Loma Linda University Health Care ophthalmologist offers new procedure for corneal transplantation
Jeannine Hart, 76, enjoys reading again. “I am so blessed to be able to read the paper [or] a magazine without a strong magnifying glass,” she says.
Jeannine Hart believes that good things will come to those who wait.
Diagnosed with cornea dystrophy in both eyes 35 years ago, she knew her vision would eventually be like looking through a glass of milky water. Yet it was so slow in progressing that she did not notice her eyesight deteriorating until 1999, when she turned 70. Four years later, she underwent cataract surgery in her right eye, which did very little to help her vision.
After this surgery she was referred to Julio Narváez, MD, an ophthalmologist at Loma Linda University Health Care, in the spring of 2004. Ms. Hart was aware that her best option for restoring her sight would be a corneal transplant.
At the time, penetrating keratoplasty (PKP), a procedure that replaces the full thickness of the cornea, was the standard of care. Few improvements had been made to this procedure in the past 50 years, and it is associated with several well-known disadvantages such as unpredictable refractive outcomes, a prolonged recovery that often takes a year, and a permanent susceptibility to trauma.
Dr. Narváez, however, knew a better procedure was just around the corner. Having the possibilities of PKP explained and with the option of a new procedure not too far off, Ms. Hart decided to wait, even though she knew her vision would get worse. And it did.
“My sight was deteriorating to the point of having to use a magnifying glass to read the paper, books, magazines, restaurant checks, and shelf prices at the grocery store,” recalls Ms. Hart. “It was so bad I couldn’t get my driver’s license. And my writing suffered the most. It’s hard to hold a piece of paper and a magnifying glass and write too. The bank called and asked if something was wrong because my written signature wasn’t matching my signature card anymore.
“I’m a Lakers fan,” she explains. “While watching the games on TV, I could tell there were Lakers on the court, but I couldn’t tell who they were.”
At this point Ms. Hart’s vision was a dismal 20/200, and the fear of falling was very real for her.
“I’m smart enough to know that if I break a hip at this age, it could be very serious,” she says.
During an appointment with Dr. Narváez on January 24, 2006, he was able to finally tell her what the new procedure was. Called Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK), this procedure replaces only the diseased posterior layer of the cornea, bypassing many of the disadvantages of traditional PKP.
DSAEK has been perfected throughout the past decade. In 1998, Dutch ophthalmologist Dr. Gerrit Melles developed a way to strip just Descemet’s membrane from the cornea and implant a manually dissected donor disc. The initial technique represented a definite improvement over PKP but was very surgeon-dependent, tedious, and required extensive manual dissection of the donor’s cornea. More recently, Mark Gorovoy, MD, automated endothelial keratoplasty (using a microkeratome) making the corneal dissection very reproducible, much like creating a LASIK flap. Automating the dissection creates a smoother surface on the donor cornea than what can be reliably obtained with a manual dissection. This translates into a better optical interface.
The DSAEK procedure starts by peeling off Descemet’s membrane through a 4.5 millimeter limbal incision, leaving a smooth corneal host interface. The posterior donor tissue is then prepared with the microkeratome that, with a deep cut, removing the majority of the stroma. The posterior lamellar donor button consists of endothelium, Descemet’s membrane, and a layer of stromal tissue. The donor disc is folded and inserted in the anterior chamber and pressed into place with an air bubble. It remains fixed in place by the suction action of the endothelium.
Postoperative care for DSAEK is similar, but less tedious than that of PKP for both the surgeon and the patient. Although techniques may differ slightly from surgeon to surgeon, most have found the results of DSAEK to be significantly better than PKP. Some consider it to be the standard of care for any patient suffering with Fuchs’ corneal dystrophy or post cataract corneal decompensation. With DSAEK, the speed of visual recovery is significantly improved. Typically, the patient’s vision recovers in two to four months with a BCVA of 20/40, or better, with little change in their spectacle correction.
The refractive outcomes are far more predictable, since there is no significant induced astigmatism.
Potentially, there is less risk of rejection. Since the procedure is performed through a small limbal incision, like that used for cataract surgery, no extensive corneal suturing is required. There is no risk of exposed or infected corneal sutures. Compared to PKP, there is much greater wound strength, which is very important in elderly patients at risk of falling.
After hearing this, Ms. Hart’s response was “I can’t wait!” though she would still have to wait another four months before the equipment arrived, and she was scheduled for surgery on April 26, 2006, to transplant the cornea in her right eye.
“I was anxious to have the surgery,” says Ms. Hart. “I counted down the days to April 26 without any question as to whether it was the right or wrong thing to do. I had the utmost faith in Dr. Narváez.”
Finally the day arrived, and Ms. Hart reported to the operating room at 12:00 noon and was prepped for surgery. The procedure began at 3:30 p.m. and lasted all of an hour and a half. One of her friends drove her home in Riverside, which she reached by 6:30 that evening.
The biggest thing Ms. Hart remembers about the surgery was that she felt no pain.
“I never even took one Tylenol,” she says. But she is very careful to be compliant to the doctor’s orders.
“The surgery has certain requirements which had to be adhered to and which I did diligently,” says Ms. Hart. “I am still putting drops in my eye as required.
“Immediately after the surgery when I could read the paper, a magazine, or a book, and distinguish who the people were on the TV, I felt like I had a whole new life,” smiles Ms. Hart. “I am so grateful to Dr. Narváez for delaying my surgery until this procedure was available. I am seriously and happily looking forward to having the same procedure on my left eye.”
Ms. Hart notices the biggest improvement in her writing and enjoys being able to write letters to her family and friends again.
Dr. Narváez obtained his medical degree and residency training at Loma Linda University School of Medicine. He served as an active duty ophthalmologist in the U.S. Air Force, and he later completed subspecialty training in cornea, anterior segment, and refractive surgery at the Emory University Eye Center, in Atlanta, Georgia.
Dr. Narváez is currently an associate professor at Loma Linda University School of Medicine. He has published numerous research articles in refractive and cataract surgery, and he presented his research at national and international meetings. He is also a reviewer for the Journal of Cataract and Refractive Surgery, as well as Cornea and the Journal of Ophthalmology. He is a principal investigator for the NIDEK Excimer Laser LASIK Hyperopic Study. His research interests are in cataract surgery, refractive surgery, and intraocular lenses. He is an active volunteer in the community and provides eye care in developing nations. He is also fluent in Spanish.
Loma Linda University Health Care department of ophthalmology is committed to providing high quality care in the context of a Christian institution. Its vision is to offer the latest treatments for eye diseases that affect patients’ vision through advanced medical sciences and research. Advanced corneal procedures are just a sampling of the advanced techniques used at the department of ophthalmology, Loma Linda University.
By Julio Narvá´ez, MD, and Preston Smith