BlueCross BlueShield of Tennessee Medical Policy Manual

Endothelial Keratoplasty

DESCRIPTION

Endothelial keratoplasty, also referred to as posterior lamellar keratoplasty, is a form of corneal transplantation in which the diseased inner layer of the cornea, the endothelium, is replaced with healthy donor tissue.

The cornea, a clear, dome-shaped membrane that covers the front of the eye, is a key refractive element of the eye. Layers of the cornea consist of the epithelium (outermost layer); Bowman’s layer; the stroma, which comprises approximately 90% of the cornea; Descemet’s membrane; and the endothelium. The endothelium removes fluid from the stroma and limits its entry, thereby maintaining the ordered arrangement of collagen and preserving the cornea’s transparency. Diseases that affect the endothelial layer include Fuchs’ endothelial dystrophy, aphakic and pseudophakic bullous keratopathy (corneal edema following cataract extraction), and failure or rejection of a previous corneal transplant.

Specific techniques for preparing donor tissue include Descemet stripping endothelial keratoplasty (DSEK), Descemet stripping automated endothelial keratoplasty (DSAEK), or Descemet’s membrane endothelial keratoplasty (DMEK). Laser procedures called femtosecond laser-assisted corneal endothelial keratoplasty (FLEK) or femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK) have also been proposed for utilization in tissue preparation.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

The evidence is insufficient to determine if Femtosecond laser-assisted corneal endothelial keratoplasty (FLEK) and femtosecond and excimer lasers‒assisted endothelial keratoplasty (FELEK) improve health outcomes.

SOURCES

American Academy of Ophthalmology (2009) Ophthalmic Technology Assessment: Descemet’s Stripping Endothelial Keratoplasty: Safety and Outcomes. Ophthalmology 2009;116:1818–1830.

Ang, M., Lim, F., Htoon, H. M., Tan, D., & Mehta, J. S. (2015). Visual acuity and contrast sensitivity following Descemet stripping automated endothelial keratoplasty. British Journal of Ophthalmology. Abstract retrieved July 22, 2015 from PubMed database.

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2016). Endothelial keratoplasty (9.03.22). Retrieved April 10,2017 from BlueWeb. (17 articles and/or guidelines reviewed)

Kim, S., Lim, S., Byun, Y., and Joo, C. (2016) Comparison of long-term clinical outcomes between descemet’s stripping automated endothelial keratoplasty and penetrating keratoplasty in patients with bullous keratopathy. Korean Journal of Ophthalmology. 2016;30(6):443-450. (Level 4 evidence)

Nahum, Y., Mimouni, M., & Busin, M. (2015). Risk factors predicting the need for graft exchange after Descemet stripping automated endothelial keratoplasty. Cornea, 34 (8), 876-879. Abstract retrieved July 22, 2015 from PubMed database.

Nanavaty, M., Wang X., and Shortt, A. (2014, December) Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy. Cochrane Database System Review. ; 2: CD008420 (Level 2 evidence)

National Institute for Health and Care Excellence (2009, June) Interventional procedure guidance: Corneal endothelial transplantation. Retrieved July 13, 2016 from  http://nice.org.uk.

Nielsen, E., Ivarsen, A., Kristensen, S., & Hjortdal, J. (2016). Fuchs’ endothelial corneal dystrophy: a controlled prospective study on visual recovery after endothelial keratoplasty. Acta Opthalmologica, 2016 June 7. Doi: 10.1111/aos.13126. [Epub ahead of print]. Abstract retrieved July 13, 2016 from PubMed database.

Van Dijk, K., Ham, L., Tse, W.H., Liarakos, V.S., Quilendrino, R., Yeh, R.Y., & Melles, G.R. (2013). Near complete visual recovery and refractive stability in modern corneal transplantation: Descemet membrane endothelial keratoplasty (DMEK). Contact Lens & Anterior Eye, 36 (1), 13-21. Abstract retrieved July 13, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  4/14/2011

MOST RECENT REVIEW DATE:  6/8/2017

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.