P324: Femtosecond-Assisted DSAEK with Fibrin Glue-Assisted Sutureless Posterior Chamber Lens Implantation

1. P324:Femtosecond-Assisted DSAEK with Fibrin Glue-Assisted Sutureless Posterior Chamber Lens Implantation Gaurav Prakash, MD Amar Agarwal, MS, FRCS, FRCOphth; Soosan Jacob, MS, FCRS,DNB; Dhivya A Kumar, MD; Prashaant Chaudhary, MD; Athiya Agarwal, MD, DO Dr Agarwal’s Eye Hospital & Eye Research Centre , Chennai , India Prof. Amar Agarwal is a paid consultant to Abott Medical Optics and Bausch & Lomb. None of the other authors have any financial disclosures.

2. Purpose • Background : Performing Descemet stripping automated endothelial keratoplasty (DSAEK) in unicameral cases with surgical aphakia with is a challenging situation. • Purpose : To describe the feasibility, technique and outcomes of femtosecond laser assisted Descemet stripping automated endothelial keratoplasty (DSAEK) with glued IOL for treatment with aphakia with endothelial decompensation.

3. Glued IOL* • Sutureless technique of trans-scleral haptic fixated posterior chamber IOL implantation • Experience of >300 eyes , starting from 2007. • 12 peer reviewed publications. • Indications : • Surgical Aphakia without capsular support • Dislocated IOL • combination with keratoplasty * Please note that Glued IOL is an Off Label Use (Non FDA Approved use ) of Fibrin glue and of the Posterior Chamber IOL .

4. Femtosecond assisted DSAEK • Femtosecond laser is a new option for creation of the posterior stromal – endothelial lenticule. • Laboratory based studies on various femtosecond laser platforms have shown satisfactory results for the same. • Clinical results are comparable to mechanical microkeratome Suwan-Apichon et al , Cornea. 2006; Jones , et al, Cornea. 2008.; Cheng , et al, Cornea. 2009. Mehta JS,et al. J Cataract Refract Surg. 2008. Cheng YY,et al. Arch Ophthalmol. 2008.

5. Methods • Three eyes (of three patients) with early corneal endothelial decompensation with post surgical aphakia underwent the technique. • The donor lenticules were created on a 60 Khz femtosecond laser platform ( Intralase, Abott Medical Optics, Santa Ana, CA) . Setting were as given in Table 1.

6. Surgical techniquePreparation of donor lenticule with femtosecond laser. • Top Left: The corneoscleral button is placed and locked in the artificial anterior chamber. • Top Right: Intraoperative view of the femtosecond laser lenticule creation. Posterior side cut is being made first. • Bottom Left: Appearance of the cornea after full lamellar pass performed in raster pattern and before anterior side cut creation. • Bottom Right: Anterior and posterior lamellas created by the femtosecond laser are separated. The posterior lamella forms the donor lenticule.

7. Surgical techniqueIntraoperative steps on Glued IOL implantation and DSAEK • Top Left: 2 Partial-thickness limbal-based scleral flap of 3* 3 mm are created after limited peritomy and placement of infusion cannula. • Top Right: an 8 mm blunt trephine is used to mark the area concentric to this mark to facilitate in Descemet scoring and stripping. • Bottom Left: The Descemet’s is stripped with a reverse Simsky hook. • Bottom Right: The IOL is held with McPherson’s forceps and inserted through the scleral incision. The leading haptic is grasped with a microcapsulorhexis forceps.

8. Surgical techniqueIntraoperative steps on Glued IOL implantation and DSAEK(cont..) • Top Left: The trailing haptic is exteriorized via the sclerotomy. • Top Right: the trailing haptic is tucked into the intrascleral lamellar pocket. • Bottom Left: The donor lenticule is inserted into the eye with the suture ends lying outside. • Bottom Right: The donor lenticule is unfolded with saline injection and adjusted by pulling the suture.

9. Results Left: Slit lamp photograph, 6 months post operative appearance of the DSAEK with glued IOL showing centered donor lenticule and the stable intraocular lens. Right: Ultrasound biomicroscopy image, 6 months post operative showing well centered donor lenticule and the stable and well centered glued intraocular lens.

10. Rationale for New Combined Procedure

11. Conclusion • The surgical options in aphakia with endothelial decompensation are limited, more so in cases with deficient iris tissue. • Our case series suggests that using glued IOL in combination with DSAEK may be a safe and efficacious alternative in such a scenario.

12. References • Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34:1433-8 • Prakash G, Ashokumar D, Jacob S, Kumar KS, Agarwal A, Agarwal A. Anterior segment optical coherence tomography-aided diagnosis and primary posterior chamber intraocular lens implantation with fibrin glue in traumatic phacocele with scleral perforation. J Cataract Refract Surg. 2009;35:782-4. • Prakash G, Jacob S, Ashok Kumar D, Narsimhan S, Agarwal A, Agarwal A. Femtosecond-assisted keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation: new triple procedure. J Cataract Refract Surg. 2009 ;35:973-9. • Cheng YY, Kang SJ, Grossniklaus HE, Pels E, Duimel HJ, Frederik PM,Hendrikse F, Nuijts RM. Histologic evaluation of human posterior lamellar discsfor femtosecond laser Descemet's stripping endothelial keratoplasty. Cornea.2009;28:73-9. • Cheng YY, Hendrikse F, Pels E,et al. Preliminary results of femtosecond laser assisted descemet stripping endothelial keratoplasty. Arch Ophthalmol.2008;126:1351-6. • Wylegała E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg. 2008;34: 1708-14. Thank you for your time