Eyeworld

EW CORNEA 96 September 2015 by Maxine Lipner EyeWorld Senior Contributing Writer Corrales views the sterile tissue as ideal for situations where prac- titioners have an emergency. An example may be a situation where a patient has an infection of the cornea that is not responding to medical treatment or has perfo- rated and needs to be taken to the operating room right away. "Then you have a red, inflamed eye; the whole immune system is revved up," he said, adding that the quandary is you have to do something, but with the immune state heightened this may compromise long-term results. "Traditionally, we have put in a fresh cornea, but what we're sacrificing is the long-term benefit because the immune system is going to get sensitized to this fresh corneal tissue," he said. "It's going to start rejecting the cornea and when you put the second one on this, it rejects Sterile graft helps ensure long-term success F or situations involving a high risk of graft rejection, VisionGraft sterile tissue (Tissue Banks Internation- al, Baltimore) is a stopgap measure ultimately preserving long- term results, according to Gustavo A. Corrales, MD, Vision Consultants and Surgeons, Falls Church, Va. One of the biggest advantages of this gamma-irradiated sterile tissue is that it shouldn't cause sensitization of the immune system, Dr. Corrales explained, adding that this tissue is devoid of any living cells that could trigger an immune memory. In addition to cases such as lamellar keratoplasty or Boston type 1 keratoprosthesis surgeries, Dr. New transplantation tack Operating microscope view of cornea with fungal keratitis and impending perforation, which warrant action. However, when the patient's immune state is heightened, traditional transplants can be compromised. Slit lamp photograph of VisionGraft cornea with central epithelial defect. A dense cataract can also be noted. as well." For every new cornea, the chances of survival will diminish, he said. A temporary solution On the other hand, in transplant cases where the immune system is not revved up, such as keratoconus, chances of graft survival are high. This is about 73% at 10 years versus an emergency situation such as a corneal melt, infectious keratitis or trauma, where graft survival may be down around 40%, Dr. Corrales said. The VisionGraft sterile tissue, which has no living cells for the immune system to detect, is not a target of the immune system. "You have time to decrease the inflam- mation, and after 6 months to a year when you have full control of the situation, you can go back and do another corneal transplant," Dr. Corrales said. The VisionGraft tissue is not meant to be a permanent solu- tion. It doesn't have an endotheli- um and can get somewhat cloudy with time, even though no obvious edema develops. But during the transplant period, it can allow the patient's immune system to quiet down enough to then give a tradi- tional graft a much better chance of survival, he said. VisionGraft in action Dr. Corrales cited a recent case involving an uncontrolled diabetic patient who was referred to him with a very advanced corneal ulcer. The problem had begun about a month earlier when some vegeta- tion had gotten into the 50-year-old patient's eye while he was mowing the lawn. visual detriment of delaying proper treatment, and the need for a com- mitment to a treatment course with the proper medication can help alle- viate noncompliance and treatment failures." Likewise, Dr. Starr emphasized the need to caution patients that Restasis can take months to work. "That's something I always tell my patients about this drop," he said, because if patients don't know this they will think it is not working and will stop the medication premature- ly. He also reminds practitioners to alert patients that there can be burning and stinging with Restasis. "We know that with Restasis, 17% of people in the FDA trial had signifi- cant burning," Dr. Starr said. "You have to tell patients that it is going to burn a little and that's normal." Overall, Dr. Shamie stressed the need for medications to address in- flammation. "Inflammation is at the crux of all ocular surface disease," she said. "Addressing the inflamma- tion is the most critical point and everything else will follow." EW Editors' note: Dr. Farid has financial interests with Allergan, Shire, and TearScience (Morrisville, N.C.). Dr. Shamie has financial interests with Allergan, Nicox (Fort Worth, Texas), and Shire. Dr. Starr has financial in- terests with Alcon (Fort Worth, Texas), Allergan, Bausch + Lomb, Rapid Pathogen Screening (Sarasota, Fla.), Shire, and TearLab (San Diego). Contact information Farid: mfarid@uci.edu Shamie: NedaShamieMD@gmail.com Starr: drstarr@gmail.com Plunging continued from page 94

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