Eyeworld

APRIL 2023 | EYEWORLD | 77 C better with a DSAEK procedure as compared to DMEK," Dr. Venkateswaran said. She said she tried to learn all the different insertion techniques for DSAEK tissue, including using multiple injection devices and suturing techniques, when she was in training because she wasn't sure what tools would be available to her when she started practice. "We have excellent visual outcomes, low graft rejection rates, and less rebubbling rates with advanced DSAEK techniques," Dr. Venkateswaran said. "I think there are some advantages to DSAEK when you're considering your patient population, too. The higher chance of needing a rebubbling procedure with DMEK can be challenging for older patients. Gas in- stillation may require longer supine positioning times than air instillation, which I typically use for DSAEK cases, and compliance with position- ing can be poor in patients with musculoskel- etal limitations or lack of support at home. In scenarios such as these, I choose DSAEK as my go-to procedure, even if the case is relatively uncomplicated." It's the shift to performing DMEK on more routine cases and DSAEK on more complex cases that Clara Chan, MD, thinks might put trainees at a disadvantage as they're learning DSAEK. "Cornea surgeons are performing DMEK earlier on patients with routine eyes now who have corneal decompensation since DMEK out- comes are good and the small incision surgery is lower risk," Dr. Chan said. "DMEK tissue is also preloaded, premarked, prestripped, prepunched, so the ability to learn tissue handling and tissue preparation is limited in many programs. With the decline in DSAEK being done in routine eyes, it is now reserved for complex eyes with ACIOL, aphakia, aniridia, multiple iris defects, post-vitrectomy, etc. These cases are challenging and are often more suitable for the cornea staff surgeon to tackle. Without the opportunity to learn DSAEK in routine eyes, doing DSAEK on complex eyes is all the more challenging." If surgeons don't think they have enough experience with either procedure, Dr. Ven- kateswaran said working with local eye banks and industry partners, attending wet labs at major medical meetings, and observing other ophthalmologists in the OR are viable options to get additional training. Dr. Chan said even beyond DMEK and DSAEK, it's important for cornea surgeons to know "all the procedures in the cornea surgery alphabet soup." "The opportunity while in fellowship to do all sorts of cases and see as much pathol- ogy as possible is invaluable," she said. "It is much easier to learn the pearls directly from a mentor than to try to muddle through on your own once in practice when the full responsibil- ity rests on your shoulders and there is no one there in the captain's chair but you. In a modern cornea practice, there will still be eyes that would benefit from DSAEK, so a cornea special- ist should maintain their skills in performing the procedure." continued on page 78 Removal of failed DSAEK graft Source: Nandini Venkateswaran, MD

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