Tips, Tricks, and Guides in Descemet Membrane Endothelial Keratoplasty Learning Curve

Lamellar keratoplasty is fast becoming the most popular form of corneal transplantation. The adoption of Descemet membrane endothelial keratoplasty (DMEK) in the management of Fuchs endothelial dystrophy and pseudophakic bullous keratopathy is partly responsible for this shift in the paradigm of management of corneal pathology. The learning curve of DMEK, however, has been proven to be much steeper than previous endothelial keratoplasty procedures. To ease the procedure, experts have proposed multiple innovative techniques from tissue preparation to graft unfolding to aid the more novice surgeon. Here, we collate and share tips and tricks from our collective experiences to support the learning curve and outcomes in DMEK for both the novice and more experienced corneal transplant surgeons.

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Corneal transplantation activity in Catalonia, Spain, from 2011 to 2018: Evolution of indications and surgical techniques

PLoS ONE ◽

10.1371/journal.pone.0249946 ◽

2021 ◽

Vol 16 (4) ◽

pp. e0249946

Author(s):

Noelia Sabater-Cruz ◽

Marc Figueras-Roca ◽

Lydia Padró-Pitarch ◽

Jaume Tort ◽

Ricardo P. Casaroli-Marano

Keyword(s):

Corneal Transplantation ◽

Surgical Techniques ◽

Annual Reports ◽

Bullous Keratopathy ◽

Corneal Transplant ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Eye Bank ◽

Increasing Trend ◽

Fuchs Endothelial Dystrophy

Purpose To report corneal transplant activity carried out in Catalonia (Spain) and the evolving indications for keratoplasty over an 8-year period. Methods Annual reports from the Catalan Transplant Organization, Spain, on corneal graft indications and techniques from 2011 to 2018 were reviewed. Results A total of 9457 keratoplasties were performed in Catalonia, from January 2011 to December 2018. The most frequent indications were bullous keratopathy (BK; 20.5%), Fuchs endothelial dystrophy (FED; 17.9%), re-graft (13.7%), and keratoconus (11.3%). Penetrating keratoplasty (PKP) accounted for 63.4% of all performed keratoplasties. Since the introduction of eye bank precut tissue for Descemet stripping automated endothelial keratoplasty (DSAEK) in 2013 and for Descemet membrane endothelial keratoplasty (DMEK) in 2017 the number of endothelial keratoplasties has drastically increased. An increasing trend of posterior lamellar techniques over the total of keratoplasties was found (p<0.001). Endothelial keratoplasties for different endothelial diseases indications (BK, FED, and re-graft), also showed and increasing trend (p<0.001). DMEK is the technique with the highest increase (statistically significantly different from linearity) over other endothelial keratoplasties in FED (p<0.001) but not in BK (p = 0.67) or re-grafts (p = 0.067). Conclusion Endothelial diseases represented the top indication for keratoplasty over the 8-year period. PKP is still the most used technique in Catalonia, but endothelial keratoplasties and especially DMEK showed a significant increasing trend over the last years. This is congruent with the main rationale nowadays for keratoplasties: to customize and transplant as less tissue as possible. Therefore, the availability of precut tissue could have definitely enforced such approach.

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Faculty Opinions recommendation of Efficacy of descemet membrane endothelial keratoplasty: clinical outcome of 200 consecutive cases after a learning curve of 25 cases.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.13410959.14782059 ◽

2011 ◽

Author(s):

H Burkhard Dick ◽

Ingo Schmack

Keyword(s):

Clinical Outcome ◽

Learning Curve ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Descemet Membrane

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Cystoid macular oedema after descemet membrane endothelial keratoplasty

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2021-319455 ◽

2021 ◽

pp. bjophthalmol-2021-319455

Author(s):

Damien Guindolet ◽

Odile Huynh ◽

Gilles C Martin ◽

Hugo Disegni ◽

Georges Azar ◽

...

Keyword(s):

Macular Oedema ◽

Univariate Analysis ◽

Cystoid Macular Oedema ◽

Bullous Keratopathy ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Descemet Membrane ◽

Spectral Domain Oct ◽

History Of ◽

Clinically Significant

AimsTo determine the incidence and risk factors of cystoid macular oedema (CMO) following descemet membrane endothelial keratoplasty (DMEK) with or without combined cataract surgery (triple-DMEK).MethodsWe reviewed the records of patients who underwent DMEK surgery alone or triple-DMEK performed at the Rothschild Foundation Hospital (Paris, France) between January 2019 and March 2020. Patients with pre-existing CMO observed on the preoperative macular optical coherence tomography (OCT) were excluded. Spectral-domain OCT was performed in patients with postoperative visual impairment. Data regarding comorbidities, intraoperative characteristics and postoperative treatments or complications were collected and analysed. Univariate and multivariate analyses were performed.ResultsTwenty three of 246 eyes (9.36%) developed clinically significant (cs)-CMO after DMEK. Triple-DMEK was not associated with a higher risk to develop CMO (12.2% in DMEK alone and 6.1% in triple-DMEK). Pseudophakic bullous keratopathy (PBK ; 39.1% vs 9%; OR=3.5 (1.0 to 11.8), p=0.045) and epiretinal membrane (ERM; 39.1% vs 7.7%; OR=10.5 (3.4 to 32.3), p<0.001) were more frequently observed in patients who developed CMO. The occurrence of hyphaema during surgery was statistically associated with postoperative CMO (13% vs 1.3%; OR=7.1 (1.0 to 48.8) p=0.045). Peroperative epithelial debridement was statistically associated with postoperative CMO (65.2% vs 33.2%, p=0.005), but only in univariate analysis.ConclusionsWe identified a clinically significant CMO incidence of 9.35% after DMEK. Patients with a history of ERM, PBK and intraoperative hyphaema may be at risk of developing CMO after DMEK surgery and should be monitored.

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Descemet Membrane Endothelial Keratoplasty Outcomes During the Initial Learning Curve of Cornea Fellows

Cornea ◽

10.1097/ico.0000000000001957 ◽

2019 ◽

Vol 38 (7) ◽

pp. 806-811 ◽

Cited By ~ 3

Author(s):

Nicolas Cesário Pereira ◽

José Álvaro Pereira Gomes ◽

Aline Silveira Moriyama ◽

Luis Fernando Chaves ◽

Adriana dos Santos Forseto

Keyword(s):

Learning Curve ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Descemet Membrane ◽

Initial Learning

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Evolution of therapies for the corneal endothelium: past, present and future approaches

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2020-316149 ◽

2020 ◽

pp. bjophthalmol-2020-316149

Author(s):

Hon Shing Ong ◽

Marcus Ang ◽

Jodhbir S Mehta

Keyword(s):

Corneal Endothelium ◽

Medical Science ◽

Corneal Transplantation ◽

Surgical Techniques ◽

Corneal Transplant ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Immunological Rejection ◽

Transplantation Procedures ◽

Rejection Rates

Corneal endothelial diseases are leading indications for corneal transplantations. With significant advancement in medical science and surgical techniques, corneal transplant surgeries are now increasingly effective at restoring vision in patients with corneal diseases. In the last 15 years, the introduction of endothelial keratoplasty (EK) procedures, where diseased corneal endothelium (CE) are selectively replaced, has significantly transformed the field of corneal transplantation. Compared to traditional penetrating keratoplasty, EK procedures, namely Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK), offer faster visual recovery, lower immunological rejection rates, and improved graft survival. Although these modern techniques can achieve high success, there are fundamental impediments to conventional transplantations. A lack of suitable donor corneas worldwide restricts the number of transplants that can be performed. Other barriers include the need for specialized expertise, high cost, and risks of graft rejection or failure. Research is underway to develop alternative treatments for corneal endothelial diseases, which are less dependent on the availability of allogeneic tissues – regenerative medicine and cell-based therapies. In this review, an overview of past and present transplantation procedures used to treat corneal endothelial diseases are described. Potential novel therapies that may be translated into clinical practice will also be presented.

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Pseudophakic corneal donor tissue in Descemet membrane endothelial keratoplasty (DMEK): implications for cornea banks and surgeons

BMJ Open Ophthalmology ◽

10.1136/bmjophth-2020-000524 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000524

Author(s):

Daniel Pilger ◽

Necip Torun ◽

Anna-Karina B Maier ◽

Jan Schroeter

Keyword(s):

Endothelial Cell ◽

Functional Results ◽

Cell Loss ◽

Tissue Preparation ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Donor Tissue ◽

Descemet Membrane ◽

The Difference ◽

Corneal Donor Tissue

ObjectiveIncreasingly, cornea banks are recovering donor tissue from pseudophakic donors. Little is known about their suitability for Descemet membrane endothelial keratoplasty (DMEK) surgery in terms of endothelial cell density (ECD) and preparation failure.Methods and AnalysisWe explored ECD during donor tissue preparation in 2076 grafts. Preparation failure was analysed in 1028 grafts used in DMEK surgery at our clinic. To monitor ECD and functional results, we matched 86 DMEK patients who received pseudophakic donor grafts with similar recipients of phakic donor grafts and followed them up for 36 months.ResultsAt recovery, mean ECD in pseudophakic donor grafts was 2193 cells/mm2 (SD 28.7) and 2364 cells/mm2 (SD 15.7) in phakic donor grafts (p<0.001). After cultivation, the difference increased as pseudophakic donor grafts lost 14% of ECD while phakic lost only 6% (p<0.001). At transplantation, mean ECD in pseudophakic donor grafts was 2272 cells/mm2 (SD 250) and 2370 cells/mm2 (SD 204) in phakic donor grafts (p<0.001). After transplantation, the difference in ECD increased as pseudophakic donor grafts lost 27.7% of ECD while phakic donor grafts lost only 13.3% (p<0.001). The risk of preparation failure in pseudophakic donor grafts was higher than in phakic donor grafts (OR 4.75, 95% CI 1.78 to 12.67, p=0.02). Visual acuity increased in both groups similarly.ConclusionsPseudophakic donor grafts have a lower ECD, are more prone to endothelial cell loss during recovery and surgery and are associated with a higher risk of preparation failure. Cornea banks and surgeons should consider this in the planning of graft preparation and transplantation.

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