Factors Affecting the Success Rate of Preloaded Descemet Membrane Endothelial Keratoplasty With Endothelium-Inward Technique: A Multicenter Clinical Study

Parekh, Mohit; Pedrotti, Emilio; Viola, P.; Leon, Pia; Neri, Enrico; Bosio, Lorenzo; Bonacci, Erika; Ruzza, Alessandro; Kaye, Stephen B.; Ponzin, Diego; Ferrari, Stefano; Romano, Vito

doi:10.1016/j.ajo.2022.03.009

Cited by 12 publications

(26 citation statements)

References 37 publications

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“…Indeed, DSAEK still accounts for approximately 57% of EK surgeries performed in the United States ( 2 ). This has been ascribed to: the technical difficulties in DMEK donor preparation and surgical technique, with the reported higher risks of early complications, namely graft detachment and iatrogenic graft failure due to inadvertent up-side-down graft ( 25 , 26 , 31 , 41 – 45 ) ( Figure 4 ). The insertion and un-scrolling of the DMEK graft, once inside the anterior chamber, are indeed the most demanding steps in DMEK.…”

Section: Discussionmentioning

confidence: 99%

“…The concept of “endothelium-in” DMEK insertion techniques have been recently introduced ( 33 – 37 , 44 , 45 ). The grafts are folded, usually in a trifold, with the endothelium on the inside.…”

Section: Discussionmentioning

confidence: 99%

“…These factors in “endothelium-in” techniques reduce the technical difficulties of intracameral graft orientation and unscrolling, making DMEK procedures more controlled and predictable. Some of these “endothelium-in” techniques also use devices created to mimic DSAEK techniques, which many corneal surgeons are accustomed to ( 33 , 44 , 45 ). Various laboratory studies have reported no significant differences in endothelial cell loss when DMEK grafts were loaded “endothelium-in” and pulled-through or loaded “endothelium-out” and injected-through different graft insertion devices ( 62 – 64 ).…”

Section: Discussionmentioning

confidence: 99%

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“Endothelium-Out” and “Endothelium-In” Descemet Membrane Endothelial Keratoplasty (DMEK) Graft Insertion Techniques: A Systematic Review With Meta-Analysis

2022

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BackgroundWe evaluated the visual outcomes and complications of “endothelium-out” and “endothelium-in” Descemet membrane endothelial keratoplasty (DMEK) graft insertion techniques.Materials and MethodsElectronic searches were conducted in CENTRAL, Cochrane databases, PubMed, EMBASE, ClinicalTrials.gov. Study designs included clinical trials, comparative observational studies, and large case series (≥25 eyes). PRISMA guidelines were used for abstracting data and synthesis. Random-effects models were employed for meta-analyses.Results21,323 eyes (95 studies) were included. Eighty-six studies reported on “endothelium-out” techniques; eight studies reported on “endothelium-in” techniques. One study compared “endothelium-out” to “endothelium-in” techniques. Eighteen “endothelium-out” studies reported that 42.5–85% of eyes achieved best-corrected visual acuity (BCVA) ≥20/25 at 6 months; pooled proportion of eyes achieving BCVA ≥20/25 at 6 months was 58.7% (95% CI 49.4–67.7%,15 studies). Three “endothelium-in” studies reported that 44.7–87.5% of eyes achieved BCVA of ≥20/25 at 6 months; pooled proportion of eyes achieving BCVA ≥20/25 at 6 months was 62.4% (95% CI 33.9–86.9%). Pooled mean endothelial cell loss was lower in the “endothelium-in” studies (28.1 ± 1.3%, 7 studies) compared to “endothelium-out” studies (36.3 ± 6.9%,10 studies) at 6 months (p = 0.018). Graft re-bubbling rates were higher in the “endothelium-out” studies (26.2%, 95% CI 21.9–30.9%, 74 studies) compared to “endothelium-in” studies (16.5%, 95% CI 8.5–26.4%, 6 studies), although statistical significance was not reached (p = 0.440). Primary graft failure rates were comparable between the two groups (p = 0.552). Quality of evidence was considered low and significant heterogeneity existed amongst the studies.ConclusionReported rates of endothelial cell loss were lower in “endothelium-in” DMEK studies at 6 months compared to “endothelium-out” studies. Outcomes of “endothelium-in” techniques were otherwise comparable to those reported in “endothelium-out” studies. Given the technical challenges encountered in “endothelium-out” procedures, surgeons may consider “endothelium-in” techniques designed for easier intra-operative DMEK graft unfolding. “Endothelium-in” studies evaluating outcomes at longer time points are required before conclusive comparisons between the two techniques can be drawn.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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“Endothelium-Out” and “Endothelium-In” Descemet Membrane Endothelial Keratoplasty (DMEK) Graft Insertion Techniques: A Systematic Review With Meta-Analysis

2022

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“…Recently, we showed a range of re‐bubbling rate following preloaded DMEK transplant (26%–56%). It was noted that larger graft size in combination with longer preservation time can increase the risk of rebubbling (Parekh et al, 2022a,b).…”

Section: Outcomes According To Dmek Graft Sizementioning

confidence: 99%

“…The correct delivery and implantation of donor graft in the anterior chamber of the host is important to reduce possible damage to the tissue (Dapena et al, 2009). Reported implantation technique of DMEK grafts according to the orientation of the endothelium include endothelium‐inward (endo‐in) or endothelium‐outward (endo‐out) (Parekh et al, 2017a,b; Parekh et al, 2022a,b; Price et al, 2018a,b). These two techniques do not differ in rate of ECL after implant, which, at 6 months, has been reported between 29.5% and 30.9% (Busin et al, 2018; Newman et al, 2018; Price et al, 2018a,b).…”

Section: Delivery and Unfolding A Dmek Graft According To Graft Sizementioning

confidence: 99%

DMEK graft: One size does not fit all

Parekh

Romano

Wongvisavavit

et al. 2022

Acta Ophthalmologica

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Descemet membrane endothelial keratoplasty (DMEK) is a popular procedure for the treatment of corneal endothelial diseases mainly targeting Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK).Although DMEK has multiple advantages, it is challenging in terms of graft preparation and delivery. One of the crucial factors of DMEK graft preparation is determining the size of the graft. Evaluating risks and benefits of transplanting larger or smaller grafts compared with the descemetorhexis performed following a standard DMEK procedure thus becomes important. Advanced techniques like pre-loaded DMEK requires pre-selection of graft diameter without physical examination of the eye making it more challenging. Therefore, recognizing the benefits of graft size and the number of transplanted endothelial cells becomes essential.Smaller DMEK grafts have been preferred and accepted for grafting. Larger diameter grafts have advantages but can be challenging due to higher detachment rates. We thus aim to review the challenges of preparing and delivering DMEK tissues with small or large diameter based on selected descemetorhexis area, discuss the outcomes based on different graft sizes, highlight related complications and suggest which cases may benefit from adopting smaller or larger graft size.

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Innovations in Descemet Membrane Endothelial Keratoplasty (DMEK)

Ting,

Ang

2023

Essentials in Ophthalmology

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Factors Affecting the Success Rate of Preloaded Descemet Membrane Endothelial Keratoplasty With Endothelium-Inward Technique: A Multicenter Clinical Study

Cited by 12 publications

References 37 publications

“Endothelium-Out” and “Endothelium-In” Descemet Membrane Endothelial Keratoplasty (DMEK) Graft Insertion Techniques: A Systematic Review With Meta-Analysis

“Endothelium-Out” and “Endothelium-In” Descemet Membrane Endothelial Keratoplasty (DMEK) Graft Insertion Techniques: A Systematic Review With Meta-Analysis

DMEK graft: One size does not fit all

Innovations in Descemet Membrane Endothelial Keratoplasty (DMEK)

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