Recipient Endothelium May Relate to Corneal Clearance in Descemet Membrane Endothelial Transfer

What does the future hold for the treatment of Fuchs endothelial dystrophy; will ‘keratoplasty’ still be a valid procedure?

“…9 In other words, the recipient bare posterior stroma (denuded after descemetorhexis) was somehow re-endothelialized. 10 This 'spontaneous clearance' of the host cornea was observed only when the indication for surgery was FECD, whereas no improvement was seen in eyes operated on for bullous keratopathy. 10 This suggests that corneal clearance depended on the underlying pathogenesis responsible for the endothelial dysfunction, which may be explained by the host peripheral endothelium having a significant role in the early repopulation of the denuded recipient posterior stroma.…”

“…10 This 'spontaneous clearance' of the host cornea was observed only when the indication for surgery was FECD, whereas no improvement was seen in eyes operated on for bullous keratopathy. 10 This suggests that corneal clearance depended on the underlying pathogenesis responsible for the endothelial dysfunction, which may be explained by the host peripheral endothelium having a significant role in the early repopulation of the denuded recipient posterior stroma. However, the presence of a donor graft may be mandatory for the migration of a recipient peripheral endothelium over denuded posterior stroma, as it appeared to be completely absent in a patient in whom a DMEK procedure was interrupted after making the descemetorhexis (ie, without graft implantation), 9 and only partly successful in a nonrandomized, prospective clinical study, where patients underwent a descemetorhexis without endothelial keratoplasty.…”

“…9,17 If, on the other hand, recipient peripheral endothelial cells do need to be stimulated toward migratory and/or regenerative activity by the donor tissue, a central descemetorhexis in combination with free-floating donor tissue, also known as 'Descemet membrane endothelial transfer' (DMET), 10 might be effective in restoring vision (Figures 2a-c). Alternatively, the transplantation of cultured donor-derived corneal endothelial cells or differentiated stem cells 59 may be future options.…”

“…7 However, we would like to challenge this concept; in our opinion, the endothelial cells are not 'dystrophic' per se, but in most cases may have acquired a dysfunction instead. This idea is based on recent clinical observations showing the important role of the 'dystrophic' host endothelium in corneal clearance after endothelial keratoplasty, [8][9][10] and current knowledge regarding the pathophysiology of FECD. 11,12 More detailed knowledge of FECD etiology might even open the door to the development of new, less invasive treatment modalities, and have far reaching consequences for patients, corneal surgeons, and eye banks.…”

“…This procedure is known as 'Descemet membrane endothelial keratoplasty' (DMEK). [14][15][16] Clinical observations made after DMEK [8][9][10] quite unexpectedly led us to reconsider the presumption that FECD is an irreversible pathological condition owing to 'dystrophic' endothelial cells. In DMEK eyes, a more rapid clearance was seen in the corneal periphery than in the central cornea overlying the transplant.…”