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EW CORNEA 60 August 2018 tration that is three times higher than standard, Dr. Iovieno noted. "I think the results of this trial will be available by the end of this year or the beginning of next," he said. Overall, Dr. Tu advised practi- tioners considering miltefosine to remember that this is still in its na- scence. "Generally, the results have been positive but they are early re- ports," he said, adding that the tra- ditional medications can work well and should be tried first. "Don't skip the other drugs to get to this one," Dr. Tu said. "But if things don't seem to be going well, this may be a treatment in the near future, and its role may expand later." EW Reference 1. Schuster FL, et al. In-vitro activity of milte- fosine and voriconazole on clinical isolates of free-living amebas: Balamuthia mandrillaris, Acanthamoeba spp., and Naegleria fowleri. J Eukaryot Microbiol. 2006;53:121–6. Editors' note: Dr. Iovieno and Dr. Tu have no financial interests related to their comments. Contact information Iovieno: alfonsoiovieno@hotmail.com Tu: etu@uic.edu to resolve the disease within 2 or 3 weeks. "Unfortunately, that's not the case for many patients with Acanthamoeba because they come late to the tertiary center," Dr. Iovieno said. "They've been seen by other ophthalmologists and might have other initial diagnosis." By the time Dr. Iovieno treats them, they often have deeper stromal disease. For these patients, he combines use of PHMB with hexamidine, another standard agent for Acanthamoeba keratitis treatment. "In the resistant cases, where we don't see a resolution of the disease within the initial 3–4 months of treatment, then we have to employ other strategies," Dr. Iovieno said, adding that use of voriconazole is usually the next step. However, this can be inconsistent. "In vitro data for voriconazole is all over the place," he said. "It seems to be active in a different way in differ- ent settings." Miltefosine becomes an option in resistant cases when practitioners want to add to the standard treatment. Until this point, the big problem with milte- fosine has been availability, where- as voriconazole is commercially available in pharmacies all over the world, Dr. Iovieno pointed out. Another possible treatment option that some practitioners con- sider is crosslinking. However, Dr. Iovieno himself does not favor this approach. "It doesn't seem to work well," he said. "It may seem to work for other kinds of infections but not for Acanthamoeba." Still, with such new treatments, the jury is still out. The main side effect to be wary of with miltefosine treatment is gastrointestinal upset, Dr. Iovieno noted, adding that he has seen this in many of his patients. "However, there wasn't enough to prompt dis- continuation of treatment," he said. Visual results with miltefosine vary depending on how severe the eye is at presentation. "For some- one with superficial disease, there is no reason the patient shouldn't regain vision fully," Dr. Iovieno said. "Unfortunately, in the vast majority of the cases they end up with some degree of corneal scarring, to the point where a transplant for optical purposes later on in patients with Acanthamoeba is common, occurring in about one-third of patients." In addition to expanded miltefosine use for the treatment of Acanthamoeba, more research is being conducted on PHMB with a new multicenter trial underway in Europe expected to lead to the approval of this agent at a concen- Adopting continued from page 58 by Liz Hillman EyeWorld Senior Staff Writer corrected Snellen visual acuity of 6/18 preoperatively, a central corneal thickness of 603 nm, and an unrecordable endothelial cell density. By 6 months postop, her vision had improved to 6/7.5, her central corneal thickness was 569 nm, and central corneal endothelial cell density was 889 cells/mm 2 . Ac- cording to the study, this patient's condition remained stable after stopping all medications, including immunosuppressants, and there were not significant postoperative complications. Soh et al. wrote that there is a "paradigm shift toward acellular DM issue is that the outcome is variable with respect to time for the cornea to clear, and some people reported endothelial scarring at the edge of the migrating endothelium," said Jodhbir Mehta, MD, associate professor, Singapore National Eye Center, Singapore, corresponding author of the study. "Hence, when we studied this using ex vivo and in vivo models, we were able to as- certain that a basement membrane … was important for cell migration and the addition of a rho kinase inhibitor was important in [patients older than 60 years]." The patient in the first-in-hu- man case (56 years old) had a best the patient's own endothelial cells migrate and repopulate. Research published in Cornea by Soh et al. describes the first-in- human trial of the technique that involves creating a small descemeto- rhexis in the patient and replacing it with an acellular donor DM. 4 The study ultimately showed that Descemet's membrane transplan- tation (DMT) might be an effective treatment for this disorder that can progressively cloud vision. It also re- ceived a best paper of session award at the 2018 ASCRS•ASOA Annual Meeting. "A lot of people were trying pri- mary DM stripping alone, [but] the Results demonstrate efficacy of acellular basement membrane acting as a scaffold for the patient's own cell migration I n between advances in endo- thelial keratoplasty technique, 1 Descemet's stripping without a graft, 2 and research for cultivat- ed endothelial cells 3 for Fuchs' endothelial corneal dystrophy (FECD) are regenerative therapy techniques that implant an acellu- lar, allogenic scaffold upon which First-in-patient case of acellular Descemet's membrane transplantation for Fuchs' dystrophy Research highlight continued on page 62 " Don't skip the other drugs to get to this one. But if things don't seem to be going well, this may be a treatment in the near future, and its role may expand later. " —Elmer Tu, MD

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