Long-term Clinical Outcomes of Femtosecond LASER-Assisted Descemet's Stripping Endothelial Keratoplasty

Byung Gil Moon; Jae Hyung Kim; Joo Eun Lee; Myoung Joon Kim; Jae Yong Kim; Hungwon Tchah

doi:10.3341/jkos.2011.52.6.679

Journal List > J Korean Ophthalmol Soc > v.52(6) > 1009056

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Moon, Kim, Lee, Kim, Kim, and Tchah: Long-term Clinical Outcomes of Femtosecond LASER-Assisted Descemet's Stripping Endothelial Keratoplasty

Original Article

J Korean Ophthalmol Soc 2011;52(6):679-689.

Published online: 31 August 2011

DOI: https://doi.org/10.3341/jkos.2011.52.6.679

Long-term Clinical Outcomes of Femtosecond LASER-Assisted Descemet's Stripping Endothelial Keratoplasty

Byung Gil Moon, MD, Jae Hyung Kim, MD, Joo Eun Lee, MD, Myoung Joon Kim, MD, Jae Yong Kim, MD, PhD, Hungwon Tchah, MD, PhD

Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Address reprint requests to Hungwon Tchah, MD, PhD, Department of Ophthalmology, Asan Medical Center #388-1 Pungnap 2-dong, Songpa-gu, Seoul 138-736, Korea Tel: 82-2-3010-3680, Fax: 82-2-470-6440, E-mail: hwtchah@amc.seoul.kr

Received 28 September 2010 Revised 22 December 2010 Accepted 13 April 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the long-term clinical outcomes of femtosecond LASER-assisted Descemet's stripping endothelial keratoplasty (DSEK).

Methods

The clinical results of endothelial keratopathy from 11 consecutive patients who were followed up for at least 12 months after femtosecond LASER-assisted DSEK were retrospectively analyzed. The best corrected visual acuities (BCVA), manifest refractions, intraocular pressures, and perioperative complications were evaluated preoperatively and up to 24 months after the femtosecond LASER-assisted DSEK.

Results

The average follow-up period was 18 months. Postoperative visual acuity had significantly improved from 1.26 (logMAR) to 0.80 (logMAR) at 3 months (p < 0.05) and this change was maintained during postoperative follow-up. All eyes underwent successful transplantation and the donor discs were well-attached. The mean endothelial cell density continued to decrease during the follow-up period. The donor-recipient stromal interface was the area where varying degree of haziness and birefringent particles were found.

Conclusions

The femtosecond LASER-assisted DSEK was effective in creating an endothelial donor disc which resulted in rapid visual recovery and low surgically-induced astigmatism. However, the operation caused rapid decrease in endothelial cell density which requires continuing further consideration by the physician.

Keywords: Anterior segment optical coherent tomography, Confocal microscopy, Femtosecond LASER-assisted Descetmet's stripping endothelial keratoplasty

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Figure 1.

The mean pre-operative and postoperative best corrected visual acuity (BCVA) expressed as the logarithm of the minimum angle of resolution (logMAR) (A). The mean values of pre-operative and postoperative intraocular pressure measured by Tonopen (B). (^* p<0.05).

Figure 2.

The recipient's corneal thickness and the donor disc at the vertex.

Figure 3.

Slit lamp photograph after air injection into the anterior chamber of patient 6 showing corneal edema and previous stromal puncture sites (A). The high resolution anterior segment optical coherence tomography showed that interface space still remained in this patient (B). Slit lamp photograph of patient 7 showing the white interface opacity between the recipient's cornea and the donor disc (C). The anterior segment OCT of the same patient showed the thickness at the vertex and at 2.0 mm and 3.5 mm on each side of the vertex (D). The high resolution anterior segment optical coherence tomography of patient 5 showed thickened posterior corneal disc center which was suspected to be caused by the donor disc being cut unevenly at the time of operation (E).

Figure 4.

The post-operative endothelial cell density (cells/ mm²). ^* p < 0.05 in ANOVA.

Figure 5.

The grading of donor-recipient stromal interface haziness: Grade 1 (very mild haze) (A), Grade 2 (mild haze) (B), Grade 3 (moderate haze) (C), and Grade 4 (severe haze) (D).

Table 1.

The preoperative patient data, femtosecond LASER settings and follow-up periods

Patient	t Sex	Age (yr)	Diagnosis	Operation	Femtosecond laser setting (Full lamellar cut)			F/U (mon)
Patient	t Sex	Age (yr)	Diagnosis	Operation	Depth (μ m)	Diameter (mm)	Energy (μ J)	F/U (mon)
1	M	78	PBK^*	FS-DSEK^†	360	8.7	2.0	24
2	M	69	Fuchs dystrophy	FS-DSEK, CE IOL^‡	380	8.7	1.8	18
3	M	66	PBK	FS-DSEK	380	8.7	1.8	24
4	M	49	ABK^Π	FS-DSEK secondary IOL	400	8.7	1.8	24
5	M	46	Traumatic bullous keratopathy	FS-DSEK	390	8.7	1.8	18
6	M	59	PBK	FS-DSEK	360	8.7	1.8	24
7	F	27	Fuchs dystrophy	FS-DSEK	380	8.7	2.0	12
8	M	78	PBK	FS-DSEK	380	8.7	1.8	18
9	M	68	PBK	FS-DSEK	380	8.75	1.8	12
10	F	35	Fuchs dystrophy	FS-DSEK	360	8.75	1.8	12
11	M	66	ACIOL^§ PBK	FS-DSEK IOL exchange	380	8.7	2.0	12
Mean		58.27			377.3	8.7	1.85	18.00

^* PBK = pseudophakic bullous keratopathy

^† FS-DSEK = femtosecond laser-assisted descemet's stripping endothelial keratoplasty

^‡ CE IOL = cataract extraction with intraocular lens implantation

^Π ABK = aphakic bullous keratopathy

^§ ACIOL = anterior chamber intraocular lens.

Table 2.

Patient's preoperative and postoperative clinical data

Patient	Preoperative exam			3 months			6 months			12 months
Patient	BCVA^*(logMAR)	IOP^†(mm Hg)	Astig^‡(D^§)	BCVA (logMAR)	IOP (mm Hg)	Astig (D)	BCVA (logMAR)	IOP(mm Hg)	Astig (D)	BCVA (logMAR)	IOP (mm Hg)	Astig (D)
1	1.52	15	2.75	0.52	14	2.25	0.70	11	NA	0.80	11	3.12
2	1.00	16	4.5	0.70	18	NA	0.70	12	NA	0.80	14	1.75
3	2.20	16	1.75	0.52	12	0.5	0.49	13	NA	0.52	34	1
4	0.80	21	1.5	1.00	20	0	1.15	19	NA	1.30	20.5	NA
5	2.30	19	2.5	0.49	17	2.5	NA	NA	NA	NA	NA	NA
6	2.20	17	2.6	0.90	18	0	1.00	17	2	0.70	19	1.37
7	0.70	18	1	0.10	12	1	0.70	13	NA	0.52	11	0.25
8	0.52	18	NA	1.52	15	NA	1.00	20	0.5	0.90	22	1.75
9	1.00	11	NA	0.80	17.5	NA	0.70	20	0.75	0.70	22	NA
10	1.52	17	1	0.80	19	NA	0.49	17	1.5	NA	NA	NA
11	1.52	16	NA	1.52	40	2	1.52	22	NA	1.52	20	NA

^* BCVA = best corrected visual acuity

^† IOP = intraocular pressure

^‡ Astig = astigmatism

^§ D = diopters.

Table 3.

Postoperative complications and management for each case

Case	Complication	Time	Management
2	Graft dehiscence	POD2	Air injection & reposition
	Rejection	PO12 mon	SC^* dexamethasone injection
	Rejection	PO18 mon	SC dexamethasone injection
3	IIOP^†	PO2 wk	IOP lowering agents
	Interface opacity	PO2 wk	Frequent topical steroids
	Rejection	PO5.5 mon	SC dexamethasone injection
4	Uneven donor corneal thickness	PO1 mon	Observation
	IIOP	PO1 mon	A/C^‡ tapping, IOP lowering agents
	Rejection	PO2 mon	SC dexamethasone inj, IV^§ methylprednisolone
5	IIOP	POD1	IOP lowering agents
	Graft dehiscence	POD3	Air injection
6	IIOP	PO1 mon	IOP lowering agents
	Corectopia	PO24 mon	Observation
7	Interface opacity	PO3 wk	Frequent topical steroids
8	Interface opacity	PO2 wk	Observation
	IIOP	PO2 wk	IOP lowering agents
	Diffuse interface opacity	PO9 mon	Frequent topical steroids
9	IIOP	PO2 mon	IOP lowering agents
10	Anterior uveitis	PO1 mon	A/C irrigation
	Graft dehiscence	PO1 mon	Air injection
	Interface opacity	PO3 mon	Frequent topical steroids
11	Graft dehiscence	PO1 wk	Air injection

^* SC = subconjunctival

^† IIOP = increased intraocular pressure

^‡ A/C = anterior chamber

^§ IV = intravenous.

Table 4.

The thickness of donor disc measured at vertex and 2 mm/3.5 mm at nasal and temporal side

Patient	The thickness of donor disc (μ m)					Exam period (mon)
Patient	Vertex	Temporal 2 mm	Nasal 2 mm	Temporal 3.5 mm	Nasal 3.5 mm	Exam period (mon)
1	147	142	211	156	150	5
2	168	135	151	153	121	4
3	130	124	219	185	265	6
4	417	286	239	208	200	6
5	147	143	285	177	418	4
6	163	200	227	189	260	3
7	245	180	299	268	289	3
8	147	202	155	354	183	3
9	246	214	277	310	356	4
10	147	177	179	242	242	3
11	246	249	244	285	285	6

Table 5.

The grading of donor-recipient stromal interface haze, other interface findings, and best-corrected visual acuity in all patients

Patient	PostDSEK (mon)	Donor-recipient stromal interface	Other findings	BCVA^* (logMAR^†)
1	3	3	Mild birefringent bodies	0.52
	12	4	Mild birefringent bodies	0.80
2	1	2	Mild birefringent bodies	0.70
	8	1	Mild birefringent bodies	0.80
3	2	4	Severe birefringent bodies	0.90
	9	2	Mild birefringent bodies	0.52
4	6	1	No birefringent bodies	1.15
	12	1	Mild birefringent bodies	1.30
5	2	3	Mild birefringent bodies	1.30
	20	3	Mild birefringent bodies	1.30
6	1	2	Mild birefringent bodies	1.52
	18	2	Moderate birefringent bodies	0.90
7	3	2	Mild birefringent bodies	0.10
	18	2	Mild birefringent bodies	0.30
8	3	4	Severe birefringent bodies	1.52
	9	3	Moderate birefringent bodies	1.00
9	1	4	Severe birefringent bodies	1.00
	3	2	Moderate birefringent bodies	0.80
10	1	3	Mild birefringent bodies	1.52
	2	3	Moderate birefringent bodies	1.0
11	1	3	Moderate birefringent bodies	1.30
	3	1	Mild birefringent bodies	1.52

^* BCVA= best corrected visual acuity

^† logMAR = logarithm of the minimum angle of resolution.

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