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4 Performing the Endothelial Keratoplasty After an IOL Exchange or Repositioning

4 Performing the Endothelial Keratoplasty After an IOL Exchange or Repositioning

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34



P.M. Phillips et al.



a



b



c



d



Fig. 2.12 Scleral secured lens positioned more posteriorly behind ciliary sulcus. (a) Note position

of lens with large space between the iris and lens. As air fills the anterior chamber, the direction of

air expansion leads to air egress behind the iris. (b) As additional air is injected, air enters behind

the lens as well and posterior pressure develops, pupillary block results, forcing air out of wounds

in the cornea and the chamber collapses. (c) A cannula on a syringe must be passed behind the iris

to aspirate air. (d) Separation of the anterior and posterior portions of the bubble results and the

pupil block is broken. Once the block is broken, air can be re-injected slowly and ideally will allow

posterior movement of the iris against the lens to allow fill of the anterior chamber with air and

positioning of the graft



When very large iris defects are present that cannot be closed, dislocation of the

graft into the posterior chamber can occur and will likely lead to significant morbidity [47, 48]. One maneuver that can be particularly helpful in these situations is the

placement of a “Stay suture” to secure the graft. Such a suture can secure a graft

both intraoperatively as well as in the early postoperative period when graft dislocation may still occur (Fig. 2.13). Such a technique is especially crucial in cases

performed in the setting of previous glaucoma procedures, where postoperative

hypotony might be expected and a higher risk of postoperative graft dislocation

might be anticipated.

When performing EK in the setting of an eye that has had a dislocated lens, the

corneal surgeon must decide which EK procedure (DSEK/DSAEK or DMEK)



2



Endothelial Keratoplasty in the Setting of a Dislocated Intraocular Lens (IOL)



a



b



c



d



e



f



35



Fig. 2.13 A 72-year-old male with history of multiple surgeries including traumatic cataract surgery

resulting in 300° of iris loss and placement of an anterior chamber lens, vitrectomy, two tube shunts

and a failed PK graft. (a) A “stay suture” is performed by first passing one arm of a 10-0 prolene

suture peripheral to the failed PK graft. (b) The second arm of the suture is passed through the

DSAEK graft. (c) This arm of the suture is then passed through the inner edge of the failed PK graft

radial to the first pass. (d) The graft is then folded and grasped with insertion forceps. (e) The graft

is then inserted into the eye. (f) The graft is then unfolded and positioned with air. The suture can then

be tied and the knot rotated internally. With this method, the graft is secure at all times, both intraoperatively and postoperatively, avoiding any risk of graft dislocation into the posterior chamber



36



P.M. Phillips et al.



should be performed. DMEK has recently gained greater popularity due to superior

vision results and a possible decrease in rejection rates when compared to DSAEK

[49–51]. However, many argue that due to the technical challenges of manipulating

a DMEK graft, this surgery should be avoided in complex eyes, specifically those

with deep anterior chambers [2]. Currently, there is not a consensus among surgeons. However, there is recent evidence of good results with DMEK in the setting

of glued IOLs [3]. Until a surgeon is very comfortable with the DMEK technique,

after performing this procedure in more anatomically “normal” eyes where the procedure is more straightforward, it is reasonable to continue performing DSEK/

DSAEK as very good results can be achieved with this surgery in complex eyes.

Ultimately, while the complex situations outlined in this chapter may lead to very

challenging surgeries, the outcomes are generally excellent. Anterior segment/cornea specialists have the opportunity to greatly improve both the comfort and quality

of vision of our patients and, consequentially, the quality of life of these often very

grateful individuals.



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3. Jacob S, Agarwal A, Kumar DA, Agarwal A, Agarwal A, Satish K. Modified technique for

combining DMEK with glued intrascleral haptic fixation of a posterior chamber IOL as a

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keratoplasty for bullous keratopathy in eyes with an anterior chamber intraocular lens.

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stripping automated endothelial keratoplasty with intraocular lens exchange, aphakia, and

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7. Aldave AJ, Baghdasaryan E, Miller KM. Descemet stripping endothelial keratoplasty after

Ophtec 311 iris reconstruction lens implantation. Cornea. 2011;30(4):405–8.

8. Huang T, Wang Y, Gao N, Wang T, Ji J, Chen J. Complex deep lamellar endothelial keratoplasty for complex bullous keratopathy with severe vision loss. Cornea. 2009;28(2):157–62.

9. Amayem AF, Terry MA, Helal MH, Turki WA, El-Sabagh H, El-Gazayerli E, Ousley PJ. Deep

lamellar endothelial keratoplasty: surgery in complex cases with severe preoperative visual

loss. Cornea. 2005;24(5):587–92.

10. Phillips PM, Terry MA, Shamie N, Chen ES, Hoar K, Dhoot D, Shah AK, Friend DJ, Rao NK,

Davis-Boozer DD. Descemet stripping automated endothelial keratoplasty in eyes with previous trabeculectomy and tube shunt procedures: intraoperative and early postoperative complications. Cornea. 2010;29(5):534–40.

11. Goshe JM, Terry MA, Li JY, Straiko MD, Davis-Boozer D. Graft dislocation and hypotony

after Descemet’s stripping automated endothelial keratoplasty in patients with previous glaucoma surgery. Ophthalmology. 2012;119(6):1130–3.

12. Nguyen P, Khashabi S, Chopra V, Francis B, Heur M, Song JC, Yiu SC. Descemet stripping

with automated endothelial keratoplasty: a comparative study of outcome in patients with preexisting glaucoma. Saudi J Ophthalmol. 2013;27(2):73–8.



2



Endothelial Keratoplasty in the Setting of a Dislocated Intraocular Lens (IOL)



37



13. Aldave AJ, Chen JL, Zaman AS, Deng SX, Yu F. Outcomes after DSEK in 101 eyes with previous trabeculectomy and tube shunt implantation. Cornea. 2014;33(3):223–9.

14. Elderkin S, Tu E, Sugar J, Reddy S, Kadakia A, Ramaswamy R, Djalilian A. Outcome of

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15. Shah AK, Terry MA, Shamie N, Chen ES, Phillips PM, Hoar KL, Friend DJ, Davis-Boozer

D. Complications and clinical outcomes of descemet stripping automated endothelial keratoplasty with intraocular lens exchange. Am J Ophthalmol. 2010;149(3):390–7.e391.

16. Lapenna L, Kadyan A, Busin M. Intraocular lens exchange 1 week after descemet stripping

automated endothelial keratoplasty. Cornea. 2010;29(2):207–9.

17. Moses L. Complications of rigid anterior chamber implants. Ophthalmology.

1984;91(7):819–25.

18. Coli AF, Price Jr FW, Whitson WE. Intraocular lens exchange for anterior chamber intraocular

lens-induced corneal endothelial damage. Ophthalmology. 1993;100(3):384–93.

19. Apple DJ, Brems RN, Park RB, Norman DK, Hansen SO, Tetz MR, Richards SC, Letchinger

SD. Anterior chamber lenses. Part I: complications and pathology and a review of designs.

J Cataract Refract Surg. 1987;13(2):157–74.

20. Ravalico G, Botteri E, Baccara F. Long-term endothelial changes after implantation of anterior

chamber intraocular lenses in cataract surgery. J Cataract Refract Surg.

2003;29(10):1918–23.

21. Shpitzer SA, Rosenblatt A, Bahar I. Outcomes of descemet stripping automated endothelial

keratoplasty in patients with an anterior chamber versus posterior chamber intraocular lens.

Cornea. 2014;33(7):686–90.

22. Esquenazi S, Esquenazi K. Endothelial cell survival after descemet stripping with automated

endothelial keratoplasty with retained anterior chamber intraocular lens. Cornea.

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23. Lima BR, Pichi F, Hayden BC, Lowder CY. Ultrasound biomicroscopy in chronic pseudophakic ocular inflammation associated with misplaced intraocular lens haptics. Am J Ophthalmol.

2014;157(4):813–7 e811.

24. Mostafavi D, Nagel D, Danias J. Haptic-induced postoperative complications. Evaluation

using ultrasound biomicroscopy. Can J Ophthalmol. 2013;48(6):478–81.

25. Hong Y, Sun YX, Qi H, Zhou JC, Hao YS. Pigment dispersion glaucoma induced by the chafing effect of intraocular lens haptics in Asian eyes. Curr Eye Res. 2013;38(3):358–62.

26. Boutboul S, Letaief I, Lalloum F, Puech M, Borderie V, Laroche L. Pigmentary glaucoma secondary to in-the-bag intraocular lens implantation. J Cataract Refract Surg. 2008;34(9):1595–7.

27. Micheli T, Cheung LM, Sharma S, Assaad NN, Guzowski M, Francis IC, Norman J, Coroneo

MT. Acute haptic-induced pigmentary glaucoma with an AcrySof intraocular lens. J Cataract

Refract Surg. 2002;28(10):1869–72.

28. Ozdal PC, Mansour M, Deschenes J. Ultrasound biomicroscopy of pseudophakic eyes with

chronic postoperative inflammation. J Cataract Refract Surg. 2003;29(6):1185–91.

29. Loya N, Lichter H, Barash D, Goldenberg-Cohen N, Strassmann E, Weinberger D. Posterior

chamber intraocular lens implantation after capsular tear: ultrasound biomicroscopy evaluation. J Cataract Refract Surg. 2001;27(9):1423–7.

30. Rauen M, Russell SR, Tauber S, Goins KM. Surgical management of a posterior dislocated

intraocular lens after descemet stripping automated endothelial keratoplasty. Cornea.

2010;29(3):350–3.

31. Werner L, Wilbanks G, Ollerton A, Michelson J. Localized calcification of hydrophilic acrylic

intraocular lenses in association with intracameral injection of gas. J Cataract Refract Surg.

2012;38(4):720–1.

32. Fellman MA, Werner L, Liu ET, Stallings S, Floyd AM, van der Meulen IJ, Lapid-Gortzak R,

Nieuwendaal CP. Calcification of a hydrophilic acrylic intraocular lens after Descemet

stripping endothelial keratoplasty: case report and laboratory analyses. J Cataract Refract

Surg. 2013;39(5):799–803.

33. Neuhann IM, Neuhann TF, Rohrbach JM. Intraocular lens calcification after keratoplasty.

Cornea. 2013;32(4):e6–10.



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34. De Cock R, Fajgenbaum MA. Calcification of Rayner hydrophilic acrylic intra-ocular lenses

after Descemet’s stripping automated endothelial keratoplasty. Eye (Lond).

2014;28(11):1383–4.

35. Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens

dislocation: incidence, prevention, and management. J Cataract Refract Surg.

2005;31(11):2193–204.

36. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract

Refract Surg. 2006;32(11):1907–12.

37. Oshika T. Transscleral suture fixation of a subluxated posterior chamber lens within the capsular bag. J Cataract Refract Surg. 1997;23(9):1421–4.

38. Altman AJ, Gorn RA, Craft J, Albert DM. The breakdown of polypropylene in the human eye:

is it clinically significant? Ann Ophthalmol. 1986;18(5):182–5.

39. Jacob S, Agarwal A, Agarwal A, Sathish K, Prakash G, Kumar DA. Glued endocapsular hemi

ring segment for fibrin glue-assisted sutureless transscleral fixation of the capsular bag in\

subluxated cataracts and intraocular lenses. J Cataract Refract Surg. 2012;38(2):193–201.

40. Gross JG, Kokame GT, Weinberg DV. In-the-bag intraocular lens dislocation. Am J Ophthalmol.

2004;137(4):630–5.

41. Malta JBBM, Banitt M, Musch DC, Sugar A, Mian SI, Soong HK. Long-term outcome of

combined penetrating keratoplasty with scleral-sutured posterior chamber intraocular lens

implantation. Cornea. 2009;28(7):741–6.

42. Price MO, Price Jr FW, Werner L, Berlie C, Mamalis N. Late dislocation of scleral-sutured

posterior chamber intraocular lenses. J Cataract Refract Surg. 2005;31(7):1320–6.

43. Fass ON, Herman WK. Four-point suture scleral fixation of a hydrophilic acrylic IOL in aphakic eyes with insufficient capsule support. J Cataract Refract Surg. 2010;36(6):991–6.

44. Gabor SG, Pavlidis M. Sutureless intrascleral posterior chamber intraocular lens fixation.

J Cataract Refract Surg. 2007;33(11):1851–4.

45. Kumar DA, Agarwal A, Prakash G, Jacob S, Saravanan Y, Agarwal A. Glued posterior chamber IOL in eyes with deficient capsular support: a retrospective analysis of 1-year postoperative outcomes. Eye (Lond). 2010;24(7):1143–8.

46. DA Kumar AA, Agarwal A, Chandrasekar R, Priyanka V. Long-term assessment of tilt of

glued intraocular lenses: an optical coherence tomography analysis 5 years after surgery.

Ophthalmology. 2015;122(1):48–55.

47. Sng CC, Mehta J, Tan DT. Posterior dislocation and immediate retrieval of a descemet stripping automated endothelial keratoplasty graft. Cornea. 2012;31(4):450–3.

48. Afshari NA, Gorovoy MS, Yoo SH, Kim T, Carlson AN, Rosenwasser GO, Griffin NB,

McCuen 2nd BW, Toth CA, Price Jr FW, et al. Dislocation of the donor graft to the posterior

segment in descemet stripping automated endothelial keratoplasty. Am J Ophthalmol.

2012;153(4):638–42.e631–632.

49. Guerra FP, Anshu A, Price MO, Giebel AW, Price FW. Descemet’s membrane endothelial

keratoplasty: prospective study of 1-year visual outcomes, graft survival, and endothelial cell

loss. Ophthalmology. 2011;118(12):2368–73.

50. Anshu A, Price MO, Price Jr FW. Risk of corneal transplant rejection significantly reduced

with Descemet’s membrane endothelial keratoplasty. Ophthalmology. 2012;119(3):536–40.

51. Price MO, Price Jr FW, Kruse FE, Bachmann BO, Tourtas T. Randomized comparison of topical prednisolone acetate 1% versus fluorometholone 0.1% in the first year after descemet

membrane endothelial keratoplasty. Cornea. 2014;33(9):880–6.



Chapter 3



Endothelial Keratoplasty in Eyes

with Glaucoma

Mark Gorovoy



Contents

3.1

3.2

3.3



Introduction

Bubble Management

Pupillary Block Glaucoma

3.3.1 Prevention

3.3.2 Inferior Iridotomy

3.4 Eyes with Tube Shunts

3.5 Eyes with Filtering Blebs

3.6 Conclusion

References



3.1



39

40

42

44

45

46

48

48

49



Introduction



EK has become the standard of care for corneas with endothelial failure, most

commonly Fuchs’, phakic or aphakic bullous keratopathy, failed PK, and the ICE

syndromes [1–8]. EK now consists of two main procedures, DSAEK and DMEK

(Figs. 3.1 and 3.2). Each procedure replaces the diseased endothelium without surface trephinations, avoiding all the pitfalls of PK. DSAEK donors are comprised of

a layer of donor stroma (approximately 125 μm) as a carrier for the donor endothelium while DMEK is pure Descemet’s membrane and endothelium (15 μm). The

difference in the donor’s thickness makes the two procedures surgically distinct, but

the underlying principles between them are the same. The goal is donor adherence

onto the host’s inner surface, thereby creating a new functioning endothelium. This

is accomplished with an air bubble (or gas) to tamponade the donor into position.

Electronic supplementary material: The online version of this chapter (doi:10.1007/978-81322-2821-9_3) contains supplementary material, which is available to authorized users.

M. Gorovoy, MD

Department of Ophthalmology, University of California,

12381 S Cleveland Ave Ste 300, Fort Myers, FL 33907, USA

e-mail: mgorovoy@gorovoyeye.com

© Springer India 2016

S. Jacob (ed.), Mastering Endothelial Keratoplasty,

DOI 10.1007/978-81-322-2821-9_3



39



40



3.2



M. Gorovoy



Bubble Management



The nuances of bubble management are crucial to both the success and safety of the

procedure. Avoiding donor dislocation (not enough bubble) and acute pupillary

block glaucoma (too much bubble) are the two ends of the complication spectrum.

Eyes with preexisting glaucoma exacerbate this conundrum.



a



b



c



d



Fig. 3.1 DSAEK – (a) The cornea has been marked with a blunt trephine. An inferior YAG PI

may be done in the preoperative period; (b) The host Descemet’s membrane is scored all along; (c)

The I/A probe is used to strip the Descemet’s membrane; (d) Venting incisions are made; (e) The

DSAEK graft is folded with forceps; (f) The graft is inserted into the AC; (g) It is unrolled; (h) The

graft is floated up into the AC and interface fluid is removed through the venting incisions as well

as by steamrolling



3



Endothelial Keratoplasty in Eyes with Glaucoma



e



f



g



h



41



Fig. 3.1 (continued)



While the bubble principles are very similar between DSAEK and DMEK, there

are some differences. DSAEK requires a “higher IOP” bubbling initially while

DMEK requires a longer acting bubble that can be less “tight.” DSAEK adherence

is quick, maybe only hours and is almost always 100 % attached or 100 % dislocated. DMEK adherence, on the other hand, can be tenuous for several days up to

weeks and if detached, almost always is only partially detached, rarely ever totally

detached. Supine postoperative positioning is not required for DSAEK after the

initial full bubble period (1 h in my technique) but is recommended for 3 days intermittently for DMEK. This recognizes the different adherent patterns between the

two procedures.



42



3.3



M. Gorovoy



Pupillary Block Glaucoma



Both procedures leave a sizeable air bubble (I do not use SF6 gas) for up to 3 days

and it is imperative that this bubble avoids pupillary block (Fig. 3.3a, b). This is a

totally preventable complication that can result in devastating permanent deficits to

both the optic nerve and anterior segment anatomy. While bubbling is necessary for

donor adherence, it should never be at the expense of permanent visual loss associated with bubble-induced acute pupillary block. Management of the bubble is even

more critical in eyes with preexisting glaucoma and bubble management modifications are necessary to reduce donor dislocations, but at the same time ensure safety.



a



b



c



d



Fig. 3.2 DMEK – (a) The host Descemet’s membrane is scored; (b) The I/A probe is used to strip

the Descemet’s membrane; (c) The DMEK graft is injected with an MIL injector and the section is

closed; (d) The graft is seen lying partially unrolled; (e) The graft is opened further; (f) The graft

is fully unrolled; (g) Air bubble is injected under the graft; (h) The graft is floated up against the

host stroma by injecting more air



3



Endothelial Keratoplasty in Eyes with Glaucoma



e



f



g



h



43



Fig. 3.2 (continued)



a



b



Fig. 3.3 (a) Pupillary block with iris pushed forward and a flat AC in the inferior quadrant; (b) A

uniformly formed AC after relieving the pupillary block



44



M. Gorovoy



The risk of further glaucoma loss can never be zero with the required bubbles in

eyes without preexisting glaucoma, but it has been my experience when the bubbleinduced elevated IOP is limited to only brief periods in the 1–2 h range, it is rare to

see further damage. That is not the case with poor bubble management that results

in prolonged acute IOP elevations secondary to angle closure.



3.3.1



Prevention



My present standard bubble techniques for both DSAEK and DMEK start with

preop miotics (pilocarpine 2 %) 1 h prior to the procedure. An inferior iridotomy

with the YAG laser is then performed. In eyes with very opaque corneas, a surgical

inferior iridectomy is made instead during the procedure (Fig. 3.4a, b). The only

exception to the inferior iris opening is eyes with functioning shunts. Eyes with filtering blebs are treated just like non-glaucomatous eyes and receive the inferior iris

laser or surgical opening. The rationale for pupillary miosis is to eliminate the risk

of the residual bubble in the first 24–48 h from migrating thru the pupil to the posterior chamber causing not a pupillary block but a partial iris bombe with severe

secondary pressure rises. Eyes that cannot be constricted run this risk and I instruct



a



b



Fig. 3.4 (a) Air bubble in AC occluding pupil and blocking circulation of aqueous; (b) Inferior

iridectomy prevents pupillary block by allowing circulation of aqueous (Image Courtesy Dr.

Soosan Jacob, Dr. Agarwal’s Eye Hospital, Chennai, India)



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