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Samarawickrama C. Novel Trephine for Descemet Membrane Endothelial Keratoplasty Surgery Improves Surgical Preparation Time and Graft Quality: Pilot Data From the "Number 7" Endothelial Keratoplasty Trephine. Cornea 2024:00003226-990000000-00682. [PMID: 39264752 DOI: 10.1097/ico.0000000000003700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 08/06/2024] [Indexed: 09/14/2024]
Abstract
PURPOSE To report the safety and efficacy of a novel asymmetric marking trephine for Descemet membrane endothelial keratoplasty (DMEK) tissue preparation. The trephine design incorporates optimized curves to distribute mechanical forces and minimize the risk of tears without loss of total endothelial cell volume transplanted compared with a standard 8.00 mm circular transplant. METHODS A retrospective case series of 40 consecutive DMEK operations comparing 20 cases using the "Number 7" trephine against 20 using a modified shark fin technique as standard. Patient and donor characteristics, tissue preparation time and complications, total surgical time, intraoperative and postoperative complications, and endothelial cell counts at 3 months postsurgery are reported. RESULTS DMEK tissue preparation was significantly faster using the "Number 7" trephine (5.4 vs. 7.6 minutes, P = 0.008). Further, fewer complications arose during tissue preparation (0 vs. 2 complications) despite the faster preparation time. Total surgical time was similar between techniques; however, time spent manipulating the graft was reduced (5.1 vs. 6.8 minutes, P = 0.007) primarily because of the lower tissue preparation complications. Fewer postoperative complications were observed (1 vs. 3, of which 1 in the standard technique group requiring a redo-DMEK), again due to the reduced tissue preparation complications. The 3-month endothelial cell count was comparable between techniques (P > 0.05). CONCLUSIONS Use of the "Number 7" trephine led to faster and safer DMEK tissue preparation, which in turn reduced graft manipulation times and postoperative complications without compromising total endothelial cell volume transplanted. This novel device is ideal for use by surgeons who prepare their own DMEK tissue and within tissue banks who provide prestripped and preloaded DMEK tissue.
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Affiliation(s)
- Chameen Samarawickrama
- Faculty of Medicine and Health, Clinical Ophthalmology and Eye Health, Westmead Institute for Medical Research (WIMR), Save Sight Institute, Westmead and Central Clinical Schools, The University of Sydney, Sydney, Australia
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Ruzza A, Grassetto A, Favaro E, Baruzzo M, Romano V, Ponzin D, Ferrari S, Parekh M. Preloaded DMEK with endo-in technique: Standardizing and minimizing the learning curve over 5 years using 599 corneal tissues. Eur J Ophthalmol 2024; 34:1071-1078. [PMID: 38099841 DOI: 10.1177/11206721231217127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
PURPOSE To report the outcomes of standardizing pre-loaded DMEK with endothelium-inwards and its associated learning curve. METHODS Between 2017 and 2021, a total of 599 tissues were stripped using 'trephine and strip' method and loaded by folding the tissue as a taco-fold with endothelium-inwards. The folded tissues were pulled inside the funnel of a 2.2 mm IOL cartridge and stored for the desired number of days in organ culture media supplemented with dextran. Donor characteristics, endothelial cell loss (ECL) and mortality assessed by trypan blue positivity before and after stripping, and eventful cases during stripping/loading were recorded. RESULTS The tissues found unsuitable for transplant after stripping (6.7%) were significantly higher compared with loading (0.67%). Central or peripheral tears, fragility of the tissues, and insufficient endothelial cell density mainly attributed towards the discard rate. Mean ECL from pre-stripping to post-stripping was 0.27% with endothelial cell mortality of 0.64% at the end of stripping. Cumulative endothelial mortality fold change (pre-strip to post-strip) was high in the first two years of operation (18.9%), which reduced to 5.1% in the following three years with significant difference (p = 0.0352). Average tissue wastage (3 operators) from first 1-150 tissues was 3%, which significantly reduced to 0.9% after achieving the learning curve (151-250) (p = 0.0492). CONCLUSION DMEK graft preparation requires a learning curve. However, an operator with DMEK stripping skills can easily adapt to pre-loading a DMEK graft in endothelium-inwards fashion with minimal learning curve.
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Affiliation(s)
- Alessandro Ruzza
- International center for ocular physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Andrea Grassetto
- International center for ocular physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Elisa Favaro
- International center for ocular physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Mattia Baruzzo
- International center for ocular physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Vito Romano
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Brescia, Italy
| | - Diego Ponzin
- International center for ocular physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Stefano Ferrari
- International center for ocular physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Mohit Parekh
- Schepens Eye Research Institute of Massachusetts Eye and Ear, Dept. of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Cho K, Ali M, Heckenlaible NJ, Jabbour S, Jun AS, Srikumaran D. Outcomes and Early Complications Using an Endothelium-in Pull-Through Descemet Membrane Endothelial Keratoplasty Technique With Preloaded Versus Surgeon-Loaded Donor Tissue in Fuchs Patients. Cornea 2024; 43:591-597. [PMID: 37607293 DOI: 10.1097/ico.0000000000003371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/18/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE This study aimed to compare outcomes and early complications using an endothelium-in pull-through Descemet membrane endothelial keratoplasty (DMEK) technique with preloaded versus surgeon-loaded donor tissue. METHODS Data from 163 eyes of 125 patients at the Wilmer Eye Institute diagnosed with Fuchs endothelial corneal dystrophy who underwent DMEK with or without cataract extraction using surgeon-loaded tissue (n = 83) or preloaded tissue (n = 80) were reviewed. Best-corrected visual acuity and early postoperative complications including small graft detachment (less than one third of the graft area), large graft detachment (more than one third), graft failure, and rebubbling were compared. RESULTS Baseline characteristics including age, sex, and visual acuity were not statistically different between the groups. Small graft detachment was observed in 18.1% of the surgeon-loaded and 22.5% of the preloaded group ( P = 0.48), whereas large detachment occurred in 12.0% and 5.0%, respectively ( P = 0.11). Among these, rebubbling was performed in 18 (21.7%) in the surgeon-loaded compared with 12 (15.0%) in the preloaded group ( P = 0.27). The rebubbling rate of the combined procedure (cataract surgery and DMEK) was 21.8% and of DMEK alone was 7.7% ( P = 0.048). Primary graft failure occurred in 2 surgeon-loaded cases (2.4%) and 1 preloaded case (1.3%) ( P = 0.58). There was no difference in postoperative best-corrected visual acuity at 1 year (logarithm of the minimum angle of resolution 0.21 ± 0.25 for the surgeon-loaded vs. 0.16 ± 0.16 for the preloaded group, P = 0.23). CONCLUSIONS DMEK surgery using preloaded endothelium-in tissue has comparable outcomes with surgeon-loaded endothelium-in tissue. However, there was a trend toward the lower rebubbling rate in DMEK alone compared with combined procedures.
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Affiliation(s)
- Kyongjin Cho
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Ophthalmology, Dankook University College of Medicine, Cheonan, Korea; and
| | - Muhammad Ali
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Samir Jabbour
- Department of Ophthalmology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Albert S Jun
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Divya Srikumaran
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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Viola P, Neri E, Occhipinti T, Parekh M, Cian R, Ponzin D, Moramarco A, Iovieno A. Predicting Long-Term Endothelial Cell Loss after Preloaded Descemet Membrane Endothelial Keratoplasty in Fuchs' Endothelial Corneal Dystrophy: A Mathematical Model. J Clin Med 2024; 13:877. [PMID: 38337570 PMCID: PMC10856122 DOI: 10.3390/jcm13030877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/25/2023] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: This study offers a biexponential model to estimate corneal endothelial cell decay (ECD) following preloaded "endothelium-in" Descemet membrane endothelial keratoplasty (DMEK) in Fuchs' endothelial corneal dystrophy (FECD) patients; (2) Methods: A total of 65 eyes undergoing DMEK alone or combined with cataract surgery were evaluated. The follow-up period was divided into an early phase (first 6 months) and a late phase (up to 36 months). Endothelial cell count (ECC) and endothelial cell loss (ECL) were analyzed; (3) Results: The half time of the ECD was 3.03 months for the early phase and 131.50 months for the late phase. The predicted time-lapse interval to reach 500 cells/mm2 was 218 months (18.17 years), while the time-lapse interval to reach 250 cells/mm2 was 349 months (29.08 years). There was no statistically significant difference between the ECL in DMEK combined with cataract extraction and DMEK alone at 24 months (p ≥ 0.20). At the late phase, long-term ECL prediction revealed a lower ECC half time in patients undergoing DMEK combined with cataract surgery (98.05 months) than DMEK alone (250.32 months); (4) Conclusions: Based on the mathematical modeling, a predicted average half-life of a DMEK graft could reach 18 years in FECD. Moreover, combining cataract extraction with DMEK could result in excessive ECL in the long term.
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Affiliation(s)
- Pietro Viola
- Ophthalmology Unit, San Bortolo Hospital, 36100 Vicenza, Italy; (P.V.)
| | - Enrico Neri
- Ophthalmology Unit, San Bortolo Hospital, 36100 Vicenza, Italy; (P.V.)
| | | | - Mohit Parekh
- Department of Ophthalmology, Schepens Eye Research Institute of Mass Eye and Ear, Harvard Medical School, Boston, MA 02115, USA;
| | - Roberto Cian
- Ophthalmology Unit, San Bortolo Hospital, 36100 Vicenza, Italy; (P.V.)
| | - Diego Ponzin
- Fondazione Banca degli Occhi del Veneto Onlus, 30174 Venice, Italy
| | - Antonio Moramarco
- Ophthalmology Unit, IRCCS, Azienda Ospedaliero-Universitaria, 40138 Bologna, Italy
| | - Alfonso Iovieno
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC V5Z 1L3, Canada
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Wojcik G, Parekh M, Romano V, Ruzza A, Scorcia V, Viola P, Leon P, Franch A, Gadhvi KA, Ponzin D, Ferrari S. Preloaded DMEK With Endothelium Outward: A Multicenter Clinical Study Using DMEK Rapid Device. Cornea 2024; 43:38-44. [PMID: 36961426 DOI: 10.1097/ico.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/08/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The objective of this study is to validate Descemet membrane endothelial keratoplasty (DMEK) Rapid device for preloading DMEK grafts with endothelium outward. METHODS In this multicenter retrospective clinical study, DMEK tissues (n = 27) were peeled and preloaded (8.25 mm) in a DMEK Rapid device. The device was loaded in a container prefilled with the storage solution and shipped from a single center in Italy to 4 different centers located in Italy and the United Kingdom. Preloaded tissues were delivered by injecting the graft in the anterior chamber. Patients were monitored at days 1 and 15 and at months 1, 3, and 6, as well as at the last follow-up (9-12 months) postoperatively. Main outcome measures included rebubbling rate and graft failure, corrected distance visual acuity, endothelial cell loss (ECL), and central corneal thickness at all time points. A one-way analysis of variance test comparing day 1 with all later time points was followed with significance at P < 0.05. RESULTS The average recorded surgical time was 6 to 25 minutes with no immediate surgical complications. Rebubbling was observed in 7 of 26 cases with one graft failure within 15 days postoperatively. The mean corrected distance visual acuity at day 1 was 0.64 ± 0.49 logMAR, which improved to 0.18 ± 0.43 logMAR at the last follow-up. Endothelial cell density values showed a significant decrease at the last follow-up (1827 ± 565 cells/mm 2 ) ( P < 0.001) compared with the preoperative value (2503 ± 128 cells/mm 2 ), with an average endothelial cell loss of 27%. Central corneal thickness significantly dropped from 694 ± 157 μm at day 1 to 502 ± 42 μm at the last follow-up ( P < 0.001). CONCLUSIONS DMEK Rapid device is quick, easy, and efficient for preloading and shipping DMEK grafts internationally in endothelium-outward orientation.
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Affiliation(s)
- Gabriela Wojcik
- International Centre for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Mohit Parekh
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
| | - Vito Romano
- Clinical Eye Research Centre, St Paul's Eye Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, United Kingdom
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Italy
| | - Alessandro Ruzza
- International Centre for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Vincenzo Scorcia
- Department of Medical and Surgical Sciences, Cornea and Ocular Surface Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Pietro Viola
- The Ophthalmology Operational Unit, Structural Department Specialist Surgery Vicenza, San Bortolo Hospital Vicenza, Vicenza, Italy; and
| | - Pia Leon
- International Centre for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
- Department of Ophthalmology, Hospital SS. Giovanni e Paolo, Venice, Italy
| | - Antonella Franch
- Department of Ophthalmology, Hospital SS. Giovanni e Paolo, Venice, Italy
| | - Kunal A Gadhvi
- Clinical Eye Research Centre, St Paul's Eye Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Diego Ponzin
- International Centre for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Stefano Ferrari
- International Centre for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
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Xiao G, Tsou BC, Soiberman US, Prescott CR, Srikumaran D, Woreta FA. Keratoplasty in the United States: Trends and Indications From 2015 to 2020. Cornea 2023; 42:1360-1364. [PMID: 36730420 DOI: 10.1097/ico.0000000000003180] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/10/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to report trends in keratoplasty techniques and indications in the United States from 2015 to 2020. METHODS This retrospective review of annual reports from the Eye Bank Association of America assessed domestic corneal graft distribution and surgical indication data for various types of keratoplasty. Trends in procedure volume and indications from 2015 to 2020 were analyzed using the Cochran-Armitage test. RESULTS The total number of corneal transplants increased from 47,903 in 2015 to 49,143 in 2019, with a decline to 42,257 in 2020, most likely due to COVID-19. Penetrating keratoplasty (PK) volume decreased from 2015 to 2020 (19,160-15,402, 40% to 36.4%, P < 0.001), continuing a trend from the previous decade. Descemet membrane endothelial keratoplasty as a percentage of all keratoplasty procedures increased (9.8%-27.8%, P < 0.001), whereas Descemet stripping automated endothelial keratoplasty (47%-33.9%, P < 0.001) and anterior lamellar keratoplasty (ALK) decreased (2.3%-1.2%, P < 0.001).From 2017 to 2020, repeat corneal transplant was the most common specific indication for PK while ectasias/thinnings decreased in prevalence (15.6%-11.5%, P < 0.001). Ectasias/thinnings and endothelial dystrophy remained the leading indications for ALK and endothelial keratoplasty, respectively. CONCLUSIONS From 2015 to 2020, keratoplasty trends in the United States showed a continuation of the decrease in PK and increase in Descemet membrane endothelial keratoplasty observed in the previous decade. The most common domestic indications from 2017 to 2020 have been repeat corneal graft, endothelial dystrophy, and ectasias/thinnings for PK, EK, and ALK, respectively.
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Affiliation(s)
- Grace Xiao
- Johns Hopkins University School of Medicine, Baltimore, MD
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Parekh M, Ruzza A, Rovati M, Tzamalis A, Romano D, Gupta N, Vaddavalli P, Bhogal M, Jhanji V, Sawant O, Semeraro F, Ponzin D, Jacob S, Dragnea DC, Rodriguez-Calvo-de-Mora M, Dhubhghaill SN, Fogla R, Sharma N, Jurkunas UV, Ferrari S, Romano V. DMEK surgical training: An instructional guide on various wet-lab methods. Surv Ophthalmol 2023; 68:1129-1152. [PMID: 37392969 DOI: 10.1016/j.survophthal.2023.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is a partial-thickness corneal transplantation procedure that involves selective transplantation of the Descemet membrane and endothelium. DMEK offers significant advantages over other keratoplasty techniques, such as faster visual rehabilitation, better final visual acuity due to minimal optical interface effects, lower risk of allograft rejection, and less long-term dependence on topical steroids. Despite all its advantages, DMEK has been found to be more challenging than other corneal transplantation techniques, and its steep learning curve appears to be an obstacle to its widespread use and adoption by corneal surgeons worldwide. DMEK surgical training laboratories (wet labs) provide a window of opportunity for surgeons to learn, prepare, manipulate, and deliver these grafts in a risk-free environment. Wet labs are a significant learning tool, especially for those institutions that have limited tissue availability in their local centers. We provide a step-by-step guide for preparing DMEK grafts using different techniques on human and nonhuman models with instructional videos. This article should eventually help the trainees and the educators understand the requirements for performing DMEK and conducting a DMEK wet lab and develop their skills and interests from a wide variety of available techniques.
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Affiliation(s)
- Mohit Parekh
- Schepens Eye Research Institute of Mass Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
| | - Alessandro Ruzza
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Marco Rovati
- Eye Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Argyrios Tzamalis
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Davide Romano
- Eye Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Nidhi Gupta
- Department of Cornea, Refractive Surgery and Ocular Surface Disorders, Dr. Shroff's Charity Eye Hospital, New Delhi, India
| | - Pravin Vaddavalli
- Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | | | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Onkar Sawant
- Department of Research and Development, Center for Vision and Eye Banking Research, Eversight, Cleveland, OH, USA
| | - Francesco Semeraro
- Eye Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Diego Ponzin
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Soosan Jacob
- Department of Cataract and Glaucoma Services, Dr. Agarwal's Refractive and Cornea Foundation, Chennai, India
| | | | | | | | - Rajesh Fogla
- Department of Ophthalmology, Apollo Hospitals, Hyderabad, Telangana, India
| | - Namrata Sharma
- Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi, India
| | - Ula V Jurkunas
- Schepens Eye Research Institute of Mass Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Vito Romano
- Eye Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy; Eye Unit, ASST Spedali Civili di Brescia, Brescia, Italy.
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Goldstein JK, Portney DS, Kirby R, Verkade A, Mian SI. Cost Drivers of Endothelial Keratoplasty: A Time-Driven Activity-Based Costing Analysis. Ophthalmology 2023; 130:1073-1079. [PMID: 37279859 DOI: 10.1016/j.ophtha.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 06/08/2023] Open
Abstract
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.
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Affiliation(s)
| | - David S Portney
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Rebecca Kirby
- Kellogg School of Management at Northwestern University, Evanston, Illinois
| | - Angela Verkade
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Shahzad I Mian
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan.
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9
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Posterior Segment Air Injection-Assisted Descemet Membrane Endothelial Keratoplasty in Pseudophakic and Vitrectomized Eyes. Cornea 2023; 42:383-388. [PMID: 36729666 DOI: 10.1097/ico.0000000000003213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/02/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE This study aimed to present a novel technique for Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic and vitrectomized eyes. METHODS The sterile air was injected into the posterior eye segment (anterior vitreous cavity) as a barrier to prevent the fluid of the vitreous cavity flowing into the anterior chamber, levitating the iris-lens diaphragm to flatten the anterior chamber during the surgery. This approach assists in the unfolding of the donor endothelial graft, helping to perform DMEK surgery on patients with a posterior intraocular lens (IOL) and vitrectomy. RESULTS Four cases presented with corneal endothelial decompensation (pseudophakic bullous keratopathy) with previous IOL implantation and vitrectomy underwent DMEK with this technique. The Descemet endothelial graft unfolding time after air injection was 68.75 ± 8.96 seconds. No graft displacement occurred during the surgery. The uncorrected and corrected distance visual acuities were improved in 3 of 4 patients. The corneas were transparent, and there was no graft detachment observed postoperatively in all 4 patients. CONCLUSIONS The posterior eye segment air injection can reduce the difficulty of unfolding the DMEK graft in patients after IOL implantation and vitrectomy and the potential intraoperative and postoperative complications, allowing for easy performance of DMEK surgery on pseudophakic and vitrectomized eyes for corneal endothelial dysfunction.
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10
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Parekh M, Romano D, Wongvisavavit R, Coco G, Giannaccare G, Ferrari S, Rocha-de-Lossada C, Levis HJ, Semeraro F, Calvo-de-Mora MR, Scorcia V, Romano V. DMEK graft: One size does not fit all. Acta Ophthalmol 2023; 101:e14-e25. [PMID: 35751171 DOI: 10.1111/aos.15202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 01/25/2023]
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is a popular procedure for the treatment of corneal endothelial diseases mainly targeting Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK). Although DMEK has multiple advantages, it is challenging in terms of graft preparation and delivery. One of the crucial factors of DMEK graft preparation is determining the size of the graft. Evaluating risks and benefits of transplanting larger or smaller grafts compared with the descemetorhexis performed following a standard DMEK procedure thus becomes important. Advanced techniques like pre-loaded DMEK requires pre-selection of graft diameter without physical examination of the eye making it more challenging. Therefore, recognizing the benefits of graft size and the number of transplanted endothelial cells becomes essential. Smaller DMEK grafts have been preferred and accepted for grafting. Larger diameter grafts have advantages but can be challenging due to higher detachment rates. We thus aim to review the challenges of preparing and delivering DMEK tissues with small or large diameter based on selected descemetorhexis area, discuss the outcomes based on different graft sizes, highlight related complications and suggest which cases may benefit from adopting smaller or larger graft size.
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Affiliation(s)
- Mohit Parekh
- Department of Ophthalmology, Schepens Eye Research Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Davide Romano
- Eye Clinic, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Rintra Wongvisavavit
- Institute of Ophthalmology, University College London, London, UK
- Faculty of Medicine and Public Health, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Giulia Coco
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto, Venice, Italy
| | - Carlos Rocha-de-Lossada
- Department of Ophthalmology (Qvision), Vithas Virgen del Mar Hospital, Almería, Spain
- Department of Ophthalmology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Departamento de Cirugia, Area de Oftalmologia, Universidad de Sevilla, Sevilla, Spain
| | - Hannah J Levis
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Francesco Semeraro
- Eye Clinic, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marina Rodríguez Calvo-de-Mora
- Department of Ophthalmology (Qvision), Vithas Virgen del Mar Hospital, Almería, Spain
- Department of Ophthalmology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Ophthalmology Department, Hospital Regional Universitario, Málaga, Spain
| | - Vincenzo Scorcia
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Vito Romano
- Eye Clinic, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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11
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Mian S, Juratli L, Qureshi S, Liles N, Hussain M, Hood C. Clinical outcomes of prestripped, prestained, and preloaded Descemet's membrane endothelial keratoplasty (”P3 DMEK”). Taiwan J Ophthalmol 2023; 13:55-61. [DOI: 10.4103/tjo.tjo-d-22-00155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/19/2022] [Indexed: 02/22/2023] Open
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12
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Clinical Outcomes of Preloaded Descemet Membrane Endothelial Keratoplasty With Endothelium Inward: A 24-Month Comparative Analysis Between Fuchs Endothelial Corneal Dystrophy and Bullous Keratopathy. Cornea 2022:00003226-990000000-00121. [PMID: 36538420 DOI: 10.1097/ico.0000000000003138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/25/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of this study was to compare long-term clinical outcomes of preloaded Descemet membrane endothelial keratoplasty (DMEK) between Fuchs endothelial corneal dystrophy (FECD) and bullous keratopathy (BK). METHODS In this single-center retrospective clinical case series, 71 eyes of 64 patients indicated with FECD (62%) or BK (38%) (with or without cataract) were treated with preloaded DMEK grafts between March 2018 and February 2020. Standard DMEK peeling, followed by manual folding of the tissue with endothelium-inward orientation and storing in a preloaded fashion inside a 2.2-mm intraocular lens cartridge. All tissues were delivered using a bimanual pull-through technique, followed by air tamponade. Graft unfolding time, endothelial cell loss, corrected distance visual acuity, central corneal thickness, rebubbling rate, and intraoperative and postoperative complications at 1, 3, 6, 12, and 24 months were recorded. RESULTS The mean intraoperative graft unfolding time in FECD did not differ from the BK group ( P = 0.6061). Cystoid macular edema did not differ in either group ( P = 0.6866). The rebubbling rate was found to be significantly higher in FECD compared with the BK group ( P = 0.0423). Corrected distance visual acuity significantly improved at the first month after surgery ( P = 0.0012), with no differences between FECD and BK at 24 months ( P = 0.2578). Central corneal thickness was stable postoperatively and showed no differences between the groups ( P = 0.3693). Significantly higher endothelial cell counts were observed in the FECD group at 24 months ( P = 0.0002). CONCLUSIONS Preloaded DMEK with "endothelium-in" offers acceptable intraoperative time, rebubbling rate, and clinical outcomes in both FECD and BK groups. Patients with FECD show better postoperative clinical outcomes even if the rebubbling rate is relatively high.
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13
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Ong HS, Htoon HM, Ang M, Mehta JS. “Endothelium-Out” and “Endothelium-In” Descemet Membrane Endothelial Keratoplasty (DMEK) Graft Insertion Techniques: A Systematic Review With Meta-Analysis. Front Med (Lausanne) 2022; 9:868533. [PMID: 35775001 PMCID: PMC9237218 DOI: 10.3389/fmed.2022.868533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background We evaluated the visual outcomes and complications of “endothelium-out” and “endothelium-in” Descemet membrane endothelial keratoplasty (DMEK) graft insertion techniques. Materials and Methods Electronic searches were conducted in CENTRAL, Cochrane databases, PubMed, EMBASE, ClinicalTrials.gov. Study designs included clinical trials, comparative observational studies, and large case series (≥25 eyes). PRISMA guidelines were used for abstracting data and synthesis. Random-effects models were employed for meta-analyses. Results 21,323 eyes (95 studies) were included. Eighty-six studies reported on “endothelium-out” techniques; eight studies reported on “endothelium-in” techniques. One study compared “endothelium-out” to “endothelium-in” techniques. Eighteen “endothelium-out” studies reported that 42.5–85% of eyes achieved best-corrected visual acuity (BCVA) ≥20/25 at 6 months; pooled proportion of eyes achieving BCVA ≥20/25 at 6 months was 58.7% (95% CI 49.4–67.7%,15 studies). Three “endothelium-in” studies reported that 44.7–87.5% of eyes achieved BCVA of ≥20/25 at 6 months; pooled proportion of eyes achieving BCVA ≥20/25 at 6 months was 62.4% (95% CI 33.9–86.9%). Pooled mean endothelial cell loss was lower in the “endothelium-in” studies (28.1 ± 1.3%, 7 studies) compared to “endothelium-out” studies (36.3 ± 6.9%,10 studies) at 6 months (p = 0.018). Graft re-bubbling rates were higher in the “endothelium-out” studies (26.2%, 95% CI 21.9–30.9%, 74 studies) compared to “endothelium-in” studies (16.5%, 95% CI 8.5–26.4%, 6 studies), although statistical significance was not reached (p = 0.440). Primary graft failure rates were comparable between the two groups (p = 0.552). Quality of evidence was considered low and significant heterogeneity existed amongst the studies. Conclusion Reported rates of endothelial cell loss were lower in “endothelium-in” DMEK studies at 6 months compared to “endothelium-out” studies. Outcomes of “endothelium-in” techniques were otherwise comparable to those reported in “endothelium-out” studies. Given the technical challenges encountered in “endothelium-out” procedures, surgeons may consider “endothelium-in” techniques designed for easier intra-operative DMEK graft unfolding. “Endothelium-in” studies evaluating outcomes at longer time points are required before conclusive comparisons between the two techniques can be drawn.
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Affiliation(s)
- Hon Shing Ong
- Department of Corneal & External Eye Diseases, Singapore National Eye Centre, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Hon Shing Ong,
| | - Hla M. Htoon
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Marcus Ang
- Department of Corneal & External Eye Diseases, Singapore National Eye Centre, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jodhbir S. Mehta
- Department of Corneal & External Eye Diseases, Singapore National Eye Centre, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- School of Materials Science and Engineering, Nanyang Technological University, Singapore, Singapore
- *Correspondence: Jodhbir S. Mehta,
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14
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Semler-Collery A, Bloch F, Hayek G, Goetz C, Perone JM. Comparison of triple-DMEK to pseudophakic-DMEK: A cohort study of 95 eyes. PLoS One 2022; 17:e0267940. [PMID: 35551322 PMCID: PMC9098022 DOI: 10.1371/journal.pone.0267940] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
Previous comparative studies show that triple Descemet membrane endothelial keratoplasty (DMEK) (i.e. phacoemulsification followed immediately by DMEK) has either equivalent or better visual outcomes than DMEK in pseudophakic patients. To resolve this discrepancy, a retrospective cohort study was conducted. All consecutive patients with Fuchs Endothelial Corneal Dystrophy who underwent triple or pseudophakic DMEK in 2015–2019 in a tertiary-care hospital (France) and were followed for >12 months were compared in terms of best spectacle-corrected visual acuity (BSCVA), final refractive outcomes, and endothelial-cell loss at 12 months as well as rebubbling rates. The triple-DMEK (40 eyes, 34 patients) and pseudophakic-DMEK (55 eyes, 43 patients) groups were similar in terms of age and other baseline variables. They also did not differ in final BSCVA (both 0.03 logMAR), final endothelial-cell loss (54% vs. 48%), or astigmatism (-1.25 vs. -1 D). At 12 months, triple-DMEK associated with significantly smaller residual hyperopia (0.75 vs. 1 D; p = 0.04) and spherical equivalence (0 vs. 0.5 D; p = 0.02). Triple-DMEK also tended to associate with more frequent rebubbling (40% vs. 24%, p = 0.09). In conclusion, while triple-DMEK and pseudophakic-DMEK achieved similar visual acuity improvement, triple-DMEK was superior in terms of final sphere and spherical refraction but also tended to have higher complication rates.
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Affiliation(s)
- Axelle Semler-Collery
- Ophthalmology Department, Mercy Hospital, Metz-Thionville Regional Hospital Center, Metz, France
| | - Florian Bloch
- Ophthalmology Department, Mercy Hospital, Metz-Thionville Regional Hospital Center, Metz, France
| | - George Hayek
- Ophthalmology Department, Mercy Hospital, Metz-Thionville Regional Hospital Center, Metz, France
| | - Christophe Goetz
- Research Support Unit, Mercy Hospital, Metz-Thionville Regional Hospital Center, Metz, France
| | - Jean Marc Perone
- Ophthalmology Department, Mercy Hospital, Metz-Thionville Regional Hospital Center, Metz, France
- Institut Jean Lamour, Team 404, UMR 7198 Nanomaterials and Health, Lorraine University, Nancy, France
- * E-mail:
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15
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Parekh M, Wongvisavavit R, Cubero Cortes ZM, Wojcik G, Romano V, Tabernero SS, Ferrari S, Ahmad S. Alternatives to endokeratoplasty: an attempt towards reducing global demand of human donor corneas. Regen Med 2022; 17:461-475. [PMID: 35481361 DOI: 10.2217/rme-2021-0149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The cornea is an anterior transparent tissue of the eye that enables the transmission of surrounding light to the back of the eye, which is essential for maintaining clear vision. Corneal endothelial diseases can lead to partial or total blindness; hence, surgical replacement of the diseased corneal tissue with a healthy cadaveric donor graft becomes necessary when the endothelium is damaged. Keratoplasties face a huge challenge due to a worldwide shortage in the supply of human donor corneas. Hence, alternative solutions such as cell or tissue engineering-based therapies have been investigated for reducing the global demand of donor corneas. This review aims at highlighting studies that have been successful at replacing partial or total endothelial keratoplasty.
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Affiliation(s)
- Mohit Parekh
- Institute of Ophthalmology, University College London, London, EC1V 9EL,UK
| | - Rintra Wongvisavavit
- Institute of Ophthalmology, University College London, London, EC1V 9EL,UK.,Faculty of Medicine & Public Health, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, 10210, Thailand
| | | | - Gabriela Wojcik
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, 30174, Italy
| | - Vito Romano
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK.,Department of Ageing & Chronic Diseases, University of Liverpool, Liverpool, L7 8XL, UK
| | - Sara Sanchez Tabernero
- Cornea & external eye disease, Moorfields Eye Hospital NHS Trust Foundation, London, EC1V 2PD, UK
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, 30174, Italy
| | - Sajjad Ahmad
- Institute of Ophthalmology, University College London, London, EC1V 9EL,UK.,Cornea & external eye disease, Moorfields Eye Hospital NHS Trust Foundation, London, EC1V 2PD, UK
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16
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Zhao J, Tian M, Li Y, Su W, Fan T. Construction of tissue-engineered human corneal endothelium for corneal endothelial regeneration using a crosslinked amniotic membrane scaffold. Acta Biomater 2022; 147:185-197. [PMID: 35358736 DOI: 10.1016/j.actbio.2022.03.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 11/01/2022]
Abstract
Descemet's membrane endothelial keratoplasty (DMEK) may provide fast visual rehabilitation in the therapy of corneal endothelial disorders. However, due to shortage of donated corneas, how to construct a corneal endothelial substitute with powerful functions that can be used for DMEK is still unsolved. Herein, we introduced the method of corneal crosslinking (CXL) and conjugated the components of native Descemet's membrane (DM) to improve the mechanical properties and the biocompatibility of denuded amniotic membrane (dAM), further assessed their effects on cell adhesion, proliferation, YAP translocation, and metabolic activity in human corneal endothelial (HCE) cells. Using modified crosslinked dAM (mcdAM) and non-transfected HCE cells, we constructed a tissue-engineered HCE (TE-HCE) and evaluated its functions in cat and monkey models as well. Our results showed that the mechanical properties of mcdAM were improved effectively by CXL, and the adhesion, proliferation, and YAP translocation of HCE cells were dose-dependently improved after ECM modification. The combination of 0.01 mg/mL laminin with 0.1 mg/mL fibronectin showed the highest efficacy. Then, the TE-HCE was constructed in vitro, with a high density of 3612 ± 243 cells/mm2. Results of DMEK in animal models showed that corneal transparency was maintained, accompanied with normal morphology and histological structure of the regenerated corneal endothelium. Therefore, CXL combined with DM-mimic-coating methods could effectively improve the mechanical properties of dAM and enhance the biocompatibility with HCE cells. The constructed TE-HCE had normal histological structure and functioned well in animal models via DMEK, which could be used as a promising powerful equivalent of HCE. STATEMENT OF SIGNIFICANCE: Using high-quality corneal endothelium and an appropriate endothelial keratoplasty is the most effective way for the treatment of corneal endotheliopathy. Descemet's membrane endothelial keratoplasty (DMEK) which can provide better visual acuity, lower immunological rejection rates, and improved graft survival is an ideal surgery at present. However, due to the shortage of donated corneas, it is urgent to find an equivalent substitute of corneal endothelial donor which is suitable for the DMEK surgery to solve the problem of corneal endothelial regeneration. Herein, we introduced the clinical cornea-crosslinking and Descemet's membrane-mimic-coating methods to build the modified crosslinked denuded amniotic membrane scaffold and further constructed a high-quality corneal endothelial functional substitute that can be used in DMEK surgery.
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Affiliation(s)
- Jun Zhao
- Key Laboratory for Corneal Tissue Engineering, College of Marine Life Sciences, Ocean University of China, Qingdao 266003, Shandong Province, China
| | - Meng Tian
- Key Laboratory for Corneal Tissue Engineering, College of Marine Life Sciences, Ocean University of China, Qingdao 266003, Shandong Province, China
| | - Yun Li
- Key Laboratory for Corneal Tissue Engineering, College of Marine Life Sciences, Ocean University of China, Qingdao 266003, Shandong Province, China
| | - Wen Su
- Key Laboratory for Corneal Tissue Engineering, College of Marine Life Sciences, Ocean University of China, Qingdao 266003, Shandong Province, China; Present address: Department of traditional Chinese Medicine and Immunizations, Institute of Chinese Medicine and Pharmacy, Shandong University of traditional Chinese Medicine, Jinan 250355, Shandong Province, China
| | - Tingjun Fan
- Key Laboratory for Corneal Tissue Engineering, College of Marine Life Sciences, Ocean University of China, Qingdao 266003, Shandong Province, China.
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17
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Parekh M, Romano V, Hassanin K, Testa V, Wongvisavavit R, Ferrari S, Willoughby C, Ponzin D, Jhanji V, Sharma N, Daniels J, Kaye SB, Ahmad S, Levis H. Delivering Endothelial Keratoplasty Grafts: Modern Day Transplant Devices. Curr Eye Res 2022; 47:493-504. [PMID: 34986709 DOI: 10.1080/02713683.2021.2016852] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To summarize the graft loading, transporting and delivery devices used for endothelial keratoplasty (EK). METHODS A literature search of electronic databases was performed. RESULTS New techniques and devices have been introduced and implemented to prepare, load, transport and transplant the grafts for EK. The advantages are not only limited to the surgical theatre but also widely spread across the eye banking field. Investigation of advanced materials and designs have been rapidly growing with continuous evolution in the field of eye banking and corneal transplantation. Innovative techniques and modern devices have been evaluated to reduce the endothelial cell loss and increase the precision of the transplant in order to benefit both surgeons and the patients. CONCLUSIONS It is extremely important to reduce any potential wastage and optimize the use of every available donor cornea due to the limited availability of healthy cadaveric donor corneas required for transplants. As a result, the use of pre-cut and pre-loaded grafts supplied by the eye banks in calibrated devices have been gaining momentum. Innovation in the field of bioengineering for the development of new devices that facilitate excellent clinical outcomes along with reduction in learning curve has shown promising results.
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Affiliation(s)
- Mohit Parekh
- Institute of Ophthalmology, Faculty of Brain Sciences, University College London, London, UK
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Vito Romano
- St.Paul's Eye Unit, Royal Liverpool Broadgreen University Hospital, Liverpool, UK
- Instituto Universitario Fernandez-Vega, Universidad de Oviedo and Fundacion de Investigacion on Oftalmologica, Oviedo, Spain
- Institute of Life Course and Medical Sciences, Department of Eye and Vision Science, University of Liverpool, Liverpool, UK
| | - Kareem Hassanin
- St.Paul's Eye Unit, Royal Liverpool Broadgreen University Hospital, Liverpool, UK
| | - Valeria Testa
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
- Department of Ophthalmology, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Rintra Wongvisavavit
- Institute of Ophthalmology, Faculty of Brain Sciences, University College London, London, UK
- HRH Princess Chulabhorn College of Medical Sciences, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | | | - Diego Ponzin
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Namrata Sharma
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Julie Daniels
- Institute of Ophthalmology, Faculty of Brain Sciences, University College London, London, UK
| | - Stephen B Kaye
- St.Paul's Eye Unit, Royal Liverpool Broadgreen University Hospital, Liverpool, UK
| | - Sajjad Ahmad
- Institute of Ophthalmology, Faculty of Brain Sciences, University College London, London, UK
- Cornea, cataract and external eye diseases, Moorfields Eye Hospital NHS Trust Foundation, London, UK
| | - Hannah Levis
- Institute of Life Course and Medical Sciences, Department of Eye and Vision Science, University of Liverpool, Liverpool, UK
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18
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Parekh M, Pedrotti E, Viola P, Leon P, Neri E, Bosio L, Bonacci E, Ruzza A, Kaye SB, Ponzin D, Ferrari S, Romano V. Factors Affecting the Success Rate of Preloaded Descemet Membrane Endothelial Keratoplasty With Endothelium-Inward Technique: A Multicenter Clinical Study. Am J Ophthalmol 2022; 241:272-281. [PMID: 35288072 DOI: 10.1016/j.ajo.2022.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate factors affecting the outcomes of preloaded Descemet membrane endothelial keratoplasty (pl-DMEK) with endothelium-inward. DESIGN Retrospective clinical case series and a comparative tissue preparation study. METHODS Participants: Fifty-five donor tissues for ex vivo study and 147 eyes of 147 patients indicated with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy with or without cataract. INTERVENTION Standardized DMEK peeling was performed with 9.5-mm-diameter trephination followed by second trephination for loading the graft (8.0-9.5 mm diameter). The tissues were manually preloaded with endothelium-inward and preserved for 4 days or shipped for transplantation. Live and dead assay and immunostaining was performed on ex vivo tissues. For the clinical study, the tissues were delivered using bimanual pull-through technique followed by air tamponade at all the centers. MAIN OUTCOME MEASURES Tissue characteristics, donor and recipient factors, rebubbling rate, endothelial cell loss (ECL), and corrected distance visual acuity (CDVA) at 3, 6, and 12 months. RESULTS At day 4, significant cell loss (P = .04) was observed in pl-DMEK with loss of biomarker expression seen in prestripped and pl-DMEK tissues. Rebubbling was observed in 40.24% cases. Average ECL at 3, 6, and 12 months was 45.87%, 40.98%, and 47.54%, respectively. CDVA improved significantly at 3 months postoperation (0.23 ± 0.37 logMAR) (P < .01) compared to the baseline (0.79 ± 0.61 logMAR). A significant association (P < .05) between graft diameter, preservation time, recipient gender, gender mismatch, and recipient age to rebubbling rate was observed. CONCLUSION Graft loading to delivery time of pl-DMEK tissues in endothelium-inward fashion must be limited to 4 days after processing. Rebubbling rate and overall surgical outcomes following preloaded DMEK can be multifactorial and center-specific.
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19
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Greenwald MF, Nanji AA, Clements JL, Stutzman RD, Stoeger CG, Chamberlain WD. Early Complications With Preloaded Descemet Membrane Endothelial Keratoplasty Are Not Dependent on Optisol-GS Washout or Trypan Blue Restaining. Cornea 2021; 40:1402-1405. [PMID: 33332894 PMCID: PMC8206225 DOI: 10.1097/ico.0000000000002634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the intraoperative and early postoperative complications using preloaded Descemet membrane endothelial keratoplasty (DMEK) grafts with intraocular injection of the graft in Optisol-GS and omission of trypan blue restaining. METHODS This is a retrospective case series of 132 consecutive eyes with Fuchs endothelial dystrophy or endothelial failure who underwent DMEK using preloaded donor tissue prepared as previously described. The graft was not restained with trypan blue by the surgeon, and Optisol-GS was injected with the graft into the eye instead of being rinsed from the injector. Early postoperative complications (0-8 wk) including intraoperative fibrin formation, intraocular inflammation, elevated intraocular pressure, partial graft detachment requiring rebubble, and early graft failure were recorded. RESULTS No eyes developed intraoperative fibrin formation or postoperative inflammation (such as toxic anterior segment syndrome) or elevated intraocular pressure. For eyes with Fuchs corneal dystrophy, our rebubble rate was 21% (22/106 eyes). Early graft failure was noted in 2% (3/132 eyes), which is similar to previous reports. CONCLUSIONS Our results suggest that injection of Optisol-GS into the anterior chamber during DMEK graft injection does not lead to increases in intraoperative or early postoperative complications. Trypan blue restaining is not necessary for intraoperative visualization. This simplification can reduce graft manipulation and save time and resources for this procedure.
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Affiliation(s)
- Miles F Greenwald
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Afshan A Nanji
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - John L Clements
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
- Department of Ophthalmology, Veterans Affairs Medical Center, Portland, Oregon
| | - Richard D Stutzman
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | | | - Winston D Chamberlain
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
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20
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Pagano L, Gadhvi KA, Parekh M, Coco G, Levis HJ, Ponzin D, Ferrari S, Virgili G, Kaye SB, Edwards RT, Romano V. Cost analysis of eye bank versus surgeon prepared endothelial grafts. BMC Health Serv Res 2021; 21:801. [PMID: 34384422 PMCID: PMC8359056 DOI: 10.1186/s12913-021-06828-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 07/27/2021] [Indexed: 11/12/2022] Open
Abstract
Background Selective lamellar corneal transplantation (keratoplasty) has overtaken full thickness penetrating keratoplasty as the graft choice for endothelial failure. Even more recently eye bank prepared tissues are becoming increasing popular as a way to reduce the risks of tissue loss and stress during endothelial keratoplasty preparation in the surgical theatre. This study compares costs between surgeon and eye bank prepared tissues for Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet’s membrane endothelial keratoplasty (DMEK). Methods Retrospective study conducted at the Royal Liverpool University Hospital including endothelial keratoplasties with a minimum of 6 months follow-up time. Cost analysis included surgical expenses, tissue acquisition fees, cost of patient’s ward admission and out-patient expenses, including cost of re-bubbling procedures, costs of visits, anterior segment imaging and optometrist visits within the first 6 months follow-up. Results Ninety-eight eyes of 98 patients were included in the study of which 42 underwent DSAEK surgery and 56 DMEK surgery. Cost analysis of surgical expenses in the DSAEK group showed a significant difference between using surgeon prepared and eye bank prepared tissue (£3866 ± 296 and £4389 ± 360, respectively; p < 0.01) and the same was found in the DMEK group (£3682 ± 167 and £4162 ± 167 for surgeon prepared and eye bank prepared tissues, respectively; p < 0.01). Cost of out-patient visits did not differ significantly in either group. Conclusions At the Royal Liverpool University Hospital, eye bank prepared tissues had higher surgical expenses compared to those prepared by the surgeon, while the post-operative care expenses were similar between the two groups.
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Affiliation(s)
- Luca Pagano
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - Kunal A Gadhvi
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Giulia Coco
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.,Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Hannah J Levis
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, UK
| | - Diego Ponzin
- International Center for Ocular Physiopathology, The Venice Eye Bank Foundation, Venice, Italy
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, The Venice Eye Bank Foundation, Venice, Italy
| | - Gianni Virgili
- Centre for Public Health, Queen's University Belfast, Belfast, UK.,Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Stephen B Kaye
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.,Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, UK
| | - Rhiannon T Edwards
- Department of Public Health, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK.,Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
| | - Vito Romano
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK. .,Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, UK. .,Instituto Universitario Fernandez-Vega, Universidad de Oviedo and Fundacion de Investigacion Oftalmologica, Oviedo, Spain. .,Department of Corneal and External Eye Diseases, St Paul's Eye Unit, Royal Liverpool University Hospital, Prescot St, Liverpool, L7 8XP, UK.
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21
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Abstract
Corneal endothelial cells (CECs) facilitate the function of maintaining the transparency of the cornea. Damage or dysfunction of CECs can lead to blindness, and the primary treatment is corneal transplantation. However, the shortage of cornea donors is a significant problem worldwide. Thus, cultured CEC therapy has been proposed and found to be a promising approach to overcome the lack of tissue supply. Unfortunately, CECs in humans rarely proliferate in vivo and, therefore, can be extremely challenging to culture in vitro. Several promising cell isolation and culture techniques have been proposed. Multiple factors affecting the success of cell expansion including donor characteristics, preservation and isolation methods, plating density, media preparation, transdifferentiation and biomarkers have been evaluated. However, there is no consensus on standard technique for CEC culture. This review aimed to determine the challenges and investigate potential options that would facilitate the standardization of CEC culture for research and therapeutic application.
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Affiliation(s)
- Rintra Wongvisavavit
- Institute of Ophthalmology, University College London, London, UK.,Faculty of Medicine & Public Health, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Mohit Parekh
- Institute of Ophthalmology, University College London, London, UK
| | - Sajjad Ahmad
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Julie T Daniels
- Institute of Ophthalmology, University College London, London, UK
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22
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Complications and Management of Prestripped Descemet Membrane Endothelial Keratoplasty Grafts. Cornea 2021; 39:1576-1577. [PMID: 32882114 DOI: 10.1097/ico.0000000000002426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prestripped Descemet membrane endothelial keratoplasty is a relatively new technique that offers advantages in reduced surgical time and reduced tissue wastage compared with surgeon-stripped graft. Here, we report the following 2 types of prestripped Descemet membrane endothelial keratoplasty graft complications and their management: 1 free floating in the transport media and the other graft mispositioned.
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23
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Català P, Thuret G, Skottman H, Mehta JS, Parekh M, Ní Dhubhghaill S, Collin RWJ, Nuijts RMMA, Ferrari S, LaPointe VLS, Dickman MM. Approaches for corneal endothelium regenerative medicine. Prog Retin Eye Res 2021; 87:100987. [PMID: 34237411 DOI: 10.1016/j.preteyeres.2021.100987] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 12/13/2022]
Abstract
The state of the art therapy for treating corneal endothelial disease is transplantation. Advances in the reproducibility and accessibility of surgical techniques are increasing the number of corneal transplants, thereby causing a global deficit of donor corneas and leaving 12.7 million patients with addressable visual impairment. Approaches to regenerate the corneal endothelium offer a solution to the current tissue scarcity and a treatment to those in need. Methods for generating corneal endothelial cells into numbers that could address the current tissue shortage and the possible strategies used to deliver them have now become a therapeutic reality with clinical trials taking place in Japan, Singapore and Mexico. Nevertheless, there is still a long way before such therapies are approved by regulatory bodies and become clinical practice. Moreover, acellular corneal endothelial graft equivalents and certain drugs could provide a treatment option for specific disease conditions without the need of donor tissue or cells. Finally, with the emergence of gene modulation therapies to treat corneal endothelial disease, it would be possible to treat presymptomatic patients or those presenting early symptoms, drastically reducing the need for donor tissue. It is necessary to understand the most recent developments in this rapidly evolving field to know which conditions could be treated with which approach. This article provides an overview of the current and developing regenerative medicine therapies to treat corneal endothelial disease and provides the necessary guidance and understanding towards the treatment of corneal endothelial disease.
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Affiliation(s)
- Pere Català
- University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, the Netherlands
| | - Gilles Thuret
- Laboratory of Biology, Engineering and Imaging of Corneal Graft, BiiGC, Faculty of Medicine, University of Saint Etienne, Saint Etienne, France; Institut Universitaire de France, Paris, France
| | - Heli Skottman
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jodhbir S Mehta
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore; Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-National University Singapore Medical School, Singapore; Singapore National Eye Centre, Singapore
| | - Mohit Parekh
- Institute of Ophthalmology, University College London, London, UK; The Veneto Eye Bank Foundation, Venice, Italy; Schepens Eye Research Institute, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Sorcha Ní Dhubhghaill
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium; Ophthalmology, Visual Optics and Visual Rehabilitation, Department of Translational Neurosciences, University of Antwerp, Wilrijk, Belgium
| | - Rob W J Collin
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rudy M M A Nuijts
- University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Vanessa L S LaPointe
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, the Netherlands
| | - Mor M Dickman
- University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, the Netherlands.
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24
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The Last 200 Surgeon-Loaded Descemet Membrane Endothelial Keratoplasty Tissue Versus the First 200 Preloaded Descemet Membrane Endothelial Keratoplasty Tissue. Cornea 2021; 39:1261-1266. [PMID: 32541187 DOI: 10.1097/ico.0000000000002400] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to compare the clinical outcomes from using eye bank-prepared, endothelium-out preloaded Descemet membrane endothelial keratoplasty (DMEK) tissue with those obtained with endothelium-out surgeon-loaded DMEK tissue using the same surgical technique at 1 site. METHODS This study retrospectively reviewed 400 consecutive cases of DMEK from March 2016 to April 2018. The last 200 cases using surgeon-loaded tissue were compared with the first 200 cases using preloaded tissue. Statistical analysis was performed using the Wilcoxon signed-rank test, binomial logistic regression, Kruskal-Wallis 1-way analysis of variance, Student t test, or Pearson χ tests. RESULTS Comparing surgeon-loaded versus preloaded DMEK tissue, respectively, no statistical difference was found in the mean 6-month postoperative values for endothelial cell loss (32.9% ± 18.5% vs. 29.9% ± 16.4%, P = 0.31), best corrected visual acuity (20/26 vs. 20/25, P = 0.54), or change in central corneal thickness (-14.4% ± 8.9% vs. -15.6% ± 11.7%, P = 0.43). The mean 1-year endothelial cell loss was also not significantly different (37.6% ± 17.2% vs. 33.2% ± 14.8%, P = 0.07). Overall, the rebubble rate for surgeon-loaded tissue was 17.5% and 12.5% for preloaded tissue, a statistically nonsignificant difference. Operative outcomes for mean tissue scroll tightness (1-4) and tissue unscroll time (minutes) for surgeon-loaded and preloaded tissue were similar between groups (2.4 vs. 2.2, P = 0.12 and 3.5 vs. 3.3 minutes, P = 0.50). CONCLUSIONS Tissue that is trephinated, stained, and loaded into an injector by the eye bank and then shipped to the surgeon had no difference in clinical outcomes compared with tissue where the surgeon performs these steps. The safety and speed of using preloaded tissue should be considered by DMEK surgeons.
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25
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Parekh M, Ferrari S, Pagano L, Angi M, Gadhvi KA, Romano V. Confounding factors influencing the scroll width of Descemet membrane endothelial keratoplasty graft. Indian J Ophthalmol 2021; 69:461-462. [PMID: 33463617 PMCID: PMC7933887 DOI: 10.4103/ijo.ijo_2642_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Mohit Parekh
- Institute of Ophthalmology, University College London, London, UK
| | - Stefano Ferrari
- Fondazione Banca degli Occhi del Veneto Onlus, Venice, Italy
| | - Luca Pagano
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Martina Angi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Kunal A Gadhvi
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Vito Romano
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
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26
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Chen C, Solar SJ, Lohmeier J, Terrin S, Baliga S, Wiener BG, Lewis DS, Chiang E, Barnes KA, Chaurasia A, Eghrari AO. Viability of preloaded Descemet membrane endothelial keratoplasty grafts with 96-hour shipment. BMJ Open Ophthalmol 2021; 6:e000679. [PMID: 34104797 PMCID: PMC8141423 DOI: 10.1136/bmjophth-2020-000679] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/10/2021] [Accepted: 03/21/2021] [Indexed: 11/22/2022] Open
Abstract
Objective To assess feasibility and compare the effects of 96-hour shipment of Descemet membrane endothelial keratoplasty (DMEK) grafts as a scroll or a tri-fold on cell viability. Methods and analysis DMEK grafts were prepared at the Rocky Mountain Lions Eye Bank. Twenty pre-stripped DMEK grafts, paired from 10 donors, were either tri-folded in an endothelium-in configuration using microforceps and loaded into a plastic Treyetech cartridge, or suctioned in a scrolled endothelium-out configuration into a modified Jones Tube. Grafts were shipped via FedEx to a secondary location and back for 48 hours each way, resulting in a total shipping time of 96 hours. After shipping, grafts were removed from inserters onto glass slides and unfolded using viscoelastic with endothelium facing upwards. Calcein-AM stained grafts were imaged with a fluorescent microscope and endothelial cell loss (ECL) was measured using trainable segmentation in Fiji by a masked grader. Results A total of 20 grafts were shipped for 96 hours, split between preloaded tri-folded (n=10) and preloaded scrolled (n=10) tissues. No significant difference in ECL was observed across groups after prolonged shipping (14.8% vs 13.7% ECL respectively, p=0.68). Conclusion For preloaded DMEK after 96 hours, both scrolled and tri-folded tissue demonstrated clinically acceptable levels of ECL. The data suggest a wider window of time for endothelial cell viability and is promising for the prospect of international shipment of preloaded grafts.
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Affiliation(s)
- Conan Chen
- University of Colorado Denver School of Medicine, Denver, Colorado, USA
| | - Steven Jared Solar
- Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - John Lohmeier
- Rocky Mountain Lions Eye Bank, Aurora, Colorado, USA
| | - Staci Terrin
- Rocky Mountain Lions Eye Bank, Aurora, Colorado, USA
| | - Satya Baliga
- Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Batya Gold Wiener
- Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Eric Chiang
- Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Akash Chaurasia
- Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Allen O Eghrari
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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27
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Price MO, Feng MT, Price FW. Endothelial Keratoplasty Update 2020. Cornea 2021; 40:541-547. [PMID: 33252380 DOI: 10.1097/ico.0000000000002565] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/31/2020] [Indexed: 12/14/2022]
Abstract
ABSTRACT Endothelial keratoplasty has revolutionized the treatment of corneal endothelial dysfunction and lowered the threshold for treatment by providing rapid visual rehabilitation and setting a high standard for safety and efficacy. Over time, endothelial keratoplasty techniques have evolved toward the use of thinner tissue to optimize visual outcomes; refinements have facilitated donor tissue preparation, handling, and attachment; and adaptations have expanded utilization in eyes with challenging ocular anatomy. Despite early concerns about graft longevity, emerging 10-year endothelial cell loss and graft survival data have been encouraging. A shortage of human donor corneas restricts utilization in many areas of the world and is driving a search for keratoplasty alternatives. Further work is needed to expand the donor supply, minimize impediments to adoption, optimize graft survival, and improve refractive predictability.
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28
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Ighani M, Dzhaber D, Jain S, De Rojas JO, Eghrari AO. Techniques, Outcomes, and Complications of Preloaded, Trifolded Descemet Membrane Endothelial Keratoplasty Using the DMEK EndoGlide. Cornea 2021; 40:669-674. [PMID: 33470675 PMCID: PMC9922541 DOI: 10.1097/ico.0000000000002648] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/22/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE To describe 2 insertion techniques, outcomes, and complications of preloaded, trifolded Descemet membrane endothelial keratoplasty (DMEK) cases using the DMEK EndoGlide inserter. METHODS This retrospective, consecutive case series analyzed the first 35 cases using the DMEK EndoGlide performed between October 2018 and October 2019 at a single center. Preloaded, trifolded DMEK tissues were delivered through a fluid-injected or pull-through technique. To inject the tissue, a burst of fluid was delivered into the lumen of the injector with a second instrument. Postoperatively, best-spectacle corrected visual acuity (BSCVA), pachymetry, graft survival, and complications were assessed. RESULTS Thirty-five eyes of 29 patients underwent DMEK alone (n = 11), with cataract surgery (n = 21), or with additional surgeries (n = 3). Of these, 19 (54.3%) grafts were injected. Video analysis revealed a median time of 3.5 minutes from graft insertion to opening for gas insertion. Median preoperative BSCVA of 0.398 logMAR improved to 0.097 logMAR (P = 0.02) at 9 months. Median pachymetry decreased from 619 μm to 551 μm (P = 0.03) at 9 months. Median donor endothelial cell count of 2890.5 cells/mm2 reduced to 2123 cells/mm2 (26.6% endothelial cell loss; P = 0.008) 6 months postoperatively. One (2.9%) graft failed due to inverted marking at the eye bank and subsequent reverse implantation. CONCLUSIONS Pre-loaded, tri-folded tissues can be implanted with acceptable levels of endothelial cell loss. We describe a no-touch method of injecting pre-loaded, tri-folded tissue and highlight incorrect marking as a potential complication. This may not be identifiable intraoperatively due to lack of scroll formation.
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Affiliation(s)
- Mehrnaz Ighani
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- University of Maryland at College Park, College Park, Maryland, USA
| | - Daliya Dzhaber
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shivani Jain
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joaquin O. De Rojas
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allen O. Eghrari
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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29
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Ong HS, Ang M, Mehta J. Evolution of therapies for the corneal endothelium: past, present and future approaches. Br J Ophthalmol 2021; 105:454-467. [PMID: 32709756 PMCID: PMC8005807 DOI: 10.1136/bjophthalmol-2020-316149] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/16/2020] [Indexed: 12/13/2022]
Abstract
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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Affiliation(s)
- Hon Shing Ong
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore
- Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore, Singapore
| | - Marcus Ang
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore
- Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore, Singapore
| | - Jodhbir Mehta
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore
- Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore, Singapore
- School of Material Science & Engineering and School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore, Singapore
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30
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Phylactou M, Matarazzo F, Din N, Maurino V. Descemet membrane endothelial keratoplasty in vitrectomized eyes: a case series of outcomes and complications. Int Ophthalmol 2021; 41:2425-2432. [PMID: 33751304 DOI: 10.1007/s10792-021-01797-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) in vitrectomized eyes. METHODS A multi-surgeon, retrospective case series of previously vitrectomized eyes that underwent DMEK between 2013 and 2018 at Moorfields Eye Hospital. Patients' demographics, preoperative, intraoperative and postoperative data were collected. RESULTS In total, 14 eyes of 13 patients, aged 63 ± 14.6 years were included. Three eyes had intraoperative posterior dislocation of the DMEK graft into the vitreous cavity, two of these were aphakic and one had an unstable PCIOL. Postoperatively, one graft had a total detachment and required repeat keratoplasty for primary failure, two grafts had visually significant partial detachment and needed rebubbling. Three patients developed high intraocular pressure (IOP) and one required an urgent glaucoma drainage device 1-month post-DMEK. The mean corrected distance visual acuity was 0.81 ± 0.42 logMAR preoperatively, and postoperatively was 0.6 ± 0.51 at 3 months (p = 0.414); 0.69 ± 0.81 at 6 months (p = 0.684); and 0.7 ± 0.8 at 12 months (p = 0.658). CONCLUSIONS DMEK in vitrectomized eyes has unique challenges that necessitate careful preoperative planning. We observed a significant proportion of dislocated grafts in vitrectomized eyes with either unstable IOL or aphakic. Moreover, vitrectomized eyes with secondary glaucoma may be particularly vulnerable to uncontrolled IOP postoperatively and close monitoring is essential to prevent worsening of visual acuity. We recommend that DMEK may not be a feasible option in eyes that are prone to collapse, in particular aphakic vitrectomized eyes, as opposed to DSAEK or penetrating keratoplasty.
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Affiliation(s)
- Maria Phylactou
- Cornea and External Diseases, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK.
| | - Francesco Matarazzo
- Cornea and External Diseases, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK
| | - Nizar Din
- Cornea and External Diseases, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK
| | - Vincenzo Maurino
- Cornea and External Diseases, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK
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31
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Böhm M, Leon P, Wylęgała A, Ong Tone S, Condron T, Jurkunas U. Cost-effectiveness analysis of preloaded versus non-preloaded Descemet membrane endothelial keratoplasty for the treatment of Fuchs endothelial corneal dystrophy in an academic centre. Br J Ophthalmol 2021; 106:914-922. [PMID: 33637619 DOI: 10.1136/bjophthalmol-2020-317536] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 01/19/2021] [Accepted: 02/05/2021] [Indexed: 11/04/2022]
Abstract
AIMS To determine the cost-effectiveness of preloaded Descemet membrane endothelial keratoplasty (pDMEK) versus non-preloaded DMEK (n-pDMEK) for the treatment of Fuchs endothelial corneal dystrophy (FECD). METHODS From a societal and healthcare perspective, this retrospective cost-effectiveness analysis analysed a cohort of 58 patients with FECD receiving pDMEK (n=38) or n-pDMEK (n=30) from 2016 to 2018 in the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA. Exclusion criteria were previous ocular surgeries (other than uncomplicated cataract surgery), including other keratoplasty procedures, ocular pathological conditions as glaucoma, amblyopia, laser treatments, or any retinal or corneal disease. The main outcome parameters were the incremental cost-utility ratio (ICUR) and net monetary benefit (NMB). RESULTS pDMEK was less costly compared with n-pDMEK (healthcare: $13 886 vs $15 329; societal: $20 805 vs $22 262), with a slighter greater utility (QALY 0.6682 vs QALY 0.6640) over a time horizon of 15 years. pDMEK offered a slightly higher clinical effectiveness (+0.0042 QALY/patient) at a lower cost (healthcare: -$1444 per patient; societal: -$1457 per patient) in improving visual acuity in this cohort of patients with FECD. pDMEK achieved a favourable ICUR and NMB compared with n-pDMEK. Based on sensitivity analyses performed, the economic model was robust. CONCLUSIONS From the societal and healthcare perspective, pDMEK was less costly and generated comparable utility values relative to n-pDMEK. Therefore, pDMEK appears to be cost-effective and cost saving with respect to n-pDMEK. Further long-term follow-up data are needed to confirm these findings.
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Affiliation(s)
- Myriam Böhm
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.,Department of Ophthalmology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Pia Leon
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam Wylęgała
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephan Ong Tone
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Tracy Condron
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Ula Jurkunas
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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32
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Ramirez DA, Schmidt GA, Worthington KS, Sales CS. Review: Optimizing DMEK Technique, 2018-2020. Int Ophthalmol Clin 2021; 61:45-55. [PMID: 33337793 DOI: 10.1097/iio.0000000000000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Three-Year Outcomes of Tri-Folded Endothelium-In Descemet Membrane Endothelial Keratoplasty With Pull-Through Technique. Am J Ophthalmol 2020; 219:121-131. [PMID: 32659279 DOI: 10.1016/j.ajo.2020.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To assess the 3-year outcomes of tri-folded endothelium-in Descemet membrane endothelial keratoplasty (DMEK) using bimanual pull-through delivery technique. DESIGN Interventional case series. METHODS In this single-center study, we included 153 consecutive eyes that underwent DMEK for various indications (Fuchs endothelial corneal dystrophy [FECD]: n = 111; bullous keratopathy [BK]: n = 24; and failed graft: n = 18). DMEK grafts were loaded into a disposable cartridge in a tri-folded, endothelium-in configuration and delivered using bimanual pull-through technique. Main outcome measures were graft preparation and unfolding times, best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), and graft survival. RESULTS Mean graft preparation time was 5.9 ± 1.1 minutes; and mean graft unfolding time was 2.9 ± 0.9 minutes. Excluding eyes with comorbidities, logarithm of minimum angle of resolution BSCVA improved significantly from baseline preoperative values of 0.92 ± 0.58 to 0.02 ± 0.07 at 1 year (P < .001) and remained stable up to 3 years. Mean postoperative ECD decreased significantly (P < .001) from eye bank values to 1,818 ± 362, 1,675 ± 372, and 1,580 ± 423 cells/mm2 at 1, 2, and 3 years, respectively. No significant differences in ECD were observed between eyes with FECD and BK, but ECD was significantly lower in eyes with previous failed graft (P < .05). Three-year cumulative graft survival rate was significantly (P < .001) lower for eyes with previous failed graft (71%) than for FECD (97%) and BK (92%). CONCLUSIONS Tri-folded endothelium-in DMEK requires minimal time for graft unfolding, which is the surgical step considered most challenging by corneal surgeons. Visual outcomes and complication rates are not adversely affected by the modification of the surgical technique.
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34
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Romano V, Kazaili A, Pagano L, Gadhvi KA, Titley M, Steger B, Fernández-Vega-Cueto L, Meana A, Merayo-Lloves J, Diego P, Akhtar R, Levis HJ, Ferrari S, Kaye SB, Parekh M. Eye bank versus surgeon prepared DMEK tissues: influence on adhesion and re-bubbling rate. Br J Ophthalmol 2020; 106:177-183. [PMID: 33127828 PMCID: PMC8788033 DOI: 10.1136/bjophthalmol-2020-317608] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/22/2020] [Accepted: 10/10/2020] [Indexed: 11/16/2022]
Abstract
Aim To investigate the difference in adhesion and rebubbling rate between eye bank and surgeon prepared Descemet membrane endothelial keratoplasty (DMEK) tissues. Methods Laboratory and clinical retrospective comparative interventional case series. Research corneal tissues were obtained for laboratory investigation. The clinical study involved patients with endothelial dysfunction who underwent DMEK surgery and tamponade with air. Tissues were stripped using a standard DMEK stripping technique (SCUBA) and shipped as prestripped or loaded in a 2.2 intra-ocular lens cartridge with endothelium facing inwards (preloaded) before transporting from the eye bank to the surgeon. For surgeon prepared tissues, all the grafts were stripped in the theatre and transplanted or stripped in the laboratory and tested immediately. Adhesion force and elastic modulus were measured in the centre and mid-periphery in a laboratory ex vivo investigation using atomic force microscopy, while rebubbling rates were recorded in the clinical study. Results There was no difference in endothelial cell viability between surgeon or eye bank prepared tissue. Surgeon-stripped DMEK grafts in the laboratory investigation showed significantly higher elastic modulus and adhesion force compared to prestripped and preloaded tissues (p<0.0001). In the clinical data, rebubbling rates of 48%, 40% and 15% were observed in preloaded, prestripped and surgeon-stripped DMEK grafts, respectively. Rebubbling rates were significantly associated with combined cataract surgery (p=0.009) and with time from harvesting the graft to the surgery (p=0.02). Conclusions Decreased adhesion forces and elastic modulus in eye bank prepared tissues may contribute to increased rebubbling rates.
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Affiliation(s)
- Vito Romano
- Instituto Universitario, Universidad de Oviedo and Fundacion de Investigacion Oftalmologica, Oviedo, Spain .,Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK.,Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Ahmed Kazaili
- Department of Biomedical Engineering, College of Engineering, University of Babylon, Hillah, Iraq.,Babylon Health Directorate, Ministry of Health, Babylon, Iraq.,Department of Mechanical, Materials and Aerospace Engineering, University of Liverpool School of Engineering, Liverpool, UK
| | - Luca Pagano
- Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Mitchell Titley
- Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Bernhard Steger
- Department of Ophthalmology, Medical University of Innsbruck, Innsbruck, Austria
| | - Luis Fernández-Vega-Cueto
- Instituto Universitario, Universidad de Oviedo and Fundacion de Investigacion Oftalmologica, Oviedo, Spain
| | - Alvaro Meana
- Instituto Universitario, Universidad de Oviedo and Fundacion de Investigacion Oftalmologica, Oviedo, Spain
| | - Jesus Merayo-Lloves
- Instituto Universitario, Universidad de Oviedo and Fundacion de Investigacion Oftalmologica, Oviedo, Spain
| | - Ponzin Diego
- International Centre for Ocular Physiopathology, Fondazione Banca Degli Occhi del Veneto, Venezia Zelarino, Italy
| | - Riaz Akhtar
- Department of Mechanical, Materials and Aerospace Engineering, University of Liverpool School of Engineering, Liverpool, UK
| | - Hannah J Levis
- Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Stefano Ferrari
- International Centre for Ocular Physiopathology, Fondazione Banca Degli Occhi del Veneto, Venezia Zelarino, Italy
| | - Stephen B Kaye
- Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK.,Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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Romano V, Pagano L, Gadhvi KA, Coco G, Titley M, Fenech MT, Ferrari S, Levis HJ, Parekh M, Kaye S. Clinical outcomes of pre-loaded ultra-thin DSAEK and pre-loaded DMEK. BMJ Open Ophthalmol 2020; 5:e000546. [PMID: 33094167 PMCID: PMC7569929 DOI: 10.1136/bmjophth-2020-000546] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To compare clinical outcomes and complications between pre-loaded ultra-thin Descemet stripping automated endothelialkeratoplasty (pl-UT-DSAEK) and pre-loaded Descemet membrane endothelial keratoplasty (pl-DMEK). Methods and analysis Comparative study in patients with endothelial dysfunction associated with Fuchs endothelial corneal dystrophy and pseudophakic bullous keratopathy who underwent pl-UT-DSAEK or pl-DMEK transplants. For both groups, the tissues were pre-loaded at the Fondazione Banca degli Occhi del Veneto (Venice, Italy) and shipped to The Royal Liverpool University Hospital (Liverpool, UK). Best corrected visual acuity (BCVA) and re-bubbling rates were the main outcome measures. Results 56 eyes of 56 patients were included. 31 received pl-UT-DSAEK and 25 received pl-DMEK. At 12 months, BCVA (LogMAR) was significantly better for pl-DMEK (0.17±0.20 LogMAR) compared with pl-UT-DSAEK (0.37±0.37 LogMAR, p<0.01). The percentage of people that achieved ≥20/30 was significantly higher in the pl-DMEK group. The rate of re-bubbling, however, was significantly higher for pl-DMEK (44.0%) than for Pl-UT-DSAEK (12.9%), p<0.01. Conclusion Pl-DMEK offers better BCVA than pl-UT-DSAEK. The higher re-bubbling rate associated with pre-loaded DMEK is of concern.
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Affiliation(s)
- Vito Romano
- Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Instituto Universitario Fernandez-Vega, Universidad de Oviedo and Fundacion de Investigacion Oftalmologica, Oviedo, Spain
| | - Luca Pagano
- Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK.,Ophthalmology, Humanitas Research Hospital, Milan, Italy
| | - Kunal A Gadhvi
- Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK
| | - Giulia Coco
- Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK.,Ophthalmology, Universita degli Studi di Roma Tor Vergata, Roma, Italy
| | - Mitchell Titley
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Hannah J Levis
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Mohit Parekh
- Institute of Ophthalmology, University College London, London, UK
| | - Stephen Kaye
- Ophthalmology, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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Effect of Anticoagulant Therapy on the Outcome of Descemet Membrane Endothelial Keratoplasty. Cornea 2020; 40:1147-1151. [PMID: 33009094 DOI: 10.1097/ico.0000000000002533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/30/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To analyze the effect of anticoagulant therapy (ACT) for systemic diseases on the outcome of Descemet membrane endothelial keratoplasty (DMEK). METHODS Consecutive eyes with Fuchs endothelial dystrophy that underwent DMEK between August 4, 2011, and July 15, 2016, were retrospectively analyzed. Data were obtained from the Cologne DMEK database at the University of Cologne, Germany. Best spectacle-corrected visual acuity (logMAR), endothelial cell density (at baseline and postoperatively up to 12 months), and rebubbling rates were compared between patients receiving ACT (ACT group) and those with no anticoagulant treatment (NCT group). RESULTS In this study, 329 eyes of 329 patients were included (ACT group n = 97, NCT group n = 232; mean age 69.9 ± 9.1 years). Bleeding was more common in the ACT group (P < 0.001). Preoperative best spectacle-corrected visual acuity was 0.59 ± 0.44 and 0.48 ± 0.35 logMAR for the ACT and NCT groups, respectively, which improved to 0.13 ± 0.08 and 0.08 ± 0.16 logMAR, respectively, at 12 months postoperatively. No significant difference in endothelial cell density loss at 12 months was found between the groups (ACT group 36.2% ± 14.7%, NCT group 38.5% ± 15.1%; P = 0.467). Rebubbling rate was 19.6% in the ACT group and 28.9% in the NCT group (P = 0.08). CONCLUSIONS Although ACT increases the risk for preoperative and intraoperative bleeding in DMEK, there seems to be no negative effect on DMEK outcome. Thus, it is not advisable to stop ACT for DMEK surgery.
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Preloaded Descemet Membrane Endothelial Keratoplasty Grafts With Endothelium Outward: A Cross-Country Validation Study of the DMEK Rapid Device. Cornea 2020; 40:484-490. [PMID: 32947407 DOI: 10.1097/ico.0000000000002493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To validate the "Descemet membrane endothelial keratoplasty (DMEK) Rapid" device for the cross-country transportation of preloaded DMEK grafts preserved with endothelium outward. METHODS DMEK grafts were stripped and loaded in the DMEK Rapid device with tissue culture medium (TCM) or transport medium (TM) with endothelium outward. The device was mounted in a 40-mL flask and preserved for 4 days on a rocker to simulate transportation (study A, n = 24) or shipped in the TM from Italy to the United Kingdom (study B, n = 9) and evaluated within 72 hours. All the tissues were stained with Alizarin red. Viability of the cells was checked postsimulations and posttransportation and was confirmed using live/dead staining. Expression of tight junction proteins was evaluated. RESULTS In study A, the endothelial cell loss observed from the TCM group was 20.8% (±5.2) compared with 19.5% (±6.7) from the TM group (P = 0.41) after transport simulation. Alizarin red showed minimal uncovered areas in both groups. There were no statistical differences in viability between the TM (80.83%) and TCM groups (78.83%). In study B, 12.9% (±7.8) endothelial cell loss was observed after transporting the tissues from Italy to the United Kingdom with no significant difference between prestrip and posttransportation (P = 0.05). Alizarin red staining did not show any uncovered area. Live/dead analysis showed 85.16% cell viability after transportation. zonula occludens-1 (ZO-1) was expressed in all tissues. CONCLUSIONS The DMEK Rapid device is safe for preloading and shipping DMEK grafts internationally with endothelium outward within 72 hours when preserved in the transport media.
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One-Year Clinical Outcomes of Preloaded Descemet Membrane Endothelial Keratoplasty Versus Non-Preloaded Descemet Membrane Endothelial Keratoplasty. Cornea 2020; 40:311-319. [PMID: 32740011 DOI: 10.1097/ico.0000000000002430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/18/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the one-year outcomes of preloaded Descemet membrane endothelial keratoplasty (pDMEK) and non-preloaded DMEK (n-pDMEK) in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS This retrospective comparative cohort study consecutively included 68 eyes with Fuchs endothelial corneal dystrophy who underwent either pDMEK (n = 38) or n-pDMEK (n = 30) performed by cornea fellows with an experienced surgeon between 2016 and 2018 at the Massachusetts Eye and Ear Infirmary. Exclusion criteria were previous surgery (other than uncomplicated cataract surgery) and any documented evidence of macular or other corneal diseases. Corrected distance visual acuity (CDVA), central corneal thickness, intraocular pressure, patient characteristics, postprocessing endothelial cell count, donor graft data, and complications were compared. RESULTS CDVA showed similar results for pDMEK (0.12 ± 0.11 logarithm of the minimal angle of resolution [LogMAR]) and n-pDMEK (0.13 ± 0.13 LogMAR) (P = 0.827). Sixty-six percent of the pDMEK eyes and 57% of the n-pDMEK eyes achieved a VA of ≥0.1 LogMAR, and 95% and 97%, respectively, achieved a CDVA ≥0.3 LogMAR. The preoperative central corneal thickness of pDMEK and n-pDMEK (644 ± 62.2 μm, 660.5 ± 56.2 μm) decreased significantly after surgery (525.1 ± 43.6 μm, 526.5 ± 45.2 μm, P < 0.001), with no difference between groups (P = 0.840). The postprocessing endothelial cell count did not differ between pDMEK (2959.2 ± 182.9 cells/mm2) and n-pDMEK (2939.3 ± 278.7 cells/mm2) (P = 0.484). Complication rates were comparable with just the rebubbling performed in a minor procedure room showing a lower rate for pDMEK (13.16%) compared with n-pDMEK (33.33%) (P < 0.045). CONCLUSIONS One-year clinical outcomes were similar between pDMEK and n-pDMEK procedures, rendering eye bank-prepared pDMEK tissues a useful tool in the treatment of endothelial dysfunction.
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Hayashi T, Schrittenlocher S, Siebelmann S, Le VNH, Matthaei M, Franklin J, Bachmann B, Cursiefen C. Risk factors for endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK). Sci Rep 2020; 10:11086. [PMID: 32632151 PMCID: PMC7338484 DOI: 10.1038/s41598-020-68023-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/10/2020] [Indexed: 11/23/2022] Open
Abstract
This study aimed to identify the risk factors for endothelial cell density (ECD) loss after Descemet membrane endothelial keratoplasty (DMEK) and analyse whether donor tissues from cold versus organ culture differ in terms of ECD loss after DMEK. Consecutive DMEK cases from a prospective database for Fuchs’ endothelial corneal dystrophy were retrospectively analysed between 2011 and 2016 at the University of Cologne, and the possible risk factors for ECD loss, including patient-related factors, type of tamponade (air or 20% sulphur hexafluoride gas), type of surgery (triple DMEK or DMEK alone), re-bubbling, immune rejection, and donor-related factors were determined. Eight hundred and forty-one eyes were selected. There was no significant difference in the best-corrected visual acuity (logarithm of the minimal angle of resolution) and corneal thickness (P = 0.540 and P = 0.667) between groups. Immune reactions were more common in cold cultures (P = 0.019), but ECD loss (1 year after DMEK) was greater in organ cultures (38.3 ± 0.8%) than in cold cultures (34.7 ± 1.4%) (P = 0.022). Only re-bubbling was significantly associated with ECD loss (P < 0.001). Re-bubbling was found to be a key factor for ECD loss at 1 year after DMEK.
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Affiliation(s)
- Takahiko Hayashi
- Department of Ophthalmology, University of Cologne, Cologne, Germany. .,Department of Ophthalmology, Yokohama Minami Kyosai Hospital, Kanagawa, Japan.
| | | | | | - Viet Nhat Hung Le
- Department of Ophthalmology, University of Cologne, Cologne, Germany.,Department of Ophthalmology, Hue College of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Mario Matthaei
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Jeremy Franklin
- Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Björn Bachmann
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Claus Cursiefen
- Department of Ophthalmology, University of Cologne, Cologne, Germany.,Centre for Molecular Medicine Cologne, CMMC, University of Cologne, Cologne, Germany
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Woo JH, Htoon HM, Tan D. Hybrid Descemet Membrane Endothelial Keratoplasty (H-DMEK): results of a donor insertion pull-through technique using donor stroma as carrier. Br J Ophthalmol 2020; 104:1358-1362. [PMID: 31949091 DOI: 10.1136/bjophthalmol-2019-314932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/20/2019] [Accepted: 12/19/2019] [Indexed: 11/04/2022]
Abstract
AIM To evaluate the outcomes and complications of hybrid Descemet membrane endothelial keratoplasty (H-DMEK) using a Descemet stripping automated endothelial keratoplasty (DSAEK) pull-through donor inserter and donor stroma as carrier. METHODS This was a retrospective interventional case series of eyes with bullous keratopathy (BK) and Fuchs endothelial corneal dystrophy (FECD), which underwent H-DMEK, performed using a bimanual pull-through technique using DSAEK-prepared donor stroma as carrier and the EndoGlide Ultrathin DSAEK donor insertion device. Complex cases with tube shunts, trabeculectomy, aphakia, aniridia, previous vitrectomy, keratoplasty or combined with intraocular lens exchange, were also included. The outcome measures were intraoperative and postoperative complications, best corrected visual acuity (BCVA) and endothelial cell loss after surgery. RESULTS Of the 85 eyes from 79 patients, 43.5% (n=37) had BK, 28.2% (n=24) had FECD while 24.7% (n=21) had failed grafts. DMEK was performed in 37 complex eyes (43.5%). Four eyes (4.7%) required rebubbling for graft detachment and two cases of graft failure were observed. A BCVA of 20/25 or better was attained in 44.7% and 57.1% of eyes without pre-existing ocular pathology at 6 and 12 months, respectively. The overall endothelial cell loss was 32.2%±20.5% at 6 months, which improved from 37.2%±20.9% to 24.2%±17.5%, comparing the first 40 and last 45 cases (p=0.012). CONCLUSION Hybrid DMEK offers a controlled 'pull-through' technique of donor insertion in the 'endothelium-in' configuration, which may be useful especially in complicated eyes. More studies are needed to confirm the long-term endothelial cell loss and graft survival associated with this technique.
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Affiliation(s)
- Jyh Haur Woo
- Singapore National Eye Centre, Singapore.,Singapore Eye Research Institute, Singapore.,Duke-National University of Singapore Medical School, Singapore
| | - Hla Myint Htoon
- Singapore Eye Research Institute, Singapore.,Duke-National University of Singapore Medical School, Singapore
| | - Donald Tan
- Singapore National Eye Centre, Singapore .,Singapore Eye Research Institute, Singapore.,Duke-National University of Singapore Medical School, Singapore
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Ighani M, Karakus S, Eghrari AO. Clinical Outcomes Of Descemet Membrane Endothelial Keratoplasty Using The Bonfadini-Todd Injector For Graft Insertion. Clin Ophthalmol 2019; 13:1869-1876. [PMID: 31571824 PMCID: PMC6759826 DOI: 10.2147/opth.s219742] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/29/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose To evaluate the clinical outcomes of using an Alcon intraocular lens (IOL) B cartridge for graft insertion during Descemet membrane endothelial keratoplasty (DMEK). Patients and methods We retrospectively reviewed medical charts of patients who underwent DMEK using the Bonfadini-Todd injector, composed of an Alcon IOL B cartridge connected to plastic tubing and a syringe, for graft insertion between May 2016 and August 2018. Patient demographics, diagnoses, donor information, visual acuity, intraocular pressure (IOP), graft position and attachment status, pachymetry, and postoperative complications were recorded. Results Twenty-four eyes of 23 patients with an average age of 72.8 ± 10.0 years (range, 48–87 years) were included. Mean follow-up duration was 13.3 ± 6.6 months (range, 3–26 months). Twenty-one (87.5%) patients had a primary diagnosis of Fuchs endothelial dystrophy, two (8.3%) patients had bullous keratopathy and one (4.2%) had Peter’s anomaly. Sixteen (66.7%) cases combined phacoemulsification and IOL implantation. Best-corrected visual acuity improved from a median of 0.398 logMAR preoperatively to 0.097 logMAR (P <0.001) at last follow-up examination, and central corneal thickness decreased from a median of 651 μm to 533.5 μm (P <0.001). Nine of 24 patients (37.5%) required re-bubbling due to partial graft detachment with a mean time of 12.1 ± 9.2 days (range, 5–35 days). One patient (4.2%) developed graft failure after re-bubbling and underwent Descemet stripping endothelial keratoplasty. Conclusion The Alcon IOL B cartridge for DMEK graft insertion is safe and simple.
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Affiliation(s)
- Mehrnaz Ighani
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sezen Karakus
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen O Eghrari
- Division of Cornea, Cataract and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sella R, Einan-Lifshitz A, Sorkin N, Chan CC, Afshari NA, Rootman DS. Learning curve of two common Descemet membrane endothelial keratoplasty graft preparation techniques. Can J Ophthalmol 2019; 54:467-472. [DOI: 10.1016/j.jcjo.2018.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/21/2018] [Accepted: 09/30/2018] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW To provide an update on new perspectives on Descemet membrane endothelial keratoplasty (DMEK). RECENT FINDINGS Preloaded DMEK grafts allow optimization of DMEK surgery time and reduce costs of the procedure, which is allowing the procedure to become more easily performed as reflected in the increasing number of cases. The surgical technique in the United States differs from the technique in Europe, but outcomes have been similar. Hemi-DMEK and quarter-DMEK have shown similar outcomes to conventional DMEK with respect to corneal transparency and visual acuity. Three-year follow-up of hemi-DMEK has also shown stability in endothelial cell count while maintaining corneal transparency. SUMMARY DMEK is becoming more accepted as the procedure of choice for treating endothelial failure. However, challenges with the surgical technique have limited wider implementation of this lamellar corneal transplantation. Preloaded DMEK provides one solution for the surgical challenges associated with the procedure while also reducing costs. Variations in the surgical technique for DMEK, including hemi-DMEK and quarter-DMEK, allow for central corneal clarity similar to traditional DMEK, but both result in lower endothelial cell density (ECD).
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Culturing Discarded Peripheral Human Corneal Endothelial Cells From the Tissues Deemed for Preloaded DMEK Transplants. Cornea 2019; 38:1175-1181. [DOI: 10.1097/ico.0000000000001998] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Karakus S, Ighani M, Noparat P, Tofigh M, Chiang E, Barnes K, Chen CY, Liu TS, Eghrari AO. Aspiration of Tri-folded, Endothelium-In Grafts for Descemet Membrane Endothelial Keratoplasty. Cornea 2019; 38:654-657. [PMID: 30702471 DOI: 10.1097/ico.0000000000001888] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE In Descemet membrane endothelial keratoplasty (DMEK), loading and positioning of tri-folded grafts into a cartridge is generally conducted with forceps or a hook, risking graft tear or trauma. We demonstrate the feasibility of loading tri-folded grafts into a cartridge with no touch to the endothelium required beyond the tri-folding process. METHODS A corneoscleral rim with a prestripped DMEK graft is placed into a petri dish. After the graft is tri-folded with forceps and removed from its stromal attachment, the graft is gently wicked into the tip of a saline-filled Alcon B IOL cartridge connected to IV extension tubing and a 3 cc syringe, drawn into the cartridge by positioning it adjacent to the graft tip. The remainder of the graft is aspirated with the addition of saline. The cartridge orientation is reversed for graft injection. In this retrospective analysis, we analyzed surgical videos for preparation times, and assessed postoperative visual acuity, pachymetry, and endothelial cell density. RESULTS Thirteen cases underwent this approach. Median preparation time from stain to cartridge eye contact was 8.5 minutes, and time from graft injection to final centration and bubbling was 2.9 minutes. Corneal thickness decreased from a median of 623 microns preoperatively to 566 μm at 1 month (P = 0.038). Visual acuity improved by 1 month by a median of 0.3 logarithm of the minimum angle of resolution (logMAR) (P = 0.016). Endothelial cell density decreased by 32.4% at 1 month compared with baseline. CONCLUSIONS Endothelium-in DMEK grafts may be loaded into a plastic cartridge using a skill set similar to aspiration of a scroll.
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Affiliation(s)
- Sezen Karakus
- Wilmer Eye Institute at Johns Hopkins, Baltimore, MD
| | | | | | - Marjan Tofigh
- Wilmer Eye Institute at Johns Hopkins, Baltimore, MD
| | - Eric Chiang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Kali Barnes
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Conan Y Chen
- University of Colorado School of Medicine, Aurora, CO
| | - Tiffany S Liu
- Wilmer Eye Institute at Johns Hopkins, Baltimore, MD
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Comparison of Tri-folded and Scroll-based Graft Viability in Preloaded Descemet Membrane Endothelial Keratoplasty. Cornea 2019; 38:392-396. [PMID: 30550395 DOI: 10.1097/ico.0000000000001831] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare corneal endothelial damage associated with 2 techniques for preloaded Descemet membrane endothelial keratoplasty (DMEK): a tri-folded graft stored in a plastic cartridge designed for DMEK and a scrolled graft stored in a modified Jones Tube, at the time of preparation and after shipping. METHODS DMEK grafts were prepared at the Rocky Mountain Lions Eye Bank. The grafts were either tri-folded and loaded in a plastic cartridge or scrolled and loaded into a modified Jones Tube. In each group, the grafts were then either immediately removed from the cartridges or shipped for 48 hours. The grafts were then stained with Calcein AM and imaged using a fluorescent microscope. Endothelial cell loss (ECL) was determined using trainable segmentation in Fiji by 2 graders. At each time point, rates of ECL loss were compared across the 2 groups. To explore the role of donor characteristics, a multivariable regression model was produced to account for method (tri-folding vs. scroll), donor age, donor gender, death-to-preservation time, death-to-preparation time, and shipping. RESULTS A total of 40 grafts were prepared, processed, imaged, and analyzed. No significant difference in cell loss was seen between groups at either time point alone. In the multivariate model, no significant increase in cell loss was associated with either tri-folding (3.7% less ECL; P = 0.051) or shipping (4.3% less ECL; P = 0.049). CONCLUSIONS All techniques used resulted in clinically acceptable levels of ECL. Tri-folded tissue in a plastic cartridge did not result in ECL inferior to a scroll when prepared either immediately or preloaded for 48 hours.
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