Case #018

Corneal Transplant to replace old distorted Corneal Transplant.

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Case #129

DSEK – Quick procedure

This is a very good illustration of a relatively quick DSEK procedure, eliminating local anesthesia and suturing. The incision utilized was a 2.4 mm incision, although most of the time we use a 3.2 mm incision, but the corneal flap was very thin and did not require enlargement to the incision.

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Case #095

DSEK replacement of three year old DSEK

This is a patient who had DSEK performed three years earlier. Cornea had become quite edematous and a replacement was indicated. This shows the relatively straight forward replacement of a DSEK with 3.2 mm incision performed with Rand-Stein analgesia protocol (Alfentanil and Profenal.) No local anesthesia and no sutures were necessary. The procedure took only approximately fifteen minutes from beginning to end.

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Case #087

DSEK and Cataract with Management of a Number of Unusual Occurrences

This is a patient who previously had a combined cataract and DSEK done in the other eye in 2009 with a 20/20 result, spectacle free for distance.

In this eye an essentially clean successful DSEK and cataract procedure was performed but there were a number of difficulties during the procedure. There was a spontaneous opening of the anterior capsule at the main incision. This was managed cleanly without a need for vitrectomy and the posterior capsule remains intact. The lens implant decentered on dialing and needed to be turned to reposition the lead haptic in the capsule bag over the area of the open anterior capsule. This was done successfully.

When the DSEK was placed, the air went behind the iris and made the eye firm and pushed the iris anteriorly. The air was removed cleanly and replaced. A proper a.c. air bubble was achieved. The eye was very clean at the end and the surgical result is excellent. There is not likely to be any significant cell loss during the insertion.

The entire procedure is performed without local anesthetics and without intracameral or topical anesthetic. The Rand-Stein analgesia protocol was utilized with Alfentanil and Propofol, both short acting medications.

The DSEK insertion is performed by folding the DSEK flap in half with a protective coat of Occucoat in the sandwich that it creates and then the flap is pulled into the eye using a forceps going into the eye through the counterincision and out through the main incision and then dragging the folded corneal tissue through the 3.2 mm incision that was used for the cataract procedure. The wound is self sealing and no stitches were required.

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Case #070

This is a quicker more simplified DSEK in which Occucoat is used only for a small amount to fold over the cornea into a taco, otherwise Occucoat is kept off the field so that there will not be anything in the interface after the graft is in place. Occucoat is always used for making the DSEK flap since it protects the endothelium while it is on the anterior chamber maintainer.  This is a very quick clean case.  One should note that there are four old RK incisions, which were carefully avoided during the procedure.  While removing the endothelium, no separation of the RK incisions occurred.  It should be noted that the procedure was done with a 3.2 mm self-sealing incision. No sutures were necessary. No local anesthetic or intracameral anesthetic was utilized. Rand-Stein protocol was utilized with IV Alfentanil and minimal dosages of Profenal as needed. 

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Case #050

1st Surgery: This a patient that had DSEK several years ago and the cornea gradually became edematous. Surgery is performed under Rand-Stein analgesia protocol without local anesthetics with a 3.2 mm incision without the need for suturing.  The outline of the previous graft is outlined with a scorer and then the previous graft is removed without difficulty with a 90 degree scraper under OcuCoat. The OcuCoat was irrigated carefully from the eye and the new cornea is placed endothelium down upon a layer of thin OcuCoat on the conjunctival surface and pulled into the eye. The surgery itself was very brief running approximately twelve to fifteen minutes.

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2nd Surgery: The patient has had two previous DSEK operations, and also he has vitreous in the anterior chamber.  There is a central scar on the cornea that would not clear. Note that when the cornea is removed, great care is exercised not to leave a shelf but to push against the host cornea with the corneal scissors so that there will be a flat vertical bed without a shelf for the cornea to insert into. The cornea is removed and one can see that the old DSEK graft remains and is peeled off separately.  There is vitreous in the anterior chamber, and this is removed with low pressure by pulling on the vitreous with a Weck-cel sponge.  In doing it with a small pupil and because, the source of the vitreous is around the edge of the implant through a weak zonular area, it was possible to remove the vitreous and have it retract so that a full mechanical vitrectomy was not necessary.  The vitreous remained posteriorly throughout the entire procedure with viscoelastic, (Viscoat) forming the anterior chamber

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Case #049

DSEK-This patient is a 93-year-old man with a posterior chamber lens implant and sector iridectomy performed in 1983.  Progressive decompensation of. 8.0 mm DSEK graft.  Air leakage was used through a 6 o'clock position where as the anterior chamber maintainer was placed. A 10-0 nylon suture was placed to seal this leak.  The use of Ocucoat provides protective coating of the endothelium and prevents endothelial contact with the lens implant in the event of positive pressure or anterior chamber collapse. This procedure was done without local anesthesia and with a 3.2 mm incision using the Rand-Stein Analgesia Protocol.

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Case #048

This is a patient with previous glaucoma filter procedure and previous cataract implant procedure (posterior chamber lens) and previous DSEK which failed after two years.  The surgery will show a fourteen-minute DSEK procedure done with a 3.2 mm incision temporally using OcuCoat for a “pull-in” technique of insertion. The graft rides in over a very thin cushion of OcuCoat placed on the conjunctival surface at 3 o’clock. OcuCoat was used in the anterior chamber and irrigated carefully from the eye once the stripping and removal of the endothelium was complete so as not to leave a film between the DSEK graft and the host stroma. It should be noted that the DSEK graft that is being removed is very thick. This is because it is edematous but also because it was cut with the 300 micron blade on the anterior chamber maintainer. We now utilize 350 to give us a 50 micron thinner graft.

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Case #046

The patient had cataract surgery many years ago and requires a DSEK procedure with intracameral anesthesia. His heart rate was 32 and the anesthesiologist felt it would be best not to utilize any medications at all for the procedure. The surgery was done with intra-cameral anesthesia. No local anesthetics were utilized. The surgery was routine but there was much positive pressure because the patient was squeezing the eyes. It was hard to keep air in the anterior chamber and there was a significant tendency for collapse. In the end we were able to fill the anterior chamber in a stable manner. The use of OcuCoat on the conjunctival surface and on the endothelium of the graft was useful because of the tendency for collapse. Otherwise, there would have been significant endothelial contact with the implant.

 
Picture of patient one hour after surgery.

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Case #039

This a patient who has corneal dystrophy and a cataract. The cataract was removed first. The pupil is constricted and then a DSEK was performed. All this was done under the Rand-Stein analgesia protocol with no local anesthetics and no sutures through a 3.2 mm incision. The endothelium was stripped and removed. The new corneal graft is pulled into the eye with a Duet forceps and repositioned with air. Great care is used to get rid of all of the residual OcuCoat from the interface  between the stroma of the DSEK and the stroma of the host so that there would be no interface clouding.  

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Case #037

This is a patient having his fifth DSEK procedure, three at another Institution and the second one performed at the Rand Eye Institute.  It is remarkable for visualization of the older technology with incisions made through the cornea to evacuate fluid from the interface (no longer necessary in today’s procedure). This procedure was done without sutures and without local anesthetic. During the removal of the previous endothelial layer with further dissection, the DSEK caps from one of the initial procedures was identified and removed revealing a virtually untouched host cornea making this fifth DSEK look as though this was the first procedure done.  Apparently, the 2nd or 3rd DSEK was performed without removing the previous DSEK transplant. When we did his 4th DSEK, the endothelium came right out and we did not anticipate other tissue left behind. No sutures were utilized in the closing of the 3.2 mm incision. The result appears to be excellent.

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Case #021

DSEK with secondary IOL into the old Corneal Transplant.

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Case #019

DSEK and Vitrectomy

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Case #052

This a patient with keratoconus with inferior scarring too thin in the center to allow a DALK procedure.  This is a fairly routine penetrating keratoplasty with anti-torque continuous sutures leaving the four interrupted sutures intact. Care was taken not to over tighten the wound but at the same time not to allow it to have any looseness because the host cornea is thin.

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Case #038

The patient had a granular cornea dystrophy (Schnyder's Crystalline Dystrophy) in both eyes.  The DALK procedure involves removal of essentially a “manhole cover” leaving the Descemet’s membrane intact. Sometimes we can leave some of the anterior stroma with Descemet’s but in this case, the granular material was adherent to Descemet’s membrane and very dense at that point. The stroma including the granular material had to be removed piece by piece. During this time, it was possible to maintain Descemet’s membrane intact and then the new corneal transplant minus the Descemet’s membrane on the endothelium were layered in as if a “manhole cover” was being replaced and sutured into position.  Patient subsequently underwent cataract surgery as intended and visual acuity was returned to 20/30 level.

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