Lecture on Decimator Access without Endothelial Care

Introduction

• Presented by: Greg Maloney
• Location: Mosman Eye Centre, Sydney Hospital
• Funding: Sydney Hospital Foundation, Sydney University
• Objective: Share experiences with decimator access without endothelial care (D-WIC) and assist doctors in performing and communicating this procedure.

Operation Background

• Target Condition: Fuchs' dystrophy
• Candidate Criteria:
  • Debilitating glare or difficulty non-driving
  • Reduction in best spectacle-corrected vision (20/30 to 20/80 range)
  • Focal edema with clear periphery
  • Healthy peripheral endothelial cell reserve (measured via confocal microscopy)

Rationale Behind the Operation

• Historical Context:
  • Spontaneous clearing of corneas without attached DMEK grafts has been noted.
  • Reports of spontaneous clearing post-cataract or intraocular surgery without grafts.
• Key Concepts:
  • If guttae reduce visual quality, can they be removed selectively without grafting?
  • Healing capacity of endothelium to clear the cornea is variable between patients.

Endothelial Cell Dynamics

• Guttae Study:
  • Endothelial cells can migrate over small defects but not over large excrescences.
• Healing Process:
  • Mainly through cell migration rather than mitosis.
  • Peripheral endothelial cell reserve is crucial.

Surgical Technique

• Critical Factors:
  • Limit decimator axis size to under 4mm.
  • Proper centering and pre-op pupil marking are vital.
  • Avoid engaging stroma; peel rather than scrape.
• Tools:
  • Use blunt grasping forceps (e.g., Hoffman decimo stripping forceps).

Postoperative Care

• Typical Surgery Time: About 6 minutes
• Monitoring Factors:
  • Well-centered decimator axis
  • Absence of stromal scarring
• Potential Challenges:
  • Edge placement and stromal scarring
  • Variability in healing response among patients

Post-Operative Management

• Medications:
  • Topical antibiotic
  • Topical hypertonic saline
  • Steroid usage is minimal

Future Directions

• Challenges:
  • Predicting patient response to the operation.
• Focus Areas:
  • Identifying best candidates preoperatively.
  • Evaluating the effectiveness of ROCK inhibitors.

Patient Communication

• Explanation: "One step backwards to go two steps forwards"
• Expected Course: Vision worsens temporarily before improvement.
• Benefits:
  • Fast surgery, minimal cataract risk.
  • Low post-op steroid requirement.
• Unknowns: Duration and need for future grafts.

Conclusion

• Invitation: Attend Sydney DMEC course in January or February.
• Acknowledgments: Thanks to the Sydney Hospital Foundation for support.