Офтальмохирургия. 2019; : 20-26
Сравнительный анализ клинико-функциональных результатов задней послойной кератопластики с использованием фемтосекундного лазера и микрокератома
https://doi.org/10.25276/0235-4160-2019-1-20-26Аннотация
Цель. Сравнить клинико-функциональные результаты задней послойной кератопластики (ЗПК) с выкраиванием трансплантата при помощи лазера (ФЛ-ЗПК) либо механического автоматизированного микрокератома (ЗАПК).
Материал и методы. В проспективное моноцентровое рандомизированное исследование включено 38 пациентов (39 глаз) с эндотелиальной дистрофией роговицы Фукса и сопутствующей катарактой. В основной группе, 19 пациентов (19 глаз), проведена ФЛ-ЗПК и факоэмульсификация с имплантацией ИОЛ. В группе контроля, 19 пациентов (20 глаз), выполнена ЗАПК с использованием микрокератома одномоментно с факоэмульсификацией и имплантацией ИОЛ. В ходе исследования применяли стандартные и специализированные (оптическая когерентная томография переднего отрезка глаза, иммерсионная конфокальная микроскопия, кератопахиметрия, эндотелиальная микроскопия) методы обследования. Оценку геометрии трансплантата проводили, изучая соотношение его толщин в центре и на периферии (индекс Ц:П). Максимальный срок наблюдения за оперированными пациентами составил 1 год.
Результаты. В основной группе прозрачное приживление зарегистрировано в 89,5% случаев, в группе контроля - в 95%. В отдаленные сроки наблюдения (более 6 мес.) не выявлено различий показателей НКОЗ и КОЗ между группами (p>0,05). В основной и контрольной группах значения Ц:П составили 0,88 (0,85; 0,95) и 0,55 (0,48; 0,68) соответственно (p<0,001). Значение гиперметропического сдвига в основной группе было равно 0,27±0,9 дптр и 1,25±0,81 дптр - в группе контроля (p=0,002). Выявлена взаимосвязь между гиперметропическим сдвигом и индексом Ц:П трансплантата (r=-0,406; p=0,019). Снижение ПЭК к 12 мес. наблюдения в основной группе была выше, чем в контрольной, составив 64,1±8,8 и 54,6±4,8% соответственно (p<0,001).
Заключение. Клинико-функциональные результаты в ближайшие и отдаленные сроки наблюдения были сопоставимы между двумя вариантами техники операции. Использование фемтосекундного лазера позволяет получить более равномерный по своей толщине трансплантат по сравнению с техникой ЗАПК. Нами выявлено наличие зависимости между индексом Ц:П трансплантата и развитием гиперметропии у пациентов после операции, а также подтвержден меньший гиперметропический сдвиг (0,27±0,9 дптр) при ФЛ-ЗПК в сравнении с ЗАПК (1,25±0,81 дптр).
Список литературы
1. Малюгин Б.Э., Мороз З.И., Борзенок С.А. и др. Первый опыт и клинические результаты зад¬ней автоматизированной послойной кератопла¬стики (ЗАПК) с использованием предваритель¬но выкроенных консервированных ультратон¬ких роговичных трансплантатов. Офтальмохирургия. 2013;3:12-16.
2. Дроздов И.В. Хирургическое лечение эпите-лиально-эндотелиальной дистрофии роговицы ме-тодом задней автоматизированной послойной кера-топластики с использованием ультратонких транс-плантатов. Дис. ... канд. мед наук. М., 2013.
3. Погорелова С.С., Грдиканьян А.А., Ченцова Е.В. и др. Анализ плотности эндотелиальных клеток в среднесрочный период наблюдения после эндоте-лиальной кератопластики с формированием транс-плантата фемтосекундным лазером со стороны эндо-телия. Российский медицинский журнал. 2016;1:10- 13.
4. Яковлева С.С. Инвертное фемтолазерное формирование трансплантата для задней кератопла-стики: Дис. ... канд. мед. наук. М., 2017.
5. Aнтонова О.П. Современные аспекты ди-агностики и лечения первичной эндотелиаль¬ной дистрофии роговицы (Фукса). Дис. ... канд. мед наук. M., 2017.
6. Afshari N.A., Pittard A.B., Siddiqui A., Klintworth G.K. Clinical study of fuchs corneal endothelial dystrophy leading to penetrating keratoplasty: A 30-year experience. Arch. Ophthalmol. 2006;6:777-780. Available from: https://doi.org/10.1001/archopht.124.6.777.
7. Terry M.A., Shamie N., Chen E.S. et al. Endothelial Keratoplasty for Fuchs’ Dystrophy with Cataract. Complications and Clinical Results with the New Triple Procedure. Ophthalmology 2009;4:631-639. Available from: https://doi.org/10.1016/j.ophtha.2008.11.004.
8. Melles G.R.J., Ong T.S., Ververs B., van der Wees J. Descemet membrane endothelial keratoplasty (DMEK). Cornea. 2006;2:199-206. Available from: https://doi. org/10.1111/j.1574-695X.2006.00082.x.
9. Da Reitz Pereira C., Guerra F.P., Price F.W., Price M.O. Descemet’s membrane automated endothelial keratoplasty (DMAEK): Visual outcomes and visual quality. Br. J. Ophthalmol. 2011;7:951-954. Available from: http://dx.doi.org/10.1136/bjo.2010.191494.
10. Sikder S., Snyder R.W. Femtosecond laser preparation of donor tissue from the endothelial side. Cornea. 2006;4:416-422. Available from: https://doi. org/10.1097/01.ico.0000195948.86071.98.
11. Gorovoy M.S. Descemet-stripping automated endothelial keratoplasty. Cornea. 2006;8:886- 889. Available from: https://doi.org/10.1097/01. ico.0000214224.90743.01.
12. Mehta J.S., Parthasarthy A., Por Y.-M. et al. Femtosecond laser-assisted endothelial keratoplasty: a laboratory model. Cornea. 2008;27:706-712. Available from: https://doi.org/10.1097/qai.0b013e31815ee267.
13. Rosa A.M., Silva M.F., Quadrado M.J. et al. Femtosecond laser and microkeratome-assisted Descemet‘s stripping endothelial keratoplasty: First clinical results. Br. J. Ophthalmol. 2013;9:1104- 1107. Available from: http://dx.doi.org/10.1136/ bjophthalmol-2012-302378.
14. Chylack L.T., Wolfe J.K., Singer D.M. et al. The Lens Opacities Classification System III. Arch. Ophthalmol. 1993;6:831-836.
15. Covert D.J., Koenig S.B. New Triple Procedure: Descemet’s Stripping and Automated Endothelial Keratoplasty Combined with Phacoemulsification and Intraocular Lens Implantation. Ophthalmology. 2007;6:670-674.
16. Dickman M.M., Cheng Y.Y.Y., Berendschot T.T.J.M. et al. Effects of graft thickness and asymmetry on visual gain and aberrations after descemet stripping automated endothelial keratoplasty. JAMA Ophthalmol. 2013;6:737-744. Available from: https:// doi.org/10.1001/jamaophthalmol.2013.73.
17. Heinzelmann S., Maier P., Bohringer D. et al. Visual outcome and histological findings following femtosecond laser-assisted versus microkeratome- assisted DSAEK. Graefe’s Arch. Clin. Exp. Ophthalmol. 2013;8:1979-1985. Available from: https://doi. org/10.1007/s00417-013-2359-7.
18. Bahar I., Kaiserman I., Livny E. et al. Changes in corneal curvatures and anterior segment parameters after descemet stripping automated endothelial keratoplasty. Curr. Eye Res. 2010;11:961-966. Available from: https://doi.org/10.3109/02713683.2010.506967.
19. Dupps W.J., Qian Y., Meisler D.M. Multivariate model of refractive shift in Descemet-stripping automated endothelial keratoplasty. J. Cataract Refract. Surg. 2008;4:578-584. Available from: https://doi. org/10.1016/j.jcrs.2007.11.045.
20. Holz H.A., Meyer J.J., Espandar L. et al. Corneal profile analysis after Descemet stripping endothelial keratoplasty and its relationship to postoperative hyperopic shift. J. Cataract Refract. Surg. 2008;34:211- 214. Available from: https://doi.org/10.1016/j. jcrs.2007.09.030.
21. Yoo S.H., Kymionis G.D., Deobhakta A.A. et al. One-year results and anterior segment optical coherence tomography findings of descemet stripping automated endothelial keratoplasty combined with phacoemulsification. Arch. Ophthalmol. 2008;8:1052- 1055. Available from: https://doi.org/10.1001/ archopht.126.8.1052.
22. Hjortdal J. Inverse Cutting of Posterior Lamellar Corneal Grafts by a Femtosecond Laser. Open Ophthalmol. 2012;6:19-22. Available from: https://doi. org/ 10.1001/archopht.126.8.1052.
23. Sikder S., Snyder R.W. Femtosecond laser preparation of donor tissue from the endothelial side. Cornea. 2006; 4: 416-422. Available from: https://doi. org/ 10.1001/archopht.126.8.1052.
24. Koenig S.B., Covert D.J., Dupps W.J., Meisler D.M. Visual acuity, refractive error, and endothelial cell density six months after Descemet stripping and automated endothelial keratoplasty (DSAEK). Cornea. 2007; 6:670-674. Available from: https://doi.org/ 10.1097/ICO.0b013e3180544902.
25. Busin M., Madi S., Santorum P. et al. Ultrathin descemet’s stripping automated endothelial keratoplasty with the microkeratome double-pass technique: Two-year outcomes. Ophthalmology. 2013;6:1186- 1194. Available from: https://doi.org/10.1016/j. ophtha.2012.11.030.
26. Jun B., Kuo A.N., Afshari N.A. et al. Refractive change after descemet stripping automated endothelial keratoplasty surgery and its correlation with graft thickness and diameter. Cornea. 2009;1:19-23. Available from: https://doi.org/10.1097/ico.0b013e318182a4c1.
27. Woodward M.A., Titus M.S., Shtein R.M. Effect of microkeratome pass on tissue processing for descemet stripping automated endothelial keratoplasty. Cornea. 2014;5:507-509. Available from: https://doi. org/10.1097/ico.0000000000000093.
28. Liu YC, Teo EPW, Adnan KB, et al. Endothelial approach ultrathin corneal grafts prepared by femtosecond laser for descemet stripping endothelial keratoplasty. Invest. Ophthalmol. Vis Sci. 2014;12:8393-8401. Available from: https://doi.org/10.1167/iovs.14-15080.
29. Li JY, Terry MA, Goshe J, Davis-Boozer D, Shamie N. Three-year visual acuity outcomes after Descemet’s stripping automated endothelial keratoplasty. Ophthalmology 2012; 6: 1126-1129. Available from: https://doi.org/10.1016/j.ophtha.2011.12.037.
Fyodorov Journal of Ophthalmic Surgery. 2019; : 20-26
Clinical and functional results following femtosecond laser-assisted DSEK versus microkeratome-assisted DSAEK surgeries. A comparative study
https://doi.org/10.25276/0235-4160-2019-1-20-26Abstract
Purpose. To compare the clinical and functional outcomes of posterior lamellar keratoplasty using the femtosecond laser (FS-DSEK) and manual microkeratome (DSAEK) for graft preparation.
Material and methods. The prospective single-center randomized study included 38 patients (39 eyes) with simultaneous Fuchs endothelial dystrophy and cataract. There were enrolled in the study group 19 patients (19 eyes) following FS-DSEK combined with phacoemulsification and IOL implantation. The control group included 19 patients (20 eyes) following microkeratome-assisted DSAEK combined with phacoemulsification and IOL implantation. Pre- and post-operatively the standard and special diagnostic methods were used (optical coherence tomography, confocal immersion microscopy, keratopachymetry, endothelial microscopy). Evaluation of transplant geometry was performed using the ratio between central and peripheral graft thickness (C:P ratio). The maximum followup period was 1 year.
Results.In the study group the corneas were transparent in 89.5% of cases and 95% in the control group. At long-term follow-up periods (6 months and more) postoperatively there were no significant difference of UCVA and BCVA between groups (p>0.05). In the study and control group the median C:P ratio were 0.88 (0.85; 0.95) and 0.55 (0.48; 0.68), respectively (p<0.001). The mean hyperopic shifts in the study group were 27±0.9D and 1.25±0.81D in the control group (p=0.002). A correlation was revealed between hyperopic shift and C:P ratio of transplant, (r=- 0.406; p=0.019). Endothelial cell density loss at 12 months in the study group was higher in comparison to the control group and averaged 64.1±8.8% and 54.6±4.8%, respectively (p<0.001).Conclusion. Clinical and functional results in the early and long-term follow- up periods were comparable between both surgical techniques. The use of femtosecond laser in comparison to microkeratome-assisted DSAEK allows to obtain a more uniform graft creation in its thickness. We detected a correlation between the C:P ratio index and the development of hyperopic shift. For the first time the presence of a smaller hyperopic shift was confirmed (0.27±0.9D) in FS-DSEK compared with microkeratome- assisted DSAEK (1.25±0.81D).
References
1. Malyugin B.E., Moroz Z.I., Borzenok S.A. i dr. Pervyi opyt i klinicheskie rezul'taty zad¬nei avtomatizirovannoi posloinoi keratopla¬stiki (ZAPK) s ispol'zovaniem predvaritel'¬no vykroennykh konservirovannykh ul'traton¬kikh rogovichnykh transplantatov. Oftal'mokhirurgiya. 2013;3:12-16.
2. Drozdov I.V. Khirurgicheskoe lechenie epite-lial'no-endotelial'noi distrofii rogovitsy me-todom zadnei avtomatizirovannoi posloinoi kera-toplastiki s ispol'zovaniem ul'tratonkikh trans-plantatov. Dis. ... kand. med nauk. M., 2013.
3. Pogorelova S.S., Grdikan'yan A.A., Chentsova E.V. i dr. Analiz plotnosti endotelial'nykh kletok v srednesrochnyi period nablyudeniya posle endote-lial'noi keratoplastiki s formirovaniem trans-plantata femtosekundnym lazerom so storony endo-teliya. Rossiiskii meditsinskii zhurnal. 2016;1:10- 13.
4. Yakovleva S.S. Invertnoe femtolazernoe formirovanie transplantata dlya zadnei keratopla-stiki: Dis. ... kand. med. nauk. M., 2017.
5. Antonova O.P. Sovremennye aspekty di-agnostiki i lecheniya pervichnoi endotelial'¬noi distrofii rogovitsy (Fuksa). Dis. ... kand. med nauk. M., 2017.
6. Afshari N.A., Pittard A.B., Siddiqui A., Klintworth G.K. Clinical study of fuchs corneal endothelial dystrophy leading to penetrating keratoplasty: A 30-year experience. Arch. Ophthalmol. 2006;6:777-780. Available from: https://doi.org/10.1001/archopht.124.6.777.
7. Terry M.A., Shamie N., Chen E.S. et al. Endothelial Keratoplasty for Fuchs’ Dystrophy with Cataract. Complications and Clinical Results with the New Triple Procedure. Ophthalmology 2009;4:631-639. Available from: https://doi.org/10.1016/j.ophtha.2008.11.004.
8. Melles G.R.J., Ong T.S., Ververs B., van der Wees J. Descemet membrane endothelial keratoplasty (DMEK). Cornea. 2006;2:199-206. Available from: https://doi. org/10.1111/j.1574-695X.2006.00082.x.
9. Da Reitz Pereira C., Guerra F.P., Price F.W., Price M.O. Descemet’s membrane automated endothelial keratoplasty (DMAEK): Visual outcomes and visual quality. Br. J. Ophthalmol. 2011;7:951-954. Available from: http://dx.doi.org/10.1136/bjo.2010.191494.
10. Sikder S., Snyder R.W. Femtosecond laser preparation of donor tissue from the endothelial side. Cornea. 2006;4:416-422. Available from: https://doi. org/10.1097/01.ico.0000195948.86071.98.
11. Gorovoy M.S. Descemet-stripping automated endothelial keratoplasty. Cornea. 2006;8:886- 889. Available from: https://doi.org/10.1097/01. ico.0000214224.90743.01.
12. Mehta J.S., Parthasarthy A., Por Y.-M. et al. Femtosecond laser-assisted endothelial keratoplasty: a laboratory model. Cornea. 2008;27:706-712. Available from: https://doi.org/10.1097/qai.0b013e31815ee267.
13. Rosa A.M., Silva M.F., Quadrado M.J. et al. Femtosecond laser and microkeratome-assisted Descemet‘s stripping endothelial keratoplasty: First clinical results. Br. J. Ophthalmol. 2013;9:1104- 1107. Available from: http://dx.doi.org/10.1136/ bjophthalmol-2012-302378.
14. Chylack L.T., Wolfe J.K., Singer D.M. et al. The Lens Opacities Classification System III. Arch. Ophthalmol. 1993;6:831-836.
15. Covert D.J., Koenig S.B. New Triple Procedure: Descemet’s Stripping and Automated Endothelial Keratoplasty Combined with Phacoemulsification and Intraocular Lens Implantation. Ophthalmology. 2007;6:670-674.
16. Dickman M.M., Cheng Y.Y.Y., Berendschot T.T.J.M. et al. Effects of graft thickness and asymmetry on visual gain and aberrations after descemet stripping automated endothelial keratoplasty. JAMA Ophthalmol. 2013;6:737-744. Available from: https:// doi.org/10.1001/jamaophthalmol.2013.73.
17. Heinzelmann S., Maier P., Bohringer D. et al. Visual outcome and histological findings following femtosecond laser-assisted versus microkeratome- assisted DSAEK. Graefe’s Arch. Clin. Exp. Ophthalmol. 2013;8:1979-1985. Available from: https://doi. org/10.1007/s00417-013-2359-7.
18. Bahar I., Kaiserman I., Livny E. et al. Changes in corneal curvatures and anterior segment parameters after descemet stripping automated endothelial keratoplasty. Curr. Eye Res. 2010;11:961-966. Available from: https://doi.org/10.3109/02713683.2010.506967.
19. Dupps W.J., Qian Y., Meisler D.M. Multivariate model of refractive shift in Descemet-stripping automated endothelial keratoplasty. J. Cataract Refract. Surg. 2008;4:578-584. Available from: https://doi. org/10.1016/j.jcrs.2007.11.045.
20. Holz H.A., Meyer J.J., Espandar L. et al. Corneal profile analysis after Descemet stripping endothelial keratoplasty and its relationship to postoperative hyperopic shift. J. Cataract Refract. Surg. 2008;34:211- 214. Available from: https://doi.org/10.1016/j. jcrs.2007.09.030.
21. Yoo S.H., Kymionis G.D., Deobhakta A.A. et al. One-year results and anterior segment optical coherence tomography findings of descemet stripping automated endothelial keratoplasty combined with phacoemulsification. Arch. Ophthalmol. 2008;8:1052- 1055. Available from: https://doi.org/10.1001/ archopht.126.8.1052.
22. Hjortdal J. Inverse Cutting of Posterior Lamellar Corneal Grafts by a Femtosecond Laser. Open Ophthalmol. 2012;6:19-22. Available from: https://doi. org/ 10.1001/archopht.126.8.1052.
23. Sikder S., Snyder R.W. Femtosecond laser preparation of donor tissue from the endothelial side. Cornea. 2006; 4: 416-422. Available from: https://doi. org/ 10.1001/archopht.126.8.1052.
24. Koenig S.B., Covert D.J., Dupps W.J., Meisler D.M. Visual acuity, refractive error, and endothelial cell density six months after Descemet stripping and automated endothelial keratoplasty (DSAEK). Cornea. 2007; 6:670-674. Available from: https://doi.org/ 10.1097/ICO.0b013e3180544902.
25. Busin M., Madi S., Santorum P. et al. Ultrathin descemet’s stripping automated endothelial keratoplasty with the microkeratome double-pass technique: Two-year outcomes. Ophthalmology. 2013;6:1186- 1194. Available from: https://doi.org/10.1016/j. ophtha.2012.11.030.
26. Jun B., Kuo A.N., Afshari N.A. et al. Refractive change after descemet stripping automated endothelial keratoplasty surgery and its correlation with graft thickness and diameter. Cornea. 2009;1:19-23. Available from: https://doi.org/10.1097/ico.0b013e318182a4c1.
27. Woodward M.A., Titus M.S., Shtein R.M. Effect of microkeratome pass on tissue processing for descemet stripping automated endothelial keratoplasty. Cornea. 2014;5:507-509. Available from: https://doi. org/10.1097/ico.0000000000000093.
28. Liu YC, Teo EPW, Adnan KB, et al. Endothelial approach ultrathin corneal grafts prepared by femtosecond laser for descemet stripping endothelial keratoplasty. Invest. Ophthalmol. Vis Sci. 2014;12:8393-8401. Available from: https://doi.org/10.1167/iovs.14-15080.
29. Li JY, Terry MA, Goshe J, Davis-Boozer D, Shamie N. Three-year visual acuity outcomes after Descemet’s stripping automated endothelial keratoplasty. Ophthalmology 2012; 6: 1126-1129. Available from: https://doi.org/10.1016/j.ophtha.2011.12.037.
