Outcomes of phacoemulsification after Descemet membrane endothelial keratoplasty

ARTICLE

Outcomes of phacoemulsification after Descemet membrane endothelial keratoplasty Fayyaz U. Musa, MB ChB, FRCOphth, Javier Cabrerizo, MD, Ruth Quilendrino, MD, Isabel Dapena, MD, PhD, Lisanne Ham, PhD, Gerrit R.J. Melles, MD, PhD

PURPOSE: To evaluate the feasibility and outcomes of phacoemulsification after Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy and bullous keratopathy. SETTING: Tertiary referral center. DESIGN: Comparative case series. METHODS: The case notes of all phakic DMEK patients who subsequently had cataract surgery were reviewed, and data from a prospectively recorded database were analyzed. This included demographic details, visual acuity, corneal pachymetry, endothelial cell density (ECD), refractive outcomes, and complications. RESULTS: From a series of 106 consecutive phakic DMEK eyes, 5 eyes (4.7%) required phacoemulsification a mean of 9.2 months G 3.7 (SD) (range 4 to 14 months) after the initial DMEK. All phacoemulsification procedures were uneventful, and no dislocations and/or detachments of the Descemet graft were observed. At 6 to 12 months, all eyes reached a corrected distance visual acuity of 20/30 (0.6) or better and were within G0.50 diopter of the target refraction. Endothelial cell density decreased from a mean of 1535 G 195 cells/mm2 before phacoemulsification to 1158 G 250 cells/mm2 6 to 12 months after phacoemulsification. No significant changes in pachymetry values were observed, and all corneas remained clear throughout the study. CONCLUSIONS: Phacoemulsification after DMEK can be performed with minimal risk for graft detachment. The postoperative refractive outcomes were predictable, and visual acuity is likely to improve; there was an acceptable decrease in ECD. Financial Disclosure: Dr. Melles is a consultant to D.O.R.C. International BV/Dutch Ophthalmic USA. No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2013; 39:836–840 Q 2013 ASCRS and ESCRS

Phacoemulsification is routinely performed by most corneal surgeons before or during Descemet-stripping automated endothelial keratoplasty (DSAEK) or Descemet-stripping endothelial keratoplasty (DSEK)

Submitted: November 21, 2012. Final revision submitted: November 28, 2012. Accepted: December 19, 2012. From Netherlands Institute for Innovative Ocular Surgery (Musa, Cabrerizo, Quilendrino, Dapena, Ham, Melles), the Melles Cornea Clinic (Musa, Cabrerizo, Quilendrino, Dapena, Ham, Melles), and Amnitrans EyeBank (Ham, Melles), Rotterdam, The Netherlands. Corresponding author: Gerrit R.J. Melles, MD, PhD, Netherlands Institute for Innovative Ocular Surgery, Laan op Zuid 88, 3071 AA Rotterdam, The Netherlands. E-mail: [email protected].

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Q 2013 ASCRS and ESCRS Published by Elsevier Inc.

to remove a concomitant cataract, or when the crystalline lens is clear, to deepen the recipient anterior chamber for easier manipulation and positioning of the graft.1,2 Recently, we reported that in Descemet membrane endothelial keratoplasty (DMEK), phakic eyes seem to do better, possibly through preservation of still-remaining accommodation, faster visual rehabilitation, and better overall optical quality of the operated eye with the crystalline lens in situ.3 If so, phacoemulsification may be avoided in DMEK in the absence of a cataract, especially because DMEK does not require deepening of the recipient anterior chamber to improve the feasibility of the procedure.3 Furthermore, we found the incidence of iatrogenic cataract after DMEK to be relatively low, at approximately 4%.3 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.12.032

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PHACOEMULSIFICATION AFTER DMEK

Table 1. Characteristics by individual patient. Donor

Patient Pt

Age (Y)/ Sex

Eye

Indication for DMEK

1 2

47/M 35/M

R L

FED BK

3

63/M

R

FED

4 5

48/F 47/F

L R

FED BK

Concurrent Pathology None Buphthalmos, preexisting glaucoma (GDD) Preexisting glaucoma (GDD) None AC IOL–induced ocular hypertension and macular edema (AC IOL removed before DMEK)

After DMEK; Before Phaco

ECD (Cells/mm2)

Snellen CDVA (Decimal)

ECD (Cells/mm2)

Pachy (mm)

IOP (mm Hg)

2450 2380

20/40 (0.5) 20/60 (0.3)

1230 1595

498 492

6 11

2440

20/25 (0.8)

1760

592

25

2550 2230

20/25 (0.8) 20/50 (0.4)

1690 1400

565 435

13 15

AC IOL Z anterior chamber intraocular lens; BK Z bullous keratopathy; CDVA Z corrected distance visual acuity; DMEK Z Descemet membrane endothelial keratoplasty; ECD Z endothelial cell density; FED Z Fuchs endothelial dystrophy; FU Z follow-up; GDD Z glaucoma drainage device; IOP Z intraocular pressure; Pachy Z central corneal pachymetry; Pt Z patient *Follow-up data available for 20 months after phacoemulsification only

Although phacoemulsification before or during DMEK may initially be avoided, future cataract surgeries can be anticipated. It is therefore important to evaluate the outcomes of phacoemulsification cataract surgery after DMEK, particularly with regard to graft function. The purpose of this study was to evaluate the refractive and visual outcomes, the potential graft damage during or after phacoemulsification, and other complications of phacoemulsification after DMEK. PATIENTS AND METHODS This study comprised eyes that required standard cataract surgery after DMEK within the study period. All phacoemulsification procedures were performed by experienced surgeons. Phacoemulsification with intraocular lens (IOL) implantation was performed under topical anesthesia (Cases 1, 4, and 5), retrobulbar anesthesia (Case 3), or general anesthesia (Case 2). The main incision size was 2.0 to 3.0 mm in all cases. A dispersive ophthalmic viscosurgical device (OVD) alone was used in Case 4, a combined cohesive and dispersive OVD in Case 2, and a cohesive OVD alone in Cases 1, 3, and 5. The IOLs implanted were an AR40E (Abbott Medical Optics, Inc.) (Case 3), a Tecnis ZA9003 (Abbott Medical Optics, Inc.) (Case 4), and an Acrysof (Alcon Laboratories, Inc.) (Cases 1, 2, and 5). The postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell density (ECD), corneal pachymetry, and refractive outcomes were measured using the Snellen visual acuity chart, Goldmann applanation tonometry, noncontact autofocus specular microscopy (SP3000p, Topcon Medical Europe BV), Scheimpflug imaging (Pentacam HR, Oculus Optikger€ate GmbH), and anterior segment ocular coherence tomography (OCT) (Slitlamp OCT, Heidelberg Engineering GmbH).

RESULTS From a larger series of 461 consecutive eyes that had DMEK for Fuchs endothelial dystrophy or bullous keratopathy, 106 (23.0%) were phakic. Of these eyes, 5 (4.7%) required standard cataract surgery after DMEK within the study period and were included in the study (Table 1). The mean age of the 3 men and 2 women was 48 years G 8.9 (SD) (range 35 to 63 years). Phacoemulsification was performed at a mean interval of 9.2 G 3.7 months (range 4 to 14 months) after the initial DMEK procedure (Table 1). All surgeries were uneventful, and the duration of surgery ranged from 15 to 20 minutes in all cases. No dislocation and/or detachment of the Descemet membrane graft was observed (Figure 1). The mean follow-up time after phacoemulsification was 21.8 G 11.7 months (range 7 to 42 months). Cases 1 and 4 reached a CDVA of 20/16 (1.2); Cases 2, 3, and 5 reached 20/30 (0.6), 20/28 (0.7), and 20/25 (0.8), respectively. All 5 eyes were within G0.5 diopter (D) of the predicted emmetropic refractive outcome after IOL power calculation. The mean ECD decreased from 1535 G 195 cells/mm2 before phacoemulsification to 1158 G 250 cells/mm2 at 6 to 12 months after phacoemulsification (Figure 2). Pachymetry readings did not show a significant preoperative to postoperative change (516 G 56 mm versus 522 G 43 mm). All corneas remained clear throughout the study period. DISCUSSION Phacoemulsification after DMEK raises 2 major concerns among surgeons. First, detachment or

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Table 1. (Cont.) 6–12 Months After Phaco

Remarks

Snellen CDVA (Decimal)

ECD (Cells/mm2)

Pachy (mm)

IOP (mm Hg)

Time Between DMEK and Phaco (Mo)

Total FU After Phaco (Mo)

20/18 (1.2) 20/30* (0.6)

1000 O1500*

510 530*

13 12*

6 4

42 20

20/28 (0.7)

1190

565

10

14

15

20/18 (1.2) 20/25 (0.8)

1320 780

560 445

10 10

10 12

21 7

dislocation of the relatively fragile Descemet graft could be anticipated on entering the anterior chamber with a keratome, during phacoemulsification itself, or

during irrigation and aspiration. In eyes that required removal of the Descemet graft during a secondary endothelial keratoplasty, we unexpectedly found that

Figure 1. Case 1 with an anterior subcapsular cataract. A and B: Before cataract surgery. C and D: Postoperative pictures show a clear cornea and IOL.

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Figure 2. Change in ECD over time. Arrows denote timing of cataract surgery; color of arrows matches the color of the corresponding ECD curve. Normal values refer to the overall group of DMEK eyes and were taken from Baydoun et al.4

the transplanted donor Descemet membrane showed stronger adherence to the recipient posterior stroma than a virgin Descemet membrane removed during descemetorhexis.5,6 Hence, the risk for detachment or dislocation of a Descemet graft may be considered to be relatively low and no such problem was observed in the current study. To further avoid the risk for graft detachment, we recommend that the anterior chamber be filled with air before the anterior chamber is entered so that any change in the position of the graft will be easily visualized because of the difference in the refractive index between the air bubble and the corneal tissues.7 For the reported cases, despite different surgeons performing the cataract surgery with variations in the OVD and IOLs used, no intraoperative complications occurred and all DMEK grafts remained completely attached. Another concern is that phacoemulsification after DMEK may affect the donor endothelial cell layer. A decrease in ECD of approximately 5% has been reported 6 to 12 months after cataract surgery in eyes without previous corneal graft surgery.8,9 Little data are available on phacoemulsification after DSEK/ DSAEK, with only a single study2 reporting a nonsignificant decrease in ECD of 16 G 144 cells/mm2 at the 13-month follow-up. In the current study, the decrease in (donor) ECD was approximately 25% 6 to 12 months after phacoemulsification compared with an expected normal decrease in ECD after DMEK of approximately 6% per annum.4 Two eyes (Cases 2 and 3) in this study had advanced glaucoma, Case 2 had a preexisting drainage tube, and Case 3 had a tube placed 5 months after DMEK. Glaucoma and a tube shunt surgery for IOP control are recognized causes of increased endothelial cell loss.10,11 This could have significantly

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skewed the results in this small series toward a higher rate of ECD decrease. However, Case 3 had the steepest fall in ECD after cataract surgery, although no additional treatment for IOP control was required. Despite these factors, the ECD decrease observed after phacoemulsification in our case series compares favorably to the reported ECD decrease of approximately 40% 6 months after phacoemulsification in eyes with previous penetrating keratoplasty.9 It has recently been shown that there is a minimal refractive change after DMEK of C0.33 D,12 unlike the larger hyperopic shift after DSEK.13 This is due to the near-normal anatomic restoration of the anterior segment with DMEK. As a consequence, accurate biometric results using “normal-eye” formulas are possible and all 5 eyes in the reported case series achieved a refractive outcome within G0.50 D of the predicted outcome with no specific nomogram adjustments. In conclusion, in our study, all cataracts were successfully managed with phacoemulsification; that is, the CDVA and refractive outcomes were good and there were no secondary graft failures or graft detachments. WHAT WAS KNOWN  Descemet membrane endothelial keratoplasty can be performed in phakic eyes with good results. Leaving the crystalline lens in situ results in secondary cataract formation in approximately 5% of eyes.  A modified technique to perform phacoemulsification cataract surgery after DMEK has been suggested to minimize the risk for graft detachment. WHAT THIS PAPER ADDS  Phacoemulsification after DMEK can be performed with minimal risk for graft detachment and an acceptable decrease in ECD.  The postoperative refractive outcomes appear to be predictable; that is, similar to outcomes in virgin eyes.

REFERENCES 1. Dapena I, Ham L, Melles GRJ. Endothelial keratoplasty: DSEK/ DSAEK or DMEK - the thinner the better? Curr Opin Ophthalmol 2009; 20:299–307 2. Price MO, Price DA, Fairchild KM, Price FW Jr. Rate and risk factors for cataract formation and extraction after Descemet stripping endothelial keratoplasty. Br J Ophthalmol 2010; 94:1468–1471. Available at: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2976606/pdf/bjophthalmol175174.pdf. Accessed January 13, 2013 3. Parker J, Dirisamer M, Naveiras M, Tse WHW, van Dijk K, Frank LE, Ham L, Melles GRJ. Outcomes of Descemet

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4.

5.

6.

7.

8.

9.

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membrane endothelial keratoplasty in phakic eyes. J Cataract Refract Surg 2012; 38:871–877 Baydoun L, Tong CM, Tse WW, Chi H, Parker J, Ham L, Melles GRJ. Endothelial cell density after Descemet membrane endothelial keratoplasty: 1 to 5-year follow-up [letter]. Am J Ophthalmol 2012; 154:762–763 Dapena I, Ham L, Tabak S, Balachandran C, Melles G. Phacoemulsification after Descemet membrane endothelial keratoplasty. J Cataract Refract Surg 2009; 35:1314–1315 Dapena I, Yeh R-Y, Quilendrino R, Melles G. Surgical step to facilitate phacoemulsification after Descemet membrane endothelial keratoplasty. J Cataract Refract Surg 2012; 38:1106–1107 Dapena I, Ham L, Moutsouris K, Melles GRJ. Incidence of recipient Descemet membrane remnants at the donor-to-stromal interface after descemetorhexis in endothelial keratoplasty. Br J Ophthalmol 2010; 94:1689–1690 Dholakia SA, Vasavada AR. Intraoperative performance and longterm outcome of phacoemulsification in age-related cataract. Indian J Ophthalmol 2004; 52:311–317. Available at: http://www.ijo.in/text.asp?2004/52/4/311/14564. Accessed January 13, 2013 Acar BT, Utine CA, Acar S, Ciftci F. Endothelial cell loss after phacoemulsification in eyes with previous penetrating keratoplasty, previous deep anterior lamellar keratoplasty, or no previous surgery. J Cataract Refract Surg 2011; 37: 2013–2017

10. Bertelmann E, Pleyer U, Rieck P. Risk factors for endothelial cell loss post-keratoplasty. Acta Ophthalmol Scand 2006; 84:766–770. Available at: http://www3.interscience.wiley.com/ cgi-bin/fulltext/118606545/PDFSTART. Accessed January 13, 2013 11. Kim P, Amiran MD, Lichtinger A, Yeung SN, Slomovic AR, Rootman DS. Outcomes of Descemet stripping automated endothelial keratoplasty in patients with previous glaucoma drainage device insertion. Cornea 2012; 31:172–175 12. van Dijk K, Ham L, Tse WHW, Liarakos VS, Quilendrino R, Yeh R-Y, Melles GRJ. Near complete visual recovery and refractive stability in modern corneal transplantation: Descemet membrane endothelial keratoplasty (DMEK). Contact Lens Anterior Eye 2013; 36:13–21 13. Dupps WJ Jr, Qian Y, Meisler DM. Multivariate model of refractive shift in Descemet-stripping automated endothelial keratoplasty. J Cataract Refract Surg 2008; 34:578–584

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First author: Fayyaz U. Musa, MB ChB, FRCOphth Netherlands Institute for Innovative Ocular Surgery and Melles Cornea Clinic, Rotterdam, The Netherlands