Postoperative Complications Following Descemet-Stripping Automated Endothelial Keratoplasty in Patients with Prior Glaucoma Surgery Melissa B Daluvoy MD, Ajoy S Virdi MD, Neelofar Ghaznawi MD, Edwin S Chen MD, Kristin M Hammersmith MD, Christopher J Rapuano MD Cornea Service, Wills Eye Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA The authors have no financial interest in the subject matter of this poster

Introduction Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) has become the surgery of choice for endothelial dysfunction. This procedure has well documented advantages over penetrating keratoplasty but also has complications including graft dislocation, graft failure or rejection, and elevation of intraocular pressure (IOP)1. The presence of aqueous filtering or glaucoma drainage devices (GDD) in the anterior chamber can create technical challenges with graft placement, manipulation and achieving a complete air fill for graft adhesion2,3.

Purpose To study post operative complications after DSAEK in patients who had previous history of glaucoma surgery including trabeculectomy and glaucoma drainage devices.

Methods A retrospective chart review of clinical data of ten pseudophakic eyes of nine patients who underwent DSAEK between 3/2006 and 9/2009 in the presence of previous glaucoma surgery was performed. Pre & post operative visual acuity (VA), IOP, and post operative complications were recorded. No attempt was made to occlude the glaucoma filters or tubes intraoperatively. Pre-op glaucoma medication regimens were reinstituted immediately after surgery. Decision for further medical or surgical intervention was left to the discretion of the managing surgeon and their consultants.

Results Nine of the 10 eyes had prior trabeculectomies and 1 had a prior GDD. Two eyes (20%) required graft repositioning with an air bubble post operatively for a displaced graft. One of these (10%) dislocated again and was replaced with a penetrating keratoplasty; the other did well. Three eyes (30%) required additional topical antiglaucoma medications. Of those requiring additional topical medications, two (20%) went on to require additional glaucoma surgery; one received a repeat trabeculectomy & the other a GDD. One eye (10%) had post operative cystoid macular edema (CME) which resolved with one intravitreal Kenalog injection with no increase in IOP. In total, 60% of eyes required a post-operative intervention as listed above. All the complications were in patients who had prior trabeculectomies. The patient with prior GDD had an uneventful post-operative course.

Results Pt Eye Past Ocular History Pre-Op Post-op Course Post-op IOP Post-op VA VA IOP 1 mo 3 mo 6 mo 12mo 6mo 1 OS PBK; PDS; Trab (prior to 2001); no medications 20/200 9 POD#5 graft dislocated;POD#14 graft dislocated; POD#21 PK PK 2 OD Fuchs’Dys; POAG; Trab; no medications 7 Uneventful 11 10 NA 20/80 3 Failed PK (Fuchs’); POAG; Trab; no medications POD#1 brimonidine started for wound leak 12 14 20/40 20/50 4 PBK; PXF; Trab (’95 & ’05); Tube shunt (’07); no 20/400 8 20/70 20/100 5 PBK; POAG; Trab; no CF 10ft 6 POD#3 graft dislocated 20/60 PBK; POAG; Trab (’05); brimonidine TID, CF @ 1 ft 13 17 PBK; PDS; Trab (86); pilocarpine BID, timolol 0.5% qam, brimatoprost qHs CF 2ft 16 POD#1 brimonidine added (IOP 40); POM#2 bleb needling (IOP 25); Trab (IOP 40) 19 15 PBK; POAG; Trab (’04); revision for hypotony (’09); no medications CF 4ft POM#1 CME; IVK; resolved by POM#4, no significant IOP increase Brimonidine BID, timolol 0.5% QD, latanoprost qHs 23 20 PBK; POAG; Trab; timolol 0.5%BID, dorzolamide BID, brimonidine BID, travoprost qhs CF @ POM#3 brimonidine increased (IOP 32); POM#4 Tube shunt (IOP 27) 18 Pt: patient; VA: visual acuity; IOP: intraocular pressure; PBK: Pseudophakic bullous keratopahty; PDS :pigment dispersion syndrome; Trab: trabeculectomy; POD: post-operative day; PK: penetrating keratoplasty; POAG: Primary open angle glaucoma; PXF: pseudoexfoliation; TID: three times daily; BID: twice daily; POM: post-operative month; QD: daily; CME: cystic macular edema; IVK: intravitreal Kenalog

Post-operative day #1 slit lamp photograph of patient #3 Results Post-operative day #1 slit lamp photograph of patient #3

Post-operative month #3 slit lamp photograph of patient #3 Results Post-operative month #3 slit lamp photograph of patient #3

Conclusions Graft displacement, graft failure, and poor IOP control are important complications after DSAEK and may be expected to occur at a higher rate in patients with pre-existing glaucoma surgery. In our small case series, the graft dislocation rate of 20% was within the reported range of 1-34% in patients without previous glaucoma surgery1,4,5. However, one small study evaluating the outcomes of DSAEK in 4 eyes with tube shunts in the anterior chamber showed no effect on graft dislocations3. In our study, 30% of patients required additional IOP lowering medications and 20% went on to need additional glaucoma surgery. In a previous study comparing patients with and without glaucoma, 38% of eyes with prior glaucoma surgery required additional IOP lowering medications and 19% needed surgery6.

Conclusions Despite the obstacles that prior glaucoma surgery may present to the DSAEK surgeon, this procedure can successfully be completed in patients with prior glaucoma surgery. A larger series would help to determine more accurately the incidence of these complications.

References Shih CY, Ritterband DC, et al. Visually significant and nonsignificant complications arising from Descemet stripping automated endothelial keratoplasty. Am J Ophthalmol. 2009 Dec;148(6):837-43. Esquenazi s, Rand W. Safety of DSAEK in patients with previous glaucoma filtering surgery. J Glaucoma. 2009; [In press]. Riaz KM, Sugar J, et. al. Early results of Descemet –stripping and automated endothelial keratoplasty(DSAEK) in patients with glaucoma drainage devices. Cornea. 2009 Oct;28(9):959-62. Chen ES, Terry MA, Shamie N, Hoar KL, Friend DJ. Precut tissue in Descemet's stripping automated endothelial keratoplasty donor characteristics and early postoperative complications. Ophthalmology. 2008 Mar;115(3):497-502.   Koenig SB, Covert DJ. Early results of small-incision Descemet's stripping and automated endothelial keratoplasty. Ophthalmology. 2007 Feb;114(2):221-6. Epub 2006 Dec 5.   Vajaranant TS, Price MO, et al. Visual acuity and intraocular pressure after Descemet’s stripping endothelial keratoplasty in eyes with and without preexisting glaucoma. Ophthal. 2009;116:1644-1650.