Combined Descemet Membrane Endothelial Keratoplasty Research Articles

Enhanced Monofocal Intraocular Lenses in Fuchs' Endothelial Dystrophy Patients: Results from Triple Descemet Membrane Endothelial Keratoplasty Procedure.

Descemet membrane endothelial keratoplasty (DMEK) is currently regarded as the most effective surgical procedure for addressing Fuchs Endothelial Corneal Dystrophy (FECD), frequently performed in conjunction with cataract surgery. In this retrospective study, we present a comparison of visual performance, clinical outcomes, and optical quality between two types of monofocal Intraocular Lenses (IOLs): one standard and one enhanced intermediate vision model, implanted in patients who underwent combined phacoemulsification and DMEK surgery. This single center comparative retrospective study was conducted at the Eye Clinic of the University of Florence (Italy) and included a total of 48 eyes of 48 patients affected by FECD and cataract. All patients underwent combined DMEK with phacoemulsification procedures. The patients' data were analyzed and divided into two groups: one group (standard group) consisted of 24 eyes that underwent phaco-DMEK with implantation of a monofocal IOL, and the second group (enhanced monofocal group) included 24 eyes that underwent phaco-DMEK with implantation of an enhanced monofocal IOL. In both groups, the following monocular visual outcomes were evaluated 6 months after surgery: Uncorrected Distance Visual Acuity (UDVA) and Best-Corrected Distance Visual Acuity (BCDVA) at 4 mts; Uncorrected Intermediate Visual Acuity (UIVA), Distance-Corrected Intermediate Visual Acuity (DCIVA) at 66 cm; Uncorrected Near Visual Acuity (UNVA) and Best Corrected Near Visual Acuity (BCNVA). Monocular defocus curves were also assessed. Furthermore, optical quality in terms of Contrast Sensitivity (CS) in photopic conditions, Higher-Order Aberrations (HOAs) at a pupil size of 5 mm. Modulation Transfer Function (MTF), Objective Scatter Index (OSI), and Strehl ratio, were also analyzed. A Patient-Reported Spectacle Independence Questionnaire was revised to evaluate spectacle independence outcomes. the two groups did not exhibit statistically significant differences in terms of UDVA, BCDVA, UNVA and BCNVA, photopic CS, HOAs, OSI, Strehl ratio, and MTF. However, in the phaco-DMEK enhanced monofocal IOL group, significantly better results were observed in terms of UIVA and DCIVA as well as a different defocus curve profile at 1.50 D, providing better defocus results at intermediate distance compared with the ZCB00 IOL. In our study, we found that enhanced monofocal lens performed favorable visual outcomes, even in cases of FECD, compared to standard monofocal IOLs. Comparable optical quality observed in the Eyhance group could allow surgeons to consider these lenses as a viable option for selected patients with FECD.

Impact of topographic hot spots on the refractive outcomes of combined DMEK and cataract surgery.

To compare the refractive results of combined Descemet membrane endothelial keratoplasty (DMEK) and cataract surgery in eyes with Fuchs endothelial corneal dystrophy (FECD) with and without topographic hot spots. "Villa Igea" Hospital, Forlì, Italy. Interventional case series. 57 eyes of 52 patients with FECD undergoing combined DMEK, cataract surgery, and monofocal intraocular lens (IOL) implantation were included in this single-center study. Patients were classified based on the presence or absence of topographic hot spots on the preoperative axial power map. Prediction error (PE) was calculated as the postoperative manifest spherical equivalent (SE) refraction minus the SE predicted refraction. 6 months postoperatively, mean PE was +0.79 ± 1.12 diopters (D). In eyes with hot spots, mean keratometry (K), K flat, and K steep significantly decreased after surgery (all P < .05), whereas no significant changes were observed in eyes without hot spots (all P > .05). Eyes with hot spots showed a significantly more hyperopic PE than eyes without hot spots (+1.13 ± 1.23 vs +0.40 ± 0.86 D; P = .013). Combined DMEK and cataract surgery can result in a hyperopic refractive surprise. The presence of topographic hot spots before surgery is associated with a higher hyperopic shift.

Combined or sequential DMEK in cases of cataract and Fuchs endothelial corneal dystrophy-A systematic review and meta-analysis.

To compare the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed after phacoemulsification and intraocular lens (IOL) implantation (sequential DMEK) and DMEK combined with phacoemulsification and IOL implantation (combined DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and cataract. Systematic literature review and meta-analysis performed according to the PRISMA guidelines and registered in PROSPERO. Literature searches were conducted in Medline and Scopus. Comparative studies reporting sequential DMEK and combined DMEK in FECD patients were included. The main outcome measure of the study was the corrected distance visual acuity (CDVA) improvement. Secondary outcomes were postoperative endothelial cell density (ECD), rebubbling rate and primary graft failure rate. Bias risk was assessed and a quality appraisal of the body of evidence was completed using the Cochrane Robin-I tool. A total of 667 eyes (5 studies) were included in this review, 292 eyes (43.77%) underwent a combined DMEK, while 375 (56.22%) eyes underwent a sequential DMEK surgery. We found no evidence of a difference between the two groups (mean difference, 95% CI) regarding: (1) CDVA improvement (-0.06; -0.14, 0.03 LogMAR; 3 studies, I2 : 0%; p = 0.86); (2) postoperative ECD (-62; -190, 67 cells/mm2 ; 4 studies, I2 : 67%; p = 0.35); (3) rebubbling (risks ratio: 1.04; 0.59, 1.85; 4 studies, I2 : 48%; p = 0.89); and primary graft failure rate (risks ratio: 0.91; 0.32, 2.57; 3 studies, I2 : 0%; p = 0.86). Of all the 5 non-randomized studies, all (100%) were graded as low quality. The overall quality of the analysed studies was low. Randomized controlled trials are needed to confirm no difference or superiority of one approach in terms of CDVA, endothelial cell count and postoperative complication rate between the two arms.

IOL Power Calculation in Eyes Undergoing Combined Descemet Membrane Endothelial Keratoplasty and Cataract Surgery.

To assess the accuracy of different corneal powers for intraocular (IOL) power calculation in combined Descemet membrane endothelial keratoplasty (DMEK) and cataract surgery and investigate whether preoperative parameters correlate to the prediction error (PE). This prospective case series involved patients with Fuchs endothelial dystrophy receiving combined DMEK and cataract surgery. Preoperatively, patients underwent optical biometry and anterior segment OCT (AS-OCT). AS-OCT measurements were repeated 6 months postoperatively, when final refraction was assessed. The PE was calculated using the preoperative average keratometry (Kave) measured by the optical biometer and User Group for Laser Interference Biometry (ULIB) constants. It was also calculated, after constant optimization, using the preoperative Kave from both devices and the total corneal power (TCP) measured by AS-OCT, as well as the postoperative Kave and TCP measured by AS-OCT. ULIB constants resulted in the highest hyperopic PE (P < .0001). Constant optimization improved the results, because the PE was zeroed out and the absolute PEs decreased. No significant difference was found among the Barrett Universal II, Emmetropia Verifying Optical 2.0, Haigis, Hoffer Q, Holladay 1, Kane, and SRK/T formulas. Further improvement was achieved with the postoperative Kave and TCP, although the accuracy remained moderate. The PE based on preoperative corneal measurements was correlated to the amount of corneal flattening; the latter could be predicted by multiple linear regression accounting for anterior and posterior corneal radii (P = .0002) and was correlated to the preoperative anterior/posterior ratio. Constant optimization is beneficial for combined DMEK and phacoemulsification. Predicting postoperative corneal flattening may improve the results of IOL power accuracy. [J Refract Surg. 2022;38(7):435-442.].

Refractive accuracy and visual outcomes after combined descemet membrane endothelial keratoplasty and cataract surgery: A French multicentric study

Descemet membrane endothelial keratoplasty (DMEK) combined with cataract extraction and intraocular lens insertion (new triple procedure) limits postoperative refractive errors. The objective of this study was to assess refractive accuracy after DMEK combined with cataract extraction and intraocular lens implantation. Four university hospitals (Rouen, Paris, Reims, Grenoble). This retrospective multicenter study included patients with symptomatic corneal endothelial decompensation and cataract. The primary outcome was the difference between the target spherical equivalent and postoperative refraction at months 2 and 6. Secondary outcomes were visual acuity, keratometry, pachymetry and endothelial cell density. A total of 130 eyes of 111 patients (mean age 66.2 years) were included (94% with Fuchs' endothelial dystrophy). For a mean refractive target set at -0.50 (±0.57) D, the mean (95% CI) refractive error was hyperopia of +0.49 (0.314; 0.664) D at 2 months and +0.46 (0.299; 0.619) D at 6 months. Best corrected distance visual acuity was improved in all patients: from 0.49 (±0.3) logMAR to 0.14 (±0.14) logMAR at 2 months and 0.05 (±0.1) logMAR at 6 months. Mean corneal thickness decreased from 621.6 (±37.6) μm to 515.2 (±42.6) μm at 2 months and 539.0 (±39.0) μm at 6 months. Good refractive accuracy was obtained after the new triple procedure with DMEK. Hyperopic shift is common after triple procedures, and its persistence should be evaluated in future studies in order to anticipate a change in its value to optimize intraocular lens power calculation.

Effect of Intracameral Cefuroxime on Graft Endothelial Cells in Descemet Membrane Endothelial Keratoplasty: A Comparative Study

ABSTRACT Purpose: To evaluate the effect of intracameral cefuroxime on graft endothelial cell loss after simple Descemet Membrane Endothelial Keratoplasty (DMEK) and combined DMEK and cataract surgery. Materials and Methods: Single-center retrospective comparative analysis. One hundred and three patients were included, 31 in the cefuroxime group and 72 in the non-cefuroxime (NC) group. Best Spectacle-Corrected Visual Acuity (BSCVA), endothelial cell density (ECD) of the graft measured by specular microscopy, and the recipient’s pachymetry were recorded pre-operatively and at 1, 3, and 6 months after surgery. Results: In the cefuroxime group, BSCVA was 0.22 ± 0.27 LogMAR, 0.15 ± 0.24 LogMAR and 0.07 ± 0.22, respectively, at 1, 3, and 6 months after surgery with no significant differences found when compared to the NC group (p > .05). Anatomical outcomes were similar as mean pachymetry decreased from 599 ± 51 µm preoperatively to 511 ± 30 µm at 6 months after surgery in the cefuroxime group and from 607 ± 67 µm preoperatively to 519 ± 32 µm at 6 months in the NC group (p = .25). Endothelial cell loss was comparable between both groups: 33.4% versus 33.6% at 1 month (p = .97), 37.4% versus 34.9% at 3 months (p = .68) and 41.6% versus 38.3% at 6 months (p = .42) in the cefuroxime and NC groups, respectively. The rates of rebubbling, graft rejection, and cystoid macular edema were not significantly higher in the cefuroxime group. Conclusion: The use of intracameral cefuroxime during simple or combined DMEK did not lead to higher graft endothelial cell loss.

Case Series of Urrets-Zavalia Syndrome After Descemet Membrane Endothelial Keratoplasty

To present a case series of Urrets-Zavalia syndrome (UZS) that developed after Descemet membrane endothelial keratoplasty (DMEK). A retrospective chart review was performed to identify patients who underwent DMEK by a single surgeon at the Duke Eye Center from 2017 to 2019 and subsequently developed UZS. Demographic data, preoperative history, operative notes, and postoperative course were reviewed. We describe 5 cases of UZS after DMEK (ages 19-74 years; 3 men and 2 women). Onset of UZS was noted at postoperative week 1 (n = 1), 2 (n =3), or 4 (n = 1). Four patients had an underlying diagnosis of Fuchs endothelial dystrophy and 1 had posterior polymorphous corneal dystrophy. Sixty percent (n = 3) of patients had an elevated intraocular pressure on postoperative day 0 or 1, and 40% (n = 2) of patients also had a pupillary block. One patient developed UZS after a rebubbling procedure for partial graft detachment and another developed UZS after repeat DMEK transplantation. Of the 3 patients who underwent bilateral combined DMEK and cataract surgery, 1 developed UZS in the second eye, whereas 2 developed UZS in the first eye. Most patients experienced monocular diplopia or had cosmetic concerns because of their mydriatic pupils. Two patients had spontaneous improvement in mydriasis. UZS after DMEK is rare, with only 2 cases in the literature: Holtmann et al and Isac et al. We present the largest case series of UZS after DMEK to date. Postoperative elevation in intraocular pressure is a common contributing factor. Evaluation of more patients may elucidate additional risk factors for this condition.

Combined Descemet membrane endothelial keratoplasty and extracapsular cataract extraction: management of an intraoperative challenge

Endothelial corneal transplantation (Descemet membrane endothelial keratoplasty [DMEK]) combined with cataract surgery as a triple procedure has been demonstrated to be safe and cost-effective. Where the corneal opacity is more significant, this may preclude safe phacoemulsification. This may not be apparent during preoperative assessment. An 80-year-old man with corneal decompensation secondary to herpes simplex endotheliitis and cataract underwent combined cataract extraction and DMEK. Intraoperatively, the surgical view became too poor to continue with conventional phacoemulsification. The lens was extracted by conversion to extracapsular surgery (extracapsular cataract extraction [ECCE]). Descemet membrane endothelial keratoplasty surgery was then completed without complication. Postoperatively, the graft remained attached, and by 3 months, acuity improved to 20/32 (Snellen). A poor intraoperative view during the triple procedure does not preclude a successful outcome. Corneal opacity can be overcome, avoiding full-thickness penetrating keratoplasty or discarding healthy graft tissue. Conversion to ECCE combined with DMEK is a feasible option intraoperatively that can still provide good outcomes.

Effective Tissue Layer Separation of Donor Cornea for DMEK by Fluid Injection Between Descemet Membrane and Corneal Stroma: Results of First Series of Operations

To evaluate clinical outcomes of Descemet Membrane Endothelial Keratoplasty (DMEK) using a novel hydro-separation of donor Descemet membrane (DM) endothelial graft with 6 months follow up. In this retrospective single-center; single surgeon cohort study, 16 consecutive eyes underwent DMEK or combined DMEK and cataract surgery with DMEK donor graft hydro-separation. The hydroseparation method used Ringer’s solution injected by a syringe with a flat end cannula between DM and corneal stroma to separate DMEK graft from donors’ cornea. Endothelial cell count, corrected and uncorrected distance visual acuities (CDVA, UDVA), corneal astigmatism and keratometric values were evaluated before and 6 months after the surgery. DMEK grafts were successfully hydro separated, without a membrane tear in all cases and successful adhesion to recipient corneas was achieved in all cases. Overall CDVA improved significantly (p < 0.0001) from preop.0.69 logMAR (0.45–0.92, 95%CI) to 0.1 logMAR (0.04–0.15) 6 months postop. However UDVA was slightly worse in cataract combined cases 0.38 logMAR (0.18–0.43) vs 0.3 logMAR (0.14–0.61) in DMEK cases at 6 months. Corneal astigmatism K2-K1 improved significantly (p=0.0137) from preop. mean 2.89 D (0.19–0.43) to 0.98 D (0.48–1.48) 6 months postop. Hydro-separation is fast and effective donor graft preparation method for DMEK. The DMEK using donor graft hydro-separation results in improved vision and induces a low amount of astigmatism at 6 months follow up. Further clinical data are needed to confirm the success rate and to explore optimization of the selection of IOLs in combined cataract cases

Avoiding Hyperopic Surprises After Descemet Membrane Endothelial Keratoplasty in Fuchs Dystrophy Eyes by Assessing Corneal Shape

It is unclear which patients unexpectedly have a hyperopic refractive outcome after combined Descemet membrane endothelial keratoplasty and cataract surgery (triple DMEK). We assessed how corneal shape predicts hyperopia after triple DMEK. Retrospective cohort study. Patients with Fuchs endothelial corneal dystrophy (FECD) with Scheimpflug examinations before uncomplicated triple DMEK at a tertiary referral center were included. The arithmetic error was calculated (stable postoperative refraction minus predicted refraction). Using multinomial logistic regression, risk ratios of >+0.5 diopter (D) hyperopic and > 0.5 D myopic arithmetic errors were calculated. In 112 eyes, the median predicted refraction was-0.43 D (interquartile range [IQR],-0.47 to-0.17) with an achieved refraction of-0.63 to 0.56 (IQR). The arithmetic error was 0.34 D (IQR,-0.22 to 0.81). A hyperopic arithmetic error was present in 46% of eyes. FECD eyes with an oblate posterior cornea (Q value >0) had a 3.0 times higher risk of hyperopic shift after triple DMEK (95% confidence interval [CI], 1.3-7.0; P= .011), compared to spherical or prolate corneas (Q value ≤ 0). In eyes with posterior Q > 0, the mean prediction error was+0.50 D higher than in eyes with negative Q values (95% CI, 0.19-0.82; P= .002), independent of corneal thickness. Hyperopic surprises after triple DMEK particularly occur in corneas that are flatter centrally than the periphery because of edematous changes (oblate posterior profile). Eyes with a positive Q value on Scheimpflug imaging should be considered for additional power at the intraocular lens level.

Role of Initial Intraocular Pressure in Graft Adhesion After Descemet Membrane Endothelial Keratoplasty.

To analyze the role of initial intraoperative intraocular pressure (IOP) in graft adhesion in Descemet membrane endothelial keratoplasty (DMEK) during early follow-up. This retrospective, observational, single-center case series included 118 eyes from 118 consecutive patients treated between May and July 2015 for DMEK or combined DMEK and phacoemulsification (triple-DMEK). Exclusion criteria were previous eye surgery other than cataract surgery, loss of follow-up, any application of IOP-lowering medication before and after surgery, and low intraindividual repeatability of IOP measurements. The main outcome measure was graft adhesion that was correlated to the magnitude of IOP measured by Schiötz tonometry intraoperatively. Fifty-four eyes of 118 (45.8%) patients undergoing DMEK met the above-mentioned inclusion and exclusion criteria. In 43 (79.6%) eyes, complete graft adhesion was achieved at 1-week follow-up examination. Differences of the initial IOP in the presence of the air bubble were not statistically significant between eyes with complete and incomplete graft adhesion. Incomplete graft adhesion during early follow-up could not be associated with the magnitude of the initial IOP in DMEK. We found no evidence that higher IOP values enhance graft adhesion resulting in lower rebubbling rates after DMEK.

Descemet Membrane Endothelial Keratoplasty in an Eye with Fuchs Endothelial Dystrophy and Keratoconus

Purpose To report a case of Descemet membrane endothelial keratoplasty (DMEK) performed with phacoemulsification and intraocular lens implantation (triple procedure) for coexisting keratoconus (KC), Fuchs endothelial dystrophy (FED), and visually significant cataract. Case description One eye of one patient with moderate and stable KC, FED, and visually significant cataract was treated with combined DMEK and phacoemulsification with intraocular lens implantation (triple procedure). Visual acuity and corneal reflectivity/densitometry, thickness, and topographic measurements were recorded and compared to their preoperative values. At all postoperative time points, the endothelial graft was found to be completely attached. By 3 months postoperatively, the patient's best spectacle corrected vision had improved from 20/50 (0.4) to 20/25 (0.8) where it remained stable. No intra- or postoperative complications were experienced. Conclusions DMEK may be an effective alternative to penetrating keratoplasty in eyes with coexisting stable KC and FED.