Descemet Stripping Automated Lamellar Keratoplasty

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Descemet Stripping Automated Lamellar
KeratoplastyDSAEK

• Alaa El Danasoury, MD
• Medical Director
• Chief Refractive Surgery Service
• Magrabi Hospital Centers

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Endothelial Pathology

• Pseudophakic corneal edema
• Aphakic corneal edema
• Fuchs Degeneration

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Options

• Endothelio-plasty
• Posterior keratoplasty
• Full thickness keratoplasty

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Endothelial Exchange

• Theoretically the best option
• Practically ?

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PKP

• Advantages
• Techniques established
• Instrumentation well developed
• Optical results very good
• Long term results available

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Graft Rejection
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Delayed Epithelial Healing
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Sutures Related Complications
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Surgically Induced Astigmatism
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Late Astigmatism
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PKP

• Disadvantages
• Allograft Rejection
• Late graft failure
• Slow wound healing
• Sutures related complications
• Irregular astigmatism
• Slow rehabilitation

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Lamellar versus Full Thickness KP

• Theory
• Replace only pathological layers
• Healthy portions remain
• Stronger healing
• Less antigen load
• Less surgically induced astigmatism
• Faster Rehabilitation

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Lamellar Vs Full Thickness KP

• Challenges
• Technically challenging
• Techniques under development
• New instrumentation
• Transition period

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Posterior Lamellar KP

• Barraquer 1960s
• DLEK (Melles) 1990s
• EndoKP with MK late 1990s
• DSAEK (Price) 2004

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DSAEK Technique
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Artificial Chamber
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Determine the plate thickness
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CB Microkeratome
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Lamellar Keratectomy
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Removing Anterior Stromal Disc
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Measuring Needed Disc Diameter
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5.0 mm Scleral Tunnel
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Descemets Scoring
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Staining
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Descemets Stripping
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Trephination of Donor disc
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Folding Posterior Corneal Disc
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AC Maintainer
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Insertion of Posterior Donor Disc
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Filling AC with Air
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Drainage of Inter-lamellar fluid
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DSAEK for Bullous Keratopathy

• Prospective Clinical Trial

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Study Population

• 10 eyes of 10 patients
• 7 Pseudophakic Corneal edema
• 6 PC lenses
• 1 AC lens
• 3 Aphakic Corneal edema
• 6/10 had retinal pathology

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Technique

• DSAEK
• ALTK system with Moria Artificial Chamber
• ALTK head 300 (2 cases) 350 (8 cases)
• Follow up 1 6 months (mean 4.3 months)

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Posterior disc thickness

• Mean 153.9 microns
• Range 245 to 119 microns
• SD 42.7

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Results

• Clear Cornea
• 1 wk 9/10
• 1 mo 9/10
• 3 Mo 6/7
• 6 Mo 5/6
• Primary Graft Failure 1/10

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Visual ResultsLast Examination (Mean 4.3 months)

• SCVA of 20/60 or better 5/10
• Manifest cylinder lt2.0 D 7/10
• Regular topography 7/10

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Corneal Topography
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Complications

• Graft Failure 1 eye Iris Fixed lens
• Disc displacement 1 eye Insignificant
• Delayed disc attachment 1 eye Recovered

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ALTK System

• Easier donor tissue preparation
• Smoother dissection compared to manual
• Reproducible
• User friendly

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4 Hours after DSAEK
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Preoperative
1 week post DSAEK
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1 week post DSAEK
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1 Day post DSAEK
1 Month post DSAEK
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1 Month post DSAEK
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Conclusion

• DSAEK is an effective procedure to treat
  endothelial decompensation
• Visual outcome comparable to PKP
• ALTK system gives reproducible results
• No interface complications were encountered
• Longer follow up is needed

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Why DSAEK?

• Peeling ? No manual dissection
• Single cut ? Smoother surface
• No interface irregularities ? Better optics
• Small Incision ? Minimal astigmatism
• No corneal sutures ? Regular topography
• Corneal Stroma preserved ? Stronger globe

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Future Improvement

• Easier disc insertion through smaller incision
• Best disc thickness
• Long term effect of increased corneal thickness
• Long term endothelial studies

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MEACO (PAACO) Middle East African Council of
Ophthalmology 29 March -1 April 2007 DUBAI
www.meaco.org