Evolution of therapies for the corneal endothelium: past, present and future approaches

Abstract

Corneal endothelial diseases are leading indications for corneal transplantations. With significant advancement in medical science and surgical techniques, corneal transplant surgeries are now increasingly effective at restoring vision in patients with corneal diseases. In the last 15 years, the introduction of endothelial keratoplasty (EK) procedures, where diseased corneal endothelium (CE) are selectively replaced, has significantly transformed the field of corneal transplantation. Compared to traditional penetrating keratoplasty, EK procedures, namely Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK), offer faster visual recovery, lower immunological rejection rates, and improved graft survival. Although these modern techniques can achieve high success, there are fundamental impediments to conventional transplantations. A lack of suitable donor corneas worldwide restricts the number of transplants that can be performed. Other barriers include the need for specialized expertise, high cost, and risks of graft rejection or failure. Research is underway to develop alternative treatments for corneal endothelial diseases, which are less dependent on the availability of allogeneic tissues – regenerative medicine and cell-based therapies. In this review, an overview of past and present transplantation procedures used to treat corneal endothelial diseases are described. Potential novel therapies that may be translated into clinical practice will also be presented.

Eye Banks: Future Perspectives

“…The availability of various treatment modalities is clinically significant, as each is more or less appropriate for different circumstances. Imaging techniques can potentially enable the individual chances of success of each therapy to be evaluated [28]. It appears that in the medium term the work of cornea banks is becoming more complex and will require a higher degree of specialisation.…”

“…Currently, most corneal transplants in Germany are posterior lamellar keratoplasties for diseases of the corneal endothelium [27], and, as such, this article outlines some examples of developments in replacing diseased corneal endothelia. One alternative to endothelial keratoplasty (for instance, Descemet membrane endothelial keratoplasty (DMEK)) is the use of cultured corneal endothelial cells, which are injected as a suspension into the anterior chamber [28,29]. After injection, the recipient must remain in a prone position for a few hours.…”

“…Corneal tissue would still need to be harvested following to-dayʼs established procedure, however, further processing would require specialised laboratory facilities including a GMP (good manufacturing practice) area and associated class A clean room [28]. The processes required for production will also need to meet all regulatory standards, just as is the case at present for quality assurance of further processing of donor corneas [10].…”

Biomaterials for corneal endothelial cell culture and tissue engineering

“…9 Another limitation of the cadaveric donor transplantation is the long-term risk of allogenic graft rejection and failure. 18 Transplant failure is often due to loss of hCECs from the donor layer. It has been reported that 30% of hCECs are lost within the first 6 months of transplantation.…”

Cost Burden of Endothelial Keratoplasty in Fuchs Endothelial Dystrophy: Real-World Analysis of a Commercially Insured US Population (2014–2019)

“…Novel, alternative treatments based on regenerative medicine and cell-based therapies are being developed for FECD. 14 For example, tissue-sparing surgical approaches, such as Descemet-stripping only (DSO), eliminate the need for transplanted endothelial replacement and provide an alternative strategy without the use of donor tissue. 15 Given the gap since previous assessments and the availability of new treatment options, an up-to-date robust assessment of the cost of transplant surgery can provide benchmark information to evaluate the cost-effectiveness of new-generation FECD treatments.…”