Martin Dirisamer

Efficacy of Descemet Membrane Endothelial Keratoplasty: Clinical Outcome of 200 Consecutive Cases After a Learning Curve of 25 Cases

OBJECTIVEnTo evaluate Descemet membrane endothelial keratoplasty for management of corneal endothelial disorders.nnnMETHODSnDescemet membrane endothelial keratoplasty was performed in 200 patients with Fuchs endothelial dystrophy or bullous keratopathy. Best-corrected visual acuity, subjective and objective refractive outcome and stability, and endothelial cell density were evaluated at 1, 3, and 6 months postoperatively, and intraoperative and postoperative complications were documented.nnnRESULTSnAt 6 months, 94% reached a best-corrected visual acuity of 20/40 or better (≥0.5); 77%, 20/25 or better (≥0.8); 47%, 20/20 or better (≥1.0), and 16%, 20/17 or better (≥1.2) (n = 159). The preoperative to 6 months postoperative spherical equivalent showed a mean (SD) +0.38 (1.2) diopter hyperopic shift (P = .001) that correlated with a decrease in central corneal thickness (n = 143) (P = .047). Two-thirds of eyes showed refractive stability at 3 months. Donor endothelial cell density showed a decrease from mean (SD) 2560 (186) cells/mm(2) preoperatively to 1690 (520) cells/mm(2) at 6 months after surgery (n = 173) (P < .001). Graft detachment was the main complication and occurred in 18 eyes (9%). Recipient Descemet membrane remnants were present in 12 eyes (6%). Secondary glaucoma was seen in 8 eyes (4%), of which 4 showed air-bubble dislocation behind the iris. In 2 of 33 phakic eyes (6%), a secondary cataract developed requiring phacoemulsification.nnnCONCLUSIONSnDescemet membrane endothelial keratoplasty may offer complete visual rehabilitation within 1 to 6 months after surgery in a majority of eyes. Similar to earlier keratoplasty techniques, Descemet membrane endothelial keratoplasty may be associated with a one-third decrease in donor endothelial cell density in the early postoperative phase. Incidence of (partial) graft detachment stabilized at about 5% but could be further reduced by patient selection and/or technique modification.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00521898.

Prevention and Management of Graft Detachment in Descemet Membrane Endothelial Keratoplasty

OBJECTIVEnTo describe the prevention and management of various types of graft detachment after Descemet membrane endothelial keratoplasty.nnnMETHODSnIn 150 consecutive eyes that underwent Descemet membrane endothelial keratoplasty, the incidence and type of graft detachment were studied at 1, 3, 6, 9, 12, and 24 months after surgery in a nonrandomized, prospective clinical study at a tertiary referral center. Four groups of detachments were identified: a partial detachment of one-third or less of the graft surface area (n = 16; group 1); a partial detachment of more than one-third of the graft surface area (n = 8; group 2); a graft positioned upside down (n = 4; group 3); and a free-floating Descemet roll in the host anterior chamber (n = 8; group 4).nnnRESULTSnPartial or complete graft detachment was found in 36 cases (24%), of which 18 (12%) were clinically significant. All 24 eyes with a partial detachment (groups 1 and 2) showed spontaneous corneal clearance, and all but 6 of these eyes (75%) reached visual acuity of 20/40 or better (≥0.5). A reversed clearance pattern and interface spikes were observed in eyes with the graft positioned upside down (group 3). Eyes with a free-floating graft (group 4) showed persistent corneal edema. Detachments were associated with inward folds (12 eyes [33%]), insufficient air-bubble support (7 eyes [19%]), upside-down graft positioning (4 eyes [11%]), use of plastic materials (2 eyes [6%]), irido-graft synechiae (1 eye [3%]), poor endothelial morphology (1 eye [3%]), and stromal irregularity under the main incision (1 eye [3%]); 14 (58%) of the partial detachments were localized inferiorly.nnnCONCLUSIONSnAwaiting spontaneous clearance may be advocated in eyes with a partial detachment. Minor adjustments in surgical protocol as well as careful patient selection may further reduce the incidence of graft detachment after Descemet membrane endothelial keratoplasty to 4% or less.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00521898.

Patterns of Corneal Endothelialization and Corneal Clearance After Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Dystrophy

PURPOSEnTo describe various endothelial migration healing patterns after Descemet membrane endothelial keratoplasty (DMEK), and to determine the contribution of the donor and host endothelium in the clearance of a transplanted cornea.nnnDESIGNnNonrandomized, prospective clinical study.nnnMETHODSnIn a total of 150 consecutive eyes that underwent DMEK (ie, transplantation of an isolated Descemet graft, for Fuchs endothelial dystrophy), re-endothelialization patterns were studied. Of these eyes, 36 showed a stromal gap between the descemetorhexis edge and the graft, or (partial) graft detachment. Endothelialization patterns of the host posterior stroma were documented at 1, 3, 6, 9, 12, and 24 months after surgery with Pentacam imaging, specular microscopy, optical coherence tomography, confocal microscopy, and slit-lamp biomicroscopy.nnnRESULTSnComplete corneal clearance was seen in 28 of 36 eyes (78%) with a stromal gap, or (partial) detachment, progressing from the periphery toward the center; and 27 of 34 eyes (79%) with normal visual potential reached a visual acuity of ≥20/40 (≥0.5) or better. In 3 eyes that had the Descemet graft implanted upside-down, a reversed corneal clearance pattern was observed (ie, persistent edema where the graft was attached), while the area overlying the detachment cleared. One case that had a descemetorhexis performed without endothelial graft implantation showed persistent stromal edema.nnnCONCLUSIONnThe presence of donor endothelium in the recipient anterior chamber may be required for endothelial migration and/or recovery of corneal clarity. Re-endothelialization may be associated with massive endothelial migration and some form of cell signaling to draw donor endothelial cells toward the recipient posterior stroma (homing).

Recipient Endothelium May Relate to Corneal Clearance in Descemet Membrane Endothelial Transfer

PURPOSEnTo describe corneal clearance after re-endothelialization of the recipient posterior stroma through Descemet membrane endothelial transfer (DMET) (ie, a free-floating donor Descemet graft in the recipient anterior chamber after descemetorhexis), in managing corneal endothelial disorders.nnnDESIGNnNonrandomized prospective study at a tertiary referral center.nnnMETHODSnTwelve eyes enrolled in our study, 7 suffering from Fuchs endothelial dystrophy and 5 with bullous keratopathy. The clinical outcome was monitored by biomicroscopy, optical coherence tomography, confocal microscopy, endothelial cell density, and pachymetry measurements.nnnRESULTSnAll eyes operated on for Fuchs endothelial dystrophy showed corneal clearance, with pachymetry values returning to normal (533 ±47 μm). The denuded recipient stroma re-endothelialized with an average endothelial cell density of 797 (± 743) cells/mm(2) at 6 months after surgery. In contrast, none of the bullous keratopathy eyes showed any improvement throughout the follow-up period.nnnCONCLUSIONnDMET may be effective in the management of Fuchs endothelial dystrophy (primarily a Descemet membrane disorder), but not in bullous keratopathy (primarily an endothelial depletion). Apparently, the indication for surgery (ie, a dystrophy vs a depletion of recipient endothelial cells) relates to the capacity of the cornea to clear. This suggests that the remaining rim of recipient endothelium (after descemetorhexis) is involved in the re-endothelialization of the recipient posterior stroma after DMET.

Causes of Glaucoma After Descemet Membrane Endothelial Keratoplasty

PURPOSEnTo describe the incidence and causes of glaucoma after Descemet membrane endothelial keratoplasty (DMEK).nnnDESIGNnNonrandomized prospective cohort study at a tertiary referral center.nnnMETHODSnThe incidence of glaucoma was evaluated in the first 275 consecutive eyes that underwent DMEK for Fuchs endothelial dystrophy (260 eyes) or bullous keratopathy (15 eyes). Glaucoma was defined as a postoperative intraocular pressure (IOP) elevation of ≥24 mm Hg, or ≥10 mm Hg from the preoperative baseline. If possible, the cause of glaucoma was identified, and best-corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative course were documented, with a mean follow-up of 22 (± 13) months.nnnRESULTSnOverall, 18 eyes (6.5%) showed postoperative glaucoma after DMEK. Seven eyes (2.5%) had an exacerbation of a pre-existing glaucoma. Eleven eyes (4%) presented with a de novo IOP elevation, associated with air bubble-induced mechanical angle closure (2%), steroid response (0.7%), or peripheral anterior synechiae (0.4%), or without detectable cause (0.7%). Two eyes (0.7%) required glaucoma surgery after DMEK. At 6 months, all eyes had a BCVA of ≥20/40 (≥0.5), and 81% reached ≥20/25 (≥0.8) (n = 16); mean ECD was 1660 (± 554) cells/mm(2) (n = 15) (P > .1).nnnCONCLUSIONnGlaucoma after DMEK may be a relatively frequent complication that could be avoided by reducing the residual postoperative air bubble to 30% in phakic eyes, applying a population-specific steroid regime, and avoiding decentration of the Descemet graft. Eyes with a history of glaucoma may need close IOP monitoring in the first postoperative months, especially in eyes with an angle-supported phakic intraocular lens.

Identifying causes for poor visual outcome after DSEK/DSAEK following secondary DMEK in the same eye

Purpose:u2002 To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and to determine whether such eyes can be successfully ‘repaired’ with a secondary Descemet membrane endothelial keratoplasty (DMEK).

Hemi-Descemet membrane endothelial keratoplasty transplantation: a potential method for increasing the pool of endothelial graft tissue.

IMPORTANCEnThis study evaluates the technical feasibility and clinical outcomes of a Descemet membrane endothelial keratoplasty (DMEK) technique that could increase the availability of donor tissue for DMEK.nnnOBJECTIVEnTo evaluate the clinical outcome of using a semicircular, large-diameter Descemet membrane graft in DMEK (hemi-DMEK), potentially allowing the use of a single donor cornea for 2 DMEK procedures.nnnDESIGN, SETTING, AND PARTICIPANTSnA prospective, interventional case series was conducted at a tertiary referral center. Three eyes of 3 patients with Fuchs endothelial dystrophy received a hemi-DMEK.nnnINTERVENTIONnTransplantation of a semicircular, large-diameter hemi-DMEK graft.nnnMAIN OUTCOMES AND MEASURESnBest-corrected visual acuity, endothelial cell density, pachymetry, and intraoperative and postoperative complications.nnnRESULTSnThe patients best-corrected visual acuity at 6 months was 0.70 (Snellen equivalent, 20/29), 0.50 (20/40 [amblyopic eye]), and 1.20 (20/17). At 1 month, endothelial cell density decreased by 49%, 31%, and 39%, respectively, and endothelial cell migration appeared to continue for up to 6 months. Central corneal thicknesses decreased from 682, 707, and 681 μm before surgery to 523, 534, and 489 μm, respectively, at 6 months. No intraoperative or postoperative complications were seen.nnnCONCLUSIONS AND RELEVANCEnHemi-DMEK (using half-moon-shaped grafts) is technically feasible and may provide visual outcomes similar to those obtained with routine DMEK (full-moon-shaped graft). If so, this technique may have the potential to double the availability of donor endothelial tissue for DMEK surgery.

One year outcome of hemi-Descemet membrane endothelial keratoplasty

PurposeTo evaluate the 1-year clinical outcome after semi-circular Descemet membrane endothelial keratoplasty (hemi-DMEK) in a first case series.MethodsIn three eyes of three patients with Fuchs endothelial dystrophy, best corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry, and intra- and postoperative complications were evaluated after transplantation of a semi-circular ~12xa0mm diameter Descemet graft (hemi-DMEK graft).ResultsAll corneas cleared within 6xa0months and showed a stable pachymetry thereafter (527, 535, and 490xa0μm, respectively). Compared to preoperative measurements, average central ECDs dropped by 51xa0% (56, 39, and 59xa0%, respectively) at 3 months, 53xa0% (57, 38, and 63xa0%, respectively) at 6xa0months, and 59xa0% (60, 47, and 71xa0%, respectively) at 12xa0months. Denuded stromal areas adjacent to the hemi-DMEK graft cleared and at 12xa0months peripheral ECD counts ranged from 724 to 1051 cells/mm2. At 12xa0months, BCVA was 20/22 (0.9), 20/40 (0.5, amblyopic eye) and 20/17 (1.2). No postoperative complications occurred throughout the study period.ConclusionsHemi-DMEK may provide visual outcomes similar to those in standard DMEK at the 1-year postoperative mark. If also graft survival and complication rates prove to be similar, hemi-DMEK could become the next step in endothelial keratoplasty, owing to its potential to double the yield of transplants from the same donor pool (two hemi-DMEK grafts can be prepared from one donor cornea).

Standardisierte Descemet-Membran-Endothelkeratoplastik (DMEK)

ZusammenfassungHintergrundZur Behandlung endothelialer Hornhauterkrankungen haben sich die Verfahren der posterioren lamellären Keratoplastiken inzwischen als Therapie der Wahl durchgesetzt. Die „Descemet membrane endothelial keratoplasty“ (DMEK) stellt das jüngste Verfahren dar. Mit dieser Studie wurden 400 konsekutive Fälle nach der standardisierten No-touch-DMEK evaluiert.MethodenEs handelt sich um eine nicht randomisierte, retrospektive klinische Studie. Von 400 konsekutiven DMEK-Augen (321xa0Patienten) wurden der bestkorrigierte Visus, die Endothelzelldichte (EZD) und Hornhautpachymetrie sowie Komplikationen innerhalb der ersten 6xa0Monate nach DMEK evaluiert. Zusätzlich wurden 2xa0Subgruppen (I: Fälle 1 bis 200; II: Fälle 201 bis 400) getrennt voneinander ausgewertet.ErgebnisseNach 6xa0Monaten erreichten 80u2009% aller Augen einen bestkorrigierten Visus von ≥u20090,8, 44u2009% von ≥u20091,0 und 14u2009% von ≥u20091,2. Zwischen den Subgruppen bestand kein signifikanter Unterschied. Die Endothelzelldichte nahm durchschnittlich von präoperativ 2542 (±u2009217) Zellen/mm2 auf 1622 (±u2009500) Zellen/mm2 nach 6xa0Monaten ab (−u200936u2009%). Die Anzahl der Folgeeingriffe lag bei 5u2009%, wobei drei Viertel davon in der ersten Subgruppe durchgeführt wurden.SchlussfolgerungDie nun standardisierte No-touch-DMEK-Technik ermöglicht bei der Mehrzahl der operierten Augen eine rasche und fast vollständige Visusrehabilitation. Sie ist eine sichere Operationsmethode, die sich zum Standardverfahren der posterioren lamellären Keratoplastiken entwickelt.AbstractBackgroundThe 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.MethodsThis 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).ResultsAt 6 months postoperatively 80u2009% of all eyes had a BCVA of ≥u200920/25 (≥u20090.8), 44u2009% of ≥u200920/20 (≥u20091.0) and 14u2009% of ≥u200920/18 (≥u20091.2). There were no significant differences between the two subgroups. The mean ECD preoperatively was 2,542 (±u2009217) cells/mm2 and 6 months postoperatively 1,622 (±u2009500) cells/mm2. The mean ECD decrease was 36u2009% 6 months after DMEK. No difference between the subgroups was noted. In 5u2009% a re-operation was needed of which 75u2009% were performed in subgroup I.ConclusionWith 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.BACKGROUNDnThe 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.nnnMETHODSnThis 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).nnnRESULTSnAt 6 months postoperatively 80u2009% of all eyes had a BCVA of ≥u200920/25 (≥u20090.8), 44u2009% of ≥u200920/20 (≥u20091.0) and 14u2009% of ≥u200920/18 (≥u20091.2). There were no significant differences between the two subgroups. The mean ECD preoperatively was 2,542 (±u2009217) cells/mm(2) and 6 months postoperatively 1,622 (±u2009500) cells/mm(2). The mean ECD decrease was 36u2009% 6 months after DMEK. No difference between the subgroups was noted. In 5u2009% a re-operation was needed of which 75u2009% were performed in subgroup I.nnnCONCLUSIONnWith 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].

ZusammenfassungHintergrundZur Behandlung endothelialer Hornhauterkrankungen haben sich die Verfahren der posterioren lamellären Keratoplastiken inzwischen als Therapie der Wahl durchgesetzt. Die „Descemet membrane endothelial keratoplasty“ (DMEK) stellt das jüngste Verfahren dar. Mit dieser Studie wurden 400 konsekutive Fälle nach der standardisierten No-touch-DMEK evaluiert.MethodenEs handelt sich um eine nicht randomisierte, retrospektive klinische Studie. Von 400 konsekutiven DMEK-Augen (321xa0Patienten) wurden der bestkorrigierte Visus, die Endothelzelldichte (EZD) und Hornhautpachymetrie sowie Komplikationen innerhalb der ersten 6xa0Monate nach DMEK evaluiert. Zusätzlich wurden 2xa0Subgruppen (I: Fälle 1 bis 200; II: Fälle 201 bis 400) getrennt voneinander ausgewertet.ErgebnisseNach 6xa0Monaten erreichten 80u2009% aller Augen einen bestkorrigierten Visus von ≥u20090,8, 44u2009% von ≥u20091,0 und 14u2009% von ≥u20091,2. Zwischen den Subgruppen bestand kein signifikanter Unterschied. Die Endothelzelldichte nahm durchschnittlich von präoperativ 2542 (±u2009217) Zellen/mm2 auf 1622 (±u2009500) Zellen/mm2 nach 6xa0Monaten ab (−u200936u2009%). Die Anzahl der Folgeeingriffe lag bei 5u2009%, wobei drei Viertel davon in der ersten Subgruppe durchgeführt wurden.SchlussfolgerungDie nun standardisierte No-touch-DMEK-Technik ermöglicht bei der Mehrzahl der operierten Augen eine rasche und fast vollständige Visusrehabilitation. Sie ist eine sichere Operationsmethode, die sich zum Standardverfahren der posterioren lamellären Keratoplastiken entwickelt.AbstractBackgroundThe 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.MethodsThis 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).ResultsAt 6 months postoperatively 80u2009% of all eyes had a BCVA of ≥u200920/25 (≥u20090.8), 44u2009% of ≥u200920/20 (≥u20091.0) and 14u2009% of ≥u200920/18 (≥u20091.2). There were no significant differences between the two subgroups. The mean ECD preoperatively was 2,542 (±u2009217) cells/mm2 and 6 months postoperatively 1,622 (±u2009500) cells/mm2. The mean ECD decrease was 36u2009% 6 months after DMEK. No difference between the subgroups was noted. In 5u2009% a re-operation was needed of which 75u2009% were performed in subgroup I.ConclusionWith 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.BACKGROUNDnThe 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.nnnMETHODSnThis 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).nnnRESULTSnAt 6 months postoperatively 80u2009% of all eyes had a BCVA of ≥u200920/25 (≥u20090.8), 44u2009% of ≥u200920/20 (≥u20091.0) and 14u2009% of ≥u200920/18 (≥u20091.2). There were no significant differences between the two subgroups. The mean ECD preoperatively was 2,542 (±u2009217) cells/mm(2) and 6 months postoperatively 1,622 (±u2009500) cells/mm(2). The mean ECD decrease was 36u2009% 6 months after DMEK. No difference between the subgroups was noted. In 5u2009% a re-operation was needed of which 75u2009% were performed in subgroup I.nnnCONCLUSIONnWith 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.