Purpose: To evaluate the surgical outcome and refractive status after triple procedure in patients with Fuchs’ dystrophy combined with cataract. Patients and Methods: Thirty four consecutive eyes of 29 patients with coexisting cataract and Fuchs’ dystrophy entered the study. All patients underwent phacoemulsification and IOL implantation through a temporal incision followed by Descemet stripping automated endothelial keratoplasty  (DSAEK). Patients were assessed regarding best corrected visual acuity (BCVA), refractive cylinder and refractive spherical equivalent before surgery, after 3 months and 3 years of follow-up. Results: The mean BCVA was 0.87 ± 0.448 logMAR pre-operatively which increased to 0.29 ± 0.164 logMAR at three months (p &lt;0.001), and 0.19 ± 0.129 at three years (p &lt;0.001). The mean preoperative spherical equivalent was 0.758 ± 2.384 which reached 0.32 ±0.55 (p &lt;0.001) and 0.24 ± 0.46 (p &lt;0.001) three months and three years after the simultaneous surgery, respectively. The mean preoperative cylinder was -1.43 ± 1.141 which reached -0.87 ±0.55 (p &lt;0.001) and -0.69 ± 0.39 (p &lt;0.001); three months and three years after the simultaneous surgery, respectively. Conclusion: Refractive and visual outcomes after triple surgery are favorable in terms of BCVA, refractive cylinder and refractive spherical equivalent. Therefore, triple procedure might be recommended in older patients due to its rapid visual rehabilitation.Keywords: Descemet stripping automated endothelial keratoplasty; phacoemulsification; best corrected visual acuity; refractive cylinder; spherical equivalent

Abolhassani, Abbas

Pourmatin, Rama

Shojaei, Ahmad

Vafaei, Fatemeh

English

Journals Portal, Shahid Beheshti University of Medical Sciences

1Journal of Ophthalmic and Optometric Sciences.Volume 1, Number 4, Summer 2017. This work is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)Original ArticleDescemet Stripping Automated Endothelial Keratoplasty Combined with Phacoemulsification; a Follow up StudyAbbas Abolhassani 1, MD; Rama Pourmatin 1, MD; Ahmad Shojaei * 2, MD;Fatemeh Vafaei 1, MSc1. Basir Eye Health Research Center, Tehran, Iran.2. Department of Ophthalmology, Baqiyatallah University of Medical Sciences, Tehran, Iran.*Corresponding Author: Ahmad ShojaeiE-mail: dr.a.shojaei@gmail.comArticle Notes:Received: Apr. 28, 2017Received in revised form:May. 13, 2017Accepted: May. 31, 2017Available Online: Jun. 24, 2017Keywords:Descemet stripping automated Endothelial keratoplastyPhacoemulsificationBest corrected visual acuityRefractive cylinderSphereAbstractPurpose: To evaluate the surgical outcome and refractive status after triple procedure in patients with Fuchs’ dystrophy combined with cataract.Patients and Methods: Thirty four consecutive eyes of 29 patients with coexisting cataract and Fuchs’ dystrophy entered the study. All patients underwent phacoemulsification and IOL implantation through a temporal incision followed by 4 Descemet strippingautomated endothelial keratoplasty (DSAEK). Patients were assessed regarding best corrected visual acuity (BCVA), refractive cylinder and refractive sphere before surgery, after 3 months and 3 years of follow-up.Results: The mean BCVA was 0.87 ± 0.448 LogMAR pre-operatively which increased to 0.29 ± 0.164 LogMAR at three months (P < 0.001), and 0.19 ± 0.129 at three years (P < 0.001) post-operatively. The mean preoperative sphere was 0.758 ± 2.384, which reached 0.32 ± 0.55 and 0.24 ± 0.46; three months and three years after the simul-taneous surgery, respectively. The mean preoperative cylinder was-1.43 ± 1.141 which reached - 0.87 ± 0.55 and - 0.69 ± 0.39; three months and three years after the simultaneous surgery, respectively.Conclusion: Refractive and visual outcomes after triple surgery are favorable in terms of BCVA, refractive cylinder and refractive sphere. Therefore, triple procedure might be recommended in older patients due to its rapid visual rehabilitation.How to cite this article: Abolhassani A, Pourmatin R, Shojaei A, Vafaei F. Descemet Stripping Automated Endothelial Keratoplasty Combined with Phacoemulsification; a Follow up Study. Journal of Ophthalmic and Optometric Sciences. 2017;1(4):1-7. DSAEK Combined with Phacoemulsification Abolhassani et al.2 Journal of Ophthalmic and Optometric Sciences.Volume 1, Number 4, Summer 2017. This work is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)IntroductionDescemet stripping automated endothelial keratoplasty (DSAEK) has been known as the gold standard for the treatment of corneal endothelial diseases 1. This innovation opened a new chapter in the field of corneal transplan-tation. The major indication of DSAEK is any kind of abnormality in corneal endothelium such as Fuchs’ endothelial dystrophy and pseudophakic bullous keratopathy 2. DSAEK is a lamellar corneal procedure which has been of growing interest in terms of rapid visual rehabilitation, maintaining corneal integrity and less postoperative limitations 3. Performing penetrating keratoplasty (PK)after cataract extraction; a 2-staged surgery, has shown convincing results compared with PK alone in patients suffering from cataract and a coexisting endothelial disease; however; there are a number of limitations and/orcomplications. Some studies have indicated endothelial cell loss after the two-step surgery, delayed visual rehabilitation which questions the cost-effectiveness of the procedure, and difficulties in measuring IOL power due to uncertainty in post-PK corneal curvature mea-surements 4. The alternative technique would be a combination of DSAEK with simultane-ous phacoemulsification, named new triple procedure, which might reduce the possibility of above mentioned complications. There is an ongoing controversy in the existing literature regarding whether sequential or triple surgery leads to better postoperative results. The aim of present study was to present 3-year follow-up results of patients with cataract and Fuchs’ dystrophy undergoing DSAEK combined with phacoemulsification in terms of visual out-comes and refraction. Patients and MethodsIn the present study triple-DSAEK (DSAEK with simultaneous phacoemulsification and IOL implantation) was performed in 34 con-secutive eyes of 29 patients (11 male and 18 female patients) with Fuchs’ dystrophy. Allpatients fulfilled indication of surgery which was Fuchs’ endothelial decompensation along with cataract. The study was approved by the ethics committee of Basir Eye Health Center, Basir Eye Clinic, Tehran, Iran, and all patients gave informed written consent before entering the study.Surgical procedurePatients underwent combined phacoemul-sification and DSAEK. At first phaco was performed using a 2.8 mm temporal inci-sion (infinity) and PC IOL was inserted in bag; then we performed DSAEK by adding 1incision for forceps. Lenticule was attached to recipient cornea using air bubble support and centered. Finally we sutured all incisions while 60 percent of air remained.Follow-upAs well as pre-operation, patients were assessed 3 months and 3 years after surgery in terms of BCVA (LogMAR and decimal), refractive sphere and refractive cylinder. Statistical analysisWe performed statistical evaluation using SPSS version 18.0 (SPSS Inc, Chicago, Illinois, USA). Dependent T-test was employed for detecting differences between pre-operative and post-operative results. Level of significance was considered less than 0.05 in our analysis. DSAEK Combined with PhacoemulsificationAbolhassani et al.3Journal of Ophthalmic and Optometric Sciences.Volume 1, Number 4, Summer 2017. This work is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)ResultsThirty-four eyes from 29 consecutive patients were included in the present study. There were 18 females and 11 males with the mean age of 59.05 ± 10.56. All patients had clinically ap-proved cataract along with Fuchs’ dystrophy. Five eyes had very low pre-operative visual aquity (hand motion). BCVA measurementTable 1 represents achieved BCVA after 3 months and 3 years of follow up. The mean BCVA was 0.87 ± 0.448 LogMAR (0.13 ± 4.48 line) pre-operatively and increased to 0.29 ± 0.164 LogMAR (0.5 ± 1.64 line) at three months (P < 0.001), and 0.19 ± 0.129 (0.63 ± 1.29 line) at three years post-operatively (P < 0.001). The increase in BCVA within the first three months (P < 0.001), between 3 months and 3 years (P < 0.001), and within three years (P < 0.001) were all statistically significant.Refractive sphereTable 2 shows the mean preoperative sphere of 0.758 ± 2.384 which reached 0.32 ± 0.55 and 0.24 ± 0.46 three months and three years after the simultaneous surgery, respectively. Table 1: Visual acuity of patients before surgery, as well as 3 months and 3 years after surgeryBCVA Decimal LogMARPre-operation 0.13 ± 4.48 line 0.87 ± 0.448Post-operation After 3 months 0.5 ± 1.64 line 0.29 ± 0.164Post-operation After 3 years 0.63 ± 1.29 line 0.19 ± 0.129P value when comparing pre-operation and three months post-operation results 0.000*P value when comparing pre-operation and three years post-operation results 0.000*P value when comparing three months and three years post-operation results0.000*P value when comparing pre-operation, three months post-operation, and three years post-operation results0.000***Wilcoxon Test **Friedman TestTable 2: Refractive outcomes of patients before surgery, as well as 3 months and 3 years after surgery Pre-Operation Three Months Post-Operation Three Years Post-OperationSphere 0.758 ± 2.384 0.32 ±0.55 0.24 ± 0.46Cylinder - 1.43 ± 1.141 - 0.87 ±0.55 - 0.69 ± 0.39Axis 88.66 ± 53.15 80.83 ± 43.63 88.96 ± 45.14DSAEK Combined with Phacoemulsification Abolhassani et al.4 Journal of Ophthalmic and Optometric Sciences.Volume 1, Number 4, Summer 2017. This work is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)Refractive cylinderThe mean preoperative cylinder was -1.43 ± 1.141 which reached - 0.87 ± 0.55 (P < 0.001) and - 0.69 ± 0.39 (P < 0.001) in three months and three years after the simultaneous surgery, respectively. DiscussionToday, the treatment of choice for thickDescemet membrane due to cornealendothelial decompensations such as Fuchs’dystrophy is endothelial keratoplasty. We found in previous studies that traditional PK is no longer the point of interest compared with DSAEK and DMEK 5,6, while in eyes presenting with Fuchs’ dystrophy and concom-itant cataract without thickened epithelium, the choice of treatment would be cataract extraction and lens implantation 7. DSAEK providesrapid visual rehabilitation and better refractive results after surgery compared with PK; and the difference depends on pre and post-oper-ative factors as well as the surgical technique 8. Triple procedure have some disadvantages including notable alteration in anterior and posterior curvature which leads to myo-pic shift and reduction in the predictability of post-operative refraction; whereas delayed cat-aract surgery in many surveys shows better re-fractive outcomes using Toric IOLs 9. The diffi-culty in accurate measurement of IOL power is the other chief drawback in triple surgery. De-viations from the aimed refraction after suture removal may be the result of pre-operative bio-metric information including K-readings and an-terior chamber depth in triple method; however there are multiple proposed correcting formulas in the literature to improve refractive outcomes among patients who undergo triple surgery 10.Fuchs’ endothelial corneal dystrophy (FECD) is a progressive condition characterized by endotheli-al cell loss, formation of corneal guttae and stromal edema. Patients with FECD are at higher risk ofdeveloping cataract as their endothelialdamage progresses 11. This may be a unique challenge for ophthalmologists when faced with a combination of both FECD and cataract since they should determine how much of patients’ visual loss is caused by each condition and what is the best surgical approach. Theoretically, several factors are involved in the management of a patient with both FECD and cataract. The crucial consideration should be the severity of each condition in patient; also the age at the time of surgery matters as there is a direct relation between cataract and advanced age. Long-term results have showed that advance age in the time of penetratingkeratoplasty is a predisposing factor forupcoming cataract surgery 12. In a retrospective study, Payant et al., 13 showed that after anaverage follow up of 6.62 years, postkeratoplasty cataract happens in 75 % ofpatients aged 60 years or older. Also females are at higher risk of developing cataract after PK surgery 14. In the present study, all of 34 eyes achieved desired BCVA three months and three years postoperatively; which is favorablycomparable to previous reported visual out-comes after triple surgery indicating between 48 % and 81 % of eyes achieving desired BCVA; although follow-up periods variedbetween studies 15,16. This finding is in line with previous observations by Scorcia et al.,17 who proposed DSAEK and phacoemulsifica-tion with implantation of a hydrophilic acrylicbitoric IOL as an effective treatment for eyes with post-PK astigmatism and corneal endothe-lial damage. Das et al., 18 showed good refractive and visual outcomes following PK-only without a significant difference with the triple surgery; therefore triple surgery has been introduced as the treatment of choice in elderly patients who suffer from both Fuchs’ dystrophy andco-existing mild to moderate cataract 18. Sykakis DSAEK Combined with PhacoemulsificationAbolhassani et al.5Journal of Ophthalmic and Optometric Sciences.Volume 1, Number 4, Summer 2017. This work is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)et al., 19 have reported the results of staged and combined DSAEK and phacoemulsification with intraocular lens implant (Phaco + IOL). Complications such as re-bubbling and disloca-tion of endothelial disc were higher among the group undergoing combined triple surgery while visual outcomes did not differ significantly 19.Nonetheless, combined triple surgery in most cases is performed in one session without the need for waiting for secondary cataract extraction. There is a relatively high risk of suprachoroi-dal hemorrhage in the cataract extraction ofsimultaneous surgery while it is accomplished in the open-sky state 20. A crucial determi-nant of the success of combined surgery is theproficiency of the surgeon. We believe that triple procedure should be performed by experienced corneal surgeons to prevent any complication in the implantation of IOLs in capsular bag.The limitations of the present study were the lack of a control group undergoing PK plus cataract extraction; relatively small sample size and no assessment of endothelial cell density. To decide the best surgical technique in this regard, future randomized controlledinvestigations are needed to investigate the best choice of procedure. We also did not reportcomplications of the performed triple surgery; which has been indicated in the literature; likedonor disc dislocation, primary graft failure and posterior capsule opacity requiring YAG lasercapsulotomy 6,21.ConclusionRefractive and visual outcomes after triple surgery are favorable in terms of BCVA,refractive cylinder and sphere. Therefore,triple procedure might be recommended inolder patients due to its rapid visualrehabilitation.DSAEK Combined with Phacoemulsification Abolhassani et al.6 Journal of Ophthalmic and Optometric Sciences.Volume 1, Number 4, Summer 2017. This work is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)References1. Covert DJ, Koenig SB. New triple procedure: Descemet's stripping and automated endotheli-al keratoplasty combinedwith phacoemulsification and intraocular lens implantation. Ophthalmology. 2007;114(7):1272-7.2. Gorovoy MS, Gorovoy IR, Ullman S, Gorovoy JB. Descemet stripping automated endothelial keratoplas-ty for spontaneous descemet membrane detachment in a patient with osteogenesis imperfecta. Cornea. 2012;31(7):832-5.3. Jastaneiah SS. Descemet's Stripping-Automat-ed Endothelial Keratoplasty for Traumatic An-iridia and Aphakia. Case Rep Ophthalmol Med. 2012;2012:982657. 4. Das S, Langenbucher A, Jacobi C, Nguyen NX, Kruse FE, Naumann GO, et al. Long-term refractive and visual outcome after penetrating keratoplasty only versus the tripleprocedure in Fuchs' dystrophy. Graef-es Arch Clin Exp Ophthalmol. 2006;244(9):1089-95.5. Terry MA, Shamie N, Chen ES, Phillips PM, Shah AK, Hoar KL, et al. Endothelial keratoplasty for Fuchs' dystrophy with cataract: complications and clinical results with the new triple procedure. Oph-thalmology. 2009;116(4):631-9.6. Pineros OE, Cohen EJ, Rapuano CJ, Laib-son PR. Triple vs nonsimultaneous procedures in Fuchs' dystrophy and cataract. Arch Ophthalmol. 1996;114(5):525-8.7. Seitzman GD, Gottsch JD, Stark WJ. Cataract surgery in patients with Fuchs' corneal dystrophy: expanding recommendations for cataract surgery without simultaneous keratoplasty. Ophthalmology. 2005;112(3):441-6.8. Cohen KL, Holman RE, Tripoli NK, Kupper LL. Effect of trephine tilt on corneal button dimensions. Am J Ophthalmol. 1986;101(6):722-5.9. Terry MA, Ousley PJ. In pursuit of emmetropia: sphere refraction results with deep lamellar endothe-lialkeratoplasty (DLEK). Cornea. 2003;22(7):619-26.10. Viestenz A, Seitz B, Langenbucher A. Intraocular lens power prediction for triple procedures in Fuchs' dystrophy using multipleregression analysis. Acta Ophthalmol Scand. 2005;83(3):312-5.11. Zinger C, Borderie V. Cataract and Fuchs Dystro-phy. Investigative Ophthalmology & Visual Science, 2013;54(15):3009.12. Pineros O, Cohen EJ, Rapuano CJ, Laibson PR. Long-term results after penetrating keratoplasty for Fuchs' endothelial dystrophy. Arch Ophthalmol. 1996;114(1):15-8.13. Payant JA, Gordon LW, VanderZwaag R, Wood TO. Cataract formation following corneal transplan-tation in eyes with Fuchs' endothelial dystrophy. Cor-nea. 1990;9(4):286-9.14. Klein BE, Klein R, Linton KL. Prevalence of age-related lens opacities in a population. The Beaver Dam Eye Study. Ophthalmology. 1992;99(4):546-52. 15. Davis EA, Azar DT, Jakobs FM, Stark WJ. Re-fractive and keratometric results after the triple pro-cedure: experience with early and latesuture removal. Ophthalmology. 1998;105(4):624-30.16. Javadi MA, Feizi S, Moein HR. Simultaneous penetrating keratoplasty and cataract surgery. J Oph-thalmic Vis Res. 2013;8(1):39-46.17. Scorcia V, Lucisano A, Beltz J, Busin M. Com-bined Descemet-stripping automated endothelial keratoplasty and phacoemulsification with toric in-traocular lens implantation for treatment of failed penetrating keratoplasty with highregular astigma-tism. J Cataract Refract Surg. 2012;38(4):716-9.18. Das S, Langenbucher A, Jacobi C, Nguyen NX, Kruse FE, Naumann GO, et al. Long-term refractive and visual outcome after penetrating keratoplasty only versus the tripleprocedure in Fuchs' dystrophy. Graef-es Arch Clin Exp Ophthalmol. 2006;244(9):1089-95.19. Sykakis E, Lam FC, Georgoudis P, Hamada S, Lake D. Patients with Fuchs Endothelial Dystrophy and Cataract Undergoing Descemet StrippingAuto-mated Endothelial Keratoplasty and Phacoemulsi-fication with Intraocular Lens Implant: Staged ver-sus Combined Procedure Outcomes. J Ophthalmol. 2015;2015:172075.20. Hayashi K, Hayashi H.Simultaneous versusDSAEK Combined with PhacoemulsificationAbolhassani et al.7Journal of Ophthalmic and Optometric Sciences.Volume 1, Number 4, Summer 2017. This work is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)sequential penetrating keratoplasty and cataract sur-gery. Cornea. 2006;25(9):1020-5.21. Terry MA, Shamie N, Chen ES, Phillips PM, Shah AK, Hoar KL, Endothelial keratoplasty for Fuchs' dystrophy with cataract: complications and clinical results with the new triple procedure. Ophthalmology. 2009;116(4):631-9.Footnotes and Financial DisclosuresConflict of Interest:The authors declare no conflict of interest with the subject matter of the present manuscript. 

Descemet Stripping Automated Endothelial Keratoplasty Combined with Phacoemulsification; a Follow up Study

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Descemet Stripping Automated Endothelial Keratoplasty Combined with Phacoemulsification; a Follow up Study

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