1. DSAEK Outcomes in Normal and Abnormal, High-Risk Eyes at an University Practice Hugo Y. Hsu and Sean L. Edelstein The authors have no financial interest in the subject matter of this poster This study was supported in part by an unrestricted grant from Research to Prevent Blindness (RPB), Inc.

2. Background An important step in the successful attachment of a donor lenticule for endothelial keratoplasty in its currently popular form (Descemet-stripping--DSAEK) is the ability to fill the anterior chamber completely with an air bubble after the introduction of the donor lenticule. Many post-surgical anterior segment changes (e.g. aphakia) makes a successful air-fill difficult if not impossible, and this potentially leads more tissue handling and damage. Several investigators have published series on the outcomes and results of DSAEK in relatively “normal” eyes, but few have tackled the outcomes (surgical and functional) in the “high-risk” eyes.

3. Purpose To compare the outcomes of our initial experience with DSAEK involving “normal” eyes such as isolated Fuch’s dystrophy or primary post cataract-extraction cornea edema and abnormal, high-risk eyes such as those having undergone multiple surgeries and/or have abnormalities of the anterior segment with compromise of the iris-lens diaphragm.

4. Methods The initial series of DSAEK patient at our inner-city, university-based, referral practice from April 2007 to December 2008 were retrospectively reviewed.* Patients were separated into “normal” and high-risk groups (defined next). Lenticule detachment, visual recovery, endothelial cell counts, and complication rates were compared between the two groups. Chi-square, and t-test statistics were employed to determine the difference between the two groups. * All surgeries were performed by the senior author (HYH) using the technique described by Terry et al.

5. “normal” vs. “high-risk” eyes Normal Fuch’s dystrophy Post cataract-surgery cornea edema High-risk Aphakia Post vitrectomy eyes Partial or complete loss of iris Glaucoma tubes or trabs Anterior-chamber IOL’s Iris-cornea adhesion or anterior chamber fibrosis

6. Example of a “normal” eye 77 yo woman with Fuch’s dystrophy and cataract who is status-post a traditional triple procedure with penetrating keratoplasty in the left eye 2 year prior wished to have surgical intervention to improve the failing vision in her right eye. Patient underwent a “new” triple procedure with cataract extraction via phacoemulsification, capsule-placement of an intra-ocular lens, and DSAEK.

7. Example of a “high-risk” eye 73 yo male blind in the left eye due to glaucoma developed cornea edema in the right eye after a history cataract extraction with a sulcus-placed IOL, anterior vitrectomy, failed trabeculectomy, glaucoma tube implantation, and multiple trans-scleral cyclophotocoagulation treatments. Patient underwent DSAEK. Intra-operatively, it was discovered that the patient’s IOL was unstable in the sulcus space. He had broad areas of iris-corneal adhesions, and he had poor tissue integrity.

8. Results: Patient Characteristics N (eyes)Age% Female Normal126533% High-risk196263%

9. Results: Endothelial Cell Density Donor age Initial 0.5 year 1.0 year 1.5 year Norma l 47.25 2824 N=12 1266 N=7 1306 N=7 902 N=7 High- risk 50.67 3044 N=18 1666 N=6 1512 N=5 1370 N=4 P- value 0.480.0250.250.36<0.01

10. Results: Visual Acuity Initial1 year1.5 year Normal 0.72 (20/105) N=12 0.35 (20/45) N=12 0.37 (20/47) N=11 High-risk 1.21 (20/324) N=18 0.27 (20/37) N=8 0.24 (20/35) N=6 P-value0.040.390.35

11. Results: Adverse Events & Complications Normal (n=12) Non-attachment (1; 8%) Detachment week one (1; 8%) Late increase IOP (3) Cataract formation (1) High-risk (n=19) Non-attachment (5; 26%) Detachment week one (2; 10.5%) Failure to reattach (3) Primary failure (3) Dropped lenticule (1) Rejection--resolved (1) Rejection--graft failure (1) Day-one pressure spike (1)* Rupture globe (1) *Air occlusion of trab ostomy

12. Conclusion High-risk eyes have high complication rates. However, collectively, the visual recovery and endothelial cell survival in high-risk eyes compare favorably against normal eyes. Therefore, despite the increased challenge, DSAEK should, in general, be offered to patients with higher risk profiles. Techniques to further minimize complications need to be developed and evaluated.