Eyeworld

MARCH 2020 | EYEWORLD | 77 C lymphatics, and based on this, we are going to prescribe drug A + B + C, or A + B instead of just A,'" Dr. Gupta said. She views the study as bringing to light a new aspect of graft rejection. "I think the takeaway is just because you can't see them, doesn't mean they're not there," Dr. Gupta said. "We need to turn our attention with full force to the lymphatics to understand their role and to advance the field. If we can easily pick them up in the clinic and target these as part of preventing graft failure, it would be a way to advance the field and personalize care." This would ultimately reduce the burden of graft failure on the donor tissue supply, which is an issue worldwide, she concluded. Multipronged approach To help curtail graft failure, drugs that target lymphatics are needed, Dr. Gupta said. "We may need to hone in on specific targets to get rid of these lymphatic vessels as part of the process," she explained, adding that these are part of the afferent pathway of the immune system and a vehicle for inflammatory infiltrates. While traditionally practitioners have stringently treated those experiencing graft rejection with a panoply of topical corticoste- roids, immunosuppressive agents, cyclosporine, and other agents, it hasn't been sufficient, given that the graft failure rate has not gone down in decades, Dr. Gupta said. She would like to see such treatment used in conjunction with traditional therapy. "We can continue to offer patients steroids, hitting the inflammatory component, to try to get those blood vessels to regress. But wouldn't it be great to add something to the mix that was anti-lymphatic so that we could make sure that we were also hitting the immune system arm and able to salvage the cornea that way?" Dr. Gupta said. Down the line, it may be possible to use an in vivo imaging system to detect those who have lymphatic vessels and treat them accord- ingly. "It's highly reasonable that with sophisti- cated imaging tools such as OCT or some other technology to look at the cornea microscopi- cally, we might be able to say, 'This patient has Reference 1. Diamond MA, et al. Lymphatic vessels identified in failed cor- neal transplants with neovas- cularisation. Br J Ophthalmol. 2019;103:421–427. Relevant disclosures Gupta: None "The fact that we consistently found lymphatic vessels in all of the failed grafts in which we detected neovascularization suggests that they play some role in corneal transplant failure and that they need attention." —Neeru Gupta, MD Compass.OnPeak.com/e/012604383/0

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