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DSEK, IOL exchange promising for pseudophakic bullous keratopathy
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Combined Descemet’s stripping endothelial keratoplasty and IOL exchange may be able to treat pseudophakic bullous keratopathy.
A study included 11 patients with a mean age of 76 years who had a mean preoperative visual acuity of 0.004.
Patients received a CZ70BD single-piece PMMA IOL (Alcon). Donor lenticules in a “taco” fold configuration were inserted through a scleral tunnel. Patients underwent complete examination at 2 weeks and 1, 3, 6, 9 and 12 months after surgery.
At final follow-up, mean uncorrected visual acuity was 0.16 and mean best corrected visual acuity was 0.36. Mean spherical equivalent was +0.30 D; mean astigmatism was 2.2 D. Mean endothelial cell loss was 36%.
A slight hyperopic shift was attributed to over-calculated IOL power designed to compensate for reduced corneal power resulting from the concave shape of the donor lenticules.
DSEK and lens exchange is an excellent option for treating corneal decompensation associated with an anterior chamber IOL.
The results support the advantages of using DSEK instead of PK to treat the corneal decompensation from an anterior chamber IOL. DSEK reduces the risk of expulsive hemorrhage, retinal detachment and surgically induced astigmatism. Some surgeons prefer to perform DSEK without replacing the anterior chamber IOL. However, as the authors point out, this makes it more difficult to unfold the graft and may increase the risk of graft failure. Also, if the DSEK graft detaches, as several did in this series, it will be ruined when it contacts the anterior chamber IOL.
In this study, the DSEK and IOL exchange procedures were combined. However, the combined procedure is lengthy and most cases were performed with general anesthesia. We prefer to stage the IOL exchange first using a retrobulbar injection and then follow up a month later with DSEK using topical anesthesia and monitored IV sedation. Two eyes in the study had flap erosion over the fixation suture. By passing a double-arm polypropylene suture through the haptic eyelet and rotating the knot into the sclera, instead of using a flap to cover the knot, this complication can be avoided (Reference: Price FW Jr., Wellemeyer M. Transcleral fixation of posterior chamber intraocular lenses. J Cataract Refract Surg. 1995;21:567-573).
It will be interesting to get feedback from additional DSEK surgeons on their outcomes in treating this condition.
– Marianne O. Price, PhD, MBA
Executive Director, Cornea Research Foundation of America