Primary Descemet Membrane Endothelial Keratoplasty Research Articles

Clinical Outcomes of Repeat Descemet Membrane Endothelial Keratoplasty After Graft Failure.

To evaluate the clinical outcomes after repeat Descemet membrane endothelial keratoplasty (DMEK) for technical failure (TF) and secondary graft failure (SGF). Retrospective analysis of 49 eyes that underwent repeat DMEK either for TF (ie, persistent graft detachment, n = 24) or for SGF (ie, late endothelial graft failure, n = 25). Surgery indications for primary DMEK were Fuchs endothelial corneal dystrophy (FECD, 80%) and bullous keratopathy (BK, 20%). Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), corneal backscattering, pachymetry, and graft survival. Outcomes were compared with an age-matched control group of 49 primary DMEK eyes. Logarithm of the minimum angle of resolution BCVA improved from 0.92 ± 0.6 before to 0.20 ± 0.3 at 1 year after repeat DMEK with better outcomes for eyes with TF than those with SGF (P = 0.046). Donor ECD decreased from 2618 ± 171 cells/mm2 before to 1247 ± 422 cells/mm2 at 1 year postoperatively, with no difference between technical TF and SGF eyes (P > 0.05). One-year BCVA and ECD outcomes were better in the control group than in the repeat DMEK group (P < 0.05). Five-year graft survival probability after repeat DMEK was better for TF than for SGF eyes (100% vs. 75%, P = 0.010) and better for eyes with FECD than BK as primary indication for surgery (92% vs. 65%, P = 0.042). Repeat DMEK gives acceptable clinical outcomes especially when performed for TF in the early period after primary DMEK. Long-term graft survival probability after repeat DMEK is comparable to primary DMEK for FECD eyes, whereas BK eyes may show an elevated risk to develop graft failure again.

Descemet Membrane Endothelial Keratoplasty: 10-Year Cell Loss and Failure Rate Compared With Descemet Stripping Endothelial Keratoplasty and Penetrating Keratoplasty.

The aim of this study was to assess long-term endothelial cell loss (ECL) and graft failure with Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping endothelial keratoplasty (DSEK) versus penetrating keratoplasty (PK) performed for the same indications (primarily Fuchs dystrophy and pseudophakic corneal edema) in the Cornea Donor Study. This retrospective study included consecutive primary DMEK (529 recipients, 739 eyes) and DSEK cases (585 recipients, 748 eyes) with 1 or more endothelial cell density (ECD) measurements at 6 months to 16 years. Main outcomes were ECD, longitudinal ECL, and graft failure. Between 6 months and 8 years the ECD declined linearly by approximately 118 cells/mm2/yr after DMEK and 112 cells/mm2/yr after DSEK. Beyond 8 years postoperatively the rate of decline slowed substantially. Selective dropout from graft failure did not significantly affect the ECD trend. At 10 years, median ECL (interquartile range) was 63% (45, 73) with DMEK, 68% (48, 78) with DSEK, and 76% (70, 82) with PK (P = 0.01 DMEK vs. DSEK, P <0.001 DMEK vs. PK, and P < 0.001 DSEK vs. PK). The proportion of surviving grafts with 10-year ECD <500 cells/mm2 was 1.4% with DMEK, 7.3% with DSEK, and 23.9% with PK. The cumulative risk of graft failure between 6 months and 10 years was 5% with DMEK, 11% with DSEK, and 19% with PK (P < 0.001). Compared with PK and DSEK, DMEK had significantly lower ECL and significantly lower risk of secondary graft failure through 10 years.

Corneal Guttae After Descemet Membrane Endothelial Keratoplasty.

The aim of this study was to report on the occurrence of corneal guttae after Descemet membrane endothelial keratoplasty (DMEK). In this retrospective case series, 13 eyes of 13 patients who underwent DMEK at 2 tertiary referral centers between 2007 and 2021 (average available follow-up 73 ± 52 months, range 18-174 months) and showed corneal guttae during postoperative examinations were included. Eye bank images were retrospectively reviewed. Occurrence of guttae was observed by specular microscopy in 13 eyes. In 11 cases, presence of guttae was confirmed by confocal microscopy and in 1 case by histology. Five eyes showed an increase in guttae density during the postoperative course. Surgery indications were Fuchs endothelial corneal dystrophy (n = 11), pseudophakic bullous keratopathy (n = 1), and DMEK graft failure after allograft rejection (n = 1); the latter eye had shown no signs of guttae after primary DMEK. Two eyes with guttae required a repeat DMEK due to graft failure. At the last available follow-up, all 11 remaining eyes had clear corneas and 10 eyes had a best-corrected visual acuity of ≥0.9 (decimal). During donor cornea processing in the eye bank, no guttae were observed on the donor tissue. Corneal guttae can occur after DMEK including in eyes operated for indications other than Fuchs endothelial corneal dystrophy and most likely guttae were present on the donor graft but were not detectable by routine slit-lamp and light microscopy evaluation in the eye bank. Postoperative guttae density varies among patients and especially small isolated guttae do not seem to affect clinical outcomes.

Donor and recipient characteristics associated with rebubbling rate, endothelial cell loss, and graft failure in primary descemet membrane endothelial keratoplasty

Aim: To determine whether donor and recipient characteristics are associated with rebubbling rate, endothelial cell loss (ECL), and graft failure 3 years after primary Descemet membrane endothelial keratoplasty (DMEK).&#x0D; Material and Method: Records of 295 consecutive DMEK surgery and match with corresponding donor data were reviewed at a tertiary referral clinic. Recipients with intraoperative complications and coexisting ocular pathologies were excluded. Age, sex of donor and recipient, cause of donor death, death-to-preservation time (DtPT), storage time, donor endothelial cell density (ECD), and indications for surgery were analyzed for correlation with rebubbling rate, postoperative ECL, and graft failure. Further, subgroup analyses of the cause of death, donor sex, DtPT (median value, 3.5 h), and indications were performed. Multiple regression and receiver operating characteristics (ROC) analysis were used to determine the independent risk factors for graft failure.&#x0D; Results: This study included 114 eyes that underwent DMEK for bullous keratopathy (BK; 64%) and for Fuchs’ endothelial corneal dystrophy (FECD; 36%). The graft failure percentage was the only parameter that was higher in patients with DtPT &gt; 3.5 h (p=0.047) than those with shorter DtPT. The probability of graft failure was seven times higher in eyes with DtPT &gt; 3.5 h than with shorter DtPT (odds ratio 7.36, 95% confidence interval CI 1.34‒40.53) and 10 times higher in eyes with BK than those with FECD (odds ratio 10.29, 95% CI 1.01‒104.54).&#x0D; Conclusion:. DtPT and recipients with BK diagnosis were found to be independent risk factors for graft failure. Therefore, surgeons should consider DtPT for DMEK in eyes with BK.

Ability of routinely collected clinical factors to predict good visual results after primary Descemet membrane endothelial keratoplasty: a cohort study

BackgroundA comprehensive analysis of routinely collected pre/perioperative demographic/clinical factors that could predict final visual acuity after primary Descemet membrane endothelial keratoplasty (DMEK) has not been conducted previously.MethodsA retrospective monocenter cohort study was performed with consecutive patients with Fuchs endothelial corneal dystrophy (FECD) who underwent DMEK or triple-DMEK (DMEK combined with cataract surgery) in 2016–2020 in a French tertiary-care hospital. DMEK-only patients were pseudophakic. Patients were followed for 12 months. Surgery was considered successful when 12-month best-corrected visual acuity (BCVA) was ≤0.1 logMAR (≥0.8). Exploratory multivariate analysis was conducted with the following routinely collected variables to determine their ability to predict 12-month BCVA: patient age and sex; graft donor age; triple DMEK; preoperative values of BCVA, endothelial cell density (ECD), central corneal thickness (CCT), and mean anterior keratometry; and rebubbling.ResultsOf 100 eyes (100 patients; mean age, 72 years; 61% female), 81 achieved a 12-month BCVA of ≤0.1 logMAR. Logistic regression analysis showed that older age was a significant prognosticator for 12-month BCVA > 0.1 logMAR (Odds Ratio = 0.914, 95% confidence intervals = 0.846–0.987; p = 0.02).ConclusionsAn older age associated with worse visual acuity outcomes after DMEK. This was confirmed by our analysis of the literature and supports the notion that DMEK should be conducted without delay once symptoms appear. Patient sex, donor age, triple-DMEK, and anterior keratometry also did not predict final BCVA in the literature. Preoperative CCT, ECD, and BCVA, and rebubbling occasionally appear in the literature as BCVA predictors, possibly reflecting an underlying ECD-BCVA axis.

The effect of anterior segment parameters on surgical success of Descemet membrane endothelial keratoplasty: a prospective study.

To investigate how anterior segment parameters affect the success of Descemet membrane endothelial keratoplasty (DMEK) in patients with endothelial insufficiency without stromal opacities and to identify factors predisposing them to repeat keratoplasty. Our prospective observational study included patients who underwent primary DMEK for Fuchs' endothelial dystrophy and pseudophakic bullous keratopathy between March 2019 and March 2020. After a detailed ophthalmologic examination, corneal topographic analysis, anterior segment optical coherence tomography (AS-OCT) scans, endothelial cell density (ECD) and axial length (AL) measurements were performed. Surgical success was defined as no endothelial dysfunction during follow-up. Changes in the parameters and how preoperative parameters affect surgical success were investigated. In 43 eyes of 43 patients (mean age: 68.58 ± 8.51years), mean visual acuity was 1.73 ± 0.74 LogMAR before DMEK and 0.31 ± 0.29 LogMAR in the final visit. Central corneal thickness (CCT, p = 0.026) and mean anterior chamber depth (ACD, p = 0.001) affected surgical success. Preoperative CCT values greater than 770µm increased the risk of repeat keratoplasty by 8.75-fold, whereas preoperative ACD values less than 2.5mm increased the risk by 2.92-fold. Preoperative higher CCT and lower ACD values were associated with surgical failure after DMEK. Early surgery may be considered for more successful results. This prospective study has been registered on the ClinicalTrials.gov system with the registration number NCT04420429 on 06/06/2020.

Secondary DMEK following failed primary DMEK.

To report the outcomes of secondary Descemet Membrane Endothelial Keratoplasty (DMEK) performed for failed primary DMEK. The medical records of all patients undergoing secondary DMEK due to failure of primary DMEK were reviewed. Reasons for failure were sought and best-corrected visual acuity (BCVA), endothelial cell density (ECD) and complications of secondary DMEK were evaluated. A total of 10 cases undergoing secondary DMEK following failed primary DMEK were identified. Presumed reasons for failure included donor ECD ≤ 2300 cells/mm2 (n = 4), difficulty during graft preparation (n = 2), graft detachment (n = 2), acute angle closure due to retroiridal air dislocation (n = 1), inverse graft positioning (n = 1) and phacoemulsification (n = 1). Eyes with low visual potential were not excluded from the study group. We should note that one patient (case no7) had both low ECD and graft detachment as reasons for failure and as a result he is counted twice. Median BCVA (decimal fraction) increased from 0.1 (range, 0.01; 0.3) to 0.5 (0.05; 1.0) at one month and remained stable thereafter. A BCVA of 0.5 or higher was achieved in 7 cases at the final follow-up. Mean ECD fell from 2628 ± 284 cells/mm2 to 1391 ± 252cells/mm2 at 6months (47% reduction) and 959 ± 225cells/mm2 at 24months (64% reduction) (P ≤ 0.028). Complications included the incomplete removal of the primary graft and mild iris bleeding, decompensation of a preexisting primary open-angle glaucoma and retroiridal air dislocation. Apart from low donor ECD, surgical challenges, i.e., difficulty with graft preparation, inverse graft positioning, and retroiridal air dislocation, were main reasons for failure of primary DMEK. Secondary DMEK showed a good safety profile and reasonable visual outcomes.

Descemet membrane endothelial keratoplasty (DMEK) for graft failure after penetrating keratoplasty and in vascularized high-risk eyes

Descemet membrane endothelial keratoplasty (DMEK) is considered the gold standard for the treatment of corneal endothelial dysfunction and generally leads to good postoperative results. Recently, studies have also analyzed the outcome of DMEK in so-called high-risk eyes. The relevant literature and own data on DMEK for graft failure after penetrating keratoplasty and in vascularized high-risk eyes are presented and discussed. A DMEK for the treatment of transplant failure after penetrating keratoplasty can be considered for eyes without stromal scars and without high astigmatism. A retrospective analysis of 52patients with failed penetrating grafts showed that DMEK leads to asignificant increase in visual acuity, albeit to alesser extent than after primary DMEK. Rejection and transplant failure rates seem to be similar those seen after penetrating re-keratoplasty and are thus higher than after primary DMEK. A DMEK might also be afeasible option for eyes with corneal neovascularization and stromal edema without stromal scars. A retrospective analysis of 24eyes with at least 2vascularized corneal quadrants demonstrated that DMEK leads to asignificant improvement in visual acuity and regression of corneal neovascularization. The rejection rate in this cohort was 4.2% and is therefore slightly higher than after low-risk DMEK in eyes without corneal neovascularization but still much better compared to penetrating keratoplasty. Indications for DMEK are expanding and it can be atherapeutic option for transplant failure after penetrating keratoplasty with acceptable outcomes. Furthermore, DMEK seems to be agood option for the treatment of endothelial dysfunction in vascularized high-risk eyes without stromal scars.

Real-World Outcomes of DMEK: A Prospective Dutch registry study

This study analyzed real-world practice patterns, graft survival, and outcomes of Descemet membrane endothelial keratoplasty (DMEK) in the Netherlands. Population-based interventional clinical study. In this prospective registry study, all consecutive primary DMEK procedures registered in the Netherlands Organ Transplant Registry were identified. Short-term graft survival and outcomes of primary transplants for Fuchs' endothelial dystrophy (FED) were analyzed using Kaplan-Meier survival curves with log-rank test and Cox regression. Linear mixed model analyses were used for best spectacle-corrected visual acuity (BSCVA), spherical equivalent, hyperopic shift, and endothelial cell density. 752 DMEKs were identified between 2011 and 2018. In 90% of cases, the indication for DMEK was FED. Graft survival measured 87% at 3months, 85% at 6months, 85% at 1 year, and 78% at 2 years. DMEK procedures after 2015 showed better survival compared to previous years (Hazard ratio= 0.4; P < .001). Baseline BSCVA in primary transplants with FED measured on average 0.45 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI], 0.41-0.49), and significantly improved (overall P < .001) to 0.17 logMAR (95% CI, 0.14-0.21) at 3months, 0.15 logMAR (95% CI, 0.11-0.18) at 6months, 0.12 logMAR (95% CI, 0.08-0.16) at 1 year, and 0.08 (95% CI, 0.05-0.12) at 2 years. At 3months, a hyperopic shift of+0.36 diopters (P < .001) was observed and endothelial cell loss measured 33%. Our findings provide real-world support that DMEK is an effective treatment for FED with respect to vision restoration, inducing a small hyperopic shift with an acceptable endothelial cell loss. Graft survival improved over time, suggesting a learning curve on a national level.

Long-Term Outcomes of Descemet Membrane Endothelial Keratoplasty in Eyes with Prior Glaucoma Surgery

The purpose of this study was to evaluate the long-term outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes that had previously undergone trabeculectomy and/or drainage device implantation. Retrospective, noncomparative case series. Medical records of 251 consecutive DMEK procedures performed by 1 surgeon (S.X.D.) from 2013 to 2017 were reviewed. Patients with ≥2 years of follow-up were divided into 3 groups: eyes with prior glaucoma surgery (ST), eyes with medically treated glaucoma (MT), and eyes without glaucoma (NG). Main outcomes measured were visual acuity, endothelial cell count (ECC), rates of secondary graft failure (SGF), and postoperative complications. Ninety procedures (87 eyes) met inclusion criteria. The mean follow-up period of all eyes was 38.4 ± 11.2months (range, 24.2-64.4months). At last follow-up, the proportion of eyes reaching a vision of ≥20/40 was higher than that before the DMEK procedure in each group (all P < .05). The rate of ECC loss was the highest in the ST group compared to that in the MT and NG groups (63.8% vs 47.6% vs 44.0%, respectively; P < .05) as well as the rate of SGF (41.6% vs 0% vs 2.4%, respectively; P < .05). The rate of SGF of repeat DMEK was higher than that of primary DMEK (P < .05). The rates of postoperative complications were similar among all groups (all P > .05). In eyes with prior glaucoma surgery, DMEK achieved good long-term visual outcomes but experienced a higher rate of SGF than eyes without such comorbidity.

Descemet Membrane Endothelial Keratoplasty: Ten-Year Graft Survival and Clinical Outcomes

To evaluate the 10-year graft survival and clinical outcomes of the first case series after Descemet membrane endothelial keratoplasty (DMEK). Retrospective, interventional case series. After excluding the very first 25 DMEK eyes that constitute the technique learning curve, the following 100 consecutive primary DMEK eyes (88 patients) were included. Main outcome parameters (survival, best-corrected visual acuity [BCVA], central endothelial cell density [ECD], and central corneal thickness [CCT]) were evaluated up to 10 years postoperatively, and postoperative complications were documented. At 5 and 10 years after DMEK, 68 and 57 of 100 eyes, respectively, were still available for analysis. Of those eyes, 82% and 89% reached a BCVA of ≥20/25 (decimal VA ≥0.8) at 5- and 10 years postoperatively, respectively. Preoperative donor ECD decreased by 59% at 5 years and 68% at 10 years postoperatively. CCT averaged 668 ±74μm preoperatively and 540 ± 33μm and 553 ± 43μm at 5 and 10 years, respectively, after surgery. Within 10 years, 4% of eyes developed allograft rejection, no primary graft failures occurred, and 6% of the eyes developed secondary graft failure. Graft survival probability was 0.83 (95% confidence interval [CI], 0.75-0.92) and 0.79 (95% CI, 0.70-0.88) at 5 and 10 years postoperatively, respectively. Most eyes that underwent surgery in the pioneering phase of DMEK showed excellent and stable clinical outcomes with low postoperative complication rates and promising graft longevity over the first decade after surgery. This suggests that DMEK may be a safe long-term treatment option for corneal endothelial diseases.

Repeat Descemet Membrane Endothelial Keratoplasty for Failed Primary Descemet Membrane Endothelial Keratoplasty at a Referral Center for Keratoplasty in Spain: DIMOEK Study

To analyze the clinical results of repeat Descemet membrane endothelial keratoplasty (re-DMEK) for failed primary DMEK graft at a referral center for keratoplasty in Spain. Retrospective, interventional, comparative case series. From a single-center, single-surgeon series of 189 consecutive DMEK surgeries, 14 (7.41%) were re-DMEK eyes. The primary outcome was best-corrected visual acuity change (ΔBCVA, logarithm of minimal angle of resolution [logMAR]) from baseline (before first DMEK) to last follow-up. Secondary outcomes were ΔBCVA from baseline at 3, 6, and 12months postoperatively, endothelial cell loss (%ECL), rebubbling rate, and re-DMEK graft failure. Outcomes were compared with an age-matched control group of 18 successful primary DMEK eyes. After re-DMEK (median follow-up time 14.5 [42.5] months), mean BCVA improved from 0.55 (0.42) logMAR (Snellen 20/71 [20/53]) at baseline to 0.09 (0.26) logMAR (Snellen 20/25 [20/36]; P= .037). ΔBCVA from baseline was statistically significant at months 3 (P= .028), 6 (P= .023), and 12 (P= .012), and ΔBCVA was significant observed between months 6 and 12 (P= .028). BCVA differences between patient groups were statistically nonsignificant at 3 (P= .397), 6 (P= .468), and 12months (P= .647). Mean %ECL in re-DMEK eyes with follow-up ≥12months was 48.2 (15.1%), and the rebubbling rate was 28.6%; differences between groups were statistically nonsignificant for both variables (P= .580 and P= .669, respectively). Three re-DMEK eyes developed graft failure, all achieving final BCVA ≤0.30 logMAR (Snellen ≥20/40) after tertiary keratoplasty. Repeat DMEK produces significant, continuous visual improvement after failed primary DMEK. Although visual outcomes and %ECL were comparable to primary DMEK, there was a relatively high rate of graft failure after re-DMEK.

How to Avoid an Upside-Down Orientation of the Graft during Descemet Membrane Endothelial Keratoplasty?

Purpose Incorrect anterior-posterior orientation of the Descemet endothelial complex (DEC) is one of the causes of failure of Descemet membrane endothelial keratoplasty (DMEK). We evaluated a new marking technique to avoid such a misorientation. Method A new marking technique of the DEC was evaluated in patients requiring primary DMEK. A Braille-“R”-letter was applied dot by dot onto the stromal surface of the DEC after lifting it by injecting an air-bubble into the interface between the endothelial surface of the partially stripped graft. The positioning of the graft was intraoperatively controlled by an orientation of the Braille-“R”-letter. Laboratory tests were conducted to test the impact of the marking technique on endothelial cell count. Results We included prospectively 37 eyes of 30 patients. Four eyes were phakic and 33 pseudophakic. Five grafts (14%) presented an undifferentiated rolling tendency in the anterior chamber, and evaluation of their positioning was possible due to orientation of the mark alone. In case of an upside-down orientation, grafts were flipped immediately. A correct orientation of the graft was achieved in all cases at the end of the surgery. The endothelial cell loss due to the mark was estimated to be less than 0.3%. At 3- and 6-month follow-ups, the mean best-corrected visual acuity was 0.21 ± 0.15 and 0.15 ± 0.11 logMAR, respectively, and endothelial cell density was 1661 ± 349 and 1618 ± 396 cells/mm2, respectively. Only one patient (3%) needed re-bubbling. Conclusions To rely on the natural rolling tendency of the graft alone does not assure its correct positioning in all cases. Creation of the mark with 4 dots punctuated on the air-lifted stromal side of the DEC is a simple and endothelial cell saving marking method to ensure correct orientation of the graft during DMEK.

Corneal Densitometry After Secondary Descemet Membrane Endothelial Keratoplasty.

To evaluate Scheimpflug corneal densitometry (CD) in patients undergoing secondary Descemet membrane endothelial keratoplasty (DMEK) after previous Descemet stripping automated endothelial keratoplasty or DMEK surgery. This was a retrospective institutional case series of 37 eyes of 37 patients. Two secondary DMEK groups, group 1A (n = 12 DMEK after Descemet stripping automated endothelial keratoplasty), group 1B (n = 11 repeat DMEK), and group 2 (n = 14 primary DMEK for Fuchs endothelial dystrophy) were formed. CD was obtained preoperatively, 1, 6, and 12 months postoperatively. In addition, corrected distance visual acuity, central corneal thickness, and endothelial cell density were assessed. A significant decrease in grayscale units was observed in the 0- to 2-mm and 2- to 6-mm zones in all groups. For the 0- to 2-mm zone, values decreased from 49.11 ± 17.96 preoperatively to 22.87 ± 5.24 at 12 months (group 1A), from 45.16 ± 9.22 to 24.53 ± 14.21 (group 1B), and from 27.90 ± 8.30 to 16.64 ± 1.51 (group 2) (P < 0.01). Group 2 showed significantly lower grayscale units than groups 1A and 1B preoperatively and 12 months postoperatively in the 0- to 2-mm and 2- to 6-mm zones. Significant correlations of CD and corrected distance visual acuity were found in groups 1A and 1B in the 0- to 2-mm zone at 12 months. There were no significant correlations between CD and central corneal thickness postoperatively. A decrease in CD could be demonstrated in secondary DMEK. Nevertheless, CD values remained significantly higher than in controls. This might point out the relevance of secondary corneal structural changes.

Functional outcome of repeat Descemet membrane endothelial keratoplasty (DMEK) for corneal decompensation following graft failure after primary DMEK.

PurposeTo evaluate if repeat Descemet membrane endothelial keratoplasty (DMEK) is appropriate to achieve functional improvements in patients with corneal decompensation from secondary graft failure after primary DMEK.MethodsThis is a retrospective monocentric cohort study including 13 eyes of 13 patients with repeat DMEK for corneal decompensation following primary DMEK. Eyes with primary DMEK only and comparable preoperative corrected distance visual acuity (CDVA) served as control. Main outcome parameter was CDVA. Secondary outcome measures were central corneal thickness (CCT), endothelial cell density, and rebubbling rate (RR).ResultsThe average time interval (±SD) between primary and secondary DMEK was 12.5±6 months. Preoperative CDVA (logMAR) was 1.97±0.90 in the repeat DMEK group and 1.38±0.92 in the primary DMEK group. At 6 months, both groups showed significant improvement in visual acuity (repeat DMEK group, 0.49±0.35, P<0.01 and primary DMEK group, 0.40±0.36, P<0.01). CDVA did not differ significantly between both groups at all time points examined (1, 3, and 6 months postoperatively). Mean CCT values at 3 and 6 months postoperatively did not differ significantly between the two groups (P>0.05). The RR was 23% (n=3) in both groups.ConclusionRepeat DMEK is a useful therapeutic approach in the setting of corneal decompensation following primary DMEK. Functional results of repeat DMEK, visual acuity in particular, are comparable to patients with single DMEK only.

Outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes with failure of primary Descemet membrane endothelial keratoplasty (DMEK)

AimTo evaluate the outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes after failure of primary Descemet membrane endothelial keratoplasty (DMEK).MethodsThis was a retrospective, non-comparative interventional case...

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.

Clinical Outcome of Rebubbling for Graft Detachment After Descemet Membrane Endothelial Keratoplasty.

To assess the clinical outcome after successful rebubbling procedures for visually significant graft detachment after Descemet membrane endothelial keratoplasty (DMEK). From a total of 760 consecutive DMEK surgeries, 41 eyes required rebubbling. Of those, 33 eyes of 31 patients were successful and were included in our retrospective outcome analysis study. Main outcome measures were compared with those of matched controls with uneventful primary DMEK (attached DMEK grafts without rebubbling). Rebubbling was performed on average 25 (±20) days (range 7-91 days) after DMEK. All eyes were evaluated for best-corrected visual acuity, endothelial cell density (ECD), pachymetry, and complications up to 6 months after rebubbling. At 6 months after DMEK, best-corrected visual acuity in rebubbled eyes did not differ from that in control eyes (P = 0.514). The mean ECD decrease was higher in rebubbled than in control eyes (54% vs. 35%, respectively, P = 0.001). Pachymetry did not differ between both groups (P = 0.153). After rebubbling, one buphthalmic eye showed temporary intraocular pressure elevation and 5 eyes had minor graft edge detachment that did not require further treatment. Rebubbling for DMEK graft detachment may result in similar visual outcomes as in uncomplicated DMEK, when performed within the first 6 to 8 postoperative weeks. However, rebubbled eyes may have lower ECD, which may be attributed to additional air bubble trauma and/or selection bias through more extensive manipulation during initial DMEK or higher risk of graft detachment in more complicated eyes.

Splitting of the Recipient's Descemet Membrane in Descemet Membrane Endothelial Keratoplasty—Ultrastructure and Clinical Relevance

In Descemet membrane endothelial keratoplasty (DMEK), lamellar splitting of the Descemet membrane (DM) may occur during stripping of host DM, leaving residual DM on the recipient's DMEK interface. The purpose of this study was to determine the incidence rate of lamellar splitting of DM during DMEK and to describe the ultrastructure of DM in theseeyes. Retrospective consecutive case series. setting: Institutional, single-center. Total of 664 eyes with Fuchs endothelial corneal dystrophy (FECD) scheduled for primary DMEK. DMEK. The incidence rate of lamellar DM splitting in the recipients' eyes; ultrastructural alterations of stripped DM specimens (transmission electron microscopy); preoperative best-corrected visual acuity (BCVA), central corneal thickness (CCT), and prevalence of diabetes mellitus. Sixty-three of 664 eyes (9.5%) with FECD showed lamellar splitting of DM resulting in the dissociation of 2 separate layers. Transmission electron microscopy revealed accumulations of banded and wide-spaced collagen between the thicker posterior banded layer and the thin anterior banded layer, which is adhesive to the corneal stroma. Lamellar splitting occurred along these abnormal collagen inclusions, demarcating the borderline between both layers of DM. Lamellar DM splitting occurs during DM stripping in almost 10% of eyes with FECD. This phenomenon appears to be caused by abnormal collagenous material deposits at the borderline between anterior and posterior layers of DM.

Repeat Descemet Membrane Endothelial Keratoplasty: Secondary Grafts with Early Intervention Are Comparable with Fellow-Eye Primary Grafts

To evaluate the outcomes of secondary Descemet membrane endothelial keratoplasty (DMEK) after failed primary DMEK. Retrospective, interventional case series. Fifty-five DMEK recipients 42 to 89 years of age. An initial consecutive series of 1655 DMEK surgeries was reviewed to identify cases of secondary DMEK after failed primary DMEK (n = 55). A paired fellow-eye analysis was performed with a subgroup of 29 patients who underwent secondary DMEK in 1 eye and successful primary DMEK in the fellow eye. Corrected distance visual acuity (CDVA), central corneal thickness, and 1-year endothelial cell loss. The median follow-up after DMEK regraft was 18 months (range, 3-61 months). All 55 regrafts cleared, 8 (15%) had air reinjected to promote attachment, 1 eye (2%) with trabeculectomy and progressive synechiae demonstrated late endothelial failure, and no rejection episodes occurred (0%). In the paired analysis, the median duration of endothelial decompensation before the regraft was 21 days (range, 2-133 days). At 1, 3, 6, or 12 months, CDVA did not differ between the primary and secondary grafts in fellow eyes (mean difference, ≤2 Snellen letters; P > 0.05 at all examinations). At 1 year, the visual acuity was ≥20/20 in 61%, ≥20/25 in 81%, and ≥20/40 in 100% of the secondary grafts in the paired analysis, excluding 1 eye with retinal problems. Vision differed by ≤1 line between fellow eyes in all but the 1 patient with the longest time to regraft (133 days), who demonstrated central haze and irregular astigmatism from anterior stromal scarring during that period. At 1 year, CDVA associated with the scarring was 20/40 versus 20/20 for the fellow-eye primary graft. The central corneal thickness was comparable between fellow-eye primary and secondary grafts at 3, 6, and 12 months (mean difference at 1 year, 2 μm; P = 0.57). The 1-year endothelial cell loss was comparable in primary and secondary grafts (27% vs. 31%, respectively; P = 0.58). In patients who received prompt intervention to minimize the duration of central corneal decompensation, the visual outcomes with secondary DMEK matched the fellow-eye visual outcomes with primary DMEK.