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DMEK and ALK at forefront of corneal transplantation

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WAILEA, Hawaii — A presenter here discussed several approaches to corneal transplantation, including Descemet's membrane endothelial keratoplasty and anterior lamellar keratoplasty.

"Instead of transplanting the full-thickness cornea, we are just removing selective parts of the corneal tissue that is diseased and replacing it with healthy tissue," Thomas John, MD, said at Hawaiian Eye 2012.

Selective corneal transplantation, known as lamellar keratoplasty, includes a posterior approach that incorporates Descemet's membrane endothelial keratoplasty (DMEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK), as well as an anterior approach called anterior lamellar keratoplasty (ALK).

In DMEK, surgeons transfer only Descemet's membrane and healthy endothelium to the cornea. Dr. John advised staining Descemet's membrane beforehand and using a larger air bubble to keep it in place. In an analysis of 72 eyes followed for an average of 9.3 months, corneal thickness returned to close to normal, and 75% of patients attained 20/40 to 20/15 vision. By contrast, in DSAEK, added tissue makes the cornea thicker.

For ALK, Dr. John again recommended staining donor tissue or stroma for dissection. During difficult cases, combination techniques are useful, and irrigating the interface before returning the cornea to its rightful place may be beneficial, he said.

ALK also allows for a retained endothelium, making the surgery valuable for younger patients, because they will not experience endothelial graft rejection.

"DMEK and ALK procedures really have brought corneal transplantation procedures to the center stage," Dr. John said.

• Disclosure: Dr. John receives royalties from Jaypee Medical Publishers and ASICO. He is a consultant for Bausch + Lomb and iScience, and he is on the speakers bureau for Alcon, Allergan, Bausch + Lomb and Ista.

Hawaiian Eye and Retina 2013 will be held January 20-25, 2013, at the Hilton Waikoloa Village on Hawaii's Big Island. Learn more at OSNHawaiianEye.com or RetinaMeeting.com.