Advancing Fuchs dystrophy care: Longterm success of descemet stripping only

Author(s):

Key Takeaways

Descemet stripping only (DSO) offers a novel approach to FECD management, avoiding donor tissue complications and promoting endothelial restoration.
Rho kinase inhibitors, such as ripasudil, may enhance corneal endothelial healing and improve postoperative outcomes in DSO.
Dr. Dhaliwal's study reports long-term success in 92% of patients undergoing DSO, with most achieving good visual acuity.
The study highlights DSO's potential in FECD management, though further research is needed to assess the impact of rho kinase inhibitors.

Deepinder Dhaliwal, MD, LAc, explores advancements in managing Fuchs endothelial corneal dystrophy, highlighting Descemet stripping only (DSO). Long-term outcomes show promising results, supporting DSO as a viable alternative to traditional donor-tissue-based keratoplasty procedures.

(Image credit: Adobe Stock/Chiraphong)

Fuchs endothelial corneal dystrophy (FECD) is a disease of the corneal endothelium, for which surgical management has evolved greatly over recent decades.

As part of the Journal Club series between the NYU Grossman School of Medicine Department of Ophthalmology and Ophthalmology Times, participants will discuss recent impactful papers with visiting faculty members across multiple disciplines within ophthalmology.

Deepinder Dhaliwal, MD, L.Ac, a cornea and refractive surgeon at the University of Pittsburgh, discusses the latest research in surgical management of Fuchs endothelial corneal dystrophy and one of her recent papers on long-term outcomes in Descemet stripping only (Cornea 2024;43:994-998, PMID 37921677).¹

Over the last 15 years, FECD has been primarily managed with either Descemet membrane endothelial keratoplasty (DMEK) or Descemet stripping endothelial keratoplasty (DSEK).² A relatively novel surgical technique for surgical management of FECD, Descemet striping only (DSO), involves removal of Descemet membrane and endothelial tissue without replacement by donor issue, reducing the complications associated with donor tissue and such as rejection and steroid-related complications.^3,4

In well-chosen patients with FECD, DSO allows for the restoration of normal central corneal endothelium, thought to be a result of the migration of peripheral endothelial cells into the center of the cornea. As such, appropriate patients are those with central guttae and preserved peripheral endothelium.⁵

Moreover, it has been shown that the addition of a rho kinase inhibitor, such as ripasudil, can accelerate corneal endothelial wound healing and result in higher post operative endothelial cell densities.⁶ Prior studies have demonstrated that DSO can result in corneal clearance and good visual acuity; however, data on long-term outcomes has been limited, with a total of only 7 eyes reported prior to this study by Dr. Dhaliwal and her team.^7-9

In this recent paper¹, Dhaliwal and her team report long-term outcomes of 11 patients and 13 eyes that underwent DSO for FECD, the largest report to date with follow up as long as 6 years in 8 of the patients. They found that 92% of patients achieved initial success postoperatively with resolution of edema. At post-operative month 6, 10 of 11 eyes had a VA of 20/40 or better. Only 2 patients (17%) experienced secondary failure for which they had a subsequent DMEK.

Importantly, many of these patients underwent DSO before the benefit of Rho kinase inhibitors was discovered, and they were not started on the medication. As such, it’s possible that long-term outcomes may be more favorable than those reported in this case series.

Long-term outcomes, such as those presented here, are instrumental in establishing the role of DSO in the management of FECD, and this study provides valuable information on the favorable outcomes and supports the role of DSO in the management of FECD. Ongoing studies in the field will continue to assess outcomes in DSO as well as investigate the safety and efficacy of Rho kinase inhibitors in DSO.

References

1. Huertas-Bello M, Sem K, Alba DE, Donaldson KE, Koo EH. Descemet Membrane Endothelial Keratoplasty as Treatment for Late-Onset Interface Fluid Syndrome After Laser In Situ Keratomileusis. Cornea. 2024 Sep 1;43(9):1171-1175. doi: 10.1097/ICO.0000000000003538. Epub 2024 Mar 13. PMID: 38478758.

2. Blitzer AL, Colby KA. Update on the Surgical Management of Fuchs Endothelial Corneal Dystrophy. Ophthalmol Ther. 2020 Dec;9(4):757-765. doi: 10.1007/s40123-020-00293-3. Epub 2020 Aug 25. PMID: 32840804; PMCID: PMC7708572.

3. Borkar DS, Veldman P, Colby KA. Treatment of Fuchs Endothelial Dystrophy by Descemet Stripping Without Endothelial Keratoplasty. Cornea. 2016 Oct;35(10):1267-73. doi: 10.1097/ICO.0000000000000915. PMID: 27310885.

4. Bleyen I, Saelens IE, van Dooren BT, van Rij G. Spontaneous corneal clearing after Descemet's stripping. Ophthalmology. 2013 Jan;120(1):215. doi: 10.1016/j.ophtha.2012.08.037. PMID: 23283191.

5. Northey LC, Moloney G. Role of descemet's stripping without keratoplasty in management of endothelial disease. Curr Opin Ophthalmol. 2023 Jul 1;34(4):348-353. doi: 10.1097/ICU.0000000000000963. Epub 2023 May 3. PMID: 37254864.

6. Macsai MS, Shiloach M. Use of Topical Rho Kinase Inhibitors in the Treatment of Fuchs Dystrophy After Descemet Stripping Only. Cornea. 2019 May;38(5):529-534. doi: 10.1097/ICO.0000000000001883. PMID: 30720541.

7. Colby K. Descemet Stripping Only for Fuchs Endothelial Corneal Dystrophy: Will It Become the Gold Standard? Cornea. 2022 Mar 1;41(3):269-271. doi: 10.1097/ICO.0000000000002796. PMID: 34864799.

8. Artaechevarria Artieda J, Wells M, Devasahayam RN, Moloney G. 5-Year Outcomes of Descemet Stripping Only in Fuchs Dystrophy. Cornea. 2020 Aug;39(8):1048-1051. doi: 10.1097/ICO.0000000000002270. PMID: 31990847.

9. Iovieno A, Moramarco A, Fontana L. Descemet stripping only in Fuchs' endothelial dystrophy without use of topical Rho-kinase inhibitors: 5-year follow-up. Can J Ophthalmol. 2022 Dec;57(6):402-407. doi: 10.1016/j.jcjo.2021.06.010. Epub 2021 Jul 17. PMID: 34283965.