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16 EW SHOW DAILY Monday, April 22, 2013 ASCRS Symposia Examining corneal transplant rejection by Vanessa Caceres EyeWorld Contributing Writer C orneal surgeons discussed how to prevent and manage corneal transplant failure at the Sunday afternoon symposium "Objection to Rejection: Prevention and Management of Corneal Transplant Failure," sponsored by the Cornea Society. W. Barry Lee, MD, Atlanta, and Christopher Rapuano, MD, Philadelphia, moderated the symposium. Dr. Lee discussed what studies have reported regarding the incidence of corneal transplant rejections. He said that 25% of all penetrating keratoplasties (PKs) are thought to undergo endothelial rejection. The incidence of endothelial rejection after Descemet's membrane endothelial keratoplasty (DSEK) appears lower, with only a 0% to 2% Is Your Administrator Certified? +ORTQXGRTQƂVCDKNKV[CPFUVCHH GHƂEKGPE[YKVJC%GTVKƂGF 1RJVJCNOKE'ZGEWVKXG %1' Leaders in Managing the Business of Ophthalmology r%1'KUVJGPCVKQPCN UVCPFCTFHQTQRJVJCNOKE RTCEVKEGOCPCIGOGPV r%1'TGEQIPK\GU KPFKXKFWCNUYJQCEJKGXG VJG0$%1'GNKIKDKNKV[ TGSWKTGOGPVUHQT QRJVJCNOKEMPQYNGFIG CPFUMKNNU r%1'RTQOQVGU GZEGNNGPEGCPF RTQHGUUKQPCNKUO Get Certified. YYYCUQCQTIEQG 6JG%1' JCPFDQQMUCORNG GZCOCPFUVWF[ TGUQWTEGUCTG CXCKNCDNGQPNKPG %GTVKƂGF1RJVJCNOKE 'ZGEWVKXG Questions: EQG"CUQCQTI or 703-788-5778 YYYCUQCQTIEQG W. Barry Lee, MD, moderates the "Objection to Rejection: Prevention and Management of Corneal Transplant Failure" symposium. rejection rate, although there is not much long-term data available yet from this type of surgery, Dr. Lee explained. Endothelial rejection does not occur with Descemet's automated lamellar keratoplasty (DALK), although epithelial and subepithelial and stromal rejection may occur with this procedure. Rejection after DALK is more often reversed than after PK, Dr. Lee said. Examining another aspect of how to manage corneal transplant rejection, Stephen C. Kaufman, MD, Minneapolis, focused on the use of calcineurin inhibitors to prevent rejection. He explained that cyclosporine ophthalmic emulsion 0.05%—otherwise known as Restasis (Allergan, Irvine, Calif.)—is a calcineurin inhibitor. However, corneal transplants do not typically use Restasis after corneal transplantation. Some transplant physicians will use more potent systemic forms of calcineurin inhibitors, more frequently for transplants in other parts of the body. Dr. Kaufman commonly uses the calcineurin inhibitor tacrolimus (Protopic, Astellas, Northbrook, Ill.) 0.03%, noting that a 0.1% formulation is also available. Tacrolimus is a thick topical ointment that is hard to get into the eye; in fact, dermatologists have more experience than ophthalmologists do with this medication as they use it to treat eczema. Some patients have trouble tolerating tacrolimus because they experience discomfort. The medication also has a black box warning from the U.S. Food and Drug Administration as a few patients developed lymphomas after using the drug. Still, Dr. Kaufman believes that tacrolimus can be useful for the treatment of high-risk PKs and that there is more potential for the use of the medication in ophthalmology. With an eye on preventing corneal neovascularization, Natalie Afshari, MD, San Diego, noted that the modulation of angiogenesis within the body could have a major impact on 21st-century ophthalmic medicine. Research into angiogenesis assists with the treatment of corneal neovascularization, helping to prevent further growth, she explained. Graft failure in patients who have glaucoma drainage devices occurs in anywhere from 9% to 30% of cases, said Richard Davidson, MD, Denver. "Glaucoma drainage devices are good at controlling IOP but graft clarity is often compromised," he said. Some pearls to help avoid graft failure in patients with glaucoma drainage devices is to consider temporary tube obstruction, inject with a 30-gauge needle rather than a cannula, and leave 100% air filter inside the eyes, he said. Donald T.H. Tan, FRCS, Singapore, reported on the increasing prevalence of cytomegalovirus (CMV) keratitis, which often masquerades for Descemet's stripping endothelial keratoplasty rejection. He noted that this problem is currently more common in Asia, although there are some cases reported in the United States. "We misdiagnose, and sometimes the clinical picture may mimic other conditions," he said. One condition that it mimics is corneal decompensation following cataract and glaucoma surgery. Common signs of CMV keratitis include mile iritis, stromal and epithelial edema, keratic precipitates, mild anterior chamber activity, and nodular endothelial lesions. EW Editors' note: Dr. Afshari has financial interests with Jobson Publishing (New York). Dr. Kaufman has financial interests with IOP (Costa Mesa, Calif.). Dr. Lee has financial interests with Allergan, Bausch + Lomb (Rochester, N.Y.), and Merck (Whitehouse Station, N.J.). Drs. Rapuano and Tan have financial interests with Alcon (Fort Worth, Texas), Allergan, Bausch + Lomb, and other ophthalmic companies.