Surgeon prefers DMEK for corneal transplants
ATLANTA – When referring patients for selective corneal transplantation, “It’s important for you to think about enabling your patients to see someone who offers a range of options and is able to tailor the procedure to the disease at hand,” Peter Veldman, MD, told attendees at a special session here at SECO.
“We should be restoring the best potential vision, and that is possible with DMEK [Descemet’s membrane endothelial keratoplasty] and DSAEK [Descemet’s stripping automated endothelial keratoplasty],” he said.
While a proponent of both procedures, Veldman said he prefers DMEK in the majority of cases.
A study by Afshari showed one to 2 lines of better vision with DMEK, he said.
In addition, patients will experience a faster recovery with this procedure.
“DMEK has great vision at 2 weeks,” Veldman said. “I give pretty permanent glasses at 6 weeks. DSAEK can have appreciable changes up to a year.”
He said that patients experience rejection less frequently with DMEK – less than 1%.
Less steroid is required with DMEK, Veldman said.
“I’m transitioning people to fluorometholone at 6 months,” he said. “Even off steroids, the rejection rate is slightly less or equivalent to the on-steroid rate.”
Patients experience less trauma due to the 3-mm incision with DMEK, Veldman continued.
“Endothelial attrition and survival in DMEK appears to be profoundly better than penetrating keratoplasty,” he said. “At 6 or 7 years, the DMEK survival rate is 95%. These grafts last a long time.”
He said only 17% of penetrating keratoplasty cases are surviving 15 to 20 years.
“The improved longevity will absolutely play out for DMEK,” he added.
“There are times when I do prefer DSAEK,” Veldman said: When patients have a history of vitrectomy, an anterior chamber intraocular lens, a large iridectomy or a glaucoma drainage device.
DMEK requires longer positioning, so if the patient cannot hold position, DSAEK is better, he said.
“I have a number of patients with macular disease that are fabulously happy with DMEK,” he said. “I offer it in cases of macular degeneration and retinal conditions.”
Veldman speculated on the future of corneal transplantation.
“We will have better physical control of DMEK, expanded indications, increased understanding of the genetics of Fuch’s dystrophy (Is it really just a catch-all of a bunch of different mutations?)” he said. “Then we’ll better understand what patients we can treat with Descemet stripping without endothelial keratoplasty as opposed to a transplant.
“As we identify these conditions, we’ll identify people and ways to intervene earlier,” he continued.
The children of patients with advanced Fuch’s dystrophy have a 50% chance of developing the condition, Veldman said.
“Maybe we can put them on drops in their 30s or 40s and they’ll never advance,” he said.
Non-tissue/transplant options, adjuvant therapies and cellular injection are all big topics, he said. – by Nancy Hemphill, ELS, FAAO
Veldman P. Skinning cats: Corneal transplantation from front to back. Presented at: SECO; March 1-5, 2017; Atlanta.
Disclosure: Veldman reported no relevant financial disclosures.