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DSAEK offers similar graft survival as PK despite higher endothelial cell loss
Ophthalmology. 2010;117(3):438-444.
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Penetrating keratoplasty and Descemet's stripping automated endothelial keratoplasty showed similar graft survival, but DSAEK had higher endothelial cell loss, according to a study.
The prospective study included 173 patients who underwent DSAEK and 410 patients who underwent PK. Primary outcome measures were endothelial cell loss and graft clarity at 12 months.
Donor grafts for the PK and DSAEK groups had similar death to preservation and death to surgery times. Mean donor age was 3 years younger in the DSAEK group than in the PK group. DSAEK recipients were a mean 2 years older than PK recipients.
The DSAEK and PK groups had an 85% and 64% incidence of Fuchs' dystrophy, respectively. The PK and DSAEK groups had a 32% and 13% incidence of pseudophakic/aphakic cornea edema, respectively.
Study data showed a 34% endothelial cell loss in the DSAEK group at 6 months and a 38% cell loss at 12 months. The PK group had an 11% endothelial cell loss at 6 months and 20% cell loss at 12 months. The differences were statistically significant (P < .001). Both groups had similar graft survival rates at 12 months.
This prospective study of DSAEK by two different surgeons emphasizes that there is a higher donor endothelial cell loss that occurs in the early postoperative time frame following DSAEK compared to the cell loss found with full-thickness PK reported by the landmark Corneal Donor Study. The strong point of this study is that the specular microscopy measurements were analyzed by the same reading center for both DSAEK and PK, and the increased initial central trauma to DSAEK tissue compared to PK is undeniable. The increase of cell loss with DSAEK was even more impressive given that the PK cohort had a more complex mix of eyes with more pseudophakic bullous keratopathy eyes than the DSAEK group, which was overwhelmingly Fuchs’ dystrophy.
What is not reported in the study, however, is that there was a significant difference between the endothelial cell loss between the subgroup of DSAEK surgery which utilized a 5-mm incision for insertion of the donor tissue and that which used a 3-mm incision for insertion. The increased cell loss of the 3-mm incision technique (compared with the 5-mm incision technique) of this same DSAEK study group was reported in an ARVO 2009 poster by the authors, and that information will be reported by the authors in a subsequent publication. However, the safety of larger insertion incisions has practical relevance for the DSAEK surgeon right now.
The authors are to be congratulated on a controlled study which confirmed the level of cell loss published by individual DSAEK surgeons. We look forward to see if the longer term cell loss of this prospective study confirms the plateau of cell loss that occurs between 1 and 3 years after DSAEK currently reported by individual investigators.
– Mark A. Terry, MD
Director, Corneal
Services, Devers Eye Institute, Portland, Ore.
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