Purpose: To analyze if 6-month endothelial cell density (ECD) affects long-term ECD outcome and graft survival 5 years after Descemet membrane endothelial keratoplasty (DMEK) in eyes with Fuchs... Show morePurpose: To analyze if 6-month endothelial cell density (ECD) affects long-term ECD outcome and graft survival 5 years after Descemet membrane endothelial keratoplasty (DMEK) in eyes with Fuchs endothelial corneal dystrophy (FECD).Design: Retrospective cohort study.Participants: A total of 585 DMEK eyes were included. The study group was divided into 4 groups based on 6-month ECD quartiles: group 1 (n = 146) with 313 to 1245 cells/mm(2), group 2 (n = 148) with 1246 to 1610 cells/mm(2), group 3 (n = 145) with 1611 to 1938 cells/mm(2), and group 4 (n = 146) with 1939 to 2760 cells/mm(2). Group 1 was further split into subgroups 1a (n = 36) with 6-month ECD of <828 cells/mm(2), 1b (n = 37) with 829 to 1023 cells/mm(2), 1c (n = 37) with 1024 to 1140 cells/mm(2), and 1d (n = 36) 1141 to 1245 cells/mm(2).Methods: Descemet membrane endothelial keratoplasty.Main Outcome Measures: Long-term ECD, graft survival, and postoperative complication rates.Results: For group 1, 6-month ECD decreased from 951 (+/- 233) cells/mm(2) (n = 146) to 735 (+/- 216) cells/mm(2) (n = 99) at 5 years postoperatively. Group 1 graft survival probability was 0.95 (95% confidence interval [CI], 0.91-0.99] at 5 years postoperatively, which was lower than for groups 2 to 4 (P = 0.001). Five-year graft survival in subgroup 1a was 0.79 (95% CI, 0.67-0.94), which was lower than in subgroups 1b to 1d (P = 0.001). Preoperative ECD did not influence graft survival (P = 0.400), and higher 6-month ECD values were associated with lower graft failure rates (hazard ratio, 0.994; 95% CI, 0.99-1.00; P = 0.001).Conclusions: Six-month ECD is associated with DMEK graft survival. High early cell loss after DMEK negatively affects long-term ECD outcome and graft survival. Grafts in the lowest 6-month ECD subgroup (<828 cells/mm(2)) are at higher risk of failure within 5 years after DMEK. To ensure sufficiently high 6-month ECD, preoperative graft quality assessment should be optimized, and cellular stress induced to the graft should be minimized. Additionally, developing therapeutic options for the treatment of low postoperative ECD could further improve DMEK graft longevity. (C) 2021 by the American Academy of Ophthalmology Show less
Within the past two decades, full thickness penetrating keratoplasty (PK) has been largely supplanted by lamellar endothelial keratoplasty (EK) procedures that have revolutionized the treatment of... Show moreWithin the past two decades, full thickness penetrating keratoplasty (PK) has been largely supplanted by lamellar endothelial keratoplasty (EK) procedures that have revolutionized the treatment of corneal endothelial diseases such as Fuchs endothelial dystrophy. Since the introduction of EK in 1998, these techniques have undergone continuous transition, from Deep lamellar endothelial keratoplasty (DLEK) to Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and eventually to Descemet membrane endothelial keratoplasty (DMEK). While the graft in DLEK and DSEK/DSAEK consists of endothelium, Descemet membrane and stroma, in DMEK only an isolated Descemet membrane with its endothelium, devoid of stroma, is transplanted. Notably, the thinner graft used in DMEK may have three main advantages over earlier techniques: Faster and better visual rehabilitation, predictable small refractive change, and a reduced risk of immunologic reactions. This thesis will investigate the clinical outcomes after DMEK, the latest refinement of lamellar endothelial keratoplasty techniques. The focus will be on DMEK graft survival and on allograft rejection (and its prediction), a complication that may potentially lead to graft failure and hereby reduce the overall survival probability. Show less
Vasiliauskaite, I.; Oellerich, S.; Ham, L.; Dapena, I.; Baydoun, L.; Dijk, K. van; Melles, G.R.J. 2020
PURPOSE: To evaluate the 10-year graft survival and clinical outcomes of the first case series after Descemet membrane endothelial keratoplasty (DMEK).DESIGN: Retrospective, interventional case... Show morePURPOSE: To evaluate the 10-year graft survival and clinical outcomes of the first case series after Descemet membrane endothelial keratoplasty (DMEK).DESIGN: Retrospective, interventional case series.METHODS: After excluding the very first 25 DMEK eyes that constitute the technique learning curve, the following 100 consecutive primary DMEK eyes (88 patients) were included. Main outcome parameters (survival, best-corrected visual acuity [BCVA], central endothelial cell density [ECD], and central corneal thickness [CCT]) were evaluated up to 10 years postoperatively, and postoperative complications were documented.RESULTS: At 5 and 10 years after DMEK, 68 and 57 of 100 eyes, respectively, were still available for analysis. Of those eyes, 82% and 89% reached a BCVA of >= 20/25 (decimal VA >= 0.8) at 5- and 10 years postoperatively, respectively. Preoperative donor ECD decreased by 59% at 5 years and 68% at 10 years postoperatively. CCT averaged 668 +/- 74 mu m preoperatively and 540 +/- 33 mu m and 553 +/- 43 mu m at 5 and 10 years, respectively, after surgery. Within 10 years, 4% of eyes developed allograft rejection, no primary graft failures occurred, and 6% of the eyes developed secondary graft failure. Graft survival probability was 0.83 (95% confidence interval [CI], 0.75-0.92) and 0.79 (95% CI, 0.70-0.88) at 5 and 10 years postoperatively, respectively.CONCLUSIONS: Most eyes that underwent surgery in the pioneering phase of DMEK showed excellent and stable clinical outcomes with low postoperative complication rates and promising graft longevity over the first decade after surgery. This suggests that DMEK may be a safe long-term treatment option for corneal endothelial diseases. ((C) 2020 Elsevier Inc. All rights reserved.) Show less
Treder, M.; Leclaire, M.D.; Vietmeier, F.; Uhlig, C.E.; Alnawaiseh, M.; Eter, N.; Baydoun, L. 2020
Purpose To assess whether combined analysis of specular microscopy and Scheimpflug imaging improves detection of an upcoming allograft rejection following Descemet membrane endothelial keratoplasty... Show morePurpose To assess whether combined analysis of specular microscopy and Scheimpflug imaging improves detection of an upcoming allograft rejection following Descemet membrane endothelial keratoplasty (DMEK).Methods Retrospective analysis of 22 eyes that had developed a clinical proven allograft rejection 28 (+/- 22) months (range: 4-84 months) after DMEK. Specular microscopy and Scheimpflug images routinely made after DMEK were retrospectively analysed for changes in endothelial cell morphology (e.g. nuclear activation), cell density (>10%) and pachymetry (>7%), and/or the presence of subclinical keratic precipitates. The same parameters were evaluated for 22 control eyes matched for age, gender and surgery indication.Results A total of 20/22 eyes (91%) showed detectable changes 0.25-75 months before allograft rejection became clinically manifest: 13/22 (59%) showed both specular microscopy and Scheimpflug imaging changes; 5/22 (23%) only had changes on Scheimpflug imaging; and 2/22 (9%) only had specular microscopy changes. In 18/22 (82%) and 14/22 (64%) eyes, subclinical keratic precipitates and endothelial cell morphology changes could be detected, respectively. A total of 11/22 (50%) eyes concurrently showed a >10% drop in endothelial cell density and 4/22 (18%) a >7% pachymetry increase. Of the control eyes, 7/22 (32%) showed changes with specular microscopy but not with Scheimpflug imaging.Conclusions Combined analysis of specular microscopy and Scheimpflug imaging may allow recognizing an upcoming allograft rejection in over 90% of eyes and up to 6 years before rejection becomes clinically manifest. Early recognition of eyes at risk may allow for targeted intensified steroid treatment to prevent endothelial cell damage associated with rejection. Show less
Birbal, R.S.; Baydoun, L.; Ham, L.; Miron, A.; Dijk, K. van; Dapena, I.; ... ; Melles, G.R.J. 2020
PURPOSE: To analyze 6-month results of 1000 consecutive Descemet membrane endothelial keratoplasty (DMEK) cases, and to evaluate if outcomes are influenced by surgical indication and preoperative... Show morePURPOSE: To analyze 6-month results of 1000 consecutive Descemet membrane endothelial keratoplasty (DMEK) cases, and to evaluate if outcomes are influenced by surgical indication and preoperative lens status.DESIGN: Retrospective, interventional case series.METHODS: A series of 1000 eyes (738 patients) underwent DMEK mainly for Fuchs endothelial corneal dystrophy (FECD; 85.3%) or bullous keratopathy (BK; 10.5%). Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density, postoperative complications, and retransplantations.RESULTS: At 6 months after DMEK, there was no difference in BCVA outcome between FECD and BK eyes (P = .170), or between phakic and pseudophakic FECD eyes (P = .066) after correcting for patient age and preoperative BCVA. Endothelial cell loss at 6 months postoperatively was similar for phakic and pseudophakic FECD eyes (39%; P = .852), but higher for BK eyes than for FECD eyes (46% vs 39%, P = .001). Primary and secondary graft failure occurred in 3 (0.3%) and 2 eyes (0.2%), respectively, and 7 eyes developed allograft rejection (0.7%). Eighty-two eyes (8.2%) received rebubbling for graft detachment and retransplantation was performed in 20 eyes (2.0%). Rebubbling was more often required in eyes treated for BK vs FECD eyes (12.4% vs 7.4%, P = .022).CONCLUSION: DMEK consistently provides excellent short-term results, with similar high visual acuity levels for both FECD and BK eyes. As preoperative lens status did not influence DMEK outcomes, for phakic FECD eyes with a still relatively clear crystalline lens, lens preservation may be preferable in a selected group of younger patients, who may still benefit from their residual accommodative capacity. (C) 2019 Elsevier Inc. All rights reserved. Show less
PURPOSE: To evaluate which parameters may affect endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK) by comparing eyes in the low vs high quartile of endothelial cell loss... Show morePURPOSE: To evaluate which parameters may affect endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK) by comparing eyes in the low vs high quartile of endothelial cell loss over a follow-up period of 4 years.DESIGN: Retrospective cohort study.METHODS: Donor endothelial cell density (ECD) decline was evaluated for 351 eyes of 275 patients up to 4 years after DMEK for Fuchs endothelial corneal dystrophy (FECD). Eyes with a postoperative endothelial cell loss in the lower quartile at all available follow-up moments were assigned to Group 1 (n = 51) and those in the upper quartile to Group 2 (n = 42). Multinomial regression was used to assess which covariates were related to greater ECD decline.RESULTS: Mean endothelial cell loss as compared to preoperative donor ECD for the entire study group was 33 (+/- 16)%, 36 (+/- 17)%, and 52 (+/- 18)% at 1, 6, and 48 months postoperatively. Endothelial cell loss of Group 1 was 12 (+/- 7)%, 13 (6)%, and 26 (+/- 8)% at, respectively, 1, 6, and 48 months postoperatively, and 59 (+/- 10)%, 64 (+/- 9)%, and 75 (+/- 5)% in Group 2. Partial graft detachment, donor death cause cardiovascular/stroke (vs cancer), postoperative complications other than graft detachment, and severity of preoperative FECD (all P<.01) showed the strongest relation with greater ECD decline.CONCLUSIONS: DMEK eyes with a completely attached graft and operated in an early stage of FECD may show the lowest endothelial cell loss postoperatively. ((C) 2019 Elsevier Inc. All rights reserved.) Show less
Purpose:To report clinical outcomes of the first Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK) case series performed for central Fuchs endothelial corneal dystrophy.Methods:This... Show morePurpose:To report clinical outcomes of the first Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK) case series performed for central Fuchs endothelial corneal dystrophy.Methods:This is a prospective, interventional case series analyzing the clinical outcomes of 19 eyes of 19 patients with central Fuchs endothelial corneal dystrophy, that is, with guttae predominantly in the 6- to 7-mm optical zone, who underwent unilateral Quarter-DMEK at a tertiary referral center. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications. Included eyes had up to 2 years of postoperative follow-up.Results:At 6 months postoperatively, all eyes reached a BCVA of >= 20/40 (>= 0.5): 18 of 19 eyes (95%) with >= 20/25 (>= 0.8) and 9 of 19 eyes (42%) with >= 20/20 (>= 1.0). Thereafter, BCVA remained stable up to 2 years postoperatively. The mean donor ECD decreased from 2842 139 cells/mm(2) (n = 19) before implantation to 913 +/- 434 cells/mm(2) (-68%) at 6 months (n = 19), 869 +/- 313 cells/mm(2) (-70%) at 12 months (n = 18), and 758 +/- 225 cells/mm(2) (-74%) at 24 months (n = 13) after Quarter-DMEK. Visually significant graft detachment requiring rebubbling occurred in 8 of 19 eyes (42%).Conclusions:Quarter-DMEK surgery yields visual outcomes similar to those of conventional DMEK and may potentially quadruple the availability of endothelial grafts. Further modifications of the graft preparation and the surgical technique may improve clinical outcomes in terms of lower ECD decrease and fewer graft detachments. Show less
