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DSAEK pre and post op instructions
Instructions for DSAEK patients
You have chosen to have a special surgery to replace just the diseased endothelial layer of your cornea. We originally called this surgery “Deep Lamellar Endothelial Keratoplasty” or “DLEK”, and the modification of this surgery is called “Descemet’s Stripping Anterior Endothelial Keratoplasty” or “DSAEK”. Regardless of the name, the idea is to remove the least amount of your corneal tissue and replace it with healthy donor tissue to clear the swelling of the cornea and restore your vision.
Before Surgery:
Do not eat or drink anything for at least 8 hours prior to the time of your surgery. You may take any medication pills that you need to take with a TINY sip of water.
Please bring your DSAEK surgical consent form to the hospital with you and sign it there in front of the nurses.
Please use whatever medical eye drops (eg for glaucoma) that you would normally use for the operative eye on the same day as the surgery.
The Operation:
The surgery is usually performed under local anesthesia where the anesthesiologist only puts you to sleep for about 5 minutes and during that time we give some anesthetic shots to completely numb the eye. You do not even remember the shots and the operation is completely pain free. The shots also prevent you from seeing the surgery or moving the eye. The anesthesiologist also gives you medicine by vein in order to keep you happy and a little sleepy during the surgery. Using local anesthesia avoids many of the risks to your heart or lungs that complete general anesthesia involves. (General anesthesia is when you are completely asleep during the surgery.) However, if you have a strong preference for general anesthesia, (or if Dr. Paglen decides that general anesthesia is safer for your particular case) then this can be done.
During the surgery a single line incision with a length of only 5 mm is made in the sclera (the white part of the eye), a pocket is formed into the cornea, and the diseased endothelial layer of your cornea will be removed. The healthy donor endothelium and back layer of the donor cornea is then placed through the incision and pocket and placed into position on the back surface of your cornea to replace the diseased tissue which was removed. The initial incision is then closed with one to three small sutures and the procedure is completed. A small air bubble is left inside the eye to help insure the stability of the donor transplant tissue and it is most effective when you are lying down on your back, facing the ceiling. This air bubble is simply absorbed and disappears over about 48 hours.
The surgical procedure will take about one hour to perform, slightly longer than a standard full thickness corneal transplant (45 minutes). If you also have a cataract of the lens of the eye, then cataract surgery can be performed at the same time as DSAEK surgery. If cataract and DSAEK surgery are done, then the surgery takes about one and a half hours. You will be in the recovery room for about an hour after the surgery, lying flat on your back facing the ceiling, before your family can see you, and then kept another hour after that. Surgery is usually done as an outpatient procedure at the hospital and you are sent home with a patch on your eye that same afternoon. You should have minimal discomfort after surgery, and standard over-the-counter pain medications can be taken if necessary. You may also be given other pill medications to take for the eye if indicated. Keep the eye patched until Dr. Paglen sees you the next day.
Immediate Post-operative Instructions:
We request that you try to stay lying down on your back, facing the ceiling as much as possible after the surgery for the first 24 hours. (Do not sit up watching TV or working on a computer that first night.) You are quite free to stand up and walk around for going to the bathroom or to sit up for eating meals as much as necessary in that first 24 hours after surgery and it is not a danger to your transplant to do so, but whenever possible, try to rest in bed lying on your back and facing the ceiling. This will allow the small air bubble inside the eye to best stabilize the transplant tissue. Do NOT bend over. Should you experience increasing pain, call Dr. Paglen on his cell phone (707) 688-0518, he may advise you to go to the Emergency Department where he will check your eye to be certain the eye pressure is OK.
Post op Visits Schedule:
You will return to see Dr. Paglen the next day. The patch will be removed and your eye will be examined. You will be placed on antibiotic and steroid drops to prevent infection and to help with healing. This first visit after surgery will only take about 15 to 30 minutes, and is primarily done to check the pressure and to be sure that the donor disc is in good position. You will have a brief visit to the clinic one week after surgery, and then again at one and three months. These visits can be done by your local referring doctor if it is more convenient for you and if your referring doctor agrees with this.
Medication Dosage and Schedule: (Note: you can use your various drops at the same time, just separate them from each other for about 5 minutes so each drop has time to sink in.)
Prednisolone Acetate 1%: (a milky white drop): (shake it up really well before application)
Begin using this drop FOUR times a day (breakfast, lunch, dinner and bedtime) from the first day post-op until 3 months after the surgery. From 3 to 6 months after surgery, use it 3 times a day. From 6 to 9 months after surgery, use it 2 times a day. From 9 to 12 months after surgery, use it once a day. After that your doctor may discontinue it or wean it down in frequency even more or switch to another medication.
This drop (Prednisolone acetate 1%) is what keeps your body from rejecting your transplant tissue, and so it is extremely important that you do NOT stop taking this medication unless advised by your corneal doctor.
Zymar (tan cap)
Begin using this drop FOUR times a day (breakfast, lunch, dinner and bedtime) from the first day until 2 weeks after surgery, and then stop using it.
This drop (Zymar) is an antibiotic and keeps your eye from getting infected.
Please use any other eye medications (especially any glaucoma medications) that you were using prior to your surgery, use them on the day of surgery and start them again the morning after surgery when the patch is removed.
Activities:
Immediately after surgery, we like you to be lying down on your back facing the ceiling and resting as much as possible for the first 24 hours. (see comments above)
Go slowly on the food the night after you have had surgery, as anesthesia sometimes can cause people some nausea. Start with soup, then progress to solids if comfortable.
The day after surgery, the patch is removed and does not need to be re-applied. You will, however, be asked to wear a protective shield over the eye (without a patch) at night while sleeping for about 5 days. No protection is needed during the day, but if you normally wear glasses for the other eye, go ahead and wear them.
Normal activities are permitted following the first day after surgery. You can then shower, wash your hair, and do normal activities like shopping etc. However, you are at risk for infection for the first two weeks after surgery, so do not do activities that put you at risk for infection (like gardening, cleaning out stalls or attics, etc.) Just use common sense and it will be fine. Finally, avoid any activities that may lead to taking a direct hit to the eye. (eg playing with small children, wrestling with animals, etc!).
No sports activities of any kind for 2 weeks after surgery. No swimming under water for 4 weeks, but doing water exercises (head always out of water) is fine after two weeks.
Vision Expectations:
The day after surgery, the patch will be removed and the vision will be absolutely terrible! This is normal.
(It is not like Hollywood where the blind see when the patch is removed!)
Expect that the vision will allow you to only see well enough to count my fingers at about 2 feet away, but not much better than that. The reason why the vision is so poor is that the donor tissue is still swollen and although it starts to clear your cornea nearly immediately, it does so in patches, and those clear patches of cornea are rarely over the visual axis on the first day.
By one week after surgery the vision is about 20/100 and most patients are aware that their cornea is getting better.
By one month the vision is usually around 20/60 and all patients feel that success is at hand.
By three months, the vision is usually around 20/50 or better, but this is highly variable, with many patients achieving 20/30 or so.
At one year after surgery, over 65% of patients have 20/40 or better vision. (This is the vision that allows one to drive a car with no visual restrictions). The patients that have no other ocular problems (like macular degeneration or other retinal disease) have the best vision of all after DSAEK surgery.
The vision continues to improve over time, with many patients improving their vision even from one to two to three years after surgery.
I have given you the “average” visions at various time gates after surgery to give you some idea of what you might expect. The ultimate vision after DSAEK surgery, however, will depend more upon the health of the patient’s retina and central vision of the macula than upon the clarity of the cornea, as nearly all DSAEK patients attain a clear cornea with good surface focus after this surgery. Vision of 20/20 is possible, but even with a crystal clear cornea, the vision is dependent upon the function of the retina and may not attain 20/20. It is most important to remember that while the vision will be better after surgery than it was before surgery, there is high variability between patients on the amount of vision improvement and the rapidity of vision improvement. Generally speaking, the patients that are younger than 65 years old, and the patients that start off with vision better than 20/60 prior to surgery have the fastest visual recovery. Some of our patients have been 20/25 at just one week after surgery, but these are the exceptions. Patience is still a virtue, even with DSAEK surgery.
Donor Disc Dislocation:
On that first day after surgery, all that I plan to do is check to make sure that your donor tissue disc is still in the same position that I left it at the end of the surgery. If the disc is in good position, then I will be happy and you will heal very well.
If the donor disc is NOT in proper position, then the disc will have to re-positioned by me, and that means a visit to the minor operating room in our office for a 15 minute procedure. The risk of this happening is about 10%. Nonetheless, this is a real risk of DSAEK surgery. Fortunately, a dislocated donor disc can be successfully re-positioned with good function and restoration of vision over 90% of the time. In the worst case scenario, if the disc cannot be successfully repositioned with a simple air bubble, then the donor transplant can be replaced with another surgery and the vision ultimately restored.
Please contact me if you have ANY questions, and it is an honor for me to be your surgeon.
Patrick Paglen, MD
Contact Laura Ligon (707) 566-5232
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