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Home , Corneal transplantation

Vol. 5, No. 2 - August 2017

Welcome Improving Outcome in Corneal Specialist Dr. Justin Transplantation Roman! By Justin Roman, MD In 2004, Melles developed the Justin Roman, MD returns to the descemetorhexis to strip and remove Upstate joining Clemson after the 's Descemet membrane and completing a cornea fellowship under endothelium, the Descemet stripping the tutelage of Drs. Kerry Solomon and endothelial keratoplasty (DSEK). With Charlene Grice of Carolina Eyecare History of the invention of the microkeratome for Physicians in Charleston, SC. After Eduard Konrad Zirm performed the first automated preparation of donor cornea, becoming a Mechanical Engineer, Dr. successful full thickness penetrating the thickness of the donor tissue was Roman completed a Masters in keratoplasty in 1905, and in doing so, significantly decreased and it was Bioengineering at Clemson University, became the first person to perform a renamed Descemet stripping automated then decided to pursue a career in solid organ transplant. Ironically, the endothelial keratoplasty (DSAEK). medicine. He attended medical school indication was for bilateral alkali burns, DSAEK allowed to achieve at the University of New Mexico and one of the most challenging indications postoperative visual acuity results in the residency in at the in ophthalmology. 20/25-20/30 range. Eye banks began Medical University of South Carolina preparing this tissue around 2006, which (MUSC). He is American Board of Over the following century, keratoplasty resulted in quick spread of the Ophthalmology Certified and will offer techniques continued to evolve technique. our network of referring physicians his considerably. In 1914, to spare healthy expertise in cornea, external disease, tissue, Anton Elschnig performed the Soon thereafter, Melles described the advanced dry eye, cataract and first anterior lamellar keratoplasty. It Descemet membrane endothelial refractive . Specialized wasn’t until 1956 that Charles Tillet keratoplasty (DMEK) in 2006. DMEK procedures like corneal transplants, performed the first successful allows the surgeon to avoid implantation DMEK, DSEK, Lasik and cross-linking endothelial keratoplasty (EK). Tillet's of donor stroma. Pure descemet will also be his central focus. Dr. technique was successful, but was not membrane and endothelium could be Roman is now accepting referrals and pursued until the late 1990s when Gerrit transplanted in the exact anatomical sees patients in all of the Clemson Eye Melles developed the posterior lamellar location of the diseased tissue. locations: Anderson, Clemson, Easley keratoplasty (PLK). The posterior and Greenville. Justin Roman enjoys cornea was dissected out and replaced The reported number of corneal competitive marathon running (3x with donor posterior stroma and transplants performed in the United Boston Marathoner), and lives with his endothelium. In 1999, Mark Terry States was 48,792 in 2015. While full wife, Allison, a Greenville native, and simplified Melles' technique resulting in thickness transplants continue to their baby daughter, Riley. the deep lamellar endothelial decrease (19,160, -0.7%), the number keratoplasty (DLEK). However, both of of EK procedures increased (27,208, these techniques were not widely +4.8%). The growth in EK was due to adopted due to difficulty and limited increased DMEK procedures (4,694, postoperative visual acuity. +63.8%), whereas DSEK/DSAEK remains the predominant EK of choice (22,514, -2.5%).1

Clemson Eye News continued

Surgical options Surgical indications surgery, specific instructions include Once endothelial dysfunction results in Common indications for EK include lying flat for 24-48 hours in order for the decreased quality of vision from corneal Fuchs’ endothelial dystrophy, post- gas bubble to tamponade the transplant edema, decompensation or guttae- corneal edema, and stimulate proper union. On induced glare, there are three surgical posterior polymorphous membrane occasion, an additional air bubble may options to consider. While full thickness dystrophy, congenital hereditary be placed at the slit lamp in the days transplants were the norm in the past, it endothelial dystrophy, iridocorneal following the surgery in order to extend is becoming less common, and most endothelial (ICE) syndrome and failed this support. In most cases, patients surgeons are turning to lamellar endothelial keratoplasty. can expect to see significant techniques such as improvements in vision within a few DSAEK or DMEK. 2 weeks of surgery. Due to its technical 6 month BSCVA: DSAEK vs. DMEK ease, DSAEK 100% 94% Here at Clemson Eye, we pride remains the 85% ourselves in ensuring that our patients predominant surgical 80% 67% are getting the most up to date preference. treatments that they deserve. Our 60% However, while 46% DSAEK purpose is to offer the best opportunity DMEK is a more 40% 31% DMEK for a great visual outcome, and in the challenging surgery, process, improving their overall quality 20% 13% there are many of life. DMEK now offers us that advantages that 0% opportunity. must be considered. > 20/40 > 20/25 > 20/20 1. Association of America. 2015 Eye Banking Statistical Report. 2016 Advantages of DMEK 2. Hamzaoglu EC, Straiko MD, Mayko ZM, et al. The First Compared to DSAEK, DMEK allows While DMEK has the above-mentioned 100 of Standardized Descemet Stripping Automated Endothelial Keratoplasty versus Standardized Descemet even faster visual recovery and better advantages, DSAEK continues to play Membrane Endothelial Keratoplasty. Ophthalmology. postoperative visual acuity results an important role. In particular for more 2015;122:2193-2199. 3. Guerra FP, Anshu A, Price MO, Price FW. Endothelial 2 (Figure 1) . In 2011, Price et al complex and challenging cases such as keratoplasty: fellow eyes comparison of Descemet performed DMEK in one eye and prior glaucoma filtering surgery, stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty. Cornea. DSAEK in the fellow eye. presence of an anterior chamber IOL, 2011;30(12):1382-6. large defects and stromal scarring. 4. Anshu A, Price MO, Price FW, Jr. Risk of corneal significantly reduced with Descemet's 85% of patients perceived membrane endothelial keratoplasty. Ophthalmology. better visual quality in the Although the number of full thickness 2012;119(3):536-40. 5. Price MO, Price FW Jr, Kruse FE, Bachmann BO, DMEK eye and had objectively transplants continues to decline, Tourta T. Randomized comparison of topical prednisolone superior visual acuity3. indications remain and include prior acetate 1% versus fluorometholone 0.1% in the first year after descemet membrane endothelial keratoplasty. failed corneal transplants, dense corneal Cornea. 2014 Sep;33(9):880-6. Elimination of the stroma-to-stroma scars and select , to name a -host interface appears to play a few. significant role. As well as decreased surgical incision size from 5mm in Surgery DSAEK to 2.5mm in DMEK. Also, Patients have surgery on an outpatient rejection rates are around 1% in DMEK basis and go home within several hours. compared to 9% in DSAEK4. At one The actual surgery takes between 30 month post-op, in order to decrease the and 60 minutes, and is usually done risk of glaucoma, it is typically safe to under local anesthetic and IV sedation. switch higher potency steroids to FML or Not infrequently, cataract surgery is Lotemax without increasing the risk of performed simultaneously with either rejection5. Nonetheless, it is important to DSAEK or DMEK, which has the note that there is a surgical learning advantage of a single trip to the curve which has been a barrier to operating room and more pronounced widespread application. improvements in visual acuity. After Please be reminded that our current Lasik offer is $1,200 off!