Clinical Outcomes of Nd-YAG Laser Membranotomy in Retained Host Corneal Membrane after Keratoplasty

Yong Chan Kim; Jae Hyung Hwang; Man Soo Kim

doi:10.7469/JKOS.2015.56.05.664

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Kim, Hwang, and Kim: Clinical Outcomes of Nd-YAG Laser Membranotomy in Retained Host Corneal Membrane after Keratoplasty

Original Article

J Korean Ophthalmol Soc 2015;56(5):664-671.

Published online: 7 September 2015

DOI: https://doi.org/10.7469/JKOS.2015.56.05.664

Clinical Outcomes of Nd-YAG Laser Membranotomy in Retained Host Corneal Membrane after Keratoplasty

Yong Chan Kim, MD¹, Jae Hyung Hwang, MD, PhD², Man Soo Kim, MD, PhD¹

¹Department of Ophthalmology, The Catholic University of Korea College of Medicine, Seoul, Korea

²Department of Ophthalmology, Inje University College of Medicine, Busan, Korea

￭ Address reprint requests to Man Soo Kim, MD, PhD Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, #222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea Tel: 82-2-2258-1188, Fax: 82-2-590-4909 E-mail: mskim@catholic.ac.kr

Received 27 June 201420 October 2014 Accepted 20 April 2015

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.

초록

Purpose:

To evaluate the clinical efficacy and shortcomings of neodymium-doped yttrium aluminum garnet (Nd-YAG) laser membranotomy in inadvertently retained host membrane.

Methods:

Among 742 patients who underwent penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) surgery at Seoul St. Mary’s Hospital between January 2007 and May 2013 by a single surgeon, 10 patients had a thin, opaque membrane in the anterior chamber observed under slit lamp examination and both a subjective decrease in visual acuity and decrease i best corrected visual acuity. A single surgeon performed membranotomy using the Nd-YAG laser at 4.9 months after graft surgery. In this study we compared the differences in visual acuity, endothelial cell count and correlations between distance from donor endothelium and retained host membrane and endothelial loss before and after the graft surgery.

Results:

Patients who had Nd-YAG laser membranotomy performed on the retained host membrane showed significant improvements in visual acuity ( p = 0.039). Donor endothelial cell count was significantly reduced 1 month after Nd-YAG laser. The average distance between donor endothelium and retained host membrane was 712.0 ± 217.5 µm. The distance and the decreased donor endothelial cell count were not statistically correlated (R² = 0.39, p = 0.072). There were no significant complications after the laser membranotomy.

Conclusions:

Inadvertently retained host membrane forms close to the donor endothelium as identified on optical coherence tomography (OCT) images. Nd-YAG laser membranotomy significantly affected clear vision but endothelial cell count loss was also observed.

Keywords: DALK surgery, Endothelial cell count, Nd-YAG laser, PKP surgery, Retained host membrane

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Figure 1.

Retained host membrane after keratoplasty (slit lamp photo). (A) Retained host membrane in front of the pupil is seen in slit lamp photo taken at the day after surgery. The opacity of the membrane is marked, even by naked eyes. Clear space is seen between the membrane and recipient’s peripheral cornea. (B) Retained host membrane is perforated in rec-tangular shape, 5 months after the surgery. Visual axis is well spared with 2.0 mm wide, 2.5 mm long perforation area. The cornea is transparent.

Figure 2.

Cross sectional image at the level of grafted cornea and retained host membrane. (A, B) Distance between graft endothelium and retained host membrane is measured with spectralis-domain HRA anterior OCT imaging taken at the day after surgery. Distance is variable but relatively close to the graft cornea endothelium. Retained host membrane itself is very thin. (C) Spectralis OCT taken 5 months after the surgery. Retained host membrane is perforated, graft corneal endothelium is intact. The membrane is noticeably thicker. HRA = Heidelberg retina angiograph; OCT = optical coherence tomography.

Table 1.

Baseline ocular characteristics of the study group by primary cause and surgical procedure

Patient	Sex	Age (years)	Primary cause of corneal decompensation	Surgical procedure	Suspected nature of the retention membrane	Membrane detection time (days)^*	Laser apply time (months)^†
1	F	68	Traumatic scar	DALK	Double anterior chamber	1	4
2	M	67	BK after surgery	PKP	Detached host DM	1	7
3	M	48	Chemical burn	PKP	Detached host DM	1	4
4	M	38	BK after surgery	PKP	Detached host DM	1	5
5	M	64	Lipid degeneration	DALK	Double anterior chamber	1	7
6	F	67	Granular dystrophy	DALK	Double anterior chamber	1	4
7	F	73	ICE syndrome	PKP	Detached host DM	1	5
8	F	53	Traumatic scar	DALK	Double anterior chamber	1	4
9	M	69	ICE syndrome	PKP	Detached host DM	1	4
10	F	22	Acanthoamoeba keratitis	DALK	Double anterior chamber	1	5
Average		56.9 ± 16.5				1	4.9 ± 1.2

Values are presented as mean ± SD unless otherwise indicated.

DALK = deep anterior lamella keratoplasy; BK = bullous keratopathy; PKP = partial penetrating keratoplasy; DM = descemet membrane; ICE = iridocorneal endothelial.

^* Days after surgery;

^† Months after surgery.

Table 2.

Pre- and post operative visual acuity (log MAR)

Patient	BCVA 1 week before PKP (log MAR)	BCVA 1 month after PKP (log MAR)^*,†	BCVA 1 month after laser apply (log MAR)^*	BCVA 6 months after laser apply (log MAR)^*	BCVA 12 months after laser apply (log MAR)^*
1	1.4	1.1	0.8	0.7	1.0
2	1.6	2.4	2.4	2.4	2.4
3	1.8	1.2	0.3	0.4	1.4
4	0.9	0.6	0.9	0.9	0.8
5	1.7	1.5	0.4	0.5	0.5
6	2.4	1.9	0.6	0.5	0.4
7	2	1.7	1.4	1.4	1.6
8	2	1.8	1.7	1.8	2.0
9	1.8	0.6	0.3	0.3	0.3
10	1.8	2.4	2.4	2.4	2.4
Average	1.74 ± 0.21	1.52 ± 0.18	1.12 ± 0.13	1.18 ± 0.78	1.28 ± 0.8

Values are presented as mean ± SD unless otherwise indicated.

log MAR = logarithm of the minimum angle of resolution; BCVA = best corrected visual acuity; PKP = partial penetrating keratoplasy.

^* Laser apply timing is variable within 2 weeks due to outpatient department schedule;

^† Laser is not yet applied 1 month after PKP.

Table 3.

Pre- and postOperative endothelial cell counts by specular microscopy

Patient	CD before PKP^*,†	CD 1 month after PKP^*,†,‡	CD 1 month after laser^*,†	CD 6 months after laser^*,†	CD 12 months after laser^*,†
1	Error ^c	2,759	1,709	584	729
2	Error ^c	1,461	Error ^c	Error ^c	Error ^c
3	453	2,702	1,908	1,109	1,342
4	Error ^c	1,883	1,033	984	702
5	Error ^c	2,049	1,024	786	724
6	Error ^c	2,369	1,248	675	724
7	Error ^c	1,915	1,048	849	801
8	Error ^c	1,742	629	Error ^c	Error ^c
9	Error ^c	1,097	880	866	840
10	Error ^c	903	548	426	Error ^c
Average	453	1,888 ± 621.7	1,114.1 ± 451.6	784.9 ± 219.3	837.4 ± 227.9

Values are presented as mean ± SD unless otherwise indicated.

CD = cell density; PKP = partial penetrating keratoplasy; Error^c = unable to identify specific count due to corneal edema.

^* Corneal endothelial cell numbers in 1 mm² area;

^† Timing of specular microscopy is variable within 2 weeks due to outpatient department schedule;

^‡ Laser is not yet applied 1 month after PKP.

Table 4.

Pre- and post operative corneal thickness by ultrasound pachymetry

Patient	CT before PKP (μ m)	CT 1 month after PKP (μ m)^*	CT 1 month after laser (μ m)	CT 6 months after laser (μ m)	CT 12 months after laser (μ m)
1	404	499	504	561	543
2	874	605	689	764	787
3	584	593	587	543	583
4	889	652	651	800	868
5	411	569	629	661	682
6	558	669	624	667	674
7	525	564	597	699	678
8	768	771	784	841	883
9	590	564	564	689	712
10	342	893	542	538	572
Average	594.5 ± 192.9	637.9 ± 116.4	617.1 ± 79.5	676.3 ± 106.1	698.2 ± 118.1

Values are presented as mean ± SD unless otherwise indicated.

CT = corneal thickness; PKP = partial penetrating keratoplasy.

^* Laser is not yet applied 1 month after PKP.

Table 5.

Distance between donor endothelium and donor endothelial cell count differential after laser and Nd-YAG laser delivered energy and numbers of pulses

Patient	Pulse energy (mJ)	Number of pulses	Distance between donor endothelium and retained host membrane (μ m)^*	Differential in cell counts 1 month after laser (cells/mm³)^†
1	1	17	474	1,050
2	0.8	21	1,186	N/A
3	1	11	696	794
4	1	16	831	850
5	0.8	27	591	1,025
6	1	17	496	1,740
7	0.8	14	714	867
8	1	10	675	494
9	0.8	13	911	23
10	0.8	9	546	903
Average	0.9 ± 0.1	15.5 ± 5.5	712 ± 217.5	821.3 ± 469.0

Values are presented as mean ± SD unless otherwise indicated.

Nd-YAG = neodymium-doped yttrium aluminum garnet; N/A = not available.

^* Corneal endothelial cell numbers in 1 mm² area;

^† Differential of cell count between 1 month after partial penetrating keratoplasy and 1 month after laser timing of specular microscopy is variable within 2 weeks due to outpatient department schedule.

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