One-year Outcomes of Ultrathin Descemet Stripping Automated Endothelial Keratoplasty Combined with Cataract Surgery in the Korean Population.

PURPOSE: To evaluate the refractive outcomes after ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) combined with phacoemulsification and intraocular lens implantation (triple procedure) in the South Korean population. METHODS: This retrospective observational study included 37 eyes of 36 patients who underwent the UT-DSAEK triple procedure between 2012 and 2021 in a single tertiary hospital. Preoperative and postoperative refractive outcomes and endothelial parameters at 1, 3, 6, and 12 months were observed. RESULTS: At the final postoperative 12-month period, the average best-corrected visual acuity was 0.4 ± 0.5 in logarithm of the minimum angle of resolution. The mean endothelial cell density at 12 months was 1,841.92 ± 731.24 cells/mm2, indicating no significant endothelial cell loss compared to the baseline (p = 0.128). The mean postoperative central corneal thickness at 12 months was 597.41 ± 86.26 µm. The postoperative mean absolute error at 12 months was 0.96 ± 0.89 diopters (D) and mean error was 0.89 ± 0.97 D. CONCLUSIONS: The results of our South Korean cohort study on UT-DSAEK triple surgery showed favorable and safe outcomes. Regardless of graft thickness, it should be noted that a hyperopic shift of 1.00 to 2.00 D needs to be considered in the case of UT-DSAEK triple surgery.

Combined or sequential DMEK in cases of cataract and Fuchs endothelial corneal dystrophy-A systematic review and meta-analysis.

To compare the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed after phacoemulsification and intraocular lens (IOL) implantation (sequential DMEK) and DMEK combined with phacoemulsification and IOL implantation (combined DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and cataract. Systematic literature review and meta-analysis performed according to the PRISMA guidelines and registered in PROSPERO. Literature searches were conducted in Medline and Scopus. Comparative studies reporting sequential DMEK and combined DMEK in FECD patients were included. The main outcome measure of the study was the corrected distance visual acuity (CDVA) improvement. Secondary outcomes were postoperative endothelial cell density (ECD), rebubbling rate and primary graft failure rate. Bias risk was assessed and a quality appraisal of the body of evidence was completed using the Cochrane Robin-I tool. A total of 667 eyes (5 studies) were included in this review, 292 eyes (43.77%) underwent a combined DMEK, while 375 (56.22%) eyes underwent a sequential DMEK surgery. We found no evidence of a difference between the two groups (mean difference, 95% CI) regarding: (1) CDVA improvement (-0.06; -0.14, 0.03 LogMAR; 3 studies, I2 : 0%; p = 0.86); (2) postoperative ECD (-62; -190, 67 cells/mm2 ; 4 studies, I2 : 67%; p = 0.35); (3) rebubbling (risks ratio: 1.04; 0.59, 1.85; 4 studies, I2 : 48%; p = 0.89); and primary graft failure rate (risks ratio: 0.91; 0.32, 2.57; 3 studies, I2 : 0%; p = 0.86). Of all the 5 non-randomized studies, all (100%) were graded as low quality. The overall quality of the analysed studies was low. Randomized controlled trials are needed to confirm no difference or superiority of one approach in terms of CDVA, endothelial cell count and postoperative complication rate between the two arms.

Comparison of Long-Term Outcomes of DSEK and DMEK in Fuchs Endothelial Dystrophy.

PURPOSE: This study aimed to compare the long-term endothelial cell loss, graft survival, and clinical outcomes in patients with Fuchs endothelial dystrophy (FED) after Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK) using a standardized surgical protocol. METHODS: Three hundred and six consecutive DSEK and DMEK grafts of 223 patients with FED performed by 8 surgeons between January 2006 and August 2022 were analyzed. The primary outcome measures were graft survival, endothelial cell loss, and best spectacle-corrected visual acuity. RESULTS: At 5 years, graft survival was 96% for both DSEK and DMEK eyes. The mean percentage of endothelial cell loss was 57.7 ± 17.1 in DSEK and 56.8 ± 15.2 in DMEK eyes ( P = 0.430). The mean best spectacle-corrected visual acuity was 0.13 ± 0.14 logMAR in DSEK and 0.01 ± 0.18 logMAR in DMEK grafts ( P <0.00001) at 5 years postoperatively. Rebubbling was performed in 7.8% DSEK and 2.1% DMEK grafts ( P = 0.441). Cox regression identified rejection episodes (HR 6.5; 95% CI: 1.70-24.8; P = 0.0062) as a significant contributing factor for graft failure. CONCLUSIONS: DMEK had superior visual acuity outcomes compared with DSEK in these patients up to 5 years after surgery. At 5 years, there was no significant difference in graft survival or endothelial cell loss between DSEK and DMEK eyes with FED. We propose that our standardized technique reduces the need for rebubbling.

Comparison of efficacy of three gases for anterior chamber tamponade in Descemet's membrane endothelial keratoplasty.

PURPOSE: To compare the efficacy of three different gases for intraocular tamponade: 100% air, 10% perfluoropropane (C3F8), and 10% sulfur hexafluoride (SF6), in Descemet's membrane endothelial keratoplasty (DMEK). MATERIALS AND METHODS: The medical records of 138 patients who underwent DMEK were reviewed retrospectively, with the primary outcome being the rebubbling rate in the first week following surgery. Other clinical outcomes, such as best-corrected visual acuity (BCVA), central corneal thickness (CCT), incidence of rebubbling after the first week, endothelial cell density (ECD), graft detachment, graft failure, pupillary block, and intraocular pressure (IOP) changes were also analyzed. RESULTS: Of the 138 patients, 57 were in group 1 (treated with air), 44 in group 2 (treated with 10% C3F8), and 37 in group 3 (treated with 10% SF6). Group 3 showed significantly lower rates of graft detachment and rebubbling compared to groups 1 and 2 (P<0.001). However, there was no significant difference in postoperative BCVA among the groups. At one year, the mean endothelial cell loss was 32% in group 1, 30% in group 2, and 33% in group 3 (P=0.715). One patient in group 1 experienced pupillary block and increased IOP, while there were no such occurrences in the other groups. There was no difference between the groups in terms of graft failure. CONCLUSION: The use of 10% SF6 in DMEK surgery may be a good option due to its efficacy in preventing graft detachment, low rebubbling rate, and potential for minimizing complications.

New forceps free injection technique for delivering descemet membrane endothelial keratoplasty preloaded endothelium-in grafts.

PURPOSE: To describe a new method for delivering DMEK grafts into the recipient's eye with endothelium inward configuration using a no-forceps injection technique. METHODS: We retrospectively review 11 patients that underwent DMEK surgery at our institution using a no-forceps injection technique. The graft was preloaded into an intraocular lens (IOL) cartridge and connected to an anterior chamber maintainer (ACM). A 5 ml non luer lock syringe was inserted into the other end of the ACM to create a one-flow system. The cartridge was inserted into the posterior end of an injector, and the graft was successfully delivered into the recipient's eye. RESULT: Twelve eyes of 11 patients were included. Mean follow-up was 9.16 ± 1.3 months. At baseline, mean best corrected visual acuity (BCVA) was 0.76 ± 0.13 logMAr and mean endothelial cell density (ECD) was 2619.00 ± 115.89 cells/mm2. At follow-up, BCVA significantly improved to 0.22 ± 0.05 logMAR (p = 0.003). Although we observed a significant reduction in ECD at follow-up (1688 ± 182.20, p = 0.002), our patients lost only 35.69 ± 6.36% of endothelial cells. CONCLUSION: Our technique can help surgeons safely deliver an endothelium-in graft into the recipient's eye. The method doesn't require the use of a forceps, minimizing the risk of endothelial cell loss or graft damage.

Retrospective Study of Preoperative Laser Peripheral Iridotomy Versus Intraoperative Surgical Peripheral Iridectomy in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: The aim of this study was to examine the outcomes of laser peripheral iridotomy (LPI) and surgical peripheral iridectomy (SPI) for Descemet membrane endothelial keratoplasty (DMEK) and DMEK with cataract extraction (triple DMEK). METHODS: This retrospective interventional study included 135 eyes of 135 patients who underwent DMEK alone or triple DMEK. Primary outcomes were graft detachments necessitating rebubbling, repeat grafts, and pupillary block. The secondary outcomes included rejection, cystoid macular edema, uveitis, intraoperative hyphema, visual disturbances, and surgical time. RESULTS: Thirty-one eyes in the LPI group and 104 eyes in the SPI group were included. Fifty-six eyes had DMEK alone, and 79 had triple DMEK. Visually significant graft detachments occurred in 7 of 31 eyes in the LPI group versus 19 of 104 eyes in the SPI group ( P = 0.61). No statistical significance in DMEK alone versus triple DMEK groups ( P = 0.61 vs. P > 0.99). Two patients in the LPI group and 5 in the SPI group required regraft ( P = 0.66). One (3.2%) experienced pupillary block compared with 5 (4.8%) ( P = 0.99) in the LPI and SPI groups, respectively. Secondary outcomes were similar in both groups ranging from 0% to 3% ( P > 0.99). None had visual disturbances. In DMEK alone, duration of surgery was significantly shorter in the LPI versus SPI group (32.8 vs. 44.1 minutes, P = 0.02). CONCLUSIONS: This study demonstrated similar outcomes between LPI and SPI, although the LPI group had a shorter duration of surgery when DMEK was performed alone. The remainder of the outcomes demonstrated no statistically significant differences.

Cost Drivers of Endothelial Keratoplasty: A Time-Driven Activity-Based Costing Analysis.

PURPOSE: To determine cost drivers of endothelial keratoplasty (EK) through evaluation of surgical costs and procedure length based on type of EK, use of preloaded grafts, and performance of simultaneous cataract surgery. DESIGN: This study was an economic analysis of EKs at a single academic institution using time-driven activity-based costing (TDABC) methodology. PARTICIPANTS: Endothelial keratoplasty surgical cases, including Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK), at the University of Michigan Kellogg Eye Center from 2016 to 2018 were included in the analysis. METHODS: Data and inputs were obtained via the electronic health record (EHR) and from prior literature. Simultaneous cataract surgeries were included and separately categorized for analysis. Endothelial keratoplasty expenses were determined with TDABC, a method for cost calculation that incorporates the time that key resources are used and each resource's associated cost rate. MAIN OUTCOME MEASURES: Main outcome measures included surgery length (in minutes) and day-of-surgery costs. RESULTS: There were 559 EKs included: 355 DMEKs and 204 DSAEKs. Fewer DSAEKs had simultaneous cataract extraction (47; 23%) than DMEK (169; 48%). Of the DMEKs, 196 (55%) used preloaded corneal grafts. Descemet membrane endothelial keratoplasty cost $392.31 less (95% confidence interval, $251.05-$533.57; P < 0.0001) than DSAEK and required 16.94 fewer minutes (14.16-19.73; P < 0.0001). Descemet membrane endothelial keratoplasty cases that used preloaded corneal grafts cost $460.19 less ($316.23-$604.14; P < 0.0001) and were 14.16 minutes shorter (11.39-16.93; P < 0.0001). In multivariate regression, preloaded graft use saved $457.19, DMEK (compared with DSAEK) saved $349.97, and simultaneous cataract surgery added $855.17 in day-of-surgery costs. CONCLUSIONS: Cost analysis of TDABC identified a day-of-surgery cost and surgical time reduction associated with the use of preloaded grafts for DMEK, DMEK compared with DSAEK, and isolated EK compared with EK combined with cataract surgery. This study provides an improved understanding of surgical cost drivers and margin incentivization, which may explain trends and indirectly influence patient care decisions in cornea surgery practices. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Manufacturing of human corneal endothelial grafts.

PURPOSE: Human corneal endothelial cells (HCECs) play a significant role in maintaining visual function. However, these cells are notorious for their limited proliferative capacity in vivo. Current treatment of corneal endothelial dysfunction resorts to corneal transplantation. Herein we describe an ex vivo engineering method to manufacture HCEC grafts suitable for transplantation through reprogramming into neural crest progenitors. METHODS: HCECs were isolated by collagenase A from stripped Descemet membrane of cadaveric corneoscleral rims, and induced reprogramming via knockdown with p120 and Kaiso siRNAs on collagen IV-coated atelocollagen. Engineered HCEC grafts were released after assessing their identity, potency, viability, purity and sterility. Phase contrast was used for monitoring cell shape, graft size, and cell density. Immunostaining was used to determine the normal HCEC phenotype with expression of N-cadherin, ZO-1, ATPase, acetyl-α-tubulin, γ-tubulin, p75NTR, α-catenin, ß-catenin, and F-actin. Stability of manufactured HCEC graft was evaluated after transit and storage for up to 3 weeks. The pump function of HCEC grafts was measured by lactate efflux. RESULTS: One HCEC graft suitable for corneal transplantation was generated from 1/8th of the donor corneoscleral rim with normal hexagonal cell shape, density, and phenotype. The manufactured grafts were stable for up to 3 weeks at 37 °C or up to 1 week at 22 °C in MESCM medium and after transcontinental shipping at room temperature by retaining normal morphology (hexagonal, >2000 cells/mm2, >8 mm diameter), phenotype, and pump function. CONCLUSIONS: This regenerative strategy through knockdown with p120 and Kaiso siRNAs can be used to manufacture HCEC grafts with normal phenotype, morphology and pump function following prolonged storage and shipping.

Deep Learning Using Preoperative AS-OCT Predicts Graft Detachment in DMEK.

Purpose: To evaluate a novel deep learning algorithm to distinguish between eyes that may or may not have a graft detachment based on pre-Descemet membrane endothelial keratoplasty (DMEK) anterior segment optical coherence tomography (AS-OCT) images. Methods: Retrospective cohort study. A multiple-instance learning artificial intelligence (MIL-AI) model using a ResNet-101 backbone was designed. AS-OCT images were split into training and testing sets. The MIL-AI model was trained and validated on the training set. Model performance and heatmaps were calculated from the testing set. Classification performance metrics included F1 score (harmonic mean of recall and precision), specificity, sensitivity, and area under curve (AUC). Finally, MIL-AI performance was compared to manual classification by an experienced ophthalmologist. Results: In total, 9466 images of 74 eyes (128 images per eye) were included in the study. Images from 50 eyes were used to train and validate the MIL-AI system, while the remaining 24 eyes were used as the test set to determine its performance and generate heatmaps for visualization. The performance metrics on the test set (95% confidence interval) were as follows: F1 score, 0.77 (0.57-0.91); precision, 0.67 (0.44-0.88); specificity, 0.45 (0.15-0.75); sensitivity, 0.92 (0.73-1.00); and AUC, 0.63 (0.52-0.86). MIL-AI performance was more sensitive (92% vs. 31%) but less specific (45% vs. 64%) than the ophthalmologist's performance. Conclusions: The MIL-AI predicts with high sensitivity the eyes that may have post-DMEK graft detachment requiring rebubbling. Larger-scale clinical trials are warranted to validate the model. Translational Relevance: MIL-AI models represent an opportunity for implementation in routine DMEK suitability screening.

Long-term Outcomes After Lamellar Endothelial Keratoplasty Compared With Penetrating Keratoplasty for Corneal Endothelial Dysfunction: A Systematic Review.

PURPOSE: The purpose of this study is to evaluate long-term outcomes of endothelial keratoplasty (EK) compared with penetrating keratoplasty (PK) for corneal endothelial dysfunction [Fuchs endothelial corneal dystrophy (FECD) and bullous keratopathy (BK)]. METHODS: In this systematic review, we searched PubMed, the Cochrane Library, and Embase up to May 2022 and considered all types of studies addressing our objective. Graft survival at 5, 10, and 15 years was the main outcome. RESULTS: Fifty cohort studies were included. At 5 years, in FECD and BK, graft survival seemed higher after EK than PK. Two comparative studies showed either a higher 5-year graft survival after EK than PK or no significant differences. Including noncomparative studies, in FECD, the 5-year graft survival ranged from 0.69 to 0.98 for PK, from 0.93 to 1.00 for DSEK, and from 0.93 to 0.99 for Descemet membrane endothelial keratoplasty (DMEK). In BK, the 5-year graft survival ranged from 0.39 to 0.91 for PK, from 0.65 to 0.89 for DSEK, and from 0.84 to 0.95 for DMEK. The 10-year graft survival ranged from 0.20 to 0.90 for PK and from 0.62 to 0.92 for EK. The mean 5-year best spectacle-corrected visual acuity ranged from 0.73 to 0.43 LogMAR for PK, from 0.61 to 0.09 for DSEK, and from 0.31 to 0.05 for DMEK. The 5-year rejection rate ranged from 11.0% to 28.7% for PK, from 5.0% to 7.9% for DSEK, and from 1.7% to 2.6% for DMEK. CONCLUSIONS: These results suggest a higher 5-year graft survival and better secondary outcomes after EK. Nevertheless, the level of evidence was low. PROSPERO REGISTRATION: CRD42021260614.

Topical Ripasudil for the Treatment of Segmental Corneal Edema: A Case Series.

PURPOSE: Ripasudil, a rho-kinase inhibitor, has gained popularity as an adjunctive therapy after Descemet stripping only to hasten visual recovery. Ripasudil has been shown to increase corneal endothelial cell proliferation and intercellular adhesion, and decrease endothelial cell apoptosis. We present 4 cases in which persistent corneal edema after various anterior segment surgeries was successfully treated with topical ripasudil, and 1 case in which corneal edema did not improve with use of ripasudil. METHODS: Retrospective chart review revealed 5 patients treated with topical ripasudil for persistent corneal edema that failed to improve with conventional, nonsurgical treatments. RESULTS: In each case, the patient had symptomatic, persistent, focal corneal edema which followed a surgical procedure in the anterior segment. The various etiologies of corneal edema included graft failure after Descemet stripping endothelial keratoplasty, a failed penetrating keratoplasty, and 3 cases of pseudophakic corneal edema. These patients experienced improved vision and partial or complete resolution of corneal edema after 2 to 4 weeks of topical ripasudil administered 4 times daily. One patient with pseudophakic bullous keratopathy had edema that initially improved on topical ripasudil, but after cessation of the medication, developed progressive corneal edema and required endothelial keratoplasty. CONCLUSIONS: In patients with focal corneal edema resulting from surgical trauma to the endothelium who failed to clear over time with conservative measures, topical ripasudil was shown to be an effective treatment option that in most cases improved vision and helped reduce the need for endothelial transplantation.

A Comparison of the Corneal Thickness Following Descemet's Stripping Automated Endothelial Keratoplasty and Descemet's Membrane Endothelial Keratoplasty.

PURPOSE: To compare the central corneal thickness before and after Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK), and to evaluate the recipient corneal thickness following DSAEK. METHODS: The corneal thickness was compared between two groups of eyes following DMEK and DSAEK, performed by a single surgeon between 2015 and 2017. We evaluated the recipient corneal thickness and central corneal thickness pre- and postoperatively at 1, 3, and 6 months using anterior segment optical coherence tomography. Recipient corneal thickness was defined as the corneal thickness without graft thickness. RESULTS: We included DMEK and DSAEK eyes (n = 26 each), which were similar in terms of their etiologies. Preoperatively, there was no significant difference in the central corneal thickness between the groups (DSAEK, median [interquartile range]: 721 [606.5 to 847.8] µm; and DMEK: 690 [618 to 722.3] µm; p = 0.30). Despite the tendency of the central corneal thickness to be significantly greater (p < .01) at 6 months following DSAEK (619.5 [607.8 to 661.3] µm) compared with that following DMEK (497.5 [475.8 to 525.3] µm), there was no significant difference at 6 months between the recipient corneal thickness following DSAEK (488.5 [443.8 to 515] µm) and central corneal thickness following DMEK (p = 0.54). CONCLUSIONS: DSAEK eyes display a similar tendency of stromal thinning as DMEK eyes.

Clinical Outcomes of Transscleral-Sutured Intraocular Lens Combined With Descemet Membrane Endothelial Keratoplasty.

PURPOSE: The aim of the study was to report clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) combined with transscleral-sutured intraocular lens (IOL) compared with DMEK combined with phacoemulsification and posterior chamber IOL (Phaco-DMEK). METHODS: A retrospective chart review of all patients who underwent DMEK combined with transscleral-sutured intraocular lens fixation or combined with phacoemulsification for Fuchs endothelial corneal dystrophy from 2016 to 2021 at the Toronto Western Hospital or the Kensington Eye Institute (Toronto, ON, Canada) and had at least 18 months of follow-up was performed. Main outcomes were postoperative distance-corrected visual acuity, rebubbling rate, graft survival rate, and complications. RESULTS: Twenty-one cases of DMEK combined with transscleral-sutured IOL (DMEK-TSS-IOL) and 44 cases of Phaco-DMEK were evaluated. Twelve eyes (57.15%) had a foldable acrylic 3-piece IOL (AR40E) and 9 (42.85%) had a single-piece polymethylmethacrylate (PMMA) IOL (CZ70BD). LogMAR distance-corrected visual acuity improved significantly from 1.48 ± 0.62 (SD) to 0.86 ± 0.82 ( P = 0.01) 12 months after DMEK-TSS-IOL and from 0.41 ± 0.29 logMAR to 0.11 ± 0.11 logMAR ( P < 0.0001) after Phaco-DMEK. No statistically significant differences were observed in donor ( P = 0.97) or 1-year postoperative endothelial cell density ( P = 0.11) between the groups. Rebubbling was necessary in 33.33% of eyes in DMEK-TSS-IOL compared with 25% of Phaco-DMEK eyes ( P = 0.55). Graft survival rate was 76.19% in the DMEK-TSS-IOL group compared with 90.90% in the Phaco-DMEK group ( P = 0.13). CONCLUSIONS: Transscleral-sutured IOL combined with DMEK is an option for the management of endothelial diseases in aphakic eyes or those which require IOL exchange for the experienced surgeon. However, when compared with routine Phaco-DMEK, there are higher complication and lower survival rates at 18 months.

[Risk factors for failure of pre-cut eye bank UT-DSAEK grafts]. / Évaluation des greffes UT-DSAEK prédécoupées en banque multi-tissus.

INTRODUCTION: The main risk factors for graft failure in penetrating keratoplasty are well known. However, few studies have examined donor characteristics or more precise data on endothelial keratoplasty. MATERIALS AND METHODS: This was a retrospective, single-center study at the Nantes University Hospital, aiming to identify factors predictive of one-year success or failure of eye bank UT-DSAEK endothelial keratoplasty grafts prepared between May 2016 and October 2018. The outcome measure was success or failure at 12months post keratoplasty. RESULTS: One hundred and five grafts were included: 93 successes and 12 failures at 12months. The failure rate was higher in 2016 compared to 2017 and 2018. The characteristics associated with higher failure rate were elderly donor, shorter time between harvesting and grafting, lower endothelial cell density, significant pre-graft endothelial cell loss, re-graft for Fuchs dystrophy, history of corneal transplant. DISCUSSION: Our results are consistent with those in the literature. However, some factors, such as the type of corneal harvesting or pre-graft endothelial cell loss, were not found. UT-DSAEK has demonstrated better results than DSAEK, but still appears to be somewhat inferior to DMEK. CONCLUSION: The main factor for graft failure in our study was an early re-graft within 12months. However, the low incidence of graft failure limits interpretation of these results.

Influence of Descemet Membrane Endothelial Keratoplasty Graft Preparation Patterns on Postoperative Clinical Outcome.

PURPOSE: The aim of this study was to quantify preparation difficulties and complications during DMEK graft preparation and their influence on clinical outcome. METHODS: A retrospective evaluation of 214 consecutive DMEK surgeries from the prospective Cologne DMEK database was performed between July 2018 and December 2019. Preparation conditions (such as central and peripheral adherences, tissue fragility, and Descemet membrane splitting) were quantified and divided into 3 groups: easy, difficult, and very difficult preparation. At follow-up (3, 6, and 12 months after DMEK), best spectacle-corrected visual acuity, endothelial cell count (ECC), and rebubbling rates were evaluated and compared between groups. RESULTS: An easy preparation was possible in 41.6% of cases (group 1, n = 89), a difficult preparation of the DMEK graft occurred in 30.8% (group 2, n = 66), and a very difficult preparation occurred in 27.6% (group 3, n = 59). There was no difference between groups for best spectacle-corrected visual acuity at 3, 6, and 12 months ( P = 0.179, P = 0.325, and P = 0.682, respectively) or for ECC at 3 and 6 months ( P = 0.537 and P = 0.606, respectively). Only at 12 months, the ECC was slightly significant between groups ( P = 0.045). Regarding the rebubbling rate, there was no difference ( P = 0.585). 17.9% of eyes from group 1, 25.7% of eyes from group 2, and 23.7% of eyes from group 3 received at least 1 rebubbling. CONCLUSIONS: These data suggest that difficult preparation conditions do not lead to any worsening of visual acuity or rebubbling rate in the 1-year outcome after DMEK. The endothelial cell density at 12 months showed slightly poorer results in the cases of very difficult preparation.

Outcomes of cystoid macular edema following Descemet's membrane endothelial keratoplasty in a referral center for keratoplasty in Spain: retrospective study.

The aim of this study was to analyze the outcomes of eyes with visually significant cystoid macular œdema (vs-CMO) after Descemet membrane endothelial keratoplasty (DMEK) in a referral center for keratoplasty in Spain. We conducted a retrospective, single-surgeon case series of eyes that developed post-DMEK vs-CMO performed between January 2011 and December 2020. Data collected included: indication for DMEK; biometric data; ocular comorbidities; past medical history; time to detection of vs-CMO after DMEK (T, weeks); best-corrected visual acuity (BCVA, logMAR) and central retinal thickness (CRT, µm) at diagnosis of vs-CMO, after resolution of CMO, and at last follow-up; and management strategy. Main outcomes analyzed were incidence of vs-CMO, improvement in BCVA and CRT after treatment of vs-CMO. Of 291 consecutive DMEK surgeries, 14 eyes of 13 patients (4.8%) developed vs-CMO. Five patients (38.5%) had history of CMO, and 28.6% of eyes had ophthalmic comorbidities. Median (P25-P75) T was 4 (3-10) weeks. Treatment success was observed in 12/13 eyes (92.3%), two of which required second-line treatment. In successful cases (median time-to-resolution 3.0 (2.0-3.5) months), median BCVA improved from 0.60 (0.40-0.80) logMAR to 0.30 (0.15-0.40) logMAR (p = 0.002) after treatment, and median CRT improved from 582.5 (400.0-655.0) µm to 278.0 (258.0-294.0) µm (p = 0.005). In our study, we found a 4.8% rate of post-DMEK vs-CMO, with most cases occurring in the first 3 months after surgery. Good functional and anatomical outcomes are expected in most eyes, without treatment-related complications or implications in graft outcomes. Additional studies are encouraged to determine a standardized protocol for post-DMEK vs-CMO.

Descemet membrane endothelial keratoplasty graft detachments in superior versus temporal approach.

PURPOSE: To evaluate the difference in Descemet Membrane Endothelial Keratoplasty (DMEK) graft detachment rate comparing superior versus temporal main incision approach. METHODS: Retrospective comparative study on patients who underwent DMEK surgery for Fuchs endothelial dystrophy or bullous keratopathy with main wound incision performed at either 90° in the superior approach, or at 180°/0° in the temporal approach. All main incisions were secured with a single 10-0 nylon suture at the end of surgery. Data collected were donor age and gender, endothelial cell counts, graft diameter, recipient age and gender, indication for transplant, surgeon grade, re-bubbling rate, air fill in the anterior chamber (AC) at day one and intra- and early postoperative complications. RESULTS: 187 eyes were included in the study. 99 eyes had DMEK surgery with superior approach, while 88 eyes had temporal approach. The two groups had no differences in donor age and sex, endothelial cell counts, graft diameter, recipient age and sex, indication for transplant, surgeon grade, and air fill in the anterior chamber at day one. Re-bubbling rate was 38.4% for surgeries performed with superior access and 29.5% for those with temporal access(p = 0.186). After exclusion of patients with intraoperative and/or postoperative complication, the difference in re-bubbling rate was higher, although non-significant (37.5% and 25% for superior and temporal approach respectively, p = 0.098). CONCLUSION: The temporal approach in DMEK showed a trend towards a clinically significant lower rate of post-operative re-bubbling compared to the superior approach, however, no statistically significant difference was noted comparing the two approaches, which both remain feasible options in DMEK surgery.

Comparison of Pre-Descemet Endothelial Keratoplasty and Descemet Membrane Endothelial Keratoplasty in Endothelial Decompensation.

PURPOSE: The purpose of this study was to compare the outcomes of pre-Descemet endothelial keratoplasty (PDEK) and Descemet membrane endothelial keratoplasty (DMEK) in cases of endothelial decompensation. METHODS: This was a prospective, randomized, interventional study conducted at a tertiary eye hospital in North India. Thirty eyes of 28 patients with corneal decompensation were randomly subjected to PDEK (n = 15 eyes) and DMEK (n = 15 eyes). Preoperative demographic details, surgical indications, uncorrected distance visual acuity, corrected distance visual acuity, contrast sensitivity, anterior and posterior segment details, intraocular pressure, central corneal thickness, endothelial cell count, and corneal aberrometry tracing on wavefront analysis were recorded. Patients were followed up for 6 months postsurgery. Visual and graft survival outcomes were assessed. RESULTS: Intraoperatively, a surgeon reported better ease of preparation and intracameral handling with PDEK grafts. Both groups showed comparable improvement in visual acuity, contrast, and high-order aberrations. A decrease in central corneal thickness was significantly higher in DMEK (196 ± 26 vs. 140 ± 14 µm) patients. DMEK grafts were significantly thinner than PDEK grafts at the 6-month follow-up (16 ± 2.17 vs. 27.2 ± 1.93 µm). Endothelial cell loss (35% in DMEK vs. 33.4% in PDEK, P = 0.48) and rise of intraocular pressure (from 15.33 ± 2.85 mm Hg to 15.53 ± 2.2 mm Hg in the DMEK group vs. from 14.6 ± 1.99 mm Hg to 16.2 ± 1.43 mm Hg in the PDEK group) were comparable. Rebubbling rates were higher in the DMEK group (3/15, 20%) compared with the PDEK group (1/15, 6.66%; P = 0.165). CONCLUSIONS: DMEK and PDEK were comparable for both quantitative and qualitative visual outcomes and anatomically for graft survival at the 6-month follow-up.

Sutured Descemet Membrane Endothelial Keratoplasty in Patients With Complex Anatomy or Difficulty Positioning.

PURPOSE: In Descemet membrane endothelial keratoplasty (DMEK), some patients cannot adhere to postoperative positioning requirements or lack anatomic support for a gas bubble in the anterior chamber. We describe a suturing technique that stabilizes the graft postoperatively without tearing or tenting it. METHODS: One to two 10-0 nylon sutures with a spatulated needle are used to secure DMEK grafts. Tied with minimal tension, the sutures traverse the corneal stroma at a steep, almost perpendicular angle and approach the graft from the limbus at an angle tangential to the circular graft to prevent vaulting the tissue off the central cornea. We report preoperative and postoperative best spectacle-corrected visual acuity, corneal pachymetry, and anterior segment optical coherence tomography confirming graft attachment in 3 patients. RESULTS: In case 1 (aphakia, postvitrectomy, and positioning difficulty), pachymetry decreased from 637 µm preoperatively to 495 µm and best spectacle-corrected visual acuity improved from 20/70 to 20/50 at postoperative week 1. In case 2 (aphakia, limited follow-up, and medication adherence), pachymetry decreased from 1106 µm preoperatively to 783 µm at postoperative month 1. In case 3 (tube shunt and loss of gas bubble at 2 hours), slit-lamp examination at postoperative day 1 showed corneal clearing and graft attachment. Pachymetry decreased from over 795 µm preoperatively to 582 µm at postoperative month 1. Anterior segment optical coherence tomography confirmed graft attachment in all patients. CONCLUSIONS: Single or opposing tangentially oriented sutures can be safely applied to secure DMEK grafts postoperatively in challenging cases.