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Achyut N. Mukherjee, Peter Thomas, George Voyatzis, Madhavan S. Rajan; Analysis Of Optical Factors Influencing Visual Outcomes In Endothelial Keratoplasty With Optimised Graft Thickness (thin-dsaek). Invest. Ophthalmol. Vis. Sci. 2012;53(14):3135.
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To assess visual outcomes and optical performance in thin DSAEK with a surgical technique directed at obtaining thinner donor grafts (< 130 um).
A consecutive cohort of patients undergoing thin DSAEK underwent pre and postoperative assessment at 1, 3 and 6 months. An automated microkeratome (Moria) with standardised pressure, pass duration and pachymetry were used, aiming for grafts < 130 um. Postoperatively, donor graft thickness, shape profile, anterior and posterior corneal curvature changes were analysed by ocular coherence tomography (AS-OCT, Zeiss) and scheimpflug topography (Pentacam). Qualitative and quantitative analysis of the graft-host interface was undertaken using in vivo confocal microscopy and OCT with a custom automated image analysis programme Endothelial density and Pre-operative donor characteristics were analysed.
48 eyes of 46 patients underwent Thin-DSAEK surgery. Mean age was 73yrs (SD 13 range 23 -98) and 33 eyes (65%) underwent combined phacoemulsification with DSAEK. Preoperative mean donor thickness was 607u (SD 54) resulting in a mean endothelial graft thickness of 103.5 um (SD 31.8 range 40-168) using Thin DSAEK technique. 75% of grafts were less than 130u at 6 months. Mean spherical equivalent error was +0.76D (SD 1.0) with mean anterior and posterior astigmatism 1.7 and 0.49D, mean posterior curvature -6.6D. Mean interface OCT reflectance increased by 40.1% (SD 25.3) with correlated cellular changes of activated keratocytes, stromal disarray and interface debris. Mean endothelial cell loss was 34.7% (SD 12.2) at 6 months. Primary failure and graft detachment were encountered in 4 (8.3%) and 3 (6.2%) eyes respectively. 7 eyes (14%) had visual comorbidity. Excluding comorbidity, mean acuity was 0.31 (SD0.22), 0.23 (SD0.15) and 0.21(SD 0.16) at 1,3 and 6 months, with 64% 20/30 Snellen or better and 82% 20/40 or better at 3 months postoperatively. At 6 months, 94% of thinner (< median 108u) grafts saw 20/30 or better vs. 53% of thicker grafts. (p=0.017).
The Thin DSAEK technique results in faster visual recovery with a high percentage of patients achieving 20/30 Snellen’s acuity, and a significantly greater proportion in thinner donors. Future developments in improving graft thickness predictability would enable better outcomes in endothelial keratoplasty.
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