EyeWorld Asia-Pacific September 2011 Issue

47 EW CORNEA September 2011 out of us.” While those who just completed their fellowships may take this in stride, others who have been in practice for decades are less likely to be embrace DALK over tried-and-true PK. “We’ve done regular full-thickness transplants essentially the same way since the 30s,” Dr. Florakis said. It has also become clear that DALK is a time-consuming procedure to perform. “It takes two to three times longer than a PK,” Dr. Florakis said. “Ambulatory surgical centers and even hospitals in the present economic environment may not like that.” After all that, the practitioner may end up doing a PK anyway. “You spend 2 hours working DALK and have to convert, and you’ve already taken 2–3 hours of OR time,” he said. From a tissue perspective there’s not much need for DALK in the US. “Unlike other countries where good donors with fresh and healthy endothelial cells may be hard to come by, in the US we generally have good tissue,” Dr. Florakis said. “For example, if I have a 25-year-old keratoconus patient who I want to do DALK on, you know that he could reasonably expect a good cornea within a month or 6 weeks,” he said. In another country, without a good donor network, it could take years to get a cornea with good endothelium. Also, in terms of payment, there’s not any inducement for practitioners to undertake the more difficult DALK procedure. “We get paid less even though it’s more work since it’s really a lamellar keratoplasty rather than a PK,” Dr. Florakis said. “There is no code for DALK right now, and so the code that we have to use because we’re not going full thickness is for lamellar keratoplasty.” Historically speaking, lamellar keratoplasty—shaving off part of the cornea and sewing on a new one—was considered not as risky as going into the eye to do a PK. “Obviously things have changed, but the codes have not caught up with DALK yet,” Dr. Florakis said. The importance of transitioning While there are still some drawbacks, Dr. Verdier thinks DALK has come to a place where it can no longer be overlooked by US surgeons. He sees some inherent aspects to the procedure that give it a distinct leg up over PK. “The advantage is that you can retain the patient’s own endothelium, and the endothelium is the one part of the cornea that can’t regenerate its own cells,” Dr. Verdier said. “If you run out of endothelial cells you end up with a cornea that decompensates.” With PK, endothelial cell loss is par for the course. “We know that with penetrating keratoplasty, the cell loss is significant,” he said. “In low to moderate risk corneas, 70% of the endothelial cells are lost in the first 5 years.” “Not only does an approximately 30% loss of endothelial cells occur in the first year, what is really bothersome is that the cell loss continues thereafter at an accelerated pace compared to what normal non- operated cornea cell loss would be,” Dr. Verdier said. “We are quite fearful that many of our younger patients are going to run out of cells before the end of their life and will not have a transplant that lasts a lifetime.” This is particularly important because many corneal procedures are done in younger adults. “Many anterior lamellar keratoplasty for keratoconus and corneal stromal dystrophies are performed quite often in people under age 40,” Dr. Verdier said. There’s no question continued on page 48 © 0RULD 2QH 8VH 3OXV 6%. LV D VDIH DQG DFFXUDWH DXWRPDWHG PLFURNHUDWRPH IRU WKH FUHDWLRQ RI PLFURQ SODQDU ÁDSV ,W DOORZV UHIUDFWLYH VXUJHRQV WR SURYLGH KLJK OHYHO RI VDIHW\ VXUJHULHV IRU SDWLHQWV ZLWK D XQLTXH VLQJOH XVH VROXWLRQ ª LASIK Surgery 025,$ 6 $ UXH *HRUJHV %HVVH $QWRQ\ )5$1&( 3KRQH )D[ PRULD#PRULD LQW FRP ZZZ PRULD VXUJLFDO FRP • Thin, 100-micron, planar flaps • Accuracy and predictability equivalent to Femto-SBK • Smoother stromal bed • No femto-complications • … At a fraction of the cost Think Thin SBK without compromise François Malecaze, MD, PhD (Toulouse, France) 0DOHFD]H ) 6LQJOH XVH 6XE %RZPDQ·V .HUDWRPLOHXVLV SURFHGXUH ZLWKRXW D IHPWRVHFRQG ODVHU 0\ ÀUVW FDVHV WK (6&56 :LQWHU PHHWLQJ )HE ,VWDQEXO 7XUNH\ 0DOHFD]H ) 8WLOLVDWLRQ GX PLFURNpUDWRPH HQ FKLUXUJLH UpIUDFWLYH /HV &DKLHUV G·2SKWDOPRORJLH PDL 'RZQORDG ORQJ YHUVLRQ WHVWLPRQLDOV RQ ZZZ PRULD VXUJLFDO FRP 5RXQGWDEOH ZLWK LQWHUQDWLRQDO 6%. H[SHUWV $ $VN IRU D GHPR PRULD#PRULD LQW FRP 6%. QHZVOHWWHUV QRZ RQ OLQH .(5$720( 2QH 8VH 3OXV 6%. 0RULD 68&7,21 5,1*6 86(' 6LQJOH XVH GLVSRVDEOH 1% 2) (<(6 H\HV RI SDWLHQWV $&&85$&< PLFURQV 35(',&7$%,/,7< “ PLFURQV 5(352'8&,%,/,7< PLFURQV )/$3 352),/( PLFURQ GLIIHUHQFH IURP FHQWHU WR SHULSKHU\ ,175$23 )/$3 &203/,&$7,21 IUHH FDS LQFRPSOHWH ÁDS EXWWRQKROH ÁDS WHDUV 2%/ 326723 )/$3 &203/,&$7,21 1R HQHUJ\ UHODWHG NHUDWRF\WH DFWLYDWLRQ QR '/. QR SKRWRSKRELD QR KD]H