Lamis Baydoun

Repeat Descemet membrane endothelial keratoplasty after complicated primary Descemet membrane endothelial keratoplasty.

PURPOSE To describe the clinical outcome and complications of repeat Descemet membrane endothelial keratoplasty (re-DMEK). DESIGN Retrospective case series study at a tertiary referral center. PARTICIPANTS From a series of 550 consecutive DMEK surgeries with ≥ 6 months follow-up, 17 eyes underwent re-DMEK for graft detachment after initial DMEK (n = 14) and/or endothelial graft failure (n = 3). The outcomes were compared with an age-matched control group of uncomplicated primary DMEK surgeries. METHODS The re-DMEK eyes were evaluated for best-corrected visual acuity (BCVA), densitometry, endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications. MAIN OUTCOME MEASURES Feasibility and clinical outcome of re-DMEK. RESULTS In all eyes, re-DMEK was uneventful. At 12 months, 12 of 14 eyes (86%) achieved a BCVA of ≥ 20/40 (≥ 0.5); 8 of 14 eyes (57%) achieved ≥ 20/25 (≥ 0.8), 3 of 14 eyes (21%) achieved ≥ 20/20 (≥ 1.0), and 1 eye (7%) achieved 20/17 (1.2); 5 eyes were fitted with a contact lens. Average donor ECD decreased from 2580 ± 173 cells/mm(2) before to 1390 ± 466 cells/mm(2) at 6 months after surgery, and pachymetry from 703 ± 126 μm to 515 ± 39 μm, respectively. No difference in densitometry could be detected between re-DMEK and control eyes (P = 0.99). Complications after re-DMEK included primary graft failure (n = 1), secondary graft failure (n = 2), graft detachment requiring rebubbling (n = 1), secondary glaucoma (n = 2), cataract (n = 1), and corneal ulcer (n = 1). One eye received tertiary DMEK. CONCLUSIONS In the management of persistent graft detachment and graft failure after primary DMEK, re-DMEK proved a feasible procedure. Acceptable BCVA may be achieved, albeit lower than after DMEK in virgin eyes, and some cases may benefit from contact lens fitting. Complications after re-DMEK may be better anticipated than after primary DMEK because graft detachment and graft failure tended to recur, suggesting that intrinsic properties of the host eye play a role in graft adherence and graft failure.

Endothelial Survival After Descemet Membrane Endothelial Keratoplasty: Effect of Surgical Indication and Graft Adherence Status

IMPORTANCE This study evaluates the longevity of Descemet membrane endothelial keratoplasty (DMEK) grafts in terms of endothelial survival and endothelial failure. OBJECTIVE To determine endothelial survival and its association with the indication for surgery and/or partial graft detachment in DMEK. DESIGN, SETTING, AND PARTICIPANTS Retrospective cross-sectional study of data collected from August 8, 2006, until June 17, 2015, at a tertiary referral center. A total of 352 eyes were evaluated up to 8 years after DMEK for Fuchs endothelial corneal dystrophy (FECD; n = 314), bullous keratopathy (BK; n = 31), and failed previous endothelial graft (n = 7), of which 314 eyes had complete graft attachment and 38 eyes had partial graft detachment (one-third of the graft surface area or less). Endothelial cell density was measured with specular microscopy, and Kaplan-Meier survival estimates were based on eyes with endothelial failure. Endothelial survival was followed up to 8 years after DMEK. MAIN OUTCOMES AND MEASURES Endothelial cell density, endothelial failure, and endothelial survival. RESULTS Endothelial cell density decreased to a mean (SD) of 952 (366) and 771 (321) cells/mm2 at 7 and 8 years postoperatively, respectively. Higher endothelial cell densities were found in eyes with FECD compared with those with BK (estimated mean difference, 261 cells/mm2; 95% CI, 118-404; P = .003) and in eyes with attached grafts compared with those with partially detached grafts (estimated mean difference, 330 cells/mm2; 95% CI, 208-452; P < .001), until 8 years. In 11 eyes (3.1%) that had concomitant ocular pathology, endothelial failure occurred within 4 years after DMEK. The overall graft survival probability was 0.96 at 5 and 8 years (95% CI, 0.94-0.99). At 8 years, better survival rates were found in eyes with FECD than in those with BK (survival probability, 0.97 [95% CI, 0.95-0.99] vs 0.84 [95% CI, 0.70-0.99], respectively); until the same follow-up, survival probabilities in eyes with attached and partially detached grafts were 0.97 (95% CI, 0.95-0.99) and 0.91 (95% CI, 0.82-0.99), respectively. CONCLUSIONS AND RELEVANCE Endothelial decay was higher in eyes with a partial graft detachment than in those with attached grafts and lower in eyes with FECD than in those with BK. Endothelial failure only occurred in eyes with concomitant ocular pathology. These results suggest that eyes with DMEK that have undergone surgery for FECD with a completely attached graft may have an excellent prognosis.

Two-year Clinical Outcome of 500 Consecutive Cases Undergoing Descemet Membrane Endothelial Keratoplasty

Purpose: To evaluate the clinical outcome of 500 consecutive cases up to 2 years after Descemet membrane endothelial keratoplasty (DMEK) and to assess which parameters may have influenced the clinical outcome. Methods: From a group of 500 eyes (393 patients), which underwent DMEK for Fuchs endothelial corneal dystrophy (FECD), bullous keratopathy, failed corneal transplants and other indications, clinical outcomes [best-corrected visual acuity (BCVA), central endothelial cell density (ECD), and central corneal thickness] were evaluated before, and at 6, 12, and 24 months after DMEK and postoperative complications were documented. Results: At 12 months postoperatively, 81% of eyes reached a BCVA of ≥20/25 (≥0.8), 49% ≥20/20 (≥1.0), and 15% ≥20/18 (≥1.2) (n = 396) and remained stable up to 24 months (P = 0.828). Compared with preoperative ECD, mean postoperative ECD decreased by 37 (±18)%, 40 (±18)%, and 45 (±18)% at 6, 12, and 24 months, respectively (P < 0.05 for all time points). Surgery indication and graft attachment status were related to postoperative BCVA and ECD results. Eyes with FECD and attached grafts showed better BCVA outcomes and higher ECD (P < 0.05). Central corneal thickness decreased by 20 (±11)% to 525 (±46) &mgr;m from preoperative to 6 months postoperatively and remained stable thereafter (P > 0.05). Within the study period, retransplantation was required in 32 eyes (6.4%). Principal longer-term complications were secondary graft failure (1.4%) and allograft rejection (1.4%). Conclusions: Clinical outcomes remain excellent up to 2 years after DMEK, in particular for eyes operated on for FECD and with completely attached grafts.

Corneal Densitometry and Higher Order Aberrations After Bowman Layer Transplantation: 1-Year Results.

Purpose: To evaluate corneal densitometry and higher order aberrations (HOAs) up to 1 year after Bowman layer (BL) transplantation. Methods: This was a retrospective study carried out at a tertiary referral center. Fifteen eyes of 14 patients who underwent BL transplantation for advanced keratoconus and had at least 1 year of follow-up were examined before BL transplantation and postoperatively at 1 day, 1 week, and 1, 3, 6, and 12 months. Corrected distance visual acuity (CDVA) with spectacles and contact lenses, anterior and posterior HOAs, and corneal densitometry were analyzed. Results: One year after surgery, average logarithm of the minimum angle of resolution of spectacle-CDVA changed from 1.35 (±0.46) preoperatively to 0.96 (±0.32, P < 0.001), whereas average logarithm of the minimum angle of resolution of CDVA with contact lens remained stable after surgery (P = 0.126). Anterior and posterior HOA root mean square decreased from 3.08 ± 0.59 to 2.67 ± 0.71 &mgr;m and 7.32 ± 2.20 to 6.30 ± 2.18 &mgr;m, respectively (P < 0.05). Spherical aberration ( ) improved on both anterior and posterior corneal surfaces (P < 0.001). After 1 year, corneal backscattering values showed an increase as compared with preoperative values mostly involving the central and posterior layers of the cornea, with a peak 1 month after surgery (P < 0.005 in zones 2–6 and 6–10 mm). No correlation between HOAs or corneal backscatter and CDVA was found. Conclusions: Corneal HOAs, especially spherical aberration, decreased for both anterior and posterior corneal surfaces after BL transplantation, whereas corneal backscattering increased, mostly in the central and posterior layers, where the graft has been placed. Changes in HOAs and corneal backscattering did not correlate with CDVA.

Preliminary outcome of hemi-Descemet membrane endothelial keratoplasty for Fuchs endothelial dystrophy

Background/aims To evaluate the clinical outcome of a full-diameter, untrephined, semicircular Descemet graft in a consecutive series of Descemet membrane endothelial keratoplasty (hemi-DMEK), potentially allowing the harvesting of two grafts from a single donor corneoscleral rim. Methods Interventional case series of 10 eyes of 10 patients with Fuchs endothelial dystrophy. Best corrected visual acuity (BCVA), endothelial cell density (ECD) and central corneal thickness (CCT) were evaluated up to 6 months postoperatively, and intraoperative and postoperative complications were recorded. Results Hemi-DMEK was successful in 9 out of 10 eyes; one eye showed persistent graft detachment despite rebubbling and underwent a secondary DMEK. BCVA improved in all successful hemi-DMEK eyes: at 6 months 100% of eyes (n=7) reached ≥20/40 (≥0.5), 86% (n=6) ≥20/25 (≥0.8), 29% (n=2) ≥20/20 (≥1.0) and 14% (n=1) reached 20/17 (≥1.2). Two eyes were excluded from visual analysis due to low visual potential. Preoperative donor ECD declined from 2744 (±181) cells/mm2 to 940 (±380) cells/mm2 centrally at 6 months postoperatively (n=9), with (donor and/or host) endothelial cell redistribution over bare stromal areas adjacent to the graft. Average CCT decreased from 745 (±153) µm preoperatively to 520 (±37) µm at 6 months. Four eyes required rebubbling for visually significant graft detachment. No other complications occurred throughout the study period. Conclusions Hemi-DMEK may give visual outcomes similar to those in conventional DMEK. If ECD decrease and graft detachment rate would prove acceptable in larger series, hemi-DMEK could have the potential to double the availability of donor tissue for endothelial keratoplasty.

Case Report of Quarter-Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Dystrophy.

Purpose: To describe a further modification of Descemet membrane endothelial keratoplasty (DMEK), using a quarter of an untrephined full-size donor Descemet membrane (DM) sheet (“Quarter-DMEK”). Methods: A 58-year-old patient underwent Quarter-DMEK for Fuchs endothelial dystrophy in his pseudophakic right eye, with a single quadrant of a full-size, 11.5-mm-diameter DM graft. Results: Best-corrected visual acuity improved from 20/50 (0.4) before surgery to 20/40 (0.5) at 1 day, 20/30 (0.7) at 1 week, 20/25 (0.8) at 1 month and 20/20 (1.0) at 3 months after surgery. Central endothelial cell density decreased from 2700 cells/mm2 before surgery to 1551 cells/mm2 at 1 week, 1104 cells/mm2 at 1 month, and 846 cells/mm2 at 3 months after surgery. Pachymetry returned to normal values within the first month. No complications were observed. Conclusions: Quarter-DMEK may give fast visual rehabilitation within the first month similar to visual outcomes after circular DMEK or semicircular DMEK (hemi-DMEK). If long-term endothelial cell density would prove acceptable in a larger number of cases, quarter-DMEK may have the potential to quadruple the availability of donor endothelial tissue for endothelial keratoplasty.

Standardisierte Descemet-Membran-Endothelkeratoplastik (DMEK)

BACKGROUND The procedure of posterior lamellar keratoplasty has now become established as first choice therapy for the treatment of corneal endothelial diseases, with Descemet membrane endothelial keratoplasty (DMEK) as the most recent refinement of endothelial keratoplasty techniques. In this study the outcome of 400 consecutive cases after standardized no-touch DMEK was evaluated. METHODS This was a non-randomized retrospective clinical study of 400 consecutive eyes in 321 patients who underwent standard DMEK. Outcome measures included best corrected visual acuity (BCVA) preoperatively and postoperatively at 1, 3 and 6 months, endothelial cell density (ECD), pachymetry and complications within the first 6 months. In addition two subgroups were analyzed (subgroup I cases 1-200 and subgroup II cases 201-400). RESULTS At 6 months postoperatively 80 % of all eyes had a BCVA of ≥ 20/25 (≥ 0.8), 44 % of ≥ 20/20 (≥ 1.0) and 14 % of ≥ 20/18 (≥ 1.2). There were no significant differences between the two subgroups. The mean ECD preoperatively was 2,542 (± 217) cells/mm(2) and 6 months postoperatively 1,622 (± 500) cells/mm(2). The mean ECD decrease was 36 % 6 months after DMEK. No difference between the subgroups was noted. In 5 % a re-operation was needed of which 75 % were performed in subgroup I. CONCLUSION With the standardized no-touch DMEK technique a rapid and nearly complete visual rehabilitation as well as ECD values similar to earlier endothelial keratoplasty techniques can be achieved. Therefore DMEK may become the preferred treatment for corneal endothelial disorders.

[Standardized Descemet membrane endothelial keratoplasty (DMEK): technique and latest results].

BACKGROUND The procedure of posterior lamellar keratoplasty has now become established as first choice therapy for the treatment of corneal endothelial diseases, with Descemet membrane endothelial keratoplasty (DMEK) as the most recent refinement of endothelial keratoplasty techniques. In this study the outcome of 400 consecutive cases after standardized no-touch DMEK was evaluated. METHODS This was a non-randomized retrospective clinical study of 400 consecutive eyes in 321 patients who underwent standard DMEK. Outcome measures included best corrected visual acuity (BCVA) preoperatively and postoperatively at 1, 3 and 6 months, endothelial cell density (ECD), pachymetry and complications within the first 6 months. In addition two subgroups were analyzed (subgroup I cases 1-200 and subgroup II cases 201-400). RESULTS At 6 months postoperatively 80 % of all eyes had a BCVA of ≥ 20/25 (≥ 0.8), 44 % of ≥ 20/20 (≥ 1.0) and 14 % of ≥ 20/18 (≥ 1.2). There were no significant differences between the two subgroups. The mean ECD preoperatively was 2,542 (± 217) cells/mm(2) and 6 months postoperatively 1,622 (± 500) cells/mm(2). The mean ECD decrease was 36 % 6 months after DMEK. No difference between the subgroups was noted. In 5 % a re-operation was needed of which 75 % were performed in subgroup I. CONCLUSION With the standardized no-touch DMEK technique a rapid and nearly complete visual rehabilitation as well as ECD values similar to earlier endothelial keratoplasty techniques can be achieved. Therefore DMEK may become the preferred treatment for corneal endothelial disorders.

Two-Year Refractive Outcomes After Descemet Membrane Endothelial Keratoplasty.

Purpose: To monitor refractive changes after Descemet membrane endothelial keratoplasty (DMEK) and to determine what may influence these changes and the time point of stabilization. Methods: From 67 pseudophakic DMEK eyes operated on for Fuchs endothelial dystrophy at a tertiary referral center, biomicroscopy, visual acuity, subjective refraction, and Scheimpflug-based corneal tomography data were obtained before and up to 2 years postoperatively. Visual acuity and changes in spherical equivalent (SE), mean anterior and posterior simulated keratometry (Km), and central pachymetry were analyzed. Results: At 3 months postoperatively, both hyperopic (28/67 eyes) and myopic (21/67 eyes) shifts were observed; 18/67 eyes showed no SE change. The mean change in SE at 3 months was +0.33 diopters (D) (95% confidence interval = [0.11, 0.54], P = 0.028), which stabilized thereafter (P > 0.466). Initial flattening of mean anterior Km by 0.66D (95% confidence interval = [−0.81, −0.51], P < 0.001) at 3 months was followed by a slow steepening, which became significant between 1 and 2 years postoperatively (P < 0.001). Posterior Km stabilized after 3 months (P > 0.252). Preoperative to 3 months postoperative absolute changes in anterior Km were positively related to preoperative backscattered light from the central anterior cornea (P = 0.035), and the presence of partial graft detachment postoperatively (P = 0.013). Conclusions: After DMEK, SE and posterior corneal curvature were on average stable at 3 months after surgery, whereas the mean anterior corneal curvature showed an ongoing gradual change. Changes in anterior corneal curvature may be related to preoperative anterior corneal densitometry or postoperative partial graft detachment.

Interface Fluid Syndrome After Laser In Situ Keratomileusis (LASIK) Because of Fuchs Endothelial Dystrophy Reversed by Descemet Membrane Endothelial Keratoplasty (DMEK).

Purpose: To describe a case that developed “interface fluid syndrome” after previous laser in situ keratomileusis (LASIK) because of Fuchs endothelial dystrophy (FED), which was reversed by Descemet membrane endothelial keratoplasty (DMEK). Methods: A 58-year-old male patient presented with bilateral visual impairment owing to FED and visually significant cataract. Cataract surgery was carried out in both eyes followed by DMEK in his left eye. Results: After cataract surgery, visual acuity did not improve sufficiently because corneal thickness increased and a fine cleft with interface fluid developed between the LASIK-flap and the residual stromal bed. After uneventful DMEK in his left eye, the fluid resolved within a week and visual acuity improved rapidly. Conclusions: This case demonstrates that “interface fluid syndrome” after LASIK caused by concomitant endothelial dysfunction may be reversed by DMEK allowing fast visual recovery.