New Triple Procedure: Descemet’s Stripping and Automated Endothelial Keratoplasty Combined with Phacoemulsification and Intraocular Lens Implantation

Analysis of posterior donor corneal parameters 1 year after Descemet stripping automated endothelial keratoplasty (DSAEK) triple procedure

“…Since the vast majority of reports on refractive outcome have measured a variable hyperopic shift of approximately +1.00 D or more, as a common occurrence after DSAEK [2,5,8,22], surgeons actually used to perform combined DSAEK and phacoemulsification targeting the IOL refractive power more myopic than intended, based on empirical data of their own early experience. On the other hand, such an approach can yield to error due to the variability in amount of hyperopic shift between patients: donor lenticule parameters have been hypothesized to be the main factors of postoperative refractive inaccuracy [11][12][13][14][15].…”

“…One may clearly note how the center of the graft is thinner than the periphery in manifest refraction [8,10]. DSAEK with sclero-corneal tunnel incision was confirmed to be a surface topographic power neutral procedure, further without any increase in corneal or refractive astigmatism postoperatively.…”

“…In both cases, results of DSAEK from many centers have shown how the technique yields rapid and significant improvement in vision with no increase in endothelial cell loss or postoperative complications in comparison with former EK procedures [4][5][6][7]. On the other hand, the postoperative refractive outcome is not yet as accurate as expected: there has been, in general, reported an average hyperopic shift of approximately 1.00 diopter (D) or even more [4,5,[8][9][10]. Since DSAEK can be performed in patients with clinically significant cataract that need concurrent phacoemulsification, it becomes desirable to identify factors that may affect predictability of surgical outcomes.…”

The visual and refractive outcomes of combined and sequential penetrating keratoplasty, cataract extraction, and intraocular lens insertion

“…[5][6][7][8]12,18,21,43 The latter technique may not be acceptable for patients who are elderly and have other health problems, or cannot tolerate a second procedure. Newer triple procedure surgery involving endothelial keratoplasty 44,45 combined with phacoemulsification and IOL implantation have demonstrated good predictability in postoperative refractive error.…”

“…Sequential surgery has been associated with increased graft endothelial cell count loss, and graft failure as high as 13-21%. 34,35,45,[48][49][50][51] However, improved surgical techniques and the use of intraocular viscoelastic agents may mean that secondary surgery can be performed with greater safety as suggested by a lower failure rate of 0-16% in more recent studies. 13,29,30,34,35,43,[49][50][51][52] Other authors have found no higher risk of graft failure from sequential surgery over triple procedure surgery, 13,28,35,46 with no significant difference in the percentage of endothelial cell loss 27,28 or increase in graft rejection episodes.…”