Surgeon: ‘Sensitive hands’ needed for endokeratoplasty procedure

NUREMBERG, Germany — Descemet-stripping lamellar endokeratoplasty is a complex procedure that requires sensitive hands, one surgeon told an audience here during live surgery.

Francis W. Price Jr., MD, performed this surgery from a local hospital as one of the world’s leading experts in its techniques. He performed the surgery under topical anesthesia to illustrate that it can be done under these conditions.

“It is more difficult with topical anesthesia because the patient can move,” he told attendees of the German Congress of Ophthalmic Surgeons.

His technique included removal of Descemet’s membrane with the aid of trypan blue to better visualize the complete removal of the endothelium inside the cornea.

He then removed the internal lamella from the donor cornea and folded it endothelium-on-endothelium to protect it from the stroma during insertion.

The difficulty during insertion, he said, is that viscoelastic cannot be used; otherwise, the anterior chamber will become shallow, and the graft will not adhere properly inside the cornea.

“You can only work with balanced salt solution or air,” he said.

Before unfolding the graft, Dr. Price placed two sutures at opposite sides of the cornea to prevent astigmatism.

“The wound is a self-sealing wound, so the sutures are only there to prevent development of astigmatism, not to seal the wound,” he said.

He then used balanced salt solution to unfold the graft once inside the cornea, a process that can be exceptionally difficult if the anterior chamber is too shallow, he said.

Air is then injected to create contact pressure and fixate the graft. Once the unfolding and fixation are complete, Dr. Price created four incisions with a diamond knife to drain the excess fluid from the cornea. Visual recovery times vary, he said.

“The more the edema, the slower the recovery,” Dr. Price said.