Eyeworld

EW CORNEA 110 October 2017 by Maxine Lipner EyeWorld Senior Contributing Writer do well with the aid of a new ROCK inhibitor. "Patients are able to get a medicine from Japan called Glanatec [ripasudil hydrochloride hydrate, Kowa Company, Nagoya, Japan], which is a ROCK inhibitor," she said. "I can't give it because it's not FDA approved." Since patients have been using the ripasudil, there have not been any failures with the Descemet's stripping technique, Dr. Colby said, adding that this may be because the drug stimulates the migration of the endothelium. Fail-safe in place Dr. Colby views the clinical implica- tions of having Descemet's stripping available for Fuchs' patients as huge. "It has the potential to revolutionize the way we take care of the disease that is responsible for the greatest number of corneal transplants that we do in the United States," she said. In addition, knowing that even in cases where this does not succeed patients can still benefit from DMEK is important for those considering the approach. "That's always a fail- safe that will work," Dr. Colby said. "We published it so people would know you can do DMEK after De- scemet's stripping and it works." Going forward, Dr. Colby envisions big changes in the way that practitioners think about the handling of Fuchs' dystrophy. "We did 17,000 transplants for Fuchs' dystrophy, and if you don't need to do them, if you can convince the body's own cells to spread out and start pumping, that is better for the patient, for the healthcare costs associated with it, and for leaving tissue for other indications," she said. EW References 1. Rao R, et al. Descemet membrane endo- thelial keratoplasty after failed Descemet stripping without endothelial keratoplasty. Cornea. 2017;36:763–766. 2. Borkar DS, et al. Treatment of Fuchs' endothelial dystrophy by Descemet stripping without endothelial keratoplasty. Cornea. 2016;35:1267–73. Editors' note: Dr. Colby has no finan- cial interests related to her comments. Contact information Colby: kcolby@bsd.uchicago.edu eral endothelium either migrates or proliferates, we don't know which." The healthier cells then spread to cover the area where the guttae pre- viously were and can do a better job of clearing fluid from the cornea. However, in the initial series, the approach did not work for ev- eryone. 2 "Maybe some people have too many guttae to remove them all," Dr. Colby said, adding that in the initial series she had stripped a 4-mm area, while currently she tries to remove as much of the central guttae as possible. "I just did one of these and I removed 5.5 mm because when I measured, that was the area of her confluent guttae." In the initial series, genetics did not seem to play a role in the failure of the stripping procedure. "We looked at the genetics of my origi- nal cohort, wondering if this would predict success or failure of Descem- et's stripping, but we couldn't find anything in this small cohort," she said. "All of the people who had mutations had the trinucleotide repeat expansion that is responsible for about two-thirds of Fuchs' in the United States in Caucasians." Fortunately, there may be some steps practitioners can take to broad- en the reach of Descemet's stripping success. "Some have suggested that if you cover the bare stroma it might encourage endothelial migration," Dr. Colby said, adding that she has seen Descemet's stripping patients ing the DMEK procedure. "That's the standard treatment for Fuchs', and it worked fine," she said. As a rule, the Descemet's stripping procedure works best for patients who have predominant- ly central guttae and a preserved peripheral endothelium. "Someone with diffuse guttae across the entire cornea is not going to be a good candidate," Dr. Colby said. "The rationale for this is that the cells are contact-inhibited, meaning that when they hit up against another cell, they don't grow anymore. By removing all the bad cells with all the guttae in the center, the periph- How this fail-safe may boost confidence with Descemet's stripping E ndothelial stripping has opened a new door for patients with Fuchs' dys- trophy: the possibility of allowing their own cells to spread out into areas that had been occupied by diseased tissue rather than undergo a transplant. While promising, one of the concerns has been what to do in those cases where endothelial stripping doesn't work, according to Kathryn Colby, MD, PhD, Louis Block Professor of Ophthalmology and Visual Science, University of Chicago. "If you do a stripping and it works, that's great; everyone is happy because the patient doesn't have anyone else's cornea in their eye and they don't need chronic steroids," Dr. Colby said, adding that the worry has been what might happen in cases where the stripping is not a success. Considering failures In a recent issue of Cornea, investi- gators reported on how three failed endothelial stripping patients fared after subsequently undergoing endothelial keratoplasty. 1 "Those patients didn't clear—they had swollen corneas," Dr. Colby said. "We went ahead and rehabilitated them using DMEK." Investigators found that the corneas of all three patients ultimately did clear follow- DMEK to the rescue Research highlight A 49-year-old man with Fuchs' dystrophy 1 month after 4-mm Descemet's stripping Source: Kathryn Colby, MD, PhD Solutions to DMEK problems John Males, MD, discusses how to meet DMEK challenges.

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