1. DSEK for the treatment of endothelial disease in India -Initial Experience in 80 eyes- Authors have no financial interest Dr Ashish Nagpal MD, FRCS Dr Sandeep Arora MD, FRCS Cornea and External Disease Services, Retina Foundation, Ahmedabad, Gujarat, INDIA www.retinafoundation.com Authors have no financial interest

2. PURPOSE To evaluate clinical experience and outcome of Descemet’s Stripping Endothelial Keratoplasty (DSEK) in Indian patients with primary or secondary endothelial decompensation. Study Design : Retrospective Non comparative Surgical Case Series Study Period: October 2006 and November 2009

3. METHODS DSEK was performed in 80 eyes of 76 patients with endothelial decompensation. Indications Pseudophakic Bullous Keratopathy 54 Fuchs' Dystrophy20 Failed corneal graft4 ICE Syndrome2 Post Viral Endothelitis Decompensation 4

4. OBSERVATIONS Demographic Data Age65.43 years(range 21 – 78 years) SexMales:Females Mean Follow up 18 months( 4 to 36 months) All patients underwent a standard DSEK as shown in video. (also available on youtube – search drashishnagpal) In 18 cases phacoemulsification with implantation of an intraocular lens into the capsular bag was combined with DSEK surgery. Visual acuity, refraction and endothelial cell count were evaluated prospectively at 1, 3, 6, and 12, 18,24, 30 months after DSEK.

5. Preoperative, Surgical and Post operative data Eyes Recipient preoperative lens status Pseudophakic Phakic 60 20 Procedures combined with DSEK Phacoemulsification with IOL implantation Manual SICS with IOL implant IOL exchange/Scleral Fixated IOL Epithelial removal Superficial Keratectomy 18 1 77 01 Postoperative surgical procedures Donor tissue reposition / rebubbling DSEK for primary donor failure PKP for primary donor failure PKP for secondary graft failure 32123212 OBSERVATIONS & RESULTS

6. Main Outcome Measures Improvement in Corneal Clarity 74 of 80 Graft Attachment75 of 80 Best Spectacle Corrected Visual Acuity 68 eyes had better than 6/12 OBSERVATIONS & RESULTS Secondary Outcome Measures Refraction79 of 80 had less than 2 D of astigmatism Endothelial Cell Count 33.2 % (+ 12.5 %) Perioperative Complications

7. Main Outcome Measures Improvement in Corneal Clarity 74 of 80 eyes OBSERVATIONS & RESULTS Cause for no Improvement in Corneal Clarity in 6 eyes Iatrogenic Failure4 eyes Endophthalmitis1 eye ICE syndrome1 eye

8. OBSERVATIONS & RESULTS Main Outcome Measures Graft Attachment75 of 80 eyes Type of non attachment in 5 eyes Partial Detachment2 eyes Total Detachment3 eyes In 3 eyes it was managed successfully with single rebubbling, while 2 eyes had to undergo re DSEK / Keratoplasty due to repeated bubblings and non attachment

9. OBSERVATIONS & RESULTS Main Outcome Measures Best Spectacle Corrected Visual Acuity 68 eyes had better than 6/12 Reason for Limited Vision in 12 eyes CME ( Cystoid macular Oedema) 4 eyes Glaucoma3 eyes Macular Degeneration 3 eyes Anterior Stromal Scar 2 eyes

10. OBSERVATIONS & RESULTS Secondary Outcome Measures Refraction79 of 80 had less than 2 D of astigmatism Endothelial Cell Count 33.2 % (+ 12.5 %) 3 months 1364/ cmm2 23months 1297/ cmm2 Endothelial Cell Count Attrition rate varied from 20.7 % to 45.7 % from 3 months to 24 months 4 months 1388 /cmm2 26 months 744/ cmm2

11. Other Peri and Post operative Complications Thick Donor2 Pupillary Block2 Interface haze2 Interface bleeding 1 Graft Rejection3 Glaucoma2 OBSERVATIONS & RESULTS

12. CONCLUSION DESCEMET’S STRIPPING ENDOTHELIAL KERATOPLASTY (DSEK) surgery allows fast visual rehabilitation of Indian patients with decompensated endothelium as compared to penetrating Keratoplasty. Endothelial cell loss and dislocations were more in the initial learning curve of DSEK.