Early Outcomes of Descemet’s Stripping Automated Endothelial Keratoplasty in Pseudophakic Eyes with Anterior Chamber Intraocular Lenses Preeya K. Gupta MD 1, Anna Bordelon MD 1, David T. Vroman MD 2, Natalie Afshari MD 1, Terry Kim MD 1 1.Dept of Ophthalmology, Duke Eye Center Durham, NC 2.Carolina Cataract and Laser Center; Ladson, SC Financial Disclosures: TK— consultant for Alcon

Background Descemet’s stripping automated endothelial keratoplasty (DSAEK) is a newer surgical technique offering faster visual recovery compared to penetrating keratoplasty in the treatment of endothelial dysfunction. Anterior chamber intraocular lens (ACIOL) in patients requiring DSAEK can make this procedure more complicated due to decreased anterior chamber depth, difficulty in unfolding the graft, and/or escape of air via existing peripheral iridectomy.

Background Complications of DSAEK include graft dislocation, primary graft failure, and pupillary block. Current surgical approach in these patients include ACIOL exchange for sutured posterior chamber intraocular lens Little has been reported in the literature as to the outcomes of DSAEK in patients with preexisting ACIOL who do not undergo intraocular lens exchange.

Purpose To evaluate visual outcomes, refractive changes, and complications of Descemet’s stripping automated endothelial keratoplasty (DSAEK) in the management of corneal endothelial disorders in eyes with preexisting anterior chamber intraocular lenses (ACIOL)

Methods Retrospective review of 31 patients having DSAEK with preexisting ACIOL from May 2006 to March 2009 Patients had minimum follow-up of 1 month and up to 30 months. Pre and post-operative best spectacle-corrected visual acuity (BSCVA), manifest refraction, co-morbid conditions, and complications were recorded. Graft dislocation and failure rates were calculated. Seven patients had history of severe retinal and/or optic nerve pathology (retinal detachment, macular hole, macular degeneration, and optic atrophy) with pre and post-operative acuity range from 20/200 to count fingers. These patients were excluded from the analysis.

Methods Surgical Technique Paracentesis incisions were made in the supero- and inferotemporal quadrants and the anterior chamber was inflated with a cohesive viscoelastic. The corneal epithelium was marked with an 8.0 mm trephine and then a bent, 25-gauge needle was used to score Descemet's membrane 360° corresponding to the trephine mark. A temporal clear corneal incision was then made in the host with a 2.5 mm keratome. A Gorovoy stripper on a 3cc syringe was then used to strip off the host endothelium and Descemet's membrane. The irrigation-aspiration unit was used to remove any remaining viscoelastic material and the wound was enlarged to approximately 4mm.

Methods Surgical Technique Pre-cut DSAEK donor graft tissue was trephinated to the appropriate size, a small amount of viscoelastic was placed on the endothelial surface of the graft, which was then folded in a 60/40 “taco” fashion. The graft was inserted into the anterior chamber using a Utrata- type forceps and filtered air was injected into the anterior chamber to unfold the graft and completely attach the pre-cut DSAEK donor graft to the host cornea. A 10-0 nylon was placed in the operative wound. Lastly, four venting incisions were placed in the peripheral cornea to release any fluid in the graft-host interface to facilitate graft adherence. The patients were then instructed to lay supine for two hours immediately post-operatively, after which they were examined at the slit-lamp biomicrscope to ensure graft attachment and check intraocular pressure.

Results The mean age at surgery was 78 ± 9 years (range 53 to 91 years) All eyes had pseudophakic bullous keratopathy except one patient who had failed penetrating keratoplasty graft. Co-morbid conditions included: primary open angle glaucoma (3 patients with glaucoma tube shunts present pre-operatively), cystoid macular edema, neovascular and non-neovascular age-related macular degeneration, retinitis pigmentosa, macular hole, hypotony maculopathy, retinal detachment, optic atrophy, and keratoconus.

Results Excluding patients with limited visual potential due to non-corneal pathology, the mean BSCVA improved significantly from 20/200 to 20/400 preoperatively to –20/63 at 3 months ( n=17, p<0.0001) –20/60 at 6 months (n= 14, p=0.0006) –20/50 at greater than one year (n=13, median 23 months, p=0.0004).

Results The post-operative cylinder of 2.1 ± 1.7 D did not differ significantly from 2.6 ± 1.7 D pre-operatively (p=0.46). The pre-operative mean spherical equivalent was -0.3 ± 1.8 D compared to ± 1.5 D post-operatively (p=0.78). Graft dislocation rate was 13% (n=4/31) and graft failure rate was 16% (n=5/31). For those patients with endothelial cell density data available (n=10), the average endothelial cell loss was 48% at a mean of 14 months.

Conclusions Post-operative acuity after DSAEK in the literature varies, most achieving acuity of 20/40 to 20/60 at post- operative month 3 Our study had comparable visual acuity outcomes not only at 3-6 months post-operatively, but also at 1-2 years, suggesting that lens exchange may not always be necessary to achieve successful DSAEK surgery. Careful preoperative evaluation, including assessment of anterior chamber depth, vitreous prolapse into the anterior chamber, and documentation of peripheral anterior synechiae is recommended.

Conclusions DSAEK surgery in patients with ACIOL remains a controversial topic The visual and anatomical outcomes from this limited study support this approach as a surgical option in selected cases. Further prospective studies with endothelial cell loss analysis are warranted to provide more information on this approach.