Comparison of DMEK and DSAEK in Eyes With Endothelial Decompensation After Previous Penetrating Keratoplasty.

PURPOSE: Posterior lamellar keratoplasty is increasingly applied in patients with endothelial decompensation after penetrating keratoplasty (PK). The aim of this study was to compare the results of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) after PK. METHODS: In this retrospective study, clinical data of 30 patients who received DMEK (n = 19) or DSAEK (n = 11) for endothelial decompensation after PK were evaluated. All lamellar keratoplasties were performed at the Department of Ophthalmology at University Hospital Mainz, Germany. Primary end point included best-corrected visual acuity, and secondary end points included endothelial cell density, rebubbling, and rejection rates, all at 6 and 12 months. RESULTS: After 6 months and 12 months, 89% of DMEK and 73% of DSAEK grafts and 63% of DMEK and 64% of DSAEK grafts provided sufficient corneal deturgescence, respectively, represented by improvement in best-corrected visual acuity. DMEK group median preoperative Logarithm of the Minimum Angle of Resolution visual acuity of 1 increased to 0.5 after 6 and 12 months. DSAEK group median Logarithm of the Minimum Angle of Resolution visual acuity increased from 3 to 2 and 1.3 after 6 and 12 months. After 12 months, graft endothelial cell density had decreased by 58% in the DMEK group and by 59% in the DSAEK group. The proportion of patients requiring a rebubbling were 63% in the DMEK and 64% in the DSAEK group. No lamellar graft rejection occurred in either trial arm. CONCLUSIONS: Both DMEK and DSAEK significantly improved visual acuity in patients after PK. Lamellar graft survival, loss of endothelial cells, and mean rebubbling rates were similar in both groups.

Comparison of Descemet Membrane Endothelial Keratoplasty for Iridocorneal Endothelial Syndrome and Fuchs Endothelial Dystrophy.

PURPOSE: To evaluate the clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) for treating eyes with iridocorneal endothelial (ICE) syndrome and comparing the outcomes with those achieved after treating Fuchs endothelial dystrophy (FED). DESIGN: Prospective interventional comparative case series. METHODS: Sixty-three patients (68 eyes) with ICE syndrome or FED were enrolled at the Zhongshan Ophthalmic Center between March 10, 2014 and May 11, 2018. Eligible patients were divided into 2 groups: ICE group (eyes, 24; patients, 24) and FED group (eyes, 44; patients, 39). DMEK was performed in all cases. Corrected distance visual acuity (CDVA), endothelial cell loss (ECL), intraocular pressure (IOP), graft survival, and surgical complications were documented. RESULTS: In the ICE and FED groups, the mean follow-up duration was 24.9 ± 5 months and 25.2 ± 7.7 months, respectively. At 1 year postoperatively, Kaplan-Meier survival analysis demonstrated 85.7% and 100% cumulative graft success rates (P = .017) in patients with ICE and FED, respectively. Postoperative CDVA level was comparable between the 2 groups through 12-month follow-up; thereafter CDVA was better in the FED group than in the ICE group (P < .001). Moreover, postoperative ECL was significantly higher in the ICE group than in the FED group throughout the follow-up period (P < .001). A discernable increase in structural abnormalities of the anterior chamber angle was observed in 2 eyes (8.3%) in the ICE group; however, no significant differences were observed in the incidence of principal complications between the 2 groups. CONCLUSIONS: DMEK provides comparable short-term visual outcomes in the treatment of ICE to those observed in the treatment of FED, with higher postoperative ECL over FED.

Recovery of Contrast Sensitivity After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To study the change in contrast sensitivities in eyes with Fuchs endothelial dystrophy and bullous keratopathy after Descemet membrane endothelial keratoplasty (DMEK). METHODS: In this prospective study, 50 pseudophakic eyes of 50 patients who received DMEK surgery at the Charité-Universitätsmedizin Berlin were included. Visual acuity; contrast sensitivity using OPTEC 6500 at spatial frequencies of 1.5, 3, 6, 12, and 18 cycles/degree in photopic and mesopic light with and without glare; central corneal thickness (CCT); and anterior and posterior corneal aberrations were measured preoperatively and at 3 and 12 months postoperatively. RESULTS: Best-corrected visual acuity (preoperative 0.67 ± 0.46 and after 12 months 0.19 ± 0.16 LogMAR, P < 0.001) and photopic and mesopic contrast sensitivities with and without glare improved significantly, whereas CCT decreased significantly (preoperative 677 ± 114 µm, after 12 months 527 ± 29 µm, P < 0.001). Preoperative CCT correlates significantly with preoperative photopic contrast sensitivity (correlation coefficient -0.462, P = 0.002), and postoperative total anterior aberrations correlates with postoperative photopic contrast sensitivity (correlation coefficient -0.361, P = 0.006). CONCLUSIONS: Photopic and mesopic contrast sensitivities, especially with glare, are impaired in patients with Fuchs endothelial dystrophy and bullous keratopathy. The extent of the corneal thickening seems to mainly influence the contrast sensitivity preoperatively. DMEK surgery improves the contrast sensitivity significantly. However, higher postoperative anterior corneal aberrations limit the postoperative contrast sensitivities.

Long-term Results of a Combined Procedure of Cataract Surgery and Descemet Membrane Endothelial Keratoplasty With Stromal Rim.

PURPOSE: To evaluate the long-term results of combining cataract surgery, intraocular lens (IOL) implantation, and Descemet membrane endothelial keratoplasty with peripheral stromal support (DMEK-S). METHODS: The outcomes of 107 eyes of 37 patients who had undergone a combination of cataract surgery, IOL implantation, and DMEK-S between October 2007 and February 2015 were retrospectively evaluated. The average follow-up duration was 18.2 ± 18.3 months (range, 6-84 months). Changes in uncorrected and corrected distance visual acuity, spherical equivalent, and corneal endothelial cell density were analyzed. Intraoperative and postoperative complications were also recorded. RESULTS: The mean logMAR uncorrected distance visual acuity improved from 0.92 ± 0.60 preoperatively to 0.33 ± 0.33, 0.28 ± 0.25, 0.24 ± 0.20, and 0.27 ± 0.27 at 6, 12, 24, and 36 months postoperatively (P < 0.001), respectively. The mean logMAR corrected distance visual acuity improved from 0.62 ± 0.65 preoperatively to 0.17 ± 0.29, 0.13 ± 0.21, 0.07 ± 0.16, and 0.11 ± 0.23 at 6, 12, 24, and 36 months postoperatively (P < 0.001), respectively. The mean endothelial cell density decreases were 50.7% ± 21.1%, 50.8% ± 19.8%, 60.7% ± 16.6%, 62.2% ± 11.8%, and 61.8% ± 20.0% at 6, 12, 24, 36, and 48 months after surgery, respectively. Similar trends, although with slightly better visual outcomes, were found in the subgroup of patients without other eye diseases. The mean final deviation from intended spherical equivalent was 0.77 ± 1.19 D, representing a hyperopic shift. CONCLUSIONS: A combined procedure of cataract surgery, IOL implantation, and DMEK-S is an effective method of treatment in patients with combined corneal disease and cataract, maintaining visual rehabilitation in the long term. Future developments should be performed to minimize the incidence of complications.

Tissue Loss, Processing Time, and Primary Graft Failure in Eye Bank-Prepared Descemet Membrane Endothelial Keratoplasty Grafts Before and After Prestripped to Preloaded Graft Transition.

PURPOSE: To examine tissue loss rates, processing time, and primary graft failure (PGF) of "prestripped-only" Descemet membrane endothelial keratoplasty (DMEK) grafts at a single eye bank and how these parameters changed after the introduction of steps to preload tissue among experienced processors. METHODS: Tissue loss and processing time during DMEK graft preparation as well as PGF were analyzed retrospectively at a single eye bank between 2012 and 2018. Outcomes were assessed in consecutive grafts before and after the introduction of preloading to the eye bank's standard operating procedure. RESULTS: A total of 1326 grafts were analyzed, composed of the first 663 preloaded DMEK grafts and, for comparison, the 663 DMEK grafts processed immediately before starting the preloaded service. Mean processing time increased from 17.0 ± 3.9 minutes to 26.0 ± 5.4 minutes with the advent of preloading (P < 0.01). Initially, average processing time increased dramatically, with a maximum processing time of 51 minutes, before regressing to the average. No significant difference in the rate of tissue wastage was observed before versus after the implementation of preloaded DMEK (1.2% vs. 1.7%, P = 0.48). PGF occurred in 7 grafts before the preloaded service and 10 grafts after starting the service (1.6% vs. 2.3%, P = 0.47). CONCLUSIONS: Preloading does not affect tissue wastage for experienced technicians or the PGF rate but increases processing time. Eye banks that are considering adding preloading to their standard operating procedure may need to account for longer processing times in their daily operations.

Endothelial Keratoplasty Update 2020.

ABSTRACT: Endothelial keratoplasty has revolutionized the treatment of corneal endothelial dysfunction and lowered the threshold for treatment by providing rapid visual rehabilitation and setting a high standard for safety and efficacy. Over time, endothelial keratoplasty techniques have evolved toward the use of thinner tissue to optimize visual outcomes; refinements have facilitated donor tissue preparation, handling, and attachment; and adaptations have expanded utilization in eyes with challenging ocular anatomy. Despite early concerns about graft longevity, emerging 10-year endothelial cell loss and graft survival data have been encouraging. A shortage of human donor corneas restricts utilization in many areas of the world and is driving a search for keratoplasty alternatives. Further work is needed to expand the donor supply, minimize impediments to adoption, optimize graft survival, and improve refractive predictability.

Deep Anterior Lamellar Keratoplasty After Previous Anterior Lamellar Keratoplasty to Improve the Visual Outcomes.

PURPOSE: To describe a series of patients who underwent deep anterior lamellar keratoplasty (DALK) after previous anterior lamellar keratoplasty (ALK) to improve their visual outcomes. METHODS: This is a retrospective case series of 9 DALK eyes (9 patients) with a history of previous ALK and an unsatisfactory visual outcome. Surgery was performed in all cases at least 3 years after ALK. Cannula big bubble, air viscobubble, and manual dissection techniques were performed. Preoperative and postoperative best-corrected visual acuity, residual recipient bed thickness, and endothelial cell count were evaluated. Follow-up was at least 24 months for all eyes. RESULTS: Two subtotal anterior lamellar keratoplasties (through 1 type 1 big bubble and 1 air viscobubble) and 7 manual dissection DALKs were achieved. A small rupture of the residual recipient bed occurred during 1 case, and it was managed without penetrating keratoplasty conversion. Mean best-corrected visual acuity improved from 0.64 to 0.09 logMAR. Postoperative residual recipient central bed thickness was less than 80 µm in all cases. No postoperative complications were recorded at the last follow-up (24-36 months postoperatively). CONCLUSIONS: Different DALK techniques can be successfully used to improve visual acuity in previous ALK eyes with an unsatisfactory visual outcome.

Effect of Anticoagulant Therapy on the Outcome of Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To analyze the effect of anticoagulant therapy (ACT) for systemic diseases on the outcome of Descemet membrane endothelial keratoplasty (DMEK). METHODS: Consecutive eyes with Fuchs endothelial dystrophy that underwent DMEK between August 4, 2011, and July 15, 2016, were retrospectively analyzed. Data were obtained from the Cologne DMEK database at the University of Cologne, Germany. Best spectacle-corrected visual acuity (logMAR), endothelial cell density (at baseline and postoperatively up to 12 months), and rebubbling rates were compared between patients receiving ACT (ACT group) and those with no anticoagulant treatment (NCT group). RESULTS: In this study, 329 eyes of 329 patients were included (ACT group n = 97, NCT group n = 232; mean age 69.9 ± 9.1 years). Bleeding was more common in the ACT group (P < 0.001). Preoperative best spectacle-corrected visual acuity was 0.59 ± 0.44 and 0.48 ± 0.35 logMAR for the ACT and NCT groups, respectively, which improved to 0.13 ± 0.08 and 0.08 ± 0.16 logMAR, respectively, at 12 months postoperatively. No significant difference in endothelial cell density loss at 12 months was found between the groups (ACT group 36.2% ± 14.7%, NCT group 38.5% ± 15.1%; P = 0.467). Rebubbling rate was 19.6% in the ACT group and 28.9% in the NCT group (P = 0.08). CONCLUSIONS: Although ACT increases the risk for preoperative and intraoperative bleeding in DMEK, there seems to be no negative effect on DMEK outcome. Thus, it is not advisable to stop ACT for DMEK surgery.

Impact of Re-bubbling after Descemet Membrane Endothelial Keratoplasty on Long-term Results.

Purpose/Aim of the study: Graft detachment after DMEK can be treated easily with an additional air injection - re-bubbling. The aim of our study was to investigate the effect of a re-bubbling on the postoperative outcome.Materials and Methods: In this retrospective, comparative, cohort study we included eyes from patients that underwent DMEK surgery. A graft detachment was diagnosed by slit-lamp examination and OCT scan. All eyes were divided into three groups: no re-bubbling, one re-bubbling, more than one re-bubbling. We analyzed the visual acuity, endothelial cell density and rate of graft failure.Results: In 163 of 463 eyes (35.2%) a re-bubbling was performed (119 eyes 1 re-bubbling, 44 eyes more than one re-bubbling). Visual acuity improved significantly in all groups. After controlling for donor age, reason for surgery, time of cultivation of the graft and preoperative visual acuity, no difference in the visual acuity was seen at any point of follow-up. All patients showed a significant reduction in endothelial cell density 1 month after DMEK. Controlling for donor age, reason for surgery, type of surgery (DMEK-only or DMEK combined with cataract surgery) and the time of cultivation of the graft, the difference in endothelial cell density at 1 month post-surgery between no re-bubbling and one re-bubbling was 157 cells/mm2 (95% CI 2-310, p = .047) and between no re-bubbling and more than one re-bubbling 504 cells/mm2 (95% CI 267 - 741, p < .001). The difference in endothelial cell density remained over the course of follow-up. Twenty patients (4.3%) developed a graft failure during postoperative follow-up. Controlling for donor age, reason for surgery and the time of cultivation of the graft, we did not find any difference in the risk of graft failure between re-bubbling categories.Conclusions: Re-bubbling increased the risk for an endothelial cell loss, but did not influence the postoperative visual acuity and the rate of graft failure.

Heads-up Descemet Membrane Endothelial Keratoplasty Surgery: Feasibility, Surgical Duration, Complication Rates, and Comparison With a Conventional Microscope.

PURPOSE: To assess the feasibility of Descemet membrane endothelial keratoplasty (DMEK) surgery using the glasses-assisted 3-dimensional (3D) display system NGENUITY (Alcon Laboratories, Fort Worth, TX) and to compare with standard DMEK surgery by using a conventional operating microscope. METHODS: Twelve consecutive cases of DMEK surgery were performed using the glasses-assisted 3D display system NGENUITY (Alcon) and matched with similar cases performed by using the OPMI-Lumera 700 surgical microscope (Carl Zeiss Meditec, Jena, Germany) in this prospective cross-sectional study realized at the Rothschild Foundation, Paris, France. DMEK graft preparation time, graft unfolding time, time to perform the descemetorhexis (DM), and overall surgical time were recorded. Best corrected visual acuity, endothelial cell density of the donor tissue measured by specular microscopy, and the recipient's central corneal thickness were recorded preoperatively and again at 1 and 3 months postoperatively. RESULTS: In the 3D group, time to perform the graft preparation, DM, and global surgical time were significantly higher in the 3D group than in the conventional groups (17 minutes 36 seconds ± 3 minutes 13 seconds and 14 minutes 50 seconds ± 1 minutes 28 seconds, P = 0.04; 6 minutes 18 seconds ± 2 minutes 30 seconds vs. 3 minutes 50 seconds ± 2 minutes 8 seconds, P = 0.03; and 31 minutes 30 seconds ± 6 minutes 10 seconds vs. 24 minutes 10 seconds ± 3 minutes 26 seconds, respectively, P = 0.05). The time to unfold the graft was higher, although not significantly so, in the 3D group compared with the conventional group (5 minutes 15 seconds ± 2 minutes 40 seconds vs. 4 minutes 40 seconds ± 2 minutes 25 seconds, P = 0.89). Mean central corneal thickness decreased about 168 ± 82 µm at 3 months after surgery in the 3D group and about 228 ± 123 µm in the conventional group without significant difference (P = 0.60). Best corrected visual acuity in the 3D group was 0.33 ± 0.32 LogMAR at 3 months after surgery with no significant differences found when compared with conventional surgery. The percent endothelial cell loss from preoperative at 3 months was 35% in the 3D group and 26% in the conventional group, respectively, with no significant difference (P > 0.05). CONCLUSIONS: Performing DMEK surgery using a 3D display system is feasible; however, it is more challenging and the total surgical time is longer. This method would certainly be useful for instructional courses.

One-Year Clinical Outcomes of Preloaded Descemet Membrane Endothelial Keratoplasty Versus Non-Preloaded Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To compare the one-year outcomes of preloaded Descemet membrane endothelial keratoplasty (pDMEK) and non-preloaded DMEK (n-pDMEK) in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS: This retrospective comparative cohort study consecutively included 68 eyes with Fuchs endothelial corneal dystrophy who underwent either pDMEK (n = 38) or n-pDMEK (n = 30) performed by cornea fellows with an experienced surgeon between 2016 and 2018 at the Massachusetts Eye and Ear Infirmary. Exclusion criteria were previous surgery (other than uncomplicated cataract surgery) and any documented evidence of macular or other corneal diseases. Corrected distance visual acuity (CDVA), central corneal thickness, intraocular pressure, patient characteristics, postprocessing endothelial cell count, donor graft data, and complications were compared. RESULTS: CDVA showed similar results for pDMEK (0.12 ± 0.11 logarithm of the minimal angle of resolution [LogMAR]) and n-pDMEK (0.13 ± 0.13 LogMAR) (P = 0.827). Sixty-six percent of the pDMEK eyes and 57% of the n-pDMEK eyes achieved a VA of ≥0.1 LogMAR, and 95% and 97%, respectively, achieved a CDVA ≥0.3 LogMAR. The preoperative central corneal thickness of pDMEK and n-pDMEK (644 ± 62.2 µm, 660.5 ± 56.2 µm) decreased significantly after surgery (525.1 ± 43.6 µm, 526.5 ± 45.2 µm, P < 0.001), with no difference between groups (P = 0.840). The postprocessing endothelial cell count did not differ between pDMEK (2959.2 ± 182.9 cells/mm2) and n-pDMEK (2939.3 ± 278.7 cells/mm2) (P = 0.484). Complication rates were comparable with just the rebubbling performed in a minor procedure room showing a lower rate for pDMEK (13.16%) compared with n-pDMEK (33.33%) (P < 0.045). CONCLUSIONS: One-year clinical outcomes were similar between pDMEK and n-pDMEK procedures, rendering eye bank-prepared pDMEK tissues a useful tool in the treatment of endothelial dysfunction.

Three-Year Outcomes of Tri-Folded Endothelium-In Descemet Membrane Endothelial Keratoplasty With Pull-Through Technique.

PURPOSE: To assess the 3-year outcomes of tri-folded endothelium-in Descemet membrane endothelial keratoplasty (DMEK) using bimanual pull-through delivery technique. DESIGN: Interventional case series. METHODS: In this single-center study, we included 153 consecutive eyes that underwent DMEK for various indications (Fuchs endothelial corneal dystrophy [FECD]: n = 111; bullous keratopathy [BK]: n = 24; and failed graft: n = 18). DMEK grafts were loaded into a disposable cartridge in a tri-folded, endothelium-in configuration and delivered using bimanual pull-through technique. Main outcome measures were graft preparation and unfolding times, best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), and graft survival. RESULTS: Mean graft preparation time was 5.9 ± 1.1 minutes; and mean graft unfolding time was 2.9 ± 0.9 minutes. Excluding eyes with comorbidities, logarithm of minimum angle of resolution BSCVA improved significantly from baseline preoperative values of 0.92 ± 0.58 to 0.02 ± 0.07 at 1 year (P < .001) and remained stable up to 3 years. Mean postoperative ECD decreased significantly (P < .001) from eye bank values to 1,818 ± 362, 1,675 ± 372, and 1,580 ± 423 cells/mm2 at 1, 2, and 3 years, respectively. No significant differences in ECD were observed between eyes with FECD and BK, but ECD was significantly lower in eyes with previous failed graft (P < .05). Three-year cumulative graft survival rate was significantly (P < .001) lower for eyes with previous failed graft (71%) than for FECD (97%) and BK (92%). CONCLUSIONS: Tri-folded endothelium-in DMEK requires minimal time for graft unfolding, which is the surgical step considered most challenging by corneal surgeons. Visual outcomes and complication rates are not adversely affected by the modification of the surgical technique.

Long-Term Maintenance of Corneal Endothelial Cell Density After Corneal Transplantation.

PURPOSE: To investigate the key factors associated with eyes with an endothelial cell density (ECD) of ≥2000 cells/mm at 5 years after corneal transplantation. METHODS: This retrospective cohort study included 174 eyes that underwent penetrating keratoplasty by 1 corneal specialist surgeon at the Baptist Eye Institute, Kyoto, Japan, from 1998 through 2011 and that were carefully followed for over 5 years postoperative. In all operated eyes, corneal ECD was measured at 1, 2, 3, 4, and 5 years postoperative. Multivariate analysis with adjustment for preoperative donor ECD was performed between eyes with an ECD of ≥2000 cells/mm and those with an ECD of <2000 cells/mm at 5 years postoperative. RESULTS: Of the 174 eligible eyes, 16 eyes (9.2%) had an ECD of ≥2000 cells/mm at 5 years postoperative, and the annual rate of endothelial cell loss (mean ± SD) was 2.3% ± 3.7%. Multivariate analysis findings revealed that the donor-associated and surgery-related factors were not significant factors. Only the recipient diagnosis of bullous keratopathy was significantly associated with an ECD of <2000 cells/mm at 5 years postoperative. Of those 16 eyes, 6 (37.5%) had a recipient diagnosis of bullous keratopathy. CONCLUSIONS: None of the donor- and surgery-related factors, previously recognized as associated with a lower endothelial cell loss after penetrating keratoplasty, were found to be significant in this study, thus suggesting that there are still unknown factors associated with maintaining a higher ECD over the long-term postoperative period.

Donor DMEK Tissue Characteristics: Association With Rebubble Rate and 6-Month Endothelial Cell Loss.

PURPOSE: To determine whether specific donor characteristics influence postoperative rebubble rate and 6-month endothelial cell loss (ECL) in Descemet membrane endothelial keratoplasty (DMEK). METHODS: A retrospective analysis of a consecutive series of 857 DMEK surgeries using eye bank-prepared donor tissue was performed between September 2013 and April 2018. DMEK graft characteristics including donor age, preoperative endothelial cell density (ECD), preservation time, death-to-preservation time, and donor diabetes status were analyzed for correlation with rebubble rate and 6-month postoperative ECL. Subgroup analyses of donor age, preoperative ECD, preservation time, death-to-preservation time, preparation-to-surgery time, and diabetes severity were also performed. Statistically significant relationships between donor characteristics and rebubble rate or 6-month postoperative ECL were determined using Pearson correlation, one-way analysis of variance, t test, and χ analysis. RESULTS: The overall rate of rebubble after 857 surgeries performed by 7 surgeons during the study period was 12.6%. There was no significant relationship between postoperative rebubble rate and donor age, preoperative ECD, preservation time, death-to-preservation time, preparation-to-surgery time, or donor diabetes status. The subgroup analysis of these characteristics also yielded no significant relationship with rebubble rate. There was also no significant relationship between 6-month postoperative ECL and analyzed donor factors. CONCLUSIONS: Donor characteristics such as higher donor age, lower preoperative ECD (<2500), longer preservation time, and donor diabetes did not increase the rebubble rate or the 6-month ECL after DMEK. These results indicate that common surgeon preferences for donor tissues that are younger, fresher, with higher cell count, and without diabetes do not translate into superior postsurgical outcomes.

The Last 200 Surgeon-Loaded Descemet Membrane Endothelial Keratoplasty Tissue Versus the First 200 Preloaded Descemet Membrane Endothelial Keratoplasty Tissue.

PURPOSE: The purpose of this study was to compare the clinical outcomes from using eye bank-prepared, endothelium-out preloaded Descemet membrane endothelial keratoplasty (DMEK) tissue with those obtained with endothelium-out surgeon-loaded DMEK tissue using the same surgical technique at 1 site. METHODS: This study retrospectively reviewed 400 consecutive cases of DMEK from March 2016 to April 2018. The last 200 cases using surgeon-loaded tissue were compared with the first 200 cases using preloaded tissue. Statistical analysis was performed using the Wilcoxon signed-rank test, binomial logistic regression, Kruskal-Wallis 1-way analysis of variance, Student t test, or Pearson χ tests. RESULTS: Comparing surgeon-loaded versus preloaded DMEK tissue, respectively, no statistical difference was found in the mean 6-month postoperative values for endothelial cell loss (32.9% ± 18.5% vs. 29.9% ± 16.4%, P = 0.31), best corrected visual acuity (20/26 vs. 20/25, P = 0.54), or change in central corneal thickness (-14.4% ± 8.9% vs. -15.6% ± 11.7%, P = 0.43). The mean 1-year endothelial cell loss was also not significantly different (37.6% ± 17.2% vs. 33.2% ± 14.8%, P = 0.07). Overall, the rebubble rate for surgeon-loaded tissue was 17.5% and 12.5% for preloaded tissue, a statistically nonsignificant difference. Operative outcomes for mean tissue scroll tightness (1-4) and tissue unscroll time (minutes) for surgeon-loaded and preloaded tissue were similar between groups (2.4 vs. 2.2, P = 0.12 and 3.5 vs. 3.3 minutes, P = 0.50). CONCLUSIONS: Tissue that is trephinated, stained, and loaded into an injector by the eye bank and then shipped to the surgeon had no difference in clinical outcomes compared with tissue where the surgeon performs these steps. The safety and speed of using preloaded tissue should be considered by DMEK surgeons.

Four-Year Survival of Descemet Membrane Endothelial Keratoplasty in Patients With Previous Glaucoma Surgery.

PURPOSE: To evaluate 4-year outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with previous glaucoma surgery. DESIGN: Retrospective, comparative case series. METHODS: Patients with previous trabeculectomy or glaucoma drainage device (GDD) implantation who later underwent DMEK (study group) were matched for follow-up duration with Fuchs dystrophy DMEK patients (control group). The minimum follow-up was 18 months. Primary outcomes included graft survival and rejection rates, and secondary outcomes included rates of detachment/rebubble, endothelial cell loss, best spectacle-corrected visual acuity, intraocular pressure, and glaucoma medications/surgeries. Subgroup analysis compared eyes with and without a GDD. RESULTS: Ninety-four eyes of 91 patients were included. There were 51 eyes of 49 patients in the study group (GDD = 32 eyes, no GDD = 19 eyes) and 43 eyes of 42 patients in the control group. The mean follow-up was 37.9 ± 15.2 and 33.8 ± 13.5 months, respectively (P = .322). Graft survival probability of the study group at 12, 24, 36, and 48 months was 75%, 60%, 43%, and 27%, respectively, compared with a consistent 88% in the control group (P < .001). Survival curves of study subgroups (GDD and no GDD) were significantly lower than the control group (P < .001). Rejection rates in the study and control groups were 19.6% and 2.3%, respectively (P = .010). Endothelial cell loss in the study group was 12%-22% higher than the control group at 12, 24, 36, and 48 months (P = .049, P = .027, P = .200, and P = .004). CONCLUSIONS: In eyes with previous glaucoma surgery, DMEK has good early outcomes, but longer-term rejection and failure rates are high. Physicians and patients should be cognizant of the high likelihood of graft failure in this setting.

Endothelial Cell Loss After Descemet's Membrane Endothelial Keratoplasty for Fuchs' Endothelial Dystrophy: DMEK Compared to Triple DMEK.

PURPOSE: This study compared the outcomes after Descemet's membrane endothelial keratoplasty (DMEK) in pseudophakic patients with the outcomes after DMEK combined with cataract surgery (triple-DMEK) in patients with Fuchs' endothelial dystrophy (FED). DESIGN: Retrospective, single-institution, interventional, consecutive case series. METHODS: Outcomes of 114 DMEKs in patients with FED at a minimum of 1-year follow-up were reviewed. A total of 34 eyes (29 patients) were pseudophakic and underwent only DMEK (DMEK-only), and 80 eyes (56 patients) underwent triple-DMEK. Main outcome measurements included endothelial cell loss (ECL), best-corrected visual acuity (BCVA), central corneal thickness (CCT), and complications. RESULTS: At 1 month, ECL was 25% (±16%) and 35% (±15%) in DMEK-only and triple-DMEK groups, respectively. At 1 year, ECL was 33% (±13%) and 41% (±16%) in DMEK-only and triple-DMEK groups, respectively. There was statistically significantly less ECL after DMEK-only than after triple-DMEK at both 1 month (95% confidence interval [CI]: 1.67-15.02; P = .016) and 1 year (95% CI: 1.06-14.07; P = .034). CCT was significantly lower after DMEK-only than after triple-DMEK at 1 month but not at 1 year. BCVA was excellent and similar in the 2 groups. There were no cases of graft failure. Graft rejection and rebubbling rates were similar in DMEK-only and triple-DMEK groups: rejection occured in 8.8% and 8.75% of cases respectively (P = .50), and rebubbling in 2.9% and 2.5% respectively (P = .44). CONCLUSIONS: Both the DMEK-only and the triple-DMEK groups had low rebubbling rates and good visual outcomes, but the combined triple-DMEK procedure resulted in significantly greater loss of endothelial cells than DMEK-only surgery at both 1 month and 1 year.

Descemet Membrane Endothelial Keratoplasty versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty: A Multicenter Randomized Controlled Clinical Trial.

PURPOSE: To compare best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), refractive astigmatism, and complications after Descemet membrane endothelial keratoplasty (DMEK) and ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). DESIGN: Prospective, multicenter randomized controlled trial. PARTICIPANTS: Fifty-four pseudophakic eyes of 54 patients with corneal endothelial dysfunction resulting from Fuchs endothelial corneal dystrophy were enrolled in 6 corneal centers in The Netherlands. METHODS: Participants were allocated to DMEK (n = 29) or UT-DSAEK (n = 25) using minimization randomization based on preoperative BSCVA, recipient central corneal thickness, gender, age, and institution. Donor corneas were prestripped and precut for DMEK and UT-DSAEK, respectively. Six corneal surgeons participated in this study. MAIN OUTCOME MEASURES: The primary outcome measure was BSCVA at 12 months after surgery. RESULTS: Central graft thickness of UT-DSAEK lamellae measured 101 µm (95% confidence interval [CI], 90-112 µm). Best spectacle-corrected visual acuity did not differ significantly between DMEK and UT-DSAEK groups at 3 months (0.15 logarithm of the minimum angle of resolution [logMAR] [95% CI 0.08-0.22 logMAR] vs. 0.22 logMAR [95% CI 0.16-0.27 logMAR]; P = 0.15), 6 months (0.11 logMAR [95% CI 0.05-0.17 logMAR] vs. 0.16 logMAR [95% CI 0.12-0.21 logMAR]; P = 0.20), and 12 months (0.08 logMAR [95% CI 0.03-0.14 logMAR] vs. 0.15 logMAR [95% CI 0.10-0.19 logMAR]; P = 0.06). Twelve months after surgery, the percentage of eyes reaching 20/25 Snellen BSCVA was higher in DMEK compared with UT-DSAEK (66% vs. 33%; P = 0.02). Endothelial cell density did not differ significantly 12 months after DMEK and UT-DSAEK (1870 cells/mm2 [95% CI 1670-2069 cells/mm2] vs. 1612 cells/mm2 [95% CI 1326-1898 cells/mm2]; P = 0.12). Both techniques induced a mild hyperopic shift (12 months: +0.22 diopter [D; 95% CI -0.23 to 0.68 D] for DMEK vs. +0.58 D [95% CI 0.13-1.03 D] for UT-DSAEK; P = 0.34). CONCLUSIONS: Descemet membrane endothelial keratoplasty and UT-DSAEK did not differ significantly in mean BSCVA, but the percentage of eyes achieving 20/25 Snellen vision was significantly higher with DMEK. Endothelial cell loss did not differ significantly between the treatment groups, and both techniques induced a minimal hyperopic shift.

Pure phaco: phacoemulsification without ophthalmic viscosurgical devices.

The ophthalmic viscosurgical device (OVD) is an essential part of modern phacoemulsification surgery. Many times, OVDs are blamed for intraocular pressure spikes, toxic anterior segment syndrome, and capsular bag distension syndrome. To avoid these complications, we developed a technique in which phacoemulsification can be done without using OVDs. The irrigating cannula, on a continuous irrigation mode, was introduced through a side port, and capsulorhexis and incision construction were performed under an irrigating balanced salt solution. No hydroprocedure was performed. Phacoemulsification was done by chopping technique. At the end of the procedure, the intraocular lens was implanted by wound assistance technique under a continuous irrigation mode.