EyeWorld Asia-Pacific June 2020 Issue

36 EWAP JUNE 2020 CORNEA by Maxine Lipner Senior Contributing Writer Contact information Dhaliwal: dhaliwaldk@upmc.edu Holland: eholland@holprovision.com Terry: MTerry@deverseye.org This article originally appeared in the March 2020 issue of EyeWorld . It has DGGP UNKIJVN[ OQFKƂGF CPF CRRGCTU here with permission from the ASCRS Ophthalmic Services Corp. Endothelial transplants on the cutting edge E ndothelial transplants continue to evolve, with DSAEK grafts getting thinner and a new, graft-free option, Descemet’s stripping only (DSO), beginning to emerge. EyeWorld spoke with experts about the latest techniques as well as tried and true procedures. “The current standard of care remains DSAEK by numbers, although DMEK is probably going to become the predominant procedure in the next couple of years because it is growing so quickly,” said Mark A. Terry, MD. With DSAEK results improving, the decision of which procedure to perform comes down to whether the better vision with DMEK is worth the technique’s increased risk of graft failure in complex cases, he said. Dr. Terry thinks that in routine cases, like Fuchs dystrophy, DMEK is the best option, due to faster visual rehabilitation and better quality of vision. But in more challenging cases, such as aphakia or in the presence of an anterior chamber lens, DMEK risk is greater. “If the surgical risk `œià ˜œÌ Ü>ÀÀ>˜Ì ̅i Li˜iwÌ] you should go with the safer procedure,” Dr. Terry said. Considering thin DSAEK Historically, “standard” -Ƃ }À>vÌà ÜiÀi £xä ù“° In 2009, Edward Holland, MD, postulated that thinner DSAEK grafts resulted in better visual acuity and called DSAEK grafts that were 135 ù“ œÀ iÃà ºÌ…ˆ˜ -Ƃ °» Massimo Busin, MD, developed a technique that resulted in DSAEK grafts becoming less ̅>˜ £ää ù“ >˜` «Àœ«œÃi` the term “ultrathin DSAEK.” Dr. Holland and colleagues developed a technique that resulted in the thinnest grafts to date, “nanothin DSAEK,” ܈̅̅i }À>vÌà xä ù“ œÀ iÃð Ƃ study comparing the nanothin DSAEK technique to DMEK had promising results. 1 “We found that at 1 month the DMEK patients saw better than the nanothin grafts, but at 3, 6, and 12 months, the visual acuity was the same with both techniques,” Dr. Holland said. While nanothin DSAEK might cause a slight delay in visual recovery, the graft is easier to handle and unfold, and the detachment rate is lower than DMEK, Dr. Holland said. While DMEK is his preferred procedure for the majority of patients, if graft detachment is more likely or if the patient doesn’t have 20/20 potential, Dr. Holland favors nanothin DSAEK over DMEK because of the lower complication rate. “About 20% of my patients are at a higher risk for graft detachment, and I can offer them a DSAEK procedure that has a lower graft detachment rate and is easier to perform, >˜` ½“ ˜œÌ Ã>VÀˆwVˆ˜} ۈȜ˜]» Dr. Holland said. However, when it comes to reviving a failing penetrating keratoplasty graft, in most instances Dr. Holland still performs DMEK, reserving the nanothin approach for about 20% of complex or detachment- prone cases. Dr. Terry, who uses the ultrathin DSAEK approach, always does DMEK on a failing PKP, unless the patient has had What was once considered very thin for DSAEK at 100 μm is now surpassed by nanoth- in DSAEK with tissue of 50 μm or less. Source: Edward Holland, MD