Descemet’s membrane endothelial keratoplasty: surgical outcomes and endothelial cell count modelling from a UK centre

Fajgenbaum, Mark A. P.; Kopsachilis, Nick; Hollick, Emma J.

doi:10.1038/s41433-018-0152-x

Cited by 21 publications

(10 citation statements)

References 29 publications

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“…This may be the case by inconvenient recipient's properties like a shallow anterior chamber and the presence of vitreous pressure [6]. The endothelial cell loss of 35% after 6 months in our study was comparable to previous studies [16, 20, 21].…”

Section: Discussionsupporting

confidence: 86%

How to Avoid an Upside-Down Orientation of the Graft during Descemet Membrane Endothelial Keratoplasty?

Wasielica‐Poslednik

Schuster

Rauch

et al. 2019

Journal of Ophthalmology

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Purpose. Incorrect anterior-posterior orientation of the Descemet endothelial complex (DEC) is one of the causes of failure of Descemet membrane endothelial keratoplasty (DMEK). We evaluated a new marking technique to avoid such a misorientation. Method. A new marking technique of the DEC was evaluated in patients requiring primary DMEK. A Braille-“R”-letter was applied dot by dot onto the stromal surface of the DEC after lifting it by injecting an air-bubble into the interface between the endothelial surface of the partially stripped graft. The positioning of the graft was intraoperatively controlled by an orientation of the Braille-“R”-letter. Laboratory tests were conducted to test the impact of the marking technique on endothelial cell count. Results. We included prospectively 37 eyes of 30 patients. Four eyes were phakic and 33 pseudophakic. Five grafts (14%) presented an undifferentiated rolling tendency in the anterior chamber, and evaluation of their positioning was possible due to orientation of the mark alone. In case of an upside-down orientation, grafts were flipped immediately. A correct orientation of the graft was achieved in all cases at the end of the surgery. The endothelial cell loss due to the mark was estimated to be less than 0.3%. At 3- and 6-month follow-ups, the mean best-corrected visual acuity was 0.21 ± 0.15 and 0.15 ± 0.11 logMAR, respectively, and endothelial cell density was 1661 ± 349 and 1618 ± 396 cells/mm2, respectively. Only one patient (3%) needed re-bubbling. Conclusions. To rely on the natural rolling tendency of the graft alone does not assure its correct positioning in all cases. Creation of the mark with 4 dots punctuated on the air-lifted stromal side of the DEC is a simple and endothelial cell saving marking method to ensure correct orientation of the graft during DMEK.

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Section: Discussionsupporting

confidence: 86%

How to Avoid an Upside-Down Orientation of the Graft during Descemet Membrane Endothelial Keratoplasty?

Wasielica‐Poslednik

Schuster

Rauch

et al. 2019

Journal of Ophthalmology

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“…Since endothelial keratoplasty, including DMEK, DSAEK, and ultrathin-DSAEK, results in better visual acuity and lower graft rejection than those by penetrating keratoplasty [ 2 , 3 , 7 ], endothelial keratoplasty is currently preferred for both BK and FED despite the challenging surgical technique. For DMEK in Western eyes, the 1- and 5-year survivals of grafts are reported to be 94% and 83% [ 3 , 32 , 33 ]. The central ECD of the graft decreased by 35–38% at 6 months and by 48%–59% at 5 years in DMEK for Western eyes [ 32 , 34 ].…”

Section: Discussionmentioning

confidence: 99%

“…The annual loss rate of ECD in the graft following 1 year was -8% to -10% [ 32 ]. The proportion of visual acuity better than or equal to 20/40 has been reported as 88% and 96% in reports with more cases of FED [ 32 , 33 ]. In addition to the DMEK procedures being more challenging, ECL may be greater in Asian eyes than in Western eyes due to their tight small fissures, shallow anterior chamber, high vitreous pressure, thicker pigmented iris, and the effortless formation of fibrin and posterior synechiae thereafter [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) with imported donor corneas in eyes of Asian patients; endothelium‐in versus endothelium‐out method

2022

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Objective We investigated whether (1) imported pre-cut tissue is feasible for Descemet membrane endothelial keratoplasty (DMEK) in eyes of Asian patients, (2) the clinical outcome is comparable between the endothelium‐in and endothelium‐out methods, and (3) the corneal edema-induced anterior curvature changes may have an effect on the refractive error. Methods The medical records of 32 DMEK patients who underwent either the endothelium-out or endothelium-in method using imported pre-cut grafts with a 3-day pre-cut-to-use time were retrospectively analyzed. Fuchs’ endothelial dystrophy (37.5%) and bullous keratopathy (62.5%) cases were included. The main clinical outcome measures were graft survival, best corrected visual acuity (BCVA), endothelial cell density (ECD), corneal thickness (CT), and complications. Correlation of the anterior curvature changes with refractive error was analyzed in the DMEK with cataract surgery group. Results The overall survival rate was 71.9%. Final graft failures were caused by rejection, glaucoma, and infection. Visual acuities improved by 89.3%. BCVA better than 20/40 and 20/20 was found in 75% and 28.6% of patients, respectively. The ECDs at 3 months and 1 year were 1400 and 1083 cells/mm2, respectively. The mean survival time, ECD, BCVA, CT, and complication rates were not different between the endothelium-in and endothelium-out methods. A hyperopic shift by +0.42 D was not related to the anterior curvature changes. Conclusion Imported pre-cut tissues with a ≤ 3-day pre-cut-to-use time are feasible for DMEK in the treatment of corneal endothelial edema in eyes of Asian patients, and both endothelium-in and endothelium-out methods appear to be comparatively effective. Edema-induced anterior curvature change may not affect the refractive shift.

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“… Retrospective case series 250 eyes The median age of patients- was 72.0 [62.0, 78.0] years, and the Median age of donors was 66.0 [63.0, 71.0] years, Median BCVA- 0.6 [0.4, 1.3] LogMAR (Snellen equivalent, 20/80) preoperatively FECD-174 eyes (69.6%), Pseudophakic bullous keratopathy 36 eyes (14.4%), Failed PKP-15 eyes (6.0%), Failed DSAEK 13 eyes (5.2%), and Others 12 eyes (4.8%) Persistent corneal edema, KP at the back of Cornea, anterior chamber reaction High dose topical steroids, Repeat DMEK 13 cases, 1 repeat DSAEK, 1 repeat PKP Median BCVA 0.3 [0.2, 0.5] LogMAR (Snellen equivalent, 20/40) at 6 months, 15 had primary graft failure, 22 Pasari et al 97 Cornea 2019 Feb;38(2):151–156. Retrospective case series- 77 patients 84 eyes- 93 DMEK FECD-36, Keratoconus-27, Pseudophakic corneal edema-5, Corneal scar-6 Herpetic-5 Endothelial failure-1, previous DSEK, or failed PK-84 Persistent corneal edema, KP at the back of Cornea, anterior chamber reaction High dose topical steroids Immunological rejection 2 eyes, 15 months, and 44 months 23 Fajgenbaum et al 98 Eye (Lond), 2018 Oct;32(10):1629–1635. Retrospective case series-87 eyes 93 DMEK Mean patient age- 70 ± 11 years (range: 39–93 years) FECD-79 (90%) eyes, pseudophakic bullous keratopathy −2(2%) eyes, herpes virus endotheliitis- 2 (2% ) eyes, and other causes- 5 (5%) eyes Persistent corneal edema, KP at the back of Cornea, anterior chamber reaction Hourly dexamethasone 0.1% drops administered for 1–2 weeks Graft rejection-3 eyes (3%), 67% (48/72) achieved ≥6/6, 86% (62/72) achieved ≥6/9, and 88% (63/72) achieved ≥6/12.…”

Section: Methods Of Searchmentioning

confidence: 99%

Risk Factors for Descemet Membrane Endothelial Keratoplasty Rejection: Current Perspectives- Systematic Review

Gurnani¹,

Kaur²,

Lalgudi³

et al. 2023

OPTH

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Descemet membrane endothelial keratoplasty (DMEK) is a corneal endothelial transplantation procedure with selective removal of a patient’s defective Descemet membrane and endothelium. It is replaced with a healthy donor Descemet membrane and endothelium without a stromal component. Corneal graft rejection can be at the level of epithelium, stroma as well endothelium. DMEK graft rejection is relatively less common than rejection with DSAEK or penetrating keratoplasty, and a good outcome may be achieved with prompt management. The clinical picture of DMEK rejection is usually similar to endothelial rejection in Descemet Stripping Endothelial Keratoplasty (DSEK/DSAEK), which generally manifests as pain, redness, reduction in visual acuity, stromal edema, endothelial rejection line, keratic precipitates at the back of the cornea and corneal neovascularization. However, more subtle forms of rejection or immune reactions are more common in DMEK compared to DSAEK eyes. Early clinical diagnosis, prompt intervention, and meticulous management safeguard visual acuity and graft survival in these cases. Intensive topical steroids form the mainstay in the management of DMEK rejection. Sometimes, oral or intravenous steroids or other systemic immunomodulators may be required. DMEK graft failure can be primary or secondary, and failure usually requires a second procedure in the form of repeat DMEK or DSEK or penetrating keratoplasty (PKP). A detailed literature search was performed using search engines such as Google Scholar, PubMed, and Google books, and a comprehensive review on DMEK rejection was found to be lacking. This review is a comprehensive update on the risk factors, pathophysiology, primary and secondary graft failure, recent advances in diagnosis, prevention of rejection, and updates in the management of DMEK rejection. The review also discusses the differential diagnosis of DMEK failure and rejection, prognosis, and future perspectives considering DMEK failure and rejection.

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Descemet’s membrane endothelial keratoplasty: surgical outcomes and endothelial cell count modelling from a UK centre

Abstract: DMEK using tissue from UK eye-banks resulted in high survival and excellent visual acuity. ECD through 1 year was superior to DSEK in a similar cohort. Our low re-bubble rate (2%) may be attributable to use of intracameral air at temporarily elevated intraocular pressure.

Cited by 21 publications

References 29 publications

How to Avoid an Upside-Down Orientation of the Graft during Descemet Membrane Endothelial Keratoplasty?

How to Avoid an Upside-Down Orientation of the Graft during Descemet Membrane Endothelial Keratoplasty?

Clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) with imported donor corneas in eyes of Asian patients; endothelium‐in versus endothelium‐out method

Risk Factors for Descemet Membrane Endothelial Keratoplasty Rejection: Current Perspectives- Systematic Review

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