Endothelial keratoplasty: case selection in the learning curve.

Purpose: Many corneal surgeons are making the transition from penetrating keratoplasty to endothelial keratoplasty techniques such as Descemet's stripping endothelial keratoplasty and Descemet's stripping automated endothelial keratoplasty in the routine treatment of corneal endothelial failure. Donor dislocation is the commonest complication of these newer techniques. We set out to determine whether preoperative lens/iris diaphragm integrity might influence the rate of donor dislocation and whether donor endothelial failure was more common after surgical intervention for donor dislocation.

Design: A retrospective multisurgeon comparative case series from a large teaching and referral center.

Participants: Ninety-three eyes of 85 patients: consecutive cases of Descemet's stripping endothelial keratoplasty (n = 77) or Descemet's stripping automated endothelial keratoplasty (n = 16) performed between March 2004 and January 2007.

Methods: A retrospective review of case notes.

Main Outcome Measures: The number of eyes with an open communication between the anterior and posterior chambers (an iridectomy or lens capsular defect not covered by a posterior chamber intraocular lens), the number of eyes requiring surgical intervention to correct donor dislocation, and the number of eyes with donor endothelial failure within the follow-up period.

Results: Complete data sets were available for analysis in 89 eyes. The median follow-up interval at the time of the audit was 7 months (range 1-34 months). Donor dislocation was significantly more common (P = 0.017) in eyes with an open communication between the anterior and posterior chambers, occurring in 11 of 25 cases (44%) versus 12 of 64 cases (19%) with an intact iris/lens diaphragm. Early endothelial failure was significantly more common (P = 0.011) in cases requiring additional surgical intervention for donor dislocation, occurring in 6 of 21 cases (29%) after successful surgical reattachment of a dislocated donor disc versus 4 of 67 cases (6%) in which no additional intervention was required.

Conclusions: Donor dislocation after endothelial keratoplasty is more common in cases with an open communication between the anterior and posterior chambers. The risk of donor endothelial failure is increased in cases of donor dislocation. Trainee surgeons and surgeons in making the transition from penetrating keratoplasty should initially select cases with an intact lens/iris diaphragm.