Original article
Causes of Primary Donor Failure in Descemet Membrane Endothelial Keratoplasty

https://doi.org/10.1016/j.ajo.2007.12.006Get rights and content

Purpose

To determine the causes of primary failure of donor Descemet membrane transplants in Descemet membrane endothelial keratoplasty (DMEK).

Design

Laboratory and clinical study.

Methods

From a larger series of eyes that underwent DMEK for Fuchs endothelial dystrophy or bullous keratopathy, 11 transplanted corneas did not clear within the first week after surgery. During a secondary ‘Descemet stripping endothelial keratoplasty’ procedure, the first graft was carefully removed and analyzed with light microscopy. For each patient, the surgical video of the initial DMEK procedure was analyzed to determine the cause of transplant failure.

Results

With light microscopy, all but two explanted transplants had a endothelial cell density of 1700 cells/mm2 or higher. Three Descemet grafts may have been positioned upside down and three may have failed due to manipulation. One transplant could not be properly attached onto the recipient posterior stroma because of insufficient air-support in a post-vitrectomy eye. For four eyes, no obvious cause of failure could be determined.

Conclusion

Unexpectedly, graft failure after DMEK may not primarily result from tissue damage during implantation and associated endothelial cell loss. Detached grafts may therefore be managed by early reposition. When the graft is attached after surgery but fails to clear, secondary surgical intervention may be postponed, because these corneas may clear spontaneously after several weeks.

Section snippets

Methods

From a larger series of patients who underwent DMEK for Fuchs endothelial dystrophy or bullous keratopathy,18 11 cases showed a primary graft failure, namely, no clearance of the grafted cornea within the first three to four weeks after surgery. The patient group included three men and eight women; patient age averaged 69.4 years (standard deviation [SD] ± 13.3 years; Table).

For all DMEK procedures, grafts were obtained from donor globes less than 36 hours post mortem. From the globes,

Results

From a total of 11 DMEK failures, six eyes showed a complete detachment, that is, a donor Descemet-roll was seen floating in the anterior chamber within the first week after surgery. Of the remaining five eyes, two had a partial detachment, and in three eyes the graft was attached but failed to clear (Table).

In the six eyes with a complete detachment, an upside-down orientation of the graft was considered the most likely cause of failure in two eyes (Cases 8 and 10; Table). In both cases,

Discussion

DMEK may give faster and more complete visual rehabilitation than posterior lamellar keratoplasty techniques procedures previously described by us, and popularized in the United States as DLEK and DSEK/DSAEK/FS-DSEK.18 With all of these techniques, the most apparent complication is incomplete attachment of the unsutured, donor posterior transplant to the recipient posterior stroma. Recently, we reported that up to one-third of DMEK cases may show a detachment of the graft in the early

Lisanne Ham, MSc, graduated as a Medical Biologist in 2007. She is currently a Physician Assistant at Melles CorneaClinic Rotterdam, and a Junior Technician at Amnitrans Eyebank Rotterdam. Both organizations are part of the Netherlands Institute for Innovative Ocular Surgery (www.niios.com), in Rotterdam, The Netherlands.

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Lisanne Ham, MSc, graduated as a Medical Biologist in 2007. She is currently a Physician Assistant at Melles CorneaClinic Rotterdam, and a Junior Technician at Amnitrans Eyebank Rotterdam. Both organizations are part of the Netherlands Institute for Innovative Ocular Surgery (www.niios.com), in Rotterdam, The Netherlands.

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