Referral Questions

Endothelial dystrophy – When should I refer a patient?
In patients with an endothelial dystrophy, both objective measurements and the subjective experience of visual loss are important. The visual acuity threshold of 30 percent or less for a penetrating keratoplasty does not apply to posterior lamellar corneal transplantation. (Advanced) DMEK surgery is less invasive than penetrating keratoplasty, which means an endothelial dystrophy can usually be treated effectively. A majority of patients achieve relatively rapid and better visual recovery. Timely treatment avoids further deterioration of the patient’s activities of daily living.

Cataract extraction first, or DMEK first?
You can refer patients with an endothelial dystrophy and cataracts to us for an assessment of the cornea. During an initial consultation, we will draft a treatment plan. If the cataract is advanced, we will ask the patient to return to his or her referring ophthalmologist for a cataract extraction. We tell the patient that his or her vision may improve or decline after the cataract surgery, depending on the severity of the corneal dystrophy. If indicated, we can perform (advanced) DMEK surgery starting six weeks after the cataract operation.
If the travel distance is too great for an initial consultation alone, we can also discuss the best course of treatment with you: cataract extraction first, or DMEK first.
We can also perform (advanced) DMEK in the absence of cataracts. A cataract extraction is not a prerequisite for DMEK surgery.

Why don’t you perform cataract extraction and DMEK in a single session?
In our clinical setting, we prefer not to combine cataract removal and DMEK transplantation in a single session for several reasons.

• Cataract surgery requires the use of viscoelastics, which in our experience may interfere with the adherence of the graft to the posterior cornea and thus increases the risk of graft detachment.
• The pressurization of the eye with air after DMEK surgery, which is a very important step in order to achieve proper graft attachment, may be compromised.
• Some patients are satisfied with the vision achieved after cataract surgery, which postpones the need for corneal transplantation.

Keratoconus – What is Bowman layer transplantation?
Bowman layer transplantation is one of our newest techniques for patients with advanced keratoconus. The technique consists of implanting an isolated Bowman layer into a manually dissected mid-stromal pocket. This procedure achieves a reduction and stabilization of corneal ectasia in eyes with progressive, advanced keratoconus. Bowman layer transplantation enables continued contact lens wear. In addition, Bowman layer transplantation postpones riskier procedures such as penetrating keratoplasty or deep anterior lamellar keratoplasty. For further information about this technique, see the following article:
van Dijk K, Liarakos VS, Parker J, Ham L, Lie JT, Groeneveld-van Beek EA, Melles GRJ. Bowman layer transplantation to reduce and stabilize progressive, advanced keratoconus. Ophthalmology 2015;122:909-17.

Keratoconus – When should I refer a patient?
The criteria for referring a keratoconus patient are a progression of the disease, contact lens intolerance, and/or a decline in visual acuity. If surgical treatment is not (yet) indicated, we will follow the patient’s progression through regular pentacam screenings.

How will you keep me informed, and what about postoperative care?
After our initial consultation with your patient, we will send you a medical letter with our findings and proposed treatment plan. After the corneal transplant procedure, our medical team will inform you of the outcome.
One week after surgery, your patient will return home. As the referring doctor, you can perform the subsequent postoperative checkups. We would greatly appreciate it if you keep us informed of the clinical outcomes such as visual acuity, endothelial cell count and graft status. Your patient is also welcome to visit our clinic for his or her further checkups.
Postoperative checkups take place one, three, six, nine and twelve months after the operation and every six months thereafter.