DSEK: Vision Recovery

A prospective follow-up after Descemet stripping endothelial keratoplasty (DSEK) for Fuchs dystrophy shows there is improvement in visual acuity (VA) and corneal remodelling for at least five years, reported Sanjay V Patel MD, FRCOphth at the 2015 annual meeting of the Association for Research in Vision and Ophthalmology in Denver, USA.

Mark Terry and co-workers published their findings showing that VA after DSEK continues to improve during follow-up to three years (Li JY et al, Ophthalmology. 2012;119:126-9), but that is a retrospective analysis of non-standardised vision data, said Dr Patel, Professor and Chair, Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA.

“Our series is smaller, but it is prospective, and it has follow-up to five years with best corrected visual acuity (BCVA) measured by the electronic Early Treatment of Diabetic Retinopathy Study protocol,” said Dr Patel.

The Mayo Clinic series included 49 eyes, of which 44 eyes were seen at 12 months and 34 at five years. All eyes were ideal candidates for DSEK – they had no other ocular co-morbidity affecting vision, and if not already pseudophakic, they underwent phacoemulsification and implantation of a posterior chamber intraocular lens (IOL) at the time of DSEK surgery.

Mean BCVA was about 20/30 at one year. At five years, mean BCVA improved to about 20/24, 55 per cent of eyes were seeing 20/25 or better, and about 20 per cent achieved BCVA of 20/20 or better. The results were similar in analyses including only eyes with complete follow-up through five years.

Total corneal thickness and graft thickness were very stable between one and five years, averaging about 665 microns and 155 microns, respectively, as measured by confocal microscopy.

“There is an ongoing debate about the effect of DSEK graft thickness on BCVA outcomes. We have found no correlation between graft thickness and BCVA at one, two or five years,” added Dr Patel.

Anterior corneal haze, which was measured as corneal reflectivity with confocal microscopy, was high at one month after DSEK, improved significantly by six months, and also improved significantly between one and five years. “The continued reduction in haze between one and five years suggests there is ongoing remodelling and repair of the stroma,” he said.

Dr Patel noted that abnormal subepithelial cells, presumably fibroblasts, are seen in most corneas with Fuchs dystrophy requiring DSEK, and persisted in a number of eyes at five years.

Most endothelial cell loss occurred early, with the loss being 24 per cent at one month and 55 per cent at five years. There were five graft failures in the series. Four of these were iatrogenic and occurred in eyes operated on early during the DSEK learning curve.

Sanjay V Patel: patel.sanjay@mayo.edu