EyeWorld Asia-Pacific June 2011 Issue

June 2011 12 EW FEATURE Practitioners score with the combined approach F or patients who need a corneal replacement in addition to cataract surgery, practitioners today have an attractive option to consider—a planned combination phacoemulsification and DSEK (Descemet’s-stripping endothelial keratoplasty) procedure. With the combined approach, surgeons can first remove the clouded lens with the aid of phacoemulsification and then immediately remove the diseased Descemet’s membrane and replace it by transplanting donor tissue. The combined approach can be natural for some patients with Fuchs’ dystrophy, finds Edward J. Holland, MD, professor of ophthalmology, University of Cincinnati, and director, cornea service, Cincinnati Eye Institute, Cincinnati, Ohio, USA. “The most common group of patients is those with a significant cataract,” he said. “Then the clinician has to decide whether the cornea in Fuchs’ endothelial dystrophy is at a stage where it needs surgical intervention as well.” In Dr. Holland’s experience, one of the factors that come into play is the amount of corneal edema present. If there is identifiable edema, then a combined approach may be preferable. “If there is definitely corneal edema present and the patient wants the best visual outcome, then it should be a combined phaco/DSEK procedure,” Dr. Holland said. However, in cases with guttata where there is no edema present, with no history of corneal edema or morning blur or a 10% or greater thickening of the morning pachymetry, Dr. Holland urged performing phacoemulsification alone. “We would recommend phaco alone and advise the patient that there is an increased risk of endothelial decompensation,” he said. “The surgeon should use all the techniques to save endothelial cells such as a dispersive viscoelastic and low phaco power and try to reduce Winning combination: Phacoemulsification and DSEK? by Maxine Lipner Senior EyeWorld Contributing Editor AT A GLANCE • For patients with significant cataracts, if Fuchs’ dystrophy is severe enough with signs of corneal edema, a combination approach may be beneficial • If a Fuchs’ patient has a significant cataract, there is often no advantage to leaving this behind since endothelial cell loss will inevitably be greater with two procedures • The combination procedure can be technically easier for the experienced surgeon since there is less space to maneuver in the phakic eye • For a beginning surgeon, however, allowing the lens implant to fibrose in the eye for a month or so may make the procedure easier • Outcomes are usually contingent on the DMEK portion of the procedure • Using thinner tissue ultimately provides better visual acuity In this combined procedure, Descemet’s membrane is stripped after phaco and IOL placement are completed DSEK lenticule is shown folded in preparation for insertion Source: Jonathan B. Rubenstein, MD the amount of phaco time if that’s possible.” Francis W. Price, MD, Price Vision Group, Indianapolis, and chairman of the board and founder, Corneal Research Foundation of America, Indianapolis, Ind., USA, uses the combined approach for patients who have fairly significant cataract and significant corneal edema, as well as dense guttata. “They’re good candidates for the procedure,” he said. However, for those who have decreased vision but for whom he is unsure whether this is stemming from the cornea or from a cataract, he takes a different tact. “You can go ahead and do the cataract by itself. A lot of times, especially if the Fuchs’ dystrophy is mild to moderate, that might be all the patient needs for a period of time until the Fuchs’ progresses,” Dr. Price said. While many practitioners shy away from combined surgery in those with a clear lens, new research may give them something to think about. Marianne O. Price, PhD, executive director, Cornea Research Foundation of America, conducted a study that was published in the November 2010 issue of the British Journal of Ophthalmology that assessed the risk of cataract formation after DSEK. “Sometimes people in their 40s and 50s with Fuchs’ dystrophy who are having DSEK still have a clear lens,” she said. “We have gone back and taken a look at what the chances are of someone getting a cataract within the subsequent 3 years,” she said. Investigators found that age played a prominent role here. “People who are under age 50 have about a 10% chance of getting a cataract within the subsequent 3 years,” she said. “People who are over 50 have a lot higher chance—the lens is more sensitive.” She sees these results as helping practitioners to decide what to do with the relatively young patients in whom they used to avoid transplant altogether. Judging combined advantages For his part, Dr. Holland sees the combined approach as beneficial to any Fuchs’ patient with a bona fide cataract. “If you know that there’s a significant cataract, I don’t think there’s any advantage to leaving the lens behind,” he said. “Number one, any cataract present is going to progress, and number two, if you have to go back in, even if you’re a tremendous phaco surgeon, you’re going to lose endothelial cells.” As a result, Dr. Holland reasons that if you know that the lens is going to be an issue in the near future, there’s no reason to leave it behind. “I would say that it’s rare that we leave the lens,” he said. Dr. Holland also finds that the combination procedure tends to be an easier one in terms of performing the DSEK portion. “In the vast majority of cases there’s no advantage to leaving the lens,” he said. “The procedure is actually technically harder in the phakic eye because there is less space.” Dr. Francis Price said economics are an important advantage favoring the combined approach. “The biggest advantage is decreased cost and convenience to the patient with one surgery instead of two,” he said. “In DSEK I don’t think that we’ve seen any difference in