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Three Year Visual and Endothelial Density Outcomes after Endothelial Keratoplasty

Three Year Visual and Endothelial Density Outcomes after Endothelial Keratoplasty. Authors Sabah Ali Shah, M.S. Albany Medical College, MS-4 Abraham Sleem , MD Albany Medical College, PGY-4 Robert L. Schultze , MD Director, Cornea and Refractive Surgery, Albany, NY.

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Three Year Visual and Endothelial Density Outcomes after Endothelial Keratoplasty

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  1. Three Year Visual and Endothelial Density Outcomes after Endothelial Keratoplasty Authors Sabah Ali Shah, M.S. Albany Medical College, MS-4 Abraham Sleem, MD Albany Medical College, PGY-4 Robert L. Schultze, MD Director, Cornea and Refractive Surgery, Albany, NY Disclosure: The authors have no financial/conflicting interests to disclose

  2. Purpose / Introduction • Purpose: To report changes in best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) up to 3 years after DLEK. • Introduction: This case series reviews longer-term outcomes on patients undergoing Deep Lamellar Endothelial Keratoplasty. While this procedure has largely been replaced by Descemet’s Stripping Automated Endothelial Keratoplasty, the cases in this series represent the primary surgeon’s (RLS) early learning curve on a relatively invasive corneal procedure.

  3. Methods • 14 eyes underwent deep lamellar endothelial keratoplasty (DLEK) by one surgeon (RLS). • BSCVA and ECC were obtained pre-operatively and annually for 3 years. • All donor tissue came from the Lions Eye Bank in Albany, NY • Pre-operative donor endothelial cell density was determined at the procuring the Eye Bank and post-operative measurements were determined in office 1, 2, and 3 years postoperatively. • SP4000 noncontact specular microscope, Konan Medical Corp.

  4. Surgical Technique • DLEK procedure using a Moria artificial anterior chamber and LSK-ONE microkeratome for donor preparation • “350” or “300” head used Slit lamp photo showing smooth interface after DLEK

  5. Results • BSCVA after DLEK improved from an average of 20/127 pre-operatively to 20/47, 20/40, 20/32 at years 1, 2, and 3 post-operatively, respectively (p=0.005 at year one). • Average ECC decreased from 2859±465 pre-operatively to 1302±698 (54.1% loss), 914 ±554 (68.7% loss), and 920±696 (68.4% loss) at years 1, 2 and 3 post-operative, respectively (p<0.01 at year one)

  6. Preop vs. Postop Best Spectacle Corrected Visual Acuity Snellen Equivalent 20/XX p=0.0005 p>0.05

  7. Preop vs. Postop Endothelial Cell Count p=0.0001

  8. Endothelial Cell Loss In Other Studies Mashor RS, Kaiserman I, Kumar N, Sansanayudh W, Rootman DS. Deep Lamellar Endothelial Keratoplasty Up to a 5-Year Follow-up. Ophthalmology 2010;117:680-6. Terry MA, Endothelial Keratoplasty: Clinical Outcomes in the Two Years following Deep Lamellar Endothelial Keratoplasty (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc 2007;105:530-63. Terry MA, Wall JM, Hoar KL, Ousley PJ. A Prospective Study of Endothelial Cell Loss during the 2 Years after Deep Lamellar Endothelial Keratoplasty. Ophthalmology 2007;114:621-9.

  9. BSCVA in Other Studies Mashor RS, Kaiserman I, Kumar N, Sansanayudh W, Rootman DS. Deep Lamellar Endothelial Keratoplasty Up to a 5-Year Follow-up. Ophthalmology 2010;117:680-6. Terry MA, Endothelial Keratoplasty: Clinical Outcomes in the Two Years following Deep Lamellar Endothelial Keratoplasty (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc 2007;105:530-63.

  10. Factors Thought to Influence Endothelial Cell Survival • Progressive cell loss in the second year post –op may be due to the delayed effect on central ECC caused by folding and added manipulation of the tissue in small-incision DLEK • Mashor RS, Kaiserman I, Kumar N, Sansanayudh W, Rootman DS. Deep Lamellar Endothelial Keratoplasty Up to a 5-Year Follow-up. Ophthalmology 2010;117:680-6. • Insertion techniques: small incision causes higher rate of cell loss as opposed to larger incision • Terry MA, Wall JM, Hoar KL, Ousley PJ. A Prospective Study of Endothelial Cell Loss during the 2 Years after Deep Lamellar Endothelial Keratoplasty. Ophthalmology 2007;114:621-9. • ACIOLs may accelerate the rate of endothelial cell loss in DLEK patients. • Chen ES, Terry MA, Neda S, Friend DJ. Endothelial Keratoplasty: Endothelial Cell Loss After Deep Lamellar Endothelial Keratoplast y With Retention of an Open-Loop Anterior Chamber Intraocular Lens. Cornea 2010;29:162-6

  11. Conclusions • Patients that have undergone DLEK have significant improvement in BSCVA at 1 year. • BCVA and ECC do not show statistically significant change after the first year. • Our cell loss was in agreement with other published studies

  12. Discussion • Incision size and insertion technique may contribute to differences in endothelial cell loss. • May provide a better alternative to traditional PK for the treatment of endothelial dysfunction • DLEK has been mostly abandoned in favor of DSAEK, although they show similar ECL and BSCVA. • Bahar I, Sansanayudh W, Levinger E, Kaiserman I, Srinivasan S, Rootman D. Posterior lamellar keratoplasty—comparison of deep lamellar endothelial keratoplasty and Descemet stripping automated endothelial keratoplasty in the same patients: a patient’s perspective. Br J Ophthalmol 2009 93: 189-190.

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