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EW FEATURE 46 All you need to know about cornea transplants • January 2018 is often overwhelming and confus- ing for patients. "Having said that, I typically let my patients know about the differ- ent types of EK, but focus on the surgery I think is most appropriate for them," Dr. Shah said. He provides them with hand- outs explaining the different forms of EK and has them come back for an additional visit, typically with a family member, prior to surgery to address any questions or concerns. Although more data and long- term studies with ultra-thin DSAEK are needed, Dr. Shah said, a con- sensus is that the 3-year rejection rate is 1–2.5% for DMEK, 3–6% for ultra-thin DSAEK, and 5–10% for standard DSAEK. There is general evidence that EK has less rejection than PK, Dr. Busin said. He noted that prolonged steroidal treatment can lower DMEK rejection rates below 1% annually at 2 years. However, the higher DSAEK rejection rate remains much lower than PK. In his statistics review, Dr. Busin found a 6.9% rejection rate at 5 years for ultra-thin DSAEK, com- pared to a 17% rate for DSAEK and 2.4% for DMEK. Patient selection Dr. Deng said selecting which pro- cedure to use is based on surgeons' experience. "I do DMEK in every patient except the aphakic and those with ACIOLs," Dr. Deng said. All eyes with anatomical abnormalities that may cause graft luxation into the vitreous cavity are suitable only for DSAEK or ultra- thin DSAEK, Dr. Busin said. "It is useless to choose DMEK in eyes with poor visual potential, as 20/20 vision does not come in question," Dr. Busin said. "In gener- al each surgeon should choose the method he is comfortable with, as long-term results show identical vi- sual outcomes for DSAEK, ultra-thin DSAEK, and DMEK." Among patients with glaucoma or post-glaucoma surgery, Dr. Sham- ie said the selection of procedures depends on the condition of the anterior segment. "If the iris structures are normal and there are no large iridotomies, if the tube is not too disruptive in the AC, and if the patient's corneal view allows for DMEK surgery, I would proceed with DMEK," Dr. Shamie said. However, the difficulty of air tamponade in post-surgical glau- comatous eyes may make DSAEK preferable, unless other issues are more relevant, Dr. Busin said. For in- stance, surgeons may limit possible immunologic rejection in eyes at higher risk by preforming DMEK. Dr. Deng has found in her experience that DMEK is better for glaucoma patients. "We have published our out- comes of DMEK in eyes with pre- vious glaucoma surgery," Dr. Deng said. 1 "However, the majority of surgeons still feel more comfortable with DSAEK in these patients." EW Reference 1. Aravena C, et al. Outcomes of Descem- et membrane endothelial keratoplasty in patients with previous glaucoma surgery. Cornea. 2017;36:284–289. Editors' note: Dr. Shamie has financial interests with SightLife (Seattle) and KeraLink (Baltimore). Dr. Busin has financial interests with Moria (Antony, France). Drs. Shah and Deng have no financial interests related to their comments. Contact information Busin: massimo.busin@unife.it Shah: kevin.j.shah@gmail.com Shamie: nshamie@doheny.org Deng: deng@jsei.ucla.edu New continued from page 44 " For blindness will only be preventable when the causes of blinding diseases are eradicated." - THOMAS D. DUANE, MD Ophthalmologist-In-Chief 1973-1981 WILLS EYE ACADEMIC PROGR AMS For 185 years, Wills Eye has been renowned for helping eye physicians and surgeons make the world's very best ophthalmic investment: practical, patient-oriented, case-based knowledge that integrates the very latest in research and innovation. Join us. WEBINARS Chiefs Rounds Saturday Updates Retina Imaging Conference Retina Surgical Conference IN PERSON Atlantic Coast Retina Conference and Macula Meeting Fuchs Symposium VI 43rd Annual Ophthalmology Review Course 70th Annual Wills Conference Wills Eye Hospital 840 Walnut Street Philadelphia, PA 19107 willseye.org 1-877-289-4557 SIGN UP TODAY willseye.org/education

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