1. Bryan Y Kim 1, Shintaro Kanayama MD PhD 1, Tueng T Shen MD PhD 1, Thomas E Gillette MD 2 1 University of Washington Department of Ophthalmology, 2 Eye Associates Northwest, Seattle, WA April 7, 2010 Financial Disclosure: The authors have no financial interest in the subject matter of this poster.

2. BACKGROUND Descemet’s stripping automated endothelial keratoplasty (DSAEK) is the most widely performed endothelial keratoplasty. (1) Numerous benefits over penetrating keratoplasty (PKP) for treatment of corneal endothelial disease including less induced astigmatism, shorter visual recovery, and better tectonic support. Few studies exist on outcomes of DSAEK performed with concurrent procedures such as cataract phacoemulsification and intraocular lens implantation (PE/IOL) or IOL exchange. (2,3,4) PURPOSE To report clinical outcomes of a large retrospective study of DSAEK and to compare to existing published data. To compare clinical outcomes of DSAEK performed with concurrent procedures to DSAEK performed alone. 1.Lee WB et al. Descemet’s Stripping Endothelial Keratoplasty: Safety and Outcomes. Ophthalmology 2009;116:1818-1830. 2.Terry MA et al. Endothelial Keratoplasty for Fuchs’ Dystrophy with Cataract. Ophthalmology 2009;116:631-639. 3.Covert DJ, Koenig SB. New Triple Procedure: Descemet’s Stripping and Automated Endothelial Keratoplasty Combined with Phacoemulsification and Intraocular Lens Implantation. Ophthalmology 2007;114:1272-1277 4.Shah AK et al. Complications and Clinical Outcomes of Descemet Stripping Automated Endothelial Keratoplasty With Intraocular Lens Exchange. Am J Ophthalmology 2010;149:390-397.

3. STUDY METHODS Retrospective, nonrandomized case series of 218 consecutive DSAEK operations. Performed between April 2006 and April 2009 by a single surgeon (TEG) at an ambulatory surgery center. Chart review performed with approval of and in accordance with policies of institutional review board of parent medical center. Statistical analysis –Visual acuity measured by Snellen BCVA. Pinhole VA used when manifest refraction not available. –BCVA converted to logMAR for analysis. –Groups compared using Student’s T test, ANOVA, and Chi-squared test with statistical significance at P<0.05. For small n values, Fisher’s exact test and randomization test for goodness-of-fit were used. SURGICAL METHODS DSAEK technique –Anesthesia by retrobulbar block and IV sedation. –Anterior chamber entered through 5.0mm temporal corneal incision and paracentesis. –6.5-8.5mm diameter descemetorhexis. –Graft dissected with Moria CB microkeratome and trephinated to match stripping area. –Graft inserted in 40/60 taco configuration, placed into position, and unfolded with air. –Anterior chamber filled with air for 10 minutes to promote graft adhesion. –Air replaced by small bubble and incisions made in host cornea as needed to drain residual fluid. –Postoperatively, patient remained supine for 1 hour. If performed, concurrent surgical procedures (PE/IOL or IOL exchange) were performed prior to DSAEK.

4. Preoperative Clinical Data Most patients received DSAEK for treatment of Fuch’s dystrophy or pseudophakic corneal edema. “Pseudophakic/aphakic corneal edema” includes 3 cases of aphakic corneal edema. “Other corneal edema” includes 1 Descemet’s detachment and 8 unspecified corneal edema.

5. Overall Complications Comparative complication rates reported in a DSAEK outcomes literature review by Lee et al. (1) : –Average graft dislocation rate: 14.5% (range 0-82%) –Average endothelial rejection rate: 10% (range 0-45%) –Average primary graft failure rate: 5% (range 0-29%) 1.Lee WB et al. Ophthalmology 2009;116:1818-1830.

6. Overall Visual Acuity Outcomes LogMAR BCVASnellen BCVA Comparative VA outcomes reported by Lee et al.: (1) –Mean VA over 3 to 21 month follow up periods ranged from 20/34 to 20/66. –Percentage seeing 20/40 or better ranged from 38% to 100% (from 3 to 20 months) 1.Lee WB et al. Ophthalmology 2009;116:1818-1830.

7. Comparison by Donor Graft Diameter No significant difference in outcomes between graft diameters for: Complication rates 6 month postoperative BCVA Visual Acuity Demographics and Complications

8. 129 total DSAEK performed to treat Fuchs’ dystrophy. 88 DSAEK performed with concurrent PE/IOL (triple procedure). 41 DSAEK performed alone. No significant difference of: Complication rates. Percentages of patients at various VA’s at 6 months. Significant difference: Mean BCVA of DSAEK performed with PE/IOL better than without at 6 months. Comparison of DSAEK for Fuch’s Dystrophy With or Without Concurrent PE/IOL Visual Acuity Demographics and Complications

9. 16 DSAEK performed with concurrent IOL exchange 15 due to pseudophakic corneal edema 1 due to PKP graft failure 111 DSAEK performed alone Multiple indications No significant difference of: Complication rates Mean BCVA at 6 months. Percentages of patients at most VA’s at 6 months. Significant difference: Higher percentage of patients receiving DSAEK alone had 20/40 VA or better at 6 months. Comparison of DSAEK With or Without Concurrent IOL Exchange Visual Acuity Demographics and Complications

10. Overall DSAEK outcomes for our series of 218 eyes are comparable with existing literature data. Concurrent PE/IOL implantation does not lead to worse visual outcomes or higher complication rates when compared to DSAEK alone. Similarly, concurrent IOL exchange generally does not lead to worse visual outcomes or higher complication rates compared to DSAEK alone. Donor graft diameter from 7.5mm to 8.5mm does not have a significant affect on visual outcomes or complication rates. This study data strengthens the existing literature supporting DSAEK as an effective treatment for corneal endothelial disease and further provides evidence that PE/IOL and IOL exchange can safely and efficaciously be performed concurrently with DSAEK.

11. Chen ES et al. Descemet-Stripping Endothelial Keratoplasty: Six-month Results in a Prospective Study of 100 Eyes. Cornea 2008;27:514-520. Covert DJ, Koenig SB. New Triple Procedure: Descemet’s Stripping and Automated Endothelial Keratoplasty Combined with Phacoemulsification and Intraocular Lens Implantation. Ophthalmology 2007;114:1272-1277 Gorovoy MS. Descemet-Stripping Automated Endothelial Keratoplasty..Cornea 2006;25:886-9. Koenig SB, Covert DJ. Early Results of Small-Incision Descemet’s Stripping Endothelial Keratoplasty. Ophthalmology 2007;114:221-26 Koenig SB et al. Visual Acuity, Refractive Error, And Endothelial Cell Density Six Months After Descemet Stripping And Automated Endothelial Keratoplasty (DSAEK). Cornea 2007;26:670–4. Lee WB et al. Descemet’s Stripping Endothelial Keratoplasty: Safety and Outcomes. Ophthalmology 2009;116:1818-1830. Melles GR et al. Preliminary Clinical Results of Descemet Stripping Endothelial Keratoplasty. Am J Ophthalmology 2008;145:222-227 Price FW, Price MO. Descemet’s Stripping with Endothelial Keratoplasty in 200 Eyes: Early Challenges and Techniques to Enhance Donor Adherence. J Cataract Refract Surg 2006;32:411-418. Shah AK et al. Complications and Clinical Outcomes of Descemet Stripping Automated Endothelial Keratoplasty With Intraocular Lens Exchange. Am J Ophthalmology 2010;149:390-397. Terry MA et al. Endothelial Keratoplasty for Fuchs’ Dystrophy with Cataract. Ophthalmology 2009;116:631- 639.

12. Special thanks to: Thomas E. Gillette, MD Tueng T. Shen, MD PhD Shintaro Kanayama, MD PhD Staff at Eye Associates Northwest Author: Bryan Y. Kim is a medical student at the University of Washington School of Medicine and is pursuing ophthalmology as a career.