EDITORIAL URRENT C OPINION

Evolution of a revolution in keratoplasty Shahzad I. Mian

Surgical treatment of endothelial disorders has rapidly evolved over the last decade with endothelial keratoplasty replacing penetrating keratoplasty (PKP) as the procedure of choice. After 100 years of steady but slow improvements, these recent advances in corneal transplantation have evolved from a need to improve clinical outcomes, advances in microsurgical technology and instrumentation, with a focus on techniques that can be replicated by all surgeons in the field to benefit patients everywhere. Endothelial keratoplasty now accounts for over 50% of corneal transplants performed in the USA with nearly 25 000 surgeries performed in 2013, a 27% increase over the last 5 years [1]. This does include a 103% increase in Descemet membrane endothelial keratoplasty (DMEK) cases from 750 to over 1500 in 2013. This revolutionary evolution in management of corneal disease is helping set a new benchmark for outcomes of ocular surgery. This issue reviews the current state of endothelial keratoplasty with tips for improving outcomes and discusses the future directions in the field. In the USA, endothelial disorders remain the primary indication for corneal transplantation with Fuchs corneal dystrophy remaining the leading cause followed by postcataract surgery corneal edema, which has been gradually declining [1]. Ple-Plakon et al. (300–305) indicate that endothelial keratoplasty will remain the procedure of choice for the majority of patients needing corneal transplantation with evolving indications and techniques. In this issue, Veldman et al. (306–311) discuss the evolving indications for Descemet stripping automated endothelial keratoplasty (DSAEK) suggesting that although DMEK is being performed more commonly and may replace DSAEK as the primary endothelial keratoplasty procedure, DSAEK will continue to play an essential role in complex indications, including post keratoplasty and glaucoma surgery, aniridia, aphakia, and in the setting of anterior chamber intraocular lenses. Busin and Albe´ (312– 318) indicate that Ultra-Thin DSAEK may provide the best compromise by providing improved visual outcomes and reduced risk of immunologic rejection without limiting indications or increasing risk of complications. www.co-ophthalmology.com

Long-term success of DMEK will require further standardization of the surgical technique. Boynton and Woodward (319–324) help summarize how the role of eye bank preparation of donor tissue has been instrumental in the success of DSAEK and now in the availability of precut tissue for DMEK. Kruse et al. (325–334) provide pearls for each step of the DMEK procedure for successful implementation even for novice endothelial keratoplasty surgeons. In addition, Chang et al. (335–339) review current methods to improve outcomes when combining cataract surgery with endothelial keratoplasty, and Anwar and Danasoury (340–346) suggest that endothelial keratoplasty is a suitable alternative to PKP even in children. Finally, alternatives to keratoplasty must be considered in managing patients with endothelial disorders because some patients may not be good candidates for keratoplasty. Ji-Yee Siu et al. (347–352) review other medical and surgical options such as conjunctival flaps, anterior stromal puncture, amniotic membrane transplantation, phototherapeutic keratectomy, bandage contact lenses, and hypertonic saline eye drop. Newer interventions include use of collagen crosslinking to treat symptomatic bullous keratopathy. The future of endothelial keratoplasty will focus on enhancing the number and functionality of endothelial cells either with surgical techniques such as Descemet membrane endothelial transfer as proposed by Lam et al. (353–357), gene therapy, or Rho-associated kinase inhibitors. Future progress needs to set a high bar to continue to focus on defined outcome measures including long-term graft failure at >5 years, endothelial cell counts, rate of rejection, visual acuity, induced refractive error, and quality of vision measures including higher order aberrations and contrast sensitivity, appropriate utilization of tissue, and distribution of corneal tissue. In addition,

W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA Correspondence to Shahzad I. Mian, MD, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, Michigan 48105, USA. E-mail: [email protected] Curr Opin Ophthalmol 2014, 25:298–299 DOI:10.1097/ICU.0000000000000076 Volume 25  Number 4  July 2014

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Evolution of a revolution in keratoplasty Mian

long-term success will require creating innovative platforms, such as in-person and online courses, for training physicians to efficiently embrace and promote this revolutionary evolution. Acknowledgements None.

Conflicts of interest There are no conflicts of interest.

REFERENCE 1.

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Eye Bank Association of America. 2013 Eye Banking Statistical Report. Washington, DC: Eye Bank Association of America; 2014.

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Evolution of a revolution in keratoplasty.

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