To evaluate the clinical outcome of 500 consecutive cases after Descemet's membrane endothelial keratoplasty (DMEK) and the effect of technique standardization.
Prospective, interventional case ...series at a tertiary referral center.
A total of 500 eyes of 393 patients who underwent DMEK for Fuchs' endothelial corneal dystrophy, bullous keratopathy, or previous corneal transplant failure.
Best-corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications were evaluated before and 1, 3, and 6 months after DMEK.
Comparison between 2 groups (group I: cases 1-250, outcome of "early surgeries" during transition to technique standardization; group II: cases 251-500, outcome of "late surgeries" after technique standardization).
At 6 months, 75% of eyes reached a BCVA of ≥20/25 (≥0.8), 41% of eyes achieved ≥20/20 (≥1.0), and 13% of eyes achieved ≥20/18 (≥1.2) (n=418) when excluding eyes with ocular comorbidities (n=57). When including all available eyes at 6 months (n=475), 66% of eyes reached a BCVA of ≥20/25 (≥0.8), and 36% of eyes achieved ≥20/20 (≥1.0). Mean ECD decreased by 37% (±18%) to 1600 (±490) cells/mm2 (n=447) at 6 months (P<0.001). Postoperative pachymetry averaged 525 (±46) μm compared with 667 (±92) μm preoperatively (P<0.001). None of these parameters differed among the 2 groups (P>0.05). (Partial) graft detachment presented in 79 eyes (15.8%), and 26 eyes (5.2%) required a secondary surgery within the first 6 months (re-bubbling in 15, secondary keratoplasty in 11). With technique standardization, the postoperative complication rate decreased from 23.2% to 10% (P<0.001) and the rate of secondary surgeries decreased from 6.8% to 3.6% (P=0.10).
In comparison with earlier endothelial keratoplasty techniques, DMEK may consistently give higher visual outcomes and faster visual rehabilitation. When used for the extended spectrum of endothelial pathologies, DMEK proved feasible with a relatively low risk of complications. Technique standardization may have contributed to a lower graft detachment rate and a relatively low secondary intervention rate. As such, DMEK may become the first choice of treatment in corneal endothelial disease.
To evaluate the 10-year graft survival and clinical outcomes of the first case series after Descemet membrane endothelial keratoplasty (DMEK).
Retrospective, interventional case series.
After ...excluding the very first 25 DMEK eyes that constitute the technique learning curve, the following 100 consecutive primary DMEK eyes (88 patients) were included. Main outcome parameters (survival, best-corrected visual acuity BCVA, central endothelial cell density ECD, and central corneal thickness CCT) were evaluated up to 10 years postoperatively, and postoperative complications were documented.
At 5 and 10 years after DMEK, 68 and 57 of 100 eyes, respectively, were still available for analysis. Of those eyes, 82% and 89% reached a BCVA of ≥20/25 (decimal VA ≥0.8) at 5- and 10 years postoperatively, respectively. Preoperative donor ECD decreased by 59% at 5 years and 68% at 10 years postoperatively. CCT averaged 668 ±74 μm preoperatively and 540 ± 33 μm and 553 ± 43 μm at 5 and 10 years, respectively, after surgery. Within 10 years, 4% of eyes developed allograft rejection, no primary graft failures occurred, and 6% of the eyes developed secondary graft failure. Graft survival probability was 0.83 (95% confidence interval CI, 0.75-0.92) and 0.79 (95% CI, 0.70-0.88) at 5 and 10 years postoperatively, respectively.
Most eyes that underwent surgery in the pioneering phase of DMEK showed excellent and stable clinical outcomes with low postoperative complication rates and promising graft longevity over the first decade after surgery. This suggests that DMEK may be a safe long-term treatment option for corneal endothelial diseases.
To report the 5-year graft survival and clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK).
A retrospective, interventional case series was performed at a tertiary referral ...center. Five hundred eyes of 393 patients that underwent DMEK for Fuchs endothelial corneal dystrophy, bullous keratopathy, failed previous corneal transplants other than DMEK, or other indications were evaluated for graft survival, best-corrected visual acuity (BCVA), endothelial cell density, postoperative complications, and retransplantation rate.
Kaplan-Meier analysis demonstrated an estimated survival probability of 0.90 95% confidence interval, 0.87-0.94 for the entire cohort at 5 years after DMEK. At this time point, 82% of the eyes achieved a BCVA of ≥20/25 (0.8), 54% achieved ≥20/20 (1.0), and 16% achieved ≥20/17 (1.2). BCVA continued to improve from 6 to 36 months after DMEK surgery (P ≤ 0.005) and then remained stable up to 60 months postoperatively (P > 0.08). Preoperative donor endothelial cell density averaged 2530 (±210) cells/mm and decreased by 37% at 6 months, 40% at 1 year, and 55% at 5 years after DMEK surgery (P < 0.001 between all follow-up time points). During the study period, allograft rejection episodes developed in 2.8% of the eyes, primary graft failure occurred in 0.2%, and secondary graft failure in 2.8% of the eyes. Re-keratoplasty was required in 8.8% of the eyes.
Five-year graft survival after DMEK is high, and visual acuity outcomes remain excellent and are accompanied by a low longer-term complication rate.
To evaluate the clinical outcome of 500 consecutive cases up to 2 years after Descemet membrane endothelial keratoplasty (DMEK) and to assess which parameters may have influenced the clinical ...outcome.
From a group of 500 eyes (393 patients), which underwent DMEK for Fuchs endothelial corneal dystrophy (FECD), bullous keratopathy, failed corneal transplants and other indications, clinical outcomes best-corrected visual acuity (BCVA), central endothelial cell density (ECD), and central corneal thickness were evaluated before, and at 6, 12, and 24 months after DMEK and postoperative complications were documented.
At 12 months postoperatively, 81% of eyes reached a BCVA of ≥20/25 (≥0.8), 49% ≥20/20 (≥1.0), and 15% ≥20/18 (≥1.2) (n = 396) and remained stable up to 24 months (P = 0.828). Compared with preoperative ECD, mean postoperative ECD decreased by 37 (±18)%, 40 (±18)%, and 45 (±18)% at 6, 12, and 24 months, respectively (P < 0.05 for all time points). Surgery indication and graft attachment status were related to postoperative BCVA and ECD results. Eyes with FECD and attached grafts showed better BCVA outcomes and higher ECD (P < 0.05). Central corneal thickness decreased by 20 (±11)% to 525 (±46) μm from preoperative to 6 months postoperatively and remained stable thereafter (P > 0.05). Within the study period, retransplantation was required in 32 eyes (6.4%). Principal longer-term complications were secondary graft failure (1.4%) and allograft rejection (1.4%).
Clinical outcomes remain excellent up to 2 years after DMEK, in particular for eyes operated on for FECD and with completely attached grafts.
To describe the clinical outcome and complications of repeat Descemet membrane endothelial keratoplasty (re-DMEK).
Retrospective case series study at a tertiary referral center.
From a series of 550 ...consecutive DMEK surgeries with ≥ 6 months follow-up, 17 eyes underwent re-DMEK for graft detachment after initial DMEK (n = 14) and/or endothelial graft failure (n = 3). The outcomes were compared with an age-matched control group of uncomplicated primary DMEK surgeries.
The re-DMEK eyes were evaluated for best-corrected visual acuity (BCVA), densitometry, endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications.
Feasibility and clinical outcome of re-DMEK.
In all eyes, re-DMEK was uneventful. At 12 months, 12 of 14 eyes (86%) achieved a BCVA of ≥ 20/40 (≥ 0.5); 8 of 14 eyes (57%) achieved ≥ 20/25 (≥ 0.8), 3 of 14 eyes (21%) achieved ≥ 20/20 (≥ 1.0), and 1 eye (7%) achieved 20/17 (1.2); 5 eyes were fitted with a contact lens. Average donor ECD decreased from 2580 ± 173 cells/mm(2) before to 1390 ± 466 cells/mm(2) at 6 months after surgery, and pachymetry from 703 ± 126 μm to 515 ± 39 μm, respectively. No difference in densitometry could be detected between re-DMEK and control eyes (P = 0.99). Complications after re-DMEK included primary graft failure (n = 1), secondary graft failure (n = 2), graft detachment requiring rebubbling (n = 1), secondary glaucoma (n = 2), cataract (n = 1), and corneal ulcer (n = 1). One eye received tertiary DMEK.
In the management of persistent graft detachment and graft failure after primary DMEK, re-DMEK proved a feasible procedure. Acceptable BCVA may be achieved, albeit lower than after DMEK in virgin eyes, and some cases may benefit from contact lens fitting. Complications after re-DMEK may be better anticipated than after primary DMEK because graft detachment and graft failure tended to recur, suggesting that intrinsic properties of the host eye play a role in graft adherence and graft failure.
To describe Descemet membrane endothelial keratoplasty (DMEK) complications and strategies for their prevention and management.
Five hundred consecutive eyes with DMEK of 393 patients were reviewed ...in this retrospective study for intraoperative and postoperative complications up to 2 years and for corresponding management.
Intraoperative challenges (difficult graft unfolding/positioning, high vitreous pressure, iris root hemorrhage, and Descemet membrane remnants) were encountered in 81 eyes (16.2%). Visually significant graft detachment was the main postoperative complication (34 eyes, 6.8%). Graft failure occurred in 8 eyes (1.6%). Other postoperative complications were an increase of intraocular pressure/decompensated glaucoma in 48 eyes (9.6%), significant cataract in 11 of 124 phakic eyes (8.9%), allograft rejection in 7 eyes (1.4%), cystoid macular edema in 5 eyes (1.0%), microbial keratitis in 2 eyes (0.4%), and retinal detachment in 1 eye (0.2%). Different strategies for prevention and management of these complications have been identified.
DMEK shows acceptable rates of complications up to 2 years after surgery, which can be managed successfully. Anticipation of potential challenges and difficulties may aid in modifying intraoperative strategies for predisposed eyes. This knowledge may further minimize complications, in particular, when performing DMEK for an extended spectrum of corneal endothelial disorders.
Endothelial keratoplasty has been adopted worldwide as an alternative to penetrating keratoplasty in the treatment of corneal endothelial disorders. Descemet stripping (automated) endothelial ...keratoplasty (DSEK/DSAEK) may be the current standard, whereas Descemet membrane endothelial keratoplasty (DMEK), that is, isolated transplantation of Descemet membrane, may allow further improvement of clinical outcome.
DSEK/DSAEK may still have three major challenges: suboptimal visual acuity and relatively slow visual rehabilitation, limited accessibility due to required investments in equipment or the purchase of predissected tissue, and a drop in donor endothelial cell density in the early postoperative phase. Although DMEK may allow much quicker and (near) complete visual rehabilitation as well as easier logistics in donor preparation, the surgical technique may initially require more training to obtain consistent outcomes.
Compared with DSEK/DSAEK, DMEK may have higher clinical potential with 75% of cases reaching 20/25 or better (> or =0.8) within 1-3 months. Furthermore, preparation of isolated Descemet grafts does not require large investments and may increase overall donor tissue availability. Hence, corneal surgeons may consider 'to make the switch' from DSEK/DSAEK to DMEK.
To analyze 6-month results of 1000 consecutive Descemet membrane endothelial keratoplasty (DMEK) cases, and to evaluate if outcomes are influenced by surgical indication and preoperative lens status.
...Retrospective, interventional case series.
A series of 1000 eyes (738 patients) underwent DMEK mainly for Fuchs endothelial corneal dystrophy (FECD; 85.3%) or bullous keratopathy (BK; 10.5%). Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density, postoperative complications, and retransplantations.
At 6 months after DMEK, there was no difference in BCVA outcome between FECD and BK eyes (P = .170), or between phakic and pseudophakic FECD eyes (P = .066) after correcting for patient age and preoperative BCVA. Endothelial cell loss at 6 months postoperatively was similar for phakic and pseudophakic FECD eyes (39%; P = .852), but higher for BK eyes than for FECD eyes (46% vs 39%, P = .001). Primary and secondary graft failure occurred in 3 (0.3%) and 2 eyes (0.2%), respectively, and 7 eyes developed allograft rejection (0.7%). Eighty-two eyes (8.2%) received rebubbling for graft detachment and retransplantation was performed in 20 eyes (2.0%). Rebubbling was more often required in eyes treated for BK vs FECD eyes (12.4% vs 7.4%, P = .022).
DMEK consistently provides excellent short-term results, with similar high visual acuity levels for both FECD and BK eyes. As preoperative lens status did not influence DMEK outcomes, for phakic FECD eyes with a still relatively clear crystalline lens, lens preservation may be preferable in a selected group of younger patients, who may still benefit from their residual accommodative capacity.
To evaluate the clinical outcome of mid-stromal isolated Bowman layer transplantation, a new surgical technique to reduce and stabilize ectasia in eyes with advanced keratoconus, to postpone ...penetrating keratoplasty or deep anterior lamellar keratoplasty, and to enable continued daily contact lens wear.
Prospective, nonrandomized cohort study at a tertiary referral center.
Twenty-two eyes of 19 patients with progressive, advanced keratoconus not eligible for ultraviolet cross-linking.
The mid-stroma was manually dissected and an isolated donor Bowman layer was positioned within the stromal pocket.
Before and up to 36 months after surgery (mean follow-up, 21±7 months), best spectacle-corrected visual acuity (BSCVA), best contact lens-corrected visual acuity (BCLVA), Scheimpflug-based corneal tomography measurements, endothelial cell density, biomicroscopy, refraction, and intraoperative and postoperative complications were recorded.
Two surgeries were complicated by an intraoperative perforation of Descemet membrane; no other intraoperative or postoperative complications were observed. Maximum keratometry decreased on average from 77.2±6.2 diopters (D) to 69.2±3.7 D (P < 0.001) at 1 month after surgery and remained stable thereafter (P ≥ 0.072). Mean BSCVA improved from 1.27±0.44 logarithm of the minimum angle of resolution units before surgery to 0.90±0.30 logarithm of the minimum angle of resolution units 12 months after surgery (P < 0.001), whereas BCLVA remained stable (P = 0.105). Mean thinnest-point pachymetry increased from 332±59 μm before surgery to 360±50 μm at the latest follow-up (P = 0.012), and no change in endothelial cell density was found (P = 0.355).
With isolated Bowman layer transplantation, reduction and stabilization of corneal ectasia was achieved in eyes with progressive, advanced keratoconus. Given the low risk for complications, the procedure may be performed to postpone penetrating or deep anterior lamellar keratoplasty.
To define various Descemet graft unfolding techniques in Descemet membrane endothelial keratoplasty.
In a retrospective analysis, the surgical videos of 100 consecutive Descemet membrane endothelial ...keratoplasty cases with at least 6 months of follow-up were evaluated and categorized. The Descemet graft unfolding methods were categorized into 4 basic techniques and 3 auxiliary techniques.
All Descemet membrane endothelial keratoplasty surgical procedures could be completed using (a combination of) 4 Descemet graft unfolding techniques: (1) standardized no-touch graft unfolding using a double roll, (2) carpet unrolling while fixating 1 graft edge (Dirisamer technique), (3) small air bubble-assisted unrolling (Dapena maneuver), (4) the single sliding cannula maneuver. Additional maneuvers included turning over the graft when oriented upside down (flushing); manual graft centration with a cannula; and bubble bumping to unfold peripheral inward folds. In 73% of surgical procedures, technique 1 was used, while a combination of techniques was used in 44% and auxiliary techniques in 62%. None of the techniques showed a correlation with the best-corrected visual acuity, endothelial cell density, or postoperative complication rate (P > .10).
Descemet membrane endothelial keratoplasty may be further facilitated by using controlled techniques for unfolding the Descemet graft inside the recipient anterior chamber, either as stand-alone techniques or used in various combinations.
PDF