CORNEA 34 EWAP JUNE 2023 procedure with DMEK can be challenging for older patients. Gas instillation may require longer supine positioning times than air instillation, which I typically use for DSAEK cases, and compliance with positioning can be poor in patients with musculoskeletal limitations or lack of support at home. In scenarios such as these, I choose DSAEK as my go-to procedure, even if the case is relatively uncomplicated.” It’s the shift to performing DMEK on more routine cases and DSAEK on more complex cases that Clara Chan, MD, thinks might put trainees at a disadvantage as they’re learning DSAEK. “Cornea surgeons are performing DMEK earlier on patients with routine eyes now who have corneal decompensation since DMEK outcomes are good and the small incision surgery is lower risk,” Dr. Chan said. “DMEK tissue is also preloaded, premarked, prestripped, prepunched, so the ability to learn tissue handling and tissue preparation is limited in many programs. With the decline in DSAEK being done in routine eyes, it is now reserved for complex eyes with ACIOL, aphakia, aniridia, multiple iris defects, post-vitrectomy, etc. These cases are challenging and are often more suitable for the cornea staff surgeon to tackle. Without the opportunity to learn DSAEK in routine eyes, doing DSAEK on complex eyes is all the more challenging.” If surgeons don’t think they have enough experience with either procedure, Dr. Venkateswaran said working with local eye banks and industry partners, attending wet labs at major medical meetings, and observing other ophthalmologists in the OR are viable options to get additional training. Dr. Chan said even beyond DMEK and DSAEK, it’s important for cornea surgeons to know “all the procedures in the cornea surgery alphabet soup.” “The opportunity while in fellowship to do all sorts of cases and see as much pathology as possible is invaluable,” she said. “It is much easier to learn the pearls directly from a mentor than to try to muddle through on your own once in practice when the full responsibility rests on your shoulders and there is no one there in the captain’s chair but you. In a modern cornea practice, there will still be eyes that would benefit from DSAEK, so a cornea specialist should maintain their skills in performing the procedure.” Dr. Chamberlain said the currently enrolling DETECT multicenter, randomized, controlled trial will provide high-level evidence as to DMEK tissue with gas bubble with two S stamps. Source (all): Nandini Venkateswaran, MD Unfurling of DMEK graft.
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