P324: Femtosecond-Assisted DSAEK with Fibrin Glue-Assisted Sutureless Posterior Chamber Lens Implantation Gaurav Prakash, MD Amar Agarwal, MS, FRCS, FRCOphth; Soosan Jacob, MS, FCRS,DNB; Dhivya A Kumar, MD; Prashaant Chaudhary, MD; Athiya Agarwal, MD, DO Dr Agarwal’s Eye Hospital & Eye Research Centre, Chennai, India Chennai, India Prof. Amar Agarwal is a paid consultant to Abott Medical Optics and Bausch & Lomb. None of the other authors have any financial disclosures.

Purpose Background : Performing Descemet stripping automated endothelial keratoplasty (DSAEK) in unicameral cases with surgical aphakia with is a challenging situation. Purpose : To describe the feasibility, technique and outcomes of femtosecond laser assisted Descemet stripping automated endothelial keratoplasty (DSAEK) with glued IOL for treatment with aphakia with endothelial decompensation.

Glued IOL * Sutureless technique of trans-scleral haptic fixated posterior chamber IOL implantation Sutureless technique of trans-scleral haptic fixated posterior chamber IOL implantation Experience of >300 eyes, starting from Experience of >300 eyes, starting from peer reviewed publications. 12 peer reviewed publications. Indications : Indications : Surgical Aphakia without capsular support Surgical Aphakia without capsular support Dislocated IOL Dislocated IOL combination with keratoplasty combination with keratoplasty * Please note that Glued IOL is an Off Label Use (Non FDA Approved use ) of Fibrin glue and of the Posterior Chamber IOL.

Femtosecond assisted DSAEK Femtosecond laser is a new option for creation of the posterior stromal – endothelial lenticule. Femtosecond laser is a new option for creation of the posterior stromal – endothelial lenticule. Laboratory based studies on various femtosecond laser platforms have shown satisfactory results for the same. Laboratory based studies on various femtosecond laser platforms have shown satisfactory results for the same. Clinical results are comparable to mechanical microkeratome Clinical results are comparable to mechanical microkeratome Suwan-Apichon et al, Cornea. 2006; Jones, et al, Cornea ; Cheng, et al, Cornea Mehta JS,et al. J Cataract Refract Surg Cheng YY,et al. Arch Ophthalmol

Methods Three eyes (of three patients) with early corneal endothelial decompensation with post surgical aphakia underwent the technique. The donor lenticules were created on a 60 Khz femtosecond laser platform ( Intralase, Abott Medical Optics, Santa Ana, CA). Setting were as given in Table 1.

Surgical technique Surgical technique Preparation of donor lenticule with femtosecond laser. Top Left: The corneoscleral button is placed and locked in the artificial anterior chamber. Top Right: Intraoperative view of the femtosecond laser lenticule creation. Posterior side cut is being made first. Bottom Left: Appearance of the cornea after full lamellar pass performed in raster pattern and before anterior side cut creation. Bottom Right: Anterior and posterior lamellas created by the femtosecond laser are separated. The posterior lamella forms the donor lenticule.

Surgical technique Surgical technique Intraoperative steps on Glued IOL implantation and DSAEK Top Left: 2 Partial-thickness limbal- based scleral flap of 3* 3 mm are created after limited peritomy and placement of infusion cannula. Top Right: an 8 mm blunt trephine is used to mark the area concentric to this mark to facilitate in Descemet scoring and stripping. Bottom Left: The Descemet’s is stripped with a reverse Simsky hook. Bottom Right: The IOL is held with McPherson’s forceps and inserted through the scleral incision. The leading haptic is grasped with a microcapsulorhexis forceps.

Surgical technique Surgical technique Intraoperative steps on Glued IOL implantation and DSAEK (cont..) Top Left: The trailing haptic is exteriorized via the sclerotomy. Top Right: the trailing haptic is tucked into the intrascleral lamellar pocket. Bottom Left: The donor lenticule is inserted into the eye with the suture ends lying outside. Bottom Right: The donor lenticule is unfolded with saline injection and adjusted by pulling the suture.

Results Left: Slit lamp photograph, 6 months post operative appearance of the DSAEK with glued IOL showing centered donor lenticule and the stable intraocular lens. Right: Ultrasound biomicroscopy image, 6 months post operative showing well centered donor lenticule and the stable and well centered glued intraocular lens.

Rationale for New Combined Procedure

Conclusion The surgical options in aphakia with endothelial decompensation are limited, more so in cases with deficient iris tissue. Our case series suggests that using glued IOL in combination with DSAEK may be a safe and efficacious alternative in such a scenario.

References Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34: Prakash G, Ashokumar D, Jacob S, Kumar KS, Agarwal A, Agarwal A. Anterior segment optical coherence tomography-aided diagnosis and primary posterior chamber intraocular lens implantation with fibrin glue in traumatic phacocele with scleral perforation. J Cataract Refract Surg. 2009;35: Prakash G, Jacob S, Ashok Kumar D, Narsimhan S, Agarwal A, Agarwal A. Femtosecond-assisted keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation: new triple procedure. J Cataract Refract Surg ;35: Cheng YY, Kang SJ, Grossniklaus HE, Pels E, Duimel HJ, Frederik PM,Hendrikse F, Nuijts RM. Histologic evaluation of human posterior lamellar discsfor femtosecond laser Descemet's stripping endothelial keratoplasty. Cornea.2009;28: Cheng YY, Hendrikse F, Pels E,et al. Preliminary results of femtosecond laser assisted descemet stripping endothelial keratoplasty. Arch Ophthalmol.2008;126: Wylegała E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg. 2008;34: