Ординатура / Офтальмология / Английские материалы / Corneal Endothelial Transplant (DSAEK, DMEK & DLEK)_John_2010
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Figure 23-23: John Dexatome spatula (ASICO Inc., Westmont, IL) is introduced into the anterior chamber from the right temporal wound and Descemetorhexis is performed 180-degrees in a clockwise direction with Healon filling the anterior chamber.
Figure 23-24: John Dexatome spatula (ASICO Inc., Westmont, IL) is then taken back to the distal staring point and Descemetorhexis is continued in a counter-clockwise direction to complete the 360-degrees of Descemetorhexis from a single wound entry site.
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Figure 23-25: Following Descemetorhexis, initial controlled, surgical detachment of the Descemet’s membrane (arrow) using the John Dexatome spatula (ASICO Inc., Westmont, IL).
Figure 23-26: Progressive detachment of the Descemet’s membrane (arrows) using the John Dexatome spatula (ASICO Inc., Westmont, IL).
Figure 23-27: Progressive detachment of the Descemet’s membrane (arrows) using the John Dexatome spatula (ASICO Inc., Westmont, IL).
Figure 23-28: Total detachment of the Descemet’s membrane (arrows) using the John Dexatome spatula (ASICO Inc., Westmont, IL).
following DSAEK surgery as compared to a PKP procedure (Figures 23-48 and 23-49). Following DSAEK, the cornea can be studied using corneal OCT and Confoscan units (Figure 23-50). Both DLEK and DSAEK usually look similar clinically after donor-recipient interface has cleared (Figure 23-51). Cornea may also be evaluated using wavefront analysis techniques that gives information as to the quality of vision and also helps in removal of the limbal wound sutures (Figure 23-52). Fuchs’ corneal dystrophy with endothelial decompensation is a common diagnosis for
DSAEK (Figure 23-53). Following DSAEK there usually is good clearance of the corneal edema (Figure 23-54) and with postoperative healing process there is good uniform adherence of the donor corneal disk to the patient’s cornea (Figure 23-55). Corneal epithelium may be removed to increase intraoperative visualization of the donor corneal disk and the anterior chamber (Figure 23-56). When a triple procedure is planned, namely, phacoemulsification along with DSAEK surgery, the cataract may be removed using the upside-down phacoemulsification (John technique)
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Figure 23-29: The peripheral stroma within the epithelial circular mark is made rough by using the John DSAEK scrubber (ASICO Inc., Westmont, IL) to enhance donor disk attachment to the recipient cornea. This is completed 360-degrees, first in a clockwise direction, followed by a counterclockwise direction.
Figure 23-30: Complete removal of Healon from the anterior chamber using an irrigation/aspiration unit. The peripheral iridectomy is from the previous surgery performed elsewhere.
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Figure 23-31: The donor corneal disk is folded into a “taco-fold” after placing a small amount of Healon on the endothelial surface (upperleft).
Figure 23-32: Donor corneal disk is introduced into the recipient anterior chamber after enlarging the entry wound to 5.0 mm and the wound is closed with three interrupted 10-0 nylon sutures.
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Figure 23-33: The donor disk is unfolded using filtered-air. The air is injected in a steady, controlled fashion.
Figure 23-34: Donor disk is uniformly adherent to the patient’s cornea and it is well centered. Also seen is the double-ring sign.
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Figure 23-35: “Fork-lift” taco helps in intial stroma-to-stroma adherence and facilitates unfolding of the taco. The cannula is placed between the folded taco and the anterior iris surface and sterile balanced salt solution is injected to gently lift the taco.
Figure 23-36: Fluid unfolding of the donor disk in a patient with a deep anterior chamber.
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Figure 23-37
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Figures 23-37 to 23-39: John Fixation Hook (ASICO Inc., Westmont, IL) pins the donor disk against the recipient cornea, followed by air-unfolding of the donor disk.
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Figure 23-40: Use of John DSAEK Glider to remove macrofolds from the donor corneal disk following air attachment of the donor corneal disk to the recipient cornea.
Figures 23-41A and B: A– The donor corneal disk is uniformly adherent to the patient’s cornea without any macrofolds; B – Macrofolds are seen in the donor corneal disk and requires the use of Lindstrom Roller (insert) or John DSAEK Glider.
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Figure 23-42: Various donor corneal disk insertion techniques.
Figure 23-43: Suture-drag technique to pull the folded donor corneal disk into the recipient anterior chamber.
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Figure 23-44: Use of Busin Glide and vitreous forceps to pull the donor corneal disk into the anterior chamber.
Figure 23-45: Various features associated with the suture-drag |
Figure 23-46: Various features associated with the pull-through |
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Busin Glide technique. |