MAR 2020

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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MARCH 2020 | EYEWORLD | 75 C Contact Dhaliwal: dhaliwaldk@upmc.edu Holland: eholland@holprovision.com Terry: MTerry@deverseye.org for DMEK. 2 However, a benefit of DSO is avoiding the graft and immunosuppres- sion. Dr. Dhaliwal does recommend using a rho kinase inhibitor 4 times a day for 6–8 weeks to help stimulate the peripheral endothelium. In DSO cases where the cornea does not clear after 6 weeks, Dr. Terry performs a "rescue" DMEK procedure to avoid cor- neal haze. Dr. Terry views this as a transformative time for endothelial transplant procedures. "The advances in treating endothelial fail- ure have never been more exciting than they are right now," he concluded. "About 20% of my patients are at a higher risk for graft detachment, and I can offer them a DSAEK procedure that has a lower graft de- tachment rate and is easier to perform, and I'm not sacrificing vision," Dr. Holland said. However, when it comes to reviving a failing penetrating keratoplasty graft, in most instances Dr. Holland still performs DMEK, reserving the nanothin approach for about 20% of complex or detach- ment-prone cases. Dr. Terry, who uses the ultrathin DSAEK approach, always does DMEK on a failing PKP, unless the patient has had a prior pars plana vitrectomy. Dr. Terry chooses ultrathin DSAEK for complex eyes with previous pars plana vitrectomies, aphakia or anterior chamber IOLs. Choosing DSO DSO involves removing the central 4 mm of Descemet's membrane. From there the patient's own cells are used to "rejuvenate" the area, with no graft necessary, explained Deepinder K. Dhaliwal, MD. "We don't know if the endothe- lial cells are actually dividing and proliferating or just migrating," she said, adding that patients are often motivated by this option to avoid a graft. Dr. Terry reserves DSO for Fuchs patients who have confluent guttata in the central 4–5 mm of cornea. Dr. Dhaliwal recommended only selecting patients who have functional vision in their fellow eye, citing prolonged visual recovery, even in rapid responders. Visual recovery can take 3–4 weeks. "The person has to be well educated [on the procedure] and very patient," she said, explaining that vision on the first day post-DSO is like a "whiteout" from corneal edema. She also requires that patients have a peripheral endothelial cell count of more than 1,000 mm 2 . In a study, Dr. Dhaliwal and co-in- vestigators found that 20/40 vision was attained 7.2 weeks after DSO vs. 2.2 weeks References 1. Kurji KH, et al. Comparison of visual acuity outcomes between nanothin Descemet stripping automated endothelial kerato- plasty and Descemet membrane endothelial keratoplasty. Cornea. 2018;37:1226–1231. 2. Huang MJ, et al. Descem- etorhexis without endothelial keratoplasty versus DMEK for treatment of Fuchs endothelial corneal dystrophy. Cornea. 2018;37:1479–1483. Relevant disclosures Dhaliwal: CorneaGen, Trefoil Holland: CorneaGen, Minnesota Lions Eye Bank Terry: None DMEK tissue, such as that pictured above, can be more difficult to prepare. Source: David Vroman, MD

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