Should You Take a DSEK Course?

Pioneers drive adoption by sharing their knowledge.

BY JERRY HELZNER, SENIOR EDITOR

The stunning, rapid and almost universal adoption of Descemet's stripping (automated) endothelial keratoplasty (DSEK/DSAEK) for partial corneal transplants in numerous cases that involve endothelial cell failure has led to a great demand for training in this advanced procedure. DSEK/DSAEK has proven to be especially valuable for treating such common conditions as Fuchs' endothelial dystrophy and Pseudophakie bullous keratoplasty.

Fortunately the demand for DSEK/DSAEK training is being superbly met by three American transplant pioneers described in a previous article in this magazine (June 2009) as belonging on the “Mount Rushmore” of corneal transplantation. The trio includes Mark Gorovoy MD, of Fort Myers, Fla., Francis Price, MD, of Indianapolis, and Mark Terry, MD, of Portland, Ore. The fourth pioneer on this Mount Rushmore is Gerrit Melles, MD, of the Netherlands, who also offers training courses in Europe.

And unlike most pioneers, whose work is only recognized years after their accomplishments, Drs. Gorovoy, Price and Terry are all in active practice and at the peak of their skills and willing to share their knowledge with the corneal specialists who come to them from all over the globe.

“Between the three of us, we have trained hundreds of surgeons from around the world over the last several years,” says Dr. Price.

Dr. Price provides DSAEK instruction in the wet lab.

“Actually I have seen a drop-off recently in requests for training,” says Dr. Gorovoy. “We have trained so many surgeons in DSEK that they have been able to go back to the universities and train their own residents and fellows.”

Who Takes These Courses?

The typical attendee at a DSEK training course is usually a corneal specialist who has experience performing full-thickness penetrating keratoplasty (PK), which was the procedure of choice for corneal transplant prior to the advent of DSEK about a decade ago. Many attendees have also been corneal fellows.

“I would say that about 95% of the doctors who take my DSEK course have done PK and now want to learn DSEK,” says Dr. Price. “And about 25% have also done some DSEK and now want to improve their technique.”

Thomas Mauger, MD, chairman of the department of ophthalmology at Ohio State University's Havener Eye Institute, is typical of the corneal specialists who have taken Dr. Price's DSEK course.

“I am a full-time cornea specialist at OSU and have a lot of experience with cornea surgeries,” says Dr. Mauger. “I had taken a course with Dr. Melles in Rotterdam and had started to do DSEKs. I knew Dr. Price had a lot of experience and felt an additional intensive experience would be helpful in refining my techniques.

Dr. Terry (right) performs DSAEK while the surgeon being trained observes the procedure through the microscope.

Dr. Mauger found that Dr. Price's course was well organized and comprehensive. He says it gave him “a significant jump on the learning curve that we all go through” on new procedures.

“I have cornea fellow that I train in these techniques and I find that I learn a lot through the process of teaching others,” notes Dr. Mauger. “I am sure Dr. Price has found this to be true. There is a user group that the course participants have to discuss challenging cases and other issues — this is also helpful.”

And this from Steven Silverstein, MD, of Kansas City, Mo.:

“I took Dr. Price's DSEK course two years ago. I have been doing all other types of transplants since 1990 and have done many hundreds of grafts over the years at least, including full thickness procedures, lamellars, etc. I have not had the need to contact Dr. Price since, but I know I could if I needed to.”

Dr. Silverstein says his principal purpose in learning this new skill was to add this procedure to his portfolio for patients who likely will benefit from DSEK over full-thickness procedures in the setting of endothelial dysfunction. He chooses DSEK for these patients due to its faster healing and visual recovery, less induced astigmatism, the potential for a lower infection and rejection rate, as well as greater protection in the face of blunt trauma.

Instructors' Perspectives

In choosing a DSEK course, it is worth noting that Dr. Gorovoy is located in southwest Florida, Dr. Price in Indianapolis and Dr. Terry in Oregon, offering US attendees the opportunity to take one of the three courses without having to travel a great distance.

A DSAEK procedure showing donor cornea centered in the anterior chamber.

As Dr. Gorovoy wryly notes, the DSEK courses taught by the three transplant specialists are “similar but different.”

Dr. Terry teaches a DSEK technique that he says must be exactly followed to achieve the low graft dislocation rate and graft failure rate that he and his trainees have achieved.

“Over 500 cases, this method has produced a dislocation rate of 1.8% and a primary graft failure rate of zero,” he asserts. “It is not my hand that is producing these outcomes. It is the technique — and that is why I emphasize that it must be strictly followed.”

Surgeons attending Dr. Terry's DSEK course usually stay for one-and-a-half to two days. He limits the course to two trainees at any one time so that they can be “right at the microscope” observing live surgeries.

Dr. Price teaches a two-day course that covers all aspects of DSEK, including the surgery's mechanics and aesthetics, potential complications, IOP management and postop care.

“The course includes practice in the wet lab, observing live surgery, examining postops and problem-solving,” says Dr. Price. He does not have a strict “Price method” but instead offers his trainees some latitude when alternative techniques can be used with equal success.

Dr. Price also encourages surgeons to bring an assistant, who can attend for a reduced fee.

“There's a lot of information to absorb,” he says. “I think it helps to have an assistant who is knowledgeable with the instruments and the overall procedure.”

“The real value of the course is the difference it has made for patients,” says Dr. Price. “DSEK is really so much better than PK in these cases.”

Dr. Gorovoy's DSEK course is one day, and involves demonstrating surgical techniques, observing surgery, folding tissue, wet lab and seeing postops.

Cutting donor tissue for DSAEK with a microkeratome.

“My relationship with the surgeons I train does not end with the course,” he says. “We develop ongoing relationships. This is a humbling procedure for even experienced surgeons. I encourage the surgeons I train to begin with the most routine cases to get through the learning curve.”

Dr. Gorovoy finds it interesting that a number of the surgeons he has trained in DSEK are later able to make their own contributions in advancing the procedure.

He says the expansion of knowledge to a larger number of transplant surgeons motivates him to keep teaching.

Contacts for Courses

All three of the DSEK courses cost in the $2,500 to $3,000 range but it is best to obtain the specifics — such as travel tips and what you might need to bring with you — from the course coordinators listed below:

Dr. Gorovoy's course is coordinated by Robet Lehet, who can be reached via e-mail at blehet@gorovoyeye.com. The practice Web site, www.gorovoyeye.com, also contains dates and information for Dr. Gorovoy's DSEK course.

Dr. Price's DSEK course is coordinated by Wendy Mickler at wendymickler@pricevisiongroup.net. The practice Web site, www.pricevisiongroup.com, also contains information on Dr. Price's courses.

Dr. Price also teaches several courses a year on Descemets membrane endothelial keratoplasty (DMEK), a more advanced and difficult partial-transplant procedure.

Surgeons taking the DMEK course must have extensive experience in DSEK. In addition, Dr. Price teaches one course each year in deep anterior lamellar keratoplasty (DALK), which is an increasingly popular treatment for keratoconus, corneal scarring and poor LASIK outcomes.

Dr. Terry's DSEK course is coordinated by David Davis-Boozer at ddboozer@deverseye.org. Dr. Terry's Web site, www.dlek-dsek.com, contains information on Dr. Terry's DSEK and DALK courses. OM