Early Outcomes of DSAEK in Pseudophakic Eyes with Anterior Chamber IOLs Hong A, Boehlke CS, Afshari NA, Kim T Duke University Medical Center Authors have no financial interest

Background DSAEK has significant advantages over standard penetrating keratoplasty in the management of corneal endothelial disorders Faster Visual Rehabilitation More predictable corneal power Preserves the structural integrity of the eye Decreased suture-related complications

This technique has gained widespread popularity for use in phakic and pseudophakic eyes with posterior chamber IOLs The role of DSAEK in eyes with anterior chamber IOLs (ACIOLs) remains unclear Generally considered a surgical contraindication due to higher risk of surgical complications and graft failure Reduced space in the anterior chamber Escape of air posteriorly through the peripheral iridectomy Greater potential for vitreous interference Possibly greater surgical manipulation of donor tissue May necessitate an IOL exchange (iris- or scleral-sutured IOL)

Purpose To report on the early results of DSAEK in eyes with pre-existing ACIOLs To evaluate the visual outcomes, refractive changes, and complications in this patient population

Methods Retrospective case study Nine eyes of 9 patients with ACIOLs that subsequently developed corneal edema requiring DSAEK were identified from May 2005 to February 2008. The host Descemet membrane was stripped followed by insertion of a microkeratome-dissected donor endothelial graft that was delivered through a 3-mm corneal incision. Donor adherence to the host cornea was maximized by air tamponade and graft interface venting incisions. Best spectacle-corrected visual acuity (BSCVA), manifest refraction, donor dislocation and graft failure rates were measured up to 12 months after DSAEK.

Preoperative Clinical Data Mean Age (yrs) 71.2 ± 10.8 (range 53 to 84) Male: Female 7:2 Indications Pseudophakic bullous keratopathy: 8 Recent failed penetrating keratoplasty: 1 Fuchs’ corneal dystrophy: 1 Preoperative comorbidities Chronic CME: 1 Advanced Retinitis Pigmentosa: 1 Open-angle glaucoma: 6 Anterior chamber glaucoma tube: 1 Pars plana glaucoma tube: 1

Refractive Outcomes Preoperative Postoperative P-value Mean spherical equivalent (D) 0.26 ± 1.6 0.05 ± 1.4 0.26 Mean refractive astigmatism (D) 2.4 ± 1.7 1.6 ± 1.5 0.50 Postoperative refractive status was obtained at 3 to 6 months D = diopters; n = 8

Visual Outcomes and Comorbidities Patient No. Preoperative BSCVA Postoperative BSCVA Comorbidity 1 20/200 20/70 Chronic CME, glaucoma 2 20/40 Prior penetrating keratoplasty 3 20/50 Glaucoma, pars plana glaucoma tube 4 20/60 20/30 Glaucoma 5 6 Count Fingers 7 20/400 Retinitis pigmentosa, AC glaucoma tube 8 9 20/100 Mean p=0.0007 BSCVA = best spectacle-corrected visual acuity; AC = anterior chamber Postoperative BSCVA = obtained at 3 to 6 months

Complications Complication No. of Patients (%) Donor dislocation, requiring repositioning 2 (22.2%) Primary graft failure, requiring repeat DSAEK* Pupillary block glaucoma 0 (0%) n = 9 *In one case, the donor tissue had first detached, was repositioned with repeat air injection, detached again and was regrafted

Conclusions Average visual outcomes of DSAEK in eyes with ACIOLs may be comparable to vision after DSAEK with posterior chamber IOLs. Patients with ACIOLs may still be good candidates for DSAEK if they meet the ideal surgical criteria of a deep chamber, no vitreous interference, absent peripheral anterior synechiae, and the ability to maintain air tamponade for a prolonged period DSAEK in eyes with ACIOLs can result in excellent visual outcomes with rapid visual recovery and may eliminate the need for an IOL exchange