Eyeworld

EW FEATURE 92 by Maxine Lipner Senior EyeWorld Contributing Editor Winning combination: Phacoemulsification and DSEK? Practitioners score with the combined approach F or patients who need a corneal replacement in ad- dition to cataract surgery, practitioners today have an attractive option to con- sider—a planned combination pha- coemulsification and DSEK (Descemet's stripping endothelial keratoplasty) procedure. With the combined approach, surgeons can first remove the clouded lens with the aid of phacoemulsification and then immediately remove the dis- eased Descemet's membrane and re- place it by transplanting donor tissue. The combined approach can be natural for some patients with Fuchs' dystrophy, finds Edward J. Holland, M.D., professor of oph- thalmology, University of Cincin- nati, and director, cornea service, Cincinnati Eye Institute. "The most common group of patients is those with a significant cataract," he said. "Then the clinician has to decide whether the cornea in Fuchs' en- dothelial dystrophy is at a stage where it needs surgical intervention as well." In Dr. Holland's experience, one of the factors that comes into play is the amount of corneal edema present. If there is identifiable edema then a combined approach may be preferable. "If there is defi- nitely corneal edema present and the patient wants the best visual outcome, then it should be a com- bined phaco/DSEK procedure," Dr. Holland said. However, in cases with guttata where there is no edema present, with no history of corneal edema or morning blur or a 10% or greater thickening of the morning pachymetry, Dr. Holland urged per- forming phacoemulsification alone. "We would recommend phaco alone and advise the patient that there is an increased risk of endothelial de- compensation," he said. "The sur- geon should use all the techniques to save endothelial cells such as a dispersive viscoelastic and low phaco power and try to reduce the amount of phaco time if that's possi- ble." Francis W. Price, M.D., Price Vi- sion Group, Indianapolis, and chair- man of the board and founder, Corneal Research Foundation of America, Indianapolis, uses the com- bined approach for patients who have fairly significant cataract and significant corneal edema, as well as dense guttata. "They're good candi- dates for the procedure," he said. However, for those who have decreased vision but for whom he is unsure whether this is stemming from the cornea or from a cataract, he takes a different tact. "You can go ahead and do the cataract by itself. A lot of times, especially if the Fuchs' dystrophy is mild to moder- ate, that might be all the patient needs for a period of time until the Fuchs' progresses," Dr. Price said. While many practitioners shy away from combined surgery in those with a clear lens, new research may give them something to think about. Marianne O. Price, Ph.D., ex- ecutive director, Cornea Research Foundation of America, conducted a study that was published in the No- vember 2010 issue of the British Jour- nal of Ophthalmology that assessed the risk of cataract formation after DSEK. "Sometimes people in their 40s and 50s with Fuchs' dystrophy who are having DSEK still have a clear lens," she said. "We have gone back and taken a look at what the chances are of someone getting a cataract within the subsequent 3 years," she said. Investigators found that age played a prominent role here. "People who are under age 50 have about a 10% chance of getting a cataract within the subsequent 3 years," she said. "People who are over 50 have a lot higher chance— the lens is more sensitive." She sees these results as helping practitioners to decide what to do with the rela- tively young patients in whom they used to avoid transplant altogether. Judging combined advantages For his part, Dr. Holland sees the combined approach as beneficial to any Fuchs' patient with a bona fide cataract. "If you know that there's a significant cataract, I don't think there's any advantage to leaving the lens behind," he said. "Number one, any cataract present is going to progress, and number two, if you have to go back in, even if you're a tremendous phaco surgeon, you're going to lose endothelial cells." As a result, Dr. Holland reasons that if you know that the lens is going to AT A GLANCE • For patients with significant cataracts, if Fuchs' dystrophy is severe enough with signs of corneal edema, a combination approach may be beneficial • If a Fuchs' patient has a significant cataract, there is often no advan- tage to leaving this behind since endothelial cell loss will inevitably be greater with two procedures • The combination procedure can be technically easier for the experi- enced surgeon since there is less space to maneuver in the phakic eye • For a beginning surgeon, however, allowing the lens implant to fibrose in the eye for a month or so may make the procedure easier • Outcomes are usually contingent on the DMEK portion of the procedure • Using thinner tissue ultimately provides better visual acuity continued on page 94 In this combined procedure, Descemet's membrane stripped after phaco and IOL placement are completed Source: Jonathan B. Rubenstein, M.D. For patients with Fuchs' dystrophy (pictured here) and cataracts, combined phacoemulsification and DSEK might be beneficial Source: Ricardo Amin, M.D. February 2011 COMBINED SURGERY March 2011

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