Case series and techniques of Descemet’s Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury

BMC Ophthalmology, Aug 2015

Background To evaluate clinical outcomes of Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) for severe bullous keratopathy that develop as a late complication of endothelial injury to the baby during forceps delivery at birth. Case presentations Four eyes (four patients; mean age, 51.5 years) with severe bullous keratopathy as a late complication of forceps delivery at birth were enrolled. All patients had amblyopia from childhood due to cloudy cornea. Nontheless, DSAEK was indicated in these patients for the irritation and severe light sensation caused by apparent bullous change of the injured cornea. All patients underwent DSAEK and two patients had simultaneous cataract surgery. Intraoperative and postoperative complications were recorded. Postoperative donor endothelial-cell densities (ECDs) were measured prospectively at six and 12 months and compared with preoperative values. Best corrected visual acuity (BCVA) was measured at 6 and 12 months postoperatively. All cases required corneal epithelial removal; two cases with simultaneous cataract surgeries required lens anterior capsule staining by trypan blue and illumination of the cornea for visualization. There were no cases of graft dislocation or primary graft failure. Mean BCVA improved from 0.06 to 0.15 at 6 months and to 0.38 at 12 months. Postoperative ECD was 2270 cells/mm 2 (mean loss, 24.4 %) at 6 months and 2130 (mean loss, 29.1 %) at 12 months. Postoperative intraocular pressure elevation was observed in two cases, and a rejection episode occurred in one case at 4 months postoperatively. Conclusions In this case series, the clinical outcome of DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance, which was comparable to uncomplicated cases. Cataract and DSAEK surgery was safely performed using techniques including epithelial removal, lens anterior capsule staining and illuminating the cornea, which enabled better visualization of the anterior chamber.

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Case series and techniques of Descemet’s Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury

Kobayashi et al. BMC Ophthalmology Case series and techniques of Descemet's Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury Akira Kobayashi 0 Hideaki Yokogawa 0 Natsuko Mori 0 Kazuhisa Sugiyama 0 0 Department of Ophthalmology, Kanazawa University Graduate School of Medical Science , 13-1 Takara-machi, Kanazawa-shi, Ishikawa-ken 920-8641 , Japan Background: To evaluate clinical outcomes of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for severe bullous keratopathy that develop as a late complication of endothelial injury to the baby during forceps delivery at birth. Case presentations: Four eyes (four patients; mean age, 51.5 years) with severe bullous keratopathy as a late complication of forceps delivery at birth were enrolled. All patients had amblyopia from childhood due to cloudy cornea. Nontheless, DSAEK was indicated in these patients for the irritation and severe light sensation caused by apparent bullous change of the injured cornea. All patients underwent DSAEK and two patients had simultaneous cataract surgery. Intraoperative and postoperative complications were recorded. Postoperative donor endothelial-cell densities (ECDs) were measured prospectively at six and 12 months and compared with preoperative values. Best corrected visual acuity (BCVA) was measured at 6 and 12 months postoperatively. All cases required corneal epithelial removal; two cases with simultaneous cataract surgeries required lens anterior capsule staining by trypan blue and illumination of the cornea for visualization. There were no cases of graft dislocation or primary graft failure. Mean BCVA improved from 0.06 to 0.15 at 6 months and to 0.38 at 12 months. Postoperative ECD was 2270 cells/mm2 (mean loss, 24.4 %) at 6 months and 2130 (mean loss, 29.1 %) at 12 months. Postoperative intraocular pressure elevation was observed in two cases, and a rejection episode occurred in one case at 4 months postoperatively. Conclusions: In this case series, the clinical outcome of DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance, which was comparable to uncomplicated cases. Cataract and DSAEK surgery was safely performed using techniques including epithelial removal, lens anterior capsule staining and illuminating the cornea, which enabled better visualization of the anterior chamber. - Background Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) is widely performed as a preferred treatment of endothelial dysfunction [1–5]. DSAEK completely eliminates any surface corneal incisions or sutures, maintains much of the structural integrity of the cornea and induces minimal refractive change, suggesting distinct advantages over standard penetrating keratoplasty (PK) [6, 7]. However, DSAEK requires a completely smooth host corneal rear surface since only air pressure is used for donor attachment. Therefore, endothelial surface irregularity is one of the contraindications of DSAEK. Forceps delivery is sometimes performed in the course of vaginal childbirth when the mother and/or baby are having difficulties during the pushing stage of labor. In a forceps delivery, a doctor applies forceps, an instrument shaped like a pair of large spoons or salad tongs, to the baby's head to help guide the baby out of the birth canal. One complication of a forceps delivery is that the baby’s Descemet’s membrane can be damaged, which causes late corneal endothelial failure with an irregular endothelial surface [8]. In this report, clinical outcomes and detailed surgical tips of DSAEK (and phacoemulsification of concomitant cataract surgery) for severe bullous keratopathy due to endothelial injury after forceps delivery are presented. Also, this report highlights surgical techniques to enhance visualization of severe bullous change in cases of birth injury with or without simultaneous cataract surgery. This information may be useful for DSAEK not only in cases with corneal birth injury, but also in similar corneal endothelial pathologies with severe bullous keratopathy. Case presentations Patients This prospective, non-comparative study was approved by the Ethical Committee of Kanazawa University Graduate School of Medical Science and followed the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients for publication of this Case report and any accompanying images. Four eyes (four patients; mean age, 51.5 years) with bullous keratopathy as a late complication of endothelial injury after forceps delivery at birth were enrolled (Table 1, Fig. 1). All patients had amblyopia from childhood due to cloudy cornea. Therefore, the diagnosis of endothelial injury due to forceps delivery was already made at childhood by characteristic Descemet’s membrane breaks (Haab’s striae). Nontheless, DSAEK was indicated in these patients later in their lives for the irritation and severe light sensation caused b (...truncated)


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Akira Kobayashi, Hideaki Yokogawa, Natsuko Mori, Kazuhisa Sugiyama. Case series and techniques of Descemet’s Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury, BMC Ophthalmology, 2015, pp. 92, 15, DOI: 10.1186/s12886-015-0094-z