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

Dimitri Chaussard,Arpiné Ardzivian Elnar,Jean-Charles Vermion,Yinka Zevering,Florian Bloch,Jean-Marc Perone,Rémi Moskwa,Hidenaga Kobashi

doi:10.1371/journal.pone.0264401

Dimitri Chaussard, Arpiné Ardzivian Elnar + Show 6 more

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https://doi.org/10.1371/journal.pone.0264401

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Abstract

Low postoperative endothelial-cell density (ECD) plays a key role in graft failure after Descemet-membrane endothelial keratoplasty (DMEK). Identifying pre/perioperative factors that predict postoperative ECD could help improve DMEK outcomes. This retrospective study was conducted with consecutive adult patients with Fuchs-endothelial corneal dystrophy who underwent DMEK in 2015-2019 and were followed for 12 months. Patients underwent concomitant cataract surgery (triple-DMEK) or had previously undergone cataract surgery (pseudophakic-DMEK). Multivariate analyses assessed whether: patient age/sex; graft-donor age; preoperative ECD, mean keratometry, or visual acuity; triple DMEK; surgery duration; surgical difficulties; and need for rebubbling predicted 6- or 12-month ECD in the whole cohort or in subgroups with high/low ECD at 6 or 12 months. The subgroups were generated with the clinically relevant threshold of 1000 cells/mm2. Surgeries were defined as difficult if any part was not standard. In total, 103 eyes (95 patients; average age, 71 years; 62% women) were included. Eighteen eyes involved difficult surgery (14 difficult graft preparation or unfolding cases and four others). Regardless of how the study group was defined, the only pre/perioperative variable that associated significantly with 6- and 12-month ECD was difficult surgery (p = 0.01, 0.02, 0.05, and 0.0009). Difficult surgery also associated with longer surgery duration (p = 0.002). Difficult-surgery subgroup analysis showed that difficult graft dissection associated with lower postoperative ECD (p = 0.03). This association may reflect endothelial cell loss due to excessive graft handling and/or an intrinsic unhealthiness of the endothelial cells in the graft that conferred unwanted physical properties onto the graft that complicated its preparation/unfolding.

Highlights

In 1998–2002, endothelial keratoplasty became a feasible alternative to penetrating keratoplasty (PKP) for corneal endothelial disorders such as Fuchs endothelial corneal dystrophy (FECD) and moderate bullous keratopathy (BK)
38 were excluded because the indication was not FECD (n = 19) or there was a history of an ocular intervention other than cataract surgery (n = 11), another corneal, retinal, or optic nerve disease (n = 4), or intraoperative complications (n = 4; two extreme brunescent cataracts that led to high effective phaco time, and two eyes that were converted to Descemet stripping automated endothelial keratoplasty (DSAEK) due to extensive progression of stromal edema between the last visit and the surgery)
Our study focused on FECD cases but two comprehensive studies [20, 45] and other studies on cohorts with mixed indications found that severe FECD, or BK rather than FECD, associate with higher endothelial cell loss (ECL) [38, 71]

Summary

Introduction

In 1998–2002, endothelial keratoplasty became a feasible alternative to penetrating keratoplasty (PKP) for corneal endothelial disorders such as Fuchs endothelial corneal dystrophy (FECD) and moderate bullous keratopathy (BK) At this timepoint, Melles introduced deep lamellar endothelial keratoplasty (DLEK). Melles introduced deep lamellar endothelial keratoplasty (DLEK) This procedure involves (i) dissecting off a posterior lamellar disc from the diseased recipient cornea; (ii) inserting a folded donor disc consisting of posterior stroma, Descemet membrane, and endothelium via a self-healing tunnel incision; and (iii) unfolding the disc and appending it to the recipient cornea with an air bubble [1–3]. Multiple studies showed that compared to PKP, endothelial keratoplasty leads to more predictable refractive outcomes, increased tectonic stability, faster postoperative visual rehabilitation, and overall better and faster visual recovery This reflects in part the absence of graft sutures, which can induce ocular surface complications and high or irregular astigmatism [11–15]

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