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Cataract and Fuchs' dystrophy: DSEK has changed the equation
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Since the widespread availability of Descemet's stripping endothelial keratoplasty, have you noticed how much simpler the discussion of cataract surgery has become for patients with Fuchs' dystrophy? Before DSEK, most of us cataract surgeons probably spent many hours explaining to Fuchs' patients how their upcoming cataract surgery might make their vision worse. To be sure, corneal decompensation still happens after cataract surgery, despite newer viscoelastics and phacoemulsification technology. But the significance of a decompensated cornea is now a much simpler matter to correct, thanks to DSEK.
More than 5 years ago, I started doing deep lamellar endothelial keratoplasty (the precursor procedure to DSEK) for endothelial replacement. It was not a pretty procedure. None of the eye banks even knew what DLEK was, let alone could provide pre-cut donor tissue. The femtosecond laser was not yet approved for cutting corneas for this procedure. We had to manually cut the tissue on an artificial anterior chamber. Trauma to the endothelial graft, perforations and inconsistency of the graft tissue were extremely common. Naturally, this very much affected the results of surgery. Donor dislocations happened in nearly 50% of cases, and recovery of vision took months and yielded results that were really no better than PK. Nevertheless, the procedure had merits. The idea of not needing sutures and not creating irregular astigmatism was very appealing.
Now, DSEK has become a truly simple procedure. High-quality, properly pre-cut tissue is routinely available from nearly any eye bank, and we've learned enough lessons about surgical technique that we can consistently provide somewhat rapid and predictable visual recovery. No more repetitive topographies and selective suture removal sessions. No more broken sutures on the weekend. And no more apologies to patients about their bizarre corneal irregularity despite what seemed like great surgery.
This procedure has really been a gift to both patients and corneal surgeons, and let me take a moment to recognize Gerrit Melles, Frank Price, Mark Terry and others who tireless efforts helped make DSEK the procedure it is today.
Nowadays, my cataract conversation with Fuchs' patients, while still long, is much simpler. I like to give patients a percentage chance that their cornea will decompensate based on all the data available. Of course there is some guesswork in coming up with a number, but patients do seem to find it comforting to think in terms of numerical odds. More importantly, I explain that the subsequent procedure of replacing the defective endothelial cells is a fairly simple one that takes no more than 20 minutes. The healing is fairly painless, steadily progressive and generally allows very satisfactory vision (20/25 to 20/30 with minor correction is not unusual).
I welcome readers to comment on what preoperative parameters you use to assess risk in cataract patients with Fuchs' dystrophy.
Get more expert perspective from Dr. Hovanesian live at Hawaiian Eye 2010, to be held January 17-22, 2010 at the Grand Hyatt Kauai. Learn more at OSNHawaiianEye.com.