Endothelial Keratoplasty for Fuchs' Dystrophy with Cataract: Complications and Clinical Results with the New Triple Procedure

doi:10.1016/j.ophtha.2008.11.004

Ophthalmology

Volume 116, Issue 4, April 2009, Pages 631-639

https://doi.org/10.1016/j.ophtha.2008.11.004 Get rights and content

Purpose

To report the immediate postoperative complications and the 6- and 12-month clinical results in a large series of cases undergoing the new triple-procedure Descemet's stripping automated endothelial keratoplasty (DSAEK) and concurrent cataract surgery.

Design

Prospective, noncomparative, interventional case series.

Participants

Three hundred fifteen eyes of 233 patients with Fuchs' corneal dystrophy were evaluated for the complications of dislocation and iatrogenic primary graft failure (IPGF). Two hundred three eyes of 149 patients had 6-month postoperative data available for other outcome analysis.

Methods

A standardized technique of DSAEK with extensive use of cohesive viscoelastic was performed in all 315 eyes with Fuchs' dystrophy, and 225 of those eyes had cataract surgery concurrently. Of the 203 eyes with 6-month data, concurrent phacoemulsification with intraocular lens placement (triple procedure) was performed in 149 of those eyes.

Main Outcome Measures

The complications of graft dislocation and IPGF were recorded for all eyes. Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive spherical equivalent (SE), and central donor endothelial cell density (ECD) were measured prospectively and then compared with preoperative values for the triple-procedure eyes.

Results

There were 4 dislocations (4%) among the 90 straight DSAEK cases and 4 dislocations (1.8%) among the 225 triple-procedure cases (P = 0.327). There was not a single case of IPGF in any of the 315 DSAEK cases. After the triple procedure, the BSCVA in eyes without comorbidity (n = 122) improved with 93% at 20/40 or better at 6 months and 97% at 20/40 or better at 12 months. Refractive SE at 6 months averaged 0.11±1.08 diopters (D), with 73% of eyes within 1 D of emmetropia and 95% within 2 D of emmetropia. The postoperative mean ECD was 1955 cells/mm² at 6 months (n = 125) and 1979 cells/mm² at 12 months (n = 89) and represented a 32% cell loss from that before surgery (P<0.001) for both postoperative time points.

Conclusions

The new triple-procedure DSAEK combined with cataract surgery provides rapid visual recovery and allows selection of an appropriate intraocular lens. Dislocations are rare (1.8%) and primary graft failure did not occur.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Protocol

An institutional review board-approved and Health Information Portability and Accountability Act-compliant clinical protocol and surgical consent form for EK was developed, and enrollment was initiated for patients with endothelial dysfunction. All cases in this report are the initial consecutive cases of DSAEK in Fuchs' dystrophy; surgery was performed between September 2005 and June 2008. This report is restricted to only those patients with Fuchs' endothelial dystrophy who were treated with

Results

Before surgery, every patient had a diagnosis of Fuchs' endothelial dystrophy with clinically evident stromal edema and central guttata. There were 315 eyes with Fuchs' endothelial dystrophy treated with DSAEK in 233 patients. Concurrent cataract surgery was performed in 225 of these eyes. Cataract surgery was performed concurrently if the patient had a visually significant cataract or mild cataract with expectation of progression and minimal remaining accommodative amplitude. There were 4 eyes

Discussion

The development of EK has been rapid, and although the advantages of the surgery generally have been accepted, there remains disagreement among surgeons as to the relative risks and benefits of specific steps in the surgical procedure. This is especially true when it comes to the use of viscoelastic during the procedure and the coupling of DSAEK with concurrent cataract surgery.

Melles¹³ has maintained that the use of viscoelastic for anterior chamber maintenance during EK surgery is a major

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Cited by (174)

Hitting the refractive target in corneal endothelial transplantation triple procedures: A systematic review
2024, Survey of Ophthalmology
In phakic patients Descemet stripping automated endothelial keratoplasty (DSAEK) or Descemet membrane endothelial keratoplasty (DMEK) are frequently combined with phacoemulsification and intraocular lens (IOL) implantation (triple procedure). This surgery might cause a refractive shift difficult to predict. Early DMEK and DSAEK results have shown a tendency toward a hyperopic shift. Myopic postoperative refraction is typically intended to correct this postoperative refractive defect and to bring all eyes as close to emmetropia as possible. We sought to understand the mechanism underlying the hyperopization and to identify predictive factors for poorer refractive outcomes, the most suitable target refraction and IOL calculation methods in patients undergoing combined cataract extraction and lamellar endothelial corneal transplantation (DSAEK or DMEK) for endothelial dysfunctions. Of the 407 articles analyzed, only 18 were included in the analysis. A myopic target between −0.50 D and −0.75 was the most common (up to −1.50 for DSAEK triple procedures), even though no optimum target was found. Hyperopic surprises appeared more frequently in corneas that were flatter in the center than in the periphery (oblate posterior profile). Among the numerous IOL calculation formulas, there was no apparent preference.
Descemet Stripping Automated Endothelial Keratoplasty versus Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy: A National Registry-Based Comparison
2023, Ophthalmology
To compare the outcome between posterior lamellar corneal transplant procedures for Fuchs endothelial corneal dystrophy, taking preoperative patient characteristics in consideration. Surgical methods compared were Descemet membrane endothelial keratoplasty (DMEK), Descemet stripping automated endothelial keratoplasty (DSAEK), and DSAEK with concomitant cataract surgery (phacoemulsification plus DSAEK).
Registry-based study with propensity score matching.
One thousand six hundred seventy-seven patients from all Swedish corneal transplantation units treated from 2012 through 2019.
All patients undergoing endothelial keratoplasty performed from 2012 through 2019 with completed 2-year follow-up data reported to The Swedish Corneal Transplant Register were included, totaling 1677 patients. Three comparable groups (DMEK, DSAEK, and phacoemulsification plus DSAEK) with 216 patients in each group were generated with propensity score matching based on preoperative visual acuity, age, sex, year of surgery, and preoperative risk factors such as inflammation, vascularization, and glaucoma.
Best-corrected visual acuity (BCVA) at the 2-year follow-up, frequency of graft dislocation, graft rejection episodes, and graft failure within 2 years including primary graft failure.
The preoperative corneal status was affected more severely in the DSAEK group before matching. In the matched groups, the median BCVA 2 years after surgery was 0.1 logarithm of the minimum angle of resolution (logMAR) in both the DMEK and the phacoemulsification plus DSAEK groups and 0.15 logMAR in the DSAEK group (P = 0.001). The frequency of graft dislocation was higher among the patients undergoing phacoemulsification plus DSAEK, but the frequency of graft failure and primary graft failure was higher in the DMEK group.
Visual acuity improved in most patients (90%) with all 3 surgical methods. However, DMEK and phacoemulsification plus DSAEK reached higher levels of visual acuity 2 years after surgery, and phacoemulsification plus DSAEK was superior considering graft survival rate. All 3 surgical procedures showed both strengths and weaknesses, suggesting that the choice of surgical method should be individualized, taking into consideration not only the cornea, but each patient’s complete medical status as well as the entire course of postoperative medical care.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Corneal Pathology and Cataract Surgery Considerations
2023, Advances in Ophthalmology and Optometry
Outcomes of cataract surgery in patients with Fuchs endothelial corneal dystrophy
2021, Journal Francais d'Ophtalmologie
Alors que la greffe endothéliale a amélioré le pronostic de la dystrophie de Fuchs, la stratégie chirurgicale à adopter en première intention chez le patient présentant une cataracte associée reste débattue. L’objectif était de rapporter les résultats postopératoires chez ces patients, pour lesquels une phaco-exérèse seule a été décidée sur la base de critères préopératoires simples.
Étude rétrospective, monocentrique comprenant 64 yeux de 50 patients atteints d’une dystrophie de Fuchs non décompensée et ayant bénéficié d’une phaco-exérèse seule. La décision était prise devant l’absence de brouillard matinal, une épaisseur cornéenne centrale ne dépassant pas 630 microns et si possible une visualisation des cellules endothéliales en périphérie.
Le recul moyen était de 21 ± 14,1 mois. L’épaisseur cornéenne centrale préopératoire était de 571 ± 43 microns. À 6 mois postopératoire, elle était de 584 ± 52 microns (p= 0,12). Vingt deux pour cent des yeux ont nécessité la réalisation d’une greffe endothéliale en postopératoire de la chirurgie seule du cristallin. Leur épaisseur cornéenne centrale moyenne pré opératoire (595 ± 23 microns) était significativement plus élevée que celle des yeux n’ayant pas nécessité de greffe par la suite (564 ± 45 microns, p= 0,022). Au delà de 570 microns, 34 % des yeux nécessitaient une greffe endothéliale dans les suites opératoires de la chirurgie seule du cristallin. Aucune cornée de 540 microns ou moins n’a nécessité de geste complémentaire.
Les critères pré opératoires utilisés permettent à 78,1 % des patients porteurs d’une dystrophie de Fuchs et opérés d’une chirurgie seule du cristallin, d’éviter une greffe endothéliale en première intention.
While endothelial keratoplasty has become the standard treatment for Fuchs dystrophy, the strategy for first-line surgery in patients with associated cataract is still debated. The purpose of this study was to evaluate the surgical outcomes of eyes with Fuchs endothelial corneal dystrophy (FECD) undergoing phacoemulsification alone, to ascertain preoperative factors that predict the need for endothelial keratoplasty (EK).
Single-center retrospective study. Cataract surgery alone was performed in 64 eyes of 50 patients with FECD. This decision was made if the patient did not have morning blur, the central corneal thickness (CCT) was below 630 microns, and endothelial cells were visible in the periphery.
Mean follow-up was 21 months (range 5–55 months). The mean preoperative CCT was 571 ± 43 μm. 6 months after surgery, it was 584 ± 52 μm (P = 0.12). During follow-up, 14 eyes (22%) required an EK because of poor visual outcome after cataract surgery alone. Mean pre-operative CCT of these eyes (595 ± 23 μm) was significantly higher than eyes that did not require EK during follow-up (564 ± 45 μm, P = 0.022). Over 570 microns, 34% of eyes required an endothelial keratoplasty after the cataract surgery alone.
CCT below 630 μm associated with the absence of morning blur are preoperative criteria allowing 78.1% eyes with FECD to obtain good visual outcomes after cataract surgery alone. In these eyes, EK can therefore be avoided while ensuring good results.
Refractive accuracy and visual outcomes after combined descemet membrane endothelial keratoplasty and cataract surgery: A French multicentric study
2021, Journal Francais d'Ophtalmologie
Descemet membrane endothelial keratoplasty (DMEK) combined with cataract extraction and intraocular lens insertion (new triple procedure) limits postoperative refractive errors. The objective of this study was to assess refractive accuracy after DMEK combined with cataract extraction and intraocular lens implantation.
Four university hospitals (Rouen, Paris, Reims, Grenoble).
This retrospective multicenter study included patients with symptomatic corneal endothelial decompensation and cataract.
The primary outcome was the difference between the target spherical equivalent and postoperative refraction at months 2 and 6. Secondary outcomes were visual acuity, keratometry, pachymetry and endothelial cell density.
A total of 130 eyes of 111 patients (mean age 66.2 years) were included (94% with Fuchs’ endothelial dystrophy). For a mean refractive target set at −0.50 (±0.57) D, the mean (95% CI) refractive error was hyperopia of +0.49 (0.314; 0.664) D at 2 months and +0.46 (0.299; 0.619) D at 6 months. Best corrected distance visual acuity was improved in all patients: from 0.49 (±0.3) logMAR to 0.14 (±0.14) logMAR at 2 months and 0.05 (±0.1) logMAR at 6 months. Mean corneal thickness decreased from 621.6 (±37.6) μm to 515.2 (±42.6) μm at 2 months and 539.0 (±39.0) μm at 6 months.
Good refractive accuracy was obtained after the new triple procedure with DMEK. Hyperopic shift is common after triple procedures, and its persistence should be evaluated in future studies in order to anticipate a change in its value to optimize intraocular lens power calculation.
Les nouvelles triples procédures associant chirurgie de cataracte et greffe endothéliale DMEK ont permis de limiter les erreurs réfractives. L’objectif de cette étude était d’évaluer la précision réfractive dans cette chirurgie combinée.
Cette étude rétrospective multicentrique réalisée dans 4 centres hospitalo-universitaires (Rouen, Paris, Reims, Grenoble) a inclus des patients présentant une décompensation endothéliale symptomatique et une cataracte. Le critère de jugement principal était l’erreur réfractive qui correspondait à la différence entre la réfraction sphérique ciblée et la réfraction sphérique obtenue à 2 et 6 mois postopératoire. Les critères secondaires étaient l’acuité visuelle, la kératométrie, la pachymétrie et la densité cellulaire endothéliale.
Un total de 130 yeux de 111 patients (âge moyen de 66,2 ans) a été inclus (94 % avec une dystrophie de Fuchs). La cible réfractive moyenne était de −0,50 (±0,57) D, l’erreur réfractive moyenne (IC à 95 %) était une hypermétropisation de +0,49 (0,314 ; 0,664) D à 2 mois et de +0,46 (0,299 ; 0,619) D à 6 mois. L’acuité visuelle corrigée de loin a été améliorée de 0,49 (±0,3) logMAR à 0,14 (±0,14) logMAR à 2 mois et 0,05 (±0,1) logMAR à 6 mois. La pachymétrie a diminué de 621,6 (±37,6) μm à 515,2 (±42,6) μm à 2 mois et 539,0 (±39,0) μm à 6 mois.
La réfraction obtenue dans ces triples procédures était satisfaisante. L’hypermétropisation semble être habituelle mais sa persistance devrait être évaluée dans les études futures afin de pouvoir l’anticiper dans le choix de la puissance de l’implant.
Corneal endothelial dysfunction: Evolving understanding and treatment options
2021, Progress in Retinal and Eye Research
The cornea is exquisitely designed to protect the eye while transmitting and focusing incoming light. Precise control of corneal hydration by the endothelial cell layer that lines the inner surface of the cornea is required for optimal transparency, and endothelial dysfunction or damage can result in corneal edema and visual impairment. Advances in corneal transplantation now allow selective replacement of dysfunctional corneal endothelium, providing rapid visual rehabilitation. A series of technique improvements have minimized complications and various adaptations allow use even in eyes with complicated anatomy. While selective endothelial keratoplasty sets a very high standard for safety and efficacy, a shortage of donor corneas in many parts of the world restricts access, prompting a search for alternatives. Clinical trials are underway to evaluate the potential for self-recovery after removal of dysfunctional central endothelium in patients with healthy peripheral endothelium. Various approaches to using cultured human corneal endothelial cells are also in clinical trials; these aim to multiply cells from a single donor cornea for use in potentially hundreds of patients. Pre-clinical studies are underway with induced pluripotent stem cells, endothelial stem cell regeneration, gene therapy, anti-sense oligonucleotides, and various biologic/pharmacologic approaches designed to treat, prevent, or retard corneal endothelial dysfunction. The availability of more therapeutic options will hopefully expand access around the world while also allowing treatment to be more precisely tailored to each individual patient.

View all citing articles on Scopus

: Manuscript no. 2008-957.

: Financial Disclosure(s): The author(s) have made the following disclosure(s):

: Mark A. Terry - Financial Interest - Bausch and Lomb specialized instruments used in this surgery.

: Bausch and Lomb Surgical, St. Louis, Missouri, manufactured and supplied the specially designed instruments free of charge.

: Supported by the Oregon Lions Sight and Hearing Foundation, Portland, Oregon.

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Original articleEndothelial Keratoplasty for Fuchs' Dystrophy with Cataract: Complications and Clinical Results with the New Triple Procedure

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Protocol

Results

Discussion

Ophthalmology

J Cataract Refract Surg

Am J Ophthalmol

J Cataract Refract Surg

Ophthalmology

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

Ophthalmology

Ophthalmology

Ophthalmology

Endothelial keratoplasty: history, current state, and future directions

Cornea

In pursuit of emmetropia: spherical equivalent refraction results with deep 1amellar endothelial keratoplasty (DLEK)

Cornea

The new triple procedure: Descemet's stripping automated endothelial keratoplasty with concurrent phacoemulsification cataract extraction and intraocular lens placement

Tech Ophthalmol

Original article
Endothelial Keratoplasty for Fuchs' Dystrophy with Cataract: Complications and Clinical Results with the New Triple Procedure