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ELK allows for the successful transplantation of corneal endothelium
Posterior corneal lamellar transplantation proves beneficial for endothelial dysfunction, such as Fuchs dystrophy, study says.
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ORLANDO, Fla. — Endothelial lamellar keratoplasty (ELK) is indicated in cases where there is endothelial dysfunction. It is not for all corneal diseases, but for those patients in which the endothelium fails, such as with Fuchs endothelial dystrophy, or because of congenital reasons, postoperative inflammation or trauma that occurs after cataract surgery.
“The reason why [ELK] is advantageous is because you are only transplanting the diseased part of the cornea and preserving what is healthy,” said Juan Batlle, MD, president of the Pan-American Association of Eye Banks. “It is only the endothelium that decompensates. Rejection is reduced markedly.” Dr. Batlle presented preliminary results here at the American Academy of Ophthalmology (AAO) meeting on two cases of corneal transplantation using ELK. William Culbertson, MD, is co-discoverer of this innovative technique and collaborated with the presented study.
The preservation of the anterior surface of the cornea, mainly the epithelium, Descemet’s membrane and stroma, preserves refractive power. There is potentially less astigmatism or refractive error as result of the procedure, according to Dr. Batlle.
Additionally, the pain associated with conventional penetrating keratoplasty (PKP) is markedly reduced in ELK. Also, patients at 1 week postoperative had opened their eyes pain free and with little inflammation.
Novel surgical technique
---The procedure is not complication free, according to Dr. Batlle. Immediately after the procedure, there is a cleft or space between the donor lamella and the host lamella. Dr. Batlle said the cleft must collapse.
Retrobulbar anesthesia is utilized. A microkeratome pass with a 350 µm plate creates a corneal flap. The 9-mm flap is lifted, followed by 7-mm trephination of the posterior lamella. Donor lamella is sutured with 10-0 nylon into the recipient bed. The flap is lowered to cover the transplanted lamella and sutured with a running 10-0 nylon. Sutures are removed within 1 month.
The procedure is not complication free, according to Dr. Batlle. Immediately after the procedure, there is a cleft or space between the donor lamella and the host lamella. Dr. Batlle said the cleft must collapse. “It depends on the endothelium to start pumping fluid again outside of the cornea in order for the cleft to collapse,” Dr. Batlle said. “We had one case where that never happened. The cleft never went away, and it needed to be regrafted.” Intraocular pressure also can go up if there is a narrow angle, leading to glaucoma.
According to Dr. Batlle, if a surgeon runs into problems with ELK, PK can be done.
Cases
--- Photograph of postoperative course (top) of first case after 12 months showed visual acuity at 20/40, refraction at -4.50 -2.00x005. The endothelial count was 1100 per sq. mm. Topography of the first case (bottom).
Dr. Batlle et al have done six cases, two of which have been followed for 12 months. The 12-month data was presented at the AAO.
In the first case, a 73-year-old female with a history of bilateral aphakic bullous keratopathy who received a corneal transplant in 1997 in her right eye volunteered to receive ELK. At 12 months postoperatively, the patient had 20/40 visual acuity, refraction of –4.50 – 2.00 x 005, endothelial count totaling 1,100 mm2 and slit lamp examination demonstrating excellent central clarity.
The second case was an 81-year-old male patient with a 3-month history of cataract surgery complicated with vitreous loss, eccentric IOL placement and aphakic bullous keratopathy. At 12 months, the patient’s visual acuity was 20/40, with refraction totaling +1.00 – 2.75 x 060, an endothelial cell count of 1,790 mm2, corneal topography demonstrating regular astigmatism and slit lamp examination showing excellent central corneal clarity.
Both patients experienced minimal pain and discomfort from the procedure. Sutures were removed at 1 month, and a steroid was used and tapered until 12 months. Additionally, there was reduced antigenic load, astigmatism and recovery time.
Photograph of postoperative course (left) of second case after 12 months showed visual acuity at 20/60, refraction at +1.00 -2.75x060. The endothelial count was 1790 cells per sq. mm. Topography of the second case (right).
For Your Information:
- Juan F. Batlle, MD, can be reached at Calle Pantino Faio, 5 Naco, Santo Domingo, Republica Dominicana; (809) 563-1324; fax: (809) 544-1885; e-mail: jbatlle@codetel.net.do. Dr. Batlle has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.