1. Glaucoma Progression after Descemet’s Stripping Endothelial Keratoplasty
Neelofar Ghaznawi MD, Melissa B Daluvoy MD, Ajoy Virdi MD, Edwin S Chen, Kristin M Hammersmith MD, Christopher J Rapuano MD
The authors have no financial interest in the subject matter of this presentation

2. Descemet’s Stripping Endothelial Keratoplasty
DSEK provides rapid healing, predictable refractive outcomes, and tectonic stability.
Evolution of DSEK technique has resulted in better visual outcomes and fewer post-operative complications.
DSEK has become the preferred treatment for any endothelial dysfunction.
The indications for DSEK have expanded from Fuchs Dystrophy and PBK, failed PK, aphakic bullous keratopathy, aniridia, ICE syndromes and CHED.

3. Purpose and Design Purpose 51 22 Glaucoma 29 Control 12 Surgical
To characterize the pattern of glaucoma progression after Descemet’s stripping endothelial keratoplasty in patients without preexisting glaucoma and in those with preexisting glaucoma with and without prior glaucoma surgery
To compare visual outcomes among the 3 groups 51
DSAEK
22 Glaucoma
29 Control
12 Surgical
10 Medical
Outcome Measures
Visual Acuity
IOP
Steroid dose
IOP lowering medications
Rejection
Glaucoma procedures
Little is known regarding the incidence of glaucoma and its effect on visual outcome after DSAEK.
Preexisting glaucoma was defined as any of the following: documented history of glaucoma, preoperative use of anti glaucomatous medications and preoperative IOP >24, of C/D > 0.6.
Post operative IOP increase was defined as any initiation or increase in anti glaucomatous medications or IOP > 25 or a relative increase in IOP >10 mmHg above baseline

4. Summary of Demographics and Baseline Characteristics
Demographics/ Baseline Characteristics
Controls
(29 eyes)
Glaucoma
(Medical)
( 10 eyes)
(Surgical)
(12 eyes)
p values
OD:OS
16:13
7:3
5:7
0.55
% Caucasian
89%
100%
86%
0.07
% Fuchs' Endothelial Dystrophy
77%
30%
29%
.0001
Preoperative VA (median [min, max])
20/100 (20/25, CF)
20/400 (20/50, CF)
20/400 (20/100, CF)
.003
Preoperative IOP (mmHg, median [min, max]
13 (8,22)
15 (12,18)
11 (5,17)
.013
Cup-to- disc ratio
0.30 ( )
0.49 ( )
0.65 ( )
There are some significant differences between the two group. 1)Although differences in preoperative IOP were not statistically significant, important and significant differences were in the indications for DSAEK, preoperative vision and Cup to disc ratio

5. Results 2 Surgical Medical Control p< .05 p< .05 p< .05
Initiation or Increase in Glaucoma Medications
Incidence of IOP Elevation
p< .05
p< .05
Use of a Less Potent Steroid 2
Glaucoma
Procedures
Surgical
Medical
Control
Incidence of post op IOP elevation at any point during study. IOP elevation again defined as IOP greater than or equal to 24 or 10 mmHg above baseline at any point during the follow up period. 21% of patients with out any history of glaucoma experienced at least one episode of elevated IOP. Which was significantly lower than either the medically managed glaucoma group and those with prior glaucoma surgeries.
p< .05

6. Percentage of Control Eyes With Elevated IOP
Over the course of the of follow up, the percentage of eyes without elevated IOP remained consistently above 84 % with the peak incidence of glaucoma occurring at 4-5 months post operatively

7. Final Visual Outcomes in Subgroups
VA Median
(min, max)
Without Preexisting
Glaucoma
N=29
With Preexisting
N=10
With Prior
Glaucoma Surgeries
N=12
P Value
Preoperative
20/100 (20/25, CF)
20/400 (20/50, CF)
20/400 (20/100, CF)
0.003
1 year
20/40 (20/25, 20/400)
20/50 (20/40, 20/70)
20/60 (20/25, 20/400)
0.112
Median lines of
improvement
5.3
5.5
5.2
0.979
1 year compared to baseline
P<
All 3 groups gained statistically significant improvement in vision at 12 months compared with baseline. Compared with controls the patients with pre existing glaucoma had poorer median VA at baseline but showed comparable vision at 12 months. Furthermore, all groups gained about 5 lines of vision, the differences between the groups were not statistically significant.

8. Conclusions Incidence of elevated IOP after DSEK:
Without preexisting glaucoma: 21%
With glaucoma and no h/o surgery: 50%
With glaucoma and prior surgery: 42%
At 1 year follow up glaucoma medication added in:
5 % of patients without glaucoma
50 % of patients with medically managed glaucoma
13% of patients with prior glaucoma surgery
At 1 year 17% of patients with prior surgery required an additional glaucoma drainage procedure.
All groups gained statistically significant improvement in VA at 12 months compared with baseline

9. Conclusions
Given high incidence of post operative IOP elevation, close monitoring of IOP is warranted.
Preexisting glaucoma does not negatively affect improvement of VA after DSEK.

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