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Descemet’s membrane stripping may repopulate central corneal endothelium in Fuchs’ patients
The application of a ROCK inhibitor may also facilitate the proliferation and migration of the endothelial cells after Descemet's stripping.
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Patients with Fuchs’ endothelial dystrophy who underwent phacoemulsification experienced repopulation of the central corneal endothelium with corneal deturgescence when 4 mm of their central Descemet’s membrane was stripped and removed after IOL insertion.
The application of a topical Rho kinase (ROCK) inhibitor also shows great promise in facilitating the proliferation and migration of the endothelial cells, Kathryn A. Colby, MD, PhD, told Ocular Surgery News.
“The procedure causes us to rethink our understanding of Fuchs’ dystrophy and our approach to treatment. Future applications of the ROCK inhibitor and determining which patients are best for this technique is likely to change the way we manage Fuchs’ dystrophy on a significant scale,” Colby said.
Methods
Thirteen eyes of 11 patients with Fuchs’ endothelial dystrophy and cataract were included in the retrospective series. Each patient underwent stripping of 4 mm of the central Descemet’s membrane after phacoemulsification and IOL insertion. Patients’ preoperative visual acuity ranged from 20/25 to 20/400, according to Colby.
By 1 month postop, Colby and colleagues found four eyes in the cohort demonstrated resolution of the corneal edema with visible central endothelial cell mosaic with a range of 410 cells/mm2 to 864 cells/mm2. Visual acuity ranged between 20/25 and 20/40. Four additional eyes demonstrated similar visual acuity and resolution of the corneal edema with visible central endothelial cell mosaic by 3 months. Additionally, at 6 months, two eyes experienced resolution of corneal edema with an intact central endothelial mosaic, she said.
Results
Cell counts were maintained in the 10 successful patients at final follow-up, and visual acuity ranged from 20/15 to 20/20, except in two eyes with retinal pathology. In total, 75% of the eyes that underwent deliberate Descemet’s stripping with cataract removal and IOL placement showed corneal clearance and repopulation of the central endothelial mosaic, the researchers wrote in the study.
“Some of them would clear by the time they came in at the 1-month visit, but the majority were clear by 3 months. A few patients took a little longer for the cornea to clear, but they eventually cleared from anywhere from 4 to 7 months. There are a few theories about what might influence whether patients succeed with this technique. One is a purely physical technique — perhaps the size of the descemetorhexis needs to be optimized for each patient,” Colby said.
Additionally, severity may also influence the success of the procedure, Colby said.
Five patients in the cohort had a preoperative pachymetry greater than 625 µm, which may be associated with a reduced response rate, Colby said.
“Two of them succeeded, but the three that failed were in that group where the preoperative pachymetry was 625 µm or greater. It may be that if you wait to the point where the cornea was swollen, this has less of a chance of having a positive effect,” she said.
A previously published case report from Shigeru Kinoshita and colleagues, Colby noted, showed corneal clarity restoration after destruction of the central corneal endothelium by transcorneal freezing with the addition of a topical ROCK inhibitor. However, the authors could not conclude whether the ROCK inhibitor, the endothelial destruction by cryotherapy or the combination of the two interventions was responsible for the corneal clearance.
“There is some lab evidence and evidence in patients from my colleague Greg Moloney that a topical ROCK inhibitor can actually facilitate the process and turn some of the patients who were failures into successes,” Colby said.
Colby stressed the procedure is effective only for patients with Fuchs’ endothelial dystrophy and will not work for patients with pseudophakic bullous keratopathy. The procedure will be successful in those who have a confluent central guttae in the center of the cornea with a maintained peripheral endothelium. – by Robert Linnehan
- References:
- Borkar DS, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000915.
- Koizumi N, et al. Cornea. 2013;doi:10.1097/ICO.0b013e318285475d.
- For more information:
- Kathryn A. Colby, MD, PhD, can be reached at Department of Ophthalmology and Visual Science, The University of Chicago Medicine & Biological Sciences, 5841 S. Maryland Ave., Chicago, IL; email: kcolby@bsd.uchicago.edu.
Disclosure: Colby reports no relevant financial disclosures.