Triple procedure preferred over staged approach for DSAEK and cataract removal

With proper technique, Descemet's stripping automated endothelial keratoplasty (DSAEK) with phacoemulsification is not any riskier than DSAEK alone, said Mark A. Terry, MD, director of cornea services, Devers Eye Institute, Portland, OR.

Dr. Terry presented outcomes from DSAEK cases being followed prospectively in an ongoing IRB-approved study at the institute. The series includes 223 eyes, of which 52% underwent a triple procedure with DSAEK, phacoemulsification, and IOL implantation.

Results showed that in the entire series of 223 eyes where an ophthalmic viscosurgical device (OVD) (Healon, Advanced Medical Optics) was used in all procedures, the donor dislocation rate was very low (1.3%). Dislocation rates were similar comparing eyes that underwent DSAEK alone with those that had triple surgery, and there was also no evidence that DSAEK combined with cataract surgery increased endothelial cell loss measured at 6 months. There were no cases of primary graft failure in the entire series of 223 eyes, precluding any analysis of the effect of triple surgery on that outcome.

"Some surgeons advocate doing phacoemulsification first and DSAEK weeks later based on a concern about residual viscoelastic promoting graft dislocation and fear that the newly placed IOL will be unstable and touch the graft, causing endothelial damage," Dr. Terry said. "However, a combined procedure reduces cost, time and risk for the patient, and our data present an evidence based-rationale for combining DSAEK with phacoemulsification in eyes with significant Fuchs dystrophy and cataract formation."

He noted that initial laboratory studies were performed to investigate the suitability of the OVD use during DSAEK. Their results confirmed 1) the extremely cohesive nature of the OVD does not allow it to coat the anterior chamber surface, and 2) the OVD is easily and completely removed from the anterior chamber surface with a simple I/A technique.

In order to prevent graft-IOL touch, Dr. Terry emphasized creating a small diameter (4.5 mm or less) capsulorhexis to secure the IOL in the capsular bag and to constrict the pupil pharmacologically prior to insertion of the graft.