Ultrathin Descemet's Stripping Automated Endothelial Keratoplasty with the Microkeratome Double-Pass Technique: Two-Year Outcomes

doi:10.1016/j.ophtha.2012.11.030

Ophthalmology

Volume 120, Issue 6, June 2013, Pages 1186-1194

Presented in part at: American Academy of Ophthalmology Annual Meeting, October 2010, Chicago, Illinois, and October 2011, Orlando, Florida.

https://doi.org/10.1016/j.ophtha.2012.11.030 Get rights and content

Purpose

To evaluate the outcomes and graft survival rates after ultrathin (UT) Descemet's stripping automated endothelial keratoplasty (DSAEK) using the microkeratome-assisted double-pass technique.

Design

Prospective, consecutive, interventional case series.

Participants

Patients with endothelial decompensation of various causes (Fuchs endothelial dystrophy, pseudophakic or aphakic bullous keratopathy, failed previous graft, herpetic endotheliitis, or buphthalmus; n = 285 grafts).

Intervention

Donor preparation was performed using the microkeratome-assisted double-pass technique. Stripping of the Descemet's membrane was performed under air and the graft was delivered into the anterior chamber using the pull-through technique through a 3-mm clear-cornea incision using a modified Busin glide.

Main Outcome Measures

Best spectacle-corrected visual acuity (BSCVA), manifest refraction, endothelial cell density, and graft thickness (GT).

Results

Excluding all eyes with pre-existing ocular comorbidities, mean BSCVA at 3, 6, 12, and 24 months was 0.16, 0.11, 0.08, and 0.04 logarithm of the minimum angle of resolution units, respectively. The percentage of patients achieving BSCVA of 20/20 or better at 3, 6, 12, and 24 months was 12.3%, 26.3%, 39.5%, and 48.8%, respectively. A statistically significant (P < 0.0001) hyperopic shift of 0.78 ± 0.59 diopters (D; range, −0.75 to 1.75 D) was found at 1 year. The endothelial cell loss at 3, 6, 12, and 24 months was 29.8 ± 14.3%, 33 ± 15.5%, 35.6 ± 14.1%, and 36.6 ± 16.0%, respectively. The mean central GT recorded 3 months after surgery was 78.28 ± 28.89 μm. Complications included microkeratome failure to achieve perfect dissection in 21 donor tissues (7.2%), with 6 (2.1%) being discarded; total graft detachment in 11 cases (3.9%); primary failure in 4 cases (1.4%); and secondary failure in 4 additional cases (1.4%). Kaplan-Meier cumulative probability of a rejection episode at 3, 6, 12, and 24 months was 0%, 0.4%, 2.4%, and 3.3%, respectively.

Conclusions

The visual outcomes of UT DSAEK are comparable with those published for Descemet's membrane endothelial keratoplasty and better than those reported after DSAEK in terms of both speed of visual recovery and percentage of patients with 20/20 final visual acuity. However, unlike with Descemet's membrane endothelial keratoplasty, preparation and delivery of donor tissue are neither difficult nor time consuming. Complications of UT DSAEK do not differ substantially from those recorded with standard DSAEK but are much less frequent than those reported after Descemet's membrane endothelial keratoplasty.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Patients and Methods

All consecutive patients operated on by the same surgeon (M.B.) using the microkeratome-assisted double-pass technique¹⁰ at Villa Serena-Villa Igea Private Hospitals, Forlì, Italy, from January 2010 through December 2011 were included in a prospective study aimed at evaluating the outcomes of this technique.

The study followed the tenets of the 1964 Declaration of Helsinki and was approved by the local ethics committee; detailed informed consent was provided by all patients undergoing UT DSAEK.

Results

Two hundred eighty-five UT DSAEK procedures performed in 279 eyes (6 repeat UT DSAEK procedures) of 250 patients were included in the study. Demographics and indications for surgery are shown in detail in Table 2 (available at http://aaojournal.org). An example of pseudophakic bullous keratopathy is shown in Figure 3A, B. All phakic patients with a perfectly clear crystalline lens underwent simple DSAEK, whereas even minimal lens changes in elderly patients (age >60 years) were sufficient to

Discussion

Many authors claim that final visual acuity after DSAEK is suboptimal, with fewer eyes than expected achieving 20/20 vision, possibly because of the presence of a stromal interface.1, 2, 3, 13 In comparison with most of the DSAEK series published to date, DMEK has shown a decisive improvement in terms of speed of visual recovery, percentage of patients achieving 20/20 vision, and rate of immunologic rejection.6, 7, 8 However, ease of graft preparation, manipulation, delivery, and attachment, as

References (28)

W.B. Lee et al.
Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology
Ophthalmology
(2009)
A. Anshu et al.
Endothelial keratoplasty: a revolution in evolution
Survey Ophthalmol
(2012)
E. Letko et al.
Secondary graft failure and repeat endothelial keratoplasty after Descemet's stripping automated endothelial keratoplasty
Ophthalmology
(2011)
M.O. Price et al.
Descemet's membrane endothelial keratoplasty: prospective multicenter study of visual and refractive outcomes and endothelial survival
Ophthalmology
(2009)
A. Anshu et al.
Risk of corneal transplant rejection significantly reduced with Descemet's membrane endothelial keratoplasty
Ophthalmology
(2012)
F.P. Guerra et al.
Descemet's membrane endothelial keratoplasty: prospective study of 1-year visual outcomes, graft survival, and endothelial cell loss
Ophthalmology
(2011)
J.Y. Li et al.
Three-year visual acuity outcomes after Descemet's stripping automated endothelial keratoplasty
Ophthalmology
(2012)
M.O. Price et al.
Descemet's stripping with endothelial keratoplasty: comparative outcomes with microkeratome-dissected and manually dissected donor tissue
Ophthalmology
(2006)
V. Scorcia et al.
Pentacam assessment of posterior lamellar grafts to explain hyperopization after Descemet's stripping automated endothelial keratoplasty
Ophthalmology
(2009)
M.O. Price et al.
Descemet's stripping endothelial keratoplasty: five-year graft survival and endothelial cell loss
Ophthalmology
(2011)

L. Ham et al.

Endothelial cell density after Descemet membrane endothelial keratoplasty: 1- to 2-year follow-up

Am J Ophthalmol

(2009)

M.O. Price et al.

Endothelial cell loss after Descemet stripping with endothelial keratoplasty: influencing factors and 2-year trend

Ophthalmology

(2008)

J.Y. Li et al.

Graft rejection after Descemet stripping automated endothelial keratoplasty: graft survival and endothelial cell loss

Ophthalmology

(2012)

K.D. Neff et al.

Comparison of central corneal graft thickness to visual acuity outcomes in endothelial keratoplasty

Cornea

(2011)

Cited by (183)

The pre-Descemet's layer (Dua's layer, also known as the Dua-Fine layer and the pre-posterior limiting lamina layer): Discovery, characterisation, clinical and surgical applications, and the controversy
2023, Progress in Retinal and Eye Research
The pre-Descemet's layer/Dua's layer, also termed the Dua-Fine layer and the pre-posterior limiting lamina layer, lies anterior to the Descemet's membrane in the cornea, is 10 μm (range 6–16) thick, made predominantly of type I and some type VI collagen with abundant elastin, more than any other layer of the cornea. It has high tensile strength (bursting pressure up to 700 mm of Hg), is impervious to air and almost acellular. At the periphery it demonstrates fenestrations and ramifies to become the core of the trabecular meshwork, with implications for intraocular pressure and glaucoma. It has been demonstrated in some species of animals.
The layer has assumed considerable importance in anterior and posterior lamellar corneal transplant surgery by improving our understanding of the behaviour of corneal tissue during these procedures, improved techniques and made the surgery safer with better outcomes. It has led to the innovation of new surgical procedures namely, pre-Descemet's endothelial keratoplasty, suture management of acute hydrops, DALK-triple and Fogla's mini DALK.
The discovery and knowledge of the layer has introduced paradigm shifts in our age old concepts of Descemet's membrane detachment, acute corneal hydrops in keratoconus and Descemetoceles, with impact on management approaches. It has been shown to contribute to the pathology and clinical signs observed in corneal infections and some corneal dystrophies. Early evidence suggests that it may have a role in the pathogenesis of keratoconus in relation to its elastin content. Its contribution to corneal biomechanics and glaucoma are subjects of current investigations.
Risk factors for failure of pre-cut eye bank UT-DSAEK grafts
2023, Journal Francais d'Ophtalmologie
Les principaux facteurs de risque d’échec des greffes transfixiantes de cornée sont bien connus dans la littérature. Cependant, peu d’études se sont intéressées aux caractéristiques du donneur et du greffon.
Il s’agit d’une étude rétrospective monocentrique au CHU de Nantes, qui avait pour but de rechercher des facteurs prédictifs d’échec ou de réussite de greffe à 1 an dans le cadre d’UT-DSAEK préparées en banque multi-tissus entre mai 2016 et octobre 2018. Le critère de jugement principal était le succès ou l’échec à 12 mois de la greffe.
Parmi les 105 greffons inclus, on retrouvait 93 succès et 12 échecs à 12 mois. Le taux d’échec était plus important en 2016 par rapport à 2017 et 2018. Les caractéristiques associées à un taux d’échec le plus important étaient un greffon provenant d’un donneur âgé, une durée courte entre le prélèvement et la réalisation de la greffe, une faible densité cellulaire endothéliale et perte cellulaire endothéliale pré-greffe importante, une regreffe endothéliale pour dystrophie de Fuchs, et antécédent de greffe de cornée.
Nos résultats sont concordants avec ceux de la littérature. Cependant certains critères tels que le type de don ou la perte cellulaire endothéliale pré-greffe n’ont pas été retrouvés dans la littérature. L’UT-DSAEK a montré sa supériorité par rapport à la DSAEK mais semble rapporter des résultats un peu moindres par rapport à la DMEK.
Le principal facteur d’échec de greffe était la regreffe précoce dans les 12 mois. Cependant, la faible incidence des échecs de greffe en limite l’interprétation.
The main risk factors for graft failure in penetrating keratoplasty are well known. However, few studies have examined donor characteristics or more precise data on endothelial keratoplasty.
This was a retrospective, single-center study at the Nantes University Hospital, aiming to identify factors predictive of one-year success or failure of eye bank UT-DSAEK endothelial keratoplasty grafts prepared between May 2016 and October 2018. The outcome measure was success or failure at 12 months post keratoplasty.
One hundred and five grafts were included: 93 successes and 12 failures at 12 months. The failure rate was higher in 2016 compared to 2017 and 2018. The characteristics associated with higher failure rate were elderly donor, shorter time between harvesting and grafting, lower endothelial cell density, significant pre-graft endothelial cell loss, re-graft for Fuchs dystrophy, history of corneal transplant.
Our results are consistent with those in the literature. However, some factors, such as the type of corneal harvesting or pre-graft endothelial cell loss, were not found. UT-DSAEK has demonstrated better results than DSAEK, but still appears to be somewhat inferior to DMEK.
The main factor for graft failure in our study was an early re-graft within 12 months. However, the low incidence of graft failure limits interpretation of these results.
Changes in Corneal Power up to 2 Years After Endothelial Keratoplasty: Results From the Randomized Controlled Descemet Endothelial Thickness Comparison Trial
2023, American Journal of Ophthalmology
To compare changes in corneal power measurements after Descemet membrane endothelial keratoplasty (DMEK) vs ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK).
Post hoc subanalysis of the randomized controlled Descemet Endothelial Thickness Comparison Trial.
A total of 50 eyes (38 patients) with endothelial dysfunction from Fuchs’ endothelial dystrophy or pseudophakic bullous keratopathy were randomized to DMEK or UT-DSAEK 1 to 2 days before surgery. Total corneal refractive power (TCRP) and anterior/posterior simulated keratometry were obtained using Scheimpflug imaging preoperatively (baseline) and postoperatively at 3, 6, 12, and 24 months. Spectacle refractions were performed at 6, 12, and 24 months after surgery.
Setting:
Hospital centers.
The mean hyperopic shift of TCRP from baseline to 12 months was 0.80 ± 1.1 (P = .002) in the DMEK group and 0.69 ± 0.84 (P < .001) in the UT-DSAEK group. Posterior corneal curvature (average K from simulated keratometry) steepened (more negative dioptric power) by 0.42 ± 0.10 (P < .001) in DMEK and 0.54 ± 0.09 (P < .001) in UT-DSAEK. The mean change in TCRP and posterior corneal curvature did not differ between DMEK and UT-DSAEK (TCRP, P = .71; posterior average K from simulated keratometry, P = .36).
Sustained steepening in posterior corneal curvature with loss in total corneal power contributes to hyperopic shifts after endothelial keratoplasty. Changes in corneal measurements do not differ between DMEK and UT-DSAEK. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
Efficacy of Thin and Ultrathin Descemet Stripping Automated Endothelial Keratoplasty and Influence of Graft Thickness on Postoperative Outcomes: Systematic Review and Meta-analysis
2022, American Journal of Ophthalmology
Citation Excerpt :
The definition of UT-DSAEK grafts is also not consistent, varying from threshold under 10010,36 to 1307,49 µm of central graft thickness. In addition, studies referred either to the postoperative graft thickness108,109 or thickness immediately after cutting.7,9,29 In this meta-analysis, we considered thin DSAEK as DSAEK grafts <130 µm thick and ultrathin DSAEK grafts <100 µm thick,16 based on their preoperative thickness, to provide predictable results.
To conduct a systematic review and meta-analysis on the efficacy of thin and ultrathin Descemet stripping automated endothelial keratoplasty (T-DSAEK and UT-DSAEK, with graft thickness <130 and <100 µm, respectively), depending on graft thickness.
Systematic review and meta-analysis.
PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and ScienceDirect databases were searched until October 1, 2021. We computed random-effect meta-analysis on postoperative outcomes of T/UT-DSAEK, stratified by graft thickness (<80 μm, 80-100 μm, and 100-130 μm). The main postoperative outcome was visual acuity (logarithm of the minimum angle of resolution [logMAR]). Secondary outcomes were pachymetry (μm), endothelial cell count (cell/mm²), spherical equivalent (diopter [D]), rebubbling rate (%), and rejection rate (%). Meta-regressions compared postoperative outcomes depending on graft thickness and search for putative confusion factors.
We included 47 articles for a total of 2141 eyes of 2040 patients. T/UT-DSAEK globally improved visual acuity (effect size = −0.38 logMAR [95% confidence interval {CI} −0.46 to −0.30 logMAR]), without difference depending on graft thickness. Overall, pachymetry improved (−60.6 µm [95% CI −101 to −19.7 µm]), endothelial cell count decreased (−1039 cells/mm² [95% CI −1209 to −868 cells/mm²), spherical equivalent resulted in a hyperopic shift (0.74 D [95% CI −0.50 to 1.97 D), the graft rejection rate was 0.2% (95% CI −0.1% to 0.4%), and the rebubbling rate was 8.7% (95% CI 6.8%-10.5%). Grafts >100 μm induced a hyperopic shift. Metaregressions did not demonstrate differences between the 3 groups (<80 μm, 80-100 μm, or 100-130 μm) in any outcomes.
All T/UT-DSAEK thickness groups provided similar visual acuity, pachymetry, endothelial cell count, rejection rate, and rebubbling rate regardless of graft thickness. A hyperopic shift was induced by grafts >100 μm.
Manually prepared lamellae for Descemet stripping endothelial keratoplasty (Pachy-DSEK): comparison of four dissection depths
2024, Arquivos Brasileiros de Oftalmologia
Macular Thickness after Ultrathin Descemet Stripping Automated Endothelial Keratoplasty and Descemet Membrane Endothelial Keratoplasty Combined with Cataract Surgery: A Randomized Controlled Clinical Trial
2023, Cornea

View all citing articles on Scopus

: Manuscript no. 2012-973.

Financial Disclosure(s): The author(s) have made the following disclosure(s): Massimo Busin - Travel and royalties - Moria

The remaining authors have no financial interests to disclose.

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Original articleUltrathin Descemet's Stripping Automated Endothelial Keratoplasty with the Microkeratome Double-Pass Technique: Two-Year Outcomes

Purpose

Design

Participants

Intervention

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Patients and Methods

Results

Discussion

Ophthalmology

Survey Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Comparison of central corneal graft thickness to visual acuity outcomes in endothelial keratoplasty

Cornea

Original article
Ultrathin Descemet's Stripping Automated Endothelial Keratoplasty with the Microkeratome Double-Pass Technique: Two-Year Outcomes