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N. R. Fram, J. H. Skalet, D. G. Hwang; Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) in a High-Risk Patient Population. Invest. Ophthalmol. Vis. Sci. 2008;49(13):1947.
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To determine the incidence of graft repositioning, graft failure, visual outcomes and endothelial cell density at 6 months after DSAEK in a high-risk patient population.
Retrospective case review
We reviewed the records of 38 eyes of 33 consecutive patients after DSAEK performed by a single surgeon (DGH) from 2006-2007. The follow-up period ranged from 1-19 months (mean 6 months). The clinical indications for endothelial keratoplasty were Fuchs' endothelial dystrophy (55%), pseudophakic bullous keratopathy (34%), failed penetrating keratoplasty (8%) and aphakic bullous keratopathy (3%). Patients were stratified into two groups based on predicted risk of primary graft non-attachment: high-risk patients and low-risk patients. High-risk patients (n=20) were defined as those with a pre-operative history of a glaucoma filtering or tube procedure, pars plana vitrectomy (PPV), and/or anterior vitrectomy. Low-risk patients (n=18) were defined as patients without any of these high-risk factors. In this series, high-risk patients comprised 52% of the total patient population. Repositioning and/or rebubbling with 8% SF6 gas was required in 7/20 (35%) of high-risk patients and 2/18 (11%) of low-risk patients (p=.13). Graft failure occurred in 3/20 (15%) of high-risk patients and 1/18 (5.6%) of low-risk patients (p=.60). Endothelial cell density at 6 months was reviewed for 11/38 patients. The mean preoperative donor endothelial cell density was 2849 cells/mm SD +/- 170. The mean post-operative endothelial cell density at 6 months in high-risk patients was 1584 cells/mm +/- 524 (54% loss) and 1334 cells/mm +/- 446 (55% loss) in low-risk patients (p=0.60). Although visual acuity was lower in high-risk patients due to a higher incidence of associated ocular co-morobidities that limited visual potential, 50% of patients were able to achieve a Snellen visual acuity of >20/80 at 6 months with an average of 2.25 lines of improvement.
Descemet's Stripping Automated Endothelial Keratoplasty can be successfully performed in a high-risk subpopulation. Rates of graft repositioning and primary graft failure are higher in this subgroup than in a low-risk DSAEK subgroup. Endothelial cell density loss appears comparable between high-risk and low-risk groups and is consistent with that described in the literature. Despite the presence of ocular co-morbidities, high-risk patients can achieve meaningful visual improvement after DSAEK.
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