Special considerations for DSEK in monocameral eyes R. E. Fintelmann, MD S. Hannush, MD I. Raber, MD B. Ayres, MD No financial interests to disclose regarding this presentation

Purpose To outline the challenges of DSEK in eyes with direct communication between the anterior chamber and vitreous cavity. To outline techniques to manage these challenges. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

Monocameral eyes Any eye that has a communication between the anterior and posterior segment. Eyes with an ACIOL Eyes with a sulcus PCIOL after Yag Capsulotomy Eyes with a subluxated PCIOL with an opening in the posterior capsule Eyes with a big Iridectomy Aphakia Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

Challenges facing surgeon Sequestering of viscoelastic can lead to incomplete removal before the insertion of the button. Communication between the anterior and posterior segment can lead to misdirection of air leading to vitreous prolapse. Air migrates easily into the posterior segment making tamponade of the endothelial button difficult. Endothelial Button can dislocate into the posterior segment. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

Special considerations 1. Consider avoiding viscoelastic altogether during scoring and stripping, opting for irrigation to maintain the chamber. 2. Consider constricting the pupil early during the procedure to limit migration of BSS or air into the posterior segment during the procedure. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

3. Anticipate and be prepared to manage any vitreous herniation during the procedure. 4. Balance the potential advantages of replacing an ACIOL with an in-sulcus or sutured PCIOL1 against the challenges of explanting an ACIOL through a limbal incision (bleeding, etc). Suturing a PCIOL Iris clipped Artisan lens2 Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

5. If leaving an ACIOL in place, consider using a non-folding insertion technique to avoid the challenges of limited working space. 6. Consider a temporary anchoring suture in an aphakic eye with significant risk of posterior tissue subluxation3. 7. Coloring the button with Trypan blue can aid in visualization of the button after implantation3. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

9. Anticipate the larger amount of. air required for tissue 9. Anticipate the larger amount of air required for tissue tamponade, in the event of posterior air migration. 10. Learn to distinguish the different reflex of air posterior versus anterior to an IOL. 11. Avoid unnecessary irrigation, aspiration or air removal that may invite vitreous forward. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

13. Consider the role of topical NSAIDS if not usually used in EK. 12. Postoperative air bubble management is different than with usual EK. True pupillary block is extremely rare. Appositional angle closure secondary to disproportionately greater amounts of air posteriorly is not uncommon. Familiarity with reducing appositional angle closure postoperatively is essential. 13. Consider the role of topical NSAIDS if not usually used in EK. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

Conclusions EK is effective in the management of corneal endothelial dystrophy and dysfunction in monocameral eyes. A background in basic endothelial keratoplasty before attempting more complex cases is helpful. Several special considerations are helpful in accomplishing successful surgery. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD

Bibliography Wylegala E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg 2008;34(10):1708-14. Lake DB, Rostron CK. Management of angle-supported intraocular lens and iridectomy in Descemet-stripping endothelial keratoplasty. Cornea 2008;27(2):223-4. Price MO, Price FW, Jr., Trespalacios R. Endothelial keratoplasty technique for aniridic aphakic eyes. J Cataract Refract Surg 2007;33(3):376-9. Robert E. Fintelmann, MD, S. Hannush, MD I. Raber, MD, B. Ayres, MD