Eyeworld

74 | EYEWORLD | APRIL 2023 C ORNEA by Liz Hillman Editorial Co-Director About the physicians Winston Chamberlain, MD, PhD Professor of Ophthalmology Casey Eye Institute Oregon Health & Science University Portland, Oregon Clara Chan, MD Associate Professor of Ophthalmology University of Toronto Toronto, Canada Nandini Venkateswaran, MD Cornea and Refractive Surgery Service Massachusetts Eye and Ear, Waltham Waltham, Massachusetts DSAEKs still tend to be skewed toward the more complicated eyes that have had prior vitrec- tomies, glaucoma surgeries, anterior chamber IOLs, or have abnormal iris anatomy," Dr. Chamberlain continued. "The 2021 Eye Bank Association of America (EBAA) Statistical Re- port reflects that DMEK is rising and likely soon, within the next year or 2, will equal the number of DSAEKs and PKPs done in the U.S. So, the three types of surgery will almost be even in distribution. Currently, DMEK is the main choice for uncomplicated Fuchs dystrophy and bul- lous keratopathy. The EBAA Statistical Report showed that about 64% of keratoplasties in the U.S. in 2021 were DMEK or DSAEK, and 52% of DSAEK and DMEK done in the U.S. were done for endothelial dystrophy. The 52% is probably an underestimate given that some surgeons don't accurately report indications for surgery, and some EKs are done to replace a failing graft that was previously done for Fuchs dystrophy." Dr. Venkateswaran said experience with DMEK or DSAEK for those in training depends on the patient population they see and the tech- nique with which attending ophthalmologists are more comfortable. "If you have a clinic where you are predom- inately seeing patients with Fuchs dystrophy or pseudophakic bullous keratopathy in otherwise healthy eyes, I think the majority of cornea sur- geons are trending toward performing DMEK. It's the least invasive lamellar keratoplasty tech- nique [and has] lower risks of rejection with improved vision outcomes compared to DSAEK. It's an enjoyable surgical technique to learn and perform as well. But you can also have a cohort of eyes that aren't going to necessarily shine with DMEK," Dr. Venkateswaran said, noting that she did a lot of DSAEK in residency and a lot of DMEK in fellowship based on what surgical option was best for the patients she was caring for. Dr. Venkateswaran and Dr. Chamberlain think there is still a place for DSAEK in cornea practice. The status of DSAEK and DMEK continued on page 76 L ast year, an EyeWorld article took a look at the status of trabeculectomy in glau- coma practice; while it still has a place in the glaucoma treatment paradigm, according to some, it is being taught less and less in training programs in favor of newer therapies. Is the same occurring with DSAEK? Nandini Venkateswaran, MD, and Winston Chamberlain, MD, PhD, both said they had DSAEK training (DMEK wasn't even a thing when Dr. Chamberlain was in residency or fellowship, he said) and think there continues to be a place for it, even while DMEK has gained increasing popularity. Dr. Chamberlain thinks surgeons in training are likely still getting enough DSAEK exposure. "Most surgeons who perform endothelial keratoplasty are still doing both surgeries, and training centers are teaching these skills to residents and fellows," he said. "Many residen- cies, including ours at the Casey Eye Institute, now expose residents to DMEK and DSAEK. Our second year residents assist in both types of procedures and perform a small number during their senior year. Still, a majority of this surgical training takes place during a cornea fellowship. "Both surgeries are taught thoroughly with a variation of techniques to our fellows, but DSAEK clear cornea Source: Clara Chan, MD

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