Ординатура / Офтальмология / Английские материалы / Corneal Endothelial Transplant (DSAEK, DMEK & DLEK)_John_2010

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Introduction

In routine practice, the anterior segment is generally observed with the slit-lamp which gives frontal images with a subjective estimation of a few external measurements of the eye. An ultrasonic evaluation of corneal pachymetry and anterior chamber depth can be done if additional information is required. Today, with the development of sophisticated surgical techniques it has become essential to obtain elaborate static and dynamic measurements of the anterior segment in order to meet modern safety requirements. The choice now lies between optical and ultrasonic exploration of the anterior segment.

Development of the Scheimpflug technique with oblique images resulted in a new capability to evaluate the distances in the eye’s anterior segment along different optical sections. The major drawback of this technology is a difficult mathematical reconstruction, as well as scleral overexposure when taking the photos. In particular, the entire angle area is masked by this overexposure and the fine structures are indiscernible (scleral spur, irido-corneal area and the angle).

The idea of using infrared wavelengths in optical coherence tomography 1-2 is expanding rapidly (Visante™ OCT, Carl Zeiss Meditec, Jena, Germay) [See also Chapter 5, Optical Coherence Tomography in Corneal Implant Surgery, Chapter 6, Use of Optical Coherence Tomography in Descemet’s Stripping with Endothelial Keratoplasty (DSEK) and Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)]. About ten years ago, Izatt et al3 suggested using the OCT for anterior segment imaging. Reflection of the infrared light rays is captured and analysed by an optical sensor and appropriate software re-adjusts the dimensions of the images by erasing distortion errors due to different corneal optical transmission differences. Measuring software capable of evaluating the distance between two points, radius of curvature and angles is also integrated.

Ultrasonic exploration of the anterior segment [See also Chapter 7, Imaging of the Cornea and Anterior Segment with High Frequency Ultrasound] appears to have reached its limits, whether in UBM or ultra high frequency ultrasound equipment (Artemis, ArcScan, Inc., Morrison, CO, USA) where resolution is identical to the anterior segment OCT’s 1310 nm wavelength (18µm for axial resolution, 60 µm for transverse resolution). Manipulation is fairly complex and even if some ultrasonic measurements are used as references to calibrate a certain number of instruments, there is no certainty concerning the exact in-vivo ultrasonic measurements. However, the error can be considered

relative, as long as the reference scale remains constant with each technology.

Anterior Chamber Exploration with the Visante™ OCT

Anterior Chamber Measurements

Using the Visante™ OCT (Figure 4-1), several studies were carried out on the static and dynamic4,5 anatomy of the anterior chamber. A large amount of data was obtained in the field of phakic implants and accommodation.6-8 Exploration and measurement of the anterior chamber’s internal dimensions, which was fairly imprecise until recently, is now possible where before only the external measurements of the anterior chamber were considered. Based on these internal measurements, considering that the device’s calibration assessment methods are reliable and that the error margin is minimal, our studies showed that in 75% of cases the internal diameter of the anterior chamber was an oval with a large vertical axis (Figure 4-2). On the basis of the external measurements of the cornea, which is the usual method of measuring, the shape of the anterior chamber is considered to be oval with a large horizontal axis in harmony with the palpebral cleft. These internal measurements are essential when considering angle-supported phakic implants.

Accommodation

It was possible to study accommodation at different periods in life with the Visante™ OCT (Carl Zeiss Meditec, Jena,

Figure 4-1: Photograph of a Visante™ OCT device (Carl Zeiss Meditec, Jena, Germay).

Figure 4-3: Visante™ OCT (Carl Zeiss Meditec, Jena, Germay) images showing the anterior displacement of the crystalline lens during accommodation in a 10 year-old child, accounting for the decrease in the anterior chamber depth during accommodation.

Germay) and the images revealed that some very important dynamic distortions occurred in the anterior chamber during accommodation. The anatomical relationship between the iris and the crystalline lens underwent modifications, and the decrease of the anterior chamber depth was inversely proportional to the degree of accommodation. During accommodation as shown in Figure 4-3 there was a forward thrust of the anterior pole of the crystalline lens and a decrease in the anterior chamber depth. Recent studies4,5,8 have confirmed von Helmholtz’s accommodation theory that was described more than 150 years ago.9

Crystalline Lens

information that can play a role in the field of phakic IOLs.4-8 Each patient’s anterior chamber anatomy and the protrusion of the crystalline lens is of important consideration, as these individual variations can have an effect on phakic implant tolerance. For example, the study of a large series of phakic eyes with Artisan implants revealed that pigment dispersion syndrome appeared more frequently in eyes that had a significant protrusion of the crystalline lens.10

Figure 4-4 shows different aspects of the crystalline lens rise and Figure 4-5 represents a high myopic patient referred for refractive surgery. This patient suffered from microspherophakia. Although the anterior chamber was deep enough (over 3 mm), the forward protrusion of the crystalline lens was extremely significant, and because of this abnormality an Artisan type of lens implant would most certainly have been a contraindication in this case.

Today, it is possible to study the shape of the crystalline lens with the OCT as long as this can be done within the

Observations of the anatomy of the crystalline lens both in its static and dynamic state has provided significant

Figure 4-4: Different aspects of crystalline lens rise.

Figure 4-5: Visante ™ OCT (Carl Zeiss Meditec, Jena, Germay) images showing microspherophakia.

Figure 4-6: OCT image of a 2-year-old child with Peter’s anomaly and nystagmus.

pupillary area. Moreover, the OCT is a non-contact procedure and hence it is easy to use even in children. Studying congenital malformations of the anterior segment are fairly simple when using an OCT unit. Figure 4-6 is the OCT image of a 2-year-old child with Peters anomaly and nystagmus. The peripheral iris root is visible, as well as crystalline lens adhesion to the posterior surface of the cornea, leading to corneal edema. In this case, the different layers of the crystalline lens are also visible. However, studying the crystalline lens is not always as easy as in this extreme case and to date the technology at our disposal cannot give us a precise idea of the optical density of the crystalline lens. This limitation is due to the fact that along the optical axis there are significant reflection phenomena due to the laser beam, which is used as a fixation point.

The OCT unit has a fairly limited depth of focus, and to study the thickness of the natural crystalline lens, focusing has to be done towards the back of the eye. On the other hand, studying intraocular lens implants in pseudophakic eyes is fairly simple. Figure 4-7 shows piggy-back intraocular lens implants, and it is quite clear that there is no tissue in between the two intraocular lenses. It is also possible to observe the development of inter-lenticular cellular proliferation when it exists.

The relationship between the iris, crystalline lens and the cornea is easy to visualise and the OCT appears to be a useful tool for diagnosing angle-closure glaucoma (Figure

Figure 4-7: OCT image showing piggy-back intraocular lens implants. Notice the absence of any tissue in between the two intraocular lenses.

Figure 4-8: OCT imaging provides a good view of the anterior chamber angles and the anterior segment of the eye. There is iris adhesion to the peripheral cornea resulting in angle closure in this case of angle-closure glaucoma.

Figure 4-9: This is an example of a nanophthalmic patient, where there is a total absence of the anterior chamber.

4-8). Figure 4-9 shows the most extreme case, where there is a total absence of the anterior chamber in a nanophthalmic patient.

Cornea

A profile study of the corneal morphology is relatively simple. Because of the non-contact technique that is used, it is easier to observe sensitive eyes that are otherwise difficult to image with ultrasonic techniques. Examinations are easy to repeat, image acquisition is rapid, and it can be performed several times on the same meridian, as alignment is along the visual axis. The three images in Figure 4-10 show patients at different stages of keratoconus, namely,

from the early stage, to corneal hydrops. The acute hydrops in keratoconus secondary to a break in the Descemet’s membrane (Figure 4-10) is particularly interesting as it shows the intrusion of aqueous humour into the corneal stroma resulting in corneal thickening and the formation of an aqueous bleb in front of the Descemet’s membrane, stretched across the deep, posterior corneal stroma.

Corneal OCT is a remarkable clinical tool for the evaluation of both the preoperative diagnosis as well as postoperative follow-up in patients with varying disease states of the cornea.

Figure 4-11 is an OCT image of a patient with irido- corneal-endothelial (ICE) syndrome taken shortly after a penetrating keratoplasty. The corneal graft has not yet recovered its normal shape and transparency following the surgery; however, it is possible with the OCT to visualize behind the graft, without any significant

discomfort to the patient since it is a non-contact OCT. The development of pathological gonio-synechiae secondary to endothelial “metaplasia” in this case of ICE syndrome is clearly visible (Figure 4-11).

As we mentioned in the introduction, the infrared light rays cannot penetrate pigments within the eye. It is therefore generally impossible to see just behind the iris pigments. However, this does not mean that one cannot see through opaque structures. The OCT penetrates milky-white corneas and the sclera as both these structures are without pigments. Figure 4-12 shows an OCT image of the preoperative aphakic corneal edema, where the cornea is completely white due to diffuse corneal stromal and epithelial edema. Even in this totally cloudy cornea, the iridocorneal synechiae and the pathological vitreous strands are clearly visible (Figure 4-12). In this case, there

Figure 4-11: OCT image of a patient with irido-corneal-endothelial (ICE) syndrome shortly after a penetrating keratoplsty. Gonio-synechiae are clearly visible in this case of ICE syndrome.

Figure 4-12: Preoperative OCT image of an eye that has complete clouding of the cornea secondary to aphakic corneal edema. Even in this totally cloudy cornea, the iridocorneal synechiae and the pathological vitreous strands are clearly visible.

Figure 4-13: OCT image of a patient with an inferior marginal keratoconus. The image information is helpful in planning a possible decentered PKP in this case.

is no artificial lens, namely, no pseudophakic IOL, and the surgeon can therefore decide on his surgical strategy. Preoperative sizing is also easy on the corneal cuts of the OCT imaging system. For example, Figure 4-13 displays an OCT image of a patient with an inferior marginal keratoconus. In this case, a large diameter deep lamellar graft can be surgically challenging, because, if there is an intra-operative corneal perforation during the lamellar dissection, the surgeon has to convert to a large diameter penetrating keratoplasty with a high risk of postoperative corneal graft rejection. In this case, it is possible to plan a graft with an 8.0 to 8.5 mm diameter, by not only including the ectatic zone of the patient’s cornea but also sufficiently covering the optical axis.

The anterior segment OCT can be used routinely for the follow-up of penetrating and lamellar keratoplasties [See also Chapter 5, Optical Coherence Tomography in Corneal

Implant Surgery, Chapter 6, Use of Optical Coherence Tomography in Descemet’s Stripping with Endothelial Keratoplasty (DSEK) and Descemet’s Stripping with Automated Endothelial Keratoplasty (DSAEK)]. Figure 4-14 shows an OCT image of a patient with persistent corneal edema following corneal graft. OCT examination in this case shows that the edema was due to the non-adherence of the donor endothelial graft. As it was an old graft with longstanding corneal edema, a full-thickness penetrating keratoplasty was performed. A case of corneal stromal dystrophy that was treated by manual, deep anterior lamellar keratoplasty is shown in Figures 4-15 and 4-16. A small corneal perforation occurred during surgery which was closed with viscous substance. Postoperatively, there was a double anterior chamber and the recipient Descemetic-endothelial bed (Descemet’s membrane with its healthy endothelium) failed to adhere to the grafted donor corneal stroma that is devoid of its Descemet’s membrane and endothelium. Anterior chamber injection of C3F8 helped collapse the double anterior chamber, and facilitated donor-recipient tissue adherence with resolution of the corneal edema.

Using standard software, focal areas of corneal stromal edema can be visualized as seen in Figure 4-17. Figure 4-17 shows a recent Artisan phakic implant dislocation, with focal area of corneal edema that was localized to the region of implant contact with the corneal endothelium. Once the implant was re-positioned, the focal corneal edema completely disappeared without any significant endothelial cell loss, due to the early (few days) surgical intervention following implant dislocation. Today, the Visante™ OCT