1. Case conference
I’ll start my presentation
Pf. 주천기 / R3 원재연

2. Case 1 400206 서 O 수 M/73 C.C ) Dec. VA(OD) onset) 1yrs
상환 2012년 8월 부터 우안의 시력 저하 있어 local 내원하여 PBK(OD)
진단 받고 치료 받았으나 호전 안되어 각막 이식 원하여 본원 내원함
DM/HBP (-/+): for 15yrs(p.o medi)
Ocular op/trauma(+/-):
15년전 Phaco+PCL(OU) at local
Eye drop (+) : O-Lotemax x 3, O-Cravit x 3, O-NACLx3, O-SOLx3/OD
In the first case
A 73-year-old man presented complaining of worsening of vision in his right Eye for 1 year. so he visited local clinic and was diagnosed with PBK and kept applying several eyedrops but symptome didn’t improve at all.
According to his past ocular history, he got the cataract surgery of both eye at local clinic before 15yrs

3. Ocular examination VA OD 0.16 (0.2 c ph) OS (1.0+1)
IOP AP OD 14 OS mmHg at 8:00pm
EOM Straight at 1' position by H-test , No LOM(OU)
Orbit No exophthalmos(OU)
Lid OU No swelling
Conj. OD not injected
OS not injected
Cornea OD mild to mod edematous c DM foldings, microbullae(+)
OS clear
AC OD deep & cell(-)
OS deep & cell(-)
Pupil OD round & nl sized, LR(+)
OS round & nl sized, LR(+), RAPD(-/-)
Lens OD PCL in situ
OS PCL in situ
Fd. OD nl. optic disc c large PPA c flat post. pole
OS nl. optic disc c large PPA c flat post. pole
Clinical ocular examination disclosed that his best corrected visual acquity was intraocular pressure was normal.

4. Cornea OD mild to mod edematous c DM foldings, diffuse microbullae
On Slit-lamp exam, mild to moderate edematouc c DM folding and diffuse milcrobullae of cornea in right eye was observed
Cornea OD mild to mod edematous c DM foldings, diffuse microbullae

5. 766
And he got the examination including specular, pachymetry.
We could not get the endothelial cell count of his right eye.
And we could find the thickness of cornea, the center was 728 um
796
800
728
823

6. DDx Pseudophakic Bullous keratopathy Fuch’s dystrophy
Posterior polymorphorous corneal dystrophy
Postoperative corneal edema
Based On this background, we considered the several differential diagnosis.
In his cornea, because we cannot find guttata, we excluded the Fuch’s dystrophy
As you know, In the PPMD, the most characteristic finding is multiple vesicles or blisters , opacity on the posterior cornea, so we can also exclude the PPMD
Finally we can exclude the postoperative cornea edema because he hadn’t undergone any procedure recently

7. Impression Plan R/O PBK(OD) DSaEK(OD)
So we diagnosed as PBK , and he got the cornea transplant like Dsaek

8. Follow up (POD#4days) Plan O-GAFx 4, O-FMLONx 4(OD) H-LON 15mg
VA OD 0.1 IOP 16mmHg Conj.) mild injected Cornea) sl. edematous c DM folding(+), well attached endothelium 0.5x0.8 mm sized epidefect A. C) deep & cell(trace), air-bubble at sup. Pupil) round & nl sized Lens) PCL in situ/OD
In 4days after operation , The visual acuity was 0.1 and cornea was slight edema with DM folding but well attached endothelium. The patient applied gatiflo , fumelon 4times a day and had 15mg solondo
Plan
O-GAFx 4, O-FMLONx 4(OD)
H-LON 15mg

9. Follow up (POD#2wks) Plan
VA OD 0.32 IOP 21mmHg Conj.) not injected G. Cornea) clear c well attached endothelium AC) deep & cell(-) /OD
In 2wks After the operation, The visual acuity was and cornea was clear and well attached endothelium
The patient applied same eyedrops 4times a day and In 1month after operation, we checked specular, pachy and got the results that pachy was 509 um, specular 2469
Plan
O-GAFx 4, O-FMLONx 4(OD)
F-U 2wk POD #1mon pachy 509, specular 2469

10. Case 2 24054562 황 O 오 M/59 C.C ) Dec. VA(OS) onset) 2months
상환 2011년 5월 부터 좌안의 시력 저하 있어 본원 내원하여 PBK(OS) 진
단 받고 Dsaek(OS) 시행받은 후 경과 관찰하던 중 2013년 7
월 부터 좌안의 시력저하 소견 있어 본원 내원함
DM/HBP (-/+): for 2yrs(p.o medi)
Ocular op/trauma(+/-):
2004. Phaco+PCL(OS) at 전남대병원
2008. subtenon Triamcinolone inj(OS) d/t CME at 전남대 병원
2009. IVTA inj.(OS) d/t ME at 전남대 병원
DSAEK(OS) by Pf.주천기
<Donor cornea : 8.0mm, Recipient cornea : 8.25mm>
Eye drop (+) : O-LON x 4, O-CS x 2/OS
In the second case
A 59-year-old man presented complaining of worsening of vision in his left eye for 2 months.
According to his past ocular history, he got the cataract surgery of Left eye at 전남 university hospital in 2004
And got the subtenon and intravitreal trimacinolon inj of left eye in 2008,2009 respectively.
From May , 2011, he was diagonsed with PBK at our hospital and got the cornea transplantation at our hospital in august .2011

11. Ocular examination VA OD 1.0 OS FC10cm(n-c)
IOP AP OD 11 OS mmHg at 8:00pm
EOM Straight at 1' position by H-test , No LOM(OU)
Orbit No exophthalmos(OU)
Lid OU No swelling
Conj. OD not injected
OS mod injected
Cornea OD clear
OS mod edematous c DM foldings, diffuse microbulla, stromal opacity at
temporal side
AC OD deep & cell(-)
OS deep & cell(blurry visible)
Pupil OD round & nl sized, LR(+)
OS round & nl sized, LR(+), RAPD(-/-)
Lens OD mild cortical opacity
OS PCL in situ
Fd. OD nl. optic disc c flat post. pole
OS blurry visible d/t corneal opacity
Clinical examination disclosed that He can see fingers only near 10cm in lt. eye. intraocular pressure was normal

12. By Slit-lamp exam, mod edematous c DM foldings, diffuse microbullae, stromal opacity at temporal side of left cornea was observed
Cornea OS mod edematous c DM foldings, diffuse microbullae, stromal opacity at temporal side

13. 984
And he got the examination including cornea endothelial cell count and corneal thickness.
We could not get the endothelial cell count of his right eye.
And we could find the thickness of cornea, the center was 911 um
1076
911
981
1148

14. Impression Plan R/O Graft failure (OS) Re-DSaEK(OS)
According to ocular exam , specular and pachymetry, He was diagnosed with graft failure , and got re-cornea transplant like Dsaek

15. we masured 5mm by caliper
removal Epithelium by blade and make 5-mm scleral tunnel incision temporally into the clear cornea
Place an infusion port in one of the limbal incision
Descemet’s membrane was scored in a circular pattern
endothelium were stripped by stripping instrument
Grasp the folded tissue with a special forceps and insert it through the scleral tunnel incision.
Air injected slowly into AC to help unfold the donor tissue with the endothelial side downward and press the donor against recipient.
And sutured the Cornea scleral tunnel incision and conjunctiva.
Make small stab incision in midperipheral recipient cornea down to the graft interface

16. Follow up (POD#7)
VA OS 0.1 IOP 16mmHg Conj.) mild injected c subconj Hm, well approximated wound Cornea) mild edematous c DM folding , well attached endothelium epidefect(+) AC) deep & cell(+), air bubble(-) /OS
In 1week After the operation, The visual acuity was 0.1 and cornea was mild edema with DM folding but well attached endothelium

17. Follow up (POD#7) Plan O-MOX x q3hrs, O-LONx q3hr(OS)
And ant segment OCT showed that the endothelium was well attached
The patient applied vigamox , predforte per 3hours and had 60mg solondo for 1wk and tappered off
Plan
O-MOX x q3hrs, O-LONx q3hr(OS)
Solondo 60mg#1 for 1wk mg for 1wk mg for 1wk

18. Review

19. Contents Introduction to Endothelial Keratoplasty1
Introduction to Endothelial Keratoplasty 2
The fundamental basics of DSAEK surgery

20. History of KP In 1906 – Dr. Eduard Konrad Zirm
: The first successful PK on a farmer in Prague who sustained bilateral alkali burns
: Bilateral 5 mm grafts from a single donor (11 years old boy who required enucleation)

21. Problems with PK Unpredictable astigmatism Infection Ulceration
Vascularization
Rejection
Poor Wound Healing: Risk of Rupture

22. Severe Complications of Penetrating Keratoplasty: Suture Problems and Wound Healing Problems
Endophthalmitis: From retained suture fragment
Expulsive Hemorrhage:
From mild blunt trauma five yeas after PK

23. PK vs EK EK is a disease specific surgery relative to PK
Only replaces the portion that is dysfunctional
Safer for patient
Better visual results
Endothelial keratoplasty

24. Advantages of EK over PK
Mini-invasive (Closed eye during surgery)
Minor infections risk
Local anesthesia
Quick visual rehabilitation
Low astigmatism
Residual emetropia(~0.5~1.5D)
No risk of wound dehiscence(spontaneous or post traumatic)
Easy graft substitution
Less antigenic stimulus
Melles GRJ. Cornea 1998
Price FW Jr. J Refract Surg 2005
Melles GRJ. Cornea 2002, 2004
Terry MA Cornea 2004, 2005
Gorovoy MS Cornea 2006
Koenig SB Ophthalmol 2007
Koenig SB Cornea 2007
Price FW Jr. Cornea 2006

25. CATARACT & REFRACTIVE SURGERY TODAY(2005):55-59.

26. Disadvantages of EK
More time consuming and difficult procedure due to lamellar dissection
Graft dislocation- 5-20% on post-op day 1

27. Contents Introduction to Endothelial Keratoplasty1
Introduction to Endothelial Keratoplasty 2
The fundamental basics of DSAEK surgery

28. Descemets Stripping Endothelial Keratoplasty (DSAEK)
2005 Price, Gorovoy- eliminated the recipient
dissection by just removing descemets
membrane and the endothelium
Surgeon still had to perform the lamellar
dissection on the donor. If it went badly, the
tissue was wasted.

29. Indication for DSAEK - Bullous Keratopathy Fuch’s dystrophy - PPMD
ICE syndrome
Failed PK grafts

30. Indication for Corneal Transplat.
Indication 1970s (%) 1980s (%) 1990(%)
PBK
ABK
Fuchs
Keratoconus
Re-grafts
Scars
Ulcers
Corneal dystrophy
Chemical Burn
Trauma
Interstitial keratitis
Congenital
Virus
Other

31. DSAEK
Replaced donor dissection with a cut tissue made by an automated lamellar keratome
(used for LASIK refractive surgery)
Cut can be made by the surgeon or at the eye bank

32. DSaEK Injectors, Inserters, Glides
EndoInjector
(Keramed)
Neusidl Corneal Inserter
(NCI) (Fischer)
IDEEL Injector
(Kaneka)
EndoSaver (EndoSerter)
(Ocular Systems Inc)
The EndoGlide is a disposable inserter which is devised for safe donor lenticule insertion
in DSAEK surgery. Key principles underlying its development include:
Minimal endothelial damage during donor preparation and insertion
Simplicity in design, and ease of use
Full surgeon control of the donor throughout insertion
Good stabiity and maintenance of the AC during insertion, and
Use in a wide range of simple and complex forms of DSAEK surgery
Macaluso Sealing “Glide” (Janach)
Al-Ghoul injector
FDA
Approved
2009
Tan EndoGlide
(Network Medical, AngioTech)
Daya Endostar
(Duckworth & Kent)
Rieck Glide(Geuder) 32

33. Tan EndoGlide™ Donor lies coiled up inside a Glide Capsule
Design concept: Simplicity:
“thumbdrive in a USB port”
The EndoGlide is a disposable inserter which is devised for safe donor lenticule insertion
in DSAEK surgery. Key principles underlying its development include:
Minimal endothelial damage during donor preparation and insertion
Simplicity in design, and ease of use
Full surgeon control of the donor throughout insertion
Good stabiity and maintenance of the AC during insertion, and
Use in a wide range of simple and complex forms of DSAEK surgery
First commercially available disposable inserter
Utilizes “pull-through” glide principle
Approved FDA Class 1 medical device
CE Mark attained in Europe – June 2009
Launched in the US at 2009 AAO meeting
Over 3000 cases performed worldwide
Clinical data : over 24 months follow-up
Marketed by Network Medical Products and AngioTech (USA) 33

34. Surgical Procedure
1) Epithelium removal and 5-mm scleral tunnel incision temporally into the clear cornea
2) Descemet’s membrane was scored in a circular pattern under the area of the epithelial reference mark using a modified Price–Sinskey hook or Moria.
The EndoGlide is a disposable inserter which is devised for safe donor lenticule insertion
in DSAEK surgery. Key principles underlying its development include:
Minimal endothelial damage during donor preparation and insertion
Simplicity in design, and ease of use
Full surgeon control of the donor throughout insertion
Good stabiity and maintenance of the AC during insertion, and
Use in a wide range of simple and complex forms of DSAEK surgery 34

35. Surgical Procedure
3) Descemet’s membrane and endothelium were stripped from within the scored area using a 45° or 90° Descemet’s stripping instrument
4) The posterior donor tissue is folded over plate with a 40/60 overfold, with the endothelial side inward with small amount of Healon before folding.
The EndoGlide is a disposable inserter which is devised for safe donor lenticule insertion
in DSAEK surgery. Key principles underlying its development include:
Minimal endothelial damage during donor preparation and insertion
Simplicity in design, and ease of use
Full surgeon control of the donor throughout insertion
Good stabiity and maintenance of the AC during insertion, and
Use in a wide range of simple and complex forms of DSAEK surgery 35

36. 5) Grasp the folded tissue with a special forceps and insert it through the scleral tunnel incision.
6) Air injected slowly into AC to help unfold the donor tissue with the endothelial side downward and press the donor against recipient.

37. 7) Air was completely filled at the AC for 10 minutes
8) Corneal surface massaged with Lasik roller to center the donor tissue
and help remove fluid from donor/recipient interface

38. 9) Make small stab incision in midperipheral recipient cornea down to the
graft interface

39. Large air bubble is left in the eye
at the end of surgery
Patient is to be supine
the rest of the day and night
If the bubble is too big
pupillary block glaucoma can
occur

40. Techniques to Promote Donor Tissue Adherence
Precut: trimming thick donor edge
Air injected slowly into AC to prevent the insertion of air at the between donor disc and recipient
Anterior chamber was left filled with air
Cornea surface massage with LASIK flap roller
Make small stab incision in midperipheral recipient cornea down to the graft interface

41. Techniques to Promote Donor Tissue Adherence
Air injected slowly into AC to prevent the insertion of air at the between donor disc and recipient.
Air was suddenly filled at the AC, then small amount of air was inserted at the between donor disc and recipient.

42. Price et al, Ophthalmology, November, 2006 Descemet’s Stipping With EndothelialKeratoplasty eyes
Ophthalmology 2006;113:1936–1942
Microkeratome vs Manual Dissection of Donor Tissue
- 69% vs 55% had >20/40 vision after 6 months
- 0.5% vs 5% early graft failure

43. Complications Donor detachment and graft failure
Perforation of Descemet’s membrane during posterior lamellar dissection
Postoperative pupillary block
Donor tissue not centered in the posterior recipient bed
Pseudo-anterior chamber created by the presence of aqueous humor between donor and recipient stroma

44. The Causes of Complete Dislocation
Improper unfolding, requiring removal and re-insertion,
was the most significant risk factor for tissue dislocation
and graft failure.
Intra-operative inability to maintain the anterior chamber
and post-operative trauma(eye rubbing)
By Felix Y. Chau, Alan N. Carlson (2007 ASCRS)

45. The Causes of Complete Dislocation
Compression to upper marign
Excessive air bubble
Excessive air bubble
injection
Displacement of donor button
Why ?
Excessive remnant air bubbles compress the upper margin of donor disc at
sitting position and donor disc was displaced from the recipient surface.
2) When excessive air bubble was injected in AC suddenly, some air get into the
between donor button and recipient.
3) We trimmed the margin of donor disc in this case. There might be potential gap
at between precut-margin of donor disc and recipient.

46. Conclusions Advantages of DSaEK
– Predictable corneal power and astigmatism
– Tectonically strong globe
– Faster visual recovery
Disadvantages of DSaEK
– Potential interface effects on post-op VA
– Technically more demanding/time-consuming
– Secondary surgery rate higher

47. Summary Rapid visual recovery and minimal change in astigmatism
Donor detachment is most common early postoperative challenge and more studies are needed to further reduce rates
DSaEK is a safe and effective procedure and should be the procedure of choice for patients with endothelial dysfunction.

48. Thank YOU FOR listening

49. Post-operative air bubble pressing donor tissue against recipient cornea.

50. Repositioning Donor Tissue
-AC fluid removed with 30-gauge needle
-Air injected to fill the AC and push donor tissue up
against the recipient cornea
-Air removal and replacement of BSS after 1-2hr