Descemet Membrane Endothelial Keratoplasty Postoperative Year 1 Endothelial Cell Counts

doi:10.1016/j.ajo.2014.12.008

American Journal of Ophthalmology

Volume 159, Issue 3, March 2015, Pages 597-600.e2

https://doi.org/10.1016/j.ajo.2014.12.008 Get rights and content

Purpose

To report endothelial cell counts (ECC) in patients 1 year after Descemet membrane endothelial keratoplasty (DMEK) and suggest surgical techniques that may minimize intraoperative endothelial cell loss.

Design

Retrospective, observational case series.

Methods

This is a retrospective case series of 125 consecutive cases with 1 year of postoperative follow-up. Eight-millimeter DMEK grafts were prepared at a single institution via the submerged cornea, using backgrounds away technique. Grafts were introduced through a 2.4-mm incision and a “no-touch” technique was used to position them.

Results

The mean preoperative donor ECC was 2740 ± 210 (cells/mm²). Mean postoperative year 1 ECC was 2210 ± 550 for an ECC loss of 19% ± 10%. Rebubbling was performed in 5% of cases.

Conclusion

Postoperative year 1 endothelial cell counts in DMEK can equal and even surpass those of Descemet stripping automated endothelial cell keratoplasty (DSAEK) or even penetrating keratoplasty. Given reported decreased rejection rates in DMEK, these patients may have notably superior ECC 5 and 10 years out from surgery compared to if they had undergone DSAEK.

Section snippets

Patients and Outcome Analysis

This is an observational, retrospective analysis of 125 consecutive patients at a single institution with at least 1 year of follow-up. This study adheres to the tenets of the Declaration of Helsinki and Institutional Review Board approval at Gorovoy Eye Specialists was obtained. Baseline donor ECC was measured by the eye bank. Postoperative ECC was measured with specular microscopy (Konan Medical, Inc, Greensboro, North Carolina, USA) using the manufacturer's software and calibration. Manual

Results

Demographic information included a mean patient age of 70. The majority of patients were transplanted secondary to primary Fuchs endothelial dystrophy (76%, 95/125). A history of failed endothelial keratoplasty (16%, 20/125) or pseudophakic bullous keratopathy (7%, 9/125) rounded out virtually all of the other patients.

The mean preoperative donor ECC was 2740 ± 210 (cells/mm²). Mean postoperative year 1 ECC was 2210 ± 550 for an ECC loss of 19% ± 10%. Rebubbling was performed in 5% (6/125) of

Discussion

We report postoperative year 1 ECC of 125 consecutive patients with 1 year of follow-up after DMEK, which surpass counts reported after DSAEK and penetrating keratoplasty (PKP) (Table).¹² Endothelial cell loss occurs during every step of the procedure: (1) initial cornea harvest; (2) graft preparation; (3) intraoperative manipulation; (4) postoperative acute rejection and/or rebubbling, if this occurs; and (5) natural endothelial dropout/slow immunorejection. Almost certainly, the majority of

Ian Roderick Gorovoy completed his undergraduate work at Brown University in Rhode Island. He completed his medical school at the University of Pittsburgh in Pennsylvania and his ophthalmology residency at University of California, San Francisco. Currently, he is a cornea/anterior segment fellow with his father in Florida.

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Endothelial keratoplasty: fellow eyes comparison of Descemet stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty
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Cited by (32)

Clinical Outcomes of Preloaded Descemet Membrane Endothelial Keratoplasty Grafts With Endothelium Tri-Folded Inwards
2018, American Journal of Ophthalmology
Citation Excerpt :
The “F” marking was also instrumental for the surgeon in avoiding upside-down attachment of the tissue, thus eliminating primary graft failure in our series. In the series published to date, ECL following DMEK has ranged between 31% and 40% at 3 months, between 36% and 40% at 6 months, between 19% and 36% at 1 year, and up to 39% at 5 years,7–16 showing an early flattening of the curve similar to that described after DSAEK, but possibly at lower levels of ECL. In our series, early results of DMEK using preloaded tissue showed values of ECL similar to those reported for conventional DMEK employing grafts prepared in theater or tissues that are prestripped but not preloaded, all delivered with conventional methods.
To evaluate the initial outcomes and complications of Descemet membrane endothelial keratoplasty (DMEK) using donor tissues tri-folded with the endothelium inwards, preloaded at the Eye Bank, and delivered with bimanual pull-through technique.
Prospective, noncomparative, interventional case series.
Setting: Eye bank and tertiary care eye department. Patient Population: Forty-six consecutive eyes of 41 patients with Fuchs endothelial dystrophy with or without cataract operated between November 2016 and March 2017. Intervention: DMEK tissues prepared with SCUBA technique and punched to a diameter of 8.25 mm were preloaded with the endothelium tri-folded inwards in an intraocular lens (IOL) cartridge with a 2.2-mm opening filled with the same tissue culture medium contained in the vial used for shipment to the surgeon. Standardized DMEK was performed as a single procedure (n = 15) or in combination with phacoemulsification and IOL implantation (n = 31) within 48 hours from preparation using a bimanual pull-through technique. Main Outcome Measures: Preparation and surgical times, intraoperative and postoperative complications, best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), and graft detachment rate.
Preparation time averaged 26.2 ± 4.1 minutes (range 17–36 minutes), while the surgical time from opening of the stoppers to air fill of the anterior chamber never exceeded 9 minutes (range 3–9 minutes). Surgery was uneventful in all cases. Postoperative complications included graft detachment in 9 of 46 cases (19.6%), successfully managed in all cases by single rebubbling within 6 days from surgery, and glaucoma irresponsive to conservative treatment in 1 of 46 cases (2.1%). In all eyes without comorbidities (35 of 40 eyes) BSCVA was 20/25 (0.097 logMAR) or better as early as 3 months after surgery. Six months postoperatively, ECD was available in 24 of 25 eyes with an endothelial cell loss calculated as a percentage of the preoperative value determined at the eye bank (ranging from 2500 to 2800 cells/mm²) of 29.5% ± 14.8% (range 8.3%–52.1%).
Delivering a preloaded DMEK tissue, tri-folded with the endothelium inwards, minimizes surgical time and costs without negatively affecting the outcomes of the procedure.
Descemet's Membrane Endothelial Keratoplasty. Indication, surgical technic, postoperative management and review of literature
2018, Journal Francais d'Ophtalmologie
La greffe endothéliale est devenue la technique de référence des traitements des dysfonctions et dystrophies endothéliales. La Descemet Membrane Endothelial Keratoplasty (DMEK) décrite en 2006 par Gerrit Melles permet de remplacer sélectivement l’endothélium pathologique par un homologue sain. Elle permet une récupération visuelle plus rapide, de meilleurs résultats réfractifs en limitant le risque de rejet de greffe comparés à la Descemet's Stripping Automatised Endothelial Keratosplasty (DSAEK), technique de greffe endothélio-stromale. Le débat reste encore ouvert entre DMEK et DSAEK. Cet article, basé sur une revue de la littérature a pour but d’éclairer le lecteur sur la technique de DMEK, ses résultats et complications.
Endothelial keratoplasty is currently the preferred method for the treatment of endothelial dysfunctions and dystrophies. Descemet Membrane Endothelial Keratoplasty (DMEK), described by Gerrit Melles in 2006, is performed by selectively replacing the damaged endothelium with a healthy counterpart. It leads to a faster visual recovery and better refractive outcomes with a limited risk of rejection compared to Descemet's Stripping Automated Endothelial Keratosplasty (DSAEK), which includes a thin stromal layer. Open debate still exists between DMEK and DSAEK. This article aims to provide a literature review and enlighten the reader on the DMEK technique, its results and complications.
Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology
2018, Ophthalmology
To review the published literature on the safety and outcomes of Descemet membrane endothelial keratoplasty (DMEK) for the surgical treatment of corneal endothelial dysfunction.
Literature searches were last conducted in the PubMed and the Cochrane Library databases most recently in May 2017. The searches, which were limited to English-language abstracts, yielded 1085 articles. The panel reviewed the abstracts, and 47 were determined to be relevant to this assessment.
After DMEK surgery, the mean best-corrected visual acuity (BCVA) ranged from 20/21 to 20/31, with follow-up ranging from 5.7 to 68 months. At 6 months, 37.6% to 85% of eyes achieved BCVA of 20/25 or better and 17% to 67% achieved BCVA of 20/20 or better. Mean endothelial cell (EC) loss was 33% (range, 25%–47%) at 6 months. Overall change in spherical equivalent was +0.43 diopters (D; range, –1.17 to +1.2 D), with minimal induced astigmatism of +0.03 D (range, –0.03 to +1.11 D). The most common complication was partial graft detachment requiring air injection (mean, 28.8%; range, 0.2%–76%). Intraocular pressure elevation was the second most common complication (range, 0%–22%) after DMEK, followed by primary graft failure (mean, 1.7%; range, 0%–12.5%), secondary graft failure (mean, 2.2%; range, 0%–6.3%), and immune rejection (mean, 1.9%; range, 0%–5.9%). Overall graft survival rates after DMEK ranged from 92% to 100% at last follow-up. Best-corrected visual acuity after Descemet’s stripping endothelial keratoplasty (DSEK) ranged from 20/34 to 20/66 at 9 months. The most common complications after DSEK were graft detachment (mean, 14%; range, 0%–82%), endothelial rejection (mean, 10%; range, 0%–45%), and primary graft failure (mean, 5%; range, 0%–29%). Mean EC loss after DSEK was 37% at 6 months.
The evidence reviewed supports DMEK as a safe and effective treatment for endothelial failure. With respect to visual recovery time, visual outcomes, and rejection rates, DMEK seems to be superior to DSEK and to induce less refractive error with similar surgical risks and EC loss compared with DSEK. The rate of air injection and repeat keratoplasty were similar in DMEK and DSEK after the learning curve for DMEK.
Review of Descemet Stripping Automated Endothelial Keratoplasty Versus Descemet Membrane Endothelial Keratoplasty
2016, Advances in Ophthalmology and Optometry
Citation Excerpt :
However, despite this, early results have shown that the expected endothelial cell loss is comparable with that of DSAEK. Gorovoy and Gorovoy [20] retrospectively examined 125 DMEK cases and found that, at the 1-year time point, there was approximately 19% endothelial cell count loss compared with 20% for PK, 38% for DSAEK, and 35% for ultrathin DSAEK [17]. However, only 5% of their DMEK patients required rebubbling, which is less frequent compared with most other studies.
Contact lens-assisted pull-through technique for delivery of tri-folded (endothelium in) DMEK grafts minimizes surgical time and cell loss
2016, Ophthalmology
Citation Excerpt :
The relatively old age of the donors in our series was a choice of the eye bank to facilitate Descemet stripping, but also may have avoided a too-pronounced counter-folding at the time of surgery, thus optimizing our procedure. Minimizing surgical manipulation and eliminating friction against the funnel wall while both loading and delivering the DMEK tissue trifolded with the endothelium inward proved instrumental in limiting the endothelial cell loss recorded 6 months after surgery to values less than those reported after both DSAEK and DMEK.7,14,16,17 Visual outcomes in the eyes of our series were similar to those published by other authors independent of the surgical technique used, an outcome to be expected after successful DMEK surgery.7,11,16,18
To evaluate the feasibility and outcomes of contact lens-assisted bimanual pull-through delivery of Descemet membrane endothelial keratoplasty (DMEK) tissue trifolded with the endothelium inward.
Prospective, noncomparative, interventional case series.
Forty-two consecutive eyes of 42 patients with Fuchs endothelial dystrophy with or without cataract.
Standardized DMEK was performed as a single procedure (n = 9) or in combination with phacoemulsification and implantation of a posterior chamber intraocular lens (n = 33) using prestripped donor tissue punched to a diameter of 8.25 mm and then trifolded with the endothelium in. Using a sterile soft contact lens as scaffold, the tissue was loaded in this configuration into a disposable cartridge and delivered into the anterior chamber under continuous irrigation using a bimanual pull-through technique to facilitate spontaneous proper unfolding.
Surgical time, intraoperative and postoperative complications, visual acuity 3 and 6 months after surgery, and endothelial cell loss 6 months after surgery.
Surgery was uneventful in all cases and the time required for the DMEK procedure (from Descemet scoring until final air filling) never exceeded 20 minutes (average, 17.1±1.6 minutes). The only complication observed after surgery was graft detachment (10 of 42 eyes [23.8%]), successfully managed in all cases by single rebubbling within 6 days from surgery. In all eyes with a minimum postoperative follow-up of 6 months (n = 20), best spectacle-corrected visual acuity was 20/25 or better and the average endothelial cell density (±standard deviation) was 2363.8±82.7 cells/mm² (range, 2258–2490 cells/mm²). The cell loss calculated as a percentage of the preoperative value determined at the eye bank (range, 2500–2700 cells/mm²) was 9.9±2.1% (range, 4.1%–11.9%).
Delivering DMEK tissue, trifolded with the endothelium inward, reduces surgical trauma to donor cells and facilitates spontaneous unfolding, thus minimizing surgical time.
Graft detachment and rebubbling rate in Descemet membrane endothelial keratoplasty
2018, Survey of Ophthalmology
Citation Excerpt :
A 3-year comparative clinical study using 20% sulfur hexafluoride (SF6) versus 100% air tamponade to overcome graft detachment in DMEK showed a requirement of rebubble in 2.38% from SF6 group, compared with 12.8% from air tamponade group where the detachments were larger than 60%. Rebubbling was performed sooner if more than 50% detachment was observed.17 New techniques for DMEK strategies like S-stamping have shown a higher rebubbling rate (13%), as compared with a nonstamped graft (3% within first 6 months postoperative).19
Descemet membrane endothelial keratoplasty (DMEK) is a selective replacement of dysfunctional endothelium with healthy donor Descemet membrane and endothelium. Although the donor preparation and surgical methods still remain a challenge, DMEK is gaining popularity in terms of early rehabilitation and visual outcomes. New and improved donor preparation techniques like prestripped DMEK tissues are being taken up rapidly because of less manipulation that is required in the surgical theatre. Donor graft delivery in the recipient eye has also been improved because of new products like prestripped and preloaded membranes. As DMEK is at its budding stage, only early outcomes have been known so far. Early graft detachment, rebubbling rates, and primary failures are still being studied in DMEK. As there are different techniques that are currently used for preparation and injection of the graft, it becomes difficult to judge the results based on specific inclusion and exclusion criteria. Graft detachment and rebubbling rates have been a huge challenge both during the surgery and also while reporting postoperative data. We highlight the importance of defining graft detachment and rebubbling rates and their surgical relevance, which may also have an impact on graft preparation and insertion techniques.

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Mark Steven Gorovoy grew up in New Jersey. He studied economics at Duke University and then completed his medical school and ophthalmology residency at George Washington University. He was a cornea fellow at the University of Florida. He has been in private practice in Florida for thirty-two years.

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Original articleDescemet Membrane Endothelial Keratoplasty Postoperative Year 1 Endothelial Cell Counts

Purpose

Design

Methods

Results

Conclusion

Section snippets

Patients and Outcome Analysis

Results

Discussion

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

J Cataract Refract Surg

Preliminary clinical results of Descemet's membrane endothelial keratoplasty

Am J Ophthalmol

Endothelial keratoplasy: why aren’t we all doing Descemet's membrane endothelial keratoplasty?

Cornea

Endothelial keratoplasty: fellow eyes comparison of Descemet stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty

Cornea

Original article
Descemet Membrane Endothelial Keratoplasty Postoperative Year 1 Endothelial Cell Counts