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

Abstract

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.

Alternativas medicas ante las limitaciones en el trasplante de córnea penetrante: una revisión bibliográfica

“…La mala calidad del injerto (densidad de células endoteliales (ECD) <2300 células/mm 2), el posicionamiento inverso, el desprendimiento persistente y la manipulación excesiva durante la preparación del injerto o la cirugía comúnmente conducen a fallo del injerto. Pero existen otras razones o factores de riesgo más comunes y esenciales para la pérdida de células endoteliales, como la edad, el trauma iatrogénico, el diámetro del injerto, el medio de cultivo, el tipo de taponamiento con gas, la fuente del donante, la edad del donante y el tipo de cirugía (DMEK solo o triple DMEK) (Gurnani, Kaur, et al, 2023).…”

Optical quality of the cornea after Descemet membrane endothelial keratoplasty surgery: early results from Türkiye

“…Research has demonstrated that DMEK can provide significant benefits in visual acuity, contrast sensitivity, and subjective visual quality when compared to other forms of corneal transplantation, such as penetrating keratoplasty [ 8 ]. Nevertheless, the success of surgery is contingent upon a variety of factors, including the patient’s preoperative visual acuity, the severity of the corneal disease, and the surgeon’s skill level [ 9 ]. Some patients may also report photophobia and glare despite the presence of a clear graft.…”