Eyeworld

24 EW NEWS & OPINION June 2018 by Maxine Lipner EyeWorld Senior Contributing Writer good outcomes with tissue from donors with and without diabetes," she said. As for recipients with diabetes, they tended to experience a higher rate of endothelial cell loss with the graft over time, she said, explaining that control of blood sugar could be beneficial for the transplant. Dr. Francis Price agreed, stress- ing that in addition to blood sugar levels, A1C measurements, which tell you how the patient has fared over the past several months, are also important. "If someone comes in and the blood sugar is good but the hemoglobin A1C is way out of whack, you get the idea that maybe the patient just watched it a day or 2 before," he said, adding it gives you a good idea of what has been going on overall. Going forward, diabetes will unfortunately remain a big problem, Dr. Francis Price thinks. "When I went to medical school, they told us there was no diabetes in India, or relatively none, and by 2030 it's projected that 70% of the popula- tion in India is going to be diabetic," he said, adding that this all has to do with high carbohydrate food and caloric intake. The eye is just anoth- er area of the body that's affected by diabetes, he concluded. EW References 1. Price MO, et al. Effect of donor and recipient diabetes status on Descemet membrane en- dothelial keratoplasty adherence and survival. Cornea. 2017;36:1184–1188. 2. Price MO, et al. Risk factors for various causes of failure in initial corneal grafts. Arch Ophthalmol. 2003;121:1087–92. Editors' note: Dr. Francis Price and Dr. Marianne Price have no financial interests related to their comments. Contact information Francis Price: fprice@pricevisiongroup.net Marianne Price: marianneprice@cornea.org donor diabetes severity and duration by the eye bank." Dr. Francis Price said diabetic donor tissue is fairly prevalent, at about one-third of donors. At that number, inclusion of such tissue in the donor pool is important. More than half of the transplants in the country are endothelial kerato- plasties and while most are DSEK, DMEK is gaining popularity every year. "What we showed here is that there's a higher loss rate with tissue from donors with diabetes, but the surgeon was still able to prepare the tissue successfully in most cases (95%)," he said. When it came to insulin-depen- dent diabetic recipients, investiga- tors found increased difficulty for graft attachment. As such, Dr. Mari- anne Price recommended counseling patients about this ahead of time, noting that they were twice as likely to need subsequent air injection. She speculated that interface may be altered in patients with diabetes who are more severe and insulin dependent. In the clinic From a clinical perspective, Dr. Mari- anne Price is optimistic about DMEK cases with diabetic donor tissue. "The DMEK recipients can expect Research Foundation of Ameri- ca's database from March 2008 to December 2015. Dr. Marianne Price noted that documentation of donor diabetes status began in September 2011. When investigators analyzed the impact of diabetes on DMEK, the results were promising. "We did have more tissue loss in the donor preparation if the donor had diabetes," Dr. Marianne Price said. "However, the success rate was still high; we had a 99% success rate if the donor did not have diabetes and a 95% success rate if the donor did have diabetes." Francis Price, MD, president, Price Vision Group, Indianapolis, who also worked on the study, said he thinks because the tissue was all surgeon prepared, it might have made a difference. "Some eye banks have reported higher loss rates with tissue from donors with diabetes," he said. "As long as we were able to successfully prepare the tissue, we did not detect a difference in the air injection rate, in the graft survival through 4 years, or in endothelial cell loss," Dr. Marianne Price said. "However, it would be useful to study this further with more rigor- ous collection of information about How this can influence outcomes D iabetes can bring a whole new complexity to many ophthalmic conditions, but does it make a differ- ence in DMEK if you are dealing with a diabetic donor or recipient? In a study published in Cornea, 1 investigators considered the impact of diabetes on such transplants, according to Marianne Price, MD, executive director, Cor- nea Research Foundation of Ameri- ca, Indianapolis. "One in 10 U.S. adults has diabetes, and the Center for Disease Control and Prevention projects that the number of Americans with dia- betes is going to double or triple by the year 2050," Dr. Marianne Price said, adding that currently about 14% of transplant recipients and about 30% of donors have diabetes. Previous research has shown diabetes' effect on graft success. "About 15 years ago, we did a large study 2 of about 4,000 penetrating keratoplasty grafts, and when we separated out the different causes of transplant failures, one of the main causes was endothelial decompen- sation over time. When we sepa- rated that out from immunologic rejection, we found that recipient diabetes increased the risk of endo- thelial decompensation over time with penetrating keratoplasty," Dr. Marianne Price said. Concerns about diabetic grafts It was more recent findings that spurred this study. Dr. Marianne Price said eye banks have been reporting difficulty preparing tissue and an increased risk of tissue loss for DMEK if the donor had diabetes. This raised the question about the impact of a more traumatic or dif- ficult preparation on the long-term prospects of the graft. "In our study we looked at not only the degree of difficulty with the tissue preparation but also long-term graft survival," Dr. Marianne Price said. A consecutive case series includ- ed DMEK cases from the Cornea The truth about DMEK in diabetics The success rate for DMEK in cases involving diabetic donors was almost 95% and in cases without it was 99% in a recent study. Source: Mark Terry, MD Research highlight

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