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    Graft failure: Techniques for best outcomes the second time around

    Indianapolis—When a graft fails, surgeons have three factors to consider: the reason for the graft failure, the chances of success with a second surgery, and what has to be done differently to ensure the success of a new graft, said Francis Price Jr., MD.

    Endothelial keratoplasties, Descemet membrane endothelial keratoplasty (DMEK), and Descemet’s stripping endothelial keratoplasty (DSEK) seem to be better choices than penetrating keratoplasty (PK) for dealing with a failed graft, said Dr. Price, who is in private practice, Indianapolis.

    However, surgeons must be aware that the presence of a glaucoma tube or shunt can dramatically reduce the graft survival rates in these eyes, he noted.

    Related: What’s new in corneal surgery in 2015

    Dr. Price emphasized the importance of ruling out environmental causes of graft failure. These include lack of follow-up, not instilling the appropriate medications, eye rubbing or squeezing in patients who underwent endothelial keratoplasty, and the absence of an essential blepharospasm.

    Another possible environmental cause of graft failure is patient use of drugs for memory improvement or Alzheimer’s disease. Memantine, (Namenda, Actavis) can lead to repeated graft failures, he noted, because the drugs seem to affect endothelial cells and cause primary failures in virgin corneas and in those that underwent repeated grafts until the medicines are stopped.

    When treating a failed graft, Dr. Price believes that less is more—that is, the least invasive approach is best. These approaches in ascending order of complexity are DMEK, DSEK, PK, and the Boston KPro.

    Recent news: CA-CXL expands candidates to eyes with thin corneas

    “Typically, the least invasive way will also provide the best outcomes,” he said.

    “There are four scourges associated with PK,” Dr. Price said. “DSEK eliminates the ocular surface disease problems and structural deficiencies, and DMEK has greatly diminished the risk of immunologic graft rejection and glaucoma that are associated with PKs.”

    PKs are associated with an 18% failure rate because of ocular surface disease.

    Choosing PK, DSEK, or DMEK

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