Intraoperative hyphema in Descemet membrane endothelial keratoplasty alone or combined with phacoemulsification

Intracameral Fibrinous Reaction During Descemet's Membrane Endothelial Keratoplasty

PURPOSE

To determine the outcomes and predisposing factors of Descemet's membrane endothelial keratoplasty (DMEK) complicated by intraoperative fibrinous reaction.

METHODS

Retrospective cohort study of 346 DMEKs. Medical charts were reviewed for recipient demographics, surgical indications, donor characteristics, and potential predisposing ocular and systemic factors. For DMEKs complicated by fibrin, surgeons' notes on events leading to fibrin formation and on its intraoperative management, occurrence of graft detachment, primary failure, re-bubbling or regrafting, time to graft clearing, and endothelial cell density were additionally collected.

RESULTS

Fifteen (4.3%) DMEKs were complicated by fibrin, which interfered with and protracted graft unfolding in all cases. Median surgical time was longer than for uncomplicated DMEKs (p = 0.001). Graft positioning at the end of surgery was suboptimal in seven eyes (47%) and failed in three (20%). Re-bubbling, primary failure, and regraft rates were of 40%, 33% and 53%, respectively. The corneas that cleared did so in three to eight weeks, with median endothelial cell loss of 53% at 12 months. Use of anticoagulants was a preoperative risk factor (p = 0.01). Surgeon-identified intraoperative factors included beginner surgeons (87%), prolonged AC shallowing (47%) and graft manipulations (33%), intraocular bleeding (27%), new injector (20%), tight donor scroll (13%), and floppy iris (13%).

CONCLUSION

Fibrinous reaction is a rare intraoperative complication of DMEK that interferes with graft unfolding and results in poor outcomes. Anticoagulant use appears to be a risk factor and may be compounded by surgical trauma to vascular tissues and prolonged surgical maneuvers.

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

PURPOSE

The aim of this study was to examine the outcomes of laser peripheral iridotomy (LPI) and surgical peripheral iridectomy (SPI) for Descemet membrane endothelial keratoplasty (DMEK) and DMEK with cataract extraction (triple DMEK).

METHODS

This retrospective interventional study included 135 eyes of 135 patients who underwent DMEK alone or triple DMEK. Primary outcomes were graft detachments necessitating rebubbling, repeat grafts, and pupillary block. The secondary outcomes included rejection, cystoid macular edema, uveitis, intraoperative hyphema, visual disturbances, and surgical time.

RESULTS

Thirty-one eyes in the LPI group and 104 eyes in the SPI group were included. Fifty-six eyes had DMEK alone, and 79 had triple DMEK. Visually significant graft detachments occurred in 7 of 31 eyes in the LPI group versus 19 of 104 eyes in the SPI group ( P = 0.61). No statistical significance in DMEK alone versus triple DMEK groups ( P = 0.61 vs. P > 0.99). Two patients in the LPI group and 5 in the SPI group required regraft ( P = 0.66). One (3.2%) experienced pupillary block compared with 5 (4.8%) ( P = 0.99) in the LPI and SPI groups, respectively. Secondary outcomes were similar in both groups ranging from 0% to 3% ( P > 0.99). None had visual disturbances. In DMEK alone, duration of surgery was significantly shorter in the LPI versus SPI group (32.8 vs. 44.1 minutes, P = 0.02).

CONCLUSIONS

This study demonstrated similar outcomes between LPI and SPI, although the LPI group had a shorter duration of surgery when DMEK was performed alone. The remainder of the outcomes demonstrated no statistically significant differences.

Role of Direct Supervision in the Learning Curve of Descemet Membrane Endothelial Keratoplasty Surgery

PURPOSE

The aim of this study was to compare complication rates of Descemet membrane endothelial keratoplasty (DMEK) performed by directly supervised and nondirectly supervised corneal fellows.

METHODS

This study was a retrospective, comparative case series of DMEK surgeries performed by novice surgeons (less than 15 DMEK cases) with or without direct direct expert supervision. Patients who underwent surgery for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy with a minimum follow-up of 12 weeks were included. Data on patients' demographics, surgical details, surgeon level, intraoperative and postoperative complications, and rate of rebubbling were collected.

RESULTS

In this study, 41 nondirectly supervised and 48 directly supervised DMEK surgeries were included. At 6 months, 67.4% of eyes achieved a best-corrected visual acuity of ≤0.3 logMAR with no significant difference between groups ( P = 0.95). Intraoperative complications occurred in 22% of cases in the nondirect supervision group and 4.2% in the direct supervision group ( P = 0.02). Postoperative complications occurred in 9.8% of cases in the nondirect supervision group and 6.2% of cases in the direct supervision group ( P = 0.7). The rebubbling rate was comparable in the 2 groups (34.1% vs. 33.3%, P = 1.0). Five cases (12.2%), all from the nondirect supervision group, required secondary keratoplasty ( P = 0.02). The overall complication rate was significantly higher in the nondirect supervision group (31.7% vs. 10.4%, P = 0.03).

CONCLUSIONS

Functional success can be achieved in directly supervised or nondirectly supervised DMEK surgery. However, nondirectly supervised DMEK surgery may associate with higher rates of complications.

Safety and clinical outcomes of omitting same and next day review after DMEK performed with an inferior peripheral iridotomy

BACKGROUND/OBJECTIVES

To determine the incidence of day one postoperative complications after Descemet Membrane Endothelial Keratoplasty (DMEK) performed with intraoperative inferior peripheral iridotomy (PI), and whether their early detection influences postoperative intervention.

SUBJECTS/METHODS

70 eyes of 70 consecutive patients that underwent DMEK from August 2019 to August 2021 at a single UK centre were retrospectively analysed. Cases that did not have an inferior PI were excluded. Any action taken at day one and week one postoperative review was noted.

RESULTS

No pupil block or other major adverse events were found at day one review. At one week, 14 eyes (20%) required re-bubbling, all of which had been fully attached at the day one review.

CONCLUSIONS

This series suggests that inferior PI performed alongside DMEK alone or triple DMEK effectively minimizes the risk of pupil block. Since no early complications occurred in this cohort requiring immediate intervention, it may be safe to defer review of these patients to a later time point.

Clinical Outcomes of Descemet's Membrane Endothelial Keratoplasty without Routine Prophylactic Peripheral Iridotomy

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.

Considerations for Corneal Surgery With Patients in the 10th Decade of Life

PURPOSE

The purpose of this study was to report the indications, ocular and systemic comorbidities, and surgical outcomes of corneal transplantation in patients older than 90 years.

METHODS

A retrospective review was conducted to identify individuals 90 years and older who underwent corneal transplantation surgery at the Bascom Palmer Eye Institute between January 2013 and October 2020. Outcomes included best-corrected visual acuity and graft survival over time. Paired t tests were used to compare visual acuity preoperatively versus postoperatively. Graft survival was evaluated with Kaplan-Meier curves.

RESULTS

Fifty-eight eyes of 52 consecutive individuals were included. The mean age of individuals was 92 ± 2 years; 26.9% were male; and 48.1% self-identified as non-Hispanic White and 38.5% as Hispanic. Postoperative follow-up was 14.7 ± 12.1 months. Of the 58 eyes, 44.8% (26/58) underwent penetrating keratoplasty, 46.6% (27/58) Descemet stripping automated endothelial keratoplasty, and 6.9% (4/58) keratoprosthesis. All surgeries were performed under monitored local anesthesia, without major complications. Surgical indications included pseudophakic bullous keratopathy (36.2%), glaucoma-associated corneal decompensation (27.6%), Fuchs endothelial dystrophy (25.9%), and perforated corneal ulceration (19.0%). The best-corrected visual acuity improved by 0.32 (95% confidence interval 0.14-0.50; P < 0.01) as early as 1 month postoperatively, and vision gains were sustained for at least 12 months. Graft survival probability at 12 months was 88%.

CONCLUSIONS

Corneal transplantation is a safe and successful procedure in restoring the visual acuity for patients older than 90 years after careful preoperative evaluation. Further research is needed to evaluate the impact of corneal transplantation on quality of life in patients in the 10th decade of life.

Cataract surgery in patients with Fuchs' dystrophy and corneal decompensation indicated for Descemet's membrane endothelial keratoplasty

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.

Effects of Combined Cataract Surgery on Outcomes of Descemet's Membrane Endothelial Keratoplasty: A Systematic Review and Meta-Analysis

Objective

A systematic review and meta-analysis of literature-to-date regarding the effects of combined cataract surgery on outcomes of DMEK.

Methods

Multiple electronic databases were searched, including Cochrane Library databases, PubMed, Web of Science, and ClinicalTrials.gov. The final search was updated on 10th February 2022. We included randomized controlled trials (RCTs), non-randomized studies and large case series (≥25 eyes) of DMEK (pseudophakic/phakic) and “triple DMEK”. A total of 36 studies were included in this study. Meta-analyses were done with risk differences (RD) computed for dichotomous data and the mean difference (MD) for continuous data via random-effects model. Primary outcome measure: postoperative re-bubbling rate; secondary outcome measures: complete/partial graft detachment rate, best-corrected visual acuity (BCVA), endothelial cell loss (ECL), primary graft failure, and cystoid macular edema (CMO).

Results

A total of 11,401 eyes were included in this review. Based on non-randomized studies, triple DMEK demonstrated a better BCVA at 1-month postoperative than DMEK alone (MD 0.10 logMAR; 95% CI: 0.07–0.13; p < 0.001), though not statistically significant at 3–6 months postoperative (MD 0.07 logMAR; 95% CI: −0.01 to 0.15; p = 0.08). There was no significant difference in rebubbling, ECL, graft failures, and CMO postoperatively between the two groups (p = 0.07, p = 0.40, 0.06, and 0.54 respectively).

Conclusion

Our review suggests that DMEK has a similar post-operative complication risk compared to “triple DMEK” (low-quality evidence), with comparable visual outcome and graft survival rate at 6 months postoperative. High-quality RCTs specifically studying the outcomes of combined vs. staged DMEK are still warranted.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020173760, identifier: CRD42020173760.

Surgical peripheral iridotomy creation during intraocular surgery by intraocular diathermy probe-a novel technique

A novel technique for the creation of surgical iridotomies using a bipolar diathermic probe is described. In a cohort comprising 19 eyes of 18 patients, a 100% patency rate was achieved, with no intra- or postoperative complications.

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

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

Real-time intraoperative ultrasound biomicroscopy for determining graft orientation during Descemet's membrane endothelial keratoplasty

PURPOSE

To evaluate the intraoperative use of ultrasound biomicroscopy (UBM) during Descemet's membrane endothelial keratoplasty (DMEK) to determine graft's orientation.

METHODS

Prospective interventional study of eight eyes of seven patients who underwent DMEK. Following the identification of correct graft orientation using 'Blue cannula tip' sign during DMEK surgery, UBM was used to ascertain graft's orientation. The rate of successful DMEK graft orientation determined by the UBM was registered and verified postoperatively by anterior segment-optical coherence tomography (OCT). Intra- and postoperative complications, postoperative clearance of the cornea, corrected distance visual acuity and endothelial cell loss were also noted.

RESULTS

The study included five males and two females aged 54-82 years with corneal oedema due to Pseudophakic bullous keratopathy (n = 5), Fuchs' endothelial dystrophy (n = 2). In all cases, the technique allowed proper determination of the graft's orientation. In one case, 'blue cannula tip' sign showed correct orientation while UBM identified an upside-down graft. The graft was inverted in the anterior chamber using fluid jets, and repeat 'blue cannula tip' sign and UBM examination both showed correct orientation. In all cases, postoperative anterior segment-OCT demonstrated correct graft orientation.

CONCLUSIONS

Use of intraoperative UBM to determine graft orientation during DMEK correlated with proper graft orientation, as was verified postoperatively by anterior segment-OCT. The use of UBM can be particularly helpful in cases of poor graft visibility due to opaque corneal stroma, pigment or blood in the anterior chamber during surgery, or when the blue tint of the graft fades rapidly, which may preclude proper determination of graft's orientation.

Endothelial Cell Loss After Descemet's Membrane Endothelial Keratoplasty for Fuchs' Endothelial Dystrophy: DMEK Compared to Triple DMEK

PURPOSE

This study compared the outcomes after Descemet's membrane endothelial keratoplasty (DMEK) in pseudophakic patients with the outcomes after DMEK combined with cataract surgery (triple-DMEK) in patients with Fuchs' endothelial dystrophy (FED).

DESIGN

Retrospective, single-institution, interventional, consecutive case series.

METHODS

Outcomes of 114 DMEKs in patients with FED at a minimum of 1-year follow-up were reviewed. A total of 34 eyes (29 patients) were pseudophakic and underwent only DMEK (DMEK-only), and 80 eyes (56 patients) underwent triple-DMEK. Main outcome measurements included endothelial cell loss (ECL), best-corrected visual acuity (BCVA), central corneal thickness (CCT), and complications.

RESULTS

At 1 month, ECL was 25% (±16%) and 35% (±15%) in DMEK-only and triple-DMEK groups, respectively. At 1 year, ECL was 33% (±13%) and 41% (±16%) in DMEK-only and triple-DMEK groups, respectively. There was statistically significantly less ECL after DMEK-only than after triple-DMEK at both 1 month (95% confidence interval [CI]: 1.67-15.02; P = .016) and 1 year (95% CI: 1.06-14.07; P = .034). CCT was significantly lower after DMEK-only than after triple-DMEK at 1 month but not at 1 year. BCVA was excellent and similar in the 2 groups. There were no cases of graft failure. Graft rejection and rebubbling rates were similar in DMEK-only and triple-DMEK groups: rejection occured in 8.8% and 8.75% of cases respectively (P = .50), and rebubbling in 2.9% and 2.5% respectively (P = .44).

CONCLUSIONS

Both the DMEK-only and the triple-DMEK groups had low rebubbling rates and good visual outcomes, but the combined triple-DMEK procedure resulted in significantly greater loss of endothelial cells than DMEK-only surgery at both 1 month and 1 year.

Effect of Anticoagulant Therapy on the Outcome of Descemet Membrane Endothelial Keratoplasty

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.

Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review

There is variability in the management of ophthalmic patients on anti-thrombotic agents (antiplatelets and anticoagulants) during the peri-operative period. A survey carried out in a UK teaching hospital on a cohort of ophthalmologists showed majority were comfortable with antiplatelet management but there was variability in managing patients on warfarin and direct oral anticoagulants (DOACs); 40% were unaware of existing guidelines. We aim to review the recommendations in the literature with regards to managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. We reviewed incidences of complications, specifically, the haemorrhagic complications associated. Pubmed search was carried out on relevant keywords from January 2007 to August 2017. All relevant UK guidelines including the Royal College of Ophthalmologists and British Society of Haematology were reviewed. Literature recommendations for routine cataract surgery under topical or sub-Tenon's anaesthesia would be to continue all anti-thrombotic agents. For sharp needle anaesthesia, avoidance of dual antiplatelet therapy was recommended and warfarin could be continued if INR within therapeutic range. Recommendations for surgeries in glaucoma, vitreo-retinal, oculoplastic and lacrimal; and strabismus are presented. No evidence was found for corneal surgery. Haemorrhagic complications are reported in all groups. Limitations of this review include the retrospective nature, lack of randomized control trials and the limited evidence regarding DOACs. It is important for ophthalmologists to be aware of and balance the risk of thromboembolic events and risks of haemorrhagic complications for ophthalmic surgery. A multi-disciplinary approach is recommended for complex cases.

"PI-less DMEK": results of Descemet's membrane endothelial keratoplasty (DMEK) without a peripheral iridotomy

PURPOSE

To assess Descemet's membrane endothelial keratoplasty (DMEK) without performing a peripheral iridotomy (PI) prior to or during surgery ("PI-less DMEK").

MATERIALS AND METHODS

This retrospective study included consecutive patients that underwent PI-less DMEK by a single surgeon (E.L) between February 2016 and February 2017 at the Rabin Medical Center, a Tertiary Hospital. Intraoperative and postoperative complications were assessed.

RESULTS

Thirty-one patients, mean age 75.9 ± 7.9 years with 58.1% female were included. Leading indications for surgery were pseudophakic bullous keratopathy (18/31) and Fuchs' endothelial dystrophy (9/31). Preoperative best-corrected distance visual acuity was 1.13 ± 0.59 logMAR (~6/80 Snellen). For 12/31 that had postoperative endothelial cell count measurements, cell loss was 49 ± 20%. Intraoperative complications included anterior chamber (AC) hyphema during graft insertion requiring reinsertion (n = 1), and minor hyphema from the main corneal incision (n = 1). Partial slit lamp gas evacuation was performed in all patients 1.5 h postoperatively. Postoperative complications included partial graft detachment requiring rebubbling (n = 5), self-resolving minimal peripheral graft detachment (n = 5), uncontrolled intraocular hypertension requiring trabeculectomy in a patient with a history of medically controlled glaucoma (n = 1), postoperative cystoid macular edema that resolved medically (n = 1) and graft failure 5 months postoperatively (n = 1). No patients developed pupillary block. Excluding graft failure (n = 1), preoperative amblyopia (n = 2) and premature loss to follow-up (n = 1), final corrected distance visual acuity was 0.18 ± 0.14 logMAR (~20/30 Snellen) with 44.4% reaching 6/7.5 (Snellen) or more.

CONCLUSIONS

PI-Less DMEK is a safe, technically easy, and effective modification that avoids the time and complications associated with performing a PI before or during surgery.