endothelial layer
Rebuilding the Endothelial Layer
Repair may be better than a full corneal transplant.
BY RICHARD FICHMAN, M.D.

The concept of rebuilding the endothelial layer represents a major paradigm shift in the way that surgeons can assist patients with corneal damage. The shortened healing time, clarity of postoperative vision and vast improvement in patient comfort during recovery are the key reasons all surgeons should evaluate endothelial repair in addition to the traditional full cornea transplant.

Full illumination (top) and slit beam (bottom) photos of a DSEK eye 3 months after surgery. The full illumination image indicates the graft clarity and absence of any sutures. The large arrows indicate the edge of the graft. The slit beam illuminates the donor tissue behind the recipient cornea, and the small arrow indicates the interface between the donor and recipient.

Recovery Time and Refractive Error

Patients who have come through cataract surgery with complications such as aphakic bullous keratopathy, as well as those suffering from toxic anterior segment syndrome or Fuch's are all good candidates for endothelial layer surgery. In all of these cases, vision loss and impairments stem from endothelial dysfunction. Therefore, it makes sense for a surgeon to evaluate removing the problem at its source — the endothelium — rather than immediately planning to remove a large part of the ocular system in a full corneal transplant.

I have observed within my own practice that patients who undergo the endothelial procedure typically recover in 1 to 2 weeks, vs. the 18 months (or more) commonly required as a recovery period for patients who receive a corneal transplant — about 97% faster. It would be difficult to find a patient who would not be interested in recovering and resuming a normal life in a fraction of the standard recovery time. Why the difference? Morphologically, if you do a full corneal transplant, you are creating huge changes in corneal topography and in refractive error, leading to high levels of astigmatism. However, the endothelial approach causes minimal change in corneal architecture, so the recovery time is much less dramatic.

In addition, because rebuilding the endothelial layer causes little change in refractive error, patient's postop vision typically is about the same as it was before the corneal damage occurred. Thus, if a patient was wearing a specific spectacle prescription prior to the damage and endothelial procedure, he or she will wear a similar prescription post-recovery.

Does it really work? In my practice, I had a patient who literally was not able to see hand movements at a distance of 2 feet. After endothelial repair at the Price Vision Center in Indianapolis, she was 20/40, after a recovery time of about 2 weeks.

How to Think About Endothelial Layer Repair

I have said it before, and will repeat — this procedure represents a major paradigm shift in how surgeons can approach and work with patients with corneal damage. Consider the analogy to a fireplace with a blockage — a full corneal transplant would be like backing up a truck and ripping the fireplace out of the house, from top to bottom, and replacing it with a new fireplace that does not quite fit the existing space. The original problem is gone, but what remains is major structural damage with an ill-fitting solution. On the other hand, the endothelial approach is like sending a chimney sweep up the fireplace to remove the blockage, resulting in no changes to the structure of the fireplace or the home. The benefit to the patient — analogous to the home — is that the risk is lower. If, however, a patient undergoes an unsuccessful endothelial procedure, a full corneal transplant is still an option.

Additionally, the endothelial procedure may be an innovative solution for patients with failing transplants. An endothelial rebuild may solve the problems with the transplant, and allow the patient to resume normal vision. I recently saw a patient who went through this process. Her graft had failed due to rejection, and instead of an entire full-thickness graft, endothelial repair resolved her issue. Her eyesight is now good, improving to 20/20 from hand movement. Her spectacle prescription remains unchanged and she healed in several weeks.

Progressive Solution

Although the endothelial procedure became available several years ago, skepticism persists, mostly because few surgeons are trained in the procedure (for the record, I do not perform endothelial repair at my practice — yet).

Ultimately, the endothelial approach requires a new mindset, one in which a surgeon uses the best possible approach to solve a patient's particular problem, instead of using a technique simply because it is widely practiced and accepted. In my opinion, endothelial layer repair presents a hard-to-lose situation for a patient, in that if the rebuilt endothelial layer does not provide optimal results, the full corneal transplant remains as an alternative solution. Thus, rather than taking away solutions, we are simply adding a new technique to our arsenal. Endothelial layer repair represents a progressive solution that makes patients vastly more comfortable and preserves their vision — top priorities for every surgeon.

Richard A. Fichman, M.D., practices at the Fichman Eye Center in Manchester, Conn. and can be reached at rfichman@hotmail.com or at (877) 342-4626.