FEMTOSECOND LASER-ASSISTED NON-DESCEMET’S STRIPPING ENDOTHELIAL KERATOPLASTY AFTER FAILED PENETRATING KERATOPLASTY FOLLOWED WITH PHACOEMULSIFICATION AND TORIC INTRAOCULAR LENS IMPLANTATION

To describe the staged process of visual rehabilitation of the patient having failed penetrating keratoplasty (PKP) due to endothelial dysfunction (ED) managed with femtosecond laser-assisted non-Descemet stripping endothelial keratoplasty (FS-nDSEK) first followed with phacoemulsification (PE) and hydrophobic toric intraocular lens (IOL) implantation as a secondary procedure

1.S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russia

2.A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia

A 49 years-old man with failed PKP graft and cataract presented to our clinic complaining the low vision of the left eye (LE). PKP was performed 10 years for keratoconus of the same eye. On admission, preoperative examination showed low BCVA - 0,005 on the LE. In right eye BCVA was 0,7. According to optical coherence tomography (OCT), the central corneal thickness (CCT) was 956 µm. No endothelial cell (EC) count was possible. As a first stage, the FS-nDSEK was done utilizing the LDV Z8 femtosecond laser (Ziemer, Switzerland) for graft preparation from the endothelial side. The hydroxypropyl methylcellulose (HPMC 1%) was applied to the endothelium prior to laser applanation. One week postoperatively the eye was quiet, the patient showed increase at BCVA and corneal edema decrease, BCVA increased up to 0,05. The CCT averaged 640 µm. Six months postoperatively the CCT averaged 535 µm. ECD was 1985 cells/mm2. Patient underwent a comprehensive ophthalmologic examination including refractometry, ocular biometry (IOL Master 700), corneal topography (Tomey, TMS-5), corneal tomography (Pentacam). Preoperative examination revealed regular with-the-rule LE corneal astigmatism. According to tomography (Pentacam) corneal curvature was 43.7 axis 156.9° and 46.6 axis 66.9°. The data of Pentacam and IOL-Master correlated with each other. The target postoperative refraction was set at –0.50D spherical equivalent (SE). 6 months after FS-nDSEK, PE combined with a toric IOL implantation was performed. First day postoperatively the eye was quiet, the patient showed increase of BCVA with reduction in the manifest astigmatism. BCVA was 0,8 with SE -0,5D. The CCT averaged 551 um. 12 months postop FS-nDSEK and six-month postop PE+IOL UCVA and BCVA were 0.7 and 0.8, respectively, with SE -0.75D. The CCT averaged 580 µm and ECD 1372 cells/mm2.

FS-nDSEK is an effective method for the treatment of ED of failed PKP graft, which allows to achieve resorption of edema in the early postoperative period and to reduce the risk of graft rejection. A two-stage treatment strategy was chosen to correct postkeratoplasty astigmatism and achieve high functional results. Endothelial viscoprotection at the applanation stage made it possible to reduce intraoperative endothelial loss and thereby ensure a fairly high percentage of EC survival in the late postoperative periods. At 6- and 12-months postoperative periods corneal EC loss was 28% and 50% respectively.