Eyeworld

72 | EYEWORLD | FALL 2024 C ORNEA by Liz Hillman Editorial Co-Director About the physicians Christopher Ketcherside, MD Cornea Specialist Kansas City Eye Clinic Overland Park, Kansas W. Barry Lee, MD Cornea Fellowship Director Eye Consultants of Atlanta Atlanta, Georgia Elmer Tu, MD Professor of Clinical Ophthalmology University of Illinois College of Medicine Chicago, Illinois B oth W. Barry Lee, MD, and Christopher Ketcherside, MD, have heard of (and, in Dr. Ketcherside's case, experienced) the recent uptick in primary graft fail- ures, and the data seems to confirm it, but the cause is still unconfirmed. "I have a small text group of cornea sur- geons across the country, and we ping each other with things. Before this came up, we had brought it up among ourselves because I had personally seen an uptick in rebubbles and graft failures in the first quarter, and it was definitely something out of the ordinary, something no- ticeable. When I brought it up to my colleagues in different places, they were seeing the same thing," Dr. Ketcherside said. The data Dr. Lee said that recent data confirms this increase. "In analyzing the data published by the Eye Bank Association of America [EBAA] Medical Advisory Board meeting in June 2024, we see that 2018 showed a total of three report- ed primary graft failures or early regrafts, 2019 showed an increase to 32, and 2023 showed an increase to 45. The numbers certainly point to an uptick in these complications," he said. Dr. Lee defined a primary graft failure as a corneal transplant that does not clear after 8 weeks following the surgery and an early regraft as a graft that is either dislocated or thought to not clear so a repeat graft is placed in the early postoperative period. Elmer Tu, MD, said that the definition of graft failure is very different between penetrat- ing keratoplasty and endothelial keratoplasty. In the latter, it is more difficult to identify the rea- son (surgical technique or tissue preparation). "Although the increase in primary graft failures for endothelial keratoplasty may be for the same reason, the increasing graft failures of penetrat- ing keratoplasties is probably the best indication that something may be amiss," Dr. Tu said. Dr. Ketcherside, who is part of the EBAA Medical Advisory Board, said there was a decrease in reported graft failures in the fourth quarter of last year, after the uptick that had been observed, but anecdotally, there has been a perceived increase again, though the first and second quarter numbers of 2024 are not in yet. "There are a lot of theories about this, but we don't totally know why," he said. The potential culprit(s) There are several areas of active research look- ing into this complication. Dr. Lee noted that there is an increased amount of DMEK tissue preparation being done at eye banks, rather than in the operating room with the surgeon. Amphotericin supplementation in tissue storage media is also being closely examined. Ampho- tericin use as an antifungal for cornea grafts began in the last 2–3 years. Dr. Ketcherside also said amphotericin is what is most often being brought up and inves- tigated in relation to these graft failures. "We should have more on that fairly soon. We should have more definitive answers regard- ing whether or not this may be causing more graft failures," he said, adding that investigators are also looking at the amount of time DMEK grafts are stained, volume of fluid the graft is in after being stained, etc. Dr. Lee said surgeons have the choice of whether to add amphotericin B to the storage media or not. History has shown an increase in fungal infections after endothelial keratoplasty, What's causing an 'uptick' in primary graft failures? This is a failed DSAEK after 10 years. It was a late onset failure after a flu vaccine. Source: W. Barry Lee, MD

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