathi BJ, et al. Corticosteroids and glaucoma risk. Drugs & Aging 1999;15: