Eyeworld

117 EW INTERNATIONAL October 2016 SF6 gas, I initially used a higher con- centration but ended up choosing a concentration between 5 and 10%." Crucial postop hours The hours and days following DMEK surgery are crucial to graft success. For the new graft to adhere, patients should remain supine following the procedure, or be sedated for 45 minutes if unable to stay in a supine position. Because German DMEK pa- tients are hospitalized for 3 to 4 days following surgery, their progress can be closely followed according to a strict postoperative protocol. "I per- form a partial gas removal regardless of IOP. I also mark the sideport with ink for the resident on ward, and leave a written order in the chart to double check graft adherence, calling the ward myself to follow up. The second evaluation is done 4 hours after surgery. Topical steroids are used for at least 6 months post- operatively," Dr. Sekundo said. "DMEK is currently the best choice to treat endothelial mal- function. It offers the fastest visual rehabilitation of any keratoplasty procedure to date. Final visual acuity is excellent due to minimal optical interface effects. Surgical success is dependent on experience, and there are many small steps that signifi- cantly improve outcomes. Because minimal tissue is transplanted, the risk of allograft rejection is much lower." The indications for DMEK include Fuchs' corneal dystrophy, pseudophakic bullous keratopathy, decompensated corneal grafts, ICE syndrome, and other causes of cor- neal endothelial dysfunction. EW References 1. Coster DJ, et al. A comparison of lamellar and penetrating keratoplasty outcomes: a reg- istry study. Ophthalmology. 2014;121:979–87. 2. Dapena I, et al. Standardized "no-touch" technique for Descemet membrane en- dothelial keratoplasty. Arch Ophthalmol. 2011;129:88–94. Editors' note: Dr. Sekundo has no finan- cial interests related to his comments. Contact information Sekundo: sekundo@med.uni-marburg.de the endothelial cells. This posterior layer is the part that is laid down, and it is thicker with age. Other surgeons prefer to take grafts from donors that are more than 60 years. However, older corneas may make poorer grafts in terms of vitality of endothelial cells. We are quite satis- fied with the 45-year cut-off." Endotamponade In the classic Melles' technique after injecting the graft, the surgeon unrolls and positions it in the ante- rior chamber by pushing the graft against the iris by an air bubble. Thereafter, this bubble is aspirated and replaced by another bubble under the graft supporting its ad- herence to the cornea. Because most graft detachments occur early in the postoperative period, a long-lasting tamponade could reduce the need to reinject, or rebubble, gas into the anterior chamber. To explore the role of a different gaseous endotam- ponade, Dr. Sekundo relied on his experience as a vitreoretinal sur- geon. "There have not been many studies investigating different en- dotamponade options. We used air bubble endotamponade for DMEK surgery for quite awhile and wanted to try something else. As a vitreoret- inal surgeon, I decided to try a gas that is commonly implemented as a retinal tamponade, sulfur hexafluo- ride (SF6)." Led by Paraskevas Ampazas, MD, Dr. Sekundo was part of a team that conducted a retrospective study comparing the rebubbling rate of air with SF6 in patients treated with DMEK surgery. The investigation used 5% SF6 and air in 381 consecu- tive patients. Two hundred of the grafted eyes received an air endotampon- ade and the remaining 181 grafted eyes received 5% SF6. The outcomes showed that 42 out of 200 eyes with air (21%) required rebubbling of air, while 16 out of 181 (8.8%) in the SF6 group needed rebubbling (P<0.01), demonstrating the lon- ger-lasting effect of SF6 gas within the anterior chamber. The study is not yet published. Dr. Sekundo explained, "When you implant a graft, it can often oc- cur that the transplant detaches and you need to put in another bubble of air or gas. When I began using To make sure your optical dispensary is working efficiently, you need an experienced team. at's why the most successful practices turn to Partners In Vision. As a leader in Optical Dispensary Development + Management, we manage and grow your optical business through superior customer service, aention to detail, responsive inventory management and patient education. Let us be your team. Call for a free, no-risk assessment. PartnersInVision.com optical staffing • on-site presence • education • ar management managed care intgration • inventory control • marketing Since 1999 Do you really have the right team for the job? O P T I C A L D I S P E N S A R Y M A N A G E M E N T 888.748.1112

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