Retrospective comparison of staged versus combined cataract surgery and Descemet’s-stripping endothelial keratoplasty (DSEK) in patients with Fuchs’ Dystrophy Christine Garcia, MS 2, 1 Omar Krad, MD, 2 Amy Lin, MD 2 Loyola University Chicago, Stritch School of Medicine, Maywood, IL, 1 Department of Ophthalmology, Loyola University Health System, 2 Maywood, IL Introduction Fuchs’ endothelial dystrophy is a progressive hereditary corneal disease characterized by deterioration of the endothelium and overlying Descemet’s membrane (Figure 1). Patients with Fuchs’ dystrophy may develop loss of vision from corneal and stromal edema and excrescences of the Descemet’s membrane (“corneal guttata”). Because the visual disturbances are not typically seen until after age fifty, patients frequently have coexisting visually significant cataracts. The recently developed procedure indicated for patients with Fuchs’ dystrophy, Descemet’s Stripping Endothelial Keratoplasty (DSEK), can be performed in a combined surgery following cataract extraction with intraocular lens placement (CEIOL) or in a staged fashion with DSEK following CEIOL. To date there is no significant evidence that one method of performing the cataract and DSEK surgeries, staged or combined, is more advantageous, but there have been a few studies completed that indicate possible benefits of each protocol. Covert and Koenig (2007) specified that combined surgeries would enable the patient to undergo a single surgery with an overall shorter recovery time. However, according to Yoo et al. (2008) more surgical working space and better stability of the anterior chamber after recovery from cataract surgery could offer more beneficial conditions for performing DSEK, namely greater ease of DSEK donor graft tissue insertion and positioning. This may minimize the damage to the endothelial cells in the donor graft, with less likelihood of graft dislocation or failure. There is also the possibility of avoiding DSEK altogether should there be adequate visual recovery from cataract surgery. A Chicago area multi-center retrospective comparison of visual acuity and central corneal thickness was performed to determine which surgical protocol, staged versus combined, produces better clinical outcomes. Objectives 1. Report the outcomes of staged cataract extraction by phacoemulsification technique with IOL placement followed by DSEK (group 1) compared with the outcomes of combined cataract extraction with IOL placement and DSEK (group 2) 2. Evaluate advantages and disadvantages to performing staged versus combined phacoemulsification and DSEK procedure. 3. Determine the percentage of patients who were scheduled for staged phacoemulsification and DSEK procedures, but did not undergo DSEK because of favorable visual outcome and corneal appearance after cataract surgery. 4. Report the criteria (indications) for performing cataract surgery and/or DSEK in a large metropolitan area. Results cont’d Conclusion which will specifically include more combined cataract and DSEK surgery cases. This will make group 2 stronger, and contribute to the overall goal of fifty patients in each group. Using the data obtained thus far, general surface analysis showed a trend in which patients who underwent combined CEIOL and DSEK surgeries had a 29. 7% greater improvement in visual acuity than patients who underwent staged surgeries (Table 1). Also, of the 28 patients who underwent staged procedures, five had a graft dislocation treated with a repositioning, whereas two of the five patients who underwent simultaneous procedures had the same complication. This will be studied further to possibly indicate which surgical protocol has better visual outcomes and less postoperative complications. Data collection continues in order to increase the power of the study. When complete, a t-test will be performed to analyze any differences in the visual acuities and central corneal thicknesses between the two groups. At this time, the study is in progress. With the multi-center nature of the project, data continues to be collected. Thus far however, the trend seems to show better visual outcomes in patients who had combined cataract and DSEK surgeries, but a smaller percentage of cases with complications (graft dislocation) in the patients who had staged cataract and DSEK surgeries. Further analysis of the incoming data may contribute to either approval or disapproval of these trends. Evaluation of patients who did not undergo DSEK because of significant visual improvement after cataract surgery is inconclusive with the data at hand. The definitive reasons that the four post. CEIOL patients were still awaiting DSEK surgeries in the same eye were not charted. It was unclear whether or not the DSEK surgeries in these patients were postponed due to favorable visual outcome or another clinical indication. A considerable obstacle found with the retrospective study was incomplete charting and number of subjects who fit the inclusion/exclusion criteria. The incoming data will be beneficial, however, in order to make more significant conclusions comparing the staged versus combined procedures. Figure 1: Histopathology of the posterior cornea in Fuchs' dystrophy. The thickened Descemet's membrane with nodular excrescences (guttata) is seen. Endothelial cells are sparse. Results Retrospective chart review was carried out for patients identified to have both cataracts and Fuchs’ endothelial dystrophy. The multi-center study included review of 28 eyes from 28 patients who underwent staged CEIOL followed by DSEK (group 1) and 5 eyes from four patients that underwent a combined CEIOL and DSEK surgery (group 2). Visual outcomes were compared using log. MAR visual acuity and central corneal thickness measurements before and after the surgeries at post-operative months 1, 3, 6, and 12. At the present time, more data is being gathered from University of Chicago and Wheaton Eye Clinic, Table 1: Pre-operative and post -operative best spectaclecorrected visual acuity (BSCVA) in patients with staged or combined cataract and DSEK surgeries. Post-operative BSCVA is at 12 months or the latest post-operative data available within one year. Lower log. MAR values indicate better vision. **Graft dislocations. References Covert, D. J. , Koenig, S. B. 2007. “New triple procedure: Descemet’s stripping and automated endothelial keratoplasty combined with phacoemulsification and intraocular lens implantation. ” Ophthalmology. 114(7): 1272 -1277. Krachmer, J. H. , Palay, D. A. Cornea Atlas. 2 nd ed. Elsevier Inc. , 2006. p 176. Price, M. O. , Price, F. W. 2007. “Descemet’s stripping endothelial keratoplasty. ” Current Opinion in Ophthalmology. 18: 290 -294. Terry, M. , Shamie, N. , Chen, E. , Hoar, K. , Friend, D. 2008. “Endothelial Keratoplasty: A simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block. ” Ophthalmology. 115(7): 1179 -1186. Yoo, S. H. , Kymionis, G. D. , Deobhakta, A. A. , Ide, T. , Manns, F. , Culbertson, W. W. , O’Brien, T. P. , Alfonso, E. C. 2008. “One-year results and anterior segment optical coherence tomography findings of Descemet stripping automated endothelial keratoplasty combined with phacoemulsification. ” Ophthalmology. 126(8): 1052 -1055. Acknowledgements: This work was supported by the Richard A. Perritt Charitable Foundation.
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