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Year : 2017  |  Volume : 24  |  Issue : 2  |  Page : 87-90  

Outcome of descemet stripping automated endothelial keratoplasty in failed penetrating keratoplasty

Department of Surgery (Ophthalmology), College of Medicine, King Khalid University, Abha; Department of Ophthalmology, Division of Surgery, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

Date of Web Publication7-Sep-2017

Correspondence Address:
Abdulrahman S Khairallah
P.O. Box: 25186, Abha, Postal Code: 61466
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/meajo.MEAJO_248_15

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Purpose: The purpose of this study was to report the outcomes of descemet stripping automated endothelial keratoplasty (DSAEK) surgeries in eyes with failed penetrating keratoplasty (PKP).
Methods: This was a retrospective, noncomparative, descriptive case series. Patients who underwent DSAEK following PKP from January 2007 to December 2012 were reviewed. Data were collected on best-corrected visual acuity (BCVA) before and 1 week, 1 month, 3 months, 6 months, 1 year, and 2 years following DSAEK. Intra- and post-operative complications, changes in intraocular pressure (IOP) were also documented. Demographics were associated with the visual outcomes.
Results: Fifteen eyes of 15 patients with failed PKP comprised the study group. BCVA improved by 2 or more lines at 6 months after DSAEK in ten (66.6%) eyes. In the five eyes that did not experience an increase in BCVA, four had complications; detached lenticule (2 eyes), rejection (1 eye), and dislocation of the graft (1 eye). One eye had ocular comorbidity causing poor vision. The mean IOP at 12–15 weeks postoperatively was 17.4 ± 6.8 mmHg.
Conclusion: DSAEK for failed PKP resulted in improved vision in two-third of cases. Selection of cases for this repeat surgery seems to be a key in successful outcomes.

Keywords: Corneal transplant, descemet stripping automated endothelial keratoplasty, failed graft, penetrating keratoplasty

How to cite this article:
Khairallah AS. Outcome of descemet stripping automated endothelial keratoplasty in failed penetrating keratoplasty. Middle East Afr J Ophthalmol 2017;24:87-90

How to cite this URL:
Khairallah AS. Outcome of descemet stripping automated endothelial keratoplasty in failed penetrating keratoplasty. Middle East Afr J Ophthalmol [serial online] 2017 [cited 2022 Aug 16];24:87-90. Available from: http://www.meajo.org/text.asp?2017/24/2/87/214175

   Introduction Top

Historically, penetrating keratoplasty (PKP) was the standard treatment for endothelial diseases such as Fuchs endothelial dystrophy and aphakic and pseudophakic bullous keratopathy.[1],[2] Descemet stripping automated endothelial keratoplasty (DSAEK) was introduced as an alternative procedure for endothelial diseases with debatable benefits over PKP.[3]

The advantages of DSAEK over PKP include faster visual recovery and better uncorrected and spectacle-corrected visual acuity.[4] Due to the absence of sutures, there is less postoperative astigmatism and a more stable refraction compared to PKP.[5]

Price and Price documented their initial experiences with DSAEK for the treatment of failed grafts.[6] Subsequently, DSAEK was widely adopted to manage failed grafts.[7],[8],[9],[10] To the best of our knowledge, the outcomes of DSAEK for the treatment of failed grafts in the Middle East have not been published.

We evaluated the profile and outcomes of DSAEK for failed PKP at a tertiary eye hospital in central Saudi Arabia.

   Methods Top

The institutional research board of King Khaled Eye Specialist Hospital (KKESH), Riyadh, Saudi Arabia, approved this retrospective review of cases. The consent of participants was waived because this was a chart review study. Patient anonymity was maintained for all aspects of this study. All patients were included who had a failed PKP and underwent subsequent DSAEK between January 2007 and December 2012 at KKESH. Patients who did not complete at least 3 months of follow-up were excluded from the study.

Three cornea surgeons were involved in surgery. The preoperative variables collected from the patient charts were age, sex, eye involved, indication for the primary PKP, medications given to treat graft failure, and the interval between PKP and proposed DSAEK surgery. All patients underwent comprehensive ophthalmic examinations. Before surgery, the best-corrected visual acuity (BCVA) was tested using pinhole and a Snellen distance chart held at 3 m distance. The anterior segment was assessed using with slit-lamp biomicroscopy (Topcon Corp., Tokyo, Japan). The corneal and anterior segment parameters were measured using Pentacam (Oculus GmBh, Wetzlar, Germany). The intraocular pressure (IOP) was measured with applanation tonometry attached to a slit lamp. To note lens and posterior segment details, we used +78 D and +90 D retinal lenses (Volk Optical Inc., Mentor, OH, USA). The indication and causes of failed PKP were noted.

The DSAEK surgery used for failed grafts has been previously described.[11] Briefly, the main steps included harvesting the graft, removal of diseased tissue through anterior segment entry port, implanting the graft, and positioning the graft. In selective cases, air was injected to keep the graft in position for a few hours postoperatively.

The patients were reexamined on day 1, 1 week, 3 months, and 6 months. They are also requested to present for follow-up 1 year and 2 years after surgery. BCVA, IOP, corneal status, and ocular complications were noted during each follow-up.

The success of DSAEK was defined as improvement of two lines of BCVA at 6 months postoperatively in comparison to the BCVA before DSAEK.

The data were collected on an Excel® (Microsoft Corp., Redmond, WA, USA) spreadsheet. It was then transferred to Statistical Package for Social Studies (version 16) (IBM Corp., Armonk, New York, USA). The frequencies and percentage proportions were calculated for BCVA. Since the sample was small, all continuous variables were analyzed using nonparametric methods and presented as median, 25% percentile, minimum, and maximum values.

   Results Top

This study sample was comprised 15 eyes of 15 patients with failed PKP who underwent DSAEK. There were 7 males and 11 left eyes. The median age was 66 years (25% percentile, 56 years; range, 23–79 years). The causes for primary PKP were pseudophakic bullous keratopathy in 6 eyes, keratoconus in 1 eye, corneal opacity in 2 eyes, and other cause in 2 eyes. The underlying cause for PKP in 4 eyes was not documented. The number of ocular surgeries before DSAEK was 1 surgery in 6 eyes, 2 surgeries in 4 eyes, 3 surgeries in 2 eyes, and more than 3 surgeries in 3 eyes. One patient had diabetes and two had hypertension. Five eyes had ocular comorbidity (glaucoma 3 eyes, 2 eyes early cataract). The median interval between previous PKP and planned DSAEK was 4.9 years (25% percentile 1.8 years; range, 3.5–25 years).

Before DSAEK, one eye had BCVA of 20/60 and one eye had BCVA 20/100 and all other eyes had vision <20/200. The mean IOP was 16.9 ± 5.5 mmHg.

[Table 1] presents the BCVA before and at different follow-up visits of all eyes. In five eyes with BCVA <20/200 at 6 months following DSAEK, the preoperative vision was <20/400. Four of these eyes had complication and one eye had an ocular comorbidity. In ten (66.6%) eyes, the BCVA improved by 2 or more lines, 6 months after DSAEK.
Table 1: Comparison of best-corrected visual acuity before and after descemet stripping automated endothelial keratoplasty in failed penetrating keratoplasty

Click here to view

The mean IOP at 12–15 weeks following DSAEK was 17.4 ± 6.8 mmHg. Patients with previously diagnosed glaucoma as a comorbidity continued to use antiglaucoma medications postoperatively. Complications at 6 months after DSAEK included detached lenticule (2 eyes), rejection (1 eye), and dislocation of the graft (1 eye).

   Discussion Top

In this case series, the outcomes of DSAEK for previously failed PKP provided functional visual outcomes in two-third of cases. However, ease of surgery, lack of sutures, and a patient-friendly convalescence period make DSAEK a good alternative.

The visual outcomes in our study are lower than similar studies comparing DSAEK as a 2nd surgery after failed PKP. For example, Anshu et al.[12] reported that endothelial keratoplasty had a better graft survival and earlier visual recovery compared to our study.

A study from Saudi Arabia evaluating 10 cases of DSAEK as the primary surgery to manage corneal pathologies such as Fuchs endothelial keratopathy and bullous keratopathy, reported visual outcomes of 20/20–20/50.[13]

Stuart[11] suggested that selection of cases for DSAEK is of paramount importance for successful outcomes. Perhaps, this could be the underlying cause of the poor visual outcomes in our study. Cases of poor outcomes of PKP had undergone multiple surgeries in the past in as many as 50% of cases.[11] There is a greater likelihood of poor prognosis in such cases. The risk factors for poor visual outcomes after DSAEK for previous PKP would be a topic of considerable interest for the future studies.

IOP following DSAEK can vary out to 3 months postoperatively and then stabilize. However, in eyes with Fuchs endothelial keratopathy that underwent DSAEK, there was no statistical increase in IOP at 1 year postoperatively.[14] In our study, none of the eyes had a significant rise in IOP. Two eyes with glaucoma that continue antiglaucoma medications postoperatively maintained stable IOP following DSAEK.

Loss to follow-up after 6 months was a limitation in our study. If we assume that all cases who did not seek 1-year follow-up had poor visual outcome, the success rate may be even lower. In contrast, if we assume that all cases had satisfactory vision, visual outcomes of DSAEK could be much higher our study.

   Conclusions Top

Short-term outcomes of DSAEK in failed PKP indicate improved vision in two-thirds of cases. Selection of cases for this repeat surgery seems to be a key in successful outcomes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Siganos CS, Tsiklis NS, Miltsakakis DG, Georgiadis NS, Georgiadou IN, Kymionis GD, et al. Changing indications for penetrating keratoplasty in Greece, 1982-2006: A multicenter study. Cornea 2010;29:372-4.  Back to cited text no. 1
Joshi SA, Jagdale SS, More PD, Deshpande M. Outcome of optical penetrating keratoplasties at a tertiary care eye institute in Western India. Indian J Ophthalmol 2012;60:15-21.  Back to cited text no. 2
[PUBMED]  [Full text]  
Nanavaty MA, Wang X, Shortt AJ. Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy. Cochrane Database Syst Rev 2014:CD008420. doi: 10.1002/14651858.CD008420.pub3.  Back to cited text no. 3
Bahar I, Kaiserman I, Levinger E, Sansanayudh W, Slomovic AR, Rootman DS. Retrospective contralateral study comparing descemet stripping automated endothelial keratoplasty with penetrating keratoplasty. Cornea 2009;28:485-8.  Back to cited text no. 4
Bahar I, Kaiserman I, McAllum P, Slomovic A, Rootman D. Comparison of posterior lamellar keratoplasty techniques to penetrating keratoplasty. Ophthalmology 2008;115:1525-33.  Back to cited text no. 5
Price FW Jr., Price MO. Endothelial keratoplasty to restore clarity to a failed penetrating graft. Cornea 2006;25:895-9.  Back to cited text no. 6
Covert DJ, Koenig SB. Descemet stripping and automated endothelial keratoplasty (DSAEK) in eyes with failed penetrating keratoplasty. Cornea 2007;26:692-6.  Back to cited text no. 7
Lee BS, Stark WJ, Jun AS. Descemet-stripping automated endothelial keratoplasty: A successful alternative to repeat penetrating keratoplasty. Clin Exp Ophthalmol 2011;39:195-200.  Back to cited text no. 8
Straiko MD, Terry MA, Shamie N. Descemet stripping automated endothelial keratoplasty under failed penetrating keratoplasty: A surgical strategy to minimize complications. Am J Ophthalmol 2011;151:233-7.e2.  Back to cited text no. 9
Clements JL, Bouchard CS, Lee WB, Dunn SP, Mannis MJ, Reidy JJ, et al. Retrospective review of graft dislocation rate associated with descemet stripping automated endothelial keratoplasty after primary failed penetrating keratoplasty. Cornea 2011;30:414-8.  Back to cited text no. 10
Stuart A. Performing DSAEK: A Step-by-Step Guide. EyeNet Magazine; 2014. http://www.aao.org/eyenet/article/performing-dsaek-stepbystep-guide?january-2014. [Last accessed on 2015 Aug 29].  Back to cited text no. 11
Anshu A, Price MO, Price FW Jr. Descemet's stripping endothelial keratoplasty under failed penetrating keratoplasty: Visual rehabilitation and graft survival rate. Ophthalmology 2011;118:2155-60.  Back to cited text no. 12
Hantera MM, El Sayyed F, Al Arfaj KM. Initial experience with Descemet stripping automated endothelial keratoplasty in Saudi Arabia. Oman J Ophthalmol 2012;5:10-5.  Back to cited text no. 13
[PUBMED]  [Full text]  
Espana EM, Robertson ZM, Huang B. Intraocular pressure changes following Descemet's stripping with endothelial keratoplasty. Graefes Arch Clin Exp Ophthalmol 2010;248:237-42.  Back to cited text no. 14


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