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DSEK: The Sutureless Corneal Transplant

Dr. Gregory Pamel is a highly skilled cornea transplant surgeon who has helped many New York area patients regain excellent vision. In the paragraphs below Dr. Pamel describes the new DSEK sutureless corneal transplant procedure and how the procedure can be used to treat New York corneal transplant patients.

DSEK (Descemet Stripping Endothelial Keratoplasty) is a new option for patients with corneal edema who require corneal transplantation.  This procedure has several advantages over traditional corneal transplant surgery which include:

  • Faster visual recovery
  • Less astigmatism created since there are no sutures
  • Eye is much stronger and more resistant to injury since only the diseased tissue rather
  • than the entire cornea is replaced.
  • Surgery time is quicker
  • Chance of rejection is reduced significantly
  • Procedure can be combined with cataract surgery

In order to understand this new procedure one must understand the conditions and pathology that lead to corneal edema.

The back cellular layer or posterior layer of the cornea is called the endothelium and is responsible for maintaining the clarity of the cornea by pumping excess fluid from the cornea. The endothelium has a finite number of cells; that is these cells are unable to be replaced once they are damaged or die. Certain conditions can cause loss of these finite cells (endothelial cell loss) leading to corneal edema and vision loss.  Irreversible corneal edema occurs when the endothelial cell loss occurs to such an extent that fluid is no longer able to be pumped from the cornea and the cornea swells preventing light from being focused on the retina.

There are two main conditions which result in irreversible endothelial cell loss:

Pseudophakic Bullous Keratopathy – Corneal Edema (swelling)

This is a condition in which one’s cornea has become permanently swollen (corneal edema) following cataracts and intraocular lens implant procedure. The cells that line the back inside surface of the normally crystal clear cornea (the endothelium), for one of various reasons, have been injured permanently. The function of the endothelium is to pump water out of the cornea, keeping it crystal clear and thin. When injured, these cells can no longer perform this function. The fluid that circulates inside the eyeball seeps into the cornea, causing it to swell and to become cloudy. This condition is called pseudophakic bullous keratopathy.

The causes of endothelial cell damage following cataract operations are multiple. They include physical trauma during the operation, such as difficulties in removing the cataract or inserting the intraocular lens, severe inflammation following the operation, intraoperative bleeding, or a predisposing disease called Fuchs’ endothelial dystrophy that makes the cornea prone to losing endothelial cells. When one is afflicted with pseudophakic bullous keratopathy, the cornea is permanently swollen and no medications, spectacles, or contact lenses can improve the vision of a patient with this condition.

Fuchs’ Endothelial Dystrophy

The normally crystal clear cornea has a layer on its inside surface called the endothelium. The purpose of this layer of cells is to pump water out of the cornea keeping it crystal clear and thin. Normally, as we age, these cells can become thick and fat. When the ophthalmologist looks at your eyeball through the slit lamp microscope, these cells can be detected and are termed guttata. Guttata are part of the normal aging process of the corneal endothelium.

Fuchs’ endothelial dystrophy was first described more than 100 years ago. It is a process in which guttata occur throughout the entire back surface of the cornea and appear one to three decades earlier than is normally expected.

In Fuchs’ endothelial dystrophy, as the guttata increase in size and numbers, fluid begins to accumulate within the cornea. Patients develop blurry or foggy vision in the morning, see halos around lights early in the morning, are unable to read in the early part of the day, etc. As the day goes on and the cornea dehydrates on its own, it becomes clearer and thinner and the patient’s vision improves. As the process of Fuchs’ endothelial dystrophy progresses, the swelling of the cornea persists further on into the day until eventually the vision never clears.

Surgical Treatment of Pseudophakic Bullous Keratopathy & Fuch’s Endothelial Dystrophy using the DSEK procedure:

In both pseudophakic bullous keratopathy and Fuch’s dystrophy, only the endothelium is diseased-the remaining layers of the cornea are usually normal and healthy. Until recently, the treatment of choice in patients with corneal edema from endothelial cell loss was a corneal transplant operation (penetrating keratoplasty). This involves replacing the entire cornea using a full thickness donor cornea.  Recently a new procedure was developed to treat this condition called DSEK.  DSEK stands for Descemets’ stripping endothelial keratoplasty. In this procedure, the damaged endothelium is stripped and removed from the patient’s eye and replaced with a partial thickness piece of donor cornea containing a healthy endothelium (posterior graft).  Dr. Pamel was one of the first people in New York to perform this technique on patients.

This procedure is done through a sutureless incision and therefore results in a faster visual recovery.  Most patients recover useful vision (20/60 or better) within three months of surgery compared to a full thickness corneal transplant which may take up to a year or longer to achieve the same level of vision.  Dr. Pamel no longer recommends performing a standard corneal transplant on most patients with pseudophakic bullous keratopathy or Fuch’s dystrophy unless they significant corneal scarring.

DSEK Procedure:

  1. The patient’s endothelial layer is stripped from the rest of the cornea.
  2. The donor endothelium attached to a thin layer of donor cornea is folded like a taco and inserted through a 5mm incision.
  3. An air bubble is injected to push the donor cornea up against the posterior surface of the patient’s cornea.
  4. The pumping action of the new donor endothelium helps to create suction which bonds the donor tissue to the patient’s own cornea

Advantages of DSEK/Sutureless Corneal Transplant Procedure over standard Corneal Transplant:

  • Visual recovery is significantly faster.
  • The eye is left much stronger and more resistant to injury.
  • Suture related complications are essentially eliminated.
  • There is little or no change in the refractive error since the patient’s cornea is left intact.

Complications of the DSEK Procedure:

The posterior graft can dislocate and may need to be repositioned or replaced.  In some instances a regular corneal transplant may need to performed.

Call our office today at (212) 355-2215, or toll free at (888) 657-2010, to schedule a consultation. For more information on Sutureless Corneal Transplant, contact our office today.