SPS-302 Corneal Procedures: DMEK, Keratoprosthesis, Other | ASCRS
2020 ASCRS Virtual Annual Meeting

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Papers in this Session
Expand each tab below to view the paper abstract for each paper within this session.
Management of Corneal Melt in Patients with Boston Keratoprosthesis Type I: Repair Versus Replacement
Authors
Roy Daoud, MD
Saama Sabeti, MD, MPH
Mona Harissi-Dagher, MD

Purpose
To evaluate outcomes of corneal repair versus replacement of the keratprosthesis as a treatment of corneal melt in Boston KPro patients.

Methods
Retrospective study of adult patients with melt managed by corneal repair or KPro replacement by one surgeon (MHD). Recurrent episodes were considered as separate cases when melt recurred after the first episode was treated and healed. Incidence of sight or globe threatening complications and change in BCVA before and 3 months after the procedure were compared between both groups, and between primary versus secondary KPro replacement after repair attempts. Recurrence of melt after repair or replacement was also compared.

Results
Included in the study were 19 eyes of 19 patients with 28 episodes of melt and mean follow-up of 8.7 years. Primary replacement of KPro was done 32% and corneal repair in 68%. There was no significant difference in gender, age, nor incidence of complications after repair (92% complications) versus after KPro replacement (83%), nor after primary (83%) versus secondary (50%) KPro replacement post-repair p>0.05. Difference in BCVA pre and post procedures was not significant in repair versus replacement (p>0.05) and in primary versus secondary KPro replacement (p>0.05). Melt recurrence after corneal repair was significantly higher (86%) than after KPro replacement (14%) CI 4, 299.

Conclusion
Replacement of KPro is beneficial due to higher recurrence of melt after repair. However, repair may be considered when timely access to a new KPro and corneal graft isn’t possible. Delaying KPro replacement doesn’t affect BCVA. Finally, KPro replacement is the only effective treatment when melt has led to extrusion or uncontrollable infection.
Outcomes of Descemet Membrane Endothelial Keratoplasty in Aphakic and Aniridic Patients.
Authors
Gisella Santaella, MD
Michael Mimouni, MD
Nir Sorkin, MD
Clara C. Chan, MD, FRCS
David S. Rootman, MD, FRCS
Tanya Trinh, FRANZCO, MBBS

Purpose
To evaluate outcomes of Descemet Membrane Endothelial Keratoplasty (DMEK) in aphakic and aniridc eyes.

Methods
A retrospective chart review of either aphakic or aniridic patients that underwent DMEK at Toronto Western Hospital, Canada, between 2015 and 2019 was performed. Demographic characteristics, intra-operative and post-operative complications, and best-corrected visual acuity (BCVA) were analyzed.

Results
Six eyes of 6 patients, aged 51.0±9.3 years, were included (2 aniridic, 3 aphakic and 1 aniridic & aphakic). Average follow up was 22.6±13.1 months. BCVA prior to surgery and 6 months after surgery were 1.180.53 and 1.670.89 logMAR, respectively. Four eyes (66%) had graft detachment, with 2 of them (33%) requiring rebubbling. One eye (16%) developed hyphema. Primary graft failure was seen in 3 eyes (50%) – 2 of those due to detachment and 1 due to intraoperative hyphema. Secondary failure occurred in 2 eyes (33%), at 30 and 36 months. Two failures were managed with PKP and the rest were observed due to poor vision potential.

Conclusion
DMEK surgery had a high detachment and failure rate in aphakic and aniridic eyes. Performing DMEK surgery in these scenarios may not be advised.
Endoart: Innovative Artificial Implant for Treating Corneal Edema
Authors
Ofer Daphna, MD
Arie L. Marcovich, MD, PhD

Purpose
To evaluate the safety and efficacy of an artificial implant for the treatment of corneal edema, secondary to endothelial failure.

Methods
A thin polymer membrane with an adhesive coating was implanted on the posterior cornea of 3 patients suffering from chronic corneal edema and low visual potential. Slit lamp examination Visual Acuity and corneal thickness (OCT) measurements were performed.

Results
Following implantation of the EndoArt, corneal edema was dramatically improved and the cornea remained clear for 4 month, up to date. One of the patients has demonstrated a detachment of the implant and was reattached using rebulbing technic No surgical or device related complications were observed in all patient, up to date.

Conclusion
The presence of the EndoArt implant has demonstrated a dramatic improvement in corneal edema. Corneal thickness was stable as long as the implant was attached. Vision was improved, limited to other ocular comorbidity. Up to 12 patients should be recruited in the following months
Randomized Controlled Trial of Fresh Versus Frozen Corneal Donor Carriers in Boston Keratoprosthesis Type 1 Surgery: 10-Year Outcomes
Authors
Saama Sabeti, MD, MPH
Roy Daoud, MD
Marie-Claude Robert, MD, FRCSC, MSc
Mona Harissi-Dagher, MD

Purpose
This study aims to compare the 10-year clinical outcomes of fresh versus frozen corneal graft carriers for the Boston Keratoprosthesis type 1 (KPro).

Methods
Prospective, non-masked, randomized controlled trial with 10-year follow-up of 22 patients having undergone KPro implantation using either a fresh or frozen corneal allograft carrier depending on availability of fresh tissue on the day of surgery. Surgeries were performed between October 2008 and December 2009 by a single experienced surgeon at the Centre Hospitalier de l’Université de Montréal. Patients were excluded if they had previously undergone KPro implantation or if they elected to use a corneal autograft when deemed appropriate. The primary outcome measure was device retention at 10 years; secondary outcome measures included best corrected visual acuity (BCVA) and complications.

Results
Thirty-seven eyes of 37 patients were enrolled in the initial protocol of 24-months duration; of these, 22 patients consented to be followed through to 10 years, with 13 from the fresh group and 9 from the frozen group. At 10-year follow-up, device retention was 92% and 78%, and the incidence of complications per patient was 2.07 (total of 27) and 2.33 (total of 21) for the fresh and frozen groups, respectively (p>0.05 for both analyses). Mean BCVA had increased from counting fingers in both groups to 20/320 and 20/125 in the fresh and frozen groups respectively (p>0.05). There were no statistically significant differences between the two groups for any outcome measures.

Conclusion
Fresh and frozen corneal donor graft carriers offer similar clinical outcomes for KPro implantation, with no statistically significant differences in device retention, visual outcomes, or rates of complications at 10 years.
Comparison of Topography-Guided LASIK to Smile in the Management of Post-Keratoplasty Astigmatism and Spherical Refractive Error
Authors
Ioanna Kontari, MD
A. John Kanellopoulos, MD, ABO

Purpose
Comparison of different types of laser vision correction in reducing the refractive error, post-keratoplasty.

Methods
12 post-keratoplasty consecutive eyes treated for reduction of residual refractive error were included. 8 had LASIK and 4 Smile; And evaluated for: UDVA, CDVA, Refractive error (RE), topography, tomography

Results
Preoperative values in average: Sphere: 6.5 Diopters, Cylinder: 4,5 D, UDVA 20/100, CDVA: 20/40. Post LASIK: Sphere 1.25 D, Cylinder 0,75D, UDVA 20/40, CDVA 20/25. SMILE: UDVA: 20/60, CDVA 20/30, Sphere: 2.5D and Cylinder 2.25D.

Conclusion
Both procedures appear safe and effective in improving significant refractive error post-keratoplasty. Topography-guided LASIK appears to offer superior spherical and cylindrical refractive error correction compared to SMILE, and enhanced visual outcomes.
Endothelial Cell Density Following Descemet Membrane Endothelial Keratoplasty Using Peripherally-Trephinated Donor Tissue (DMEK-pD)
Authors
Samar K. Basak, FRCS, MD
Soham Basak, MS, DNB

Purpose
To evaluate the clinical outcomes and endothelial cell density (ECD) following Descemet membrane endothelial keratoplasty using peripherally-trephinated donor tissue (DMEK-pD) and compare with DMEK using centrally-trephinated donor tissue (DMEK-cD) in patients with endothelial diseases.

Methods
Retrospective comparative interventional case series. 500 eyes of 442 patients with endothelial diseases of various etiologies, who underwent either DMEK-pD (n=235) or DMEK-cD (n=265) alone or combined with cataract surgery, between Jun 2016 and Dec 2018 were included. All donor tissues were prepared by the operating surgeon during the procedure. Preoperative and postoperative best spectacle corrected visual acuity (BSCVA) and ECD were recorded at 6 months and 1 year. Subgroup analysis were done for Fuchs’ corneal endothelial dystrophy (FECD) and pseudophakic corneal edema (PCE).

Results
All eyes had preoperative mean BSCVA of 1.03 logMAR in both groups. Baseline donor mean central ECD were 2914 ± 201 and 2894 ± 168 cells/mm2 in DMEK-pD and in DMEK-cD group respectively (p=0.12). BSCVA improvement were comparable at 6 months and 1 year (p=0.28 and p=0.19). Mean ECD recorded after 6 months and 1 year was significantly higher in DMEK-pD group than DMEK-cD group: 2368 ± 224 vs 2024 ± 312 cells/mm2 (p<0.0001); and 2246 ± 250 vs 1868 ± 339 cells/mm2 (p<0.0001) respectively. Subgroup analysis showed DMEK-pD Triple in FCED had more ECD than others groups (p<0.0001). Complication rates were similar in both groups.

Conclusion
DMEK-pD exhibited similar clinical outcomes with more endothelial cell density compared to conventional DMEK-cD after 6 months and 1 year in heterogenous group of endothelial diseases. The possibility of transplanting peripherally-trephinated donor tissue in DMEK with more endothelial cells needs to be explored further in the future.
Sutureless Femtosecond Laser Assisted Anterior Lamellar Keratoplasty: Long Term Visual and Clinical Outcomes.
Authors
Mike Zein, MD
Sonia H. Yoo, MD, ABO
Florence Cabot, MD

Purpose
To assess the long term visual and clinical outcomes of sutureless femtosecond laser assisted anterior lamellar keratoplasty for the treatment of corneal dystrophies and corneal scarring.

Methods
Retrospective study performed at Bascom Palmer Eye Institute, Miami, FL, including the chart review, from 2005 through 2019, of patients who had presented with anterior cornea pathologies and subsequently underwent sutureless femtosecond laser assisted anterior lamellar keratoplasty (FALK). Uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA), anatomical features at slit lamp exam and anterior segment optical coherence tomography (AS-OCT), postoperative complications such as loss in BCVA, haze, infection, rejection, were recorded and potential risk factors were identified.

Results
Twenty six patients were included with a mean age of 50.7+/-19.3 [17-83]. Mean follow up was 49.0+/-55.2 months ranging from 0.2 to 13 years. Mean preoperative BCVA was 0.64 +/-0.37 [0.2-1.6] LogMAR. Mean preoperative corneal scar depth on AS-OCT was 202.4 +/-66.9 [80-275] microns. Adjunct PTK during FALK procedure was performed in 42% of cases. Mean BCVA at last follow up visit was 0.40 +/-0.36 [0-1.3] LogMAR. The improvement between preoperative BCVA and BCVA at last follow up visit was statistically significant, p=0.01. The most common postoperative complications were irregular astigmatism and residual scarring (30.8% of cases).

Conclusion
Sutureless FALK is a safe procedure with good and stable long term visual and clinical outcomes for the treatment of anterior corneal pathologies.
Clinical Outcomes of Descemet Membrane Endothelial Keratoplasty in Eyes with Comorbid Keratoconus and Corneal Endothelial Dysfunction
Authors
Philip W. Dockery, MPH
Jack Parker, MD, PhD
Rénuka S. Birbal, MD
Maya Tong, MD
John Parker, MD
Katelyn P. Joubert
Gerrit RJ. R. Melles, MD, PhD

Purpose
To evaluate the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) performed in eyes with comorbid keratoconus (KC) and corneal endothelial dysfunction.

Methods
Twenty-three consecutive eyes of 14 patients with comorbid KC underwent DMEK for corneal endothelial dysfunction; best spectacle corrected visual acuity (BSCVA), maximum corneal curvature (Kmax), central corneal thickness (CCT), and intra- and postoperative complications were assessed.

Results
Excluding eyes requiring re-transplantation for primary graft failure (n=3), all eyes showed improvement in BSCVA, reaching at least 20/40 (0.5) in 85%, 20/25 (0.8) in 50%, and 20/20 (1.0) in 25% by one month postoperatively; 88%, 69%, and 38% by 6 months postoperatively; and 83%, 67%, and 42% by 12 months postoperatively. CCT decreased from 594μm preoperatively to 484μm at 1 month (p<0.001) and 489μm at 12 months (p<0.001). Kmax decreased by a median of 1.9 diopters (D) at 1 month (p=0.003) and 2.8 D at 12 months (p=0.012), and every eye with a preoperative Kmax ≥ 46 D demonstrated flattening.

Conclusion
DMEK is technically feasible in eyes with comorbid KC and may give excellent visual and refractive outcomes, including significant corneal flattening, which may potentially create a visually significant hyperopic shift in patients with severely ectatic corneas.
Clinical Outcomes of Femtosecond Laser Assisted Sutureless Anterior Lamellar Keratoplasty
Authors
Nicolas C. Pereira, MD, PhD
Luiza C. Mazzafera, MD
Adriana S. Forseto, MD, PhD

Purpose
To describe the outcomes of Femtosecond Laser Assisted Sutureless Anterior Lamellar Keratoplasty (FALK) in the treatment of corneal opacities.

Methods
This is a single-center retrospective study, including 40 eyes of 36 patients with corneal opacities that underwent FALK. In 13 eyes (32.5%) the procedure was performed due to corneal dystrophy (Reis –Bucklers in 8 eyes, Schneyder in 3 eyes, Laticce in 1 eye and Thiel-Behnke in 1 eye), 7 eyes (17.5%) after Herpes simplex keratitis, 4 eyes with corneal opacity after pterygium surgery (10%), 3 eyes (7.5%) after photorefractive keratectomy (PRK), 3 eyes (7.5%) after adenoviral conjunctivitis, 2 eyes (5%) post trachoma, and not specified in 8 eyes (20%). Best spectacle corrected visual acuity (BSCVA), residual opacities and complications were evaluated up to 2 years postoperatively.

Results
The BSCVA improved in all eyes, but did not reach 20/40 in all eyes due to residual corneal irregularities and residual corneal opacities that required phototherapeutic keratectomy (PTK) in 2 eyes and penetrating or deep anterior lamellar keratoplasty (1 and 3 eyes respectively).

Conclusion
FALK was safe and effective in treating corneal opacities, but carefull assessment of the depth of the corneal opacities must be done to avoid unsatisfactory vision and new procedures for visual rehabilitation.

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