Elaine I. Wu

Graft Rejection Following Descemet Stripping Automated Endothelial Keratoplasty: Features, Risk Factors, and Outcomes

PURPOSE To investigate the clinical features, risk factors, and treatment outcomes following immunologic graft rejection in eyes that have undergone Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN Retrospective case review. METHODS The charts for 353 DSAEK procedures performed at a single clinical practice at the New York Eye and Ear Infirmary from August 2006 to November 2010 were reviewed. Cases with at least 3 months follow-up were included. Outcome measures included rates of graft rejection, clinical findings, treatment outcomes, and risk factor analysis. RESULTS Thirty of 353 DSAEKs developed graft rejection (8.5%). Kaplan-Meier rate of rejection was 6.0% at 1 year (n = 175), 14.0% at 2 years (n = 79), and 22.0% at 3 years (n = 39). Rejection episodes occurred between 0.8 and 34 months. Clinical findings included anterior chamber cells, keratic precipitates, endothelial rejection line, and host-donor interface vascularization. Risk factors for development of graft rejection were cessation of postoperative steroid (hazard ratio 5.49, P < .0001) and black race (hazard ratio 2.71, P = .02). Recipient age, sex, surgical indication, glaucoma, postoperative steroid response, corneal neovascularization or peripheral anterior synechiae, graft size, prior keratoplasty in fellow eye, and concurrent or subsequent procedures were not associated with graft rejection. Twenty-two out of 30 rejection episodes (73.3%) resolved with steroid treatment. CONCLUSIONS Graft rejection is an important complication following DSAEK. In contrast to penetrating keratoplasty, rejection following DSAEK is almost exclusively endothelial. Among risk factors traditionally associated with graft rejection, cessation of topical steroids was most significant. Prompt recognition and treatment of DSAEK rejection can lead to favorable outcomes.

Descemet stripping automated endothelial keratoplasty after failed penetrating keratoplasty.

Purpose: To report the rate of graft dislocation, surgical anatomic success, and postsurgical complications associated with Descemet stripping automated endothelial keratoplasty (DSAEK) after previous primary failed penetrating keratoplasty (PK). Methods: Institutional review board–approved, single-center, retrospective chart review study of 30 eyes of 30 patients with prior failed PK who underwent DSAEK with a minimum of 3 months follow-up. Primary outcomes measured included rates of anatomic success and failure, postoperative complications, lenticle size, visual acuity, intraocular pressure change, and a report of external factors that may affect success. Results: Thirty eyes of 30 patients were identified. The primary dislocation rate was 16.7%. Five primary DSAEKs detached; 1 was successfully rebubbled in the office, 2 had repeat successful DSAEKs, and 2 failed on a second attempt and had a subsequent PK. Despite successful anatomic attachment, 1 eye had primary graft failure, 3 that cleared initially failed within 6 months, and 1 that successfully cleared had subsequent graft rejection resulting in failure at 6 months. The 2 eyes requiring PK were excluded from the visual outcomes analysis, leaving 28 eyes with successfully attached lenticles. At 3 months postoperatively, of the 28 eyes, 19 showed an improvement in visual acuity, 6 had no change in vision from preoperative data, and 1 had worsening of vision (anatomic attachment but endothelial failure). Two of the 28 eyes had no data at that time point. Conclusions: DSAEK eyes after failed PK demonstrated improved vision with a low complication rate in a majority of patients. The graft dislocation rate and postoperative complications rates are comparable with the primary DSAEK dislocation rates in our own published series and in the literature.

Self-Assessment Test Cataract Surgery

True or False: Modern cataract surgery is minimally invasive. This means that there are virtually no risks to undergoing modern cataract surgery. Answer: False. Although modern cataract surgery has reached a unique level of safety and efficacy, no patient should undergo a procedure without understanding the process of informed consent which includes both the rewards and risks to surgery.

Corneal Transplantation: Penetrating Keratoplasty

Traditionally, the most common form of corneal transplantation is penetrating keratoplasty (PK). In PK, the entire thickness of the cornea is removed and replaced with a full thickness donor cornea.

How the Patient Gets from the Front Door of the ASC to Your OR Suite

The patient, once arriving at the ASC, will complete paperwork at the admitting/reception desk. These will typically include medical-legal consent forms, financial information, and general instructions. The patient will then be moved to the pre-op staging area.

Self-Assessment Test Corneal Surgery

The cornea consists of three layers: the outer epithelium which provides protection against infection, injury, and desiccation; the central stroma which consists of fibers that provide strength; and the inner endothelium which contains cells that pump fluid out of the cornea to maintain transparency.

Decorum in the OR

Often overlooked in the OR suite is the practice of appropriate decorum – especially once a patient has arrived in the suite. Any music playing should be turned off unless otherwise requested by the surgeon or patient. Laughing and telling jokes or speaking of personal matters should be avoided in the presence of a patient. Do not discuss complications that might have occurred to a previous patient and do not make disparaging remarks about anyone.

Setting Up in the OR

Of course, it is expected that you will perform a proper scrubbing of your hands and arms. Depending on your ASC’s protocols there will be water and brush scrubs or perhaps alcohol-based scrubs. For the first scrub of the day, we suggest a full water/soap-based scrubbing of hands and arms with under-nail cleaning usually supplied to the ASC in self-contained scrub systems with sponge, liquid soap/antiseptic. Subsequent scrubs using waterless alcohol-based systems have become popular and seem to be adequate for asepsis. Follow the manufacturer’s directions.

The Advent of Ambulatory Eye Surgery

Modern Day-Op, or Ambulatory Surgical Centers or Units (ASCs or ASUs), are safe and efficient facilitators of both the surgeon’s and patient’s needs.

Surgeon-Specific Instruments

Here are instruments that are personalized depending on the surgeon’s unique surgical technique. This is not intended to be an exhaustive list of all instrument options but rather an introduction to their functions with some examples provided.