Descemet Stripping Only, Rho-Kinase Inhibitors Can Replace Some Corneal Transplants

A subset of patients with Fuchs corneal endothelial dystrophy (FECD) can be successfully managed with Descemet stripping only (DSO), without endothelial keratoplasty, a report published in Cornea shows. In a meta-analysis of patients chosen for the DSO approach, 85% achieve complete corneal clearance.   

For more than 2 decades, Descemet membrane endothelial keratoplasty (DMEK) has been the preferred option for patients with FECD. “However, DMEK is not without its own disadvantages, including a steeper learning curve, risk of repeated rebubble, and graft rejection,” study authors explain. “Therefore, newer techniques have been sought to eliminate both short-term and long-term sequelae of endolamellar keratoplasties.”

The researchers conducted a systematic literature search to identify published cases of DSO and conduct a meta-analysis of patients with FECD, including those who underwent combined phacoemulsification and DSO and were treated with Rho-kinase inhibitors (ROC-i). The primary outcome of the study was success of corneal clearance, and secondary outcomes included time to corneal clearance, postoperative endothelial cell count (ECC), and ROC-i impact.

Patient selection is key to DSO success, the study shows. The study includes a surgical management decision tree showing that patients with corneal decompensation/corneal central scarring without visually significant cataracts are ideal candidates. Those with visually significant cataracts can also undergo simultaneous cataract surgery with phacoemulsification.

The researchers identified 37 DSO only procedures and 30 combined DSO and phacoemulsification procedures with a mean follow-up duration of 12.4 months. Mean patient age was 67±9 years, and most patients were women (75%).  

The study shows 85% of these 67 patients achieved complete corneal clearance without focal or localized corneal edema and without needing corneal transplantation. The mean time to corneal clearance was shorter for patients who received adjuvant ROC-i compared with those who did not (4.9 vs 10.1 weeks; P <.0001). The team also noted that the mean postoperative central ECC was higher in the ROC-i group compared with the observation group (1151 vs 765 cells/mm²; P <.018). 

The researchers identified 4 mm descemetorhexis size, clear peripheral ECC with no clinical sequelae of decompensation or guttae, and low central corneal thickness as predictive factors for DSO success.

“With global shortages of donor tissue in both short and long term, alongside an inability of developing countries to access eye banks, DSO provides a strategy to treat FECD with a less invasive surgical procedure that minimizes complications and costs of lamellar keratoplasty,” researchers report.

Limitations included the retrospective design, lack of a universal definition of corneal clearance, lack of conformity in the surgical technique of DSO used across studies, lack of reporting of refractive outcomes after combined cataract surgery and DSO in some studies, restriction of the literature search to the English language literature, and difficulty in obtaining measurement of the peripheral ECC.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.