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BLOG: Every patient with endothelial failure deserves modern cell replacement surgery
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As Thomas John, one of my heroes in the world of corneal surgery, has suggested in the cover story of this issue of OSN, modern endothelial keratoplasty has arrived and is becoming more achievable by corneal surgeons across the U.S. Nonetheless, some corneal specialists across the country still perform penetrating keratoplasties for endothelial replacement.
When Gerrit Melles first devised deep lamellar endothelial keratoplasty and this procedure was popularized in the U.S. by Mark Terry and Frank Price (two more of my heroes), it was a very difficult procedure to perform technically. With DLEK, we had to create a lamellar pocket at about 70% depth across the entire cornea. We then cut free a central circle of the posterior cornea, and into the pocket was introduced a disc of donor endothelium and stroma. As one of the early adopters of this procedure, back when it required an IRB’s approval, I experienced both the excitement and the challenges of a procedure that hadn’t been fully worked out. Donor dissections were performed by hand on an artificial anterior chamber, trying to get the donor thickness just right (which we sometimes did). The procedure was fraught with complications and challenges, and visual results were scarcely better than penetrating keratoplasty.
Nowadays, precut corneal tissue for Descemet’s stripping automated endothelial keratoplasty is available from every eye bank, and the corneas we transplant have a device-like consistency.
The same is becoming true of Descemet’s membrane endothelial keratoplasty grafts. Several eye banks can provide pre-stripped tissue ready for implantation. To be sure, there is an element of surgical skill to be learned for implanting, unfurling and securing these grafts in the proper location and orientation. Fortunately, a few pioneers like Thomas John have paved the way for the rest of us, who are not so eager to be early adopters this time.
I, for one, am excited about the next level of visual recovery we can achieve with endothelial replacement with DMEK as compared with DSAEK, and I applaud those pioneers who have toiled to make these procedures easier for us.