Risk Factors and Outcomes of Donor Lenticule Dislocation Following DSEK Pravin K Vaddavalli MD, Suntia Chaurasia MD, Muralidhar Ramappa MD, Prashant Garg.

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Presentation transcript:

Risk Factors and Outcomes of Donor Lenticule Dislocation Following DSEK Pravin K Vaddavalli MD, Suntia Chaurasia MD, Muralidhar Ramappa MD, Prashant Garg MD, Virender S Sangwan MD Cornea & anterior segment service LV Prasad Eye Institute Hyderabad India None of the authors have any financial interest in the subject matter of the presentation

Purpose: To review the clinical profile of graft detachment following Descemet’s stripping endothelia keratoplasty (DSEK) and analyze the outcomes of re-bubbling for graft detachment. Design: Retrospective case review

Methods 309 eyes underwent DSEK from January 2009 to February eyes (8.7%) developed graft detachment 20 males and 7 females; age range 23 to 82 years Graft detachment: complete/total if there was no area of contact between the lenticule and the host posterior stroma partial/incomplete if there was some extent of apposition of the graft with the posterior stroma re-bubbling with air with or without repositioning if complete dislocation, partial detachment with communication with anterior chamber and significant decentration

Indication for surgeryPseudophakic corneal edema: 12 patients Aphakic corneal edema: 6 patients Failed graft: 4 patients Fuchs’ endothelial dystrophy: 4 patients Silicon oil induced keratopathy: 1 patient Surgical interventionDSEK only- 11 patients Anterior vitrectomy+ DSEK- 9 patients IOL Exchange+ DSEK - 11 patients Cataract surgery+DSEK-5 patients Lens statusPhakic: 3 eyes Pseudophakic: 21 eyes (ACIOL 9; SFIOL 2; PCIOL 10) Aphakic: 3 eyes Surgical dataDonor dissection: Manual 3; Microkeratome 24 DM Stripping: 26 eyes Venting incisions: 25 eyes Donor characteristicsDonor grade: Good 18; Very good 7; Excellent 2 Age range: 9 months to 85 years, Mean= years Mean endothelial cell density: 2803 cells/mm 2 Surgical parameters

Nature of detachment Total=18 eyes (66.6%) Partial =9 eyes (33.3%) Interval between detachment and rebubbling Average 1.18 days, Range 1-4 days Number of rebubbling procedures Once = 24 patients (88.8%) Twice = 3 patients (11.1%) Outcome of rebubbling Successful graft attachment *20/27 (74%) [ Total=12; Partial=8] Persistent detachment 7/27 (25.9%) *3 patients who underwent second attempt of rebubbling had successful graft attachment Final outcomeClear graft 13/20 (65%) [Total=7/12; Partial=6/8] Primary graft failure 7 /20 (35%) Outcomes

No INDICATION Detachment Surgery Lens StatusVenting Donor ECD Second intervention OUTCOME 1 PCETOTAL IOL exchange + AV+ DSAEKACIOL Repeat Rebubbling Attached, failed graft 2 Failed graftTOTAL DSAEKphakic Repeat Rebubbling Attached, failed graft 3 ACETOTAL DSAEKNo IOL Repeat Rebubbling Attached, failed graft 4 PCETOTAL IOL Exchange+ AV+DSAEKSFIOL -2463RE DSEKclear graft 5 Failed graftTOTAL DSAEKPCIOL RE DSEKclear graft 6 FuchsTOTAL Phaco+AV+ PCIOL+DSAEKPCIOL RE DSEKclear graft 7 FuchsTOTAL Phaco+ AV+ ACIOL+DSAEKACIOL +2638PKclear graft 8 PCETOTAL AV+ IOL Exchange+ DSAEKACIOL -2967PKclear graft 9 PCETOTAL IOL Exchange +AV+ DSAEKACIOL +2915RE DSEKclear graft 10 ACEPARTIAL DSAEKNo IOL PKclear graft Clinical and surgical data of patients with Persistent detachment after first Rebubbling

Parameters No Persistent detachment (N=10) [95% CI] Successful reattachment (N=17) [95% CI] Odd ratio [95%CI] p value Aphakia 3 2 /10(20%) [3.54 to 55.78%] 1/17(5.88%) [0.31 to 30.76%] 4 [0.31 to 51.03] 0.54 Pseudophakia 21 7/10(70%) [35.37 to 91.91%] 14/17(82.3%) [55.8 to 95.33%] 0.5 [0.08 to 3.15] 0.64 Phakic 3 1/10(10%) [0.52 to 45.88%] 2/17(11.7%) [2.06 to37.74%] 0.83 [0.07 to 10.55] 1.00 Prior vitrectomy 2 1/10(10%) [0.52 to 45.88%] 1/17(5.88%) [0.31 to 30.76%] 1.78 [0.10 to 31.98] 1.00 Additional Vitrectomy 9 6/10(60%) [27.37 to 86.31%] 3/17(17.6%) [4.67 to 44.20%] 7 [1.18 to 41.36] 0.04 Mean ECD(Cells/mm 2 ) ± ± Preservation time (hrs) 29.5± ± Age of donor (years)43.98± ± Risk factors for persistent graft detachment after unsuccessful first re-bubbling intervention

Conclusions Graft dislocation rate 8.7%, all noted within the first week of surgery Graft detachment may be anticipated more commonly in aphakic and vitrectomised eyes additional vitrectomy at the time of surgery is a significant risk factor for persistent graft detachment