Blocking Air in the Filtering Bleb: Effects on Graft Adhesion After Descemet’s Stripping Automated Endothelial Keratoplasty

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Abstract

Background: To evaluate the outcome of Descemet’s stripping automated endothelial keratoplasty (DSAEK) with “blocking air” in the filtering bleb in patients with previous trabeculectomy.

Methods: In total, 299 eyes in 283 patients who underwent DSAEK were retrospectively reviewed. Endothelial graft adhesion, intraocular pressure (IOP), and air volume in the anterior chamber with (group A) or without (group B) a filtering bleb were compared between the groups. Group A was divided into two subgroups according to the presence (group A1) or absence (group A2) of air in the filtering bleb; the same three factors were compared between the subgroups.

Results: The graft detachment rate was significantly higher in group A (14.3%) than in group B (6.5%) (p = 0.04). IOP was significantly lower in group A than in group B before surgery (p = 0.01), at the end of surgery (p = 0.04), at three hours (p < 0.001), and one week postoperatively (p = 0.02). The graft detachment rate did not significantly differ between groups A1 and A2. There were no differences in IOP at each follow-up time, whereas there was a statistically significant increase in IOP from the preoperative measurement to the end of surgery in group A1 (21.0±7.0 mmHg) compared with group A2 (14.2±8.6 mmHg) (p = 0.02).

Conclusions: The presence of blocking air in the filtering bleb helps ensure increased IOP during the early postoperative period but had no significant effect on graft detachment rates.

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Most cited references 15

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Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology.

W Barry Lee, Deborah S Jacobs, David Musch … (2009)

To review the published literature on safety and outcomes of Descemet's stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea. Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives. The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection (mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from -0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%). The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment. Proprietary or commercial disclosure may be found after the references.

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Descemet's stripping with endothelial keratoplasty in 200 eyes: Early challenges and techniques to enhance donor adherence.

Francis W Price, Marianne O Price (2006)

To describe early challenges and techniques to promote donor tissue adherence in Descemet's stripping with endothelial keratoplasty (DSEK). Price Vision Group, Indianapolis, Indiana, USA. The first 200 consecutive cases of DSEK performed by a single surgeon were analyzed retrospectively. Follow-up was 7 to 20 months for 124 eyes and 2 to 6 months for 76 eyes. The surgical technique consisted of stripping Descemet's membrane and endothelium from the recipient's central cornea and transplanting an 8.0 to 9.0 mm disc of donor endothelium and posterior stroma through a 5.0 mm incision, with sutures used only to close the incision. The most frequent challenge was inadequate donor attachment. Using techniques to remove fluid from the donor-recipient graft interface, the donor detachment rate in the last 64 cases was 6%, with half attributable to patient eye rubbing. Detached grafts were reattached by injecting an air bubble to press the donor against the recipient cornea. There were 7 primary graft failures, with only 1 occurring in the second 100 cases, which primarily used microkeratome-dissected donor tissue. Other complications were infrequent and included pupillary block glaucoma (1), aqueous misdirection syndrome (1), and cataract development in 2 of 27 phakic eyes. The DSEK procedure was performed safely before and after laser in situ keratomileusis (1 each). Early outcomes in the initial 200 consecutive DSEK procedures suggest the technique provides significant advantages over penetrating keratoplasty, including more rapid healing, more predictable refractive outcomes, and better retention of corneal strength and integrity. Although donor adherence was more challenging, DSEK was technically easier and should be less traumatic to anterior chamber structures than earlier posterior grafting techniques.

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Endothelial keratoplasty - a review.

Jacqueline Price, Tulin O. Price (2010)

From its inception over a century ago, penetrating keratoplasty grew to become the most common and most successful form of solid tissue transplantation. Yet clinicians have long recognized the limitations of full-thickness corneal transplants, including prolonged visual rehabilitation, unpredictable refractive changes, susceptibility to ocular surface complications and vulnerability to traumatic wound rupture. Selective replacement of diseased or damaged posterior corneal layers was conceptualized and implemented a half century ago. However, it has only been within the past decade that improved techniques and instrumentation have allowed endothelial keratoplasty (EK) to become the preferred treatment for patients with endothelial dysfunction. EK provides more rapid visual recovery, minimizes induced astigmatism and, most importantly, better maintains globe integrity than penetrating keratoplasty. Descemet stripping automated EK is currently the most widely used method. This article covers how EK techniques have evolved over time, considers who is or is not an appropriate candidate for EK, describes Descemet stripping automated EK methods and instrumentation, discusses EK postoperative complications and management and compares visual recovery, refractive outcomes and endothelial cell loss with that of standard penetrating keratoplasty.

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Author and article information

Journal

Journal ID (nlm-ta): Cureus

Journal ID (iso-abbrev): Cureus

Journal ID (issn): 2168-8184

Title: Cureus

Publisher: Cureus (Palo Alto (CA) )

ISSN (Electronic): 2168-8184

Publication date (Electronic, pub): 22 August 2024

Publication date (Electronic, collection): August 2024

Volume: 16

Issue: 8

Electronic Location Identifier: e67459

Affiliations

[1 ] Ophthalmology, Hiroshima University, Hiroshima, JPN

[2 ] Ophthalmology, Saiseikai Kure Hospital, Kure, JPN

[3 ] Ophthalmology, Hiroshima Prefectural Hospital, Hiroshima, JPN

[4 ] Ophthalmology, Miyoshi Central Hospital, Miyoshi, JPN

[5 ] Ophthalmology, Inokawa Eye Clinic, Kure, JPN

Author notes

Tai-ichiro Chikama chikama@ 123456hiroshima-u.ac.jp

Article

DOI: 10.7759/cureus.67459

PMC ID: 11415773

PubMed ID: 39310427

SO-VID: 874c9c44-c035-4592-b384-0f0f23375a2b

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This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date accepted : 21 August 2024

Blocking Air in the Filtering Bleb: Effects on Graft Adhesion After Descemet’s Stripping Automated Endothelial Keratoplasty

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Karger: Ophthalmology

Most cited references 15

Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology.

Descemet's stripping with endothelial keratoplasty in 200 eyes: Early challenges and techniques to enhance donor adherence.

Endothelial keratoplasty - a review.

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