Outcomes of Descemet Membrane Endothelial Keratoplasty in Bangkok, Thailand

Abstract

Purpose To investigate the medium-term clinical outcomes and risk factors for primary graft failure after Descemet membrane endothelial keratoplasty (DMEK) in Thai patients. Patients and Methods This is a single-center retrospective cohort study. Sixty-two eyes of 62 patients who underwent DMEK at Ramathibodi Hospital, Bangkok, Thailand, with a minimum of 24-month follow-up were recruited. Preoperative donor and recipient characteristics, intraoperative data, and postoperative outcomes including best-corrected visual acuity (BCVA), graft clarity, endothelial cell density (ECD), central corneal thickness (CCT), and complications were evaluated at 1, 3, 6, 12, and 24 months after surgery. Results The mean age of the patients was 67.2 ± 9.9 years, and 52% were female. The mean follow-up time was 37.5 ± 11.0 months. The most common indications for DMEK were Fuchs’ endothelial corneal dystrophy (FECD) (53.2%) and pseudophakic bullous keratopathy (PBK) (17.7%). Nearly half of patients had triple-DMEK. The median preoperative BCVA was 20/400. Postoperative BCVA of ≥ 20/40 was reached in 37.1% and of ≥ 20/20 in 6.5% after 1 month which increased to 54.8% and 17.7% after 3 months; and to 67.7% and 27.4% after 24 months. Endothelial cell loss (ECL) at 3, 6, 12, and 24 months was 30.5%, 33.8%, 44.4%, and 45.9%, respectively. Graft diameter was the single factor, showing a significant relationship with postoperative ECD. Most frequent postoperative complications included graft detachment (22.6%), increased IOP/glaucoma (17.7%), and primary graft failure (16.1%). In univariate analysis, death-to-operation time and the diagnosis of PBK were significantly associated with the occurrence of primary graft failure. Conclusion DMEK is a safe, effective, and feasible treatment for endothelial failure in Asian eyes. Careful case selection, use of relatively fresh donor tissues, and appropriate surgical techniques can prevent primary graft failure and facilitate optimal outcomes following surgery.

Identification of the preoperative and perioperative factors that predict postoperative endothelial cell density after Descemet membrane endothelial keratoplasty: A retrospective cohort study

“…We found that patient sex did not associate with ECL. This was also observed by all seven comprehensive studies [ 20 , 43 – 48 ].…”

“…Patient age was not a predictor of ECL in our study or in five comprehensive studies [ 43 , 44 , 46 – 48 ] but two comprehensive studies [ 20 , 45 ], a prospective registry study of 752 eyes [ 65 ], and a retrospective study of 66 eyes [ 70 ] observed that older patient age associated with more ECL. Dunker et al proposed that older patients may be more prone to ECL because they find it more difficult to remain lying in the supine position after surgery; this is supported by the fact that graft detachments most often develop inferiorly [ 65 ].…”

“…To date, seven retrospective cohort studies have, like us, recently (2016–2021) used multivariate analysis to comprehensively assess the ability of a range of pre/perioperative variables to predict postoperative ECD/ECL [ 20 , 43 – 48 ] ( S1 Table ). The findings of these studies, and other studies that are less comprehensive and/or focused instead on the relationship between pre/perioperative variables and rebubbling/graft detachment, are as follows.…”

“…This may reflect in part the liberal use of rebubbling in our center. Other studies have also failed to detect a relationship between rebubbling and ECL [ 47 , 48 , 69 ].…”

“…With the aim of further improving DMEK outcomes, several studies have comprehensively sought to identify the preoperative and perioperative factors that associate with low ECD after DMEK ( S1 Table ) [ 20 , 43 – 48 ]. However, there are significant variations between these studies in terms of the predictive factors that have been found: for example, older patient age associates with worse ECL in two comprehensive studies [ 20 , 45 ] but not in five others [ 43 , 44 , 46 – 48 ]. To further clarify this issue, we conducted a retrospective cohort study to determine which of a large range of preoperative and perioperative factors can predict ECD at 6 and 12 postoperative months.…”