Safety of DSAEK in Patients With Previous Glaucoma Filtering Surgery

Abstract

Purpose-To report four cases of Descemet stripping automated endothelial keratoplasty (DSAEK) in the presence of previous glaucoma filtering surgery. Design-Observational case series.Methods-Review of clinical data of four patients who underwent DSAEK successfully performed in the presence of previous glaucoma filtering surgery with endothelial survival rates comparable with larger series previously published and good postoperative IOP control.Results-The endothelial cell loss was 36% and 39% mean cell loss at 6 months and 1 year postoperatively. The intraocular pressure remained well controlled within target levels in all patients. No complications were reported in any of the 4 cases.Conclusions-Corneal endothelial failure can be successfully managed with DSAEK in glaucoma patients with previous filtering surgery with good endothelial survival rates and good IOP control. KeywordsDSAEK; endothelial failure; glaucoma Descemet stripping automated endothelial keratoplasty (DSAEK) has recently gained popularity as the procedure of choice in the management of corneal endothelial disease. The advantages of DSAEK over penetrating keratoplasty (PK) include the avoidance of open sky surgery, minimal induced post-surgical astigmatism and faster visual rehabilitation (1,2). Theoretically, DSAEK performed in patients with history of previous filtering procedures may reduce the rate of intraoperative complications previously reported after conventional PK. However the presence of a fistula in these eyes may not allow the intraocular pressure (IOP) to reach the level necessary to achieve attachment of the donor graft to the posterior corneal surface. We describe four cases of DSAEK successfully performed in the presence of previous glaucoma filtering surgery with endothelial survival rates comparable with larger series previously published (4,5) and good postoperative IOP control.Correspondence: Salomon Esquenazi MD, LSU Eye and Neuroscience Center, 2020 Gravier Street, Suite D, 8th Floor, New Orleans, LA 70112, Phone: 305-733-9799, sesque@lsuhsc.edu. The authors have no financial interest in any product mentioned in this manuscript. Both authors had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. NIH Public Access Report of CasesAll patients presenting to our institution with pseudophakic bullous keratopathy in the presence of normal IOP following glaucoma surgery were included. Average age was 67 years. Previous glaucoma surgery included trabeculectomy (1 case) and glaucoma shunts (3 cases). All patients were pseudophakic. Surgery was uneventful and graft attachment was achieved in all cases. Postoperatively IOP remained within target levels in all cases with antiglaucoma topical treatment required in 2 cases. No postoperative complications were observed particularly early hypotony or graft dislocations. Table 1 illustrates the preoperative data and the 6 month and 12 month IOP values and endothelial cell density (ECD) for each patien...

Combined Deep Sclerectomy and Descemet Stripping Automated Endothelial Keratoplasty

“…2,31 Consequently, such an option, consisting of PK and trabeculectomy and/or glaucoma drainage device, 24 has been recently less reported than performing glaucoma surgery before corneal surgery. [4][5][6][7]11,13,27,29,31 Nevertheless, the combined procedure might be the preferable approach, because it may either limit the bleb or graft failures that occur with consecutive interventions, or induce less surgical trauma, less social costs and a shorter visual and working recovery time. 18 In this context, DSAEK is the preferred keratoplasty because of its low complication rate.…”

“…Theoretically, there are 3 possible alternatives: (1) to perform glaucoma surgery followed by corneal surgery after a variable time span, [2][3][4][5][6][7]18,19 (2) to perform corneal surgery followed by glaucoma surgery, 20 and (3) to perform a combined cornea-glaucoma surgery. 14,18,19,[21][22][23][24] In practice, different clinical and technical problems determine the choice among these surgical options.…”

“…4,13 Other reports have found limited graft decentration and dislocation rates, good endothelial survival and visual outcomes during the early postoperative period of DSAEK in eyes with prior trabeculectomies or glaucoma shunts. 3,5,11 Nevertheless, a higher proportion of graft failures was observed in these patients than in those with no glaucoma surgery. 7,12 The treatment approach in 2 sequential stages globally implies greater inconveniences, in treatment time, risks, and expenses, than a single intervention, even lengthening the visual recovery time.…”

“…10 Few articles have evaluated the effects of DSAEK on both pressure control and graft clarity in glaucoma-affected patients. [3][4][5][11][12][13] Some investigators have reported that these patients are at an elevated risk of developing IOP rise and related glaucoma complications after DSAEK. 4,13 Other reports have found limited graft decentration and dislocation rates, good endothelial survival and visual outcomes during the early postoperative period of DSAEK in eyes with prior trabeculectomies or glaucoma shunts.…”

“…However, there is no consensus about the ideal sequence of glaucoma surgery and keratoplasty to enhance IOP control and corneal graft survival. To date, the most frequently used approach consists of performing trabeculectomy or glaucoma drainage devices followed by Descemet stripping automated endothelial keratoplasty (DSAEK), [2][3][4][5][6][7] which has lately become the most practiced surgical procedure for endothelial keratopathy. 8,9 Indeed, it allows for faster visual rehabilitation because of a lower incidence of postoperative inflammation and graft rejection, with fewer sutures than required for conventional penetrating keratoplasty (PK).…”