Cornea Society News

WIN 2014

Cornea Society International Organization Advancing the treatment of corneal disease

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C orneal transplantation has a long and evolved history, with many facets of change and great future possibilities, Edward J. Holland, MD, Cincinnati, said. Dr. Holland delivered the Castroviejo Lecture at the "Advances in Keratoplasty: Where we are in 2013" symposium at the American Academy of Ophthalmology annual meeting. The evolution of corneal transplan- tation began with an unsuccessful first attempt in 1838, followed by the discussion of the lamellar keratoplasty approach to corneal disease starting in the late 1800s. The first successful penetrating keratoplasty (PK) using human tissue was performed in 1906, Dr. Holland said. "Finally, Ramon Castroviejo, of which this medal and lecture is named after, became the preeminent figure in the modern era of corneal transplanta- tion," Dr. Holland said. "He was very innovative with his surgical techniques … he was a high volume surgeon and made great contributions to our field." PK remained the dominant procedure for decades. "I think back to all the American Academy of Ophthalmology meetings that I went to for years, and we talked about one procedure really—it was just PK," Dr. Holland said. "And I think we all, as surgeons, got very comfortable with that." Reasons existed for PK's contin- ued dominance—one was excellent outcomes, which Dr. Holland said was actually not the case. "We all, I think, fooled ourselves in saying we had great outcomes because we were defining outcomes as graft clar- ity. We weren't talking about quality of vision," Dr. Holland explained. However, when compared to out- comes of other subspecialties, such as refractive or cataract surgery, corneal results were not as good, he said. These cases had high astigmatism, with many large studies of PK finding that the average astigmatism was more than 4 D. "We didn't even try to measure irregular astigmatism," he said. "It was off the charts." There were others issues, including significant intraoperative complica- tions. Dr. Holland said that while many surgeons thought they were doing a good job in the field, "in retrospect, we really weren't." The last decade has seen a rapidly altering corneal surgery paradigm. There was a need for more anatomic targeted procedures, and those proce- dures sought to avoid the removal of healthy corneal tissue. Endothelial ker- atoplasty—DSEK or DMEK—was created to treat endothelial disease, while deep anterior lamellar keratoplasty (DALK) was developed to target stromal disease. In more challenging cases, an ocular surface transplant procedure was useful in those instances when PK was not effective. "It's been a pretty rapid change in our approach to patients with endothelial disease," Dr. Holland said. The statistical report from the Eye Bank Association of America, which tracks corneal transplants in the U.S., found that last year, endothelial kerato- plasty for the first time "became the most common corneal transplant pro- cedure, overtaking PK, and this is going to continue to rise," according to Dr. Holland. "Endothelial keratoplasty has been one of the most significant advances in corneal surgery," he said. "It's now the leading indication for keratoplasty, with about 40 to 50% of the patients that we operate on." Gerrit Melles, MD, Rotterdam, the Netherlands, had the "breakthrough" paper in Cornea in 2004 that first described DSEK, and that research had a major impact in the field that reverberates today, Dr. Holland said. "[DSEK] became the procedure that corneal surgeons across the world embraced and really changed the way we manage our patients with endothe- lial disease," Dr. Holland said. The procedure is still undergoing evolution, with new insertion devices, thin DSEK techniques, and the transi- tion underway to DMEK. The future looks bright, he said. Possibilities include culture endothelial cells and a biosynthetic cornea. "Where are we going with corneal transplantation? We've had quite a bit of change in the last decade and some exciting things going on. I think we're moving to the cellular level," Dr. Holland said. CN Keratoplasty evolution has long and storied history Edward J. Holland, MD, the 2013 Castroviejo awardee, gives a talk on the history of keratoplasty at the Society-sponsored symposium during the American Academy of Ophthalmology meeting in New Orleans. News A C o r n e a S o c i e t y p u b l i c a t i o n W i n t e r 2 0 1 4 V o l 1 0 , N o . 1

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