Five-Year Outcomes of Ultrathin Descemet Stripping Automated Endothelial Keratoplasty

Abstract

Purpose: To report 5-year outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) with a central graft thickness intended to be <100 μm. Methods: This retrospective, consecutive, interventional case series included 354 eyes with endothelial decompensation due to various causes (Fuchs endothelial dystrophy, pseudophakic or aphakic bullous keratopathy, failed previous graft, herpetic endothelitis, or buphthalmos). Donor tissue was prepared using the microkeratome-assisted double-pass technique aiming at a graft thickness <100 μm. The Descemet membrane was stripped under air. The graft was delivered into the anterior chamber using the pull-through technique through a 3.2-mm clear corneal incision using a modified Busin glide. The best spectacle-corrected visual acuity (BSCVA), endothelial cell loss, graft survival rates, and immunologic rejection rates were evaluated. Results: Follow-up data at 1, 2, 3, and 5 years after UT-DSAEK were collected from 214, 172, 147, and 105 eyes, respectively. After excluding eyes with comorbidities, BSCVA better than or equal to 20/20 was recorded in 36.3%, 37.4%, 46.4%, and 53.4% of eyes, respectively, whereas BSCVA better than or equal to 20/40 was documented in 95.5%, 95.3%, 96.0%, and 96.6% of eyes, respectively. The mean endothelial cell loss was 35.4%, 42.3%, 43.3%, and 52.3%; Kaplan–Meier graft survival probability was 99.1%, 96.2%, 94.2%, and 94.2%, and Kaplan–Meier cumulative probability of a rejection episode was 3.4%, 4.3%, 5%, and 6.9% at 1, 2, 3, and 5 years, respectively. Conclusions: UT-DSAEK grafts allow excellent 5-year outcomes, including BSCVA, endothelial cell density, and survival rates comparable with those recorded post-Descemet membrane endothelial keratoplasty, but with a higher immunologic rejection rate.

Bilateral Ultrathin Descemet’s Stripping Automated Endothelial Keratoplasty vs. Bilateral Penetrating Keratoplasty in Fuchs’ Dystrophy: Corneal Higher-Order Aberrations, Contrast Sensitivity and Quality of Life

“…As previously exposed, clinically significant complications were ruled out in the two groups of patients included in the study, except for the 15% graft detachment rate followed by rebubbling in UT-DSAEK cases. Our rebbubling rate is higher with respect to some studies, but in agreement with one multicenter RCT [12,15,16].…”

“…However, though literature data agree in indicating that DMEK, as said above, involves high surgical skill, and it is characterized by a steep learning curve, complex graft preparation and handling with a high risk of endothelial trauma, and frequent postoperative graft detachment requiring air-gas reinjection, referred to as rebubbling [6,10,12,13,26,27]. Therefore, many surgeons stay with DSAEK, or even better with its refinement UT-DSAEK, implying a reduction of graft average central thickness from 200 µ to 100 µ [14][15][16]23,24]. Recently, a further evolution of UT-DSAEK has been proposed, described as "nanothin DSAEK (NT-DSAEK)", using grafts within 50 µ, which should provide visual outcomes and complications rates that are comparable to DMEK [28,29].…”

“…This trend depends on the evidence of improved visual outcomes with thinner DSAEK tissue [23][24][25]. As already described, prospective and retrospective studies indicate that UT-DSAEK allows for faster and better CDVA recovery with respect to DSAEK, and CDVA, endothelial cell density, and survival rates comparable to DMEK [14][15][16]. Some randomized, controlled clinical trials (RCTs) and retrospective studies indicate that DMEK, whose graft thickness is 10-15 µ, allows for superior visual acuity and lower posterior corneal HOA, compared to UT-DSAEK until 12 to 24 months postop.…”

“…Moreover, a multicenter prospective long-term study indicates that ultrathin DSAEK (UT-DSAEK) grafts, referring to grafts for the DSAEK technique not above 100 µ, result in better visual acuity compared with that of grafts over 145 µ. For some, UT-DSAEK grafts allow 5-year BSCVA, endothelial cell density, and survival rates comparable with DMEK, even if with a higher immunologic rejection rate [14][15][16].…”

Update on the Surgical Management of Fuchs Endothelial Corneal Dystrophy

“…Newer modifications to DSAEK have created thinner grafts. Ultrathin DSAEK (UT-DSAEK) (60-90 lm grafts) and nanothin DSAEK (NT-DSAEK) (grafts 50 lm or thinner) have been shown to have improved visual outcomes with faster visual recovery than standard DSAEK [17][18][19][20].…”