Surgical alternatives to penetrating keratoplasty II: endothelial keratoplasty

Abstract

Penetrating keratoplasty (PK) became the standard of care for optical and tectonic rehabilitation of corneal blindness and visual impairment in the second half of the twentieth century. Posterior corneal disorders or endotheliopathies are the reason for one-third to one-half of all corneal transplants today in the US. Any procedure that replaces the endothelium ideally should accomplish the following results: (1) a smooth surface topography without significant change in astigmatism, (2) a highly predictable corneal power, (3) a healthy donor endothelium that resolves all edema, (4) a tectonically stable globe, safe from injury and infection, and (5) an optically pure cornea. Although PK consistently can achieve results 3 and 5 above, the other goals of stable topography, predictable corneal power and tectonic stability, have remained elusive despite our best efforts at ingenious suturing and trephination techniques. Endothelial keratoplasty (EK) is a new surgical procedure designed to replace diseased corneal endothelium with healthy donor endothelium through either a lamellar corneal flap approach or through limbal scleral incision, leaving the surface of the recipient cornea untouched by surface corneal sutures. This manuscript evaluates the impact and future of EK in ophthalmology.

Comparison of Bifold Forceps and Cartridge Injector Suture Pull-through Insertion Techniques for Descemet Stripping Automated Endothelial Keratoplasty

“…[5][6][7] This problem is further aggravated by traumatic loss of the endothelium during forceps insertion of the delicate tissue, especially if the tissue slips and requires repositioning. Crush artifact associated with grasping the tissue with forceps may also damage donor endothelium, especially if single-point fixation forceps are not used.…”

“…3,4 This procedure has been rapidly adopted by corneal surgeons because it generates shorter operative times, faster visual recovery, more favorable refractive outcomes, and a more stable globe compared with PKP. [5][6][7] The insertion of the donor lenticule into the anterior chamber during DSAEK may be associated with traumatic endothelial cell loss. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Whereas endothelial cell loss may be manifested by primary graft failure and poor lenticular attachment in the early postoperative course and subsequently, by late endothelial failure, loss of graft clarity, and visual deterioration, the development of insertion techniques that minimize initial loss has been an important component of the evolution of DSAEK surgical techniques.…”

Glaucoma therapy escalation in eyes with pseudophakic corneal edema after penetrating keratoplasty and Descemet’s stripping automated endothelial keratoplasty

“…With the introduction of endothelial keratoplasty (EK), there was optimism that the elimination of many of the anatomic glaucoma risk factors associated with PKP would reduce the prevalence of postoperative GTE [21]. Unfortunately, a recent study from our institution demonstrated that the elimination of the need for corneal sutures afforded by deep anterior lamellar keratoplasty did not result in a reduction of GTE [22].…”

Impact of Eye Bank Lamellar Tissue Cutting for Endothelial Keratoplasty on Bacterial and Fungal Corneoscleral Donor Rim Cultures After Corneal Transplantation

“…1,2 Anterior lamellar keratoplasty (ALK) procedures have become increasingly popular for the treatment of keratoconus, stromal dystrophies, thinning, and superficial and deep scarring. 1 Endothelial keratoplasty (EK) has become the procedure of choice in treating eyes with endothelial dysfunction caused by dystrophy, degeneration, inflammation, or surgical trauma.…”

“…1 Endothelial keratoplasty (EK) has become the procedure of choice in treating eyes with endothelial dysfunction caused by dystrophy, degeneration, inflammation, or surgical trauma. 2 In contrast to PKP, in which no additional manipulation of donor tissue is required between tissue recovery and trephination by the surgeon, a need exists in EK techniques for lamellar cutting of a posterior stromal donor lenticule before trephination and placement in the recipient eye. 2 In the early EK era, deep lamellar endothelial keratoplasty was the procedure of choice, and lamellar cutting was usually performed by a surgeon in an operating room immediately before the final trephination.…”