EyeWorld India March 2018 Issue

March 2018 EWAP FEATURE 21 A patient with previously failed PK underwent PDEK and a single-pass four-throw pupilloplasty. Source: Amar Agarwal, MD was scheduled for cataract surgery. At 1 month, this patient’s cornea had cleared and his vision was 20/25. At 4 years out now, Dr. Colby said the patient is still 20/20 with a clear cornea. According to Dr. Colby, this and a follow-up retro- spective case series was a “proof of concept that it could work.” 9 At the same time Gregory Moloney, MD, Sydney, Australia, was doing similar work, publishing his first case in in 2015 and later describing the use of a topical ROK inhibitor (ripasudil, a ROCK inhibi- tor not FDA approved in the US) to “save” failing cases. 10–11 Dr. Colby said she has per- formed 10 such descemetorhexis cases, and all of her patients have chosen to obtain ripasudil on their own. Though she hasn’t formally analyzed her data yet, Dr. Colby said anecdotally, it seems the ripas- udil speeds endothelial clearance by a factor of two. “My average clearance in my original series was 3 months. … The average now is about 6 weeks; I’ve had some clear as quickly as 3 weeks,” Dr. Colby said. A primary descemetorhexis without a graft is not for everyone though, Dr. Colby stressed. The patients this seems to work well on are Fuchs’ patients with confluent guttae right in the center but the peripheral endothelium is pre- served. Patients who would not do well with this technique include Fuchs’ patients who have wall-to- wall guttae out to the periphery and non-Fuchs’ patients requiring a graft, such as those with pseu- dophakic bullous keratopathy. Preoperatively, patients need to be advised about the potential that the procedure will fail and they will need to have a traditional EK pro- cedure. Corneal edema within the first few months is also common, but Dr. Colby said she has not had a patient upset about that, explaining to them preoperatively this is likely to happen. Postoperatively, Dr. Colby starts patients on prednisolone six times a day and begins to taper them gradually after a week or two. If patients choose to obtain and use ripasudil, Dr. Colby said they start using it immediately postop. The procedure itself is “well within the skillset” of a cornea surgeon, Dr. Colby said, explain- ing that the descemetorhexis is the first step of any EK procedure, just smaller. She noted recent research that showed performing a capsu- lorhexis-like tear on Descemet’s, rather than scoring and removing it, provides a smoother edge that may facilitate migration better than a jagged edge. “The field of cornea has seen an incredible revolution in the last 15 years. I think forward-thinking people will look at this carefully be- cause if you don’t have to put cells from someone else and give them steroids for the rest of their life, that’s a good thing,” Dr. Colby said. “If a patient comes in and they’ve got a 720-µm cornea and there’s no clear area, don’t do it on that one, do a regular EK. But if a 45-year-old person comes in with symptoms with central guttae, what are you going to do? DMEK and give them a cataract, they’ll be pseudophakic. The [primary descemetorhexis] procedure is quick, it’s not resource intense.” Dr. Colby said her team is gear- ing up to do a side-by-side compari- son of DMEK in one eye and the descemetorhexis without a graft in the other, looking at outcomes, complications, patient satisfaction, and cost. “I know there’s people even in this country who don’t have access to a corneal surgeon for a trans- plant. … You can do this procedure and if it works that patient doesn’t need regular follow-up with a cor- nea specialist, whereas even if you do the best EK in the world, most people still give steroids and there’s risks of glaucoma and rejection and even though they’re low with a procedure like DMEK, they’re not zero,” she said. Cultivated corneal endothelial cells Dr. Mehta is part of a team that’s hoping to eliminate the issue of donor tissue availability by cultivat- ing corneal endothelial cells from continued on page 22