1. VIDEO CONFERENCE DSAEK (Descemet's Stripping Automated Endothelial Keratoplasty)
R3 박율리/ Pf.주천기

2. CASE 67/F 오O순 C/C: decreased VA(OD) Past Hx DM/HBP (-/-)
Ocular op/trauma(+/-)
2004. ALI(OU) at local
ECCE + PCL (OS)
DSaEK(OS) by Pf.주천기 d/t BK(OS)
Gls (-)
Eye drop (-)
오명순
Asymmetric folding in donal Tanglide. DSaEK fragment was inverted. So viscoelastic material was injected and makes DSaEK fragment's upside down. some viscoeleastic material was between stroma & DSaEK fragment.

3. Ocular exam VA: OD FC 50cm (n-c) OS 0.4 (n-c) IOP: OD 16
OS 15 mmHg at 7:00 PM by AP
Conj.: OU not injected
Cornea: OD diffuse opacity c mod edematous c DM folding c SPEs c several microbulla
OS well grafted cornea (prior DSaEK state), clear
AC: OD 1.5~2CT at center & 1/4 at pph c cell(-)
OS deep & cell(-)
Pupil: OD slightly irregular & nl sized, LR(+), patent ALI site at 1 o/c
OS ovoid & dilated, LR(+), post. synechiae at sup.
Lens: OD mod nucleosclerosis
OS PCL in situ

4. Ocular exam
Pachymetry: 744
Specular: uncheckable

5. Operation Imp) Bullous keratopathy c S.cat(OD) Px) Phaco+PCL+DSaEK(OD)
Phaco+PCL+DSaEK(OD) by Pf.주천기
precut tissue (Donor trephine 8 mm)
<PC60AD, +27.0D, -0.65DT(Hoffer Q)>

6. VIDEO

7. Post op. F/U POD #1d #3d #5d VA IOP FC/50cm(N-C) 18 mmHg 0.04(N-C)
Conj. : mild injected,
well approximated Wx.
Cornea : well attached graft
mod.edematous c DM folding,
AC : deep & cell(+)
Air bubble at sup.
Conj. : mild injected
Cornea : edema
DM folding
Cornea : edema
Visante OCT OD : stationary, very thin space between donor & recipient cornea (suspicious some viscoelastic material in the space)
POD#1d
POD#5d

8. Post op. F/U POD #1m. VA IOP 0.25(0.32) 11 mmHg O
Cornea : well attached graft
Specula 1388
Pachy 422
Visante OCT OD : stationary, very thin space between donor & recipient cornea (suspicious some viscoelastic material in the space)
POD#1d
POD#5d

9. REVIEW

10. Lamellar Keratoplasty
The concept of lamellar keratoplasty
developed in the late 19th century
evolve in the early 20th century.
However!!!
problems of interface haze, scarring, and epithelial ingrowth associated with lamellar transplantation.
gave way to penetrating keratoplasty
Goals of surgery
not only successful transplantation
but also optical clarity, minimal astigmatism, improved predictability of corneal refractive power, ease of recovery, and decreased rates of rejection.
Risks of open-sky corneal transplantation

11. DSEK(Descemet stripping endothelial keratoplasty)
2004
Melles et al
stripping Descemet's membrane and endothelium with simple instrumentation followed by insertion of a 9.0-mm corneal graft
Price and Terry
rapid visual recovery with best corrected visual acuity in the range of 20/25–20/30.
 both precut and surgeon-prepared donor tissue with use of a microkeratome or femtosecond laser
DSAEK(Descemet stripping automated endothelial keratoplasty)

12. DMEK(Descemet membrane endothelial keratoplasty)
transplantation of a pure Descemet's membrane and endothelium
even more rapid visual recovery than DSAEK
early donor endothelial cell survival of 2350 cells/mm2.

13. Ix and CIx Ix. CIx. Endothelial dystrophy Bullous keratopathy
Fuchs', posterior polymorphous
Bullous keratopathy
pseudophakic, aphakic
Endothelial failure
from trauma, previous surgery, angle closure, tubes
Iridocorneal endothelial (ICE) syndrome
Failed penetrating keratoplasty
(if acceptable refractive result was achieved)
CIx.
Stromal opacity or scarring that limits visual potential
Keratoconus, ectasia
Hypotony/pre-phthisical eye

14. Donor Preparation Uniform thickness Diameter Shape
easier handling and unfolding and fewer striae
Diameter
3 mm less than smallest diameter of recipient cornea(8~9mm)
 adequate clearance to anterior chamber angle and limbal region.
Shape
A meniscus shape (thinner in center than at edges) D hyperopic shift
A planar-shaped - reduce hyperopic shift.
Stromal bed consistency
smooth stromal bed surface is desired for improved Snellen vision.
Femtosecond laser
central bed - smoother to see clear
periphery - roughened to facilitate adhesion
Endothelial cell count
2000–3000 cells/mm2 preferred.

15. Initial step Wound creation
The horizontal and vertical diameters of eye
Determine EK donor buttons size
8.5–9.0 mm in diameter.
centration point is determined on recipient cornea
future reference point during endothelium/DM stripping step
Wound creation
one to three paracentesis incisions
metal 15-degree blade or 1-mm diamond blade.
appropriate chamber formation
OVD or chamber maintainer
incision into anterior chamber

16. Recipient preparation
stripping of DM and endothelium
under viscoelastic or with anterior chamber maintainer
A reverse Sinskey hook or similar device
Gentle pressure is applied to inner cornea
complete 360-degree scoring of endothelium/DM complex
 removal of host tissue
irrigating/aspirating handpiece
Forceps
specially designed angled stripping device that peels away the tissue to be removed
Meticulous removal of all DM tags

17. Donor Insertion Techniques
The donor tissue should be rinsed with BSS
Donor tissue insertion
60 : 40 taco overfold
underside of donor taco on bottom, and endothelium on inside
Injectors
Busin glide is placed at incision site
another instrument is passed through opposite paracentesis
From incision to pull tissue through wound

19. Donor Apposition Techniques
place 10-0 nylon sutures in cornea or scleral wound
tissue is unfolded - endothelium down and stroma side up
Centering tissue
gentle sweeping motion
30G needle through vent incision
Air injection
30-gauge cannula or 30-gauge needle
If tissue decentration occurs, cannula or roller may be used to sweep tissue
A reverse Sinskey hook can be used through paracentesis to rotate tissue

20. Postoperative Complications
Donor dislocation.
Suh et al. reported that in 27 (23%) of 118 eyes,
Gorovoy reported a detachment rate of 25% in 16 eyes.
Mearza et al. found detachments in 9 (82%) of 11 eyes.
Koenig and Covert reported detachments in 9 (35%) of 26 eyes.
 graft repositioning and/or rebubbling
Suh et al. found a rate of 68% of reattachment after repositioning/rebubbling.

21. Postoperative Complications
Primary graft failure
Eyes with well-apposed grafts after surgery but with persistent corneal edema
inadequate endothelial function
unhealthy donor endothelial
inadequate preservation of the cornea
traumatic pre- or intraoperative technique.
Donor should have at least 2000 cells/mm2
donor age of >70 yrs : should be avoided
Extra manipulation during surgery, after surgery, or both, may also contribute to endothelial cell loss

22. Secondary graft failure
donor endothelial tissue is detached from the recipient stromal cornea  preventing cornea from clearing.
residual fluid or viscoelastic in the interface
retained DM
graft rejection.
2% to 45% in literature.
regrafting
Refractive change
No significant change of astigmatism
hyperopic refractive shift is observed after DSAEK

23. Interface deposits
scarring and irregularity of interface
d/t viscoleastic and blood in AC
can resolve during time
Epithelial ingrowth
may be dragged onto stromal surface during insertion of donor
no progress to visual axis and well attached donor cornea
 followed closely without surgical intervention.