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S. Heinzelmann, P. Maier, D. Böhringer, T. Reinhard; Mechanical and Femtosecondlaser-Assisted Dsaek vs. Penetrating Keratoplasty for Fuchs Endothelial Dystrophy and Bullous Keratopathy. Invest. Ophthalmol. Vis. Sci. 2009;50(13):2213.
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Until recently, penetrating keratoplasty (pKP) was the only option to restore vision in advanced Fuchs endothelial dystrophy and bullous keratopathy. This procedure is effective but may induce considerably amounts of corneal astigmatism. Descemet stripping automated endothelial keratoplasty (DSAEK) is a new therapeutic option. This approach has the advantage of not requiring open sky procedures and graft suturing. Therefore it can be performed in local anaesthesia. Near Visual acuity sufficient for reading is reported to be possibly achieved within the first postoperative weeks. Optical performance beyond, however, is potentially degraded from a stromal graft host interface in the optical zone. The femtosecond laser may be used to cut endothelial grafts for DSAEK as well as a mechanical microkeratome.
Until now we performed 21 complete DSAEK procedures using either the femtosecond laser (7) or a microkeratome (14) for the preparation of the posterior lamellae. Positioning of the graft was achieved using the method previously published by Melles et. al. for DSAEK. For the 80 penetrating keratoplasties, a guided trepanation system (diameter 8.0 mm) was used.
The first clinical observations at 2 months follow up revealed good anatomical postoperative results with low astigmatism (-2,01dpt) and a slight hyperopic shift (1,8dpt) following DSAEK. However, visual acuity (20/200-20/40) remained low in comparison to pKP (1/20-20/20). Complications were glaucoma (4,7%), rejection (4,7%) and dislocation or failure of the graft (28,5%). We will present 12 months follow up results regarding endothelial cell viability, visual function and optical performance.
The new techniques of Descemet stripping automated endothelial keratoplasty necessitate a complete reappraisal of the treatment for Fuchs endothelial dystrophy and bullous keratopathy. It could be a considerable alternative to perforating keratoplasty in elder patients who do not expect full vision or who have physical limitations to achieve it. To further investigate the effectiveness of this new surgical approach we propose a randomized clinical trial to compare early visual outcome of pKP to DSAEK, either femtosecondlaser assisted or via mechanical microkeratome.
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