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ESCRS/EuCornea symposium highlights advances in modern corneal transplantation

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Posted: Tuesday, September 13, 2016

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Francois Malecaze, who chaired the joint ESCRS/EuCornea symposium

With the advent of ever-improving technology, eye banking and laser applications, modern corneal transplant surgery offers reliable safety and impressive visual rehabilitation for a wide variety of corneal conditions, delegates attending yesterday’s joint ESCRS/EuCornea Symposium on modern corneal transplantation were told.

Chaired by François Malecaze MD, PhD and Rudy Nuijts MD, PhD, the session drew a huge crowd eager to hear about the latest developments and advances in the field of corneal transplantation.

Dr Pierre Fournié, from France, opened the session with a presentation on the continuing relevance of penetrating keratoplasty (PK) in an era when more and more surgeons are moving over to lamellar surgery.
“The advantages of PK include the fact that it is an established standardised technique, with a short operation time and long-term follow-up data is available,” he said.

Despite the fact that the worldwide trend is inevitably moving towards lamellar surgery, PK is still a viable option in selected cases such as full-thickness corneal scars and paediatric keratoplasty, he said.
“PK is limited to use in diseases where the benefit of replacing all the disease tissue will provide the best optical or therapeutic results compared with lamellar keratoplasty,” he said.

Dr Fournié’s talk was followed by a presentation by Dr Vincent Borderie on deep anterior lamellar keratoplasty (DALK).

In a wide-ranging look at the indications and advantages of DALK, Dr Borderie discussed its utility in cases such as keratoconus, infectious keratitis, stromal dystrophies, after corneal trauma and in eyes with failed graft after previous penetrating keratoplasty.

Overall, the technique offers a lot of advantages to modern transplant surgeons, he said. “DALK is associated with higher endothelial cell survival, lower rejection rate, lower glaucoma incidence and higher predicted long-term graft survival. The gold standard is a recipient bend made of Dua’s layer, Descemet’s membrane and endothelium. Air injection and intraoperative optical coherence tomography are useful to reach this goal,” he said.
Next up, Dr Sadeer B Hannush from the USA outlined the reasons why he prefers Descemet’s stripping automated endothelial keratoplasty (DSAEK) in certain surgical situations.

“Despite the emergence of Descemet’s membrane endothelial keratoplasty (DMEK) or pre-Descemet’s endothelial keratoplasty (PDEK) as some surgeons’ procedure of choice for endothelial dysfunction, these procedures may not be ideal in the setting of certain comorbidities,” he said.
He noted, for instance, that some comorbidities may share conditions that make successful completion of DMEK more challenging, including hypotony, inadequate tamponade, and difficulty unscrolling the DMEK lenticule.

Dr Friedrich Kruse then outlined why he prefers DMEK surgery, saying that it outperformed DSAEK on a broad range of important criteria including safety, vision, optical properties, anatomical reconstruction and surgical simplicity.
“We now have studies that clearly show that the risk of corneal transplantation rejection is significantly reduced with DMEK,” he said.
Despite some technical difficulties with its use, DMEK also delivers better visual acuity outcomes than DSEK, he added. He noted that DMEK is the only technique that leads to complete anatomical reconstruction, relying on small incision surgery.

The importance of early recognition and intervention in tackling complications of corneal transplantation were comprehensively discussed by Dr Frank Larkin, who focused on early complications within one month of transplant. While the complications associated with PK usually occur much later, the surgical technical complications for DALK, DSEK and DMEK have a comparatively major impact, he said.

Jose L Guell MD brought the symposium to a close with a look at the indications for which surgeons may consider re-grafting a failed transplant.