An “All-laser” Endothelial Transplant

Summary

An all laser procedure is proposed in the endothelial transplant. The surgical technique is based on the use of a femtosecond laser to prepare the donor tissue. Laser welding technique is then used to secure the donor endothelium in the correct position.

Abstract

The “all laser” assisted endothelial keratoplasty is a procedure that is performed with a femtosecond laser used to cut the donor tissue at an intended depth, and a near infrared diode laser to weld the corneal tissue. The proposed technique enables to reach the three main goals in endothelial keratoplasty: a precise control in the thickness of the donor tissue; its easy insertion in the recipient bed and a reduced risk of donor lenticule dislocation. The donor cornea thickness is measured in the surgery room with optical coherence tomography (OCT), in order to correctly design the donor tissue dimensions. A femtosecond laser is used to cut the donor cornea. The recipient eye is prepared by manual stripping of the descemetic membrane. The donor endothelium is inserted into a Busin-injector, the peripheral inner side is stained with a proper chromophore (a water solution of Indocyanine Green) and then it is pulled in the anterior chamber. The transplanted tissue is placed in the final and correct location and then diode laser welding is induced from outside the eyeball. The procedure has been performed on more than 15 patients evidencing an improvement in surgery performances, with a good recovery of visual acuity and a reduced donor lenticule dislocation event.

Introduction

In this work we present an original approach to endothelial keratoplasty, based on the use of a femtosecond laser to prepare donor tissue and a near infrared diode laser to weld it onto the recipient bed. Intraoperative measurement of the donor cornea is necessary to correctly design the donor tissue dimensions. Endothelial keratoplasty has been proposed in the recent years to replace penetrating keratoplasty in treating endothelial disease^1,2. The main advantage of this technique is a faster visual recovery, with respect to penetrating keratoplasty, reduced anesthesia during surgery, a decreased risk of graft rejection and the preservation of eye integrity....

Protocol

The study was conducted with the prospectively approval of the hospital’s Ethics Committee; informed consent was obtained. The study was in adherence to the tenets of the Declaration of Helsinki.

1. Donor Endothelium Preparation

1. Use a donor cornea as prepared by the local eye bank at room temperature.
2. In the surgery room, pull out the donor cornea from its delivery container and set apart the solution for tissue preservation and nutrition that is used for corneal transport.
3. Place the donor corneo-scleral rim over an artificial anterior chamber, into which a liquid can flow and create a variable pressure....

Results

The “all laser” surgical procedure is proposed to perform minimally invasive corneal transplantation. The procedure is easy to perform (see Figure 1): with respect to a standard endothelial transplant only the steps of measuring the corneal thickness, staining the donor tissue and delivering the laser light are added. The achieved advantages largely compensate an increased surgical time of a few min. The use of intraoperative OCT to measure the donor cornea thickness and the femtosecond laser used to cus.......

Discussion

The “all laser” endothelial transplant is an original approach to minimally invasive corneal transplantation.

All the procedures described within the protocol were performed in the surgery room, observing the hygienic and sterilization procedure that are common practices during surgeries, such as the use of sterilized gloves, gown, mask and cap. The ICG solution was prepared in the surgery room, soon before its application in staining the donor endothelium. The ICG powder, the wate.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Indocyanine Green	Pulsion Medical Systems, Germany	ICG-PULSION (http://www.pulsion.com/international-english/perfusion/icg-pulsion/)	Alternative product: IC-GREEN, Akorn  Inc., Lake Forest, Illinois- US (http://www.icginjection.com/)
Femtosecond Laser	Abbott Medical Optics,  Abbott Laboratories Inc. Abbott Park, Illinois, USA	iFS150 (http://www.abbottmedicaloptics.com/products/refractive/ilasik/ifs-advanced-femtosecond-laser)
Optical Coherence Tomography (OCT)	Carl-Zeiss Meditec, Dublin, California- US (http://www.zeiss.com/meditec/en_de/home.html)	Visante
Diode Laser	E.l.En. Group s.pa., Calenzano-FI, Italy (http://www.elengroup.com/en/divisions/medical)	Mod. WELD 800
Artificial Anterior Chamber	CORONET, corneal graft products. Network Medical Products Ltd. Coronet House, Kearsley Road, Ripon, North Yorkshire, HG4 2SG, UK	Artificial Anterior Chamber (A.A.C.) with large and small tissue-retaining heads. Code 51-935 (http://www.networkmedical.co.uk/ophthalmic_artificial_ anterior_chamber.html)
Solution for tissue preservation and nutrition	AL.CHI.MI.A. Srl, Viale Austria 14, 35020 - Ponte S. Nicolò - PD  ITALY	Carry-C media for corneal deturgescence and transport at room temperature - 12 x 50 ml (http://www.alchimiasrl.com/en/organ-culture-at-31°-c-eb/carry-c-eb)