Influence of Intraoperative Air Tamponade Time on Graft Adherence in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To study the influence of different intraoperative air tamponade times on graft adherence after Descemet membrane endothelial keratoplasty (DMEK). METHODS: In this interventional case series, we evaluated 117 eyes with Fuchs endothelial corneal dystrophy (FECD) that underwent DMEK using intraoperative air tamponade times of 60 minutes (group I; n = 39), 45 minutes (group II; n = 39), or 30 minutes (group III; n = 39). At 1 and 6 months postoperatively, graft adherence status, endothelial cell density, central pachymetry, and postoperative complications were recorded. RESULTS: At 1 month, 19 of the 117 eyes (16.2%) showed a clinically significant detachment (>1/3 of the graft surface area and affecting visual axis): 6 eyes in group I (15.4%), 5 eyes in group II (12.8%), and 8 eyes in group III (20.5%) (P = 0.82). A minor detachment (<1/3 of the graft surface area and not affecting visual axis) was observed in 6 eyes in group I (15.4%), in 7 eyes in group II (17.9%), and in 4 eyes in group III (10.3%) (P = 0.82). The overall rebubbling rate was 11%, with no difference among the groups (P = 0.07). Mean endothelial cell density decrease at 6 months was 41% (±17%) (P = 0.56), whereas mean central pachymetry decreased by 23 (±10) % (P = 0.77), with no differences between the groups. CONCLUSIONS: The incidence of graft detachment after DMEK for FECD did not differ between the eyes that had a 60-, 45-, or 30-minute intraoperative air tamponade. Reducing the intraoperative air tamponade time to 30 minutes may be considered for DMEK in eyes with uncomplicated FECD.

Early Changes in Visual Quality and Corneal Structure after DMEK: Does DMEK Approach Optical Quality of a Healthy Cornea?

PURPOSE: To evaluate early changes in visual function and visual quality parameters after Descemet membrane endothelial keratoplasty (DMEK) and to compare the outcomes with healthy controls. METHODS: Thirteen patients who underwent DMEK and 14 controls were evaluated. All subjects underwent visual function evaluation, including visual acuity under photopic and mesopic lighting conditions and contrast sensitivity (CSV) tests CSV 1000 and Pelli-Robson. Corneal parameters were assessed with Oculus Pentacam. Corneal mean keratometry (Km), corneal densitometry values, and low and high order aberrations (LOA and HOA) were recorded. In DMEK patients, all tests were performed before surgery and 1 and 6 months after surgery. RESULTS: In patients who underwent DMEK, photopic visual acuity improved from 0.59 to 0.31 at 1 month (p=0.013) and 0.13 at 6 months (p=0.008); mesopic visual acuity and all contrast sensitivity values (both CSV and Pelli-Robson test) improved significantly in the first month (p < 0.005). A significant decrease was observed in corneal density in the 0-2 mm ring (from 43.83 to 35.60, p=0.043) and mean posterior Km (from -5.84 to -6.80, p=0.005) in the first month. Corneal HOAs and all corneal densities improved at 6 months after DMEK (p < 0.05). All visual function parameters and corneal aberrations remained lower and higher, respectively, compared with healthy controls (p < 0.05). Corneal densities were comparable with controls at 6 months after DMEK (p > 0.05). CONCLUSIONS: Patients undergoing DMEK present visual function improvement and a decrease in corneal density at 1 month after surgery. Decrease in corneal posterior HOAs can be observed at 6 months. However, visual function outcomes and corneal aberrations remained worse compared with healthy controls.

Clinical Outcome of Rebubbling for Graft Detachment After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To assess the clinical outcome after successful rebubbling procedures for visually significant graft detachment after Descemet membrane endothelial keratoplasty (DMEK). METHODS: From a total of 760 consecutive DMEK surgeries, 41 eyes required rebubbling. Of those, 33 eyes of 31 patients were successful and were included in our retrospective outcome analysis study. Main outcome measures were compared with those of matched controls with uneventful primary DMEK (attached DMEK grafts without rebubbling). Rebubbling was performed on average 25 (±20) days (range 7-91 days) after DMEK. All eyes were evaluated for best-corrected visual acuity, endothelial cell density (ECD), pachymetry, and complications up to 6 months after rebubbling. RESULTS: At 6 months after DMEK, best-corrected visual acuity in rebubbled eyes did not differ from that in control eyes (P = 0.514). The mean ECD decrease was higher in rebubbled than in control eyes (54% vs. 35%, respectively, P = 0.001). Pachymetry did not differ between both groups (P = 0.153). After rebubbling, one buphthalmic eye showed temporary intraocular pressure elevation and 5 eyes had minor graft edge detachment that did not require further treatment. CONCLUSIONS: Rebubbling for DMEK graft detachment may result in similar visual outcomes as in uncomplicated DMEK, when performed within the first 6 to 8 postoperative weeks. However, rebubbled eyes may have lower ECD, which may be attributed to additional air bubble trauma and/or selection bias through more extensive manipulation during initial DMEK or higher risk of graft detachment in more complicated eyes.

Outcome and Histopathology of Secondary Penetrating Keratoplasty Graft Failure Managed by Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To describe the clinical outcome and histopathology of Descemet membrane endothelial keratoplasty (DMEK) performed for secondary graft failure after penetrating keratoplasty (PK). METHODS: A total of 11 eyes from 10 patients who underwent DMEK for secondary PK graft failure at a tertiary referral center were included in this retrospective study. Best-corrected visual acuity, endothelial cell density, and central pachymetry were evaluated before and at regular time intervals up to 36 months after DMEK and complications were recorded; 1 post mortem cornea was available for light microscopy. RESULTS: At their last follow-up visit (on average, 16 months after DMEK), 7 of 11 transplanted corneas were clear. In the 7 eyes with clear grafts, 5 had a best-corrected visual acuity of ≥20/25 (≥0.8), central pachymetry averaged 535 (±70) µm, and endothelial cell density averaged 1045 (±500) cells/mm. Of the 11 eyes, 4 required rebubbling in the early postoperative phase; 1 eye was left with a small (<1/3) detachment. Light microscopy of the pathology specimen showed complete attachment of the DMEK graft onto the preexisting PK posterior stroma, with interface scarring over DMEK graft folds and underneath the graft area that had initially been detached. CONCLUSIONS: DMEK may be a viable option to manage secondary PK graft failure with acceptable outcomes in many cases. Rebubbling for graft detachment may be anticipated, especially because of preexisting glaucoma conditions (severe decompensation, hypotony, and tubes from glaucoma-draining devices). Graft reattachment may occur through interface scarring.

Ten-Year Clinical Outcome of the First Patient Undergoing Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To describe the 10-year clinical outcome of the first patient worldwide who underwent Descemet membrane endothelial keratoplasty (DMEK). METHODS: In 2006, a 63-year-old man presented at the Melles Cornea Clinic, Rotterdam, with bilateral Fuchs endothelial dystrophy and cataract. After phacoemulsification, in vivo DMEK was performed in the left eye and 10 months later in the right eye. Best spectacle-corrected visual acuity (BSCVA), endothelial cell density, pachymetry, and complications were recorded every 6 months over a 10-year period. RESULTS: BSCVA in the left eye improved from 20/60 (0.3) before surgery to 20/17 (1.2) at 1 month, and remained stable over 10 years, ranging from 20/20 (1.0) to 20/13 (1.5). BSCVA in the right eye improved from 20/50 (0.4) preoperative and 20/60 (0.3) at 1 month to 20/25 (0.8) at 3 months and 20/17 (1.2) at 6 months, ranging from 20/25 (0.8) to 20/17 (1.2) over 9 years. Both eyes underwent YAG-laser-capsulotomy to manage posterior capsule opacification at 5 and 4 years after DMEK, respectively. Endothelial cell density in the right and left eyes, respectively, decreased by 43% and 45% at 1 year, 52% and 59% at 5 years, and 72% and 68% at 10/9 years, respectively. No intraoperative or postoperative complications occurred; at the last follow-up, both corneas were clear. CONCLUSIONS: The first DMEK patient worldwide may show all short and long-term characteristics of this endothelial keratoplasty technique: outstanding patient satisfaction, quick visual recovery, low incidence of complications, and graft longevity. Published studies in the past decade would suggest that this case was the start of a new era in corneal transplantation.

Rebubbling Techniques for Graft Detachment After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To describe rebubbling techniques in eyes with a visually significant graft detachment after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Retrospective observational analysis at a tertiary referral center. A total of 41 eyes (39 patients) received rebubbling: 39 eyes (37 patients) had 1 and 2 eyes had 2 rebubbling procedures. Anterior segment optical coherence tomography and surgical videos were used to determine the best incisional approach for air injection, intraoperative maneuvers, and success rate (graft reattachment) at 1 week postoperatively. RESULTS: Rebubbling was performed on average 26 (±21) days (range: 7-92 days) after DMEK. Graft edge visibility and configuration of graft detachment were important parameters for the incisional approach for air injection: the air cannula was introduced in the area of graft attachment (attached area approach) (n = 25) or detachment (detached area approach) (n = 16). After excluding upside-down grafts (n = 3), the rebubbling success rate in total was 87% (33/38 eyes); in the attached area approach, it was 92% (22/24 eyes); and in the detached area approach, it was 79% (11/14). Of 14 eyes that had rebubbling later than 1 month postoperatively, 11 were successful; in 8 eyes, the graft seemed too stiff and/or immobile to allow complete unfolding. CONCLUSIONS: Rebubbling is a feasible procedure to manage graft detachment after DMEK if the graft is correctly oriented. Proper preoperative planning may aid in minimizing intraoperative complications and may increase the success rate. Late interventions (>1 month postoperatively) may still produce graft reattachment, but increased graft stiffness and/or fibrosis may complicate complete graft unfolding.

Preliminary outcome of hemi-Descemet membrane endothelial keratoplasty for Fuchs endothelial dystrophy.

BACKGROUND/AIMS: To evaluate the clinical outcome of a full-diameter, untrephined, semicircular Descemet graft in a consecutive series of Descemet membrane endothelial keratoplasty (hemi-DMEK), potentially allowing the harvesting of two grafts from a single donor corneoscleral rim. METHODS: Interventional case series of 10 eyes of 10 patients with Fuchs endothelial dystrophy. Best corrected visual acuity (BCVA), endothelial cell density (ECD) and central corneal thickness (CCT) were evaluated up to 6 months postoperatively, and intraoperative and postoperative complications were recorded. RESULTS: Hemi-DMEK was successful in 9 out of 10 eyes; one eye showed persistent graft detachment despite rebubbling and underwent a secondary DMEK. BCVA improved in all successful hemi-DMEK eyes: at 6 months 100% of eyes (n=7) reached ≥20/40 (≥0.5), 86% (n=6) ≥20/25 (≥0.8), 29% (n=2) ≥20/20 (≥1.0) and 14% (n=1) reached 20/17 (≥1.2). Two eyes were excluded from visual analysis due to low visual potential. Preoperative donor ECD declined from 2744 (±181) cells/mm2 to 940 (±380) cells/mm2 centrally at 6 months postoperatively (n=9), with (donor and/or host) endothelial cell redistribution over bare stromal areas adjacent to the graft. Average CCT decreased from 745 (±153) µm preoperatively to 520 (±37) µm at 6 months. Four eyes required rebubbling for visually significant graft detachment. No other complications occurred throughout the study period. CONCLUSIONS: Hemi-DMEK may give visual outcomes similar to those in conventional DMEK. If ECD decrease and graft detachment rate would prove acceptable in larger series, hemi-DMEK could have the potential to double the availability of donor tissue for endothelial keratoplasty.

Descemet Membrane Endothelial Keratoplasty for a Decompensated Penetrating Keratoplasty Graft in the Presence of a Long Glaucoma Tube.

PURPOSE: To describe specific maneuvers and technical modifications to the standardized "no-touch" technique of Descemet membrane endothelial keratoplasty (DMEK) to successfully handle the presence of a glaucoma drainage device (GDD) tube in the anterior chamber of an eye with a failed primary penetrating keratoplasty (PK) graft. METHODS: A 42-year-old male patient underwent DMEK because of a failed primary PK graft in his phakic right eye. The patient was then evaluated at 3 and at 6 months after surgery. RESULTS: A modified no-touch DMEK technique proved a feasible treatment option for a decompensated primary PK graft in the presence of a long GDD tube. CONCLUSIONS: With specific technical modifications DMEK can be successfully performed in eyes with decompensated primary PK grafts in the presence of a long GDD tube. The very thin DMEK graft allows positioning between the GDD tube and the failed PK graft, leaving the tube in place.

Bowman layer transplantation to reduce and stabilize progressive, advanced keratoconus.

OBJECTIVE: To evaluate the clinical outcome of mid-stromal isolated Bowman layer transplantation, a new surgical technique to reduce and stabilize ectasia in eyes with advanced keratoconus, to postpone penetrating keratoplasty or deep anterior lamellar keratoplasty, and to enable continued daily contact lens wear. DESIGN: Prospective, nonrandomized cohort study at a tertiary referral center. PARTICIPANTS: Twenty-two eyes of 19 patients with progressive, advanced keratoconus not eligible for ultraviolet cross-linking. INTERVENTIONS: The mid-stroma was manually dissected and an isolated donor Bowman layer was positioned within the stromal pocket. MAIN OUTCOME MEASURES: Before and up to 36 months after surgery (mean follow-up, 21±7 months), best spectacle-corrected visual acuity (BSCVA), best contact lens-corrected visual acuity (BCLVA), Scheimpflug-based corneal tomography measurements, endothelial cell density, biomicroscopy, refraction, and intraoperative and postoperative complications were recorded. RESULTS: Two surgeries were complicated by an intraoperative perforation of Descemet membrane; no other intraoperative or postoperative complications were observed. Maximum keratometry decreased on average from 77.2±6.2 diopters (D) to 69.2±3.7 D (P < 0.001) at 1 month after surgery and remained stable thereafter (P ≥ 0.072). Mean BSCVA improved from 1.27±0.44 logarithm of the minimum angle of resolution units before surgery to 0.90±0.30 logarithm of the minimum angle of resolution units 12 months after surgery (P < 0.001), whereas BCLVA remained stable (P = 0.105). Mean thinnest-point pachymetry increased from 332±59 µm before surgery to 360±50 µm at the latest follow-up (P = 0.012), and no change in endothelial cell density was found (P = 0.355). CONCLUSIONS: With isolated Bowman layer transplantation, reduction and stabilization of corneal ectasia was achieved in eyes with progressive, advanced keratoconus. Given the low risk for complications, the procedure may be performed to postpone penetrating or deep anterior lamellar keratoplasty.

Clinical outcome of 500 consecutive cases undergoing Descemet's membrane endothelial keratoplasty.

PURPOSE: To evaluate the clinical outcome of 500 consecutive cases after Descemet's membrane endothelial keratoplasty (DMEK) and the effect of technique standardization. DESIGN: Prospective, interventional case series at a tertiary referral center. PARTICIPANTS: A total of 500 eyes of 393 patients who underwent DMEK for Fuchs' endothelial corneal dystrophy, bullous keratopathy, or previous corneal transplant failure. METHODS: Best-corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications were evaluated before and 1, 3, and 6 months after DMEK. MAIN OUTCOME MEASURES: Comparison between 2 groups (group I: cases 1-250, outcome of "early surgeries" during transition to technique standardization; group II: cases 251-500, outcome of "late surgeries" after technique standardization). RESULTS: At 6 months, 75% of eyes reached a BCVA of ≥20/25 (≥0.8), 41% of eyes achieved ≥20/20 (≥1.0), and 13% of eyes achieved ≥20/18 (≥1.2) (n=418) when excluding eyes with ocular comorbidities (n=57). When including all available eyes at 6 months (n=475), 66% of eyes reached a BCVA of ≥20/25 (≥0.8), and 36% of eyes achieved ≥20/20 (≥1.0). Mean ECD decreased by 37% (±18%) to 1600 (±490) cells/mm2 (n=447) at 6 months (P<0.001). Postoperative pachymetry averaged 525 (±46) µm compared with 667 (±92) µm preoperatively (P<0.001). None of these parameters differed among the 2 groups (P>0.05). (Partial) graft detachment presented in 79 eyes (15.8%), and 26 eyes (5.2%) required a secondary surgery within the first 6 months (re-bubbling in 15, secondary keratoplasty in 11). With technique standardization, the postoperative complication rate decreased from 23.2% to 10% (P<0.001) and the rate of secondary surgeries decreased from 6.8% to 3.6% (P=0.10). CONCLUSIONS: In comparison with earlier endothelial keratoplasty techniques, DMEK may consistently give higher visual outcomes and faster visual rehabilitation. When used for the extended spectrum of endothelial pathologies, DMEK proved feasible with a relatively low risk of complications. Technique standardization may have contributed to a lower graft detachment rate and a relatively low secondary intervention rate. As such, DMEK may become the first choice of treatment in corneal endothelial disease.

Multicenter study of descemet membrane endothelial keratoplasty: first case series of 18 surgeons.

IMPORTANCE: Surgeons starting to perform Descemet membrane endothelial keratoplasty (DMEK) should be informed about the learning curve and experience of others. OBJECTIVE: To document the clinical outcome of standardized "no-touch" DMEK and its complications during the learning curves of experienced surgeons. DESIGN, SETTING, AND PARTICIPANTS: Retrospective multicenter study. A total of 431 eyes from 401 patients with Fuchs endothelial dystrophy (68.2%) and bullous keratopathy (31.8%) underwent DMEK performed by 18 surgeons in 11 countries. EXPOSURES: Descemet membrane endothelial keratoplasty. MAIN OUTCOMES AND MEASURES: Best-corrected visual acuity (BCVA), endothelial cell density, and intraoperative and postoperative complications. RESULTS: Of 275 eyes available for BCVA pooled analysis, BCVA improved in 258 eyes (93.8%), remained unchanged in 12 (4.4%), and deteriorated in 5 (1.8%). Two hundred seventeen eyes (78.9%) reached a BCVA of at least 20/40 (≥0.5), 117 (42.5%) at least 20/25 (≥0.8), and 61 (22.2%) at least 20/20 (≥1.0). Eyes with at least 6 months of follow-up (n = 176) reached similar BCVA outcomes. Mean (SD) decrease in endothelial cell density at 6 months was 47% (20%) (n = 133 [P = .02]). Intraoperative complications were rare, including difficulties in inserting, unfolding, or positioning of the graft (1.2%) and intraoperative hemorrhage (0.5%). The main postoperative complication was graft detachment (34.6%); 20.4% underwent a single rebubbling procedure, occasionally requiring a second (2.6%) and a third rebubbling (0.7%), and 17.6% underwent a second keratoplasty. CONCLUSIONS AND RELEVANCE: Our multicenter study showed that the standardized no-touch DMEK technique was feasible in most hands. The main challenges for surgeons starting to perform the procedure may be (1) to decide whether graft preparation is outsourced or performed during surgery, (2) to limit the number of graft detachments and secondary procedures, and (3) to obtain organ cultured donor corneal tissue.

Optical quality of the cornea after Descemet membrane endothelial keratoplasty.

PURPOSE: To evaluate corneal higher-order aberrations (HOAs) and backscattered light before and after Descemet membrane endothelial keratoplasty (DMEK) and their correlation with visual outcome. DESIGN: Retrospective study. METHODS: In a total of 118 consecutive eyes of 118 patients who underwent uneventful DMEK for Fuchs endothelial dystrophy at a tertiary referral center, best spectacle-corrected visual acuity (BSCVA), corneal HOAs, and backscattered light were evaluated preoperatively and at 6 months postoperatively. Outcome data were compared to an age-matched control group with uncomplicated eyes (n = 27). RESULTS: Compared to the control group, Fuchs endothelial dystrophy eyes, before as well as 6 months after DMEK, showed higher values of anterior and posterior HOAs and backscattered light (P < .033). Postoperative anterior HOAs and backscattered light (0-2 mm) were associated with lower 6-month BSCVA (positively related with logMAR BSCVA) (P ≤ .020). Anterior corneal HOAs did not change from preoperative to 6 months after DMEK (P = .649), while total posterior HOAs (RMS third to sixth Zernike order) and haze decreased (P < .001). CONCLUSIONS: Anterior and posterior corneal HOAs, as well as backscattered light from the cornea, were elevated in eyes suffering from Fuchs endothelial dystrophy and remained higher throughout 6 months after DMEK. If present, anterior surface irregularities and anterior corneal haze may be the most important limiting factors in visual rehabilitation after DMEK.

The effect of subconjunctival ranibizumab on corneal and anterior segment neovascularization: study on an animal model.

PURPOSE: To evaluate the effect of subconjunctival anti-vascular endothelial growth factor (VEGF) ranibizumab on corneal and anterior segment neovascularization. METHODS: In this experimental study and laboratory investigation, chemical cauterization was utilized to induce corneal neovascularization in 16 rabbits randomly divided in 2 equal groups. Cauterized eyes were either treated with 0.1 mL (1 mg) of subconjunctival ranibizumab or administered a sham injection. A third group of 4 rabbits served as control for side effects after ranibizumab administration. All animals were monitored daily for 14 days and the extent of corneal scarring and neovascularization was measured on days 1, 7, and 14. After enucleation, ocular tissues were separated under a surgical microscope and VEGF levels were measured with ELISA. Statistical analysis was performed to compare the extent of corneal neovascularization and VEGF levels between treated and untreated eyes. RESULTS: Subconjunctival ranibizumab inhibited corneal neovascularization significantly both in the first and the second week compared to untreated controls (p = 0.006 and p = 0.001, respectively). The VEGF levels were significantly lower in all anterior segment tissues like the cornea, iris, aqueous humor, and conjunctiva of the treated eyes (p<0.01). The reduction of VEGF levels ranged from 19% to 73% in different ocular tissues. Corneal scarring was not significantly affected by anti-VEGF treatment (p = 0.7). No side effects were noticed. CONCLUSIONS: Early subconjunctival administration of ranibizumab may successfully inhibit alkali-induced corneal neovascularization in an animal model. Subconjunctival ranibizumab reduces VEGF levels significantly not only in the cornea and the bulbar conjunctiva but also in the aqueous humor and the iris.

Endothelial keratoplasty for bullous keratopathy in eyes with an anterior chamber intraocular lens.

PURPOSE: To describe how to approach eyes with phakic or pseudophakic bullous keratopathy that have an anterior chamber intraocular lens (AC IOL) using thin Descemet-stripping endothelial keratoplasty (thin-DSEK) or Descemet membrane endothelial keratoplasty (DMEK) with or without AC IOL removal. SETTING: Tertiary referral center. DESIGN: Comparative case series. METHODS: Descemet membrane endothelial keratoplasty or thin-DSEK was performed in pseudophakic eyes with iris-claw AC IOLs (Group 1) or in phakic eyes with angle-supported AC IOLs (Group 2). In both groups, DMEK was routinely performed except in eyes with insufficient corneal transparency or a high risk for graft detachment. Preoperative surgical considerations, postoperative corrected distance visual acuity (CDVA), endothelial cell density, and complications were documented. RESULTS: In Group 1, all AC IOLs were left in situ. In Group 2, AC IOLs were removed in 90% of cases. At 6 months, the CDVA was 20/40 (≥0.5 decimal) or better in 36% of eyes in Group 1 and 90% in Group 2. Graft detachment occurred in 20% of eyes and de novo or glaucoma exacerbation in 29%. CONCLUSIONS: Bullous keratopathy treatment in eyes with an AC IOL was feasible with DMEK. Intraocular lens removal may be required if postoperative complications are anticipated, but not to facilitate surgery. Overall, the surgical approach may aim to minimize postoperative complications; that is, thin-DSEK in eyes with low visual potential and/or concomitant pathology and DMEK in eyes with a phakic AC IOL and normal visual potential.

Incidence of irregular astigmatism eligible for contact lens fitting after Descemet membrane endothelial keratoplasty.

PURPOSE: To evaluate the incidence and causes of anterior corneal surface irregularities after successful Descemet membrane endothelial keratoplasty (DMEK) and the efficacy of contact lens fitting in these cases. SETTING: Tertiary referral center. DESIGN: Retrospective study of prospectively collected data. METHODS: Eyes with a subnormal visual outcome or monocular diplopia after successful DMEK were fitted with a contact lens. These cases were evaluated with Pentacam rotating Scheimpflug camera imaging preoperatively and 6 months postoperatively, and outcomes were compared with those in a randomly selected DMEK control group. RESULTS: In a series of 262 surgeries, 23 eyes (21 patients) were fitted with contact lenses; the control group comprised 23 eyes. Indications for contact lens fitting included (1) obvious corneal surface irregularities due to preexisting corneal scarring, (2) surface irregularities associated with longstanding preoperative stromal edema, and (3) undetectable optical imperfections. The postoperative corrected distance visual acuity (CDVA) with spectacles improved after contact lens correction (P<.001). Preoperative and postoperative irregularity indices were significantly higher in the contact lens group than in the DMEK control group (P<.05). Positive correlations were found between the duration of preoperative stromal edema and postoperative Scheimpflug camera indices (P<.02). CONCLUSIONS: After successful DMEK, 23 of 262 eyes (9%) showed subnormal spectacle CDVA and/or monocular diplopia due to corneal scarring, surface irregularities, or undetectable optical imperfections that could be managed by contact lens fitting. Prolonged preoperative corneal edema for more than 12 months may be a risk factor for diffuse irregular astigmatism after DMEK. FINANCIAL DISCLOSURE: Dr. Melles is a consultant to DORC International BV/Dutch Ophthalmic USA. No author has a financial or proprietary interest in any material or method mentioned.

Intraocular graft unfolding techniques in descemet membrane endothelial keratoplasty.

OBJECTIVE: To define various Descemet graft unfolding techniques in Descemet membrane endothelial keratoplasty. METHODS: In a retrospective analysis, the surgical videos of 100 consecutive Descemet membrane endothelial keratoplasty cases with at least 6 months of follow-up were evaluated and categorized. The Descemet graft unfolding methods were categorized into 4 basic techniques and 3 auxiliary techniques. RESULTS: All Descemet membrane endothelial keratoplasty surgical procedures could be completed using (a combination of) 4 Descemet graft unfolding techniques: (1) standardized no-touch graft unfolding using a double roll, (2) carpet unrolling while fixating 1 graft edge (Dirisamer technique), (3) small air bubble-assisted unrolling (Dapena maneuver), (4) the single sliding cannula maneuver. Additional maneuvers included turning over the graft when oriented upside down (flushing); manual graft centration with a cannula; and bubble bumping to unfold peripheral inward folds. In 73% of surgical procedures, technique 1 was used, while a combination of techniques was used in 44% and auxiliary techniques in 62%. None of the techniques showed a correlation with the best-corrected visual acuity, endothelial cell density, or postoperative complication rate (P > .10). CONCLUSIONS: Descemet membrane endothelial keratoplasty may be further facilitated by using controlled techniques for unfolding the Descemet graft inside the recipient anterior chamber, either as stand-alone techniques or used in various combinations.

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

PURPOSE: To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and to determine whether such eyes can be successfully 'repaired' with a secondary Descemet membrane endothelial keratoplasty (DMEK). METHODS: Twelve eyes of 12 patients, who underwent secondary DMEK to manage poor visual outcome after initial DSEK/DSAEK, were evaluated with biomicroscopy, Pentacam imaging, and specular and confocal microscopy, before and at 1, 3 and 6 months after DMEK. RESULTS: Four causes of reduced optical quality of the transplanted host cornea could be identified in DSEK/DSAEK: five eyes (42%) showed large host-Descemet remnants within the visual axis during surgery; six eyes (50%) irregular graft thickness; six eyes subtle 'stromal waves'; and nine eyes (75%) high reflectivity at the donor-to-host interface. After DMEK graft replacement, all corneas cleared and achieved a best corrected visual acuity of ≥20/25 (≥0.8), except for one with a partial Descemet graft detachment. Pachymetry values decreased from 670 (±112) µm before to 517 (±57) µm after secondary DMEK. Higher-order aberrations (Coma and Trefoil) at the posterior surface tended to be lower (p = 0.07) in DMEK grafts than in DSEK/DSAEK grafts. CONCLUSION: Host-Descemet remnants at the donor-to-host interface, interface reflectivity, graft thickness irregularity and donor stromal contraction may contribute to poor visual outcome after DSEK/DSAEK, without causing permanent host corneal damage, as in most cases, complete visual recovery could be achieved by performing a secondary DMEK.

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.

Near complete visual recovery and refractive stability in modern corneal transplantation: Descemet membrane endothelial keratoplasty (DMEK).

OBJECTIVE: To report the 6 months results of a large prospective study on Descemet membrane endothelial keratoplasty (DMEK) for management of corneal endothelial disorders. METHODS: DMEK was performed in 300 consecutive eyes with Fuchs endothelial dystrophy, bullous keratopathy or previous corneal transplant failure. Best spectacle corrected visual acuity (BSCVA), refractive outcome and endothelial cell density (ECD) were evaluated before and at 1, 3, and 6 months after surgery. Intra- and postoperative complications were documented. RESULTS: At 6 months, 98% of eyes reached a BCVA of ≥20/40 (≥0.5), 79% ≥20/25 (≥0.8), 46% ≥20/20 (≥1.0), and 14% ≥20/18 (≥1.2) (n=221). The pre- to 6 months postoperative spherical equivalent (SE) showed a +0.33D (±1.08D) hyperopic shift (P=0.0000). Refractive stability was shown at 3 months after DMEK, i.e. no significant change in SE (P=0.0822) or refractive cylinder (P=0.6182) at 3 versus 6 months follow-up. Donor ECD showed a decrease from 2561 (±198)cells/mm(2) before, to 1674 (±518)cells/mm(2) at 6 months after surgery (n=251) (P=0.0000). The main complication was (partial) graft detachment occurring in 31 eyes (10%). Secondary ocular hypertension was seen in 13 eyes (6%): 6 induced by air-bubble dislocation posterior to the iris and 4 induced by steroids. Secondary cataract requiring phaco-emulsification developed in 3 out of 63 (5%) phakic eyes. CONCLUSIONS: DMEK may provide a refractively neutral near complete, rapid visual rehabilitation with ECDs similar to earlier endothelial keratoplasty techniques. This combined with a relatively low complication rate, would indicate that DMEK is a safe and effective treatment for corneal endothelial disorders.