Professional Documents
Culture Documents
INCIDENCE OF PK
1 PK/10.000 People Required in 1
Year
MAIN INDICATIONS
Impaired Corneal Curvature
(i.e. Keratoconus)
Impaired Corneal Transparency &
Decompensated Endothelium
(i.e. Bullous Keratopathy)
Impaired Corneal Transparency &
Normal Endothelium
(i.e. Corneal Scars)
MAIN INDICATIONS
Impaired Corneal Curvature
KERATOCONUS
MAIN INDICATIONS
Impaired Corneal
Transparency &
Decompensated
Endothelium
BULLOUS
KERATOPATHY
(Fuchs or Postoperative)
MAIN INDICATIONS
Impaired Corneal
Transparency &
Normal Endothelium
SCARS s/p KERATITIS
(viral, bacterial,
ecc.)
MAIN INDICATIONS
Impaired Corneal
Transparency &
Normal
Endothelium
CORNEAL
DYSTROPHIES AND
DEGENERATIONS
MAIN INDICATIONS
Impaired Corneal
Transparency &
Normal
Endothelium
SCARS s/p TRAUMA
MAIN INDICATIONS
(up to 2005)
KERATOCONUS
40-45%
DECOMPENSATED
ENDOTHELIUM
30-35%
NORMAL
ENDOTHELIUM
20-25%
MAIN INDICATIONS
(2015)
KERATOCONUS
30-35%
40-45%
DECOMPENSATED
ENDOTHELIUM
NORMAL
ENDOTHELIUM
20-25%
PENETRATING
KERATOPLASTY
RECOVERY OF
TRANSPARENCY
RECOVERY OF
NORMAL CURVATURE
RECOVERY OF
BOTH
PK (from60s)
One Solution for
ALL !!!
LK (up to 50s)
Hand Dissection
Bad Interface
Poor Vision
(<20/40)
TOP HAT PK
FEMTO-SHAPED PK
Top Hat
Mushroom
Zig-Zag
DISEASED STROMA
Infections
Dystrophies
Degenerations
Post-Surgical (PRK)
Others
DISEASED ENDOTHELIUM
Primary Corneal
Edema (Fuchs)
Post-Surgical BK
PK Failure
Endothelial Dystrophies
ICE Syndrome
Others
COMBINATIONS
Traumata
Infections (HSV)
Macular Dystrophy
Others
NEW KERATOPLASTY
Corneal
Disease
Healthy
Endothelium
Diseased
Endothelium
Anterior
LK
(Mushroom)
Posterior
LK
(PK)
DISSECTION:
Manual
CORNEAL DISSECTION
MANUAL:
Difficult
Non Reproducible
Interface of Poor Optical
Quality (20/20 Vision
Only if Very DEEP !!!)
CORNEAL DISSECTION
PNEUMATIC:
Learning Curve
Non Reproducible
(30-90%)
20/20 is the RULE
(DM or Duas Layer)
CORNEAL DISSECTION
MICROKERATOME:
Easy Use and Relatively
Reproducible
Relatively Imprecise
Interface of Excellent
Optical Quality (20/20
CORNEAL DISSECTION
FEMTOSECOND LASER:
Expensive but
Precise
Optical Quality
of Interface
???
CORNEAL DISSECTION
FEMTOSECOND LASER:
Does NOT
Cut through
Opacities
!!!
NEW KERATOPLASTY
Corneal
Disease
Healthy
Endothelium
Diseased
Endothelium
Anterior
LK
(Mushroom)
Posterior
LK
(PK)
ANTERIOR LK
A STAGED STRATEGY
1/3 ANT. STROMA
(Healthy Endothelium)
SALK
(SUPERFICIAL
( 200 m)
ANTERIOR LK
A STAGED STRATEGY
2/3 ANT. STROMA
(Healthy Endothelium)
DALK
(DEEP ANTERIOR LK)
( 350-400 m)
ANTERIOR LK
A STAGED STRATEGY
100% STROMA
(Healthy Endothelium)
BIG BUBBLE
ANTERIOR LK
PREOP OCT
CHOICE OF PROCEDURE
ANTERIOR LK
PREOP OCT
CHOICE OF PROCEDURE
ANTERIOR LK
PREOP OCT
CHOICE OF PROCEDURE
ANTERIOR LK
SALK Compares to LASIK
+/- Sutures
1-Month Healing
Minimal Postop
Refr. Error
ANTERIOR LK
DALK Compares to PK
Sutures
1-Year Healing
20% High
Astigmatism
SUPERFICIAL ANTERIOR
LK (SALK)
= 90-130 m
SALK
3 years post-SALK
BSCVA = 20/20
Ref. = +3.00 sph. -2.00 cyl. @ 170
SALK
HSV Keratitis pre SALK
UCVA = 20/200
BSCVA = 20/200
HSV Keratitis 1 year s/p
SALK
UCVA = 20/100
BSCVA = 20/25
IRREGULAR
ASTIGMATISM
DEEP ANTERIOR LK
(DALK)
= 300-350 m
DALK
Lattice Dystrophy
preop VA = 20/50
Lattice Dystrophy
postop VA = 20/20
DALK
Lattice Dystrophy
pre DALK
Lattice Dystrophy
post DALK
BIG BUBBLE
(DALK)
= w/o Endoth.
IRREGULAR
ASTIGMATISM
DALK
Keratoconus
VA = 20/400
2 Years postDALK
DALK
Adhesions
Risk of Perforation
Descemet
Involvment
Opacity of
Residual Bed
Infl.
Infiltrate
Scar
Tissue
CONVENTIONAL PK
SMALL Grafts
LARGE Grafts
LOWER
Rejection Rate
HIGHER
Rejection Rate
HIGHER
Refractive Error
LOWER
Refractive Error
CONVENTIONAL PK
ENDOTHELIAL MIGRATION
Imaizumi T. (1990)
Groh MJ et al. (1999, 2000)
ENDOTHELIAL MIGRATION
FROM HIGHER TO
LOWER DENSITY
FROM GRAFT
INTO HOST (ABK,
PBK, FUCHS, etc.)
ENDOTHELIAL MIGRATION
FROM HIGHER TO
LOWER DENSITY
FROM HOST
INTO GRAFT (KC,
INFECTIONS, etc.)
MUSHROOM PK
Concept:Minimal Endothelial
Replacement
S=r
2
r = 3 mm
S = 32
r = 6 mm
S = 62
MUSHROOM PK
AREA OF RESIDUAL HEALTHY
ENDOTHELIUM
(62 ) (32 )
36 9
27 mm2
>75% !!!
MUSHROOM PK
ANTERIOR LK = HAT
(thickness = 250 m; diameter = 9-9.5 mm)
POSTERIOR LK = STEM
(thickness = 300 m; diameter = 5-6 mm)
MUSHROOM PK
FULL-THICKNESS
OPACITY
HEALTHY
ENDOTHEL.
CORNEA OF
UNEVEN
THICKNESS
(NEOVESSELS !!!)
ANTERIOR LK
A STAGED STRATEGY
100% STROMA + SCAR
(Healthy Endothelium)
MUSHROOM
PK
2-Piece MUSHROOM PK
ADVANTAGES:
LK Wound Healing
PK Effect
Optimal Refraction
Endothelial Spare
GRAFT SURVIVAL
Survival Analysis (K-M)
1y
2y
5y
95.3%
98.5% 96.3%
96.1% 93.9%
Overall98.3% 97.5%
Low Risk 100%
High Risk 96.1%
GRAFT SURVIVAL
Rejection Rate
High Risk 2/71
(2.8%)
Low Risk 4/109
(3.7%)
GRAFT SURVIVAL
Endothelial Rejection
GRAFT SURVIVAL
Endothelial Repopulation?
Day 0
Month 6
Month 12
MUSHROOM PK
CASE 1 (2004):
35-year-old Male
s/p Perforating Injury OS
10 months postop
UCVA = 20/200
BSCVA = 20/20
(-2.50 sf 1.00 cil @ 20)
MUSHROOM PK
CASE 2 (2008):
39-year-old Female
s/p Amoebic K OS
5 Years postop
UCVA = 20/200
BSCVA = 20/22.5
(-3.50 sf 4.00 cil @ 70)
MUSHROOM PK
CASE 3 (2007):
9-year-old girs
s/p HZK OS
4 Years postop
UCVA = 20/40
BSCVA = 20/25
(+0.50 sf 3.50 cil @ 40)
MUSHROOM PK
CASE 4 (2010):
16-year-old Male
s/p HSK OS
2 Years postop
UCVA = 20/50
BSCVA = 20/20
(-1.50 sf 2.75 cil @ 155)
CONVENTIONAL PK
SURGERY
Primary Corneal Edema
(Fuchs)
Post-Surgical BK
PK Failure
Endothelial Dystrophies
ICE Syndrome
Others
POSTERIOR LK
Tillet
(50s)
Barraquer
(60s)
ANTERIOR ONLAY LK
Kaufman 1980
Epikeratophakia for Aphakia
LAMELLAR
KERATOPLASTY
SUBSTITUTIVE
(INLAY)
ADDITIVE
(ONLAY)
1
2
3
4
POSTERIOR ONLAY LK
(ENDOKERATOPLASTY)
ENDOKERATOPLASTY: A NEW SURGICAL TECHNIQUE
FOR THE REPLACEMENT OF DISEASED CORNEAL ENDOTHELIUM
1
c
CONCLUSION
RESULTS
Despite the technical difficulty of handling very thin corneas like the
rabbit ones, it was possible in all animals used in this experiment study
to perform endokeratoplasty as theoretically designed. By two weeks
all of the corneas with endokeratoplasty-lenticules demonstrated
substantial clearing, while the scraped cornea did not. On histology
only a small proportion of the endothelial cells were present on the
donor lenticules.
Fig. 3: Postoperative results: A) Rabbit cornea with endokeratoplasty-lenticule fixated with four 10-0 prolene mattress sutures.
The slit-lamp examination reveals tight contact between donor
lenticule and recipient cornea as well as only moderate corneal
edema; B) Control cornea exhibiting marked edema in the
central area denudes of the endothelium.
This study was supported in part by a grant from the Medical Eye Bank of Western Pennsylvania, Pittsburgh, Pennsylvania.
Busin et al.
OPHTHALMOLOGY, 1996 (Suppl.)
SUTURELESS POSTERIOR
INLAY
LK
(D)eep (L)amellar
(E)ndothelial (K)eratoplasty
SUTURELESS POSTERIOR
ONLAY
LK
(D)escemet (S)tripping
(E)ndothelial (K)eratoplasty
DSEK (2002)
ONLAY
(D)escemet (S)tripping
(A)utomated (E)ndothelial
(K)eratoplasty
SUTURELESS POSTERIOR
DSAEK (2004)
LK
SUTURELESS POSTERIOR
INLAY
LK
(D)escemet (M)embrane
(E)ndothelial (K)eratoplasty
DMEK (2006)
SUTURELESS POSTERIOR
ONLAY
LK
DSAEK
TODAY
GOLD STANDARD
FOR SURGICAL
TREATMENT OF
ENDOTHELIAL
DECOMPENSATION
USA
1.429
2005
6.122
2006
14.159
2007
17.468
2008
18.221
2009
19.159
2010
2010 statistical report
ITALY
1000/5.300 (2010)
DSAEK COMPLICATIONS
Detachment Rate
Average = 14.5% (0-82%)
DSAEK = <5%*
UT
= <1%*
*DSAEK Personal Data
*UT-DSAEK Personal Data
DSAEK COMPLICATIONS
A DOUBLE
CHAMBER
MAY BE A
VERY
SUBTLE
FINDING !!!
DSAEK COMPLICATIONS
GRAFT ATTACHMENT
NO AQUEOUS IN THE
INTERFACE !!!
DSAEK COMPLICATIONS
GRAFT ATTACHMENT
Air Tamponade
(Squeezes out
Aqueous)
Prices Venting
Incisions
(Evacuate Aqueous)
DSAEKGRAFT ATTACHMENT
GRAFT ATTACHMENT
IDEAL KERATOPLASTY
Closed System
Fast Visual
Rehabilitation
Better UCVA and
BSCVA
Reduced Astigmatism/
Other Aberrations
Rare Complications
DSAEK PROS
RARE LATE
COMPLICATIONS !!!
INTACT INNERVATION
IMMUNOLOGIC PREVILEGE
NO SUTURE RELATED
COMPLICATIONS
DMEK vs DSAEK
Patients with BSCVA 1.0
DSAEK = 0% to 33%*
DMEK
= 20% to 45%
DMEK vs DSAEK
DSAEK = Hyperopic
Shift (1 D)
DMEK
= Neutral
DSAEK vs DMEK
Graft Rejection Rate in Fuchs
DSAEK = 2% - 18%
DMEK
= < 1% (13%)
DMEK vs DSAEK
MEMBRANE
Vs
LAMELLA
DMEK
IDEAL TECHNIQUE
Easy & Reproducible
No Waste of Tissue
Allow Alternatives
(DSAEK!!!)
DMEK
SURGICAL CHALLENGES
Preparation
Delivery into AC
Positioning
Attachment
DMEK
Waste of Tissue
up to 16%
Detachment Rate
up to 63%
Primary Graft
Failure
up to 8%
DMEK
4 DAYS POSTOP
EK IN THE USA
In 2011:
DSAEK
n 21,000
DMEK
n = 343
EK IN THE USA
In 2012:
DSAEK
n 25,000
DMEK
n = 744
EK IN THE USA
In 2013:
DSAEK
n = 23,465
DMEK
n = 1,522
EK IN THE USA
In 2014:
DSAEK
n = 23,100
DMEK
n = 2,865
DMEK
IDEAL CASE:
FUCHS
&
INTACT PC
DSAEK
SAFETY
DSAEK vs DMEK
POOR VISUALIZATION
DSAEK vs DMEK
DANGER OF LUXATION
DSAEK vs DMEK
DSAEK & ACIOL
DSAEK vs DMEK
DSAEK vs DMEK
DSAEK & ACIOL in PC
DMEK CONS
HIGH SURGICAL SKILLS
REQUIRED
AVERAGE SURGEON!!!)
(NO
DMEK CONS
NOT FOR EVERY
SURGEON !!!
NOT FOR EVERY
EYE !!!
DMEK vs DSAEK
IDEAL GRAFT FOR EK
Thin Endothelial Grafts
(DMEK-Like)
Ease of Preparation
(Microkeratome)
Ease of Delivery
(DSAEKLike)
DSAEK vs DMEK
IS THE
INTERFACE THE
TRUE PROBLEM
???
RECENT
DSAEK Grafts
Thinner Than
131 m
Lead to
Improved Visual
Outcomes up to
75% VA 20/20 (Neff
SUTURELESS POSTERIOR
ONLAY
LK
UT-DSAEK
SURGICAL TECHNIQUE
Same As DSAEK
Except for:
Graft
Preparation
Graft
Delivery
Prospective Study
(Ophthalmology, June 2013)
ISSUE # 1
BSCVA 10/10
in Eyes with
10/10 Potential
Eyes
39%
41%
8/10= 20/25
71%
80%
6/10= 20/30
95%
98%
ECL
34%
36%
ISSUE # 2
SPEED OF
VISUAL
RECOVERY
BSCVA preop
DMEK
0.51 0.44
logmar
3/10
BSCVA preop
UT-DSAEK
0.76
0.49 logmar
1.5/10
BSCVA preop
DMEK
0.51 0.44
logmar
3/10
BSCVA preop
PHAKIC
UTDSAEK
0.55 0.43
logmar
ISSUE # 2
Why not 100%
BSCVA
of 10/10 ???
DSAEK/UT-DSAEK/DMEK
POSSIBLE CAUSES
INTERFACE ?
GRAFT THICKNESS ?
HOA ?
RECIPIENT CORNEA !
DMEK
Patients with BSCVA 10/10
10/10
<10/10
= 20% to 45%
= 55% to 80%
DSAEK/UT-DSAEK/DMEK
POSSIBLE CAUSES
INTERFACE ?
GRAFT THICKNESS ?
HOA ?
RECIPIENT CORNEA !
DSAEK/UT-DSAEK/DMEK
INTERFACE/THICKNESS
6 mos Postop
UT-DSAEK
BSCVA = 9/10
CGT= 61 m
DSAEK/UT-DSAEK/DMEK
INTERFACE/THICKNESS
12 mos Postop
DSAEK
BSCVA = 4/10
CGT= 127 m
DSAEK/UT-DSAEK/DMEK
INTERFACE/THICKNESS
9 mos Postop
re-DSAEK
(UT-DSAEK)
BSCVA = 10/10
CGT= 61 m
DMEK/DSAEK/PK
Corneal higher-order aberrations after
Descemet's membrane endothelial
keratoplasty.
Rudolph M1, Laaser K, Bachmann
BO, Cursiefen C, Epstein D, Kruse FE.
Ophthalmology. 2012 Mar;119(3):528-35
DSAEK/UT-DSAEK/DMEK
251
92
95
DSAEK/UT-DSAEK/DMEK
92
95
160
318
DSAEK/UT-DSAEK/DMEK
IMPROPER
PUNCHING
!!!
DSAEK/UT-DSAEK/DMEK
DSAEK/UT-DSAEK/DMEK
DSAEK/UT-DSAEK/DMEK
DSAEK/UT-DSAEK/DMEK
BSCVA
UT-DSAEK >> DSAEK !!!
UT-DSAEK DMEK !!!
(Historical Controls)
DSAEK/UT-DSAEK/DMEK
9 mos Postop
DSAEK
VA = 10/10
204
197
UT-DSAEK/DSAEK
OD UT-DSAEK
VA = 12/10
OS DSAEK
VA = 6/10
UT-DSAEK/DSAEK
OD UT-DSAEK VA = 12/10
OS DSAEK
VA = 6/10
UT-DSAEK/DMEK
OD DMEK
VA = 10/10
OS UT-DSAEK
VA = 16/10
UT-DSAEK/DMEK
OD DMEK
VA = 10/10
OS UT-DSAEK VA = 16/10
UT-DSAEK/DMEK
UT-DSAEK vs DMEK
=
PD-DALK vs DALK
DSAEK/UT-DSAEK/DMEK
DSAEK/UT-DSAEK/DMEK
RECIPIENT CORNEA
DIFFERENT PREOPERATIVE
CONDITION !!!
ISSUE # 3
IMMUNOLOGIC
REJECTION
POSTOPERATIVE TREATMENT
DSAEK/UT-DSAEK/DMEK
Cumulative Probability (K-M)
DSAEK*
1 Year
UT
DMEK
6%
2.5%
1%
2 Years 10%
2.5%
1%
COMPLICATIONS
UT-DSAEK DMEK*
Air Re-injection
3%
17-77%
Primary Failure
1%
9%
Rejection1yr
Tissue Loss
2.5%
1%
0-13%
0-13%
CONCLUSIONS
DMEK
vs
GOOD
(UT)DSAEK !!!
CONCLUSIONS
Outcomes of
UTDSAEK Compare
Favorably with Those
of Conventional
DSAEK
and
Do Not Differ
Substantially from
Those of DMEK
54
50 UT-DSAEK
204
365
DSAEK
32
52
DMEK
UT-DSAEK/DMEK
DMEK 2.0
UT-DSAEK/DMEK
DMEK 2.0
Standardization
Substantial
Advantages
UT-DSAEK/DMEK
DMEK 2.0
Simplify
Reduce Trauma
Eliminate Primary
Failure
(UPSIDE DOWN!!!)
UT-DSAEK/DMEK
DMEK 2.0
TOTAL
CONTROL
!
!!
DMEK 2.0
DMEK 2.0
DMEK 2.0
Descemet
Endothelium
DMEK 2.0
DMEK 2.0
DMEK 2.0
DMEK 2.0
DMEK 2.0
Results 6 Mos Post-DMEK
20 Consecutive Uneventful
DMEK
VA20/25 in
16/20 Eyes
DMEK 2.0
Forceps Trauma
50 m
DMEK 2.0
Results 6 Mos Post-DMEK
20 Consecutive Uneventful
DMEK
ECL 12% !!!
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