1. 1 Clinical Outcomes of DSEK Surgery Combined With Other Intraocular Procedures Neil Mahesh Vyas, MD Fei Yu, PhD Anthony J. Aldave, MD Sophie Deng, MD, PhD The authors have no financial interests to disclose

2. Purpose: Endothelial keratoplasty (EK) has become the standard of care in treating endothelial dysfunction DSEK (Descemet Stripping Endothelial Keratoplasty) remains the most popular and common version of EK especially in patients with complex anterior segments DSEK is frequently performed in combination with other procedures to minimize need for further surgeries and to improve clinical outcomes This study examines the complications and clinical outcomes of DSEK surgery performed in combination with other intraocular procedures versus DSEK done as a single procedure. 2

3. Methods: Retrospective chart review of 461 consecutive procedures at Jules Stein Eye Institute at UCLA who underwent DSEK from 5/7/06 to 12/19/12 Surgeries performed in combination with DSEK were reviewed and included: Intraocular lens (IOL) implantation or repositioning/suturing including those done in combination with cataract extraction Anterior vitrectomy In patients undergoing DSEK with pre-existing tube shunt the following concomitant procedures were reviewed: Trimming of tube shunts, lysis of irido-corneal (IK) adhesions, and removal of retrocorneal membrane (RCM) Clinical Outcomes Measured: Graft detachment, graft rejection, primary and secondary graft failure, intraocular pressure (IOP) increase, post surgical endothelial cell count 3

4. Results: Total of 461 procedures 273 DSEK alone 188 DSEK done in combination DSEK + any IOL procedure 139 (30.1%) DSEK + phacoemulsification with IOL implantation 112 (24.3%) DSEK + IOL repositioning, exchange, secondary placement or suture 27 (5.8%) DSEK + Vitrectomy 44 (9.5%) 76 procedures with prior glaucoma tubes + DSEK: Trimming of tube 20 (26.3%) Lysis of irido-corneal adhesions 19 (25.3%) Removal of retrocorneal membranes 9 (12.0%) 4

5. Incidence of Graft Detachment Incidence of Rejection Incidence of Primary Graft Failure Incidence of Secondary Graft Failure Incidence of IOP >25 Post Op Endothelial Cell Count (n=56) DSEK alone 13.92%7.33%2.93%7.69%23.08%1613.50 DSEK with any co- procedure 16.49% (P=0.50) 9.04% (P=0.60) 4.26% (P=0.45) 4.26% (P=0.17) 20.74% (P=0.57) 1779.5 (P=0.46) DSEK + any IOL 17.14% (P=0.38) 9.29% (P=0.57) 3.57% (P=0.77) 0.71% (P<0.01) 18.57% (P=0.31) 1894 (P=0.19) DSEK + Vitrectomy 22.73% (P=0.17) 4.55% (P=0.75) 4.55% (P=0.63) 4.55% (P=0.75) 43.18% (P<0.01) 1651.6 (P=0.96) DSEK + any IOL + Vitrectomy 29.63% (P=0.05) 7.41% (P=1.00) 7.41% (P=0.22) 0% (P=0.23) 48.15% (P<0.01) 1711.7 (P=0.78) 5

6. Incidence of Graft Detachment Incidence of Rejection Incidence of Primary Graft Failure Incidence of Secondary Graft Failure Incidence of IOP >25 DSEK alone 24.24%9.09%6.06%18.8%9.09% DSEK with trimming of tube, lysis of IK adhesions, AND/OR removal of RCM 15.38% (P=0.38) 12.82% (P=0.72) 7.69% (P=1.00) 12.82% (P=0.74) 23.08% (P=0.20) 6 Amongst 76 eyes with prior tubes

7. 7

8. 8

9. 9

10. 10

11. Results: Overall there were very few statistically significant differences in rates of graft detachment, graft rejection, primary or secondary graft failure, IOP elevation, or post surgical endothelial cell count between patients with one or multiple additional procedures versus DSEK alone No statistically significant differences between patients with tubes who had DSEK alone vs DSEK combined with trimming of tube, lysis of IK adhesions and/or removal of RCM Significant findings were: Increased risk of graft detachment in patients with DSEK + any IOL procedure + Vitrectomy vs DSEK alone Decreased risk of secondary graft failure in patients with DSEK + any IOL procedure vs DSEK alone Increased risk of post operative IOP > 25 in patients with DSEK + Vitrectomy OR DSEK + Vitrectomy + any IOL procedure vs DSEK alone 11

12. Discussion: DSEK can be performed in combination with various intraocular surgeries in patients with complex anterior segment anatomy and still achieve excellent clinical outcomes. There may be a higher risk of graft detachment with multiple combined procedures but this did not lead to ultimate worse outcomes By demonstrating the safety of combined surgery, patients can obtain better results faster without the risks and cost of additional surgery 12