Eyeworld

78 | EYEWORLD | DECEMBER 2021 C ORNEA by Liz Hillman Editorial Co-Director About the physicians Kathryn Colby, MD, PhD Elisabeth J. Cohen Professor and Chair Department of Ophthalmology New York University Grossman School of Medicine New York, New York Greg Moloney, MD Clinical Associate Professor University of British Columbia Vancouver, British Columbia L ess than 10 years ago, the idea that you could preserve vision and achieve corneal clearance in a patient with Fuchs without donor tissue was met with skepticism. Now, this idea is increasingly accepted, adopted, and is being more widely researched with a clinical trial underway for a pharmaceutical to aid in cell migration. Descemet's stripping only (DSO), where a descemetorhexis is made in Descemet's mem- brane without keratoplasty, was introduced in the mid-2010s. Kathryn Colby, MD, PhD, said when she started talking about it in 2016, she "wouldn't go so far as to say … that people threw tomatoes at me, but almost." "Around 5 years ago the high variability in patient outcomes was a barrier to widespread adoption of the technique," said Greg Moloney, MD, also an early proponent and researcher of DSO. "Patients and surgeons were often unwill- ing to embark on a surgical journey that had an unknown timeline and might eventually result in a graft in any case." What's changed? In more recent years, there have been published reports of improvements in clearance rates and time to clearance, Dr. Moloney said, noting that it likely relates to several factors. "It seems clear now that patient selection should be limited to those with central corneal disease. The need for a healthy peripheral cell reservoir is understood based on long-term studies of outcomes that illustrate cell migration as the primary driver of clearance," he said. What's more, surgical technique has improved with the understanding that stro- mal trauma can be counterproductive to cell migration, and preliminary data support the role rho-kinase (ROCK) inhibitors can play in cell migration. "Despite all these advancements, there are patients who will fail to clear despite good se- lection, good surgery, and the use of supplemen- tal ROCK inhibitors," he said, adding, "Those considering a DSO should be prepared to accept a DMEK as an eventual consequence." In terms of outcomes, Dr. Moloney said he has cared for patients with multiple endothe- lial grafts in the fellow eye who were treated with DSO in the ungrafted eye, with equivalent visual results. Dr. Colby offered a similar perspective as Dr. Moloney when it comes to patient selec- tion and surgical technique. Patients, she said, should have primarily central Fuchs, with guttae in the center (no more than 5–6 mm, though 4–5 mm is better) and preserved pe- ripheral endothelium. She said the peripheral endothelium can be evaluated with a confocal microscope or a specular microscope that can go to the paracentral area or by clinical exam using 40x magnification on the slit lamp. "Someone who has limbus to limbus guttae is not a candidate for this. And they have to be symptomatic," she said. "People come to me wanting to have this prophylactically. They have to have symptoms because if it doesn't work, you need to do a corneal transplant." Dr. Colby said the patient needs to be able to endure the 2–3 weeks of corneal edema post- op, and as such, she usually doesn't do DSO on monocular patients. A descemetorhexis with no graft The latest in DSO

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