Cornea perspective: Where we have come from and where we are headed
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Looking back 20 years, there have been tremendous changes in how corneal transplants are performed.
Looking forward 20 years, the need for corneal transplants may decrease greatly, and we may see tremendous changes in the diagnosis and treatment of corneal disease.
Twenty years ago in 2003, I did the first Descemet stripping endothelial keratoplasty surgery in the United States. Who could have predicted the tremendous changes endothelial keratoplasty would make in the treatment of corneal diseases such as Fuchs’ dystrophy, especially after corneal transplants had changed so little in the preceding decades?
Major improvements in anterior lamellar keratoplasty have also occurred over the last 20 years. Anwar developed the big bubble technique for deep anterior lamellar keratoplasty, resulting in visual outcomes comparable to penetrating keratoplasty. DALK also dramatically reduced the risk for immunologic rejection and endothelial cell loss relative to PK, producing a graft that was more likely to last someone’s lifetime. However, adoption in the U.S. has been slow, at least in part because of low reimbursement relative to the degree of difficulty. As intraoperative OCT is more widely adopted, it should become easier for surgeons to ensure they have a thin uniform DALK dissection bed whenever a big bubble is not feasible.
Corneal cross-linking was another amazing development in the last 20 years. We now have a treatment that can stop keratoconus progression and thereby prevent the need for a corneal transplant when caught soon enough. As of yet, we do not have enough early screening for keratoconus or public education to help stop this treatable disease. Cross-linking is also showing promise for shrinking corneal neovascularization and treating wound melting along suture tracks of PK or DALK, thereby improving the results of these surgeries.
So, what may the next 20 years hold for corneal treatments? Talks presented at the World Cornea Congress suggest a number of new contenders will be vying to become the dominant treatment for endothelial dysfunction and other corneal diseases.
Injecting cultured human corneal endothelial cells looks promising, and several variations are being evaluated in human clinical trials. Because none of these options are FDA approved yet, we do not know how the potential cost-benefit ratio will compare with endothelial keratoplasty. Could a currently little noticed treatment like an acrylic onlay placed on the back of the cornea become a viable treatment for endothelial dysfunction? Will a topical pharmaceutical or biological treatment be able to prevent or reverse progression of corneal endothelial dysfunction, or will gene therapy be able to cure Fuchs’ and other corneal dystrophies so grafts are not needed? All of these options are being investigated. There are a lot of “horses” in this race, and the starting gun just went off.
Moreover, alternative treatments to corneal transplants are more urgently needed in developing nations that do not have an adequate supply of human donor tissue, but will they be able to afford these potential new treatments?
Other developments may facilitate treating the most common corneal disease: infectious keratitis. We need better methods for rapid pathogen identification. At least one company is now selling in-office PCR supplies. While the jury is still out whether this particular product is robust enough to do away with culture plates and confocal microscopy for determining organisms in infectious keratitis, the writing is on the wall that this is the type of technology of the future. Someday, we will be able to identify the cause of infectious keratitis and determine the most effective treatment within minutes of seeing a patient, hopefully at a price point that most offices can afford.
I am encouraged the next 20 years will see as many, if not more, exciting improvements in cornea treatments than the last 20.
- For more information:
- Francis W. Price Jr., MD, of Price Vision Group in Indianapolis, can be reached at frankprice@pricevisiongroup.net.
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