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Transplant COVER STORY Improvements in Corneal Transplantation Achieving Better Outcomes (continued from cover) and because there is less tissue transplanted, it reduces the risk of rejection.” Photo: Superstock STORY HIGHLIGHTS Improvements in surgical approaches to corneal transplantation over the last decade have led to major eye centers, such as UCLA, achieving better visual results with fewer postoperative complications. Two developments have significantly improved outcomes: modifications in the design of the surgical device and better medical therapy after surgery. UCLAHEALTH.ORG Hugo Y. Hsu, MD, a corneal transplant surgeon at Doheny Eye Center UCLA in Pasadena, Arcadia and Fountain Valley, notes that until the mid-2000s, corneal transplants had been done using what he calls a “one-size-fits-all” approach. “Now we are much more selective and accurate in how we transplant the cornea, and for the vast majority of patients, that’s translating into better visual outcomes and faster recovery,” Dr. Hsu says. “The techniques are still evolving and improving, but we are getting closer to making this on par with cataract surgery in terms of the visual success, rehabilitation and minimal complication rates.” The cornea — the clear, outermost layer of the eye — plays a central role in focusing sight. The cornea can become diseased, affecting vision, from a variety of conditions, including protrusion of the center of the cornea (keratoconus), scarring or inf lammation from infections or injuries and cloudiness of the cornea’s inner layer (Fuchs’ dystrophy). Approximately 50,000 cornea transplants are performed in the United States each year. The most common indication for corneal transplantation in the United States is Fuchs’ corneal dystrophy, an inherited disorder of the cornea’s innermost layer, the endothelium. Beginning in the mid-2000s, the approach known as Descemet’s stripping endothelial keratoplasty (DSEK) gained traction in the U.S., marking a major advance. Unlike full- thickness corneal transplantation, DSEK selectively replaces the posterior portions of the cornea with the donor’s corneal tissue. “The cornea has multiple layers, and it’s clear that in most patients we don’t need to replace the 1-844-4UCLADR (1-844-482-5237) entire cornea,” says Dr. Hsu. “This has led to major improvements in visual acuity along with more rapid recovery and lower rejection risk.” Following the DSEK, a significant portion of patients with otherwise healthy eyes can expect to achieve up to 20/40 vision with glasses — far better than what most could have expected from older techniques, Dr. Hsu notes. Dr. Aldave, who began performing DSEK in 2006, notes that in the last several years, a new version of DSEK has been popularized at UCLA and other highly specialized centers, particularly for patients whose corneal edema is caused by endothelial dysfunction or failure, including Fuchs’ patients. Descemet’s membrane endothelial keratoplasty (DMEK) replaces only Descemet’s membrane, the thin innermost layer of the cornea on which the endothelial cells reside, with no stromal tissue involved. This has led to a further improvement in results for the surgeons who perform the procedure. For patients with keratoconus, a corneal disorder that affects approximately one-in-2,000 people in the U.S., Descemet’s membrane is the only healthy portion of the cornea. “In this case it’s a problem with the cornea’s shape that progresses, usually affecting people in their teens or 20s, to the point where they may not see well with glasses or contact lenses,” Dr. Aldave explains. For these patients, the surgeons transplant the diseased portion of the cornea while leaving the critical inner Descemet’s membrane layer intact in a surgery known as deep anterior lamellar keratoplasty (DALK). This, too, has led to better outcomes, including elimination of the risk of corneal endothelial rejection. For patients who can’t benefit from donor tissue, including those who have had previous corneal transplants, advances in artificial corneal