Video Transcript
Editor’s note –This transcript has been edited for clarity.
Rachel Babij, MD, PhD: Hi, I’m Dr. Rachel Babij, one of the residents here at NYU Department of Ophthalmology, and we’re here for an installment of NYU Department of Ophthalmology Journal Club, where we will be sitting down with leaders in the field to discuss some of their recent work. Today, I’m here with my faculty mentor, Dr. Andrea Blitzer, as well as our visiting professor, Dr. Deepinder Dhaliwal, who is visiting us from the University of Pittsburgh School of Medicine and the UPMC Vision Center. Today, we’re going to talk about her recent work on longterm outcomes in a novel surgical management for Fuchs dystrophy. But I thought we could maybe just start by talking a little bit about how surgical management for Fuchs dystrophy has evolved.
Deepinder Dhaliwal, MD, LAc: First of all, thank you so much, Rachel and Andrea, for inviting me to be here at NYU. I’m really honored to be here. So, I learned a lot about Fuchs dystrophy and surgical management from the chair of your department, Professor Katherine Colby, and really she gave this amazing lecture where she spoke about Descemet stripping only, and that concept that peripheral endothelial cells could migrate into the central cornea after you remove it to improve the functioning of the central cornea. And it was novel. It was really exciting. And then I jumped in. I remember my residency. We were doing PKPs for Fuchs dystrophy, and when I first started in practice, that’s what we were doing. And so, I’ve had a long enough career where I remember doing many, many sutures for Fuchs dystrophy, and then transitioning to DSEK and then to DMEK. And now we offer patients who are candidates, we offer them DSO as well. And so it’s been such an exciting journey. And I tell all my patients that Fuchs dystrophy is my favorite corneal dystrophy to deal with, because we have such amazing options. And the biology is very, very interesting.
Rachel Babij, MD, PhD: Can you walk us through, kind of, the major findings of the study?
Deepinder Dhaliwal, MD, LAc: Absolutely. So, we started doing DSO in 2016, and we wanted to understand the long-term results. So we had an amazing fellow, Dr. Fareedah Hakim, who is now at the University of Michigan on faculty, and she said, “Dr. Dhaliwal, we should really look at your results, because you have patients who come back and they’re over 5 years out. So let’s, let’s look at the results, because really, the proof is in the pudding.” We really wanted to understand how many of these patients went on to need DMEK, how many maintained clear corneas over time. And that’s what really we don’t understand. If the peripheral endothelial cells are migrating and repopulating that central denuded four millimeters, then what happens eventually? Do they stay? Do they go? And so, we did an extensive chart review, and it was a retrospective case series, and we looked at that finding. The punchline is basically out of the 12 that responded initially. We had a 92% success rate initially from DSO, 10 of 13 of them, so 77%, remained clear at 5 years out. So that’s a wonderful statistic that I tell my patients now, that, you know, you have a pretty good chance of staying clear even after 5 years. So, patients are heartened. You know, this is some of the patients that we offer DSO. In those patients who had steroid-induced glaucoma in their first eye after an EK procedure, they were dealing with glaucoma and, you know, a transplant, and so they were super excited to have a surgery where they did not need any type of immunosuppression. They didn’t have to have a transplant. And so they were, they were quite jazzed. For many of them, it worked out very well.
Andrea Blitzer, MD: So, these are patients relatively early in our understanding of DSO and how that works. Has your surgical technique or anything about the way that you do DSO changed since those early patients?
Deepinder Dhaliwal, MD, LAc: Thank you for that question. That’s a great question. You know, I think we were lucky because I watched Kathy Colby’s videos, and I noticed she was very, very gentle with her technique. So even though our technique has evolved, we’re no longer using a Cinski, a blunt Cinski, to score 360. We’re now just starting the flap and then continuing it around with forceps. I think we really got lucky, because we were very gentle in our stripping, so we did not have significant scarring in those initial patients. So, I think we were pretty fortunate, but definitely since the early days, I mean, if you engage stromal fibers, you will definitely have some reaction in that area. And I have seen patients who have prolonged corneal edema in that area, and it’s hard for the endothelial cells to migrate. So that’s a great question. I think just being very gentle with your technique is really important.
Andrea Blitzer, MD: Do you tend to use rho kinase inhibitors in these patients? Because when you started these DSOs, I don’t think we had—were using rho kinase inhibitors at the time. So what’s your practice pattern like now?
Deepinder Dhaliwal, MD, LAc: Right now, I tell everybody that they’ll have a better chance of success if they use the rho kinase inhibitors. But since we don’t have one that’s FDA approved, I’m able to follow their response to a treatment if they choose to obtain this from Japan. And so that’s what we’re doing. We’re really strongly recommending the adjunctive use of rho kinase inhibitors. Now, having said that, there are some series that have been published that show reasonable success rates, even without using a ROCK inhibitor. I will say, though, you know, for the initial series, these patients had enough edema that I would have offered DMEK to these patients over DSO. So these are not just, you know, central guttae confluent and not significant stromal edema. I mean, they all had edema enough that they were waking up with blurred vision in the morning, and enough that we might go straight to the OR with a transplant. So, it was significant. And I think that now, since we’re getting better, I think some people are just removing, you know, doing a DSO for mainly just the confluent guttae, and they may not have that visual fluctuation in the mornings.
Andrea Blitzer, MD: Now that you see the longevity or that we’re starting to get with DSO, does it change the way you counsel your patients at all?
Deepinder Dhaliwal, MD, LAc: Honestly, I’m a proponent of DSO. I was a proponent from the beginning, because I love the holistic aspect of that, and patients love the fact that they’re able to heal themselves. So, I have a lot of patients that are really interested in not having, you know, a transplant, if you will. So this has been a wonderful adjunct that I can actually hang my hat on a statistic. So, I, you know, we looked at our series, and here we go. We know that 77% of patients in our hands, in our series, will remain clear at 5 years.
Andrea Blitzer, MD: That’s great, something definitely that we can pass along to our patients.
Rachel Babij, MD, PhD: Yeah, incredible results. Unfortunately, I think we are out of time, but thank you so much for being here with us, and thank you all for listening. That concludes our Journal Club here. I’m Rachel Babij. This is Dr. Andrea Blitzer and Dr. Deepinder Dhaliwal.
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