PART III

INCIDENCE OF PK
1 PK/10.000 People Required in 1
Year

ITALY = 6,000 PKs/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

KPL IN THE XX CENTURY

PK (from60s)
One Solution for
ALL !!!

KPL IN THE XX CENTURY

LK (up to 50s)
Hand Dissection
Bad Interface
Poor Vision
(<20/40)

KPL IN THE XX CENTURY

PK = the GOLD STANDARD
Operating Microscope
Endothelial Function/Viscoprotection
Suturing Material/Technique
Trephines/Punches
Lasers

KPL IN THE XX CENTURY

Perfect Disc in a Perfectly
Round Hole
Healing > 1 Year
Suture Removal after 1 y
VA Limitated by Distortion
(Sutures in Place)
Final Astigmatism after
Suture Removal 4 D

TOP HAT PK

Busin, Arch. of Ophthalmol. 2003

FEMTO-SHAPED PK
Top Hat
Mushroom
Zig-Zag

NEW INFORMATION &

KPL

Stromal Dissection May Be

Compatible with 20/20 VA

(LASIK !!!)
Corneal Layers Can Stick
to Each Other without
Sutures (Melles 1998)

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)

NEW INFORMATION &

KPL

DISSECTION:
Manual

Pneumatic (Big Bubble)

Microkeratome
Femtosecond Laser

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

SALK (SUPERFICIAL ANTERIOR

LAMELLAR KERATOPLASTY)

Subepithelial Scarring (s/p PRK)

Subepithelial Irregularity (Bowmans
Dystrophy, s/p Superficial Keratitis)
Superficial Stromal Opacities (Granular
Dystrophy, Lattice Dystrophy)

SUPERFICIAL ANTERIOR
LK (SALK)

TISSUE REMOVAL = 130-200 m

NEW LAMELLA

= 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

(-1.00 sf. 1.25 cil. @ 175)

IRREGULAR
ASTIGMATISM

DEEP ANTERIOR LK
(DALK)

TISSUE REMOVAL = 200-300 m

NEW LAMELLA

= 300-350 m

DALK (DEEP ANTERIOR

LAMELLAR KERATOPLASTY)

Various Etiology (s/p Infection, s/pTraumas,

Dystrophies)
Scarring Limited to 2/3 of Anterior Stroma
NORMAL CORNEAL THICKNESS !!!

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)

TISSUE REMOVAL = 99% Stroma

NEW LAMELLA

= w/o Endoth.

IRREGULAR
ASTIGMATISM

DALK
Keratoconus
VA = 20/400
2 Years postDALK

SMALL BUBBLE DALK

1m Postop VA
20/25
(+1.00 sph.-2.25
cyl. @ 20)

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)

Kruse et al. (2011)

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

Previous Case (2 Years postop), Resolved with Steroids

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)

NEW ORLEANS (USA) 1984-86

Dr. H.E Kaufman, Dr. M.B.McDonald

and Cornea Fellows

ANTERIOR ONLAY LK

Kaufman 1980
Epikeratophakia for Aphakia

THE LIVING CONTACT LENS

LAMELLAR
KERATOPLASTY

SUBSTITUTIVE
(INLAY)
ADDITIVE
(ONLAY)

POSTERIOR ONLAY LK CONCEPT

1. Peeling of Descemet
+ endothelium
2. Tunnel approach
3. Preparation of
posterior donor
lamella (endothelium
+ deep stroma)
4. Suturing to the bare
posterior stromal
surface

1
2
3
4

POSTERIOR ONLAY LK
(ENDOKERATOPLASTY)
ENDOKERATOPLASTY: A NEW SURGICAL TECHNIQUE
FOR THE REPLACEMENT OF DISEASED CORNEAL ENDOTHELIUM
1

Massimo Busin , M.D., Thomas Mnks , M.D., Robert Arffa , M.D.

3
University of Bonn, Germany, Surgical Eye Center Viktoriahaus, Krefeld, Germany, Allegheny General Hospital, Pittsburgh, Pennsylvania
2

MATERIALS AND METHODS

INTRODUCTION
To date, penetrating keratoplasty (PK) is the only available surgical
treatment for endothelial decompensation. Although epithelium and
stroma are not primarily affected, this procedure involves full-thickness
transplantation, leading to unsatisfactory refractive results in a relatively
high number of patients. A new surgical technique aimed at replacing
exclusively the diseased endothelium is presented by means of a
rabbit model.

Donor lenticules were prepared as follows: Approximately 80% of the

anterior stroma of the donor corneas was removed with a microkeratome
(Storz, Heidelberg, Germany) and a 6mm button was trephined. In five
eyes a 4mm limbal incision was made and the central endothelium and
Descemets membrane were removed. In four eyes a donor lenticule was
then sutured to the posterior surface of the central cornea, using four to
five prolene 10-0 mattress sutures. The fifth eye did not receive any
lenticule and served as control. All animals were examinded 1, 3, 5, 7,
and 14 days after surgery and clinical pictures were taken. On the
fourteenth day they were killed and the excised corneas submitted for
histologic evaluation.

Fig. 2: Endokeratoplasty surgery i n a rabbit model:

A) Removal of Descemts membrane and endothelium from
the recipient central cornea; B) Entering the anterior chamber
with a 4mm keratome; C) Preparation of a 10-0 prolene
mattress suture to fixate the endokeratoplasty-lenticule;
D) Mattress suture led through the recipient cornea at the
6 oclock position.

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.

Endokeratoplasty exhibits potential for endothelial transplantation

and merits further study. Possible advantages of this procedure over
conventional PK surgery include:

Fig. 1: Schematic representation of endokeratoplasty

surgery: a) Edematous cornea; b) Removal of Endotheli um
from the center of the recipient cornea (arrows); c) Insertion
of the endokeratoplasty-lenticule through a scleral tunnel;
d) Suturing in place of the endokeratoplasty-lenticule.

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.

1) reduced postoperative corneal distortion in the absence of a

full-thickness surgical wound;
2) increased safety secondary to the use of a short tunnel approach
3) reduced immunogenicity (no epithelium is transplanted).
Improved handling of the donor lenticule and use of an alternate animal
model, e.g. primates, may improve endothelial cell transfer.

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

DLEK (Melles 1998)

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

U(ltra)T(hin)DSAEK (BUSIN, 2009)

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 VISUAL OUTCOME

BSCVA 0.5
38% to 100%
at 3-6 months
72.96% at 1 month*
81.13% at 3 mos*
*Personal Data, Excluding Co-Morbidities

Post-PK VA in ABK/PBK Patients

DSAEK VISUAL OUTCOME

BSCVA 1.0
0% to 71%**
30.19% at 6 mos*
50%% at 6 mos*
*Personal Data, Excluding Co-Morbidities
**UT-DSAEK Neff et al, *UT-DSAEK Personal Data

DSAEK GRAFT SURVIVAL

ECL at 1 Year
Average
= 41% (29-61%)
DSAEK = 23%*
UT
= 29%*
*DSAEK Personal Data
*UT-DSAEK Personal Data

Endothelial Cell Loss (ECL) in %

after DSAEK

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

100% Possible !!!

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%

*DSAEK Personal Data

DMEK vs DSAEK

Postoperative Refractive Error

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 & IOL EXCHANGE

DSAEK vs DMEK
DSAEK & ACIOL in PC

DMEK CONS
HIGH SURGICAL SKILLS
REQUIRED
AVERAGE SURGEON!!!)

(NO

PROLONGED SURGICAL TIME

COMPLICATION RATE HIGHER
NOT SUITABLE FOR ALL EYES

DMEK CONS
NOT FOR EVERY
SURGEON !!!
NOT FOR EVERY
EYE !!!

55-Year Old Patient

with Fuchs Dystrophy
+ Cataract
BSCVA preop: 20/100

BSCVA 1 m postop: 20/20

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

U(ltra)T(hin)DSAEK (BUSIN, 2009)

UT-DSAEK
SURGICAL TECHNIQUE
Same As DSAEK
Except for:
Graft
Preparation
Graft
Delivery

ULTRATHIN (UT) DSAEK

Prospective Study
(Ophthalmology, June 2013)

Preop BSCVA 6/10

ISSUE # 1
BSCVA 10/10
in Eyes with
10/10 Potential

BSCVA post UT-DSAEK in

with 10/10 Potential

Eyes

1 Year UT-DSAEK vs DMEK

UT-DSAEK DMEK
10/10= 20/20

39%

41%

8/10= 20/25

71%

80%

6/10= 20/30

95%

98%

ECL

34%

36%

Data for Fuchs or PBK indications only, w/o comorbidities

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

Pentacam Analysis !!!

DSAEK/UT-DSAEK/DMEK

High Order Aberrations

UT-DSAEK = Planar Graft !!!
315

251

92

95

DSAEK/UT-DSAEK/DMEK
92

95

Thin, Regular Shape

160

318

Thick, Irregular Shape

DSAEK/UT-DSAEK/DMEK
IMPROPER
PUNCHING
!!!

DSAEK/UT-DSAEK/DMEK

DMEK Graft Variables

ECC
Diameter
???

DSAEK/UT-DSAEK/DMEK

DS(A)EK Graft Variables

ECC
Diameter
STROMA (Thickness,
Regularity, Orientation)

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

Thick, Regular Shape !!!

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

UT-DSAEK Imm. Rej.

IMMUNOLOGIC REJECTION
Low-Risk Eyes
n = 237
High-Risk Eyes n = 48
Previous Graft(s)
n = 39
Corneal Vascul.
n= 6
Herpetic Endothelit. N = 3

POSTOPERATIVE TREATMENT

Topical Dexamethasone 0.1%

Tapered off over a 5-month Period
(from 2-Hourly to qd)
qd Lifelong
(unless Contraindicated)

For Eyes at High Risk 1.0-1.5 mg/Kg

Prednisone p.o. Tapered off over a 2month Period

UT-DSAEK Imm. Rej.

Endothelial Rejection in
4/162 Eyes (2.47%)
Low Risk n=3/142(2.1%)
High Risk n=1/21 (4.8%)
All Cases Resolved with
Steroidal Treatment !!!

DSAEK/UT-DSAEK/DMEK
Cumulative Probability (K-M)
DSAEK*

1 Year

UT

DMEK

6%

2.5%

1%

2 Years 10%

2.5%

1%

*Fuchs Indications Only

COMPLICATIONS
UT-DSAEK DMEK*
Air Re-injection

3%

17-77%

Primary Failure

1%

9%

Rejection1yr
Tissue Loss

2.5%
1%

0-13%
0-13%

Data for Fuchs or PBK indications only

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

Step #1: TRI-FOLDING

DMEK 2.0

Step #2: CL TRANSFER

DMEK 2.0
Descemet
Endothelium

Step #3: LOADING A-B

DMEK 2.0

Step #3: LOADING C-D

DMEK 2.0

Step #4: POSITIONING

DMEK 2.0

Step #5: PULL-THROUGH

DMEK 2.0

Step #5: PULL-THROUGH

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

EACH BITE = 0.03mm2 = 50-75 Cells

DMEK 2.0
Results 6 Mos Post-DMEK
20 Consecutive Uneventful
DMEK
ECL 12% !!!

Requests of Course
Electronic Copies to Be
E-mailed to:
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