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E W CORNEA 1 01 DSAEK, myofibroblast activity was not found at the interface. Why not? While there aren't m any other corneal wounds exactly like those in DSAEK surgery, where donor and host stromal tissue are put together in a lamellar fashion, the wound interface with the LASIK flap can be somewhat similar, she said. With LASIK, myofibroblasts were only found on the edges of the c ut that come through the epithe- lium, she observed. This suggests that epithelial stromal interactions, which the DSAEK interface lacks, may be necessary for the myofibrob- lastic wound healing response. Dr. Hindman theorizes the scat- ter hindering vision in DSAEK may involve misalignment and abnormal spacing of collagen fibrils at the interface. Collagen fibrils in the corneal tissue orient into little sheets called lamellae. Normally, she ex- plained, these are oriented to mini- mize the amount of scatter as the light passes through. With a hinged LASIK flap, when this flap is re- placed the orientation of the lamel- lae remains the same. However, with donor tissue in DSAEK there is no way of telling the correct orienta- tion. This, she thinks, may account for some of the interface haze that gets better with time. "My guess is there's some remodeling that occurs with time that allows the lamellae to reorient and improve their approxi- mation," Dr. Hindman said. She believes it is the stromal-to- stromal interface created in DSAEK cases from which the scatter is aris- ing. Dr. Hindman pointed out that deep anterior lamellar keratoplasty (DALK) and Descemet's membrane endothelial keratoplasty (DMEK) pa- tients, where there is no stromal-to- stromal interface, don't have nearly as much scatter. While there can be technique drawbacks, vision with these other corneal transplant tech- niques tends to be better. Still, Dr. Hindman stressed that DSAEK is a good surgery. "I think overall patients do incredibly well, and this surgery has been a great advancement over PK," she said. "We're not talking about big vision limitations." While DMEK may re- solve many of the issues of higher order aberration and scatter induc- tion, it can be more challenging for both the surgeon and the patient. Eventually, however, Dr. Hindman thinks the transition will be made. "I think we should continue to look toward DMEK as the next step in a dvancing endothelial keratoplasty," she concluded. EW Editors' note: Dr. Hindman has no financial interests related to this article. Contact information Hindman: Holly_Hindman@URMC.Rochester.edu THE MISSING PIECE GET CERTIFIED JCAHPO THE MISSING PIECE THE MISSING PIECE THE MISSING PIECE PIECE THE MISSING PIECE G GET CER TIFIED GET CER TIFIED tification and Education f Cer Cer JCAHPO tification and Education f tifications: Cer OA C OT C W 2025 jcahpo@jcahpo.or JCAHPO e Car or Ey ye Care Excellence cation f for Ey COMT A CCO OUB R MN 55125 - 800-284-3937 aul, P oodlane Drive - St. W o .jcahpo.or g - www jcahpo@jcahpo.or e Care Excellence CDOS OSA MN 55125 - 800-284-3937 g .jcahpo.or March 2014 88-107 Cornea_EW March 2014-DL2_Layout 1 3/6/14 3:47 PM Page 101