ABSTRACT
PURPOSE: To report 1-year outcomes of Descemet's membrane endothelial keratoplasty (DMEK) performed at 2 centers. DESIGN: Prospective, consecutive, interventional series. PARTICIPANTS: Patients with Fuchs' endothelial dystrophy, pseudophakic bullous keratoplasty, or failed previous graft (n = 136 eyes). INTERVENTION: The diseased central 7 mm of Descemet's membrane (DM) was stripped from the recipient cornea and replaced with healthy DM and endothelium stripped from donor corneas through a 2.8-mm corneal incision. Descemet's membrane endothelial keratoplasty was performed alone (n = 110) or combined with either phacoemulsification and intraocular lens implantation (n = 23) or pars plana vitrectomy (n = 3). MAIN OUTCOME MEASURES: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density. RESULTS: Excluding eyes with pre-existing ocular comorbidities or those lost to follow-up, mean BSCVA at 1 year was 0.07 logarithm minimum angle of resolution (logMAR) units (20/24; range, 20/15-20/40; n = 81), improving from 0.51 logMAR (20/65; range, 20/20-counting fingers); 41% of the patients achieved a BSCVA of 20/20 or better, 80% could be corrected to 20/25 or better, and 98% achieved 20/30 or better vision. A refractive hyperopic shift of +0.24 ± 1.01 diopters (D; range, -1.50 to 2.25 D) was found at 1 year, but it was not statistically significant (P = 0.08). Also, there was no significant change in the preoperative astigmatism (P = 0.17). The endothelial cell loss at 1 year was 36 ± 20% (n = 94; range, 13%-88%), with most of the loss being observed during the first 3 months after surgery: 31 ± 18% (range, 3%-77%). The DMEK graft creation could not be successfully completed in 6 cases (4.2%). All these unsuccessful attempts were among the initial 40 cases. Intracameral air was used to fix graft detachments, which usually were partial and peripheral, in 62% of the cases. Eleven grafts (8%) demonstrated primary failure and 1 eye (0.7%) had secondary failure resulting from endothelial rejection. Episodes of immunologic rejection were documented in 7 eyes (5.1%) during the first year of follow-up. CONCLUSIONS: Descemet's membrane endothelial keratoplasty had better visual acuity results in the first year after surgery than typically reported for other endothelial keratoplasty techniques, such as Descemet's stripping automated endothelial keratoplasty, while having less refractive changes and similar endothelial cell counts but a higher rebubbling rate. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Subject(s)
Corneal Endothelial Cell Loss/pathology , Descemet Stripping Endothelial Keratoplasty , Graft Survival/physiology , Visual Acuity/physiology , Aged , Aged, 80 and over , Cell Count , Endothelium, Corneal/pathology , Female , Fuchs' Endothelial Dystrophy/physiopathology , Fuchs' Endothelial Dystrophy/surgery , Humans , Intraoperative Complications , Lens Implantation, Intraocular , Male , Middle Aged , Phacoemulsification , Postoperative Complications , Prospective Studies , Refraction, Ocular/physiology , Time Factors , Treatment Outcome , VitrectomyABSTRACT
PURPOSE: To describe Descemet's membrane endothelial keratoplasty (DMEK) techniques, perioperative challenges, management, and visual and refractive outcomes. DESIGN: Prospective, multicenter, consecutive case series. PARTICIPANTS: Sixty eyes of 56 patients with Fuchs' endothelial dystrophy, pseudophakic bullous keratopathy, or failed previous graft. INTERVENTION: Descemet's membrane (DM) and endothelium were stripped from donor corneas submerged in corneal storage solution in a corneal viewing chamber. Donor DM diameters were 8.5 or 9.0 mm. The central 7 mm of DM was stripped from the recipient cornea. After staining with trypan blue to improve visualization, donor DM was inserted through a 2.8-mm incision. Descemet's membrane endothelial keratoplasty was performed alone (n = 48) or was combined with phacoemulsification and lens implantation (n = 11), pars plana vitrectomy (n = 2), or both. MAIN OUTCOME MEASURES: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density. RESULTS: Median BSCVA was 20/30 at 1 month (range, 20/20-20/60), improving from 20/50 (range, 20/25-hand movements) before DMEK, excluding 4 eyes (7%) with preexisting ocular pathologic features that limited visual potential. At 3 months, 26% had 20/20 vision, 63% saw 20/25 or better, and 94% saw 20/40 or better. Refractive cylinder remained unchanged at 0.9 diopters (D; P = 0.93), and a hyperopic shift of 0.49+/-0.63 D (P = 0.0091) was noted in DMEK single procedures. Endothelial cell loss was 30%+/-20% at 3 months and 32%+/-20% in 38 eyes that reached the 6-month examination. Median pachymetry decreased from 660 mum before surgery to 530 mum. Descemet's membrane stripped successfully from 60 of 72 donor corneas; 6 were converted successfully to Descemet's stripping automated endothelial keratoplasty (DSAEK) and 6 (8%) were discarded. Only 1 graft detached completely, but air was reinjected in 38 eyes (63%), mainly for partial detachments. Five DMEK corneas (8%) failed to clear and were replaced successfully with DMEK or DSAEK. All remained clear at last follow-up. CONCLUSIONS: Compared with DSAEK, DMEK provided a significantly higher rate of 20/20 and 20/25 vision, with comparable endothelial cell loss. Descemet's membrane endothelial keratoplasty restored physiologic pachymetry, but donor preparation and attachment currently are more challenging than with DSAEK.
