1. Kyoto Prefectural University of Medicine
Clinical Outcomes of Descemet-Stripping Automated Endothelial Keratoplasty for Bullous Keratopathy with Pre-Existing Glaucoma
Tsutomu Inatomi, Hiroko Adachi, Kazuhiko Mori, Hidetoshi Tanioka, Osamu Hieda, Shigeru Kinoshita
Kyoto Prefectural University of Medicine
Kyoto, JAPAN

2. 2007-2010 at Kyoto Prefectural Univ. of Med.
　Introduction　
Primary causes of
bullous keratopathy
Post-DSAEK in glaucoma
N=101
at Kyoto Prefectural Univ. of Med.
DSAEK has now become a first-choice treatment for bullous keratopathy, resulting in a better visual rehabilitation than that obtained by PK. The pie-chart graph on the left shows the percentage of primary diseases treated by DSAEK at Kyoto Prefectural University of Medicine between 2007 and Laser-iridotomy-induced bullous keratopathy is a major cause of bullous keratopathy in Japan. In this study, 14% of the cases were the result of repeated glaucoma surgeries. DSAEK is now considered superior to PK for these type of cases for the control of intraocular pressure.

3. Purpose Subjects and Methods
To evaluate the clinical outcomes of DSAEK for bullous keratopathy in patients with pre-existing glaucoma.
Subjects and Methods
This study involved 48 eyes with bullous keratopathy, including 12 eyes with pre-existing glaucoma (Glaucoma group), 15 eyes that had undergone laser iridotomy (LI group) for primary angle closure glaucoma,12 eyes with pseudophakic bullous keratopathy (PBK group), and 9 eyes with Fuch’s corneal dystrophy.
Patient age ranged from years (mean age: 71.3±5.8 years).
1. Subjects
2. Clinical design
Retrospective clinical study
3. Follow-up period
Follow-up ranged from 5-24 months (mean:13.5±8.8 months)

4. Preoperative Clinical Features
Type of Glaucoma
Number of Glaucoma Surgeries Received
Average number of glaucoma surgeries was 2.4. Functional bleb after trabeculectomy existed in 67% of the cases.
Anti-Glaucoma Medications Received
Visual Field (Kozaki grade)
This chart illustrates the number of anti-glaucoma medications received prior to DSAEK (average = 1.3).
Of our cases, 50% were in the advanced stage of glaucoma and 33% involved only a single eye.

5. Pre-DSAEK
Post-DSAEK
Surgical Procedure
A reversed Sinskey hook was used to strip-away an approximate 7-mm-diameter area of the Descemet’s membrane. An 8-mm pre-cut corneal graft obtained from SightLife (Seatle, USA) was then placed on a Busin glide, with the endothelial side protected with a small amount of viscoelastic material. The graft was then inserted though a 4-mm temporal corneal incision. An air bubble was then injected into the anterior chamber to promote the graft attachment for 10 minutes.

6. Visual Acuity Postoperative BCVA BCVA (LogMAR) Preoperative BCVA
Glaucoma group (N=12)
Comparison of Visual Acuity
PBK
N=12
Glaucoma
N=12 LI
N=15
Fuchs’
N=9
※、※※　Scheffe's  F test ※
Postoperative BCVA
BCVA (LogMAR) ※ ※ ※※
>0.7 2 eyes (17%)
>0.4　 5 eyes (42%)
>0.1 9 eyes (75%)
Preoperative BCVA
Decimal VA
In all patients in the Glaucoma group, visual acuity was improved at 3 months after DSAEK. The average postoperative visual acuity was 0.14 in the Glaucoma group, significantly lower than the 0.64 in the LI group, 0.40 in the PBK group, and 0.58 in the Fuchs’ group.

7. Complications Glaucoma group (N=12)
Air misdirection to filtrating blebs
Partial graft detachment
Complete graft dislocation
Pupillary block
Primary failure
1 (8%)
2 (16%)
Air misdirection into the filtrating bleb leading to an inadequate air tamponade was not observed in this study. Rates for partial detachment and graft dislocation were observed 8% and 16%, respectively.

8. Rate of IOP Elevation after DSAEK ( >25mmHg )
(%)
50%
33%
Rate of high IOP
13% 8%
　Eyes: n= 　　 n= n= n= 15
This graph shows the rate (%) of intraocular pressure (IOP) elevation after DSAEK in the various diseases. Six eyes (50% of the cases) of the glaucoma group showed high IOP, but there was no statistically significant difference between the other groups. Statistical analysis also demonstrated that the risk of postoperative high IOP was not associated with preoperative clinical features such as the number of medications received, presence of filtrating bleb, severity of the preoperative visual field, preoperative IOP, or patient age.

9. Corneal Endothelial Density (cells/mm2)
Corneal Endothelial Change
27.3%
8.5%
20.5%
31.9%
2902
Other groups:
　36 eyes
Glaucoma group:
12 eyes
Corneal Endothelial Density (cells/mm2)
2654
2111
2038
1998
1959
1808
Follow-up period (Months)
This graph shows the endothelial loss after DSAEK. Pre-cut versus postoperative endothelial loss was 8.5% and 20.5%, respectively. A loss of 31.9% was observed after 1 month, but there was no significant difference between the glaucoma group and the other groups.

10. Change of Visual Acuity after DSAEK
Failed graft
High IOP
Case 1
Needling
Postoperative BCVA
High IOP
Re-DSAEK
Case 6
Case 5
Case 4
Pre-OP
Follow-up period (Months)
This graph shows the change of visual acuity after DSAEK. Four cases showed a notable loss of vision after 6 months. In Case 1, vision recovered after re-DSAEK. Case 6 showed visual loss due to the needling procedure. Two cases (Case 5 and Case 4) showed severe visual loss due to the uncontrolled elevation of IOP and progressive visual field loss at the terminal stage of glaucoma.

11. Elevation of IOP after DSAEK in 4 Cases
IOP　(mmHg)
Needling
Case 5
Case 4
Case 1
Case 6
Pre-OP
Follow-up period (Months)
This graph demonstrates the change of IOP in four cases that led to loss of vision. Three cases showed high IOP spikes (>25mg) during the first postoperative month. One case (Case 6) required the needling procedure to control the IOP at 5 months after DSAEK. Two cases (Case 4 and Case 5) showed poorly controlled IOP elevation that led to severe visual loss during the mid-term postoperative period.

12. 　Conclusions　
DSAEK is effective for the recovery of corneal endothelial function in patients with pre-existing glaucoma, though the control of pre- and postoperative intraocular pressure is essential for a good clinical outcome.
Adequate treatment for the expected elevation of IOP after DSAEK is critical to prevent the progression of visual loss in the advanced stage of glaucoma.
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