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Ben Moussa O, Parveau L, Aouimeur I, Egaud G, Maurin C, Fraine S, Urbaniak S, Perrache C, He Z, Xxx S, Dorado Cortez O, Poinard S, Mauclair C, Gain P, Thuret G. Femtosecond Laser Cutting of Human Crystalline Lens Capsule and Decellularization for Corneal Endothelial Bioengineering. Bioengineering (Basel) 2024; 11:255. [PMID: 38534529 DOI: 10.3390/bioengineering11030255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/28/2024] Open
Abstract
The bioengineering of corneal endothelial grafts consists of seeding in vitro cultured corneal endothelial cells onto a thin, transparent, biocompatible, and sufficiently robust carrier which can withstand surgical manipulations. This is one of the most realistic alternatives to donor corneas, which are in chronic global shortage. The anterior capsule of the crystalline lens has already been identified as one of the best possible carriers, but its challenging manual preparation has limited its use. In this study, we describe a femtosecond laser cutting process of the anterior capsule of whole lenses in order to obtain capsule discs of 8 mm diameter, similar to conventional endothelial grafts. Circular marks made on the periphery of the disc indicate its orientation. Immersion in water for 3 days is sufficient to completely remove the lens epithelial cells and to enable the seeding of corneal endothelial cells, which remain viable after 27 days of culture. Therefore, this method provides a transparent, decellularized disc ready to form viable tissue engineered endothelial grafts.
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Affiliation(s)
- Olfa Ben Moussa
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Louise Parveau
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Inès Aouimeur
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Grégory Egaud
- GIE Manutech-USD, 18 Rue Professeur Benoît Lauras, 42000 Saint-Etienne, France
| | - Corantin Maurin
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Sofiane Fraine
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Sébastien Urbaniak
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Chantal Perrache
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Zhiguo He
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
| | - Sedao Xxx
- Laboratoire Hubert Curien, Jean Monnet University, 18 Rue Professeur Benoît Lauras, 42000 Saint-Etienne, France
| | - Oliver Dorado Cortez
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
- Ophthalmology Department, University Hospital, Avenue Albert Raimond, CEDEX 02, 42055 Saint-Etienne, France
| | - Sylvain Poinard
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
- Ophthalmology Department, University Hospital, Avenue Albert Raimond, CEDEX 02, 42055 Saint-Etienne, France
| | - Cyril Mauclair
- Laboratoire Hubert Curien, Jean Monnet University, 18 Rue Professeur Benoît Lauras, 42000 Saint-Etienne, France
| | - Philippe Gain
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
- Ophthalmology Department, University Hospital, Avenue Albert Raimond, CEDEX 02, 42055 Saint-Etienne, France
| | - Gilles Thuret
- Laboratory Biology, Engineering and Imaging for Ophthalmology, BiiO, Faculty of Medicine, Health Innovation Campus, Jean Monnet University, 10 Rue de la Marandière, 42270 Saint-Priest-en-Jarez, France
- Ophthalmology Department, University Hospital, Avenue Albert Raimond, CEDEX 02, 42055 Saint-Etienne, France
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Malyugin BE, Geliastanov AM, Antonova OP, Andreeva EA, Poletaeva MV, Isabekov RS. [Outcomes of hemi-Descemet membrane endothelial keratoplasty and phacoemulsification for the treatment of primary Fuchs' endothelial corneal dystrophy combined with cataract]. Vestn Oftalmol 2024; 140:36-44. [PMID: 38450465 DOI: 10.17116/oftalma202414001136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
PURPOSE This study evaluates the long-term results of surgical treatment of patients with Fuchs' endothelial corneal dystrophy and cataract. MATERIAL AND METHODS The study included 24 patients (24 eyes) with primary Fuchs' endothelial corneal dystrophy and cataract, who underwent cataract phacoemulsification with IOL implantation and of Descemet's membrane endothelial keratoplasty with a semicircular graft (hemi-DMEK). The effect of treatment was assessed by best corrected visual acuity (BCVA), central corneal thickness (CCT) and endothelial cell density (ECD). RESULTS In total, surgical treatment involved 14 donor corneas that were divided in half during the preparation and isolation of the Descemet's membrane (DM). By month 12 after the surgery an increase in visual functions and graft transparency were observed in 23 patients (23 eyes) out of 24. Repeated keratoplasty was required in one case due to fibrosis of the posterior layers of recipient's corneal stroma. At 12 months postoperatively, the study group showed an increase in BCVA from 0.16±0.1 to 0.75±20, a decrease in CCT from 650.9±4.5 μm to 519.6±43.9, and a decreased in ECD from 2850.5±84.7 cells/mm2 up to 1285.5±277.2 cells/mm2. Thus, the loss of endothelial cells at one year after surgery amounted to 54.9%. CONCLUSIONS The developed method for transplantation of a semicircular DM fragment provides a tissue-saving approach to endothelial keratoplasty, and considering the high percentage of transparent engraftment of grafts and complete visual rehabilitation, it can be recommended in the treatment of patients with cataract and Fuchs' endothelial corneal dystrophy.
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Affiliation(s)
- B E Malyugin
- S.N. Fedorov National Medical Research Center "MINK "Eye Microsurgery", Moscow, Russia
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A M Geliastanov
- S.N. Fedorov National Medical Research Center "MINK "Eye Microsurgery", Moscow, Russia
| | - O P Antonova
- S.N. Fedorov National Medical Research Center "MINK "Eye Microsurgery", Moscow, Russia
| | - E A Andreeva
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - M V Poletaeva
- S.N. Fedorov National Medical Research Center "MINK "Eye Microsurgery", Moscow, Russia
| | - R S Isabekov
- S.N. Fedorov National Medical Research Center "MINK "Eye Microsurgery", Moscow, Russia
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Leon P, Francescutti L, Gentile P, Birattari F, Ponzin D, Camposampiero D, Franch A, Parekh M. Hemi-Ultrathin Descemet Stripping Automated Endothelial Keratoplasty (Hemi-UT-DSAEK) Using Pediatric Donor Corneas: A Case Series. J Clin Med 2023; 12:5442. [PMID: 37685508 PMCID: PMC10487646 DOI: 10.3390/jcm12175442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE We sought to evaluate the clinical outcomes of hemi-UT-DSAEK grafts from the pediatric donor corneas of patients affected by Fuchs Endothelial Corneal Dystrophy (FECD). METHODS A prospective, interventional case series was conducted at the Ophthalmology Department of Venice Civil Hospital and the Veneto Eye Bank Foundation (Venice, Italy). Six eyes of six patients affected by FECD received large-diameter, semicircular hemi-UT-DSAEK grafts obtained from three pediatric donor corneas using the standard pull-through method. Endothelial cell density (ECD), central corneal thickness (CCT), best-corrected visual acuity (BCVA) and intraoperative and postoperative complications were recorded at different time intervals up to 12 months. RESULTS The average donor age was 64.6 ± 8.6 years, and the pre-operative ECD was 3266 ± 225 cells/mm2. At 12 months postoperatively, the average ECD was 1376 ± 509 cells/mm2 with a mean decrease of 56.8 ± 19.1% from the preoperative donor count. At 12 months, four out of six eyes had significantly improved and reached a BCVA of ≥20/25 (Snellen equivalent). The mean CCT significantly decreased from 788 ± 138 μm before surgery to 576 ± 30 μm at 12 months postoperatively (p < 0.01). CONCLUSIONS Hemi-UT-DSAEK grafts using pediatric donor corneas are surgically feasible and can provide similar clinical outcomes compared to conventional UT-DSAEK. Transplanting pediatric donor tissues with high ECD into two patients could potentially increase the donor tissue pool to treat endothelial disease.
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Affiliation(s)
- Pia Leon
- Department of Ophthalmology, SS Giovanni e Paolo Hospital, 30122 Venice, Italy
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Zelarino, 30174 Venice, Italy (D.P.)
| | - Lorena Francescutti
- Department of Ophthalmology, SS Giovanni e Paolo Hospital, 30122 Venice, Italy
| | - Pietro Gentile
- Department of Ophthalmology, SS Giovanni e Paolo Hospital, 30122 Venice, Italy
| | - Federica Birattari
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Zelarino, 30174 Venice, Italy (D.P.)
| | - Diego Ponzin
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Zelarino, 30174 Venice, Italy (D.P.)
| | - Davide Camposampiero
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Zelarino, 30174 Venice, Italy (D.P.)
| | - Antonella Franch
- Department of Ophthalmology, SS Giovanni e Paolo Hospital, 30122 Venice, Italy
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Zelarino, 30174 Venice, Italy (D.P.)
| | - Mohit Parekh
- Schepens Eye Research Institute, Mass Eye and Ear, Boston, MA 02114, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA 02115, USA
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García-Onrubia L, Stanojcic N, Bhogal M. Descemet Membrane Endothelial Patching: Selective Endothelial Replacement in Eyes With Localized Endothelial Dysfunction. Cornea 2023; 42:651-655. [PMID: 36745854 DOI: 10.1097/ico.0000000000003243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 12/18/2022] [Indexed: 02/08/2023]
Abstract
ABSTRACT Descemet membrane (DM) endothelial keratoplasty is considered the gold standard for treating corneal endothelial decompensation and is a true like-for-like replacement. Not all causes of endothelial dysfunction are global, with conditions such as viral endotheliitis affecting discrete populations of endothelial cells. In this study, endothelial grafts matching the area of dysfunction were produced to preserve healthy host cells and limit the immunological burden of new grafts. We have termed this modified DM endothelial keratoplasty procedure DM endothelial patching.
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Influence of Body Position on Intraocular Pressure After Descemet Membrane Endothelial Keratoplasty: A Prospective Randomized Trial. Cornea 2023; 42:320-325. [PMID: 35249977 DOI: 10.1097/ico.0000000000003010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/19/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to analyze the influence of patient positioning on intraocular pressure (IOP) after Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic patients treated for Fuchs endothelial corneal dystrophy. METHODS Forty patients were included in this prospective, single-blinded, randomized controlled clinical trial. Patients received a YAG iridotomy 1 day before surgery and an 80% anterior chamber tamponade [20% concentration of sulfur hexafluoride (SF6)]. Postoperative positioning was either supine (group 1) or seated (group 2, at least 30 degrees upper-body high position). IOP was measured with iCare. RESULTS There was no statistically significant difference in IOP postoperatively [group 1 vs. group 2-after 1h: 13.9 mm Hg (±4.2 mm Hg) versus 13.6 mm Hg (±4.1 mm Hg) ( P = 1.00); after 2h: 13.9 mm Hg (±5.4 mm Hg) versus 15.3 mm Hg (±4.6 mm Hg) ( P = 0.370); after 4h: 13.8 mm Hg (±4.2 mm Hg) versus 15.2 mm Hg (±4.2 mm Hg) ( P = 0.401]. In group 1, 10% of patients showed IOP decompensations well above 30 mm Hg, and in group 2, there were no IOP decompensations. Seated position led to relative risk reduction of 100% and absolute risk reduction of 10% regarding IOP decompensations. The number of patients needed to position seated to prevent 1 additional IOP decompensation was 10. Rebubbling rates, best spectacle-corrected visual acuity, and reduction of corneal thickness were comparable between the 2 groups in the follow-up period up to 1 month. CONCLUSIONS After DMEK in pseudophakic eyes with 80% anterior chamber tamponade, positioning patients with at least 30 degrees elevation of the upper body up immediately after surgery until bedtime prevents IOP decompensations.
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Händel A, Siebelmann S, Matthaei M, Cursiefen C, Bachmann B. Mini-DMEK for the Treatment of Chronic Focal Corneal Endothelial Decompensation. Cornea 2022; 42:12-19. [DOI: 10.1097/ico.0000000000003048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 03/10/2022] [Indexed: 11/25/2022]
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Maticorena-Quevedo J, Anduaga-Beramendi A, Beas R, Canahuire-Cairo J, Berrospi RD, Tello A. Endophthalmitis secondary to donor to host infection in posterior lamellar keratoplasties: A systematic review. Eur J Ophthalmol 2022; 32:3163-3173. [PMID: 35275016 DOI: 10.1177/11206721221085853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Donor to host transmission of infectious agents is a well-recognized entity, more commonly related to Endothelial Keratoplasty (EK) than to Penetrating Keratoplasty (PK), that involves complications ranging from interface keratitis to endophthalmitis. A systematic review of the literature was conducted to identify the published articles until December 2020 reporting cases of endophthalmitis secondary to corneal graft contamination in posterior lamellar keratoplasties (DSAEK and DMEK) along with donor characteristics, microbiological profile, treatment and outcomes. Each identified article was assessed to meet donor to host infection criteria, defined as a post-procedural infection in which the same microbiological agent was identified in both the donor corneoscleral rim or preservation medium and receptor ocular tissue. From 23 research articles, eight reports of endophthalmitis in nine patients following DSAEK or DMEK secondary to donor to host infection fulfilled the inclusion criteria. The majority were male and the median age was 72.0 (45.0-81.0) years old. Indications of surgery were primarily pseudophakic bullous keratopathy and Fuchs dystrophy. A fungal pathogen was identified in eight of nine patients. All the cases underwent surgical management with lenticule removal or endothelial plaque aspiration. The final corrected distance visual acuity (CDVA) in all cases was 20/200 or better. Endophthalmitis after an EK procedure is a rare complication whose outcome depends on the aggressive and precocious treatment. Identification of early signs of interface keratitis and lenticule removal seems mandatory in patients undergoing DSAEK or DMEK to prevent further involvement of the globe.
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Affiliation(s)
| | | | - Renato Beas
- Department of Medicine, 33217Indiana University School of Medicine, Indianapolis, USA
| | - José Canahuire-Cairo
- Cornea and External Diseases Service, Department of Ophthalmology, 279700Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Rubén D Berrospi
- 568057Centro Oftalmológico Virgilio Galvis, Floridablanca, Colombia.,Department of Ophthalmology, 27968Universidad Autónoma de Bucaramanga UNAB, Bucaramanga, Colombia.,Department of Ophthalmology, Fundación Oftalmológica de Santander FOSCAL, Floridablanca, Colombia
| | - Alejandro Tello
- Department of Ophthalmology, 27968Universidad Autónoma de Bucaramanga UNAB, Bucaramanga, Colombia.,Department of Ophthalmology, Fundación Oftalmológica de Santander FOSCAL, Floridablanca, Colombia
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Tajima K, Okada M, Kudo R, Otaka Y, Kita M, Yamashita Y, Kanai K. Primary cell culture of canine corneal endothelial cells. Vet Ophthalmol 2021; 24:447-454. [PMID: 34402563 DOI: 10.1111/vop.12924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/14/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To establish a primary cell culture and clarify the characteristics of canine corneal endothelial cells in vitro. PROCEDURES The eyes were enucleated from dogs that were euthanized for reasons unrelated to this study. Enucleated canine eyes were dissected, and the intact corneas were isolated from the globes. Using enzymes, the corneal endothelial cells were dispersed from the cornea. The obtained canine corneal endothelial cells were cultured in a cell culture dish. Cultured corneal endothelial cells were morphologically evaluated using phase-contrast microscopy. Immunohistochemical analysis of the cultured cells, particularly of the corneal endothelial cell marker, zonula occludens-1 (ZO-1), Na+ /K+ -ATPase, and vimentin, was performed to clarify whether the cultured cells were actually corneal endothelial cells. Furthermore, the post-passage morphology of cultured cells was evaluated. RESULTS Canine primary cultured corneal endothelial cells showed morphologically small, cobblestone-like structures. The isolated cells had proliferative ability in vitro and demonstrated positive expression of the corneal endothelial cell markers, ZO-1, Na+ /K+ -ATPase, and vimentin. However, repeated passages resulted in larger cell sizes as assessed by phase-contrast microscopy. Repeated passages also resulted in lower cell density. CONCLUSIONS This study demonstrated the successful culture of canine corneal endothelial cells. This might enhance the understanding of corneal endothelial cell characteristics in dogs.
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Affiliation(s)
- Kazuki Tajima
- Department of Small Animal Internal Medicine, Kitasato University School of Veterinary Medicine, Towada, Aomori, Japan.,Department of Ophthalmology, Tokyo Medical University, Tokyo, Japan.,Department of Surgery, Keio University, Tokyo, Japan
| | - Misaki Okada
- Department of Small Animal Internal Medicine, Kitasato University School of Veterinary Medicine, Towada, Aomori, Japan
| | - Rina Kudo
- Department of Small Animal Internal Medicine, Kitasato University School of Veterinary Medicine, Towada, Aomori, Japan
| | - Yuya Otaka
- Department of Small Animal Internal Medicine, Kitasato University School of Veterinary Medicine, Towada, Aomori, Japan
| | - Mizuki Kita
- Department of Small Animal Internal Medicine, Kitasato University School of Veterinary Medicine, Towada, Aomori, Japan
| | - Yohei Yamashita
- Department of Small Animal Internal Medicine, Kitasato University School of Veterinary Medicine, Towada, Aomori, Japan
| | - Kazutaka Kanai
- Department of Small Animal Internal Medicine, Kitasato University School of Veterinary Medicine, Towada, Aomori, Japan
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New Horizons in the Treatment of Corneal Endothelial Dysfunction. J Ophthalmol 2021; 2021:6644114. [PMID: 34306743 PMCID: PMC8285186 DOI: 10.1155/2021/6644114] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 07/01/2021] [Indexed: 01/17/2023] Open
Abstract
The treatment of corneal endothelial dysfunction has experienced a revolutionary change in the past decades with the emergence of endothelial keratoplasty techniques: descemet stripping automated endothelial keratoplasty (DSAEK) and descemet membrane endothelial keratoplasty (DMEK). Recently, new treatments such as cultivated endothelial cell therapy, Rho-kinase inhibitors (ROCK inhibitors), bioengineered grafts, and gene therapy have been described. These techniques represent new lines of treatment for endothelial dysfunction. Their advantages are to help address the shortage of quality endothelial tissue, decrease the complications associated with tissue rejection, and reduce the burden of postoperative care following transplantation. Although further randomized clinical trials are required to validate these findings and prove the long-term efficacy of the treatments, the positive outcomes in preliminary clinical studies are a stepping stone to a promising future. Our aim is to review the latest available alternatives and advancements to endothelial corneal transplant.
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Ong HS, Ang M, Mehta J. Evolution of therapies for the corneal endothelium: past, present and future approaches. Br J Ophthalmol 2021; 105:454-467. [PMID: 32709756 PMCID: PMC8005807 DOI: 10.1136/bjophthalmol-2020-316149] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/16/2020] [Indexed: 12/13/2022]
Abstract
Corneal endothelial diseases are leading indications for corneal transplantations. With significant advancement in medical science and surgical techniques, corneal transplant surgeries are now increasingly effective at restoring vision in patients with corneal diseases. In the last 15 years, the introduction of endothelial keratoplasty (EK) procedures, where diseased corneal endothelium (CE) are selectively replaced, has significantly transformed the field of corneal transplantation. Compared to traditional penetrating keratoplasty, EK procedures, namely Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK), offer faster visual recovery, lower immunological rejection rates, and improved graft survival. Although these modern techniques can achieve high success, there are fundamental impediments to conventional transplantations. A lack of suitable donor corneas worldwide restricts the number of transplants that can be performed. Other barriers include the need for specialized expertise, high cost, and risks of graft rejection or failure. Research is underway to develop alternative treatments for corneal endothelial diseases, which are less dependent on the availability of allogeneic tissues - regenerative medicine and cell-based therapies. In this review, an overview of past and present transplantation procedures used to treat corneal endothelial diseases are described. Potential novel therapies that may be translated into clinical practice will also be presented.
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Affiliation(s)
- Hon Shing Ong
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore
- Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore, Singapore
| | - Marcus Ang
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore
- Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore, Singapore
| | - Jodhbir Mehta
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore
- Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore, Singapore
- School of Material Science & Engineering and School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore, Singapore
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Hribek A, Clahsen T, Horstmann J, Siebelmann S, Loreck N, Heindl LM, Bachmann BO, Cursiefen C, Matthaei M. Fibrillar Layer as a Marker for Areas of Pronounced Corneal Endothelial Cell Loss in Advanced Fuchs Endothelial Corneal Dystrophy. Am J Ophthalmol 2021; 222:292-301. [PMID: 32971030 DOI: 10.1016/j.ajo.2020.09.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE We sought to assess the correlation of corneal endothelial cell (CEC) density to alterations of collagen composition of Descemet membrane (DM) in advanced Fuchs endothelial corneal dystrophy (FECD) and to image such changes by slit-lamp biomicroscopy in vivo. DESIGN Prospective, observational consecutive case series. METHODS Fifty eyes (50 subjects) with advanced FECD were enrolled. After slit-lamp biomicroscopy and corneal Scheimpflug imaging, the Descemet endothelium complex (DEC) was retrieved during DM endothelial keratoplasty (DMEK) surgery. The expression of collagens I, III, and IV (COL I, COL III, and COL IV) and corresponding CEC density were analyzed by immunofluorescence flat mount-staining. Presence, diameter and surface area of collagen expression, and CEC density served as the main outcome measures. RESULTS Immunofluorescence staining revealed central coherent collagen positive areas (mean surface area = 10 mm2 ± 6 mm2) corresponding to a fibrillar layer burying the guttae of DM in 84% (42/50) of DECs. CEC density overlying the fibrillar layer compared with the periphery was significantly reduced (-54.8%, P < .0001) with a steep decline of CEC density at its borders. Subgroup analysis revealed that the fibrillar layer may be imaged by slit-lamp biomicroscopy in vivo with significant positive correlation of mean maximum diameter detected by slit-lamp biomicroscopy (dSL max = 4.1 mm ± 0.9 mm) and by immunofluorescence staining (dIF max = 4.7 mm ± 1.1 mm; r = 0.76; P = .001). CONCLUSION A fibrillar layer with a clear geographic pattern marks areas of pronounced loss of CEC density in advanced FECD eyes and may be imaged by slit-lamp biomicroscopy in vivo.
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Weant J, Eveleth DD, Subramaniam A, Jenkins-Eveleth J, Blaber M, Li L, Ornitz DM, Alimardanov A, Broadt T, Dong H, Vyas V, Yang X, Bradshaw RA. Regenerative responses of rabbit corneal endothelial cells to stimulation by fibroblast growth factor 1 (FGF1) derivatives, TTHX1001 and TTHX1114. Growth Factors 2021; 39:14-27. [PMID: 34879776 DOI: 10.1080/08977194.2021.2012468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Utilising rabbit corneal endothelial cells (CEC) in three different paradigms, two human FGF1 derivatives (TTHX1001 and TTHX1114), engineered to exhibit greater stability, were tested as proliferative agents. Primary CECs and mouse NIH 3T3 cells treated with the two FGF1 derivatives showed equivalent EC50 ranges (3.3-24 vs.1.9-16. ng/mL) and, in organ culture, chemically lesioned corneas regained half of the lost endothelial layer in three days after treatment with the FGF1 derivatives as compared to controls. In vivo, following cryolesioning, the CEC monolayer, as judged by specular microscopy, regenerated 10-11 days faster when treated with TTHX1001. Over two weeks, all treated eyes showed clearing of opacity about twice that of untreated controls. In all three rabbit models, both FGF1 derivatives were effective in inducing CEC proliferation over control conditions, supporting the prediction that these stabilised FGF1 derivatives can potentially regenerate corneal endothelial deficits in humans.
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Affiliation(s)
| | | | | | | | - Michael Blaber
- Department of Biomedical Sciences, College of Medicine, Florida State University, Tallahassee, USA
| | - Ling Li
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - David M Ornitz
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Asaf Alimardanov
- Therapeutics Development Branch, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, USA
| | - Trevor Broadt
- Biopharmaceutical Development Program, Advanced Technology Research Facility, Frederick National Laboratory for Cancer Research (FNLCR), Leidos Biomedical Research Inc, Frederick, MD, USA
| | - Hui Dong
- Biopharmaceutical Development Program, Advanced Technology Research Facility, Frederick National Laboratory for Cancer Research (FNLCR), Leidos Biomedical Research Inc, Frederick, MD, USA
| | - Vinay Vyas
- Biopharmaceutical Development Program, Advanced Technology Research Facility, Frederick National Laboratory for Cancer Research (FNLCR), Leidos Biomedical Research Inc, Frederick, MD, USA
| | - Xiaoyi Yang
- Biopharmaceutical Development Program, Advanced Technology Research Facility, Frederick National Laboratory for Cancer Research (FNLCR), Leidos Biomedical Research Inc, Frederick, MD, USA
| | - Ralph A Bradshaw
- Trefoil Therapeutics, Inc, San Diego, CA, USA
- Department of Physiology and Biophysics, University of California, Irvine, Irvine, CA, USA
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13
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Abstract
PURPOSE To report clinical outcomes of the first Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK) case series performed for central Fuchs endothelial corneal dystrophy. METHODS This is a prospective, interventional case series analyzing the clinical outcomes of 19 eyes of 19 patients with central Fuchs endothelial corneal dystrophy, that is, with guttae predominantly in the 6- to 7-mm optical zone, who underwent unilateral Quarter-DMEK at a tertiary referral center. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications. Included eyes had up to 2 years of postoperative follow-up. RESULTS At 6 months postoperatively, all eyes reached a BCVA of ≥20/40 (≥0.5): 18 of 19 eyes (95%) with ≥20/25 (≥0.8) and 9 of 19 eyes (42%) with ≥20/20 (≥1.0). Thereafter, BCVA remained stable up to 2 years postoperatively. The mean donor ECD decreased from 2842 ± 139 cells/mm (n = 19) before implantation to 913 ± 434 cells/mm (-68%) at 6 months (n = 19), 869 ± 313 cells/mm (-70%) at 12 months (n = 18), and 758 ± 225 cells/mm (-74%) at 24 months (n = 13) after Quarter-DMEK. Visually significant graft detachment requiring rebubbling occurred in 8 of 19 eyes (42%). CONCLUSIONS Quarter-DMEK surgery yields visual outcomes similar to those of conventional DMEK and may potentially quadruple the availability of endothelial grafts. Further modifications of the graft preparation and the surgical technique may improve clinical outcomes in terms of lower ECD decrease and fewer graft detachments.
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14
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Wojcik G, Ferrari S, Romano V, Ponzin D, Ahmad S, Parekh M. Corneal storage methods: considerations and impact on surgical outcomes. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2021.1829476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Gabriela Wojcik
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto, Venice, Italy
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto, Venice, Italy
| | - Vito Romano
- St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Diego Ponzin
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto, Venice, Italy
| | - Sajjad Ahmad
- Institute of Ophthalmology, University College London, London, UK
- Cornea and external eye disease, Moorfields Eye Hospital NHS Trust Foundation, London, UK
| | - Mohit Parekh
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto, Venice, Italy
- Institute of Ophthalmology, University College London, London, UK
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15
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Price MO, Mehta JS, Jurkunas UV, Price FW. Corneal endothelial dysfunction: Evolving understanding and treatment options. Prog Retin Eye Res 2020; 82:100904. [PMID: 32977001 DOI: 10.1016/j.preteyeres.2020.100904] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/14/2020] [Accepted: 09/19/2020] [Indexed: 12/13/2022]
Abstract
The cornea is exquisitely designed to protect the eye while transmitting and focusing incoming light. Precise control of corneal hydration by the endothelial cell layer that lines the inner surface of the cornea is required for optimal transparency, and endothelial dysfunction or damage can result in corneal edema and visual impairment. Advances in corneal transplantation now allow selective replacement of dysfunctional corneal endothelium, providing rapid visual rehabilitation. A series of technique improvements have minimized complications and various adaptations allow use even in eyes with complicated anatomy. While selective endothelial keratoplasty sets a very high standard for safety and efficacy, a shortage of donor corneas in many parts of the world restricts access, prompting a search for alternatives. Clinical trials are underway to evaluate the potential for self-recovery after removal of dysfunctional central endothelium in patients with healthy peripheral endothelium. Various approaches to using cultured human corneal endothelial cells are also in clinical trials; these aim to multiply cells from a single donor cornea for use in potentially hundreds of patients. Pre-clinical studies are underway with induced pluripotent stem cells, endothelial stem cell regeneration, gene therapy, anti-sense oligonucleotides, and various biologic/pharmacologic approaches designed to treat, prevent, or retard corneal endothelial dysfunction. The availability of more therapeutic options will hopefully expand access around the world while also allowing treatment to be more precisely tailored to each individual patient.
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Affiliation(s)
- Marianne O Price
- Cornea Research Foundation of America, 9002 N. Meridian St., Suite 212, Indianapolis, IN, USA.
| | - Jodhbir S Mehta
- Singapore National Eye Centre, 11 Third Hospital Ave #08-00, 168751, Singapore
| | - Ula V Jurkunas
- Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA, USA
| | - Francis W Price
- Price Vision Group, 9002 N. Meridian St., Suite 100, Indianapolis, IN, USA
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16
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Eveleth D, Pizzuto S, Weant J, Jenkins-Eveleth J, Bradshaw RA. Proliferation of Human Corneal Endothelia in Organ Culture Stimulated by Wounding and the Engineered Human Fibroblast Growth Factor 1 Derivative TTHX1114. J Ocul Pharmacol Ther 2020; 36:686-696. [PMID: 32735473 PMCID: PMC7703086 DOI: 10.1089/jop.2019.0119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose: Corneal endothelial dystrophies are characterized by endothelial cell loss and dysfunction. Recent evidence suggests that corneal endothelial cells (CECs) can regenerate although they do not do so under normal conditions. This work sought to test whether CECs can be stimulated to proliferate in organ culture by wounding and/or by treatment with the engineered human fibroblast growth factor 1 (FGF1) derivative TTHX1114. Methods: Human donor corneas obtained from eye banks were maintained in organ culture in the presence or absence of TTHX1114. Wounds in the corneas were created by quartering the corneas. The CEC monolayer was identified as a regular layer by Hoechst staining of the nuclear DNA with cell outlines delineated by immunohistochemical identification of ZO-1. Nuclei and nuclei incorporating 5-ethynyl-2′-deoxyuridine (EdU) were counted using ImageJ. Results: CECs in normal corneas in undisturbed monolayers had low, but measurable, rates of proliferation. CECs at the edge of a wound had higher rates of proliferation, probably due to the release of contact inhibition. TTHX1114 increased proliferation at wound edges. After 7 days of culture, proliferating CECs formed contiguous groups of labeled cells that did not migrate away from one another. TTHX1114-treated cells, including the EdU labeled proliferating cells, retained normal morphology, including cell/cell junction ZO-1 staining. Conclusions: Proliferation of CECs in organ-cultured corneas is low, but can be stimulated by wounding or by the administration of TTHX1114 with the effects of each being additive. The CEC monolayer appears to have a population of progenitor cells that are susceptible to stimulation.
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Affiliation(s)
- David Eveleth
- Trefoil Therapeutics, Inc., San Diego, California, USA
| | - Sarah Pizzuto
- Trefoil Therapeutics, Inc., San Diego, California, USA
| | - Jessica Weant
- Trefoil Therapeutics, Inc., San Diego, California, USA
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17
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Ross AR, Said DG, Colabelli Gisoldi RAM, Nubile M, El-Amin A, Gabr AF, Abd Ed-Moniem M, Mencucci R, Pocobelli A, Mastropasqua L, Dua HS. Optimizing pre-Descemet endothelial keratoplasty technique. J Cataract Refract Surg 2020; 46:667-674. [PMID: 32358258 DOI: 10.1097/j.jcrs.0000000000000157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pre-Descemet endothelial keratoplasty (PDEK) is an alternative technique to Descemet membrane endothelial keratoplasty (DMEK). The preparation of PDEK tissue by pneumatic dissection is simple and reproducible. The PDEK clamp helps to consistently obtain a type 1 big bubble. The mean size of type 1 big bubble is 7.255 ± 0.535 × 6.745 ± 0.668 mm. The volume of air required to obtain type 1 big bubble is 0.14 to 0.37 mL. Dissection of PDEK tissue can be achieved by trephination or manual excision. Insertion of tissue into the recipient eye can be by injection or pulling. Unfolding techniques used for PDEK are similar to those used in DMEK. Unlike DMEK, PDEK tissue is easier to handle and unscroll and allows use of younger donors. It could help surgeons converting to endothelial keratoplasty, with significant advantages in preparation, handling, and unscrolling in the eye.
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Affiliation(s)
- Andrew R Ross
- From the Department of Ophthalmology, Nottingham University Hospitals NHS Trust and Section of Academic Ophthalmology, Division of Clinical Neuroscience, University of Nottingham (Ross, Said, Dua), Nottingham, United Kingdom; Department of Ophthalmology, Aswan University (Ross, El-Amin, Gabr, Moniem), Aswan, Egypt; Hospital San Giovanni Addolorata (Colabelli Gisoldi, Pocobelli), Rome, Department of Medicine and Science of Ageing, Ophthalmic Clinic, National High Technology Eye Center, G. d'Annunzio University of Chieti (Nubile, Mastropasqua), Pescara, Department of Oto-Neuro-Ophthalmological Surgical Sciences, Eye Clinic, University of Florence (Mencucci), Florence, Italy
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18
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Trindade BLC, Eliazar GC. Descemet membrane endothelial keratoplasty (DMEK): an update on safety, efficacy and patient selection. Clin Ophthalmol 2019; 13:1549-1557. [PMID: 31496646 PMCID: PMC6701611 DOI: 10.2147/opth.s178473] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/01/2019] [Indexed: 11/23/2022] Open
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is gaining popularity worldwide as a procedure to address corneal endothelial dysfunctions. Its perfect anatomical result improves outcomes and expedites visual recovery. This review addresses important aspects of safety, efficacy and patient selection.
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Affiliation(s)
- Bruno Lovaglio Cançado Trindade
- Cançado Trindade Eye Institute , Belo Horizonte, Brazil.,Medical Science School of Medicine - FELUMA , Belo Horizonte, Brazil.,Cornea Department, Medical Sciences University Hospital Eye Institute, Belo Horizonte, Brazil
| | - Glauber Coutinho Eliazar
- Cornea Department, Medical Sciences University Hospital Eye Institute, Belo Horizonte, Brazil.,Cornea Department, Santa Casa Eye Clinic, Belo Horizonte, Brazil
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19
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Abstract
PURPOSE OF REVIEW To provide an update on new perspectives on Descemet membrane endothelial keratoplasty (DMEK). RECENT FINDINGS Preloaded DMEK grafts allow optimization of DMEK surgery time and reduce costs of the procedure, which is allowing the procedure to become more easily performed as reflected in the increasing number of cases. The surgical technique in the United States differs from the technique in Europe, but outcomes have been similar. Hemi-DMEK and quarter-DMEK have shown similar outcomes to conventional DMEK with respect to corneal transparency and visual acuity. Three-year follow-up of hemi-DMEK has also shown stability in endothelial cell count while maintaining corneal transparency. SUMMARY DMEK is becoming more accepted as the procedure of choice for treating endothelial failure. However, challenges with the surgical technique have limited wider implementation of this lamellar corneal transplantation. Preloaded DMEK provides one solution for the surgical challenges associated with the procedure while also reducing costs. Variations in the surgical technique for DMEK, including hemi-DMEK and quarter-DMEK, allow for central corneal clarity similar to traditional DMEK, but both result in lower endothelial cell density (ECD).
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20
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Hos D, Matthaei M, Bock F, Maruyama K, Notara M, Clahsen T, Hou Y, Le VNH, Salabarria AC, Horstmann J, Bachmann BO, Cursiefen C. Immune reactions after modern lamellar (DALK, DSAEK, DMEK) versus conventional penetrating corneal transplantation. Prog Retin Eye Res 2019; 73:100768. [PMID: 31279005 DOI: 10.1016/j.preteyeres.2019.07.001] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/12/2022]
Abstract
In the past decade, novel lamellar keratoplasty techniques such as Deep Anterior Lamellar Keratoplasty (DALK) for anterior keratoplasty and Descemet stripping automated endothelial keratoplasty (DSAEK)/Descemet membrane endothelial keratoplasty (DMEK) for posterior keratoplasty have been developed. DALK eliminates the possibility of endothelial allograft rejection, which is the main reason for graft failure after penetrating keratoplasty (PK). Compared to PK, the risk of endothelial graft rejection is significantly reduced after DSAEK/DMEK. Thus, with modern lamellar techniques, the clinical problem of endothelial graft rejection seems to be nearly solved in the low-risk situation. However, even with lamellar grafts there are epithelial, subepithelial and stromal immune reactions in DALK and endothelial immune reactions in DSAEK/DMEK, and not all keratoplasties can be performed in a lamellar fashion. Therefore, endothelial graft rejection in PK is still highly relevant, especially in the "high-risk" setting, where the cornea's (lymph)angiogenic and immune privilege is lost due to severe inflammation and pathological neovascularization. For these eyes, currently available treatment options are still unsatisfactory. In this review, we will describe currently used keratoplasty techniques, namely PK, DALK, DSAEK, and DMEK. We will summarize their indications, provide surgical descriptions, and comment on their complications and outcomes. Furthermore, we will give an overview on corneal transplant immunology. A specific focus will be placed on endothelial graft rejection and we will report on its incidence, clinical presentation, and current/future treatment and prevention options. Finally, we will speculate how the field of keratoplasty and prevention of corneal allograft rejection will develop in the future.
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Affiliation(s)
- Deniz Hos
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Mario Matthaei
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Felix Bock
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Kazuichi Maruyama
- Department of Innovative Visual Science, Graduate School of Medicine, Osaka University, Japan
| | - Maria Notara
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Thomas Clahsen
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Yanhong Hou
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Viet Nhat Hung Le
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Department of Ophthalmology, Hue College of Medicine and Pharmacy, Hue University, Viet Nam
| | | | - Jens Horstmann
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Bjoern O Bachmann
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Claus Cursiefen
- Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.
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21
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New Insights Into Corneal Endothelial Regeneration. CURRENT OPHTHALMOLOGY REPORTS 2019. [DOI: 10.1007/s40135-019-00197-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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