Differences in Guttae Ultramorphology in Relation to Visual Function in Fuchs Endothelial Corneal Dystrophy.

PURPOSE: The purpose of this study was to investigate the differences in guttae ultramorphology and their relation to visual function in eyes with Fuchs endothelial corneal dystrophy (FECD). METHODS: Thirty FECD eyes without ocular comorbidities were included. Visual functional parameters (best-corrected visual acuity with high-contrast and low-contrast letters and contrast sensitivity/LogCS) and corneal morphology measured with Scheimpflug tomography (Pentacam) were assessed. The surgically removed Descemet membranes were examined by light and transmission electron microscopy. RESULTS: Preoperative mean best-corrected visual acuity (logarithm of the minimum angle of resolution) was 0.52 ± 0.18, LogCS 0.96 ± 0.21 and central corneal thickness 640 ± 55 µm. All eyes had signs of subclinical corneal edema in Scheimpflug tomography; clinically visible corneal edema was present in 40% of eyes. Histological findings included a posterior fibrillar zone (PFZ) in 10 specimens (33%) and abnormal collagen depositions in Descemet membranes in 14 specimens (47%). Guttae buried within the PFZ were present only in eyes with clinically visible edema (n = 4, 13%). There was no difference in visual function results and tomography parameters between eyes with and without PFZ or between protruding guttae and guttae embedded in a PFZ, respectively. CONCLUSIONS: Guttae morphology and density were not correlated with visual functional parameters. Guttae buried in a PFZ occurred only in eyes with clinically manifest edema, and thereby, they are an ultramorphological sign for advanced FECD. Subclinical edema was present in all eyes and might be more relevant for quality of vision than guttae ultramorphology.

Long-Term Outcomes of Keratoprosthesis With Biological Haptic: A Review of 25 Years of Single-Center Surgeries.

PURPOSE: To study the outcome of eyes that underwent surgery for keratoprosthesis with a biological haptic, osteo-odonto-keratoprosthesis (OOKP) or tibia keratoprosthesis, by a single surgeon over a time span of more than 25 years. METHODS: One hundred thirty eyes that had received a keratoprosthesis with a biological haptic between 1994 and 2022 by a single surgeon were included in this retrospective analysis. Main outcome parameters were postoperative best corrected visual acuity, postoperative refractive error, postoperative complications, anatomical and functional survival of the prosthesis as well as comparison of subgroups of the 2 different types (OOKP n = 78; tibia keratoprosthesis n = 52) of keratoprostheses, and subgroup analysis of different indications for surgery. Patients were examined every 6 months. RESULTS: The longest follow-up was 25.8 years. Reasons for implantation were graft-vs-host disease (6.9%), vascularized corneas and dry eye (22.9%), physical or chemical burns (29.8%), Stevens-Johnson syndrome (9.9%), and ocular cicatricial pemphigoid (30.5%). The functional success rate with postoperative visual acuity of better than 0.7 log MAR was achieved by 56.9%. The OOKP subgroup showed a better mean visual outcome. 14 keratoprostheses (10.7%) had to be explanted over the whole time span. In the time leading to explantation, refraction showed a statistically significant myopic shift when compared with the non-explanted prosthesis. Anatomical survival rates were better for the OOKP in the first 12 years after implantation. CONCLUSIONS: The study shows that keratoprosthesis with a biological haptic has favorable long-term outcomes. The retention rate stayed very high with excellent functional outcomes.

Characterisation of ectasia after penetrating keratoplasty in keratoconus eyes using anterior segment optical coherence tomography.

BACKGROUND/AIMS: Ectasia of the cornea can occur decades after penetrating keratoplasty (PK), especially in keratoconus eyes. The purpose of this study was to characterise ectasia after PK by morphological findings in anterior segment optical coherence tomography (AS-OCT). METHODS: In this retrospective, single-centre case series, 50 eyes of 32 patients with a history of PK at an average of 25±10 years earlier were included. The eyes were classified either as ectatic (n=35) or as non-ectatic (n=15). The main parameters included central corneal thickness (CCT), lowest corneal thickness at the interface (LCTI), anterior chamber depth, graft-host interface angle at the thinnest point and host cornea-iris angle. Furthermore, steep and flat keratometry readings obtained by AS-OCT (CASIA-2, Tomey) and Scheimpflug tomography (Pentacam, Oculus) were assessed. OCT findings were correlated with clinical grading of ectasia. RESULTS: There was a highly significant difference in LCTI, graft-host interface angle and anterior chamber depth (in pseudophakic eyes) between the groups. The ratio calculated by the quotient of LCTI divided by CCT was significantly lower in ectatic than non-ectatic eyes (p<0.001). In eyes with an LCTI/CCT ratio of ≤0.7, the OR for the occurrence of a clinical detectable ectasia was 2.4 (CI 1.5 to 3.7). Steep keratometry values were significantly higher in ectatic eyes. CONCLUSION: AS-OCT is a helpful tool to recognise and quantify ectasia in post-PK eyes objectively.

Risk factors for ocular hypotony after XEN Gel Stent implantation.

PURPOSE: To investigate the incidence of postoperative hypotony, and risk factors for the development of hypotony in eyes who had undergone XEN Gel Stent implantation. METHODS: In this retrospective, single-centre case series, medical records of 170 consecutive eyes who had undergone XEN Gel Stent implantation with or without simultaneous phacoemulsification for primary or secondary open angle glaucoma were analysed. Primary outcome parameters were the incidence of postoperative hypotony and potential risk factors for its development, and secondary parameters were pre- and postoperative visual acuity, intraocular pressure (IOP), and number of IOP-lowering eye drops. RESULTS: Postoperative hypotony ≤ 6 mmHg occurred in 57% of eyes. Hypotony was without complications in 70.1%, 13.4% had transient complications with spontaneous resolution, and 16.5% had complications requiring treatment. Mean visual acuity logMAR before surgery accounted for 0.47 ± 0.46 in all eyes and 0.47 ± 0.48 at the 4-week visit. There was no significant difference of BCVA in the group of eyes with and without postoperative hypotony before and after surgery. The mean IOP before surgery was 24.6 ± 8.4 mmHg and decreased significantly to 18.4 ± 10.2 after 4 weeks. Eyes with an axial length over 24.3 mm had a threefold increased risk for postoperative hypotony (OR 3.226, 95% confidence interval 1.121-9.279). This risk was decreased in eyes with simultaneous cataract surgery (OR 0.483, 95% confidence interval 0.258-0.903). CONCLUSION: In our sample, postoperative hypotony was a common complication after XEN Gel Stent implantation, but serious, persistent complications were rare. A longer axial length predisposes the eye for the development of hypotony.

Focus on Ophthalmopathology - Orbital Infections from Hordeolum to Necrotizing Fasciitis. / Schwerpunkt Ophthalmopathologie Orbitainfektion: vom Hordeolum bis zur nekrotisierenden Fasziitis.

(Peri)orbital infections comprise a multitude of diagnoses, ranging from common hordeolum to rare but life-threatening necrotizing fasciitis. However, these disease entities are rarely diagnosed by an ophthalmic pathologist because (peri)orbital infections are usually diagnosed clinically, with the help of imaging and microbiological techniques when indicated. In this review article, the role of ophthalmopathology in the diagnosis of (peri)orbital infections is illustrated on the basis of several exemple diagnoses. An infectious hordeolum must be distinguished from a noninfectious chalazion. A nodular thickening of the eyelid, which is diagnosed and treated as a chalazion, can hide a malignant neoplasia. The correct diagnosis and treatment of canaliculitis is often delayed. In this context the most common causative organism, Actinomyces, can be depicted histologically, as can lacrimal stones/dacryoliths. Necrotizing fasciitis is a rapidly worsening infection of the fascia, which can lead to necrosis, sepsis, and death. During the Sars-CoV2 pandemic, an increased incidence of mucormycosis cases was observed, especially in India. This superinfection was facilitated by the widespread use of steroids and immunosuppression. Histologically, it is possible to visualize infiltration of vessel walls by the fungus. Ophthalmopathology contributes to the diagnosis and to understanding the pathophysiology of these diseases.

Dysregulated Retinoic Acid Signaling in the Pathogenesis of Pseudoexfoliation Syndrome.

Pseudoexfoliation (PEX) syndrome, a stress-induced fibrotic matrix process, is the most common recognizable cause of open-angle glaucoma worldwide. The recent identification of PEX-associated gene variants uncovered the vitamin A metabolic pathway as a factor influencing the risk of disease. In this study, we analyzed the role of the retinoic acid (RA) signaling pathway in the PEX-associated matrix metabolism and evaluated its targeting as a potential candidate for an anti-fibrotic intervention. We provided evidence that decreased expression levels of RA pathway components and diminished RA signaling activity occur in an antagonistic crosstalk with TGF-ß1/Smad signaling in ocular tissues and cells from PEX patients when compared with age-matched controls. Genetic and pharmacologic modes of RA pathway inhibition induced the expression and production of PEX-associated matrix components by disease-relevant cell culture models in vitro. Conversely, RA signaling pathway activation by natural and synthetic retinoids was able to suppress PEX-associated matrix production and formation of microfibrillar networks via antagonization of Smad-dependent TGF-ß1 signaling. The findings indicate that deficient RA signaling in conjunction with hyperactivated TGF-ß1/Smad signaling is a driver of PEX-associated fibrosis, and that restoration of RA signaling may be a promising strategy for anti-fibrotic intervention in patients with PEX syndrome and glaucoma.

Management of Late Descemet's Membrane Detachment After Penetrating Keratoplasty in Keratoconus.

PURPOSE: The purpose of this study was to describe the feasibility of Descemet membrane endothelial keratoplasty (DMEK) as a treatment modality for spontaneous detachment of DM (DMD) decades after penetrating keratoplasty (PK) for keratoconus. METHODS: We describe the clinical characteristics and therapeutic surgical approach in 6 eyes of 5 patients with DMD. Clinical images, anterior segment optical coherence tomography scans, and histological findings are presented. RESULTS: Mean age of patients at time of diagnosis was 60 years (range 56-66 years). Mean interval between PK and occurrence of DM detachment was 36 years (range 29-45 years). In 4 of 6 eyes, air injections into the anterior chamber were initially attempted to reattach DM to the stroma but without long-lasting effect. Two eyes underwent repeat PK because of pronounced ectasia after long-standing DMD and stromal scars. DMEK was performed successfully in 4 eyes leading to an increase in visual acuity and a reduction in central corneal thickness. Electron microscopy showed abnormal vacuolar inclusions and collagenous material in the posterior nonbanded layer and a separation of the anterior banded layer from the posterior nonbanded layer. CONCLUSIONS: This case series provides evidence that DMEK is a viable option in eyes with spontaneous DM detachment after PK. Visual outcome is limited by the persisting high astigmatism in the ectatic cornea. Illustrated by a small series of patients, the results of DMEK in this condition are presented and new findings about the pathophysiology are given.

Descemet membrane endothelial keratoplasty: analysis of clinical outcomes of patients with 8-10 years follow-up.

PURPOSE: This study aimed to evaluate the clinical outcomes up to 10 years after Descemet membrane endothelial keratoplasty (DMEK). METHODS: In this retrospective, consecutive, single-center case series the medical files of eyes which have received DMEK between 2009 and 2012 for the treatment of endothelial dysfunction was evaluated regarding follow-up time and clinical outcomes. Annual examinations of best-corrected visual acuity (BCVA), endothelial cell density (ECD), central corneal thickness (CCT) of 66 eyes which fulfilled the criterion of a minimum of 8 years follow-up were analyzed. RESULTS: BCVA improved from 0.55 ± 0.37 logMAR (n = 54) to 0.15 ± 0.11 (n = 47) in eyes without ocular comorbidities one year after DMEK (p < 0.001), and remained stable up to 10 years after DMEK. Mean ECD decreased to 744 ± 207 cells/mm2 (n = 39) after 9 years, and to 729 ± 167 cells/mm2 (n = 21) after 10 years, respectively. CCT decreased from 650 ± 67 µm before DMEK to 525 ± 40 µm (n = 56) after 1 year, increasing slowly to 563 ± 40 µm (n = 39) after 9 years, and to 570 ± 42 µm (n = 21) after 10 years, respectively. Graft failure occurred in 4 of 66 eyes after year 8. These 4 eyes required repeat DMEK after 101-127 months. CONCLUSION: This study shows the long-term outcomes in a small subset of DMEK grafts. Visual acuity remained stable in spite of slowly increasing corneal thickness and diminishing endothelial cell density during the 10-year period after DMEK.

Influence of corneal guttae and nuclear cataract on contrast sensitivity.

AIMS: To evaluate the contrast sensitivity in patients with nuclear cataract and corneal guttae compared to patients with nuclear cataract without guttae. METHODS: In this retrospective, single-centre case series, 50 eyes of 50 patients fulfilling the inclusion criteria were enrolled. Patients with corneal guttae and nuclear cataract (n=25, study group) underwent triple Descemet membrane endothelial keratoplasty (DMEK). Patients with nuclear cataract and healthy corneas underwent cataract surgery (n=25, control group). Inclusion criteria were preoperative best-corrected visual acuity ≥20/40, no corneal oedema and similar lens opacity (nuclear opalescence 2.0-2.9). Outcome measures included MARS letter and OPTEC 6500P contrast sensitivity test, corneal volume, central corneal thickness and anterior and posterior corneal densitometry. RESULTS: Preoperative MARS letter and OPTEC 6500P contrast sensitivity was significantly worse in the study group (MARS: p<0.001; OPTEC 6500P: p<0.007 at low spatial frequencies in daylight with and without glare and nightlight without glare). After surgery, there was no significant difference in MARS letter contrast sensitivity between groups (p=0.225). OPTEC 6500P contrast sensitivity remained significantly lower in the study group in daylight and nightlight with and without glare at most spatial frequencies (p<0.01) postoperatively. Preoperative and postoperative corneal volume, central corneal thickness and anterior corneal densitometry were equal in both groups (p>0.05). Posterior densitometry was significantly higher in the study group than in the control group preoperatively (p<0.001) but turned into equal values postoperatively (p=0.07). CONCLUSIONS: Corneal guttae cause an additional significant decrease in contrast sensitivity in eyes with nuclear cataract. This is in favour of performing a triple DMEK even in eyes with a visual acuity of ≥20/40.

Refractive Outcomes After Descemet Membrane Endothelial Keratoplasty + Cataract/Intraocular Lens Triple Procedure: A Fellow Eye Comparison.

PURPOSE: Descemet membrane endothelial keratoplasty is often combined with phacoemulsification and intraocular lens implantation (DMEK + cataract/IOL triple procedure) in phakic patients. This procedure results in a refractive shift that is difficult to predict. The aim of this study was to evaluate the hypothesis that the refractive shift in the second eye follows the shift in the first eye. METHODS: In this retrospective, single-center, consecutive case series, the refractive outcomes of 254 eyes of 127 patients who underwent DMEK + cataract/IOL triple procedure in both eyes for Fuchs endothelial corneal dystrophy have been analyzed. Main outcome measures were spherical equivalent outcome (shift calculations), best spectacle-corrected visual acuity, central corneal thickness, and posterior simulated keratometry. RESULTS: The mean best spectacle-corrected visual acuity before surgery was 0.51 ± 0.24 and increased to 0.19 ± 0.15 (logMAR) after surgery (P < 0.001). After surgery, a mean hyperopic shift of 0.98 ± 0.89 D was observed. The refractive shift was 1.03 ± 0.93 D and 0.92 ± 1.02 D, in the first and second eyes, respectively (P = 0.435). In a paired analysis, the mean difference of the refractive shift between the first and second eyes was 0.49 ± 0.43 D. CONCLUSIONS: In our fellow eye comparison, the refractive shift after DMEK + cataract/IOL triple procedure in the second eye was comparable with the shift in the first eye. As a consequence, the refractive outcome of the first eye might serve as a reference for optimizing the refractive target in the second eye. Further studies investigating the influence of corneal parameters on refractive shift are needed for a more predictable lens power selection.

Can we predict the refractive outcome after triple Descemet membrane endothelial keratoplasty?

PURPOSE:: To analyze and correlate corneal parameters with refractive shift after Descemet membrane endothelial keratoplasty combined with cataract surgery (triple Descemet membrane endothelial keratoplasty). METHODS:: This single-center retrospective observational case series included 152 eyes of 152 consecutive patients undergoing triple Descemet membrane endothelial keratoplasty in the first eye for Fuchs endothelial corneal dystrophy. Patients were examined preoperatively, as well as at 3, 6, and 12 months after surgery. The main outcome measures were: refractive shift (predicted refractive outcome based on intraocular lens calculation compared to actual postoperative refractive outcome), central corneal thickness, corneal volume, anterior and posterior corneal curvature, and corneal densitometry. These parameters were analyzed and correlated with the refractive shift after surgery. RESULTS:: After 3 months from surgery, a mean refractive shift of +1.12 ± 1.10 D was observed and remained stable until the last follow-up at 12 months (+1.24 ± 1.07 D). Correlation analysis showed a weak but significant positive correlation between refractive shift and preoperative posterior curvature (rho = 0.314; p = 0.002) or preoperative posterior densitometry (rho = 0.227; p = 0.008). No correlation was found between refractive shift and preoperative central corneal thickness, corneal volume, anterior curvature, or anterior/mid-cornea densitometry. CONCLUSION:: Changes of the posterior cornea may have an influence on the refractive shift. Patients with flatter posterior corneal curvature or higher posterior corneal density seem to exhibit a higher hyperopic shift. The weak correlations indicate a poor predictive value of any preoperative parameter used in our study.

Fungal Interface Keratitis After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate the incidence, clinical course, and management of fungal interface keratitis (IK) after Descemet membrane endothelial keratoplasty (DMEK). METHODS: This is a single-center retrospective observational case series of 3950 eyes undergoing DMEK. Six eyes with fungal IK were detected and analyzed. Analysis included graft storage condition, incidence of fungal IK, identification of the pathogenic agent, topical/systemic and surgical treatment regimen, and best-corrected visual acuity. RESULTS: Fungal IK after DMEK occurred in 6 of 3950 cases (0.15%). Corneal grafts were either stored in Optisol-GS (n = 4) or in organ culture (n = 2). In all cases, Candida species were isolated (Candida tropicalis, Candida albicans, Candida orthopsilosis, and Candida guilliermondii). Four eyes developed fungal IK during the early postoperative period (3-5 d) and 2 eyes later at 16 to 42 days after surgery. All patients received topical and systemic antifungal treatment and intracameral application of antifungal agents. In the case of an early infection, graft removal was performed in 3 of 4 patients. Late infections were eradicated without graft exchange. Recurrence of fungal infection was observed in 1 case after early IK and in both cases after late IK. Final visual acuity ranged from 20/200 to 20/20. CONCLUSIONS: Fungal IK is a rare complication after DMEK. Based on our experience, we believe that treatment of early fungal IK with aggressive presentation should include both immediate graft exchange and intracameral application of voriconazole and amphotericin, in addition to topical and systemic antifungal treatment. Graft exchange seems not to be mandatory in late infections.

Air Versus Sulfur Hexafluoride Gas Tamponade in Descemet Membrane Endothelial Keratoplasty: A Fellow Eye Comparison.

PURPOSE: To perform a fellow eye comparison of outcomes and complications when using air or sulfur hexafluoride (SF6) gas as a tamponade in Descemet membrane endothelial keratoplasty (DMEK). METHODS: One hundred thirty-six eyes of 68 consecutive patients who underwent uneventful DMEK in both eyes for Fuchs endothelial corneal dystrophy were included in this retrospective study. Inclusion criteria were air tamponade (80% of the anterior chamber volume) in the first eye and 20% SF6 gas tamponade (80% of the anterior chamber volume) in the second eye; and same donor tissue culture condition in both eyes. All eyes received laser iridotomy on the day before DMEK. Main outcome measures included preoperative and postoperative best-corrected visual acuity, endothelial cell density, corneal volume, rebubbling rate, and rate of postoperative pupillary block caused by the air/gas bubble. RESULTS: Thirteen of 68 eyes (19.1%) with an air tamponade needed rebubbling compared with 4 of 68 eyes (5.9%) with an SF6 gas tamponade (P = 0.036). Postoperative pupillary block necessitating partial release of air/gas occurred in 1 eye (1.5%) with an air tamponade and 3 eyes (4.4%) with an SF6 gas tamponade (P = 0.301). There were no significant differences in preoperative and postoperative best-corrected visual acuity, endothelial cell density, and corneal volume within 3-month follow-up. CONCLUSIONS: Our results confirm the previously reported better graft adhesion when using an SF6 gas tamponade in DMEK without increased endothelial cell toxicity. The rate of pupillary block in eyes with an SF6 gas tamponade was comparable to that with an air tamponade. As a consequence, we recommend using SF6 gas as the tamponade in DMEK.

"Bubble-in-the-Roll" Technique Using the Endoject DMEK Injector: Influence of the Air Bubble on Endothelial Cell Loss.

PURPOSE: To evaluate the impact of the air bubble on endothelial cell loss using the "bubble-in-the-roll" technique during Descemet membrane endothelial keratoplasty (DMEK). METHODS: Twenty DMEK grafts not suitable for transplantation were manually prepared from organ-cultured corneoscleral discs and injected into culture media using the Endoject DMEK injector (Medicel AG, Wolfhalden, Switzerland). Based on the injection method, the grafts were divided into 2 groups: In group A (n = 10), a small air bubble was placed inside the graft roll while it was in the injector. In group B (n = 10), the grafts were injected without an air bubble inside the graft roll. Main outcome measures included endothelial cell density (ECD) after graft stripping and graft injection. RESULTS: There were no statistically significant differences between groups A and B in donor age, storage duration, and donor ECD. ECD decreased from 1929 ± 145 cells/mm to 1796 ± 303 cells/mm after graft stripping in group A and from 1801 ± 226 cells/mm to 1709 ± 290 cells/mm in group B. ECD after graft injection further decreased to 1683 ± 291 cells/mm in group A and to 1651 ± 292 cells/mm in group B. Endothelial cell loss after graft stripping and graft injection was not statistically significant between groups A and B (P = 0.29 and P = 1, respectively). CONCLUSIONS: The bubble-in-the-roll technique for injection and unfolding of the graft is a safe method for graft delivery into the anterior chamber guaranteeing orientation of the graft without harming the endothelium.

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

PURPOSE: 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 these eyes. DESIGN: Retrospective consecutive case series. METHODS: setting: Institutional, single-center. PATIENT POPULATION: Total of 664 eyes with Fuchs endothelial corneal dystrophy (FECD) scheduled for primary DMEK. INTERVENTION: DMEK. MAIN OUTCOME MEASURES: 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. RESULTS: 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. CONCLUSIONS: 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.

Long-term Clinical Outcome After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate the long-term clinical outcome up to 5 years after Descemet membrane endothelial keratoplasty (DMEK). DESIGN: Retrospective, consecutive case series. METHODS: In this single-center study, 310 consecutive DMEK operations for endothelial decompensation were reviewed; 97 eyes of 84 patients met the inclusion criterion of a minimum 3-year follow-up. Retrospective evaluation of clinical examinations occurred at 1 and 3 months and annually up to 5 years after DMEK at the Department of Ophthalmology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (FAU), Germany. Main outcome measures were corrected distance visual acuity (CDVA), endothelial cell density (ECD), central corneal thickness (CCT), and graft survival (Kaplan-Meier analysis). RESULTS: Mean follow-up was 53 ± 13 months. CDVA improved from 0.62 ± 0.42 logMAR before DMEK to 0.13 ± 0.12 logMAR (P < .001); 57% of eyes without ocular comorbidities reached ≥20/25 at 5 years after DMEK. ECD was stable after the initial postsurgical decrease (42% at 1 month, 44% at 5 years), from 2602 ± 243 cells/mm(2) before DMEK to 1460 ± 179 cells/mm(2) at 5 years. CCT decreased from 644 ± 67 µm before DMEK to 557 ± 49 µm at 5 years, with a minimum (530 ± 54 µm) at 3 months. Cumulative probability of 5-year graft survival was 95%. CONCLUSIONS: The long-term sustainability of DMEK was confirmed. DMEK not only provides fast visual rehabilitation but maintains its clinical outcome within a follow-up of 5 years. Visual acuity and endothelial cell loss remain stable between 3 months and 5 years after DMEK.

Influence of Ultrastructural Corneal Graft Abnormalities on the Outcome of Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To investigate if ultrastructural alterations in the Descemet membrane (DM) are correlated with the clinical outcome after Descemet membrane endothelial keratoplasty (DMEK). DESIGN: Retrospective cohort study. METHODS: setting: Institutional, single-center. STUDY POPULATION: One hundred and twelve residual DM specimens obtained after DM stripping. MAIN OUTCOME MEASURES: Incidence of ultrastructural abnormalities in transmission electron microscopy, graft detachment rate, graft failure rate, best-corrected visual acuity (BCVA), endothelial cell density (ECD), and central corneal thickness (CCT). Examination dates were on the day before DMEK and 1, 3, 6, and 12 months after surgery. RESULTS: Abnormalities in the ultrastructure of DM were found in 16 of 112 specimens (14%) (abnormal DM group), comprising deposits of long-spacing collagen, fine filaments (proteoglycans), a posterior collagenous layer, pseudoexfoliative material, and guttae. The secondary graft failure rate was significantly higher in the abnormal DM group compared with the normal DM group (P = .001). There was a trend for an increased graft detachment rate in the abnormal DM group (11/16) compared with the normal DM group (42/96) (P = .103). There was no significant difference in mean CCT and ECD after surgery. Mean CCT in the eyes with graft failure in the abnormal DM group at the last follow-up before regrafting was 850 µm, indicating endothelial failure with stromal edema. CONCLUSION: This study reveals a correlation between ultrastructural alterations of DM in donor corneas and the graft failure rate after DMEK. Thus, graft failure after DMEK not only is determined by surgical trauma and postoperative events but may also be influenced by intrinsic, graft-specific features.

Anterior Chamber Air Bubble to Achieve Graft Attachment After DMEK: Is Bigger Always Better?

PURPOSE: To analyze the influence of the size of the air bubble subsequent to Descemet membrane endothelial keratoplasty (DMEK) surgery on the rate of graft detachment and need for rebubbling, the incidence of pupillary block, and the observed endothelial cell loss. METHODS: This is a single-center, retrospective, consecutive case series of 74 cases undergoing DMEK and fulfilling the inclusion criteria concerning the size of the air bubble at the end of surgery. Based on the medical records, patients were divided into 2 groups (n = 37, respectively). The first group had an air bubble with a volume of approximately 50% and the second group of approximately 80% of the anterior chamber (AC) volume, respectively. Patients who did not comply with instructions to remain in the supine position until complete resorption of AC air or cases in which difficulties in graft preparation (eg, radial breaks) occurred were excluded from data analysis. The central corneal thickness and endothelial cell density were measured 6 months after surgery. RESULTS: Ten of 37 patients (27.0%) in the 50% air bubble group and 3 of 37 patients (8.1%) in the 80% air bubble group needed 1 rebubbling procedure (P = 0.032). There was no difference between the groups after 6 months regarding endothelial cell density and central corneal thickness. No pupillary block was observed. CONCLUSIONS: Larger air bubbles of 80% anterior chamber volume decrease the risk of graft detachment after DMEK with no detrimental effect on the outcome and risk for pupillary block.

Feasibility and Outcome of Descemet Membrane Endothelial Keratoplasty in Complex Anterior Segment and Vitreous Disease.

PURPOSE: Descemet membrane endothelial keratoplasty (DMEK) is becoming the method of choice for treating Fuchs endothelial dystrophy and pseudophakic bullous keratopathy. We investigated whether DMEK can serve as a routine procedure in endothelial decompensation even in complex preoperative situations. METHODS: Of a total of 1184 DMEK surgeries, 24 consecutive eyes with endothelial decompensation and complex preoperative situations were retrospectively analyzed and divided into 5 groups: group 1: irido-corneo-endothelial syndrome (n = 3), group 2: aphakia, subluxated posterior chamber intraocular lens or anterior chamber intraocular lens (n = 6), group 3: DMEK after trabeculectomy (n = 4), group 4: DMEK with simultaneous intravitreal injection (n = 6), and group 5: DMEK after vitrectomy (n = 5). Main outcome parameters were best-corrected visual acuity, central corneal thickness, endothelial cell density, rebubbling rate, and graft failure rate. RESULTS: Best-corrected visual acuity (logMAR) increased from 0.98 to 0.53 (P = 0.002), 0.53 (P = 0.091), and 0.57 (P = 0.203) after 1, 3, and 6 months, respectively. Central corneal thickness decreased from 731 ± 170 to 546 ± 152 µm (P = 0.001), 514 ± 66 µm (P = 0.932), and 554 ± 98 µm (P = 0.004) after 1, 3, and 6 months, respectively. Donor endothelial cell density decreased from 2478 ± 185 to 1454 ± 193/mm² (P < 0.001), 1301 ± 298/mm² (P = 0.241), and 1374 ± 261/mm² (P = 0.213), after 1, 3, and 6 months, respectively. The rebubbling rate was 46% (11/24). Four patients (17%) had secondary graft failure. CONCLUSIONS: Our data provide evidence that DMEK is feasible for the treatment of endothelial decompensation in complex preoperative situations.