EyeWorld India March 2018 Issue

March 2018 12 EWAP FEATURE New trends in endothelial keratoplasty by Rich Daly EyeWorld Contributing Writer AT A GLANCE • With increased experience, DMEK is feasible in more types of eyes. • The high rebubble rate in DMEK has improved as techniques and instrumentation have evolved. • Patient discussions about the different forms of EK should include the surgeon’s experience with DSAEK and DMEK. Same DMEK patient at 1 week postop, when 20/25 vision had been achieved Source: Sophie Deng, MD DMEK patient at 1 day postop Surgeons explore whether DSAEK is still better for certain patients and other lingering questions S urgeons have found that the keys to select- ing newer corneal transplant procedures involve a solid understanding of techniques, patient selection, and communication. Sophie Deng, MD, professor of ophthalmology, cornea divi- sion, University of California, Los Angeles, has found Descemet’s stripping automated endothelial keratoplasty (DSAEK) is a more fea- sible approach in complex eyes. For instance, patients who benefit most are those with anterior chamber intraocular lenses (ACIOLs), large iridectomy/sectoral aniridia, irido- corneal adhesion, post-vitrectomy, aphakia, and sutured posterior chamber intraocular lenses (PCIOLs). However, with increased ex- perience, Descemet’s membrane endothelial keratoplasty (DMEK) is feasible in many of these eyes, Dr. Deng said. Kevin Shah, MD, Eye Con- sultants of Pennsylvania, Wyomiss- ing, Pennsylvania, uses ultra-thin DSAEK for certain patients, typi- cally those who have been vitrec- tomized, have ACIOLs, glaucoma tube implants, and patients who have had previous PKs. “For any cases in which the anterior segment is disrupted and/ or unicameral or there is hardware such as an anterior chamber in- traocular lens, a DSAEK is indicat- ed and DMEK would be contrain- dicated,” said Neda Shamie, MD, Advanced Vision Care, Los Angeles, California. “Also, if the view into the anterior chamber is limited, it would make a DMEK surgery far more complex and would pose a relative contraindication.” By 2016, DSAEK was performed in more than 21,000 cases and DMEK in more than 6,000, said Massimo Busin, MD , professor of ophthalmology, Department of Morphology, Surgery, and Experi- mental Surgery, University of Fer- rara, Ferrara, Italy. “With few exceptions, DSAEK is still the more popular type of EK and for certain eyes the only avail- able choice,” Dr. Busin said. However, Dr. Shah noted that the number of DMEK cases contin- ues to increase annually while the number of DSAEK cases is begin- ning to decrease. Rebubble rate The high rebubble rate in DMEK has improved as techniques and instrumentation have evolved, said Dr. Busin. “My personal rebubble rate is now less than 10% and although it’s higher than my DSAEK rebub- ble rates, the benefits in more rapid vision recovery, better visual outcome, and lower rejection rate justify the learning curve,” Dr. Busin said. Dr. Deng noted that the rebub- bling procedure is easier to perform than the repositioning in DSAEK. “It takes 5 minutes at the of- fice or minor procedure room,” Dr. Deng said. “The rebubble rate seems to be at the same rate ob- served in DSAEK after the learn- ing curve.” Rebubbling is a “minor ac- cident” in the postop course of DMEK and occurs in 5% to more than 50% of cases, depending on many factors, Dr. Busin said. Patients should be advised about this possibility before undergoing DMEK, but they can also be told that uncomplicated rebubbling seldom affects the final outcomes.