EyeWorld Asia-Pacific March 2013 Issue

44 EWAP CORNEA March 2013 Cornea surgeons compare thin DSAEK and DMEK as options for endothelial keratoplasty procedures by Ellen Stodola EyeWorld Staff Writer DMEK gaining ground on DSEK W hen it comes to corneal endothelial disorders, endothelial keratoplasty has become popular with ophthalmologists worldwide, and many choose between Descemet’s stripping endothelial keratoplasty (DSEK) and Descemet’s membrane endothelial keratoplasty (DMEK). DSEK seems to be the current preferred method, with developments in DMEK causing the technique to gain ground. DSEK involves a transplant of the back layers of a donor cornea into a patient’s eye. This technique offers a certain ease because it has been the procedure of choice for many years. DSAEK is the automated version of this procedure, which uses a machine to cut tissue. DMEK, on the other hand, uses extremely thin donor tissue, with a better chance of restoring good vision to the patient. However, surgeons using this technique often experience obstacles with handling the donor tissue because of how fragile the grafts can be. Recently, thin DSAEK has offered an alternative to the other two techniques, utilizing the ease of DSAEK with thinner grafts. Massimo Busin, MD, Villa Igea Hospital, Forli, Italy, is one of the surgeons who has been seeing the benefits thin DSAEK can offer, and he compared the advantages and disadvantages doctors see using both DSAEK and DMEK. Similarly, Andrea Ang, MD, Royal Perth Hospital, Perth, Western Australia, prefers using the thin DSAEK technique, but she also pointed out the advantages of both DSAEK and DMEK. Meanwhile, Francis Price, MD, Price Vision Group, Indianapolis, favors DMEK and stressed some of its key advantages. The outcomes of each tech- nique “Both techniques have developed because the results of the old conventional penetrating keratoplasty were not as satisfactory as one would like them to be,” Dr. Busin said. Advancements were initially made by DSAEK, he said. However, he said that some physicians felt that there was only a limited number of eyes gaining 20/20 vision after surgery. This prompted the development of DMEK, which was an attempt to increase the number of eyes that would be able to obtain 20/20 vision after surgery. Dr. Ang agreed with the advantages of DSAEK over penetrating keratoplasty and also with the argument that only a limited number of patients achieve 20/20 vision. “Recent DMEK studies have shown faster visual rehabilitation and better visual outcomes than the earlier DSAEK studies,” Dr. Ang said. “However, recent studies have shown that the thickness of donor tissue used in DSAEK does influence visual outcome, with newer thin DSAEK techniques demonstrating improved visual outcomes approaching the visual OCT image of a post-op thin DSAEK; central donor thickness is 100 microns Source: Edward J. Holland, MD OCT image of a post-op thin DSAEK; central donor thickness is 100 microns Source: David Vroman, MD outcomes seen with DMEK and with less complications.” One of the reasons many surgeons tend to prefer DSAEK to DMEK is simply the ease with which the surgery can be performed. “It’s much easier to perform a DSAEK, even with a thin graft, than it is to perform a DMEK,” he said. To back up his point, Dr. Busin said that in the U.S. last year, there were over 21,000 DSAEK procedures, compared to around 343 DMEK procedures. Dr. Ang said new insertion devices like the EndoSerter (Ocular Systems, Winston-Salem, NC, USA), the Busin Glide (Moria, Antony, France), and the Tan EndoGlide (Angiotech, Vancouver, BC) help to handle the tissue for insertion. “At the present, thin DSAEK appears an attractive alternative while DMEK techniques continue to improve,” she said. Complications arising Despite DSAEK standing out as the easier technique, there are other factors to consider. DSAEK is often preferred to DMEK because primary failure is more common with DMEK, Dr. Busin said. He said DMEK poses the threat of a significant detachment rate. continued on page 46