CLINICAL SCIENCE Pre-Descemet Endothelial Keratoplasty With Infant Donor Corneas: A Prospective Analysis Ashvin Agarwal, MS,* Amar Agarwal, MS, FRCS, FRCOphth,* Priya Narang, MS,† Dhivya A. Kumar, MD,* and Soosan Jacob, DNB, FRCS* n corneal transplantation, the optimal donor tissue selection Purpose: To evaluate the outcomes and feasibility of the use of Ihas been controversial. Conflicting results have been infant donor tissue (,1 year) in pre-Descemet endothelial kerato- reported regarding the effect of donor age in previous studies plasty (PDEK). evaluating the visual outcomes and endothelial cell loss after 1–7 Methods: Three eyes of 3 patients with pseudophakic bullous penetrating keratoplasty. This may become increasingly keratopathy underwent the procedure in this single-center, prospec- relevant with the advent of endothelial keratoplasty, which is potentially even more traumatic to the endothelium at the time tive interventional series. Diseased Descemet membrane of the 8 recipient cornea was replaced with the pre-Descemet layer–Descemet of surgery than standard penetrating keratoplasty. Donor membrane–endothelium complex stripped from the infant donor tissue characteristics have been assumed to be associated as cornea (9–12 months old) with the creation of a type 1 bubble. The a possible reason for long-term donor graft survival. The main outcome measures were best-corrected visual acuity, endothelial Descemet membrane endothelial keratoplasty (DMEK) graft from young donors is more difficult to harvest and is also cell density, endothelial cell loss, and ease and predictability of the fi donor lenticule preparation. dif cult to unfold inside the eye because younger donor tissue tends to curl up tightly. For this reason, surgeons now prefer to Results: In the postoperative period, there was improvement in the use tissue from donors older than 40 years for DMEK cases to visual acuity in all the patients. The mean donor endothelial cell facilitate uncurling and positioning the tissue after it is inside density was 3073 6 68 cells per square millimeter, and the mean the eye.9 Another study by Terry et al10 suggested that the postoperative specular count at 6 months was 2230 6 43 cells per preoperative donor endothelial cell density (ECD) was not square millimeter. The mean percentage loss of endothelial cells at associated with donor dislocation for any form of endothelial 6 months was 27 6 2%. The mean coefficient of variation was 36 6 keratoplasty surgery. 5.2%. The mean central corneal thickness measured at a 6-month Good visual outcomes have been reported with the use postoperative period was 515 6 7 mm. No incidence of tissue loss of pediatric donor tissue for Descemet stripping endothelial during graft preparation, graft dislocation, or graft failure was keratoplasty (DSEK)11 and infant donor tissue for the reported. The mean graft thickness as measured with optical Descemet stripping automated endothelial keratoplasty coherence tomography on the first postoperative day was 35 6 3 mm. (DSAEK)12 procedure, whereas Sun et al13 have reported fl Conclusions: con icting results with neonate corneas in the DSEK pro- PDEK using an infant cornea provided an effective cedure. We report the use of an infant donor cornea for means of restoring optical clarity with good visual outcomes. The transplantation in pre-Descemet endothelial keratoplasty infant cornea can be a reliable source of donor tissue for the PDEK (PDEK)14; and to the best of our knowledge, this is the first fi procedure, and no dif culties were noted in the donor lenticule prospective study that encompasses the issue of visual preparation, insertion of the donor graft, or air bubble management. outcomes, graft survival, and endothelial cell loss with infant Key Words: endothelial keratoplasty, pre-Descemet layer, PDEK, donor corneas in PDEK. pre-Descemet endothelial keratoplasty, infant donor (Cornea 2015;34:859–865) MATERIALS AND METHODS The institutional review board approved the protocol, and each subject gave written informed consent to participate Received for publication February 18, 2015; revision received April 10, 2015; in the study. The study adhered to the tenets of the Declaration accepted April 12, 2015. Published online ahead of print June 9, 2015. of Helsinki. Eligible subjects were between 42 and 73 years ’ From the *Dr Agarwal s Eye Hospital and Eye Research Centre, Chennai, old, and all the cases had corneal endothelial decompensation India; and †Narang Eye Care and Laser Centre, Ahmedabad, India. The authors have no funding or conflicts of interest to disclose. resulting in pseudophakic bullous keratopathy (PBK). Eligible Supplemental digital content is available for this article. Direct URL citations donor corneas were from donors of 9 months to 1 year old with appear in the printed text and are provided in the HTML and PDF a measured ECD from 2996 to 3124 cells per square versions of this article on the journal’s Web site (www.corneajrnl.com). millimeter. Inclusion criteria were the candidates who con- Reprints: Amar Agarwal, MS, FRCS, FRCOphth, Dr Agarwal’s Eye Hospital and Eye Research Centre, 19, Cathedral Rd, Chennai 600 086, India sented to the procedure and were willing to return for study (e-mail: [email protected]). examination. Patients with preexisting glaucoma, optic neu- Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ropathy, or uveitis were excluded from the study. Cornea Volume 34, Number 8, August 2015 www.corneajrnl.com | 859 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Agarwal et al Cornea Volume 34, Number 8, August 2015 Data on the best spectacle-corrected visual acuity with nontoothed forceps and slowly stripped away from the (BCVA) using the Snellen chart, intraocular pressure using stroma. The previously harvested donor graft was loaded Goldmann applanation tonometry, corneal astigmatism and onto the injector of a foldable IOL (Fig. 1B), and the spring curvature using the Orbscan (Bausch & Lomb, Rochester, of the injector was removed (as originally improvised by NY), and slit-lamp biomicroscopy were recorded preopera- Price and Price17) to prevent any damage to the graft. The tively and during the entire follow-up. Preoperative ECD of graft was slowly injected inside the eye, was centered and the donor tissue was recorded using an eye bank specular oriented with the rolls of the scroll facing upward, and was microscope (donor Keratoanalyzer EKA-10; Konan), and gradually unrolled using air and fluidics(Fig.1C).An postoperative ECD was (EM-3000; Tomey) recorded using endoilluminator18 was used to check the correct orientation noncontact specular microscopy. The preoperative and post- of the graft; and once the graft had uncurled, air was injected operative central corneal thickness of the recipient eye was beneath the graft to enhance the adherence to the posterior recorded using Fourier domain optical coherence tomography corneal stroma of the recipient tissue. For case 3, fibrin glue (OCT). Postoperative examinations were performed at 1, 3, was then applied beneath the scleral flaps (Fig. 1D), and 7 days postoperatively, at every week for the first month, followed by anterior chamber air fill in all the cases at monthly intervals for 12 months, and every 3 months (Figs. 1E, F; see Video, Supplemental Digital Content 2, thereafter. http://links.lww.com/ICO/A279). Patients Postoperative Regimen Three cases (3 eyes) with PBK undergoing PDEK in The patient was advised to lie supine for the most part Dr Agarwal’s eye hospital were involved in this prospective during the first postoperative day. After surgery, all patients study, and all the surgeries were performed by a single underwent pressure patching and supine positioning over- surgeon (Am.A.). Two male patients and 1 female patient, night. The standard postoperative protocol followed was with an average age of 60 (SD, 16.1) (range, 42–73) years, dosing with ofloxacin 0.3% and prednisolone acetate 1% were followed up for a minimum period of 6 months (range, every 2 hours for the initial 2 weeks, 4 times daily for 1 6–15 months). month, twice daily for 2 months, and once daily thereafter for 3 months. Outcome Analysis Data were entered using Excel software (Microsoft RESULTS Corp) and analyzed using SPSS software (version 16.1; SPSS, The mean follow-up period was 11 6 4.6 months Inc). Continuous variables were expressed as mean 6 SD and (6–15 months). Three eyes of 3 patients with PBK categorical variables as individual counts. underwent the PDEK procedure with infant donor tissue (Table 1). Two eyes (cases 1 and 2) had an IOL in the capsular bag, whereas 1 eye (case 3) had a malpositioned Surgical Technique posterior chamber IOL with posterior capsular dehiscence. The surgery was performed under local anesthesia, and Preoperatively, there was significant corneal edema resulting supplemental anesthesia was administered as necessary. The in poor corneal clarity. One eye (case 3) underwent PDEK surgical technique has been described in detail before14 and is with IOL explantation and fixation of a 3-piece IOL by the summarized briefly here. glued IOL method, and 2 eyes (cases 1 and 2) underwent Donor preparation was done by creation of a type 1 PDEK solely under local anesthesia. bubble,14,15 and the graft was then stored in McCarey Kaufman tissue culture media (see Video, Supplemental Digital Content 1, http://links.lww.com/ICO/A278). Visual Acuity Outcomes There was improvement in the visual acuity in all patients after surgery. The mean BCVA preoperatively and Recipient Preparation and Graft Insertion postoperatively were 0.1 6 0.1 Snellen decimal equivalent Because all the cases had severe corneal edema due to and 0.5 6 0.4 Snellen decimal equivalent, respectively. At the associated PBK, the epithelium of the recipient eye was final follow-up, case 1 had 20/20, case 2 had 20/40, and case debrided to enhance visualization.