Endothelial Cell Loss in Penetrating Keratoplasty

doi:10.1016/S0161-6420(82)34754-5

Ophthalmology

Volume 89, Issue 6, June 1982, Pages 600-604

https://doi.org/10.1016/S0161-6420(82)34754-5 Get rights and content

Abstract

Quantitative specular endothelial microscopy was performed on 39 donor corneas before operation and at three and 12 months following penetrating keratoplasty. The central endothelial cell density of these corneas had decreased by 18.3% at three months after operation and by 33.6% at the end of one year. This decrease in cell density probably results both from cell death and from migration of cells toward the peripheral cornea. Postoperative cell counts were correlated closely with preoperative counts but not with donor age. Therefore, it is important to screen donor corneas before operation with the clinical specular microscope.

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Cited by (79)

Potential contraindications to scleral lens wear
2019, Contact Lens and Anterior Eye
Citation Excerpt :
Consistent with this hypothesis, ECD remains unchanged during the use of soft and corneal RGP contact lenses [171]. Reduction in ECD may also be associated with surgery of the vitreous or retina, glaucoma repair, cataract or keratoplasty [155–160]. The Cornea Donor Study Investigator Group measured ECD five years after successful penetrating keratoplasty (PK) and found cell loss of 70% [172].
Research and reviews have resulted in clear indications for scleral lens (SL) wear. Those indications include visual rehabilitation; therapeutic use in managing ocular surface diseases, lid and orbit disorders; and refractive correction to enhance visual quality, comfort and quality of life. In some cases, the use of SLs may be contraindicated: the presence of low endothelial cell density; Fuchs’ endothelial corneal dystrophy; glaucoma (because of the risk of an increase in intraocular pressure and the existence and location of draining devices and blebs); or overnight wear.
While the literature provides an extensive description of the indications for scleral lens wear, the authors recognize that there is no paper reporting the contraindications to their use. The aim of this review is to illustrate the conditions for which SL wear is potentially contraindicated or requires caution. Improved knowledge of SL limits should reduce the risk of adverse events and increase the likelihood of fitting success.
Endothelial Keratoplasty: A Revolution in Evolution
2012, Survey of Ophthalmology
Endothelial keratoplasty (EK) is continually evolving both in surgical technique and clinical outcomes. Descemet's stripping endothelial keratoplasty (DSEK) has replaced penetrating keratoplasty (PK) as the treatment of choice for corneal endothelial dysfunction. It is safe and predictable and offers early visual rehabilitation. Newer iterations include Descemet's membrane endothelial keratoplasty, Descemet's membrane automated endothelial keratoplasty, and other hybrid techniques. Early data on these newer EK techniques suggests that they provide significantly better visual outcomes compared to DSEK. Initial 5-year survival data indicates that EK is at least comparable to PK, and more widespread survival data is anticipated. Further work is needed to simultaneously optimize visual outcomes, refractive predictability, and endothelial cell survival, as well as surgical techniques of donor preparation and insertion.
Descemet's Stripping Endothelial Keratoplasty: Safety and Outcomes. A Report by the American Academy of Ophthalmology
2009, Ophthalmology
Citation Excerpt :
This demonstrates that DSEK is a relatively astigmatism-neutral surgery, as would be expected from the cataractlike incision. Table 4 describes the mean endothelial cell loss in published series of 11 eyes or more after both PK and DSEK.16,89,90,99,101,102,106,109,111–113,119–125 Mean percent endothelial cell loss in PK ranged from 11% to 29% at 2 to 6 months, 16% to 45% at 12 months, and 29% to 54% at 24 months.
To review the published literature on safety and outcomes of Descemet's stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea.
Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives.
The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%–82%), followed by endothelial graft rejection (mean, 10%; range, 0%–45%), primary graft failure (mean, 5%; range, 0%–29%), and iatrogenic glaucoma (mean, 3%; range, 0%–15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3–21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from −0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%).
The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment.
Proprietary or commercial disclosure may be found after the references.
Air Bubble-Associated Endothelial Trauma in Descemet Stripping Automated Endothelial Keratoplasty
2009, American Journal of Ophthalmology
To evaluate endothelial cell trauma by anterior chamber (AC) air bubbles in Descemet stripping automated endothelial keratoplasty (DSAEK).
Laboratory investigation.
Twelve human donor corneas (6 pairs) were sectioned using an automated microkeratome system (Moria ALTK System, Antony, France). One cornea of each pair was mounted on a Moria artificial AC, and an air bubble was injected to fill 40% of the AC. The apparatus was rotated 180 degrees for a total of 50 times to simulate air bubble trauma. The fellow corneas were used as controls. Each endothelial graft was stained with 0.25% Trypan blue for 90 seconds followed by 0.2% alizarin red for 2 minutes, and digital photomicrographs were obtained. Abnormally staining areas indicative of graft injury were removed digitally from the total graft area. The proportion of uninjured corneal endothelium was calculated, and differences were analyzed.
In this ex vivo model of air bubble trauma, the proportion of viable graft endothelium after air bubble injury was 79.8 ± 0.04% (n = 6). The proportion of viable endothelium in the control group was 89.9 ± 0.02% (n = 6). The statistically significant mean difference of 10.1% (P = .03) is indicative of greater endothelial injury after air bubble trauma.
Using this model, a moderate but significant amount of endothelial cell damage was associated with air bubble trauma compared with the control group. Air bubble trauma may account partially for the loss of endothelial cell density after DSAEK surgery and may impact graft survival.
Endothelial Cell Loss after Descemet Stripping with Endothelial Keratoplasty. Influencing Factors and 2-Year Trend
2008, Ophthalmology
Citation Excerpt :
Measurement imprecision and factors that were difficult to quantify, such as surgical trauma and variation between patients in the response to surgical trauma, probably contributed to the substantial amount of residual variance. The cumulative percentage of cell loss in the first 2 years after small-incision DSEK was within the range reported in other EK series and also was within the range that has been reported historically after PK (Table 3).3,9,15–17,19,21–23 However, it should be noted that the 2 earliest cited PK series were performed before routine use of viscoelastic, and that may have contributed to increased cell loss.15,21
To identify factors correlated with early endothelial cell loss after Descemet stripping with endothelial keratoplasty (DSEK) and to document cell loss over a 2-year period.
Cross-sectional and longitudinal retrospective analyses.
A series of 263 eyes in 216 patients who were treated with DSEK and were examined at the same center after surgery.
Six-month endothelial cell density (ECD) measurements were analyzed by multivariate analysis of variance to identify preoperative, operative, and postoperative factors that significantly influenced early cell loss. In addition, ECD measurements were compared longitudinally at 6, 12, and 24 months after grafting.
Central ECD after transplantation.
Mean ECD was 2000±550 cells/mm² 6 months after DSEK, representing cell loss of 34±18%. Factors associated with lower 6-month cell loss were use of single-point fixation forceps that compressed the donor tissue only at the tip during graft insertion (P = 0.025) and absence of any secondary donor reattachment procedure (P = 0.035). Six-month cell loss also was significantly less when DSEK was performed as a combined procedure; in combined cases, the graft was inserted through a clear corneal incision, whereas in standard cases, it was inserted through a scleral tunnel incision, which likely exerted more compression. Cell loss was comparable with manual and microkeratome donor dissection techniques (P = 0.91). Postoperative ECD was correlated positively with donor ECD (P<0.0001) and was correlated inversely with donor age (P<0.0001), although these donor characteristics explained only 10% of the total variance in 6-month ECD. Factors not significantly correlated with 6-month ECD or cell loss included donor death-to-preservation time (range, 1–22 hours; P = 0.45), donor death-to-use time (range, 2–8 days; P = 0.86), and recipient demographics. In 34 DSEK eyes analyzed longitudinally, mean ECD was 3100±250 cells/mm² before surgery, 2000±540 cells/mm² at 6 months, 1900±480 cells/mm² at 1 year, and 1800±490 cells/mm² at 2 years.
Cell loss 6 months and 1 year after DSEK was higher than in a recent penetrating keratoplasty series performed at the same center, consistent with more donor tissue manipulation in DSEK. Cell loss was reduced with certain variations in surgical technique.
Donor Age and Corneal Endothelial Cell Loss 5 Years after Successful Corneal Transplantation. Specular Microscopy Ancillary Study Results
2008, Ophthalmology
To determine whether endothelial cell loss 5 years after successful corneal transplantation is related to the age of the donor.
Multicenter, prospective, double-masked clinical trial.
Three hundred forty-seven subjects participating in the Cornea Donor Study who had not experienced graft failure 5 years after corneal transplantation for a moderate-risk condition (principally Fuchs’ dystrophy or pseudophakic corneal edema).
Specular microscopic images of donor corneas obtained before surgery and postoperatively at 6 months, 12 months, and then annually through 5 years were submitted to a central reading center to measure endothelial cell density (ECD).
Endothelial cell density at 5 years.
At 5 years, there was a substantial decrease in ECD from baseline for all donor ages. Subjects who received a cornea from a donor 12 to 65 years old experienced a median cell loss of 69% in the study eye, resulting in a 5-year median ECD of 824 cells/mm² (interquartile range, 613–1342), whereas subjects who received a cornea from a donor 66 to 75 years old experienced a cell loss of 75%, resulting in a median 5-year ECD of 654 cells/mm² (interquartile range, 538–986) (P [adjusted for baseline ECD] = 0.04). Statistically, there was a weak negative association between ECD and donor age analyzed as a continuous variable (r [adjusted for baseline ECD] = −0.19; 95% confidence interval, −0.29 to −0.08).
Endothelial cell loss is substantial in the 5 years after corneal transplantation. There is a slight association between cell loss and donor age. This finding emphasizes the importance of longer-term follow-up of this cohort to determine if this relationship affects graft survival.

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: Presented at the Eighty-sixth Annual Meeting of the American Academy of Ophthalmology, Atlanta, Georgia, November 1–6, 1981.

: Supported in part by the Florida Lions Eye Bank, Inc., Miami, Florida.

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Endothelial Cell Loss in Penetrating Keratoplasty

Abstract

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol