Arun C. Gulani, MD, MS, focuses his blog on custom designed approaches to complex cases using practical surgical techniques.

BLOG: Descemet's stripping with endothelial rejuvenation

I would like to share my experience in two patients now several months postop who had pseudophakic bullous keratopathy and cleared at 1 month after Descemet’s stripping surgery to a very satisfied vision and clarity outcome.

Both patients were prepared for Descemet’s stripping automated endothelial keratoplasty surgery and the possibility of proceeding in a staged fashion.

One of the patients previously had a successful DSAEK surgery in her right eye and was interested in proceeding without the transplant and air bubble that required her to lay on her back for 24 hours after surgery due to back problems.

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Figure 1. Preop endothelial study.

In this case, after topical anesthesia, similar steps to DSAEK surgery were undertaken with preparation of paracentesis: one temporal and one medial with surgeon position at 12 o’clock in case an entry incision was needed so it was protected superiorly under the lid.

The central cornea was marked, and a 4-mm zone was delineated. Under viscoelastic (Viscoat; chondroitin sulfate and sodium hyaluronate, Alcon), the Gulani Keyhole Transplant multidirectional modified Sinskey instrument was used from the temporal paracentesis, and the central Descemet’s membrane was scored and carefully peeled in a continuous rhexis pattern. This was checked to be complete, and the procedure was completed with no removal of epithelium.

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Figure 2. Postop endothelial study.

Viscoat was removed using automated irrigation and aspiration, exchanged for balanced salt solution and hydrated to watertight closure.

Moloney and colleagues first defined and published his technique and used it in Fuchs’ endothelial dystrophy cases while Colby has used it during cataract surgery in cases of Fuchs’ endothelial dystrophy.

The use of this concept in pseudophakic bullous keratopathy may be the first, and the  patient sees clearly (unaided 20/30) in the operated eye with documented change in endothelial study along with clarity.

Additionally, this patient at 1 month postop prefers clarity in this eye over previously successful DSAEK surgery in her other eye.

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Figure 3. DSAEK in right eye and Descemet’s stripping with endothelial rejuvenation in left eye.

 

This procedure was modified in another case of pseudophakic bullous keratopathy in which, instead of viscoelastic, an anterior chamber maintainer was used, which is my usual technique for DSAEK, and Descemet’s membrane was peeled in the central 4 mm along with central epithelial removal.

The patient experienced improved vision at month 1 with increased perception and quality of vision (20/25).

Of course, long-term follow-up is needed along with determining patient criteria for replicable results.

The two cases above in February 2017 may be the first, and I am certainly excited about the future of improving vision of Fuchs’ patients without transplants by possibly injecting stem cells in the eye and envision a conceptual surgery that could allow migration from an internal or external source of stem cells accordingly.

References:

Moloney G, et al. Can J Ophthalmol. 2015;doi:10.1016/j.jcjo.2014.10.014.

Borkar DS, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000915.