DSEK or Descemets Stripping Endothelial Keratoplasty is a newer method of preserving the function and clarity of the cornea.
What is a Cornea?
The cornea is the outermost part of the eye. It is made up of many layers of thin cells. It is clear, therefore we are not able to see it. The first structure of the eye we perceive is the iris which is the colored area: brown, blue, or green are the normal colors.
The cornea is masterfully crafted by nature. Even the most expensive man-made lenses cannot match its accuracy of function and self-preservation. The smoothness and shape of the cornea is critically important to its proper functioning as well its transparency. If either the surface level of smoothness or the quality of the cornea is altered, vision will come to be compromised.
Although appearing to be one clear membrane, the cornea is really composed of five distinct layers of tissue, each with its own function. The slim outer layer, or epithelium, is a dependable obstacle against corneal infection. It normally has to be damaged before an infectious bacteria or virus can enter between the layers of the cornea. Just below this layer is a fibrous band called Bowman’s membrane. It is important for the integrity of the cornea.
The third layer called the stroma is constructed from collagen, a connective tissue. This forms eighty percent of the cornea. Besides collagen fibrils, there are cells called keratocytes. The density of the fibres is higher towards the Bowman’s membrane. Below the stroma is again a fibrous layer. This is termed as Descemet’s membrane. It is the scaffolding for the innermost layer of cells called Endothelium cells.
When endothelial cells are healthy and balanced, they function as a “pump-leak system” to provide nutrients for the cornea. In other words these cells allow nourishing fluid from inside the eye (liquid food) to leak into the cornea. After the corneal cells have actually been nourished, the cells pump the fluid from the cornea.
If the endothelial pump is compromised for any reason the cornea will certainly over hydrate as well as become hazy. This most frequently takes place in patients that have suffered injury to the endothelial layer during complex cataract surgical procedure or individuals that have actually acquired an illness of the corneal endothelium referred to as Fuchs’ Endothelial Dystrophy.
A corneal transplant works like replacing the windshield of a car. When we drive during different times of the day we need to be able to see through the windshield out into the distance. The windshield needs to be clear at all times. Dust or rain can impair our ability to see through it. Likewise the cornea has to be always kept clear.
Light travels through the clear cornea on its course toward the retina in the back component of the eye. A healthy, clear cornea is needed for perfectly clear vision. Sometimes, the cornea is referred to as the” window” to the eye. Occasionally, either through disease or injury, the corneal tissue is harmed to a point where light could no longer successfully pass through it, causing reduced vision.
What exactly is DSEK or Descemet’s Stripping Endothelial Keratoplasty?
Some diseases of the cornea, however, just affect the inner lining of the cornea. A new version of corneal transplant, understood as a Descemet’s Removing Endothelial Keratoplasty (DSEK), has been introduced as a new medical method that utilizes just an extremely slim section of the cornea for transplant. DSEK is a partial corneal transplant technique where the harmful, diseased, posterior part of a person’s cornea is removed and replaced with a healthy and balanced thin corneal graft taken from a cadaver. Unlike the Penetrating Keratoplasty (PK), the DSEK treatment uses only a partial thickness graft. Therefore it requires a much smaller surgical cut and also requires no corneal sutures. This generally results in extra quick aesthetic rehab for the patient as well as reduces the risk of harmful problems that accompany the PK surgery.
Indications for DSEK or Descemets Stripping Endothelial Keratoplasty
When the corneal endothelium is stressed out, the endothelial cells come to be larger and also a lot more thin. As endothelial cell numbers fall in between 500 to 1000 cells/mm, the pump device can no longer preserve a clear cornea. This may occur after prolonged complicated cataract surgery. This entity is termed as Pseudophakic Bullous Keratopathy.
When it comes to Fuchs’ dystrophy the endothelial cells additionally start producing product that makes Descemet’s layer thicker and opaque. Vision at some point deteriorates to a point where these people feel like they are looking through wax paper. Such clients are ready prospects for the DSEK treatment.
Advantages of DSEK or Descemet’s Stripping Endothelial Keratoplasty
There are a lot of major benefits of the DSEK operation in comparison to the normal corneal transplant operation.
- In PK there is a time when the eye is completely open. If the patient were to strain or cough the interior structure of the eye can prolapse forward. In hypertensive patients there is even the chance the retina may come out. This is called expulsive hemorrhage. In DSEK only a small wound similar to that used in cataract eye surgery is made.
- There are many stitches used in PK or penetrating graft. DSEK or Descemets Stripping Endothelial Keratoplasty is either stich less or only one or two sutures may be required
- The chances of rejection are much less in DSEK
- The induced Astigmatism in PK is high compared to the almost negligible amount in DSEK
- Integrity of the eye is better in DSEK than in PK
- Returning to an active lifestyle and resumption of uninterrupted work is faster with DSEK.
The healing with PK can be fairly long, up to twelve months. It is likewise not unusual to have significant irregular curvature of the cornea as a result of the stitches. In many cases a prescription lens is required to achieve the best vision. Finally, a full thickness corneal transplant could have continued weakness even years later on such that even a minor trauma could disjoint the graft from its setting. Cornea specialists have performed DSEK surgery for the past ten years with amazing success. Future endothelial transplant research will center on making the procedure more reliable and not as surgeon-dependent.
Steps of Descemet’s Stripping Endothelial Keratoplasty
The transplant tissue can be made manually by the corneal surgeons in the operating suite. This is done using a special punch and fine dissection. There is a chance of damaging the graft as it is a very delicate procedure. The trend has been to order premade graft from the eyebank. Technicians there do a large number of graft harvesting so they become adept at the procedure. In addition if the graft is damaged they can utilize another donated cornea to yield the graft.
In the event the patient elects to proceed with the surgery, the physician is going to have the patient sign an educated consent form. You’re going to be awake during the process and the majority of people don’t report any discomfort. Dr. K routinely performs this treatment just utilizing eye drops to numb the eye. Some patients could be given local or general anesthesia, especially if their general medical condition is in question.
The DSEK procedure takes approximately 45 minutes to 1 hour. After the eye is prepped and draped in sterile fashion an eye retainer is inserted to keep the eyelids open. The Cornea specialist removes the unhealthy internal cell layer of the cornea. The surgeon implants healthy and balanced benefactor tissue through a tiny cut. Dr.Khanna after that utilizes an air bubble to unfold and place the donor tissue against the patient’s cornea. The small incision is either self-sealing or may be closed with a stitch or two.
Most patients have minimum pain after surgery. Patient is asked to lay flat in the recovery room for about 45 minutes to an hour and is seen again before being discharged home. For the initial 24 hours after surgery patients are requested to lie on their back with their face pointed directly at the ceiling for as much time since they can tolerate. They start to see once the bubble dissolves over the subsequent 2-3 days. They can return to normal activities a week or two following surgery.
Alternatives to DSEK or Descemets Stripping Endothelial Keratoplasty
Since damaged or scarred corneal tissue doesn’t allow light to effectively pass in the eye and get to the retina, bad vision and even blindness may come from a damaged cornea. Patients with a stromal scar as opposed to endothelial dysfunction will require a penetrating keratoplasty rather than a DSEK or Descemets Stripping Endothelial Keratoplasty.
Full Thickness Penetrating Keratoplasty and Lamellar Thickness Keratoplasty have preceded DSEK. Another newer procedure where only Descemet’s is removed is called DWEK. It has only limited indication in certain Fuchs patients. ROCK inhibitors have to be used.
More popular and a finer procedure is DMEK. Here as shown in the picture an even thinner graft is used. The graft here is one tenth the thickness of DSEK.
DISADVANTAGES OF DSEK TECHNIQUE
A difficulty that could occur from the DSEK procedure that is not associated with a conventional transplant is a graft dislocation, where the round disc slips from its desired placement. In this circumstance the donor disc needs to be repositioned in the operating area. If the air bubble escapes the graft may get dislodged requiring another air bubble. The interface between the host and donor is not completely smooth. This may limit vision in few individuals. DSEK also adds more tissue than it removes. It may result in a hyperopic shift.
Here is a DSEK eye surgery video.
When seeking a Los Angeles DSEK or Descemets Stripping Endothelial Keratoplasty surgeon it’s important to select someone with superior knowledge in matters linked to the cornea. Your cornea specialist will have the ability to decide on whether a DSEK partial cornea transplant is the ideal procedure for you.