• Cornea/External Disease

    Investigators report the safety and efficacy of descemetorhexis without donor tissue as a primary treatment for Fuchs endothelial dystrophy.

    This new technique removes the dysfunctional central endothelial cells and guttata, leaving the peripheral Descemet’s membrane intact, so that healthy cells can repopulate the entire posterior corneal surface. The procedure involves no implantation of donor tissue and thus no risk of rejection. The current preferred surgical modalities are Descemet membrane endothelial keratoplasty (DMEK) and Descemet’s stripping endothelial keratoplasty (DSAEK), which carry a risk of graft detachment and failure despite their improvement over penetrating keratoplasty (PK).

    Study design

    This prospective study included 12 eyes of 11 Fuchs endothelial dystrophy patients who underwent a primary central descemetorhexis of 4 mm or less. If a patient’s cornea failed to clear by 2-3 months postop, therapy with a topical rho-kinase (ROCK) inhibitor (either Y-27632 or ripasudil) was initiated. Endothelial keratoplasty was chosen as a final salvage option for unsuccessful cases.

    Outcomes

    Between 2 and 9 months postoperatively, 9 of 12 eyes (75%) showed spontaneous clearance of corneal edema. Of the remaining 3 eyes, 2 failed to clear by 2 and 3 months and were treated with topical ripasudil. Both subsequently experienced clearance of edema. The remaining eye failed to clear by month 5 and did not improve with Y-27632; it ultimately required endothelial keratoplasty.  

    Eyes that achieved corneal clearance demonstrated improvement in mean BCVA from 0.26 logMAR at baseline to 0.13 postoperatively (follow-up range 4–30 months). Central corneal thickness improved from a mean of 615 microns preoperatively to 577 microns at study end, and there was no change in refractive mean spherical equivalent.

    Limitations

    This is a small study, but it bolsters growing evidence that primary descemetorhexis without grafting may have a role in treating Fuchs endothelial dystrophy. The clinical results with the ROCK inhibitors were intriguing, but more evidence is needed to define the best use of this drug class in a real-world setting.

    Clinical significance

    Given these results, and taking into account findings from other research groups, primary descemetorhexis should be considered for treatment of Fuchs endothelial dystrophy in patients whose corneal guttae have not extended to the periphery.

    While it would be ideal to have a clinical trial examining the procedure in comparison with DMEK, for now practitioners may consider offering this to Fuchs patients who are willing to wait for corneal clearance and can tolerate a second procedure should their eyes fail to clear.