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4 Performing the Endothelial Keratoplasty After an IOL Exchange or Repositioning
P.M. Phillips et al.
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)
Endothelial Keratoplasty in the Setting of a Dislocated Intraocular Lens (IOL)
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
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 . Currently, there is not a consensus among surgeons. However, there is recent evidence of good results with DMEK in the setting
of glued IOLs . 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
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Endothelial Keratoplasty in the Setting of a Dislocated Intraocular Lens (IOL)
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Endothelial Keratoplasty in Eyes
Pupillary Block Glaucoma
3.3.2 Inferior Iridotomy
3.4 Eyes with Tube Shunts
3.5 Eyes with Filtering Blebs
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
© Springer India 2016
S. Jacob (ed.), Mastering Endothelial Keratoplasty,
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.
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
Endothelial Keratoplasty in Eyes with Glaucoma
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
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.
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
Endothelial Keratoplasty in Eyes with Glaucoma
Fig. 3.2 (continued)
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
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.
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
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)