Eyeworld Daily News

EW SHOW DAILY 6 Sunday, April 19, 2015 by Ellen Stodola EyeWorld Staff Writer overall, Dr. Tan said that in the first year, results for penetrating kerato- plasty (PK), deep anterior lamellar keratoplasty (DALK), and Descemet's stripping endothelial keratoplasty (DSEK) were all pretty good. But by year 3 and then year 5, there is a profound change in graft survival. Dr. Tan said that the adoption of innovations in medicine depend on a number of factors, which include the confidence in the procedure's superiority, the ease of adoption, a short learning curve, access to new technology, and the economics. "It needs to make sense financially," he said. T his year's Binkhorst Lecture was delivered by Donald Tan, MD, Singapore, on the topic of "Lamellar Surgery in Corneal Transplanta- tion: Revolution and Evolution." He dedicated his talk "to the giants and champions who are changing the field and the paradigm in how we do corneal transplantation." It's not difficult to imagine that just a few years ago we were reviewing the paradigm shift in the corneal trans- plant procedure, he said. The Singa- pore Corneal Transplant Study has tracked procedures over the last 12 years. Looking at 2,300 transplants ASCRS News Today Binkhorst Lecture highlights corneal transplantation Dr. Tan delivers the Binkhorst Lecture. DMEK surgery is anatomically the most perfect endothelial ker- atoplasty (EK) procedure, Dr. Tan said, however, it remains the most challenging surgically. It's a rela- tively low-tech procedure, and he cited 3 "master gurus" of DMEK, Gerrit Melles, MD, PhD, Francis Price, MD, and Friedrich Kruse, MD. However, only 6% of the grafts performed in the U.S. in 2014 were DMEK, and there is more donor tissue wastage, more endothelial cell loss, and a higher rebubbling rate than with DSAEK. "We are still at the evolutionary stage of DMEK," Dr. Tan said, questioning if it will ever become mainstream. "We need to try to make it easier," he said. In DMEK, there are a number of challenges in handling the Descemet's membrane. Touching it damages the endothelium, and trying to unscroll in the anterior chamber is also a challenge. One possible solution for this, Dr. Tan said, is to minimize the handling of the Descemet's membrane by using a "stromal mat." This could stop the Descemet's membrane from scroll- ing and could convert a difficult DMEK into a DSAEK procedure that surgeons are more accustomed to. Dr. Tan also highlighted DALK, Mohammed Anwar, FRCS, and the importance of his "big bubble" technique. Although there may be confidence in its superiority, DALK lacks a short learning curve and access to new technology for ease in adoption. "The economics don't make sense," he said. However, Dr. Tan believes that DALK is better especially with data comparing it to PK in the Singapore Corneal Transplant Study. We want and need an alterna- tive technology for lamellar dis- section, he said, because lamellar dissection of the deeper corneal stromal layers remain a challenge. Dr. Tan offered the option of the piezoelectric cornea knife. This type of technology is already used in cataract surgery and in other ophthalmic knives. This technology would be harnessing the vibratory movements to separate deep corneal lamellae. "The field of corneal trans- plantation is rapidly evolving with the revolution of selective lamellar keratoplasty," Dr. Tan said. EK is the gold standard for endothelial dysfunction, but surgical techniques and results continue to improve. The evolution of EK procedures will hopefully ensure better survival of corneal endothelial cells and better long-term graft outcomes, he said. Although DALK has been shown to be superior to PK, there are still a number of surgical challenges. "Technological advances are needed and will hopefully come soon," he said. EW AcuFocus session highlights approval of KAMRA inlay by Ellen Stodola EyeWorld Staff Writer D uring the AcuFocus (Irvine, Calif.) EyeWorld Corporate Morning session, the major excitement was focused on the Food and Drug Administration approval of the KAMRA inlay, which just came on Friday afternoon. George Waring, IV, MD, Charleston, S.C., Jay Pepose, MD, PhD, Chesterfield, Mo., Roger Zaldivar, MD, Mendoza, Argentina, Daniel Durrie, MD, Overland Park, Kan., and Jeffery Machat, MD, Toronto, served as speakers in the session. Dr. Durrie kicked off the session. Anytime we have an FDA approval, especially in a timely fashion, it's exciting, he said. Dr. Durrie said he has an interesting history with the company, beginning some 13 years ago when he first got involved in the development of this technology, and he remained involved throughout the cycle of early development all the way through approval. The KAMRA inlay improves near vision by extending depth of focus, he said. The central aperture is a hole in the inlay and has no power, and the inlay provides an unobstructed pathway for focused light to reach the retina. So where does it fit in the practice? This technology is for those patients who have a dysfunctional lens but it's still clear enough that they don't need a replacement, he said. It's for those between the ages of 45 and 60 who are too old for LASIK but too young for IOLs. The specific indications for the KAMRA inlay are for patients who are 45 to 60 years old, have cycloplegic refraction between +0.5 and –0.75 D, have less than or equal to 0.75 D of refractive cylinder, who do not need glasses or contact lenses for distance, and who require near correction of +1.0 D to 2.5 D of reading add. "This is all going to be up to the surgeons to just do it right," Dr. Durrie said. They will need to pick the right patients, use the right equipment, pick the right surgery, and follow up accurately. EW Editors' note: This event was sponsored by AcuFocus.

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