1
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Donner R, Schmidinger G. Clinical outcome analysis of two approaches to trypan blue dyeing for DMEK. Sci Rep 2024; 14:16663. [PMID: 39030334 PMCID: PMC11271613 DOI: 10.1038/s41598-024-67695-2] [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: 03/22/2024] [Accepted: 07/15/2024] [Indexed: 07/21/2024] Open
Abstract
To evaluate the clinical implications of the different trypan blue dyeing techniques used during liquid bubble (LBT) and manual peel (MPT) DMEK lenticule preparation techniques. This study retrospectively compared the degree to which endothelial cells are preserved using selective Descemet Membrane (DM) staining (LBT) versus bath-staining (MPT) when performed by a single surgeon, sourced from a single eye bank. Endothelial cell density measured after the 3-month follow-up was 1805 and 1916 cells/mm2 respectively, differing significantly (p = 0.012). A double-scroll graft formation was found and maintained until implantation in 94% of preparations with bath staining and 50% of preparations using selective DM staining. Preoperative visual acuity was comparable between preparation techniques at 0.4 logMAR as well as postoperatively, at an average of 0.1 logMAR. Reducing chemical stress on the endothelium by avoiding any contact with trypan blue allows for a significantly higher degree of cell preservation. However, achieving the often-desired double-scroll graft formation was possible less frequently. It remains unclear which factors define the differences graft scrolling behavior observed between LBT and MPT.
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Affiliation(s)
- Ruth Donner
- Department of Ophthalmology and Optometry, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Gerald Schmidinger
- Department of Ophthalmology and Optometry, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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2
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Reinert U, Seitz B, Munteanu C, Daas L. [Impact of the ratio between graft and host corneal size on immune rejection, re-bubbling rate and postoperative endothelial cell loss in 457 eyes after Descemet membrane endothelial keratoplasty (DMEK)]. DIE OPHTHALMOLOGIE 2024; 121:565-570. [PMID: 38639889 DOI: 10.1007/s00347-024-02030-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/10/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The aim of this study was to assess the impact of the ratio between the graft and host corneal size (RGH) on postoperative complications, such as immune reactions, re-bubbling rate and endothelial cell loss (ECL) after Descemet membrane endothelial keratoplasty (DMEK). PATIENTS AND METHODS Retrospectively, 457 patient eyes were included which had undergone surgery between 2016 and 2019 in the Department of Ophthalmology, Saarland University Medical Center in Homburg/Saar using DMEK or triple DMEK, diagnosed as Fuchs' endothelial dystrophy (n = 431), pseudophakic bullous keratopathy (n = 9) and others (n = 17). The follow-up period extended until the end of 2020. Main outcome measures included immune reaction (IR), re-bubbling rate and the postoperative endothelial cell loss (ECL) at 6 weeks, 6 months and 12 months and whether these measures depended on the RGH. RESULTS The RGH in this study ranged from 0.35 to 0.62 (0.46 ± 0.04). There were 33 (7.2%) postoperative IRs (DMEK n = 25; triple DMEK n = 8). The average RGH without IR (0.46 ± 0.04) was significantly (p = 0.038) smaller than in the group with IR (0.47 ± 0.05). Re-bubbling was necessary in 159 of 457 (34.8%) patient eyes. The RGH in patient eyes with re-bubbling (0.47 ± 0.04) was significantly (p = 0.014) higher than that in eyes without re-bubbling (0.45 ± 0.04). The mean preoperative endothelial cell count (ECD) was 2603 ± 251 cells/mm2 (min: 2161, max: 3500 cells/mm2). It was shown that a larger RGH had no positive influence on endothelial cell loss (r = 0.001; p = 0.974). CONCLUSION Our results suggest that a larger graft diameter compared to host corneal size is associated with an increased rate of immune reactions and a higher re-bubbling rate after DMEK. Otherwise, a larger RGH had no positive influence on endothelial cell loss after DMEK. Accordingly, the graft size for DMEK should not be unnecessarily large, especially in eyes with Fuchs' endothelial dystrophy.
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Affiliation(s)
- Ursula Reinert
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland.
| | - Berthold Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland
| | - Cristian Munteanu
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland
| | - Loay Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Kirrberger Straße 100, 66424, Homburg/Saar, Deutschland
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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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4
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Romano V, Passaro ML, Bachmann B, Baydoun L, Ni Dhubhghaill S, Dickman M, Levis HJ, Parekh M, Rodriguez-Calvo-De-Mora M, Costagliola C, Virgili G, Semeraro F. Combined or sequential DMEK in cases of cataract and Fuchs endothelial corneal dystrophy-A systematic review and meta-analysis. Acta Ophthalmol 2024; 102:e22-e30. [PMID: 37155336 DOI: 10.1111/aos.15691] [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: 02/23/2023] [Revised: 03/19/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
To compare the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed after phacoemulsification and intraocular lens (IOL) implantation (sequential DMEK) and DMEK combined with phacoemulsification and IOL implantation (combined DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and cataract. Systematic literature review and meta-analysis performed according to the PRISMA guidelines and registered in PROSPERO. Literature searches were conducted in Medline and Scopus. Comparative studies reporting sequential DMEK and combined DMEK in FECD patients were included. The main outcome measure of the study was the corrected distance visual acuity (CDVA) improvement. Secondary outcomes were postoperative endothelial cell density (ECD), rebubbling rate and primary graft failure rate. Bias risk was assessed and a quality appraisal of the body of evidence was completed using the Cochrane Robin-I tool. A total of 667 eyes (5 studies) were included in this review, 292 eyes (43.77%) underwent a combined DMEK, while 375 (56.22%) eyes underwent a sequential DMEK surgery. We found no evidence of a difference between the two groups (mean difference, 95% CI) regarding: (1) CDVA improvement (-0.06; -0.14, 0.03 LogMAR; 3 studies, I2 : 0%; p = 0.86); (2) postoperative ECD (-62; -190, 67 cells/mm2 ; 4 studies, I2 : 67%; p = 0.35); (3) rebubbling (risks ratio: 1.04; 0.59, 1.85; 4 studies, I2 : 48%; p = 0.89); and primary graft failure rate (risks ratio: 0.91; 0.32, 2.57; 3 studies, I2 : 0%; p = 0.86). Of all the 5 non-randomized studies, all (100%) were graded as low quality. The overall quality of the analysed studies was low. Randomized controlled trials are needed to confirm no difference or superiority of one approach in terms of CDVA, endothelial cell count and postoperative complication rate between the two arms.
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Affiliation(s)
- Vito Romano
- Ophthalmic Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Lombardy, Brescia, Italy
- Ophthalmic Unit, ASST Spedali Civili di Brescia, Lombardy, Brescia, Italy
| | - Maria Laura Passaro
- Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples "Federico II", Naples, Italy
| | - Bjoern Bachmann
- Department of Ophthalmology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lamis Baydoun
- University Eye Hospital, Munster, Germany
- ELZA Institute Dietikon/Zurich, Zurich, Switzerland
| | - Sorcha Ni Dhubhghaill
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium
- Ophthalmology, Visual Optics and Visual Rehabilitation, Department of Translational Neurosciences, University of Antwerp, Wilrijk, Belgium
| | - Mor 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
| | - Hannah J Levis
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Mohit Parekh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Massachusetts, Boston, USA
| | | | - Ciro Costagliola
- Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples "Federico II", Naples, Italy
| | - Gianni Virgili
- Department of Neuroscience, Psychology, Drug Research and Child Health, Ophthalmology, University of Florence-Careggi, Florence, Italy
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Francesco Semeraro
- Ophthalmic Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Lombardy, Brescia, Italy
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Gadhvi KA, Pagano L, Wallace A, Posarelli M, Parekh M, Romano V. New forceps free injection technique for delivering descemet membrane endothelial keratoplasty preloaded endothelium-in grafts. Eur J Ophthalmol 2024; 34:287-291. [PMID: 37861107 DOI: 10.1177/11206721231208998] [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: 10/21/2023]
Abstract
PURPOSE To describe a new method for delivering DMEK grafts into the recipient's eye with endothelium inward configuration using a no-forceps injection technique. METHODS We retrospectively review 11 patients that underwent DMEK surgery at our institution using a no-forceps injection technique. The graft was preloaded into an intraocular lens (IOL) cartridge and connected to an anterior chamber maintainer (ACM). A 5 ml non luer lock syringe was inserted into the other end of the ACM to create a one-flow system. The cartridge was inserted into the posterior end of an injector, and the graft was successfully delivered into the recipient's eye. RESULT Twelve eyes of 11 patients were included. Mean follow-up was 9.16 ± 1.3 months. At baseline, mean best corrected visual acuity (BCVA) was 0.76 ± 0.13 logMAr and mean endothelial cell density (ECD) was 2619.00 ± 115.89 cells/mm2. At follow-up, BCVA significantly improved to 0.22 ± 0.05 logMAR (p = 0.003). Although we observed a significant reduction in ECD at follow-up (1688 ± 182.20, p = 0.002), our patients lost only 35.69 ± 6.36% of endothelial cells. CONCLUSION Our technique can help surgeons safely deliver an endothelium-in graft into the recipient's eye. The method doesn't require the use of a forceps, minimizing the risk of endothelial cell loss or graft damage.
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Affiliation(s)
- Kunal A Gadhvi
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Luca Pagano
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Alexander Wallace
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Matteo Posarelli
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
- Ophthalmology Unit of the Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Mohit Parekh
- Schepens Eye Research Institute, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Vito Romano
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, Brescia, Italy
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Bichet P, Moskwa R, Goetz C, Zevering Y, Vermion JC, Perone JM. Five-year clinical outcomes of 107 consecutive DMEK surgeries. PLoS One 2023; 18:e0295434. [PMID: 38127965 PMCID: PMC10735023 DOI: 10.1371/journal.pone.0295434] [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: 06/27/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE The long-term clinical outcomes, postoperative complications, and graft survival of Descemet-membrane endothelial keratoplasty (DMEK) remain poorly understood. We retrospectively assessed these variables in all consecutive eyes that underwent DMEK for any indication in 2014-2018. The findings were compared to the long-term DMEK studies of five other groups (3-10-year follow-up). METHODS Patients underwent ophthalmological tests preoperatively, at 1, 3, 6, and 12 postoperative months, and then annually. Five-year graft survival was determined by Kaplan-Meier estimator. Change in best-corrected visual acuity (BCVA), endothelial-cell density (ECD), and central-corneal thickness (CCT) at each timepoint was determined. RESULTS 107 eyes (80 patients; 72 years old; 67% female) underwent first-time DMEK for uncomplicated Fuchs endothelial corneal dystrophy (94% of eyes), pseudophakic bullous keratopathy (3%), and regraft after previous keratoplasty (3%). The most common complication was graft detachment requiring rebubbling (18%). Thirteen grafts (12%) failed at ≤15 months. Cumulative 5-year graft-survival probability was 88% (95% confidence intervals = 79-94%). BCVA improved from 0.6 logMAR preoperatively to 0.05 logMAR at 1 year (p<0.0001) and then remained stable. Donor ECD dropped by 47% at 6 postoperative months and then continued to decrease by 4.0%/year. Five-year endothelial-cell loss was 65% (from 2550 to 900 cells/mm2). CCT dropped from 618 to 551 μm at 5 years (p<0.0001). These findings are generally consistent with previous long-term DMEK studies. CONCLUSIONS DMEK has low complication and high graft-survival rates and excellent clinical outcomes that persist up to 5 years post-surgery. DMEK seems to be a safe and effective treatment in the long term.
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Affiliation(s)
- Pierre Bichet
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Rémi Moskwa
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Christophe Goetz
- Clinical Research Support Unit, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville Regional Hospital Center, Metz, France
| | - Yinka Zevering
- Clinical Research Support Unit, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville Regional Hospital Center, Metz, France
| | - Jean-Charles Vermion
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Jean-Marc Perone
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
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Rodríguez-Calvo-de-Mora M, Rocha-de-Lossada C, Romano V, Rodríguez-Vallejo M, Fernández J. Descemet membrane endothelial keratoplasty combined with presbyopia-correcting and toric intraocular lenses - a narrative review. BMC Ophthalmol 2023; 23:483. [PMID: 38007433 PMCID: PMC10675930 DOI: 10.1186/s12886-023-03240-5] [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: 09/18/2023] [Accepted: 11/21/2023] [Indexed: 11/27/2023] Open
Abstract
Fuchs endothelial corneal dystrophy (FECD) is the leading indication for EK and may coexist with cataract and presbyopia. Notably, the outcomes of phacoemulsification in FECD patients are not as favorable as those in eyes without this condition. Historically, only monofocal intraocular lenses (IOLs) were recommended for these patients. However, recent reports have described the implantation of Premium-IOLs (such as Multifocal IOLs, Enhanced Depth of Focus IOLs, and Toric IOLs) in FECD eyes undergoing cataract surgery and Descemet membrane endothelial keratoplasty (DMEK). While the results are encouraging, they are not as optimal as those from unoperated eyes, especially when comparing simultaneous procedures to sequential ones. It's advised to perform the DMEK first to improve the accuracy of IOL calculations. Still, even successfully operated eyes may experience secondary graft failure or graft rejection after DMEK. The success rate of a secondary DMEK is typically lower than that of the initial procedure. Furthermore, if the postoperative thickness after DMEK is less than anticipated, laser enhancements might not be an option. There's a pressing need for more controlled and randomized clinical trials to ascertain the safety and effectiveness of Premium-IOLs for FECD eyes. This narrative review aims to collate evidence on the use of Premium IOL technologies in eyes receiving EK and to underscore key points for surgeons performing EK combined with cataract surgery.
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Affiliation(s)
- Marina Rodríguez-Calvo-de-Mora
- Qvision, Department of Ophthalmology of VITHAS Almería Hospital, Almería, 04120, Spain
- Ophthalmology Department, VITHAS Málaga, Málaga, 29016, Spain
- Hospital Regional Universitario de Málaga, Plaza del Hospital Civil, S/N, Málaga, 29009, Spain
| | - Carlos Rocha-de-Lossada
- Qvision, Department of Ophthalmology of VITHAS Almería Hospital, Almería, 04120, Spain
- Ophthalmology Department, VITHAS Málaga, Málaga, 29016, Spain
- Hospital Regional Universitario de Málaga, Plaza del Hospital Civil, S/N, Málaga, 29009, Spain
- Departamento de Cirugía, Área de Oftalmología, Universidad de Sevilla, Doctor Fedriani, S/N, Seville, 41009, Spain
| | - Vito Romano
- Ophthalmic Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Ophthalmic Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Joaquín Fernández
- Qvision, Department of Ophthalmology of VITHAS Almería Hospital, Almería, 04120, Spain
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Berg K, Safi T, Seitz B, Daas L. Non-invasive endothelial cell density measurement of in toto pre-stripped DMEK-roll - impact of pre- and intraoperative endothelial cell loss on postoperative midterm clinical outcome. Eye (Lond) 2023; 37:2956-2962. [PMID: 36813996 PMCID: PMC10516950 DOI: 10.1038/s41433-023-02450-x] [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: 05/15/2022] [Revised: 01/13/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND/OBJECTIVES To measure the endothelial cell density (ECD) of the in toto pre-stripped endothelial Descemet membrane lamellae (EDML) and to describe the impact of pre- and intraoperative endothelial cell loss (ECL) on postoperative midterm clinical outcome. SUBJECTS/METHODS The ECD of 56 Corneoscleral Donor Discs (CDD) was first measured with an inverted specular microscope (t0pre). The measurement was then repeated non-invasively after the preparation of the EDML (t0post). DMEK was performed the next day using these grafts. Follow-up examinations took place 6 weeks, 6 months and 1 year postoperatively where the ECD was assessed. In addition, the impact of ECL 1 (during preparation) and ECL 2 (during surgery) on the ECD, visual acuity (VA) and pachymetry at 6 months and 1 year was investigated. RESULTS The average ECD (in cells/mm²) at time points t0pre, t0post, 6 weeks, 6 months & 1 year was 2584 ± 200, 2355 ± 207, 1366 ± 345, 1091 ± 564 and 939 ± 352. The average logMAR VA and pachymetry (in µm) was 0.50 ± 0.27 and 597 ± 63, 0.23 ± 0.17 and 535 ± 54, 0.16 ± 0.12 and 535 ± 54, 0.06 ± 0.08 and 512 ± 37, respectively The ECL 1 (9% on average) had no significant impact on the main outcome measures after 6 months and 1 year (p > 0.11). The ECL 2 correlated significantly with the ECD and the pachymetry at 1 year postop (p < 0.02). CONCLUSION Our results indicate that the non-invasive ECD measurement of the prestripped EDML roll before its transplantation is feasible. Despite significantly decreasing ECD up to 6 months postoperatively, visual acuity further improved and thickness further decreased up to 1 year postoperatively.
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Affiliation(s)
- Kolja Berg
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany.
| | - Tarek Safi
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Germany
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Mukhija R, Quiney G, Nanavaty MA. Clinical Outcomes of Descemet's Membrane Endothelial Keratoplasty without Routine Prophylactic Peripheral Iridotomy. Vision (Basel) 2023; 7:vision7020041. [PMID: 37218959 DOI: 10.3390/vision7020041] [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: 04/04/2023] [Revised: 04/27/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023] Open
Abstract
Objectives: To analyze the outcomes and complications of Descemet's membrane endothelial keratoplasty (DMEK) performed without prophylactic peripheral iridotomy (PI). Methods: Design: Retrospective study. SETTING Institutional, tertiary care eye hospital. STUDY POPULATION All patients who underwent DMEK or DMEK combined with phacoemulsification (DMEK triple) for Fuchs endothelial dystrophy, using a standardized protocol between August 2016 and July 2021, were included. Previous glaucoma surgery, laser PI, aphakia, or complicated pseudophakia were excluded. MAIN OUTCOME MEASURES Primary outcomes: Incidence of pupillary block (PB). SECONDARY OUTCOMES Graft detachment (GD), rebubbling rates, uncorrected (UCDVA) and best corrected logMAR distance visual acuity (BCDVA), and endothelial cell loss (ECL) at six months. Data were analyzed using the chi-square test and stepwise backward regression analysis. Results: 104 eyes of 72 patients were included. Four eyes (3.8%) developed PB; in two of these cases, standard protocol was not followed. Overall minor GD occurred in 43.2% (n = 45); significant GD was present only in 7 eyes (6.6%). Overall slit lamp rebubbling rate was 30% (n = 35), though only four patients were rebubbled in theatre (3.8%). PB, GD, and rebubbling rates did not vary with the surgeon, surgery, or tamponade (air or SF6 gas). UCDVA, BCDVA, and ECL at 6 months were 0.29 ± 0.31, 0.20 ± 0.28, and 40.46 ± 20.36%, respectively. Conclusions: Compared to previously reported outcomes of DMEK with PI, our results of PI less DMEK using a standardized protocol have a similar incidence of pupillary block, graft detachment, and rebubbling, with comparable visual acuity and endothelial cell loss.
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Affiliation(s)
- Ritika Mukhija
- Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton BN11 2DH, UK
| | - Gabriella Quiney
- Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton BN1 9RH, UK
| | - Mayank A Nanavaty
- Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton BN11 2DH, UK
- Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton BN1 9RH, UK
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Ali M, Cho K, Srikumaran D. Fuchs Dystrophy and Cataract: Diagnosis, Evaluation and Treatment. Ophthalmol Ther 2023; 12:691-704. [PMID: 36637659 PMCID: PMC10011243 DOI: 10.1007/s40123-022-00637-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/07/2022] [Indexed: 01/14/2023] Open
Abstract
Corneal endothelium plays an important role in maintaining hydration homeostasis and clarity of the cornea. Fuchs endothelial corneal dystrophy (FECD) affects the corneal endothelium resulting in edema and characteristic excrescences on the Descemet's membrane known as corneal guttae. Descemet membrane endothelial keratoplasty (DMEK) has evolved to become the standard of care for patients with FECD with excellent visual acuity outcomes. Patients with FECD may have coexisting cataracts and therefore may require a cataract surgery, which increases the risk of corneal decompensation. The presence of FECD may not only influence the choice of intraocular lens but vision outcomes can also be affected by the corneal condition. The ability to combine the surgeries further raises important considerations regarding the timing and sequence of DMEK and cataract extraction for patients with FECD. This review provides a guide for corneal surgeons in choosing between endothelial keratoplasty and cataract surgery-alone, in combination or sequential-in their management of patients with FECD.
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Affiliation(s)
- Muhammad Ali
- Vice Chair for Education, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Kyongjin Cho
- Vice Chair for Education, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Divya Srikumaran
- Vice Chair for Education, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA.
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11
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Gurnani B, Kaur K, Lalgudi VG, Tripathy K. Risk Factors for Descemet Membrane Endothelial Keratoplasty Rejection: Current Perspectives- Systematic Review. Clin Ophthalmol 2023; 17:421-440. [PMID: 36755886 PMCID: PMC9899935 DOI: 10.2147/opth.s398418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is a corneal endothelial transplantation procedure with selective removal of a patient's defective Descemet membrane and endothelium. It is replaced with a healthy donor Descemet membrane and endothelium without a stromal component. Corneal graft rejection can be at the level of epithelium, stroma as well endothelium. DMEK graft rejection is relatively less common than rejection with DSAEK or penetrating keratoplasty, and a good outcome may be achieved with prompt management. The clinical picture of DMEK rejection is usually similar to endothelial rejection in Descemet Stripping Endothelial Keratoplasty (DSEK/DSAEK), which generally manifests as pain, redness, reduction in visual acuity, stromal edema, endothelial rejection line, keratic precipitates at the back of the cornea and corneal neovascularization. However, more subtle forms of rejection or immune reactions are more common in DMEK compared to DSAEK eyes. Early clinical diagnosis, prompt intervention, and meticulous management safeguard visual acuity and graft survival in these cases. Intensive topical steroids form the mainstay in the management of DMEK rejection. Sometimes, oral or intravenous steroids or other systemic immunomodulators may be required. DMEK graft failure can be primary or secondary, and failure usually requires a second procedure in the form of repeat DMEK or DSEK or penetrating keratoplasty (PKP). A detailed literature search was performed using search engines such as Google Scholar, PubMed, and Google books, and a comprehensive review on DMEK rejection was found to be lacking. This review is a comprehensive update on the risk factors, pathophysiology, primary and secondary graft failure, recent advances in diagnosis, prevention of rejection, and updates in the management of DMEK rejection. The review also discusses the differential diagnosis of DMEK failure and rejection, prognosis, and future perspectives considering DMEK failure and rejection.
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Affiliation(s)
- Bharat Gurnani
- Department of Cornea and Refractive Surgery, Sadguru Netra Chikitsalaya, Shri Sadguru Seva Sangh Trust, Janaki-kund, Madhya Pradesh, India,Correspondence: Bharat Gurnani, Consultant, Cataract, Cornea, External Diseases, Trauma, Ocular Surface, Uvea and Refractive Surgery, Sadguru Netra Chikitsalaya, Shri Sadguru Seva Sangh Trust, Janaki-kund, Madhya Pradesh, 485334, India, Tel +919080523059, Email
| | - Kirandeep Kaur
- Department of Pediatric Ophthalmology, Sadguru Netra Chikitsalaya, Shri Sadguru Seva Sangh Trust, Janaki-kund, Madhya Pradesh, India
| | | | - Koushik Tripathy
- Department of Vitreoretinal and Cataract, ASG Eye Hospital, Kolkata, West Bengal, India
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12
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Hollick EJ. A fuller picture? National registry studies and the assessment of corneal graft outcomes. Br J Ophthalmol 2023; 107:1-2. [PMID: 35701078 DOI: 10.1136/bjophthalmol-2022-321938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Emma J Hollick
- Ophthalmology, King's College Hospital NHS Foundation Trust, London, UK
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13
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Bloch F, Dinot V, Goetz C, Zevering Y, Lhuillier L, Perone JM. Ability of routinely collected clinical factors to predict good visual results after primary Descemet membrane endothelial keratoplasty: a cohort study. BMC Ophthalmol 2022; 22:350. [PMID: 35999622 PMCID: PMC9400293 DOI: 10.1186/s12886-022-02574-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 07/26/2022] [Indexed: 11/11/2022] Open
Abstract
Background A comprehensive analysis of routinely collected pre/perioperative demographic/clinical factors that could predict final visual acuity after primary Descemet membrane endothelial keratoplasty (DMEK) has not been conducted previously. Methods A retrospective monocenter cohort study was performed with consecutive patients with Fuchs endothelial corneal dystrophy (FECD) who underwent DMEK or triple-DMEK (DMEK combined with cataract surgery) in 2016–2020 in a French tertiary-care hospital. DMEK-only patients were pseudophakic. Patients were followed for 12 months. Surgery was considered successful when 12-month best-corrected visual acuity (BCVA) was ≤0.1 logMAR (≥0.8). Exploratory multivariate analysis was conducted with the following routinely collected variables to determine their ability to predict 12-month BCVA: patient age and sex; graft donor age; triple DMEK; preoperative values of BCVA, endothelial cell density (ECD), central corneal thickness (CCT), and mean anterior keratometry; and rebubbling. Results Of 100 eyes (100 patients; mean age, 72 years; 61% female), 81 achieved a 12-month BCVA of ≤0.1 logMAR. Logistic regression analysis showed that older age was a significant prognosticator for 12-month BCVA > 0.1 logMAR (Odds Ratio = 0.914, 95% confidence intervals = 0.846–0.987; p = 0.02). Conclusions An older age associated with worse visual acuity outcomes after DMEK. This was confirmed by our analysis of the literature and supports the notion that DMEK should be conducted without delay once symptoms appear. Patient sex, donor age, triple-DMEK, and anterior keratometry also did not predict final BCVA in the literature. Preoperative CCT, ECD, and BCVA, and rebubbling occasionally appear in the literature as BCVA predictors, possibly reflecting an underlying ECD-BCVA axis.
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Affiliation(s)
- Florian Bloch
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, 1 Allée du Château, CS 45001, 57085, Metz-Cedex 03, France
| | - Vincent Dinot
- Clinical Research Support Unit, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| | - Christophe Goetz
- Clinical Research Support Unit, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| | - Yinka Zevering
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, 1 Allée du Château, CS 45001, 57085, Metz-Cedex 03, France
| | - Louis Lhuillier
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, 1 Allée du Château, CS 45001, 57085, Metz-Cedex 03, France
| | - Jean-Marc Perone
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, 1 Allée du Château, CS 45001, 57085, Metz-Cedex 03, France.
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14
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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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15
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Chou WY, Kuo YS, Lin PY. Cataract surgery in patients with Fuchs' dystrophy and corneal decompensation indicated for Descemet's membrane endothelial keratoplasty. Sci Rep 2022; 12:8500. [PMID: 35589882 PMCID: PMC9120518 DOI: 10.1038/s41598-022-12434-8] [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: 12/02/2021] [Accepted: 05/10/2022] [Indexed: 11/21/2022] Open
Abstract
The availability of corneal donor tissue is limited in most developing countries. This study evaluated whether patients with coexisting cataract and Fuchs’ dystrophy with corneal decompensation awaiting Descemet’s membrane endothelial keratoplasty (DMEK) benefited from phacoemulsification. This is a retrospective case–control study which included patients with Fuchs’ dystrophy and evidence of corneal decompensation awaiting DMEK. Best-corrected visual acuity (BCVA) and central corneal thickness (CCT) were documented at baseline (pre-cataract surgery in the case group, or at the time of transplantation registry in the control group), 1-month and pre-DMEK. A total of 16 phakic patients with visually significant cataracts had cataract surgery during the study period, and 15 pseudophakic patients were included as controls. There was no significant difference with regard to BCVA at baseline, 1-month or pre-DMEK between the case and control groups. Similarly, no significant difference in CCT was found at baseline, 1-month or pre-DMEK. In the case group, 4 patients with improved visual acuity post-cataract surgery chose to defer DMEK. After stratification, statistical analysis showed significantly better BCVA in the deferred group (n = 4) at 1-month post-cataract surgery, compared to the DMEK group (n = 12) (0.21 ± 0.21 vs. 0.86 ± 0.29 LogMAR, P = 0.004). The other parameters, including baseline BCVA and CCT at any time point documented, were not statistically different. In conclusion, in patients with Fuchs’ dystrophy and decompensated corneas awaiting transplantation, phacoemulsification did not lead to significant increase of corneal thickness nor deterioration of visual acuity. A few patients achieved satisfactory vision after cataract surgery and deferred endothelial keratoplasty.
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Affiliation(s)
- Wei-Yi Chou
- Department of Ophthalmology, Taipei Veterans General Hospital, 201, Sec. 2, ShihPai Rd., Taipei, Taiwan, 11217.,Department of Ophthalmology, Zhongxing Branch, Taipei City Hospital, Taipei, Taiwan
| | - Yih-Shiuan Kuo
- Department of Ophthalmology, Taipei Veterans General Hospital, 201, Sec. 2, ShihPai Rd., Taipei, Taiwan, 11217
| | - Pei-Yu Lin
- Department of Ophthalmology, Taipei Veterans General Hospital, 201, Sec. 2, ShihPai Rd., Taipei, Taiwan, 11217. .,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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16
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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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17
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Chaussard D, Bloch F, Elnar AA, Zevering Y, Vermion JC, Moskwa R, Perone JM. Identification of the preoperative and perioperative factors that predict postoperative endothelial cell density after Descemet membrane endothelial keratoplasty: A retrospective cohort study. PLoS One 2022; 17:e0264401. [PMID: 35202443 PMCID: PMC8870504 DOI: 10.1371/journal.pone.0264401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/09/2022] [Indexed: 11/19/2022] Open
Abstract
Low postoperative endothelial-cell density (ECD) plays a key role in graft failure after Descemet-membrane endothelial keratoplasty (DMEK). Identifying pre/perioperative factors that predict postoperative ECD could help improve DMEK outcomes. This retrospective study was conducted with consecutive adult patients with Fuchs-endothelial corneal dystrophy who underwent DMEK in 2015–2019 and were followed for 12 months. Patients underwent concomitant cataract surgery (triple-DMEK) or had previously undergone cataract surgery (pseudophakic-DMEK). Multivariate analyses assessed whether: patient age/sex; graft-donor age; preoperative ECD, mean keratometry, or visual acuity; triple DMEK; surgery duration; surgical difficulties; and need for rebubbling predicted 6- or 12-month ECD in the whole cohort or in subgroups with high/low ECD at 6 or 12 months. The subgroups were generated with the clinically relevant threshold of 1000 cells/mm2. Surgeries were defined as difficult if any part was not standard. In total, 103 eyes (95 patients; average age, 71 years; 62% women) were included. Eighteen eyes involved difficult surgery (14 difficult graft preparation or unfolding cases and four others). Regardless of how the study group was defined, the only pre/perioperative variable that associated significantly with 6- and 12-month ECD was difficult surgery (p = 0.01, 0.02, 0.05, and 0.0009). Difficult surgery also associated with longer surgery duration (p = 0.002). Difficult-surgery subgroup analysis showed that difficult graft dissection associated with lower postoperative ECD (p = 0.03). This association may reflect endothelial cell loss due to excessive graft handling and/or an intrinsic unhealthiness of the endothelial cells in the graft that conferred unwanted physical properties onto the graft that complicated its preparation/unfolding.
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Affiliation(s)
- Dimitri Chaussard
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Florian Bloch
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Arpiné Ardzivian Elnar
- Clinical Research Support Unit, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville Regional Hospital Center, Metz, France
| | - Yinka Zevering
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Jean-Charles Vermion
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Rémi Moskwa
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
| | - Jean-Marc Perone
- Ophthalmology Department, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz, France
- Institut Jean Lamour, Lorraine University, Nancy, France
- * E-mail:
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18
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Moshirfar M, Huynh R, Ellis JH. Cataract surgery and intraocular lens placement in patients with Fuchs corneal dystrophy: a review of the current literature. Curr Opin Ophthalmol 2022; 33:21-27. [PMID: 34743088 DOI: 10.1097/icu.0000000000000816] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Late-onset Fuchs endothelial corneal dystrophy (FECD) is seen in approximately 4% of individuals over the age of 40. With the growing population of adults over the age of 65, ophthalmologists need to be aware of the preoperative, perioperative, and postoperative considerations involved in cataract surgery in Fuchs patients. RECENT FINDINGS Management of cataract patients with FECD requires preoperative assessment of endothelial cell size, density, and morphology. Considerations for perioperative endothelial cell loss include patients with hyperopia and shallow anterior chambers, phacoemulsification technique, transfer of ultrasonic energy to the cornea, corneal-protective perioperative agents, as well as thermal and mechanical damage. SUMMARY Ophthalmologists performing cataract surgery on patients with FECD must carefully consider the risks of endothelial cell loss during surgery and minimize the risk of corneal decompensation after surgery. Preoperative management should evaluate the severity of the FECD as well as individual factors such as cataract density, the health and thickness of the cornea, and the anterior chamber depth. Perioperative techniques, adjustments to biometry calculations, and intraocular lens (IOL) selection may help optimize visual outcomes and recovery time.
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Affiliation(s)
- Majid Moshirfar
- Hoopes Vision Research Center, Hoopes Vision, Draper, Utah, USA
- John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah, USA
- Utah Lions Eye Bank, Murray, Utah, USA
| | - Rachel Huynh
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James H Ellis
- University of Utah School of Medicine, Salt Lake City, Utah, USA
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19
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Descemet's membrane endothelial keratoplasty (DMEK) tissue type and endothelial cell loss over time. CANADIAN JOURNAL OF OPHTHALMOLOGY 2021; 58:187-190. [PMID: 34922899 DOI: 10.1016/j.jcjo.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/19/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate endothelial cell loss after Descemet's membrane endothelial keratoplasty (DMEK) when surgery is performed with surgeon-loaded tissue versus preloaded tissue. METHODS The endothelial cell count over time of patients who underwent the last DMEK surgery by a single surgeon with surgeon-loaded tissue from 2014-2017 was compared to that of patients who underwent the first DMEK surgery by different single surgeon with preloaded tissue from 2017-2020. RESULTS Baseline characteristics, including age, sex, and baseline endothelial cell count of DMEK grafts, were not statistically different between the groups. Endothelial cell loss both immediately after surgery and continuing over a 4-year period after surgery was greater in the surgeon-loaded DMEK group compared to the preloaded DMEK group based on log-regression curve analysis. Endothelial cell loss was statistically significantly greater at 1 year, 2 years, 3 years, and 4 years after DMEK surgery with surgeon-loaded tissue compared to preloaded tissue on analysis of variance testing. CONCLUSION Preloaded DMEK tissue has significantly less endothelial cell loss both initially after surgery and over time compared to surgeon-loaded DMEK tissue, providing support for use of preloaded DMEK tissue for surgery.
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20
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Hussien AMRM, Elmassry A, Ghaith AA, Goweida MBB. Descemet's Membrane Endothelial Keratoplasty and Phacoemulsification: Combined versus Sequential Surgery. J Curr Ophthalmol 2021; 33:277-284. [PMID: 34765815 PMCID: PMC8579805 DOI: 10.4103/joco.joco_188_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/25/2021] [Accepted: 02/06/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose: To compare the outcomes of Descemet's membrane endothelial keratoplasty (DMEK) combined with phacoemulsification versus DMEK following phacoemulsification. Methods: In this interventional retrospective comparative nonrandomized case series study, patients with Fuchs endothelial corneal dystrophy (FECD) with either cataract or previous cataract surgery with intraocular lens (IOL) implantation were assigned to one of the two groups according to lens status. Group 1 included patients who had cataract and FECD and would undergo triple procedure (phacoemulsification with IOL implantation and DMEK), whereas Group 2 included patients who had FECD and had phacoemulsification with IOL implantation earlier and would undergo DMEK only as a sequential procedure. Results: Postoperative best corrected visual acuity (BCVA) in both groups at 1 week, 1 month, 3 months, and 6 months revealed a statistically nonsignificant difference between the two groups with mean logMAR BCVA at 6 months of 0.07 ± 0.18 and 0.07 ± 0.19 in Group 1 and Group 2, respectively (P > 0.05). The drop in endothelial cell density by the end of the 6th postoperative month was by 39.44% ±7.92 and 38.73% ±8.10 in the triple-procedure group and DMEK only group, respectively (P = 0.005). Total postoperative complications rate and the rebubbling rate were statistically similar between both groups with 13.5% and 12.5% rebubbling rate in Group 1 and Group 2, respectively (P > 0.05). Conclusion: Visual outcomes, endothelial cell loss, and rebubbling rate are comparable when DMEK is combined with phacoemulsification or when it is performed as staged procedure, without statistically significant difference in the outcomes.
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Affiliation(s)
- Ahmed Mahmoud Ragab Mahmoud Hussien
- Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt.,Department of Ophthalmology, Torbay and South Devon NHS Trust, Torquay, UK
| | - Ahmed Elmassry
- Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Alaa Atef Ghaith
- Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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21
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Kiel M, Bu JB, Gericke A, Vossmerbaeumer U, Schuster AK, Pfeiffer N, Wasielica-Poslednik J. Comparison of DMEK and DSAEK in Eyes With Endothelial Decompensation After Previous Penetrating Keratoplasty. Cornea 2021; 40:1218-1224. [PMID: 34116539 DOI: 10.1097/ico.0000000000002786] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/25/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Posterior lamellar keratoplasty is increasingly applied in patients with endothelial decompensation after penetrating keratoplasty (PK). The aim of this study was to compare the results of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) after PK. METHODS In this retrospective study, clinical data of 30 patients who received DMEK (n = 19) or DSAEK (n = 11) for endothelial decompensation after PK were evaluated. All lamellar keratoplasties were performed at the Department of Ophthalmology at University Hospital Mainz, Germany. Primary end point included best-corrected visual acuity, and secondary end points included endothelial cell density, rebubbling, and rejection rates, all at 6 and 12 months. RESULTS After 6 months and 12 months, 89% of DMEK and 73% of DSAEK grafts and 63% of DMEK and 64% of DSAEK grafts provided sufficient corneal deturgescence, respectively, represented by improvement in best-corrected visual acuity. DMEK group median preoperative Logarithm of the Minimum Angle of Resolution visual acuity of 1 increased to 0.5 after 6 and 12 months. DSAEK group median Logarithm of the Minimum Angle of Resolution visual acuity increased from 3 to 2 and 1.3 after 6 and 12 months. After 12 months, graft endothelial cell density had decreased by 58% in the DMEK group and by 59% in the DSAEK group. The proportion of patients requiring a rebubbling were 63% in the DMEK and 64% in the DSAEK group. No lamellar graft rejection occurred in either trial arm. CONCLUSIONS Both DMEK and DSAEK significantly improved visual acuity in patients after PK. Lamellar graft survival, loss of endothelial cells, and mean rebubbling rates were similar in both groups.
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Affiliation(s)
- Marian Kiel
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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22
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Changes in Corneal Parameters after DMEK Surgery: A Swept-Source Imaging Analysis at 12-Month Follow-Up Time. J Ophthalmol 2021; 2021:3055722. [PMID: 34336256 PMCID: PMC8321767 DOI: 10.1155/2021/3055722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/07/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To assess the time course changes in corneal topographic parameters during the one-year follow-up after Descemet membrane endothelial keratoplasty (DMEK) surgery. Materials and Methods Twenty-one patients (24 eyes) who underwent DMEK surgery were evaluated. Best corrected visual acuity (BCVA), endothelial cell count (ECC), central corneal thickness (CCT), mean keratometry (MK), mean astigmatism (MA), astigmatism asymmetry (AA), and higher-order aberration (HOA) were assessed at baseline and 1, 3, 6 and 12 months after the surgery using CASIA2 anterior segment swept-source OCT (Tomey, Japan). Results In patients who underwent DMEK surgery, BCVA improved gradually at the subsequent visits during the 12-month follow-up. A significant reduction in ECC and CCT at the 1st month was noted, which remained stable until the 6th month postoperatively. Anterior and total MK values remained unchanged, whereas changes in posterior keratometry were noticeable until the 6th month after surgery. A significant reduction in the anterior, posterior, and total astigmatism magnitude as well as astigmatism asymmetry was observed during the first 6 months after surgery. A gradual anterior, posterior, and total HOA decrease was documented until the 12th month after surgery. Negative correlations between baseline values of CCT, MK, MA, AA, and HOA and postoperative variations in those parameters at consecutive follow-up time points were observed. Accordingly, negative correlations between baseline CCT and postoperative changes in corneal topographic parameters after surgery were found. Conclusion The stabilization of most corneal topographic parameters takes place within 6 months after the procedure, whereas HOA reduction and BCVA improvement gradually occur during the first year after surgery. Preoperative values of corneal topographic parameters strongly determine their changes detected after DMEK surgery, which may suggest that early therapeutic intervention results in better visual outcomes.
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Kim JD, Moon IH, Lee HK. A Case of Post-traumatic Corneal Endothelial Dysfunction Treated with Descemet Membrane Endothelial Keratoplasty Combined with Cataract Surgery. KOREAN JOURNAL OF OPHTHALMOLOGY 2021; 35:332-334. [PMID: 34162190 PMCID: PMC8357605 DOI: 10.3341/kjo.2021.0062] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/01/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jung Dong Kim
- Institute of Vision Research, Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - In Hee Moon
- Institute of Vision Research, Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Keun Lee
- Institute of Vision Research, Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Kam YW, Ramirez DA, Ling JJ, Greiner MA, Sales CS. Performing DMEK with Other Surgical Procedures: Staged vs. Combined Approaches in Straightforward Cases. CURRENT OPHTHALMOLOGY REPORTS 2021. [DOI: 10.1007/s40135-021-00264-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yildirim TM, Łabuz G, Hammer M, Son HS, Schickhardt SK, Auffarth GU, Khoramnia R. A Novel Approach for Assessing Visual Impairment Caused by Intraocular Lens Opacification: High-Resolution Optical Coherence Tomography. Am J Ophthalmol 2021; 226:108-116. [PMID: 33571474 DOI: 10.1016/j.ajo.2021.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/16/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To quantify in vitro straylight induced by intraocular lens (IOL) localized opacification using an anterior segment optical coherence tomography (OCT) device. DESIGN Laboratory investigation. METHODS We obtained high-resolution OCT cross-section images of 44 explanted IOLs using a new in vitro application for an anterior segment OCT device, the Anterion (Heidelberg Engineering, Heidelberg, Germany). In 24 cases, the reason for IOL explantation was a centrally localized opacification, the sequela of a secondary ocular surgery. As a control, we used 20 IOLs removed after an IOL (sub-)luxation. Using image analysis, we found a threshold area value representing a metric for the amount of opacification in a region of interest in the IOL's central optic. We used a modified C-Quant straylight meter (Oculus, Wetzlar, Germany) to quantify light scattering. We derived a linear regression from calculating the correlation between the amount of opacification and straylight. RESULTS We visualized different amounts of IOL opacification using the OCT device. The opacified lenses showed a mean threshold area of 6.7% ± 3.3% and mean straylight was 95.1 ± 75.6 deg2/sr. The clear group's mean threshold area was 2.0% ± 0.8% and 5.0 ± 3.4 deg2/sr mean straylight. Straylight correlated statistically significantly with the threshold area, with a correlation coefficient of R2 = 0.80, P < .001. CONCLUSIONS This high-resolution OCT imaging technique can be used to visualize IOL opacities. The amount of opacification correlated well with the straylight induced by the lens. Anterior segment OCT imaging might be used in the future as a tool for predicting the extent of visual impairment and aid clinicians to quantify patients' complaints.
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Endothelzellverlust nach Hornhauttransplantation: DMEK im Vergleich mit Triple-DMEK. Klin Monbl Augenheilkd 2021. [DOI: 10.1055/a-1311-9757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Long-term Results of a Combined Procedure of Cataract Surgery and Descemet Membrane Endothelial Keratoplasty With Stromal Rim. Cornea 2020; 40:628-634. [PMID: 33156081 DOI: 10.1097/ico.0000000000002574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/07/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate the long-term results of combining cataract surgery, intraocular lens (IOL) implantation, and Descemet membrane endothelial keratoplasty with peripheral stromal support (DMEK-S). METHODS The outcomes of 107 eyes of 37 patients who had undergone a combination of cataract surgery, IOL implantation, and DMEK-S between October 2007 and February 2015 were retrospectively evaluated. The average follow-up duration was 18.2 ± 18.3 months (range, 6-84 months). Changes in uncorrected and corrected distance visual acuity, spherical equivalent, and corneal endothelial cell density were analyzed. Intraoperative and postoperative complications were also recorded. RESULTS The mean logMAR uncorrected distance visual acuity improved from 0.92 ± 0.60 preoperatively to 0.33 ± 0.33, 0.28 ± 0.25, 0.24 ± 0.20, and 0.27 ± 0.27 at 6, 12, 24, and 36 months postoperatively (P < 0.001), respectively. The mean logMAR corrected distance visual acuity improved from 0.62 ± 0.65 preoperatively to 0.17 ± 0.29, 0.13 ± 0.21, 0.07 ± 0.16, and 0.11 ± 0.23 at 6, 12, 24, and 36 months postoperatively (P < 0.001), respectively. The mean endothelial cell density decreases were 50.7% ± 21.1%, 50.8% ± 19.8%, 60.7% ± 16.6%, 62.2% ± 11.8%, and 61.8% ± 20.0% at 6, 12, 24, 36, and 48 months after surgery, respectively. Similar trends, although with slightly better visual outcomes, were found in the subgroup of patients without other eye diseases. The mean final deviation from intended spherical equivalent was 0.77 ± 1.19 D, representing a hyperopic shift. CONCLUSIONS A combined procedure of cataract surgery, IOL implantation, and DMEK-S is an effective method of treatment in patients with combined corneal disease and cataract, maintaining visual rehabilitation in the long term. Future developments should be performed to minimize the incidence of complications.
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