Repeat Descemet membrane endothelial keratoplasty after complicated primary Descemet membrane endothelial keratoplasty.

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/mm(2) before to 1390 ± 466 cells/mm(2) 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.

Predictive value of optical coherence tomography in graft attachment after Descemet's membrane endothelial keratoplasty.

PURPOSE: To evaluate the predictive value of early anterior segment optical coherence tomography (AS-OCT) on graft adherence or detachment after Descemet's membrane endothelial keratoplasty (DMEK). DESIGN: Retrospective study of prospectively collected data at a tertiary referral center. PARTICIPANTS: A total of 87 eyes of 87 patients of a consecutive series of 142 DMEK surgeries. METHODS: Anterior segment OCT was performed within the first hour after DMEK and at 1 week, 1 month, 3 months, and 6 months, and for each time interval detachments were classified as "none," ≤ 1/3 detachment, >1/3 detachment of the total graft surface area, or "complete" detachment. Throughout the study, no rebubbling procedures were performed. MAIN OUTCOME MEASURES: Graft adherence at various postoperative time intervals. RESULTS: One-hour AS-OCT scans were more accurate at predicting the final 6-month graft adherence status than those at 1 week or 1 month. Grafts showing complete attachment or <1/3 detachment at 1 hour remained stable or improved in 73% of the cases at 1 week, 82% at 1 month, 86% at 3 months, and 90% at 6 months. All grafts attached at 1 week remained attached at 6 months. Graft detachments of >1/3 at 1 hour showed reattachment at 6 months in 25% of the cases, whereas 67.5% of the cases showed a persistent detachment of >1/3 at 6 months and 12.5% showed a complete detachment. CONCLUSIONS: The 1-hour AS-OCT scan showed the best predictive value on 6-month graft adherence status. The combined information of the 1-hour and 1-week AS-OCT scans may facilitate decision making about surgical reintervention after DMEK.

Long-term risk of intraocular pressure elevation and glaucoma escalation after deep anterior lamellar keratoplasty.

BACKGROUND: To determine the prevalence and severity of intraocular pressure changes after deep anterior lamellar keratoplasty and its effect on visual function. DESIGN: Retrospective cohort study. PARTICIPANTS: All patients undergoing deep anterior lamellar keratoplasty procedures at a tertiary referral centre (Leeds University Hospitals, UK) using a manual dissection technique. METHODS: Case note review of all cases between the 1st of January 2000 and the 31st of December 2005. MAIN OUTCOME MEASURES: Raised intraocular pressure, glaucoma incidence or escalation. RESULTS: Data were collected for 69 of eyes of 58 patients. The mean period of follow-up was 54.9 months (median 60, range 6-95 months). The initial diagnosis was keratoconus in 56 cases (81%), corneal scarring in four cases (5.8%), herpes simplex keratitis in four cases (5.8%), lattice dystrophy in four cases (5.8%) and one case of corneal dermoid. Temporarily intraocular pressure was thought to be related to topical steroid use occurred in 12 (17%) cases. Ocular hypertension requiring treatment occurred in three eyes. None of these eyes had progressive disc changes or visual field defects suggestive of glaucoma, and all had well-controlled intraocular pressure on topical, single-drug therapy. Overall, there was a small insignificant rise in intraocular pressure after deep anterior lamellar keratoplasty (P = 0.11). CONCLUSIONS: The long-term risk of glaucoma following deep anterior lamellar keratoplasty using the manual dissection technique appears to be low. Ocular hypertension after deep anterior lamellar keratoplasty is infrequent and can be controlled on topical medication alone.

Changes in color vision and contrast sensitivity after descemet membrane endothelial keratoplasty for fuchs endothelial dystrophy.

PURPOSE: The aim of this study is to evaluate contrast sensitivity, color vision, and subjective patient satisfaction after Descemet membrane endothelial keratoplasty (DMEK) in patients with bilateral Fuchs endothelial dystrophy (FED). METHODS: From a group of 500 DMEK surgeries performed in our center, patients with a history of bilateral FED and unilateral DMEK were identified. A total of 29 patients were included in the study and divided into 2 groups: phakic (n = 12) and pseudophakic unilateral DMEK (n = 17) and their contralateral, untreated FED-affected eye. In addition, a control group of 10 healthy eyes of 10 patients was included. Pelli-Robson contrast sensitivity and Farnsworth-Munsell 100 hue color vision tests were performed. Subjective optical quality was graded with a questionnaire. RESULTS: Compared with untreated FED-affected eyes, best spectacle-corrected visual acuity was higher after DMEK in phakic and pseudophakic eyes (P = 0.030 and P < 0.001, respectively); a similar result was obtained for contrast sensitivity (P < 0.001 and P < 0.001, respectively). Color vision did not differ between untreated FED-affected and DMEK-operated eyes in the phakic group (P = 0.802) and the pseudophakic group (P = 0.227). Subjective optical quality was better in DMEK-operated eyes than in untreated FED-affected eyes in the phakic group (P < 0.001) and in the pseudophakic group (P < 0.001). CONCLUSIONS: In FED, DMEK may not only be effective for obtaining a higher visual acuity but particularly improving the contrast sensitivity may also lead to better subjective optical performance. Although frequently mentioned spontaneously by patients, an objective change in color vision could not be substantiated. Hence, quantifying contrast sensitivity before surgery may aid in the decision for surgery, and in the evaluation of surgical outcome.

Outcomes of phacoemulsification after Descemet membrane endothelial keratoplasty.

PURPOSE: To evaluate the feasibility and outcomes of phacoemulsification after Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy and bullous keratopathy. SETTING: Tertiary referral center. DESIGN: Comparative case series. METHODS: The case notes of all phakic DMEK patients who subsequently had cataract surgery were reviewed, and data from a prospectively recorded database were analyzed. This included demographic details, visual acuity, corneal pachymetry, endothelial cell density (ECD), refractive outcomes, and complications. RESULTS: From a series of 106 consecutive phakic DMEK eyes, 5 eyes (4.7%) required phacoemulsification a mean of 9.2 months ± 3.7 (SD) (range 4 to 14 months) after the initial DMEK. All phacoemulsification procedures were uneventful, and no dislocations and/or detachments of the Descemet graft were observed. At 6 to 12 months, all eyes reached a corrected distance visual acuity of 20/30 (0.6) or better and were within ±0.50 diopter of the target refraction. Endothelial cell density decreased from a mean of 1535 ± 195 cells/mm(2) before phacoemulsification to 1158 ± 250 cells/mm(2) 6 to 12 months after phacoemulsification. No significant changes in pachymetry values were observed, and all corneas remained clear throughout the study. CONCLUSIONS: Phacoemulsification after DMEK can be performed with minimal risk for graft detachment. The postoperative refractive outcomes were predictable, and visual acuity is likely to improve; there was an acceptable decrease in ECD. FINANCIAL DISCLOSURE: Dr. Melles is a consultant to D.O.R.C. International BV/Dutch Ophthalmic USA. No author has a financial or proprietary interest in any material or method mentioned.