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Graft dislocation after DSAEK linked to previous glaucoma surgery
Wounds and blebs should be checked for leaks at the conclusion of surgery, and wounds should be sutured to prevent postoperative hypotony.
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Patients with previous glaucoma surgery who underwent Descemet’s stripping automated endothelial keratoplasty had a markedly higher rate of graft dislocation than those with no history of glaucoma surgery, a study found.
Graft dislocation correlated most strongly with postoperative hypotony in eyes that had previous glaucoma surgery, the study authors said.
“In patients with [previous glaucoma surgery] who experienced graft dislocation, postoperative hypotony was present in 83% of eyes,” Jeffrey M. Goshe, MD, the corresponding author, said in an email interview. “In our study, the primary risk factors for graft dislocation were causes of postoperative hypotony: pre-existing hypotony, postoperative bleb overfiltration and postoperative wound/bleb leaks.”
The authors cited previous glaucoma surgery as a common morbidity that requires careful attention during DSAEK.
Jeffrey M. Goshe
The study was published in Ophthalmology.
Patients and procedures
The retrospective study included 854 eyes of 582 patients who underwent DSAEK. The study group comprised 67 eyes of 58 patients who had undergone previous glaucoma surgery; 13 eyes had received glaucoma drainage implants and 54 eyes had undergone trabeculectomy.
A control group comprised 787 eyes of 524 patients who had not undergone glaucoma surgery. All eyes had visually significant Fuchs’ endothelial dystrophy.
All DSAEK procedures were performed through a 5-mm scleral tunnel main incision. Donor tissue was inserted in a 60/40 taco-fold configuration with Charlie insertion forceps (Bausch + Lomb). Air injection and surface sweeping were performed to promote graft adhesion.
To prevent wound leaks, the researchers sutured the main wound with three interrupted sutures and sutured any corneal paracentesis site that did not retain air or fluid in the anterior chamber at normal pressure.
“We did not compare any alternative techniques, but we do recommend additional precautions be taken in patients with previous glaucoma surgery,” Goshe said. “Specifically, all wounds and blebs must be closely inspected at the conclusion of surgery to identify subtle leaks. If any doubt exists, suturing the wounds is advisable to avoid postoperative hypotony.”
Results and conclusions
Before surgery, corneal thickness was 768 μm in the study group and 655 μm in the control group; the between-group difference was statistically significant (P < .001). Preoperative IOP was 13 mm Hg in the study group and 16 mm Hg in the control group (P < .001).
Study results showed a postoperative graft dislocation rate of 9% in the study group and 2% in the comparator group (P = .008).
Of eyes in which dislocation occurred, postoperative hypotony was identified in five study eyes (83%) and no control eyes, the study authors said.
“Postoperative hypotony may contribute to mechanical graft dislocation by allowing easier deformation of the corneal surface postoperatively,” Goshe said. “Additionally, eyes with glaucoma surgery may be more difficult to pressurize with air intraoperatively and thus more prone to having retained interface fluid. Intraoperative optical coherence tomography, currently in use at the Cole Eye Institute for DSAEK surgery, may better elucidate the mechanism of dislocation in these patients.”
Dislocation rates did not differ in either group according to an attending surgeon or cornea fellow performing DSAEK, Goshe said. – by Matt Hasson