EyeWorld India June 2015 Issue

Corneal lamellar surgical procedures June 2015 26 EWAP SECONDARY FEATURE Corneal graft rupture after a traumatic injury is a particularly devastating complication of penetrating keratoplasty. Source (all): Barry Lee, MD Penetrating keratoplasty in the era of lamellar surgery by Lauren Lipuma EyeWorld Contributing Writer AT A GLANCE • Penetrating keratoplasty still has a role in corneal transplant practice because not all patients are candidates for lamellar procedures. • The major challenges with full-thickness transplants are the delay in visual recovery, broken or infected sutures, high postoperative astigmatism, and late-onset traumatic graft ruptures. • Results from the Cornea Donor Study showed that donor age is not an important factor in graft survival. • Femtosecond laser-assisted transplant procedures may offer clinical benefits in the future. S ince the first successful penetrating keratoplasty (PK) was performed in 1905, corneal transplantation has become one of the most commonly performed tissue transplant procedures. With the development of surgical microscopes, microfilament sutures, a standardized eye banking system, and anti-rejection medications, the technique has evolved into a highly sophisticated and effective procedure for treating diseased corneas. Lamellar transplant procedures have further revolutionized corneal care, allowing eye surgeons to spot treat diseased layers of the cornea while sparing the healthy layers of tissue. With these techniques, surgeons can offer faster visual recovery and alleviate many of the side effects associated with full- thickness grafts. Although partial-thickness procedures have shifted the treatment paradigm in corneal transplantation, penetrating keratoplasty still has a role to play in corneal practice, and experts agree that it should still be a part of a corneal surgeon’s armamentarium. The rise of endothelial keratoplasty The development of endothelial keratoplasty (EK) procedures—Descemet’s stripping endothelial keratoplasty (DSEK) and Descemet’s membrane endothelial keratoplasty (DMEK)— has contracted the role of PK in the last 2 decades. “Almost three-fourths of the corneal transplants I perform now are endothelial keratoplasty procedures with an increasing number of these becoming [DMEK],” said Barry Lee, MD, Eye Consultants of Atlanta. “However, [DSEK] remains the most common type of keratoplasty I perform.” “For essentially any problem that’s isolated to the endothelium, DSEK or DMEK are clearly superior procedures,” said Mark Mannis, MD, professor and chair of UC Davis Eye Center, Sacramento, Calif. “They provide much more rapid visual rehabilitation, are safer for the patient, and the incidence of rejection is much lower.” “Most surgeons in the U.S. and around the world find that DSEK— and those who are doing DMEK— is a better procedure all around for the appropriate patients,” said Christopher Rapuano, MD , continued on page 28 The torque-antitorque suture technique in penetrating keratoplasty compresses the wound, allowing for optimal wound healing. director of the cornea service, Wills Eye Hospital, Philadelphia. Although PK is no longer the first choice procedure in cases of pure endothelial disease, specialists agree that it should still be a part of a corneal surgeon’s repertoire. There is still a large percentage of patients with pan-corneal disease— disease spanning the entire thickness of the cornea—who are not candidates for a lamellar procedure. That includes patients who have coexisting Fuchs’ dystrophy and keratoconus, those who