Descemet Stripping Automated Endothelial Keratoplasty – Valuable Option For Treating Bullous Keratopathy In Complex Eyes, Needing Concurrent Intraocular Lens Exchange Or Reposition In The Presence Of Posterior Capsule Break Or Zonular Rupture

In a world with increasing number of Descemet Membrane Endothelial Keratoplasty (DMEK) keratoplasties, as being a highly appreciated lamellar procedure for endothelial disorders, our purpose is to evaluate and present the efficacy and safety of the „old fashioned” Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) in eyes with bullous keratopathy associated with anterior chamber intraocular lenses (ACIOLs), or pupillary IOLs, or dislocated posterior chamber intraocular lenses (PCIOLs) – all of them needing to be addressed, in order to prolonge the corneal graft survival.

We also present the surgical difficulties of the combined procedure in these eyes, highlighting the benefit of DSAEK as an easier and safer technique than DMEK.

Oculus Eye Clinic Bucharest

We studied 15 patients who presented with bullous keratopathy after cataract surgery, having either pupillary or ACIOL, or dislocated PCIOL, all eyes having communication between the anterior and posterior segment, through a partial or complete absence of the posterior capsule, or through zonular rupture.

We performed combined DSAEK with either reposition by suture at sclera of the dislocated PCIOL, or removal of the pupillary / ACIOL, with implantation of a PCIOL in sulcus on posterior capsule remnants, or by suture at sclera.

The DSAEK step was the same in all cases: the lamella was prepared by the surgeon, using artificial anterior chamber. Host Descemet was stripped under air and no vascoelastic was used at all, throughout the procedure.

All surgeries were uneventful.

Technically, the most difficult part of the surgery was the reposition or the exchange of the preexisting IOL, due to the poor visualization through an opaque cornea and to the reduced space for maneuvers in a closed eye.

Early postoperatively, despite the communication from anterior to posterior segment, the air bubble remained in the anterior chamber, keeping the DSAEK lamella fully attached, except one eye, which needed re-bubble. The cornea became clear after one month in all cases and the PCIOL was and remained well centered. Mean visual acuity improved significantly, from 0, 05 to 0,6. Moderate transitory elevation of the intraocular pressure was noticed in all cases, but controllable with medication.

Although DMEK is more and more used in bullous keratopathy due to its faster visual recovery, there are still many cases, where DSAEK finds its place and utility.

In our group of difficult eyes, DSAEK proved to be a safe and efficient procedure, easy to be performed, while addressing the “guilty” IOL was the most challenging part of the combined surgery.

In eyes with free communication between the anterior and posterior segment, with high risk for early air-bubble migration from anterior to posterior cavity, the re-bubble rate can be high, but DSAEK graft showed good adherence to the stroma with only one re-bubble in our group, recommending even more DSAEK as a valuable choice for posterior lamellar keratoplasties in these complex eyes.