Repeat Descemet Membrane Endothelial Keratoplasty after Complicated Primary Descemet Membrane Endothelial Keratoplasty

doi:10.1016/j.ophtha.2014.07.024

Ophthalmology

Volume 122, Issue 1, January 2015, Pages 8-16

https://doi.org/10.1016/j.ophtha.2014.07.024 Get rights and content

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/mm² before to 1390±466 cells/mm² 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.

Section snippets

Methods

From a total of 550 consecutive DMEK cases, 17 eyes of 17 patients (8 male, 9 female; 3 phakic, 14 pseudophakic) with an average age of 69±14 years (range, 47–90 years) underwent re-DMEK after unsuccessful primary DMEK. The initial preoperative diagnoses included Fuchs endothelial dystrophy (n = 15), pseudophakic bullous keratopathy (n = 1), and bullous keratopathy after corneal perforation (n = 1). Primary DMEK grafts were removed and replaced by a secondary DMEK graft in a second operative

Indications for Repeat DMEK

We performed re-DMEK in a series of 17 eyes that showed unsatisfactory visual outcomes after primary DMEK and for which improvement could be expected by a transplant replacement. Low visual outcome after primary DMEK was attributed to clinically significant graft detachment (n = 14) and endothelial graft failure (n = 3; Table 3 [available at www.aaojournal.org]; Fig 1).

In eyes with graft detachment, 3 eyes had a detachment of at least one third and 8 eyes of more than one third of the graft

Feasibility of Repeat DMEK

Our study showed that re-DMEK was technically feasible in all eyes that showed graft detachment or DMEK transplant failure. Compared with primary DMEK, some modifications in the operative protocol may be considered in re-DMEK to avoid intraoperative and postoperative complications (Table 2). Unlike a virgin DM during descemetorhexis, a DMEK graft was found to show relatively strong adherence to the host posterior stroma, with a higher risk of graft remnants. Performing a “normal”

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Cited by (60)

Risk Factors for Repeat Descemet Membrane Endothelial Keratoplasty Graft Failure
2021, American Journal of Ophthalmology
To evaluate repeat Descemet membrane endothelial keratoplasty (re-DMEK) success rates and to identify risk factors for re-DMEK failure.
Retrospective case series.
Settings: Institutional. Patients and interventions: A chart review was performed, including all eyes with primary DMEK failure that underwent re-DMEK between 2013 and 2019 at the Toronto Western Hospital and the Kensington Eye Institute (Toronto, Ontario, Canada) and had at least 6 months of follow-up. Main outcome measure: Predicting factors for re-DMEK outcome.
Of 590 consecutive DMEK surgeries, 40 eyes (6.7%) were identified for having a secondary DMEK surgery after primary DMEK failure. Etiologies for primary DMEK were Fuchs endothelial corneal dystrophy (32.5%), pseudophakic bullous keratopathy (35%), previous failed graft (27.5%), and other indications (5%). Fifty-five percent of the cohort were categorized as having a complicated anterior segment including 11 eyes with previous glaucoma surgery, 7 eyes post–penetrating keratoplasty, 4 eyes post–Descemet stripping automated endothelial keratoplasty, 3 eyes peripheral anterior synechia, 3 eyes previous pars plana vitrectomy, 2 eyes aphakia, and 1 eye each with aniridia, anterior chamber intraocular lens, and iris-fixated intraocular lens. Re-DMEK failure was documented in 12 eyes (30%) of the entire cohort. The risk factor for re-DMEK failure was the presence of a complicated anterior segment (P = .01, odds ratio = 17.0 [95% confidence interval: 1.92-150.85]), with 50% re-DMEK failure rate in this subgroup.
Re-DMEK is a viable option for cases of primary DMEK failure, especially for eyes with Fuchs endothelial corneal dystrophy as the indication for primary DMEK without other ocular morbidities; however, eyes categorized with a complicated anterior segment had high re-DMEK failure rates.</ABSTRACT>
Non stripping descemet membrane endothelial keratoplasty in difficult cases: A case series
2021, Journal Francais d'Ophtalmologie
Citation Excerpt :
Consequently, Anshu et al. introduced DMEK on failed PK for the first time in 2013 with favorable results [10], confirmed by later studies [2,11–14]. Both DSAEK and DMEK involve the surgical removal of the diseased host endothelial cell layer and Descemet membrane before transplantation (descemetorhexis); a step significantly more challenging on a previously grafted than on a virgin eye because of stronger adherence of the graft to the recipient stroma [15]. Remnants of adherent DM may affect visual outcome as well as graft adherence [16,17]; therefore, interest arose when this step was suggested as non-essential if donor DM was non pathological [18–20].
Endothelial keratoplasty (EK) has been increasingly used instead of penetrating keratoplasty (PK) in the management of post PK graft rejection. Both DSAEK and DMEK involve the surgical removal of the diseased host endothelial cell layer and Descemet's membrane (DM) (descemetorhexis) before transplantation, a technically challenging step, especially in post-PK eyes. Understandably, interest arose when non-stripping DMEK (nDMEK) was described in 2013, and recent studies suggested encouraging results without increased early postoperative failures or complications requiring rebubbling. The purpose of our series was to further study the feasibility and safety of nDMEK and to compare the results with traditional DMEK. This is a single center case series of 3 eyes which underwent nDMEK performed by experienced surgeons (C.P, A.M). Two eyes had nDMEK as a secondary procedure following a failed/rejected PK, while the third case underwent nDMEK on a virgin eye. Undiseased donor DM and a regular host endothelium were required to be eligible for nDMEK. The average change in CCT at last follow-up was −21.2% (±13.3). All required intracameral air injection (rebubbling) within the first few days, with a mean of 2.33 rebubblings per eye, the first one occurring at 6.33 ± 2.52 days after surgery. Non-stripping DMEK surgery appears to be a feasible option, and results are satisfactory at mid to long term. However, in our series, the immediate postoperative period was marked by an increased rebubbling rate. While foreseeable particularly in high-risk cases, surgeons considering this technique should expect a higher risk of early rejection.
La Kératoplastie Endothéliale est de plus en plus utilisée par rapport à la Kératoplastie Transfixiante (KT) pour la prise en charge des rejets de greffes post-KT. Les deux principales techniques, la Descemet Membrane Endothelial Keratoplasty (DMEK) et la Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) incluent l’étape d’ablation de la membrane de descemet (MD) de l’hôte, ou descemetorhexis, une étape techniquement complexe, particulièrement sur des yeux déjà opérés. En 2013, des études ont suggéré que cette étape n’était pas toujours indispensable, sans risques accrus de rejets de greffe nécessitant des réappositions par injections intracamérales d’air (rebubbling). Le but de cette étude est d’analyser la faisabilité de la Non-Stripping DMEK (NDMEK) à l’aide d’une série de cas, et comparer les résultats à la traditionnelle DMEK. Il s’agit d’une série de cas monocentrique de 3 yeux ayant bénéficié d’une NDMEK. Les critères d’inclusion comportaient entre autres l’absence de pathologies de la MD hôte, ainsi qu’un endothélium régulier. La diminution de l’épaisseur cornéenne centrale moyenne après la chirurgie est de −21,2% (±13,3). Tous ont nécessité des rebubblings en postopératoire, avec une moyenne de 2,33 rebubblings par oeil, à un temps moyen de 6,33 ± 2,52 jours postopératoires. La NDMEK est une technique efficace avec des résultats qui semblent comparables à la DMEK au long terme, cependant, la fréquence de rebubblings en postopératoire immédiat était augmentée. Bien qu’envisageable notamment dans les cas à haut risque, les chirurgiens qui considèrent cette technique doivent s’attendre à un risque de rejet précoce augmenté.
Corneal transplantation after failed grafts: Options and outcomes
2021, Survey of Ophthalmology
Citation Excerpt :
Repeat grafts can also have a tendency to detach in the same quadrant,39 and rebubbling may be required in 50% of eyes that require rebubbling for their primary procedure.133 The results of the studies evaluating secondary DMEK after failed initial DMEK are presented in Table 3.5,39,54,133,215 There are variable reports regarding the visual outcomes of secondary DMEK, with some studies reporting that outcomes are comparable with those of primary DMEK when graft failure was treated promptly with secondary DMEK4,133,140,143 and others reporting inferior outcomes39 compared to historical controls.63,198
Corneal transplantation is the most commonly performed human tissue transplantation procedure worldwide. Because of the large number of transplants, corneal graft failure has become one of the most common indications for corneal transplantation. The relatively recently developed lamellar transplant techniques have brought about specific potential complications leading to graft failure that may require different approaches to repeat transplantation other than penetrating keratoplasty. On the other hand, these new lamellar techniques also provide novel ways of rescuing failed penetrating grafts, with potential advantages over successive penetrating keratoplasties, such as reduced intraoperative risks and faster visual rehabilitation. We summarize the incidence and risk factors of graft failure for penetrating and lamellar (stromal and endothelial) corneal transplants and discuss the various surgical alternatives currently available to rescue such failed grafts, with a focus on the reported outcomes and limitations.
Postoperative Complications in Medicare Beneficiaries Following Endothelial Keratoplasty Surgery
2020, American Journal of Ophthalmology
To determine national-level incidence rates of major postoperative complications following endothelial keratoplasty (EK) procedures and to stratify these rates based on EK indications over an 8-year period using Medicare claims data.
Retrospective, cohort study.
Setting: population-based; study population: Medicare beneficiaries aged ≥65 years who underwent EK procedures; main outcome measurements: 1) occurrence of major postoperative complications (i.e., endophthalmitis, choroidal hemorrhage, infectious keratitis, cystoid macular edema [CME], retinal detachment [RD], or RD surgery) following EK surgery; 2) time-to-event analysis for glaucoma surgery; and 3) occurrence of graft complications.
A total of 94,829 EK procedures (n = 71,040 unique patients) were included in the analysis. Of the total, 29% of patients had pre-existing glaucoma. The overall 90-day cumulative incidence of postoperative endophthalmitis and choroidal hemorrhage following EK was 0.03% and 0.05%, respectively. The overall 1-year cumulative rates of RD or RD surgery, infectious keratitis, and CME were 1.0%, 0.8%, and 4.1%, respectively. Approximately 7.6%, 12.2%, and 13.8% of all eyes in this study needed glaucoma surgery at 1-, 5-, and 8-years of follow-up, respectively. The probability of glaucoma surgery among patients with pre-existing glaucoma was 29% vs. 8% among those without pre-existing glaucoma at 8 years. The cumulative probabilities of developing any graft complications were 13%, 23.2%, and 27.1% at 1, 5, and 8 years, respectively, of follow-up. On average, patients undergoing EK procedures for a prior failed graft had the highest rate of complications, whereas those with Fuchs' corneal endothelial dystrophy had the lowest.
The incidence of major postoperative complications including endophthalmitis, retinal detachment, and choroidal hemorrhage following EK procedures is low. A high proportion of eyes undergoing EK eventually require glaucoma surgery and experience graft-related complications. Postoperative outcomes are typically worse for patients undergoing EK for prior failed grafts than for those undergoing EK for Fuchs' corneal endothelial dystrophy.
Repeat Descemet Membrane Endothelial Keratoplasty for Failed Primary Descemet Membrane Endothelial Keratoplasty at a Referral Center for Keratoplasty in Spain: DIMOEK Study
2020, American Journal of Ophthalmology
To analyze the clinical results of repeat Descemet membrane endothelial keratoplasty (re-DMEK) for failed primary DMEK graft at a referral center for keratoplasty in Spain.
Retrospective, interventional, comparative case series.
From a single-center, single-surgeon series of 189 consecutive DMEK surgeries, 14 (7.41%) were re-DMEK eyes. The primary outcome was best-corrected visual acuity change (ΔBCVA, logarithm of minimal angle of resolution [logMAR]) from baseline (before first DMEK) to last follow-up. Secondary outcomes were ΔBCVA from baseline at 3, 6, and 12 months postoperatively, endothelial cell loss (%ECL), rebubbling rate, and re-DMEK graft failure. Outcomes were compared with an age-matched control group of 18 successful primary DMEK eyes.
After re-DMEK (median follow-up time 14.5 [42.5] months), mean BCVA improved from 0.55 (0.42) logMAR (Snellen 20/71 [20/53]) at baseline to 0.09 (0.26) logMAR (Snellen 20/25 [20/36]; P = .037). ΔBCVA from baseline was statistically significant at months 3 (P = .028), 6 (P = .023), and 12 (P = .012), and ΔBCVA was significant observed between months 6 and 12 (P = .028). BCVA differences between patient groups were statistically nonsignificant at 3 (P = .397), 6 (P = .468), and 12 months (P = .647). Mean %ECL in re-DMEK eyes with follow-up ≥12 months was 48.2 (15.1%), and the rebubbling rate was 28.6%; differences between groups were statistically nonsignificant for both variables (P = .580 and P = .669, respectively). Three re-DMEK eyes developed graft failure, all achieving final BCVA ≤0.30 logMAR (Snellen ≥20/40) after tertiary keratoplasty.
Repeat DMEK produces significant, continuous visual improvement after failed primary DMEK. Although visual outcomes and %ECL were comparable to primary DMEK, there was a relatively high rate of graft failure after re-DMEK.
Immune reactions after modern lamellar (DALK, DSAEK, DMEK) versus conventional penetrating corneal transplantation
2019, Progress in Retinal and Eye Research
Citation Excerpt :
In addition, there are so far only few relevant studies reporting on graft rejection rates in EK patients who would have been considered as high-risk hosts in PK. These (smaller) studies demonstrate relatively low graft rejection rates when compared to high-risk PK (between 0% and 17%) (Anshu et al., 2011; Baydoun et al., 2015b; Heinzelmann et al., 2017; Kim et al., 2012; Mitry et al., 2014), and there is no general consensus whether a high-risk scenario in EK even exists so far. It will be interesting to see whether studies in larger cohorts with longer follow-up can recapitulate this fact and whether it will be necessary to further sub-define “low-low-risk” and “high-low-risk” scenarios in the already low-risk setting of EK in the future.
In the past decade, novel lamellar keratoplasty techniques such as Deep Anterior Lamellar Keratoplasty (DALK) for anterior keratoplasty and Descemet stripping automated endothelial keratoplasty (DSAEK)/Descemet membrane endothelial keratoplasty (DMEK) for posterior keratoplasty have been developed. DALK eliminates the possibility of endothelial allograft rejection, which is the main reason for graft failure after penetrating keratoplasty (PK). Compared to PK, the risk of endothelial graft rejection is significantly reduced after DSAEK/DMEK. Thus, with modern lamellar techniques, the clinical problem of endothelial graft rejection seems to be nearly solved in the low-risk situation. However, even with lamellar grafts there are epithelial, subepithelial and stromal immune reactions in DALK and endothelial immune reactions in DSAEK/DMEK, and not all keratoplasties can be performed in a lamellar fashion. Therefore, endothelial graft rejection in PK is still highly relevant, especially in the “high-risk” setting, where the cornea's (lymph)angiogenic and immune privilege is lost due to severe inflammation and pathological neovascularization. For these eyes, currently available treatment options are still unsatisfactory. In this review, we will describe currently used keratoplasty techniques, namely PK, DALK, DSAEK, and DMEK. We will summarize their indications, provide surgical descriptions, and comment on their complications and outcomes. Furthermore, we will give an overview on corneal transplant immunology. A specific focus will be placed on endothelial graft rejection and we will report on its incidence, clinical presentation, and current/future treatment and prevention options. Finally, we will speculate how the field of keratoplasty and prevention of corneal allograft rejection will develop in the future.

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: Supplemental material is available at www.aaojournal.org.

: See Editorial on page 6.

: Financial Disclosure(s):

: The authors have made the following disclosures: G.R.J.M.: Consultant – D.O.R.C. International/Dutch Ophthalmic USA. L.B., I.D., V.S.L.: received a World Ophthalmology Congress 2014 Travel Grant unrelated to the presented work. The other authors have no conflicting relationship to disclose.

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Original articleRepeat Descemet Membrane Endothelial Keratoplasty after Complicated Primary Descemet Membrane Endothelial Keratoplasty

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Methods

Indications for Repeat DMEK

Feasibility of Repeat DMEK

Cont Lens Anterior Eye

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

Am J Ophthalmol

Posterior lamellar keratoplasty: DLEK to DSEK to DMEK

Cornea

Evolution of endothelial keratoplasty

Cornea

Efficacy of Descemet membrane endothelial keratoplasty: clinical outcome of 200 consecutive cases after a learning curve of 25 cases

Arch Ophthalmol

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

Acta Ophthalmol

Secondary DMEK for poor visual outcome after DSEK: donor posterior stroma may limit visual acuity in endothelial keratoplasty

Cornea

Descemet membrane endothelial keratoplasty and hybrid techniques for managing failed penetrating grafts

Cornea

Repeat penetrating keratoplasty: indications and prognosis, 1995-2005

Eur J Ophthalmol

Original article
Repeat Descemet Membrane Endothelial Keratoplasty after Complicated Primary Descemet Membrane Endothelial Keratoplasty