CORNEA 52 EWAP MARCH 2022 by Liz Hillman Editorial Co-Director The latest in DSO Contact information Colby: Kathryn.Colby@nyulangone.org Moloney: gregorymoloney@yahoo.com.au Less than 10 years ago, the idea that you could preserve vision and achieve corneal clearance in a patient with Fuchs without donor tissue was met with skepticism. Now, this idea is increasingly accepted, adopted, and is being more widely researched with a clinical trial underway for a pharmaceutical to aid in cell migration. Descemet’s stripping only (DSO), where a descemetorhexis is made in Descemet’s membrane without keratoplasty, was introduced in the mid-2010s. Kathryn Colby, MD, PhD, said when she started talking about it in 2016, she “wouldn’t go so far as to say … that people threw tomatoes at me, but almost.” “Around 5 years ago the high variability in patient outcomes was a barrier to widespread adoption of the technique,” said Greg Moloney, MD, also an early proponent and researcher of DSO. “Patients and surgeons were often unwilling to embark on a surgical journey that had an unknown timeline and might eventually result in a graft in any case.” What’s changed? In more recent years, there have been published reports of improvements in clearance rates and time to clearance, Dr. Moloney said, noting that it likely relates to several factors. “It seems clear now that patient selection should be limited to those with central corneal disease. The need for a healthy peripheral cell reservoir is understood based on longterm studies of outcomes that illustrate cell migration as the primary driver of clearance,” he said. This article originally appeared in the December 2021 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. What’s more, surgical technique has improved with the understanding that stromal trauma can be counterproductive to cell migration, and preliminary data support the role rho-kinase (ROCK) inhibitors can play in cell migration. “Despite all these advancements, there are patients who will fail to clear despite good selection, good surgery, and the use of supplemental ROCK inhibitors,” he said, adding, “Those considering a DSO should be prepared to accept a DMEK as an eventual consequence.” In terms of outcomes, Dr. Moloney said he has cared for patients with multiple endothelial grafts in the fellow eye who were treated with DSO in the ungrafted eye, with equivalent visual results. Dr. Colby offered a similar perspective as Dr. Moloney when it comes to patient selection and surgical technique. Patients, she said, should have primarily central Fuchs, with guttae in the center (no more than 5–6 mm, though 4–5 mm is better) and preserved peripheral endothelium. She said the peripheral endothelium can be evaluated with a confocal microscope or a specular microscope that can go to the paracentral area or by clinical exam using 40x magnification on Descemetorhexis with no graft.
RkJQdWJsaXNoZXIy Njk2NTg0