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Proper patient selection essential while learning DSEK

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SAN DIEGO — For surgeons transitioning from penetrating keratoplasty to Descemet's stripping endothelial keratoplasty, careful patient selection will maximize outcomes and patient satisfaction, according to a surgeon speaking here.

"When you're transitioning to endothelial keratoplasty, you really want to try to pick those patients who will ... give time for the surgeon to develop some confidence and some skills and minimize complications," Michael K. Nordlund, MD, PhD, said during the American Society of Cataract and Refractive Surgery's Cornea Day.

Whereas penetrating keratoplasty (PK) can be used for all forms of corneal disease, Descemet's stripping endothelial keratoplasty (DSEK) is indicated only for patients with endothelial failure, he noted. Surgeons inexperienced in DSEK should explain this difference to their patients and only select those with the most flexible personalities, he said.

"I tell them that EK is going to be more work for them in the first few days after surgery," he said.

Because DSEK involves putting an air bubble in the eye, patients must be physically and emotionally willing to be positioned during the procedure, he said. Patients should also preferably live close to the office since graft dislocation is a common complication requiring follow up visits.

There are several anatomical factors to consider as well, Dr. Nordlund said. Larger eyes with deep anterior chambers are best for beginner surgeons, he noted.

"During the surgery, you're going to take typically between an 8-mm and 9-mm graft and insert it into the anterior chamber and unfold it. You're going to need between 3 mm to 4 mm to let it unfold for there to be room for that to happen," he said.

Surgeons should select patients without anterior chamber IOLs, glaucoma tubes or peripheral anterior synechiae, as they can complicate the unfolding process. Corneal clarity is also necessary for visibility, Dr. Nordlund said. He noted that a good way to take pressure off the first few cases is to select patients with limited visual potential, so the focus is more on eliminating discomfort and less on getting optimal visual results.