Postoperative Graft Detachment Research Articles

Graft Detachment after Descemet Membrane Endothelial Keratoplasty with and without Cataract Surgery.

To evaluate graft detachment after Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic eyes and DMEK combined with cataract surgery (triple DMEK). Analysis of 3 single-center prospective cohort studies and 1 randomized controlled trial. Participants with Fuchs' endothelial corneal dystrophy. A validated neural network for image segmentation quantified graft detachment on anterior segment OCT (AS-OCT) images 3 days after DMEK and at the 2-week postoperative visit. Area and volume of graft detachment were compared between DMEK only and triple DMEK using generalized estimating equation models and adjusting for participant age and the size of the air bubble. Area and volume of DMEK graft detachment. Among 207 participants with 270 eyes included, 75 pseudophakic eyes had DMEK only and 195 eyes had triple DMEK. A total of 147 eyes had less than one third of detachment at day 3. In 139 of these eyes (95%), detachment was still less than one third at the 2-week scan, indicating that postoperative graft detachment at 2 weeks occurred mainly in eyes with early detachment. When superimposing all 3-dimensional maps from 2 weeks after surgery, the central graft was mainly attached and detachment was located at the graft margin. The mean area of graft detachment decreased from 28% in DMEK only and 38% in triple DMEK to 16% in DMEK only and 25% in triple DMEK at the 2-week postoperative visit. At 2 weeks, the mean area of detachment was 1.85-fold higher (95% confidence interval [CI], 1.34-2.56) and the mean volume was 2.41-fold higher (95% CI, 1.51-3.86) in triple DMEK compared with DMEK. A total of 46 eyes received rebubbling procedures, with 7 eyes (9%) in the DMEK group and 39 eyes (20%) in the triple DMEK group (adjusted risk ratio, 3.1; 95% CI, 1.3-7.1), indicating that rebubbling was more common in eyes undergoing triple DMEK. Automated segmentation of AS-OCT images allowed precise quantification of graft detachment over time and identified DMEK combined with cataract surgery as a risk factor. Frequency of operative follow-up might be guided by extent of detachment in the first postoperative days after DMEK.

Descemet membrane endothelial keratoplasty in initial cases: analysis and management of surgical complications

Objective: To investigate causes and management of surgical complications of Descemet membrane endothelial keratoplasty (DMEK) in initial cases. Methods: A retrospective study. A total of 52 eyes of 52 patients underwent DMEK by one surgeon in Peking University Third Hospital from February 2017 to December 2019, including 17 males and 35 females, aged (66±12) years. All patients' demographic characteristics, previous surgical history, intraoperative and postoperative complications were recorded. Results: Intraoperative complications included difficulties in unfolding the graft in 6 cases (11.5%), inverted grafts in 5 cases (9.6%), grafts rushing out of the anterior chamber in 2 cases (3.8%), grafts injected behind the iris in 3 cases (5.8%) and hemorrhage in 1 case. Partial graft detachment that occurred in 28 cases (53.8%) was the most frequent postoperative complication. Rebubbling was performed in 25 cases (48.1%). Pupillary block occurred in 9 cases (17.3%) and was managed by reducing air under a slit lamp. Primary graft failure occurred in 3 cases (5.8%) and viral infection occurred in 2 cases (3.8%). Conclusions: The rate of complications of DMEK in initial cases is higher than that of Descemet stripping automated endothelial keratoplasty. Intraoperative graft inversion and postoperative graft detachment are the most common complications. It is important to select appropriate indications and discover or manage intraoperative and postoperative complications in time to reduce the incidence of complications. (Chin J Ophthalmol, 2021, 57:595-600).

Novel Technique for Descemetorhexis Under Ophthalmic Viscosurgical Devices and Air.

The aim of this study was to describe a novel technique for descemetorhexis that combines the advantages of stable anterior chamber (AC) associated with ophthalmic viscosurgical devices and optimal surgical visualization seen with air to overcome the issues of poor Descemet membrane (DM) visibility or AC instability when each is used alone. This study is a description of a new surgical approach. We describe a new technique for performing descemetorhexis. The simultaneous presence of cohesive ophthalmic viscosurgical device and air in the AC offers optimal DM visualization and guarantees a stable AC during this surgical step. It does not require an additional incision for an AC maintainer. The described technique may facilitate the surgical step of descemetorhexis, offering improved AC stability and better visualization of the DM. It may reduce early postoperative graft detachment due to the presence of residues of the recipient's diseased DM.

Postoperative supine position after primary Descemet-stripping automated endothelial keratoplasty reduces graft detachment rate

ObjectiveTo characterize the association between prolonged supine postoperative positioning of patients undergoing Descemet-stripping automated endothelial keratoplasty (DSAEK) and graft dislocation rate. MethodsIn this retrospective cohort study, medical records of patients who underwent uncomplicated DSAEK surgery at Yitzhak Shamir Medical Center between 2010 and 2019 were reviewed. Nursing documentation of patients’ adherence to supine positioning during the postoperative hospitalization period was collected. A patient was considered compliant if he or she was documented as cooperative with supine positioning throughout the first 24 hours. ResultsA total of 170 eyes of 138 patients were found eligible. Main indications for surgery were pseudophakic bullous keratopathy (50.6%), previous graft failure (25.9%), and Fuch's endothelial dystrophy (FED; 20.6%). Twelve surgeries were combined with cataract extraction. Postoperative graft detachment occurred in 26 eyes (15.3%) after an average period of 1 day (range, 0–20 days). Compliance with supine positioning was documented in 84.1% (n = 143 patients). Noncompliance rates during the first 24 hours in the detached and nondetached groups were 26.9% (n = 7) and 14.4% (n = 20), respectively; after adjustment for possible confounders, the odds ratio (OR) was 1.44 (p = 0.249). Graft dislocation was observed in 13.3% (19 of 143) and 25.9% (7 of 27) of cooperative and noncooperative patients, respectively (p = 0.17). Subanalysis of 120 eyes with either BPK or FED for which it was the first transplantation demonstrated a protective effect of supine positioning (OR 3.42, confidence interval 1.095–10.700; p = 0.034). Findings for both groups remained unchanged in multivariate analysis. ConclusionsWe found a statistically significant protective effect of 24 hours of postoperative supine positioning against graft detachment after DSAEK in eyes with no prior transplantations.

Effect of Graft Shift Direction on Graft Detachment and Endothelial Cell Survival After Descemet Membrane Endothelial Keratoplasty.

To investigate the effects of graft shift orientation on clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK). This study used intraoperative video images to retrospectively examine the effect of graft shift direction in 50 eyes of 50 patients. Correlations were assessed between graft shift direction and multiple parameters. The graft detachment rate was higher in eyes with an inferior graft shift than in those without (superior, 0% and 5.0%; nasal, 0% and 20.0%; inferior, 16.7% and 55.0%; temporal, 16.7% and 45.0%; and any segment, 23.3% and 65.0%; for graft shift-negative and graft shift-positive cases, respectively). Postoperative endothelial cell density reduction was higher in eyes with an inferior graft shift (1 month, 23.6% ± 13.7% and 37.5% ± 18.8%; 3 months, 31.6% ± 16.4% and 45.2% ± 15.2%; and 6 months, 39.8% ± 14.9% and 50.7% ± 16.6%; for graft shift-negative and graft shift-positive cases, respectively). Eyes with a superior graft shift had lower postoperative endothelial cell density reduction than those without (1 month, 36.9% ± 16.6% and 20.0% ± 13.1%; 3 months, 45.3% ± 13.3% and 27.4% ± 16.2%; and 6 months, 51.3% ± 14.6% and 35.9% ± 14.5%; for graft shift-negative and graft shift-positive cases, respectively). Graft shift direction did not affect postoperative best-corrected visual acuity or central corneal thickness. Graft shift direction in DMEK, especially inferior graft shift, affected the postoperative graft detachment rate. Superior graft shift had a beneficial effect on postoperative corneal endothelial values. These data suggest that inferior graft shift should be avoided in DMEK.

Factors Associated With Early Graft Detachment in Primary Descemet Membrane Endothelial Keratoplasty

To evaluate the risk factors for early graft detachment in Descemet membrane endothelial keratoplasty (DMEK). Case-control study. Participants: A total of 173 donor corneas and 173 eyes of the patients following DMEK or DMEK in combination with phacoemulsification and intraocular lens implantation were included. Pre-stripped DMEK grafts were transplanted using pull-through technique. At the end of surgery, the anterior chamber was filled with air, which was removed 3 hours later only if pupillary block was suspected. Rebubbling was performed in all cases with graft detachment, independently of its extension, as documented by means of anterior segment optical coherence tomography. The donor characteristics were collected from the eye bank database and matched with the recipient database. Donor and recipient characteristics affecting graft detachment using univariate and multivariate analysis. The combination of DMEK with cataract removal and IOL implantation (odds ratio [OR]= 5.31, 95% confidence interval [CI] 2.03-13.86, P < .002) and air fill of ≤75% of anterior chamber height at 2-3 hours postoperatively (OR= 2.66, 95% CI 1.12-6.34, P= .027) were found to be independent risk factors for postoperative graft detachment. Cataract removal at the time of DMEK is a risk factor for early graft detachment and therefore sequential surgery may be preferred over combined surgery in an attempt at minimizing rebubbling. Air level in the anterior chamber should be monitored and maintained above 75% in the early hours following surgery.

Factors Associated With Graft Detachment After Primary Descemet Stripping Automated Endothelial Keratoplasty.

To identify risk factors associated with postoperative graft detachment after Descemet stripping automated endothelial keratoplasty (DSAEK). In this retrospective institutional cohort study, the study group included all consecutive eyes that underwent primary DSAEK between January 2005 and October 2015 at Villa Serena-Villa Igea private hospitals (Forlì, Italy) and developed postoperative graft detachment (n = 45). The control group included all eyes that underwent primary DSAEK during the same period and did not develop graft detachment (n = 1167). The main outcome measure was whether or not postoperative graft detachment occurred. Main indications for surgery included Fuchs endothelial dystrophy (525/1212 = 41%), pseudophakic bullous keratopathy (422/1212 = 35%), and a failed penetrating keratoplasty (PK) graft (190/1212 = 16%). Postoperative graft detachment occurred in 45 of 1212 (3.7%) eyes. Medically treated glaucoma, previous trabeculectomy, previous aqueous shunt procedure, and failed PK were all associated with an increased risk for graft detachment in univariate analysis. No particular lens status at the time of graft implantation was significantly associated with graft detachment, including the presence of an anterior chamber intraocular lens [odds ratio (OR), 1.5; 95% confidence interval (CI), 0.35-6.46, P = 0.58] or aphakia at the time of graft transplantation (OR, 1.37; 95% CI, 0.41-4.57, P = 0.74). Cataract removal during surgery was not associated with an increased risk for detachment (OR, 0.77; 95% CI, 0.39-1.5, P = 0.47). Previous trabeculectomy (OR, 4.21; 95% CI, 1.53-11.56, P = 0.005) and a previous failed PK graft (OR, 3.04; 95% CI, 1.6-5.78, P = 0.001) were the only independent risk factors for graft detachment in multivariate analyses. Previous PK and trabeculectomy are independent risk factors for postoperative graft detachment in primary DSAEK.

Descemet Membrane Endothelial Keratoplasty: Preliminary Results of a Donor Insertion Pull-through Technique Using a Donor Mat Device

To evaluate a novel technique of Descemet membrane endothelial keratoplasty (DMEK) donor insertion using the EndoGlide pull-through device. Prospective, interventional cases series. We performed DMEK using the EndoGlide technique with a protoype donor carrier device (Descemet Mat, or D-Mat) in 30 patients by a single surgeon (including learning curve). Clinical data and donor and recipient characteristics were tracked from our prospective Singapore Corneal Transplant Registry. Main outcome measures were intraoperative complications and the incidence of postoperative graft detachment and primary graft failures within 3months from surgery. In our preliminary study of 30 eyes in 30 patients (73% female, mean age 64.5 ± 8.3 years), we observed 3 cases (10%) of partial donor detachment requiring rebubbling and 1 (3%) primary donor failure. Twenty of 30 eyes (66.7%) achieved ≥20/25 3-month best spectacle-corrected visual acuity. Six-month endothelial cell loss reduced from 65% ± 13% to 48% ± 11% (P= .02) comparing the first and last 15 cases. With the exception of 1 case with excessive fibrin formation, we did not experience any further intraoperative complications related to donor tissue insertion, incomplete tissue unfolding, donor tissue malposition, or incorrect orientation. Our study suggests that the described technique allows for donor control and insertion in the correct orientation with the endothelium facing down. Further studies are required to confirm if this DMEK donor insertion technique can lead to reduced endothelial cell loss and better graft survival.

Visual Outcomes and Graft Thickness in Microthin DSAEK--One-Year Results.

To evaluate visual outcomes, endothelial graft thickness, and complications in microthin Descemet stripping automated endothelial keratoplasty (DSAEK). A prospective interventional cohort of 130 eyes of 114 consecutive patients underwent microthin DSAEK. Endothelial graft preparation included pachymetry-controlled stromal dehydration to reduce donor thickness between 550 and 530 μm by a custom airflow device, before a single-pass microkeratome dissection with a uniform cutting head of 350 μm to achieve microthin endothelial grafts (<130 μm). Data on visual acuity, graft thickness, endothelial cell loss, and complication rates were analyzed. Pachymetry-controlled donor preconditioning reduced donor thickness on average by 67 μm (range 0-186, SD 44.7) from 590 μm (range 485-806, SD 53) to 528 μm (range 480-620, SD 23), P < 0.01, and allowed graft preparation without any case of intraoperative graft loss or perforation. The resultant mean graft thickness was 94 μm (SD 25) intraoperatively, 94 μm (SD 26) at 1 month, and 90 μm (SD 19) at 12 months. Of note, 98.2% of eyes without significant visual comorbidity achieved best-corrected Snellen acuity of 6/9 or more at 12 months. There was a 35.8% and 41% reduction in endothelial cell density at 3 and 12 months, respectively. Postoperative graft detachment occurred in 5% of cases (1.7% in uncomplicated eyes). There was no graft loss during preparation, and none developed immune rejection during the study period. The microthin DSAEK procedure offers a simple and safe technique to prepare thin endothelial grafts with a low risk of graft wastage, low risk of postoperative detachment, and visual results that are comparable to those of other thin endothelial keratoplasty procedures.

Risk Factors Predicting the Need for Graft Exchange After Descemet Stripping Automated Endothelial Keratoplasty.

To identify the risk factors predicting the need for graft exchange after Descemet stripping automated endothelial keratoplasty (DSAEK). This is a retrospective cohort study. The study group included all 117 eyes that underwent or necessitated repeat DSAEK performed between January 2005 and June 2014 at Villa Serena-Villa Igea private hospitals (Forlì, Italy). The control group consisted of 1033 eyes that underwent only primary DSAEK during the same period. Demographic details, indications for primary surgery, ocular preoperative status and comorbidities, donor endothelial cell density (ECD), and postoperative complications were compared between the groups using univariate and multivariate analyses. The prevalence of graft failure necessitating graft exchange was 10.2% (117 of 1150 eyes). In univariate analysis, a diagnosis of Fuchs endothelial dystrophy was a protective factor against the risk of repeat DSAEK. Prior trabeculectomy or aqueous shunt implantation, postoperative graft detachment, lower donor ECD, and a rejection episode were all associated with a significantly higher risk of requiring repeat DSAEK. The presence of buphthalmos, anterior chamber intraocular lens, aphakia, or prior penetrating keratoplasty were not risk factors for the failure of DSAEK. Of these variables, multivariate analysis showed that only prior aqueous shunt implantation [odds ratio (OR) = 5.5, 95% confidence interval (CI), 1.4-22.2], lower donor ECD (OR = 0.99, 95% CI, 0.997-0.999), and a documented postoperative rejection episode (OR = 18.2, 95% CI, 7.9-45.0) predicted the need for repeat DSAEK. DSAEK grafts have similarly good long-term survival regardless of the indication for surgery, lens status, or ocular comorbidities, with the only exception being the presence of an aqueous shunt.

Descemet stripping with automated endothelial keratoplasty: A comparative study of outcome in patients with preexisting glaucoma

PurposeTo compare postoperative complications after Descemet stripping with automated endothelial keratoplasty (DSAEK) in patients with and without glaucoma. MethodsFor this retrospective study a series of 298 DSAEK cases performed at the Doheny Eye Institute were taken, we compared postoperative complications in eyes with glaucoma on medication (55) or with previous glaucoma surgeries (64) with a time-matched group of all other DSAEK cases (179, control). ResultsWith a mean follow-up of 1.85±1.12years, the complication rates were 12.8%, 11.1%, and 26.8% for postoperative graft detachment, graft failure, and IOP elevation, respectively. Graft detachment was an independent risk factor for graft failure (odds ratio OR=12.35, 95% confidence interval CI [5.46–27.90], P<0.001). Graft detachment was not associated with either history of glaucoma or glaucoma surgery (P>0.05). Glaucoma on medication had no increased risks of graft failure compared to normal eyes (P=0.38). However, increased risk of failure was seen in eyes with prior incisional glaucoma surgeries (OR=4.26, 95% CI [1.87–9.71], P<0.001). Medically managed glaucoma has increased risks of postoperative IOP elevation (OR=2.39, 95% CI [1.25–4.57], P=0.013), whereas surgically managed glaucoma has no significant elevation (P=0.23). Elevation of IOP was not significantly correlated with graft failure (P=0.21). ConclusionDSAEK is the preferred treatment for corneal endothelial dystrophy. We observed that having glaucoma or glaucoma surgery is not associated with graft detachment. A history of glaucoma surgery and postoperative graft detachment appeared to be important risk factors for graft failure. And more studies are indicated to study long-term IOP evolution in post-DSAEK patients and its association with graft survival.

Transcorneal Suture Fixation of Posterior Lamellar Grafts in Eyes With Minimal or Absent Iris–Lens Diaphragm

To describe a technique that uses a transcorneal suture for safe delivery and fixation of donor tissue during Descemet stripping automated endothelial keratoplasty in patients that are at risk of graft dislocation into the vitreous cavity as a result of minimal or absent iris-lens diaphragm. Interventional case series. Thirteen eyes with endothelial decompensation and inadequate iris-lens diaphragm underwent modified Descemet stripping automated endothelial keratoplasty surgery. A 10-0 Prolene suture (Ethicon Inc) was passed through the endothelial graft and used to pull the graft into the eye and anchor it onto the recipient cornea. Best-corrected visual acuity, refraction, and complications were recorded. Preoperative best-corrected visual acuity was less than 20/200 in all cases. Eleven patients had a pre-existing comorbidity (glaucoma, n = 8; previous retinal detachment, n = 2; epiretinal membrane n = 1). Average follow-up was 11.3 months (range, 3 to 36 months). No graft dislocation occurred during surgery. After surgery, graft detachment was noted in 2 cases and rebubbling succeeded in achieving reattachment. All patients had successful attachment of the endothelial graft. Postoperative best-corrected visual acuity improved in 11 of 13 patients and remained unchanged in 2 patients. In patients with insufficient iris-lens diaphragm, this technique allowed safe graft delivery, prevented intraoperative and postoperative graft dislocation, and facilitated successful rebubbling in case of postoperative graft detachment.

Descemet membrane endothelial keratoplasty with a stromal rim (DMEK-S)

AimTo describe a novel technique for the preparation and transplantation of posterior corneal lamellae consisting of endothelium and bare Descemet membrane with a stromal supporting rim.MethodsPosterior lamellar discs for Descemet...