Eyeworld

FALL 2024 | EYEWORLD | 73 C Reference 1. Salisbury CD, et al. Increasing povidone-iodine exposure in endothelial keratoplasty tissue processing and fungal infection impact. Cornea. 2019;38:1093– 1096. Relevant disclosures Ketcherside: None Lee: None Tu: None Contact Ketcherside: cketch@gmail.com Lee: wblee@mac.com Tu: etu@uic.edu a rare but potentially vision-threatening compli- cation, and studies have shown amphotericin B can potentially reduce this risk of infection. "The problem is amphotericin B does have some degree of endothelial toxicity, and cell damage may be heightened by contact of the medicine with the endothelial cells from the time of tissue preparation until it is removed from the storage solution at the time of surgery," Dr. Lee said. "While it is hard to prove, the am- photericin B supplementation is a potential for the increase in primary graft failures and early regrafts. Cases of graft failures with amphoteri- cin B supplementation have shown an increase from 2.1% in 2018 to 28.5% in 2023, according to the EBAA data. 1 This is certainly an alarming increase and raises the question of whether the risk of adding amphotericin B to the media is worth reducing antifungal infections, although we still do not have unequivocal evidence that its supplementation statistically reduces the risk of fungal infections in keratoplasty." Dr. Lee said that it is safer to decontami- nate donor corneal tissue with double betadine prep applied to the donor tissue during recov- ery. "Salisbury et al. have shown the double betadine prep does have statistical significance of lowering the risk of fungal infections and is a very effective method without adding any additional toxicity to the endothelium," 1 Dr. Lee said. "While the double betadine prep does not completely eradicate fungal infections after keratoplasty, it does statistically reduce the risk of infection without the potential need for amphotericin B supplementation in the storage media. More studies must be done to assess what surgeons should do as far as adding the antifungal to their storage media or not." Dr. Tu pointed out that while the conse- quences of a fungal infection can be severe and devastating, the incidence of infection has fallen significantly over the last several years. He said that previous studies have shown supplementa- tion is likely not cost effective. "If there is an issue with toxicity, graft fail- ures would only be the most obvious, immediate consequence; an expectation would be that even those exposed grafts that did not fail initially may have a significantly shorter lifespan," Dr. Tu said. The problem When you look at the individual numbers each year of primary graft failures, it might seem small, but Dr. Ketcherside said that when a prac- tice that does 200 DMEKs a year, for example, goes from a 1% rebubble rate to 10%, that's significant. It's significant from a practice resource standpoint, for the time it's taking patients to drive back to clinic for treatment, and because of the increased infection risk due to more pro- cedures being performed. "There are small numbers on how often we get fungal infections with grafts and en- dophthalmitis as a whole, and people will tell you those tiny numbers involve a catastrophic event that is life changing for the patient and devastating for the surgeon. Graft failures aren't on the scale of that because you can replace these with another graft, but each one of these is coming from a human being. It's a gift from some person, and we have a responsibility to make sure that as many of those as possible are able to help someone," he said. Dr. Ketcherside said when it comes to cor- neal grafts, it doesn't take much of a disruption in the success rate for it to be a big deal. "It will be interesting to see what these initial looks at amphotericin B in larger numbers of patients and their graft failure rates are going to show us," he said. "[A graft is] a gift from some person, and we have a responsibility to make sure that as many of those as possible are able to help someone." —Christopher Ketcherside, MD

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