Eyeworld

JULY 2023 | EYEWORLD | 59 C BEST PRACTICES About the physicians Sophie Deng, MD, PhD Joan and Jerome Snyder Chair in Cornea Diseases Cornea Division Stein Eye Institute University of California, Los Angeles Los Angeles, California Nir Sorkin, MD Director of Cornea and Anterior Segment Research Department of Ophthalmology Tel Aviv Medical Center and Tel Aviv University Tel Aviv, Israel by Liz Hillman Editorial Co-Director I t's not uncommon for cornea specialists to come across a glaucoma patient in need of an endothelial transplant, and the manage- ment of these patients from preop through long-term postop has certain nuances. EyeWorld spoke with Sophie Deng, MD, PhD, and Nir Sorkin, MD, for their insights on how to best manage glaucoma patients who need lamellar keratoplasty. Glaucoma and endothelial cell loss A number of studies have looked at glauco- ma and associated endothelial cell loss. One suggests that there are several hypotheses for why this can occur, including direct compression of the endothelium due to high IOP and medi- cation toxicity. 1 Dr. Sorkin shared that another reason for decompensation could be due to the prior surgeries these patients might have re- ceived to treat their glaucoma (such as cataract surgery, trabeculectomy, or tube shunts). "Multiple procedures may affect their cor- nea, and that's when we come into the picture," Dr. Sorkin said of cornea specialists. When it comes to DMEK or DSAEK, Dr. Sorkin and coauthors published a paper that found the 4-year graft survival rate was similar- ly low between the two, but DMEK resulted in better visual acuity. 2 For this reason, Dr. Sorkin said he performs DMEK unless otherwise contra- indicated for the patient. A study published in 2017 found that eyes with previous trabeculectomy or tubes had good short-term outcomes, with a 0.9% rejection rate over a follow-up of 9.7±7.3 months. 3 Dr. Deng said her success rate in the short term is similar for patients with glaucoma as it is to those with- out. Long-term graft survival is a different story. In a series of 251 consecutive DMEK procedures performed by Dr. Deng, secondary graft fail- ure at a mean 38.4±11.2 months was 41.5%, 0%, and 2.4% in eyes that had prior glaucoma surgery, eyes with medically treated glaucoma, and eyes without glaucoma, respectively. 4 Endo- thelial cell loss was higher in prior surgery eyes as well, 63.8%, compared to 47.6% for eyes medically treated for glaucoma and 44.0% for eyes without glaucoma. Preop considerations When assessing a glaucoma patient for lamellar keratoplasty (of which Dr. Sorkin said DMEK is his preference provided there are no other comorbidities that should preclude it), both Dr. Sorkin and Dr. Deng said that ensuring the patient's IOP is well controlled is the first step. "Often these patients have IOP well above their target IOP, and I send them back to their glaucoma specialist," Dr. Deng said. Compliance on glaucoma medications is also important, Dr. Sorkin said. "After [DMEK] surgery, we put them in a state where their glaucoma control may be jeop- ardized because we're giving them long-term steroid therapy that can affect the pressure. You have to have them well controlled. … We don't want to put another factor into the equation if they're not stable," Dr. Sorkin said. Dr. Deng said that the patient should be able to add at least two IOP-lowering medica- tions to their regimen prior to DMEK surgery because they might need them to manage an increased IOP postop due to corticosteroid use. Special considerations for DMEK in glaucoma patients continued on page 60 A patient with prior trab postop week 1 after DMEK Source: Sophie Deng, MD, PhD

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