A NEW STRATEGY OF KERATOPLASTY: LAMINATING AND SPLITTING THE DONOR CORNEA

Purpose: to report the first case of the same day use of a single donor cornea tissue for 5 consecutive transplantations in patients with endothelial dystrophy and keratoconus. Material and methods. The Descemet membrane (DM) and the endothelium were fully detached from the stroma of the donor on the endothelial side, using first a circular and then a direct corneal cutter, forming four partial triangle-shaped Descemet grafts (each constituted a 1/4 Descemet graft). The stroma of the donor's cornea was separated by a circular cutter of a preset diameter. One patient with keratoconus underwent deep anterior lamellar keratoplasty (DALK) using the big bubble technique. Then, each of the four Descemet grafts was sequentially transplanted by the Descemet membrane endothelial keratoplasty (DMEK) method to 4 patients with Fuchs dystrophy and pseudophakia. Results. During and after the surgery, there were no complications requiring additional intervention. Six months after DALK, the best corrected visual acuity (BCVA) was 0.66. Six months after four operations each using ¼ DMEK the average BCVA was 0.95 ± 0.1 (from 0.8 to 1.0) and the endothelial cell density was, respectively, 2839 after DALK and 1680 ± 254 cells/mm2 (from 1492 to 2039 cells/mm2) after ¼ DMEK. Conclusion. One donor cornea can be successfully transplanted to at least 5 patients. Despite the fact that the implementation of DALK and several operations using the ¼ DMEK technique within one day is technically difficult, this approach can contribute to a drastic reduction in the deficit of donor tissue. This approach requires a thorough selection of patients and an extensive surgical experience. For citation: Oganesyan O.G., Makarov P.V., Grdikanyan А.А., Getadaryan V.R. A new strategy of keratoplasty: laminating and splitting the donor cornea. Russian ophthalmological journal. 2018; 11 (3): 11-8 (In Russian). doi: 10.21516/2072-0076-2018-11-3-11-18. The full English version is available online at http://roj.igb.ru/eng/issues

роговица донора, кератопластика, трансплантация роговицы, трансплантация десцеметовой мембраны, DMEK, Q-DMEK, ¼ DMEK, donor cornea, keratoplasty, corneal transplantation, Descemet membrane transplantation, DMEK, Q-DMEK, ¼ DMEK

1. Phillips P., Terry M., Shamie N. et al. Descemet’s stripping automated endothelial keratoplasty (DSAEK) using corneal donor tissue not acceptable for use in penetrating keratoplasty as a result of anterior stromal scars, pterygia, and previous corneal refractive surgical procedures. Cornea. 2009; 28: 871-6. doi: 10.1097/ICO.0b013e318199f8d7

2. Tandon R., Verma K., Vanathi M. et al. Factors affecting eye donation from postmortem cases in a tertiary care hospital. Cornea. 2004; 23: 597-601.

3. Krishnaiah S., Kovai V., Nutheti R. et al. Awareness of eye donation in the rural population of India. Indian J. Ophthalmol. 2004; 52: 73-8.

4. Vajpayee R.B., Sharma N., Jhanji V. et al. One donor cornea for 3 recipients: a new concept for corneal transplantation surgery. Arch. Ophthalmol. 2007; 125: 552-4. doi: 10.1001/archopht.125.4.552

5. Groeneveld-van Beek E.A., Lie J.T., von der Wees J. et. al. Standardized ‘no-touch’ donor tissue preparation for DALK and DMEK: harvesting undamaged anterior and posterior transplants from the same donor cornea. Acta Ophthalmol. 2013: 91: 145-50. doi: 10.1111/j.1755-3768.2012.02462.x

6. Anwar M., Teichmann K.D. Deep lamellar keratoplasty: surgical techniques for anterior lamellar keratoplasty with and without baring of Descemet’s membrane. Cornea. 2002; 21: 374-83.

7. Оганесян О.Г., Нероев В.В., Гундорова Р.А., Воробьева М.А. Первый опыт трансплантации десцеметовой мембраны. Офтальмология. 2008; 5(4): 18-22. Oganesyan O.G., Gundorova R.A., Vorobjeva M.A. The first experience of descemet's membrane transplantation. Oftal’mologija. 2008. 5: 18-22. (in Russian).

8. Zirm E. Eine erfolgreiche totale keratoplastik. Arch. Ophthalmol. 1906; 64: 580-93.

9. Lie J.T., Groeneveld-van Beek E.A., Ham L. et al. More efficient use of donor corneal tissue with Descemet membrane endothelial keratoplasty (DMEK): two lamellar keratoplasty procedures with one donor cornea. Br. J. Ophthalmol. 2010; 94: 1265-6. doi: 10.1136/bjo.2009.171629

10. Heindl L.M., Riss S., Bachmann B.O. et al. Split cornea transplantation for 2 recipients: a new strategy to reduce corneal tissue cost and shortage. Ophthalmology. 2011; 118: 294-301. doi: 10.1016/j.ophtha.2010.05.025

11. Sharma N., Agarwal P., Titiyal J. et al. Optimal use of donor corneal tissue: one cornea for two recipients. Cornea. 2011; 30: 1140-4. doi: 10.1097/ICO.0b013e318209d23c

12. Müller T.M., Lavy I., Baydoun L. et al. Case report of Quarter-Descemet membrane endothelial keratoplasty for Fuchs endothelial dystrophy. Cornea. 2017; 36: 104-7. doi: 10.1097/ICO.0000000000001008

13. Yoeruek E., Schmidt K.U. Current approaches to combat the shortage of corneal tissues: split-DMEK and double-split keratoplasty. Cornea. 2015; 34: 6-9. doi: 10.1097/ICO.0000000000000341

14. Rasouli M., Caraiscos V.B., Slomovic A.R. Efficacy of routine notification and request on reducing corneal transplantation wait times in Canada. Can. J. Ophthalmol. 2009; 44: 31-5. doi: 10.3129/i08-187

15. De By T.M. Shortage in the face of plenty: improving the allocation of corneas for transplantation. Dev. Ophthalmol. 2003; 36: 56-61.

16. Otte J.B., de Ville de Goyet J., Alberti D. et al. The concept and technique of the split liver in clinical transplantation. Surgery. 1990; 107: 605-12.

17. Cintorino D., Spada M., Gruttadauria S. et al. In situ split liver transplantation for adult and pediatric recipients: an answer to organ shortage. Transplant Proc. 2006; 38: 1096-8. doi:10.1016/j.transproceed.2006.02.146

18. Armour R., Ousley P., Wall J. et al. Endothelial keratoplasty using donor tissue not suitable for full-thickness penetrating keratoplasty. Cornea. 2007; 26: 515-9. doi:10.1097/ICO.0b013e3180335511

19. Moshirfar M., Khalifa Y., Davis D. et al. Descemet stripping automated endothelial keratoplasty using donor corneas with previous laser in situ keratomileusis or photorefractive keratectomy: a case series and donor cap histopathology. Cornea. 2012; 31: 533-7. doi: 10.1097/ICO.0b013e31820142be

20. Maharana P., Jhanji V., Vajpayee R. B. Inadvertent use of cornea with previous LASIK in deep lamellar keratoplasty. Optom. Vis. Sci. 2014; 91: 59-62. doi: 10.1097/OPX.0000000000000162

21. Huang T., Wang Y., Hu A. et al. Use of pediatric donor tissue in Descemet’s stripping endothelial keratoplasty. Br. J. Ophthalmol. 2009; 93: 1625-8. doi: 10.1136/bjo.2009.158477

22. Kim P., Yeung S.N., Lichtinger A. et al. Descemet stripping automated endothelial keratoplasty using infant donor tissue. Cornea. 2012; 31: 52-4. doi: 10.1097/ICO.0b013e31821eeac0

23. Sun Y.X., Hao Y.S., Hong J. Descemet membrane stripping endothelial keratoplasty with neonate donors in two cases. Br. J. Ophthalmol. 2009; 93: 1692-9. http://dx.doi.org/10.1136/bjo.2009.158188

24. Оганесян О.Г., Яковлева С.С., Харлампиди М.П. и др. Рациональное использование донорского материала: собственный десятилетний опыт, возможные пути развития и данные литературы. Медицинский журнал Российской Федерации. 2016; 22: 193-7. Oganesyan O.G., Yakovleva S.S., Kharlampidi M.P. et al. The rationale application of donor material: original 251 ten years’ experience, possible ways of development and literature data. Meditsinskij zhurnal Rossijskoj Federatsii. 2016; 22: 193-7. (in Russian).

25. Нероев В.В., Оганесян О.Г., Гундорова Р.А., Сметанина М.А., Данилова Д.Ю. Использование глаз с кератотомиями в качестве трансплантационного материала. Российский медицинский журнал. 2011; 5: 32-4. Neroev V.V., Oganesyan O.G., Gundorova R.A, et al. Use of keratotomy eyes as a transplant. Rossijskij meditsinskij zhurnal. 2011; 5: 3 2-4. (in Russian)

26. Fang W., Xiuming J., Yesheng X. et al. Treatment of corneal perforation with lenticules from small incision lenticule extraction surgery: a preliminary study of 6 patients. Cornea. 2015; 34: 658-63. doi: 10.1097/ICO.0000000000000397

27. Graue-Hernandez E.O., Zuniga-Gonzalez I., Hernandez-Camarena J.C. et al. Tectonic DSAEK for the management of impending corneal perforation. Case Reports in Ophthalmol. Med. 2012; Article ID 916528, 4 pages. http://dx.doi.org/10.1155/2012/916528

28. Nahum Y., Bahar I., Busin M. Tectonic Descemet stripping automated endothelial keratoplasty for the management of sterile corneal perforations in decompensated corneas. Cornea. 2016; 35: 1516-9. doi: 10.1097/ICO.0000000000001037

29. Tu E.Y. Descemet membrane endothelial keratoplasty patch for persistent corneal hydrops. Cornea. 2017; 36: 1559-61. doi: 10.1097/ICO.0000000000001351

30. Kolomeyer A.M., Chu D.S. Descemet stripping endothelial keratoplasty in a patient with keratoglobus and chronic hydrops secondary to a spontaneous Descemet membrane tear. Case Reports in Ophthalmol. Med. 2013; ID 697403. doi: 10.1155/2013/697403