SPS-101 Corneal Procedures & Diagnostics: EK, PK, CXL, Other | ASCRS
2020 ASCRS Virtual Annual Meeting

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Papers in This Session

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DMEK in Super-Seniors: Clinical Outcomes of Descemet Membrane Endothelial Keratoplasty Performed in Patients Greater Than 90 Years Old
Authors
Philip W. Dockery, MPH
Jack Parker, MD, PhD
Lisanne Ham
Christina P. Parker, MA
John Parker, MD
Gerrit RJ. R. Melles, MD, PhD

Methods
Between the years of 2009 and 2019, 20 consecutive eyes of 17 patients aged ≥ 90 underwent DMEK for endothelial dysfunction. Best corrected visual acuity (BCVA), central corneal thickness (CCT), endothelial cell density (ECD), graft survival, and intra- and postoperative complications were assessed.

Results
Except in one case in which the DMEK surgery could not be completed, all operated eyes experienced an improvement in BCVA, although only 50% achieved ≥ 20/40 (0.5) by 1 year postoperatively. One year after surgery, median CCT had declined from 641(+/-161) μm to 480 (+/-34) μm (p<0.001), and median endothelial cell density was reduced by 53%, from 2574 (+/-286) to 1226 (+/-404) cells/mm2. Six of 19 eyes receiving DMEK grafts (32%) developed partial graft detachments requiring re-bubbling. One eye experienced a secondary graft failure at 6 months and underwent repeat endothelial keratoplasty.

Conclusion
DMEK is technically feasible in the oldest old patients and may yield significant visual improvements. Because clinical follow-up may be difficult for these patients, DMEK may be preferable to Descemet stripping endothelial keratoplasty and penetrating keratoplasty because the risk of suture related issues and allograft reaction/rejection is lower.

Outcomes of Combined Anterior Chamber Intraocular Lens Exchange and Descemet Membrane Endothelial Keratoplasty
Authors
Gisella Santaella, MD
Adi Einan-Lifshitz, MD
David S. Rootman, MD, FRCS
Nir Sorkin, MD
Clara C. Chan, MD, FRCS
Lior Or, MD

Methods
Patients who underwent DMEK combined with ACIOL removal and trans scleral IOL fixation at Toronto Western Hospital, Canada, between 2015 and 2018 was included in this study. Demographic characteristics, intra-operative and post-operative complications, best-corrected visual acuity (BCVA) and endothelial cell density (ECD) were analyzed.

Results
Thirteen eyes of 13 patients were included. Average age was 76.7 ± 12.7 years. BCVA prior to surgery and 6 months after surgery was 1.85 ± 0.96 logMAR and 0.47 ± 0.09 logMAR, respectively (p=0.02). Rebubble was performed in 4 eyes (32%). Two eyes (15%) developed hyphema. One eye (8%) was diagnosed with macular edema and one eye (8%) developed retinal detachment. Primary failure due to persistent hyphema was diagnosed in one eye (8%). Average ECD loss 6 months after surgery was 50% (p<0.05).

Conclusion
ACIOL replacement with a scleral-fixated IOL combined with DMEK is a viable option in cases of ACIOL and PBK. Associated complications were graft detachment, hyphema, macular edema and retinal detachment.
Effect of Biometric Data on Descemet Membrane Endothelial Transplant Attachment Rate in Triple Procedures
Authors
Zachary Landis, MD
Brandon D. Ayres, MD
Ernest C. Gillan

Methods
Retrospective chart review of consecutive combined DMEK/CE/IOL performed by a single surgeon from January 1, 2013 to December 31, 2019. Preoperative data collected included AL, ACD, white-to-white (WTW), lens thickness, and keratometric values (Zeiss IOLMaster). The primary outcome measurement was DMEK attachment rate. Secondary outcomes collected include time to DMEK detachment, re-bubble rate, additional surgeries needed, and final best corrected visual acuity. Multivariate analysis was performed. Statistical significance was defined as a p-value < 0.05.

Results
248 eyes were included in the study. Partial detachment rate for all eyes in the study was 30.2%. The average axial length, anterior chamber depth, mean keratometry, and white-to-white of attached DMEK grafts versus partially detached DMEK grafts was 24.17 +/- 1.35 mm vs. 23.79 +/- 1.31 mm (p=0.039), 3.22 +/- 0.42 mm vs. 3.17 +/- 0.38 mm (p=0.420), 43.40 +/- 2.26 D vs. 44.04 +/- 1.55 D (p=0.028), and 12.15 +/- 0.99 mm vs. 12.10 +/- 0.44 mm (p=0.702), respectively. Eyes with mean keratometry over 43.5 diopters had a partial detachment rate of 35%, while eyes with mean keratometry less than 43.5 had a partial detachment rate of 23% (p=0.045).

Conclusion
Steeper keratometry and shorter axial length were associated with a significantly higher rate of DMEK detachment. This could be utilized in pre-operative counseling when discussing patients’ risk of requiring a re-bubbling procedure post-operatively.
Risk Factors Predicting Graft Failure in Descemet’s Membrane Endothelial Keratoplasty (DMEK)
Authors
Henry Liu, MD
Yufeng Chen, MD
Setareh Ziai, MD
George Mintsioulis, MD
Kashif Baig, MD, MBA

Methods
This is a retrospective cohort study of 308 eyes undergoing primary DMEK between January 2012 and June 2019 at a single North American tertiary care centre (i.e. the University of Ottawa Eye Institute). Clinical data on the following were collected and analyzed: demographic details, indications for DMEK surgery, ocular preoperative status and comorbidities, donor endothelial cell density (ECD), donor graft size, death to enucleation time, death to graft time, intra-operative complications and surgeon experience (i.e. cases performed within the first year). Statistical analyses were performed using univariable and multiple logistic regression with a significance level of 0.05.

Results
In the univariable regression, prior glaucoma surgery including trabeculectomy and tube shunts (OR=2.4), intra-operative complications (OR=5.4) and surgeon experience (OR=3.8) were all associated with a greater risk of requiring repeat DMEK (P<0.05). Furthermore, a diagnosis of PBK was associated with a higher rate of graft failure (OR=2.8, P=0.003) while a diagnosis of Fuchs’ was a protective factor (OR=0.4, P=0.002). Donor graft size, ECD and death to enucleation and graft times were not associated with higher rates of failure. Multiple regression showed that only a diagnosis of Fuchs’ (OR=0.2, P=0.022) and higher donor age (OR=1.1, P=0.048) were independent predictors of graft failure.

Conclusion
An indication of PBK portends a higher risk of graft failure compared to Fuchs’. Donor factors are not significantly associated with a higher risk of graft failure, with the exception of increased donor age. Results from this study may benefit future patients by allowing better risk stratification and patient counseling prior to undergoing DMEK.
Intraoperative Ultrasound Biomicroscopy(UBM) for Determining Graft Orientation during Descemet's Membrane Endothelial Keratoplasty (DMEK)
Authors
Yoav Nahum, MD
Orly Gal-Or, MD
Maya Atar, MD
Irit Bahar, MD, MHA
Eitan Livny, MD

Methods
Prospective interventional study done in a university hospital. Patients: Five patients that underwent DMEK surgery due to corneal endothelial insufficiency .Following the identification of correct graft status using 'Blue cannula tip' sign (AKA 'Moutsouris Sign') UBM was used to ascertain graft's orientation. Main outcome measures included the intraoperative feasibility of the technique in the intraoperative setting, and the postoperative orientation as demonstrated by anterior segment optical coherence tomography (AS-OCT). Intra- and postoperative complications, postoperative clearance of the cornea, corrected distance visual acuity and endothelial cell loss were also noted.

Results
In all cases the technique allowed the determination of the orientation of the graft. In two cases UBM identified a upside-down graft. In one of these cases, 'blue cannula tip' showed correct orientation while UBM identified an upside-down graft. The graft was flipped using fluid jets, and repeat 'blue cannula tip', and UBM both showed correct orientation. In all cases postoperative OCT demonstrated correct graft orientation. In one case, which had significant posterior surface irregularities, the graft partially detach, despite repeat rebubbling attempts, and DSAEK was done. The other grafts cleared during the 1st postoperative month, and endothelial cell loss rate ranged between 40-52%.

Conclusion
Intraoperative UBM is a simple and effective tool for determining graft orientation during DMEK, possibly obviating the need for other techniques and devices currently used this purpose
The Impact of Topical Glycerin on DMEK Graft Adherence
Authors
John D. Stephens, MD
Daniel C. Terveen, MD
John P. Berdahl, MD
Richard L. Lindstrom, MD
Adam Bleeker

Methods
Retrospective chart review of 29 consecutive patients undergoing DMEK surgery who received glycerin drops immediately following the procedure and 4 times daily for 3 days. Primary outcome measures were rebubble rate (%) and best corrected visual acuity (BCVA) at 1-2 months post operative. Results will be compared to a cohort of patients from the same time period who did not receive topical glycerin following the procedure.

Results
4 (13.8%) eyes treated with glycerin required a rebubble, compared to 9 (23.1%) control eyes (p=0.34). Baseline BCVA (LogMAR) for eyes receiving glycerin drops following DMEK was 0.28±0.23 versus 0.38±0.42 for control eyes (p=0.23). At one-week postoperative, BCVA was 0.34±0.31 in glycerin treated eyes and 0.57±0.5 in control eyes (p=0.03). At one month, BCVA in the glycerin treated eyes was 0.08±0.18 compared to 0.24±0.29 in controls (p<0.05). Two-month postoperative BCVA was similar between glycerin (0.09±0.19) and control eyes (0.16±0.26; p=0.44). There were no adverse events reported related to topical glycerin administration.

Conclusion
Although it did not reach statistical significance, the administration of glycerin drops decreased the overall number of post operative rebubbles and likely achieved clinical significance. Additionally, glycerin appears to accelate post operative visual recovery and may be a good option for patients in the future.
Changes in Total Corneal Power after Endothelial Keratoplasty in the Randomized Controlled Detect Trial
Authors
Elizabeth Shen, MD Samuel C. Werner, MD
Jennifer R. Rose-Nussbaumer, MD
Charles C. Lin, MD
Ariana F. Austin, MS
Winston D. Chamberlain, MD, PhD, ABO

Methods
A total of 50 eyes of 38 patients with isolated endothelial dysfunction from the DETECT trial were randomized to receive DMEK or UT-DSAEK. Total Corneal Refractive Power (TCRP) (3mm zone) for 46 eyes was obtained using Scheimpflug imaging. All data sets were assessed for normality using a Shapiro-Wilks test. Paired t-tests were used to compare baseline to post-operative measurements in 23 DMEK and 23 UT-DSAEK eyes.

Results
The mean baseline TCRP for DMEK and UT-DSAEK was 43.5±2.6 and 43.1±1.6, respectively (p=0.51). At 3 months postoperatively, mean TCRP decreased to 42.4±2.6 (p<0.001) in DMEK and 42.1±1.4 (p<0.001) in UT-DSAEK. At both 6 and 12 months, mean TCRP increased in both groups. For DMEK, mean TCRP was 42.6±2.4 (p<0.001) at 6 months and 42.7±2.4 (p<0.001) at 12 months; for UT-DSAEK, mean TCRP was 42.3±1.7 (p<0.001) at 6 months and 42.4±1.6 (p<0.001) at 12 months. Mean change in TCRP from baseline to 12 months in the DMEK and UT-DSAEK group was 0.80±1.1 (p<0.001) and 0.76±0.84 (p=0.002), respectively. There was no significant difference in TCRP at 12 months between DMEK and UT-DSAEK (p=0.59).

Conclusion
TCRP in both DMEK and UT-DSAEK initially decreased at 3 months postoperatively and subsequently increased at both 6 and 12 months. Despite this trend, TCRP decreased from baseline to 12 months. Loss of corneal power contributes to hyperopic shifts after endothelial keratoplasty but does not differ between DMEK and UT-DSAEK.
A New Technique of Descemet Membrane Endothelial Keratoplasty for Aphakic and Vitrectomized Eyes.
Authors
Daliya Dzhaber, MD
Allen O Eghrari, MD

Methods
This is a retrospective case series performed in a tertiary cornea practice. The study included five eyes which underwent DMEK surgery for corneal endothelial insufficiency for aphakic bullous keratopathy utilizing a new “Parachute” technique. Cases were reviewed for intra- and postoperative complications, postoperative clearing of the cornea, best corrected visual acuity, and endothelial cell loss.

Results
The mean BCVA improved from 1.56±0.68 LogMAR to 1.32±0.74 LogMAR at post-operative month 1 and to 1.10±0.81 at post-operative month 3. The mean endothelial cell density decreased from 2181±697 cells/mm2 pre-optatively to 2018±760 cells/mm2 3 months after surgery. No complications were recorded.

Conclusion
A new technique of DMEK is a safe and effective method to manage bullous keratopathy in aphakic and vitrectomized eyes.
Pre-Operative Laser Peripheral Iridotomy Versus Intraoperative Peripheral Iridotomy in Descemet Membrane Endothelial Keratoplasty
Author
Nichelle Warren, MD

Methods
Retrospective cohort study assessing the rates of complications in DMEK utilizing pre-operative LPI compared to intraoperative PI. Complications include: graft detachment, rebubbling, graft failure, interface heme, uveitis, and cystoid macular edema. Three surgeons’ methods were evaluated. Two of which utilize pre-operative LPI, while the third performs intraoperative PI. Inclusion criteria include patients receiving DMEK for Fuch's dystrophy, pseudophakic bullous keratopathy, and iridocorneal endothelial syndrome. Exclusion criteria include patients with history of uveitis, glaucoma, and cystoid macular edema. Average follow-up for those included in the study was for 1 year.

Results
There is no statistically significant difference in the rates of graft detachment between pre-operative laser peripheral iridotomies and intraoperative peripheral iridotomies. There is also no significant difference in the incidence of pupillary block, uveitis, interface heme or cystoid macular edema.

Conclusion
In conclusion, pre-operative laser peripheral iridotomy and intraoperative peripheral iridotomy yield similar results. Therefore surgeons may feel more reassured that one method is not superior to another.
An Artificial Intelligence (AI) Algorithm for the Autonomous Diagnosis of Corneal Graft Rejection
Authors
Mohamed Tolba, MD, MSc
Amr Elsawy, MSc
Taher K. Eleiwa, MD, MSc
Collin B. Chase
Eyup Ozcan, MD
Mohamed Abou Shousha, MD

Methods
Thirty-six eyes of 36 patients with corneal grafts were imaged using ASOCT machine (Envisu R2210, Bioptigen, Buffalo Grove, IL, USA). A deep learning AI algorithm (Bascom Palmer AI, version 1.0, Miami, FL) was used to evaluate the ASOCT scans of these grafts. Results were compared to the clinical diagnosis given by corneal experts at Bascom Palmer Eye Institute. Prediction scores for diagnosis of corneal graft rejection and receiver operating curves (ROC) were generated.

Results
The cornea experts diagnosed 22 grafts as healthy grafts and 14 as rejected grafts. The algorithm correctly diagnosed all healthy grafts and 12 out of the 14 rejected grafts. For the diagnosis of corneal graft rejection, the AI algorithm achieved an area under the curve (AUC) of 0.9231, sensitivity of 84.62 % and specificity of 100 %.

Conclusion
The deep learning AI algorithm is a novel autonomous technique that can accurately diagnose cornea grafts rejection.
Corneal Endothelial/Descemets Complex Tomography for the Diagnosis of Pre-Clinical Corneal Graft Rejection
Authors
Mohamed Abou Shousha, MD
Taher K. Eleiwa, MD, MSc
Amr Elsawy, MSc

Methods
In this longitudinal prospective study, 30 patients underwent a high-risk corneal transplant and were imaged using ASOCT (Envisu R2210, Bioptigen, Buffalo Grove, IL) at the 1st, 3rd, 6th, 9th and 12th postoperative month. We measured cDMT using corneal microlayer tomography technique, which segments and produces 3 dimensional bulls-eye and color coded maps of corneal microlayers. The ability of cDMT in diagnosing pre-clinical corneal graft rejection was assessed by correlating measured cDMT at different visits to the clinical diagnosis obtained from a cornea specialist at Bascom Palmer Eye Institute. One-year rates of corneal graft rejection were calculated using cumulative incidence.

Results
In patients with clinically diagnosed corneal graft rejection (43.3%), the cDMT increased significantly 4.7 months (95%CI: 2.8-6.6) prior to the clinical diagnosis of corneal graft rejection, while it remained stable in patients without corneal graft rejection. The 1-year cumulative incidence of corneal graft rejection was 87.5% (hazard ratio = 18, 95% CI: 2-144) in patients with a 3-month cDMT ≥19µm, versus 16.7% for cDMT <19µm (P <0.001).

Conclusion
In high-risk corneal transplants, the increase in cDMT allowed the diagnosis of pre-clinical corneal graft rejection at least 3 months before the clinical diagnosis.

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