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Melles GRJ, Parker JS. How Would Nature See Our Corneal Triumphs? The LXXIX Edward Jackson Lecture. Am J Ophthalmol 2024; 263:11-22. [PMID: 38281570 DOI: 10.1016/j.ajo.2024.01.020] [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: 06/14/2023] [Accepted: 01/18/2024] [Indexed: 01/30/2024]
Abstract
PURPOSE To describe discrepancies between clinical observation and current teachings in corneal endothelial disease, particularly in Fuchs endothelial dystrophy and its potential association with primary open angle glaucoma. DESIGN Perspective. METHODS A perspective is presented on Fuchs dystrophy, a disorder that commonly presents with a compromised endothelium but minimal stromal edema, indicating that the corneal imbibition pressure is relatively "too high." RESULTS The discrepancy between the relative lack of stromal edema in the absence of an endothelial cell layer cannot be explained by the current theories involving a circulatory pumping mechanism over the endothelial cell layer, but may point to the following: (1) secondary involvement of the corneal endothelium in Fuchs dystrophy; (2) separate hydration systems for maintaining the imbibition pressure (vertical static hydration) and corneal nutrition (horizontal dynamic hydration); (3) the cornea as net contributor of aqueous humor; (4) a close relationship between the corneal imbibition and intraocular pressure, with potentially a shared regulatory system; and (5) a potential steroid-type hormone dependency of this regulatory system. CONCLUSIONS Clinical observation shows that the stromal imbibition pressure is "too high" in Fuchs endothelial dystrophy, indicating that it may not primarily be an endothelial disease, but a type of "corneal glaucoma."
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Affiliation(s)
- Gerrit R J Melles
- From the Netherlands Institute for Innovative Ocular Surgery (G.R.J.M.), Rotterdam, the Netherlands; Melles Cornea Clinic (G.R.J.M.), Rotterdam, the Netherlands; Amnitrans EyeBank Rotterdam (G.R.J.M.), the Netherlands; NIIOS-USA (G.R.J.M., J.S.P.) San Diego, California, USA.
| | - Jack S Parker
- NIIOS-USA (G.R.J.M., J.S.P.) San Diego, California, USA; Parker Cornea (J.S.P.), Birmingham, Alabama, USA
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2
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Trouvain AM, Szurman P, Wahl S, Siegel R, Boden KT, Seitz B, Fries FN, Rickmann A. Impact of Previous Cataract Surgery in Corneal Donors on the Outcome of Descemet Membrane Endothelial Keratoplasty. Cornea 2024; 43:844-852. [PMID: 39377776 DOI: 10.1097/ico.0000000000003423] [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: 06/12/2023] [Accepted: 10/02/2023] [Indexed: 10/09/2024]
Abstract
PURPOSE The aim of this study was to investigate differences between phakic, pseudophakic, and scarred stromal donor tissue for their influence on complication rates during preparation or implantation and on the postoperative outcome of Descemet membrane endothelial keratoplasty (DMEK). METHODS We retrospectively compared 484 eyes undergoing DMEK, divided into 3 subgroups of donor tissue (1: phakic, 2: pseudophakic, and 3: scarred stromal). Visual acuity, central corneal thickness (CCT), and endothelial cell count were monitored preoperatively and postoperatively at 6 weeks and 3, 6, 12, and 24 months. The incidence of intraoperative and postoperative complications was analyzed. RESULTS The risk of adherence and tearing during preparation was significantly higher in group 2 than in the other groups (p's < 0.001). No significant difference was found for visual acuity (p's ≥ 0.368) and long-term CCT, but CCT recovery took longer in group 2 (P = 0.003), normalizing after 3 months (p's ≥ 0.096). The overall mean endothelial cell count was lower in group 2 compared with the other groups (P = 0.011). No difference in the rebubbling rate was detected (P = 0.890). However, the risk of repeat keratoplasty for phakic grafts was lower compared with group 2 (P = 0.008). CONCLUSIONS Pseudophakic donor grafts are more difficult to prepare and implant, resulting in longer recovery times and a higher risk of graft failure. However, when the preparation is uneventful and no graft failure occurs, pseudophakic grafts show a comparable outcome. Given the shortage of corneal donors and the high prevalence of pseudophakic corneal donors, they should not generally be excluded from corneal donation for DMEK.
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Affiliation(s)
- André M Trouvain
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Peter Szurman
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Silke Wahl
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Rudolf Siegel
- Industrial and Organizational Psychology, Saarland University, Saarbruecken, Germany; and
| | - Karl Thomas Boden
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg/Saar, Germany
| | - Fabian N Fries
- Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg/Saar, Germany
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Choi P, Shim KY, Jun JH. Partial Descemet Membrane Overlap Due to Previously Grafted Descemet Membrane Remnant: A Case Report. KOREAN JOURNAL OF OPHTHALMOLOGY 2024; 38:82-84. [PMID: 38152851 PMCID: PMC10869422 DOI: 10.3341/kjo.2023.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/09/2023] [Accepted: 12/27/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Pureum Choi
- Keimyung University School of Medicine, Daegu,
Korea
| | - Kyu Young Shim
- Department of Ophthalmology, Keimyung University School of Medicine, Daegu,
Korea
| | - Jong Hwa Jun
- Department of Ophthalmology, Keimyung University School of Medicine, Daegu,
Korea
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Yusef YN, Osipyan GA, Fisenko NV, Dzamikhova AK. [Modern techniques and features of selective keratoplasty]. Vestn Oftalmol 2024; 140:150-157. [PMID: 38739145 DOI: 10.17116/oftalma2024140022150] [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: 05/14/2024]
Abstract
Selective keratoplasty involves replacing the affected layers of the cornea with similar donor tissue. In case of pathological changes in the middle and posterior stroma, deep anterior lamellar keratoplasty (DALK) is performed. Chronic corneal edema caused by endothelial dysfunction is an indication for endothelial keratoplasty - Descemet membrane endothelial keratoplasty (DMEK) or Descemet Stripping Endothelial Keratoplasty (DSAEK). Compared to penetrating keratoplasty (PK), these operations are characterized by a low risk of damage to intraocular structures and a relatively short rehabilitation period. Complications of selective keratoplasty include the formation of a false chamber between the lamellar graft and the recipient's cornea, ocular hypertension during anterior chamber air tamponade. Persistent epithelial defect can be a sign of primary graft failure in DALK, DSAEK and DMEK. Selective keratoplasty is characterized by a lower incidence of immune rejection than PK. In some cases, DALK can be complicated by corneal changes related to suture fixation of the graft. Long-term postoperative use of topical glucocorticoids can cause ocular hypertension and cataracts.
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Affiliation(s)
- Yu N Yusef
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - G A Osipyan
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
| | - N V Fisenko
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
| | - A K Dzamikhova
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
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Muijzer MB, Delbeke H, Dickman MM, Nuijts RMMA, Jimale H, van Luijk CM, Imhof SM, Wisse RPL. Video Grading of Descemet Membrane Endothelial Keratoplasty Surgery to Identify Surgeon Risk Factors for Graft Detachment and Rebubbling: A Post Hoc Observational Analysis of the Advanced Visualization In Corneal Surgery Evaluation Trial. Cornea 2023; 42:1074-1082. [PMID: 36730371 PMCID: PMC10392889 DOI: 10.1097/ico.0000000000003181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/28/2022] [Accepted: 09/10/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to explore video-graded intraoperative risk factors for graft detachment (GD) and rebubbling in Descemet membrane endothelial keratoplasty surgery. METHODS A post hoc analysis of 65 eyes of 65 pseudophakic subjects with Fuchs endothelial dystrophy that underwent Descemet membrane endothelial keratoplasty surgery as part of the Advanced Visualization In Corneal Surgery Evaluation trial. All surgical recordings were assessed by 2 graders using a structured assessment form. A multinominal regression was performed to estimate the independent effect of video-graded intraoperative factors on the incidence of GD and rebubbling. Secondary outcomes are corrected distance visual acuity and endothelial cell density. RESULTS In total, 33 GDs were recorded, of which 17 required rebubbling. No significant predictors for GD or rebubbling were identified. However, the results revealed 2 clinically relevant patterns. An unfavorable graft configuration (ie, wrinkled, tight scroll, or taco-shaped) and a gas-bubble size smaller than the graft diameter were associated with an increased risk of GD [odds ratio (OR) 2.5 and OR 2.26, respectively] and rebubbling (OR 2.0 and OR 2.60, respectively). Inversely, a larger gas-bubble size was associated with a reduced risk of GD (OR 0.37) and rebubbling (OR 0.36). At 3 and 6 months postoperatively, corrected distance visual acuity was poorer in subjects requiring a rebubbling and endothelial cell density loss was higher in subjects with a partial GD. CONCLUSIONS Our analysis revealed that the gas-bubble size and graft shape/geometry seem to be relevant clinical factors for GD and rebubbling, whereas descemetorhexis difficulty, degree of graft manipulation, graft overlap, and surgical iridectomy were not associated with an increased risk.
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Affiliation(s)
- Marc B. Muijzer
- Utrecht Cornea Research Group, Ophthalmology Department, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Heleen Delbeke
- Ophthalmology Department, University Hospital Leuven, Leuven, Belgium
- KU Leuven, Biomedical Sciences Group, Department of Neurosciences, Research group Ophthalmology; Leuven, Belgium; and
| | - Mor M. Dickman
- University Eye Clinic, Department of Ophthalmology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Rudy M. M. A. Nuijts
- University Eye Clinic, Department of Ophthalmology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Hanad Jimale
- Utrecht Cornea Research Group, Ophthalmology Department, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Chantal M. van Luijk
- Utrecht Cornea Research Group, Ophthalmology Department, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Saskia M. Imhof
- Utrecht Cornea Research Group, Ophthalmology Department, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Robert P. L. Wisse
- Utrecht Cornea Research Group, Ophthalmology Department, University Medical Center Utrecht, Utrecht, the Netherlands
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Fu L, Hollick EJ. Rebubbling and graft detachment in Descemet membrane endothelial keratoplasty using a standardised protocol. Eye (Lond) 2023; 37:2494-2498. [PMID: 36522529 PMCID: PMC10397279 DOI: 10.1038/s41433-022-02362-2] [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: 08/18/2022] [Revised: 11/16/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To analyse risk factors and long-term outcomes after rebubbling and graft detachment in Descemet membrane endothelial keratoplasty (DMEK). METHODS 176 consecutive DMEK grafts of 125 patients performed by 8 surgeons with a standardised technique between January 2015 and July 2022 were analysed. Main outcome measures were graft detachments, rebubbling rate, postoperative outcomes, and risk factors for graft failure and rebubbling. RESULTS 6 (3.4%) grafts required rebubbling (>1/3 area detached). 40 (22.7%) grafts developed self-resolving partial detachments (<1/3 area detached). The mean time to rebubble was 16 ± 9.4 days. Mean BSCVAs at 5 years postoperative were 0.03 ± 0.16, 0.03 ± 0.14, and 0.15 ± 0.31 logMAR in fully attached, partially detached and rebubbled grafts (P = 0.437). 5-year graft survival were 98%, 90%, and 83% in fully attached, partially detached and rebubbled eyes (P = 0.02). There was significantly greater endothelial cell loss (ECL) in the rebubbled eyes (P = 0.018). Intraoperative trauma was a risk factor for graft failure (HR 1.81; 95% CI: 1.33-2.50; P = 0.023). An indication for surgery other than Fuchs endothelial dystrophy was a risk factor for rebubbling (HR 5.28; 95% CI: 5.11-72.4; P = 0.007). CONCLUSION DMEK grafts had better graft survival if there was no partial detachment or rebubbling at 5 years postop. There was significant ECL associated with rebubbling. A standardised technique reduces rebubbling and graft failure risk.
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Affiliation(s)
- Lanxing Fu
- Department of Ophthalmology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Emma J Hollick
- Department of Ophthalmology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
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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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8
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Dunker S, Winkens B, van den Biggelaar F, Nuijts R, Kruit PJ, Dickman M. Rebubbling and graft failure in Descemet membrane endothelial keratoplasty: a prospective Dutch registry study. Br J Ophthalmol 2023; 107:17-23. [PMID: 33597192 PMCID: PMC9763158 DOI: 10.1136/bjophthalmol-2020-317041] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/07/2020] [Accepted: 01/26/2021] [Indexed: 11/04/2022]
Abstract
AIMS To identify risk factors for rebubbling, and early graft failure after Descemet membrane endothelial keratoplasty (DMEK). METHODS In this prospective registry study, all consecutive DMEK procedures registered in the Netherlands Organ Transplant Registry were assessed (n=752). Univariable and multivariable analysis was performed using logistic regression. The effect of rebubbling on endothelial cell density was analysed using a linear mixed model. RESULTS 144 of 752 (19%) eyes underwent rebubbling. Rebubbling was successful in 101 eyes (70%). In eyes that underwent rebubbling, the graft failure rate was significantly higher than eyes that did not undergo rebubbling (30% vs 9%, respectively; OR: 4.28, 95% CI 2.72 to 6.73, p<0.001). In multivariable analysis, independent risk factors for rebubbling were surgical complication (OR: 2.28, 95% CI 1.20 to 4.33, p=0.012) and older recipient age (OR: 1.04 (per increase of 1 year), 95% CI 1.01 to 1.07, p=0.003). Risk factors for developing graft failure within 3 months were transplant before 2016 (OR: 3.32, 95% CI 1.87 to 5.90, p<0.001), and surgical complication (OR: 2.93, 95% CI 1.42 to 6.04, p=0.004). Throughout the study period, rebubbling and early graft failure were inversely related. Eyes that underwent rebubbling showed significantly lower endothelial cell densities at 3, 6 and 12 months compared with eyes that did not undergo rebubbling (all p<0.001). CONCLUSIONS This Dutch registry study identified independent risk factors for DMEK graft detachment leading to rebubbling, namely recipient age and surgical complication, and early graft failure, namely transplantation before 2016 and surgical complication. Rebubbling was associated with significantly higher endothelial cell loss in the first year after surgery.
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Affiliation(s)
- Suryan Dunker
- University Eye Clinic, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | | | - Rudy Nuijts
- University Eye Clinic, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Pieter Jan Kruit
- Euro Tissue Bank - Bio Implant Service (ETB-BISLIFE), Leiden, The Netherlands
| | - Mor Dickman
- University Eye Clinic, Maastricht University Medical Centre+, Maastricht, The Netherlands
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9
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Muijzer MB, Hoven CMW, Frank LE, Vink G, Wisse RPL. A machine learning approach to explore predictors of graft detachment following posterior lamellar keratoplasty: a nationwide registry study. Sci Rep 2022; 12:17705. [PMID: 36271020 PMCID: PMC9586999 DOI: 10.1038/s41598-022-22223-y] [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: 11/27/2021] [Accepted: 10/11/2022] [Indexed: 01/18/2023] Open
Abstract
Machine learning can be used to explore the complex multifactorial patterns underlying postsurgical graft detachment after endothelial corneal transplantation surgery and to evaluate the marginal effect of various practice pattern modulations. We included all posterior lamellar keratoplasty procedures recorded in the Dutch Cornea Transplant Registry from 2015 through 2018 and collected the center-specific practice patterns using a questionnaire. All available data regarding the donor, recipient, surgery, and practice pattern, were coded into 91 factors that might be associated with the occurrence of a graft detachment. In this research, we used three machine learning methods; a regularized logistic regression (lasso), classification tree analysis (CTA), and random forest classification (RFC), to select the most predictive subset of variables for graft detachment. A total of 3647 transplants were included in our analysis and the overall prevalence of graft detachment was 9.9%. In an independent test set the area under the curve for the lasso, CTA, and RFC was 0.70, 0.65, and 0.72, respectively. Identified risk factors included: a Descemet membrane endothelial keratoplasty procedure, prior graft failure, and the use of sulfur hexafluoride gas. Factors with a reduced risk included: performing combined procedures, using pre-cut donor tissue, and a pre-operative laser iridotomy. These results can help surgeons to review their practice patterns and generate hypotheses for empirical research regarding the origins of graft detachments.
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Affiliation(s)
- M. B. Muijzer
- grid.7692.a0000000090126352Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - C. M. W. Hoven
- grid.7692.a0000000090126352Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - L. E. Frank
- grid.5477.10000000120346234Department of Methodology and Statistics, Utrecht University, Utrecht, the Netherlands
| | - G. Vink
- grid.5477.10000000120346234Department of Methodology and Statistics, Utrecht University, Utrecht, the Netherlands
| | - R. P. L. Wisse
- grid.7692.a0000000090126352Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Singh P, Sinha A, Nagpal R, Chaurasia S. Descemet membrane endothelial keratoplasty: Update on preoperative considerations, surgical techniques, and outcomes. Indian J Ophthalmol 2022; 70:3222-3238. [PMID: 36018091 DOI: 10.4103/ijo.ijo_2933_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is the closest to the physiological replacement of endothelial cells. In the initial years, the technique was surgically challenging. Over the years, with better understanding and modifications in the surgical steps, the technique has evolved as an alternative to more popular procedure Descemet stripping endothelial keratoplasty. The article highlights the various preoperative, intraoperative, and postoperative nuances of DMEK. Additionally, it summarizes the various comparative and noncomparative studies on DMEK outcomes.
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Affiliation(s)
- Prabhakar Singh
- Department of Cornea and Anterior Segment, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Akanksha Sinha
- Cornea and Anterior Segment, Sankara Eye Hospital, Kanpur, Uttar Pradesh, India
| | - Ritu Nagpal
- Research Officer, All India Institute of Medical Sciences, New Delhi, India
| | - Sunita Chaurasia
- Cornea and Anterior Segment Services, L V Prasad Eye Institute, Hyderabad, Telangana, India
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11
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Fisenko NV, Demura TA, Trufanov SV, Voronin GV. [Morphological characteristics of Descemet's membrane removed during endothelial keratoplasty (case study)]. Vestn Oftalmol 2022; 138:81-86. [PMID: 35488565 DOI: 10.17116/oftalma202213802181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The two most used modifications of endothelial keratoplasty (EK) are Descemet's membrane endothelial keratoplasty (DMEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK). The leading complication of EK surgeries is graft detachment in the early postoperative period. This article reports on two cases of endothelial graft adhesion depending on morphological characteristics of the Descemet's membrane (DM) removed during EK. In the first case, complete graft attachment to the recipient's posterior stroma was observed after DMEK. Morphological analysis of the DM showed clean stromal surface. In the second case there was a false chamber between the endothelial transplant and the posterior stroma of the patient. OCT scans revealed separate stromal fibers protruding into the false chamber; morphological analysis of the removed DM showed stromal fragments fixed to the anterior surface of the DM. The revealed changes indicate damage to the posterior stroma the suffered received during descemetorhexis, which may be the cause for incomplete graft attachment. Complete attachment after repeated EK (DSAEK) in this case was due to a thin stromal layer on the graft that provided high degree of adhesion to the posterior corneal surface. DSAEK can be indicated as a repeated EK surgery in cases of persistent endothelial graft non-attachment after DMEK.
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Affiliation(s)
- N V Fisenko
- Research Institute of Eye Diseases, Moscow, Russia
| | - T A Demura
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - S V Trufanov
- Research Institute of Eye Diseases, Moscow, Russia
| | - G V Voronin
- Research Institute of Eye Diseases, Moscow, Russia.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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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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13
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Sampaio LP, Shiju TM, Hilgert GSL, de Oliveira RC, DeDreu J, Menko AS, Santhiago MR, Wilson SE. Descemet's membrane injury and regeneration, and posterior corneal fibrosis, in rabbits. Exp Eye Res 2021; 213:108803. [PMID: 34736886 DOI: 10.1016/j.exer.2021.108803] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/26/2021] [Accepted: 10/20/2021] [Indexed: 02/06/2023]
Abstract
The purpose of this investigation was to study Descemet's membrane and corneal endothelial regeneration, myofibroblast generation and disappearance, and TGF beta-1 localization after Descemet's membrane-endothelial excision (Descemetorhexis) in rabbits. Thirty-six rabbits had 8 mm Descemetorhexis and standardized slit lamp photos at 1, 2 and 4 days, 1, 2 and 4 weeks, and 2, 4 and 6 months, as well as multiplex IHC for stromal cell markers keratocan, vimentin, and alpha-smooth muscle actin (SMA); basement membrane (BM) components perlecan, nidogen-1, laminin alpha-5, and collagen type IV; and corneal endothelial marker Na,K-ATPase β1, and TGF beta-1, with ImageJ quantitation. Stromal transparency increased from the periphery beginning at two months after injury and progressed into the central cornea by six months. At six months, central transparency was primarily limited by persistent mid-stromal neovascularization. Stromal myofibroblast zone thickness in the posterior stroma peaked at one month after injury, and then progressively decreased until to six months when few myofibroblasts remained. The regeneration of a laminin alpha-5 and nidogen-1 Descemet's membrane "railroad track" structure was accompanied by corneal endothelial closure and stromal cell production of BM components in corneas from four to six months after injury. TGF beta-1 deposition at the posterior corneal surface from the aqueous humor peaked at one day after Descemetorhexis and diminished even before regeneration of the endothelium and Descemet's membrane. This decrease was associated with collagen type IV protein production by corneal fibroblasts, and possibly myofibroblasts, in the posterior stroma. Descemet's membrane and the corneal endothelium regenerated in the rabbit cornea by six months after eight mm Descemetorhexis. Real-time quantitative RT-PCR experiments in vitro with marker-verified rabbit corneal cells found that 5 ng/ml or 10 ng/ml TGF beta-1 upregulated col4a1 or col4a2 mRNA expression after 6 h or 12 h of exposure in corneal fibroblasts, but not in myofibroblasts. Stromal cells produced large amounts of collagen type IV that likely decreased TGF beta-1 penetration into the stroma and facilitated the resolution of myofibroblast-generated fibrosis.
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Affiliation(s)
- Lycia Pedral Sampaio
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Ophthalmology at University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Rodrigo Carlos de Oliveira
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Ophthalmology at University of Sao Paulo, Sao Paulo, Brazil
| | - JodiRae DeDreu
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - A Sue Menko
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
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Femtosecond laser-assisted descemetorhexis for Descemet membrane endothelial keratoplasty: a cell- and tissue-based ex-vivo analysis in terms of precision and safety. J Cataract Refract Surg 2021; 48:89-94. [PMID: 34091552 DOI: 10.1097/j.jcrs.0000000000000692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/27/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To analyze precision and safety of femtosecond laser-assisted descemetorhexis as well as postoperative corneal wound healing in human ex vivo specimens. SETTING Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany. DESIGN Experimental ex vivo study. METHODS Four donor corneas underwent femtosecond laser-assisted descemetorhexis. The descemetorhexis was performed using the LDV Z8 femtosecond laser followed by live/dead staining, phase contrast microscopy and scanning electron microscopy. The descemetorhexis parameters were set using a modified optical coherence tomography image capturing of 8 segments within a focus of 100 μm at the posterior corneal stroma (reversed capsulotomy program). RESULTS Live/dead sample staining analysis demonstrated that the femtosecond laser had minimal impact on the vitality of surrounding endothelial cells. Phase contrast microscopy and scanning electron microscopy evaluation showed that the laser produced precise, clear-cut edges leaving no stromal tissue bridges. CONCLUSIONS Femtosecond laser-assisted descemetorhexis could serve as a safe and precise technique with only minimal endothelial cell damage. To minimize stromal damage, further laser energy profile adjustments are necessary to optimize corneal treatment within different stages of corneal tissue swelling.
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15
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Current development of alternative treatments for endothelial decompensation: Cell-based therapy. Exp Eye Res 2021; 207:108560. [PMID: 33811914 DOI: 10.1016/j.exer.2021.108560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/03/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022]
Abstract
Current treatment for corneal endothelial dysfunction consists in the replacement of corneal endothelium by keratoplasty. Owing to the scarcity of donor corneas and the increasing number of transplants, alternative treatments such as cell-based therapies are necessary. In this article, we highlight the biological aspects of the cornea and the corneal endothelium, as well as the context that surrounds the need for new alternatives to conventional keratoplasty. We then review some of those experimental treatments in more detail, focusing on the development of the in vitro and preclinical phases of two cell-based therapies: tissue-engineered endothelial keratoplasty (TE-EK) and cell injection. In the case of TE-EK graft construction, we analyse the current progress, considering all the requirements it must meet in order to be functional. Moreover, we discuss the inherent drawbacks of endothelial keratoplasties, which TE-EK grafts should overcome in order to make surgical intervention easier and to improve the outcomes of current endothelial keratoplasties. Finally, we analyse the development of preclinical trials and their limitations in terms of performing an optimal functional evaluation of cell-based therapy, and we conclude by discussing early clinical trials in humans.
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16
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Price MO, Mehta JS, Jurkunas UV, Price FW. Corneal endothelial dysfunction: Evolving understanding and treatment options. Prog Retin Eye Res 2020; 82:100904. [PMID: 32977001 DOI: 10.1016/j.preteyeres.2020.100904] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/14/2020] [Accepted: 09/19/2020] [Indexed: 12/13/2022]
Abstract
The cornea is exquisitely designed to protect the eye while transmitting and focusing incoming light. Precise control of corneal hydration by the endothelial cell layer that lines the inner surface of the cornea is required for optimal transparency, and endothelial dysfunction or damage can result in corneal edema and visual impairment. Advances in corneal transplantation now allow selective replacement of dysfunctional corneal endothelium, providing rapid visual rehabilitation. A series of technique improvements have minimized complications and various adaptations allow use even in eyes with complicated anatomy. While selective endothelial keratoplasty sets a very high standard for safety and efficacy, a shortage of donor corneas in many parts of the world restricts access, prompting a search for alternatives. Clinical trials are underway to evaluate the potential for self-recovery after removal of dysfunctional central endothelium in patients with healthy peripheral endothelium. Various approaches to using cultured human corneal endothelial cells are also in clinical trials; these aim to multiply cells from a single donor cornea for use in potentially hundreds of patients. Pre-clinical studies are underway with induced pluripotent stem cells, endothelial stem cell regeneration, gene therapy, anti-sense oligonucleotides, and various biologic/pharmacologic approaches designed to treat, prevent, or retard corneal endothelial dysfunction. The availability of more therapeutic options will hopefully expand access around the world while also allowing treatment to be more precisely tailored to each individual patient.
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Affiliation(s)
- Marianne O Price
- Cornea Research Foundation of America, 9002 N. Meridian St., Suite 212, Indianapolis, IN, USA.
| | - Jodhbir S Mehta
- Singapore National Eye Centre, 11 Third Hospital Ave #08-00, 168751, Singapore
| | - Ula V Jurkunas
- Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA, USA
| | - Francis W Price
- Price Vision Group, 9002 N. Meridian St., Suite 100, Indianapolis, IN, USA
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17
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Zhao C, Zhou Q, Duan H, Wang X, Jia Y, Gong Y, Li W, Dong C, Li Z, Shi W. Laminin 511 Precoating Promotes the Functional Recovery of Transplanted Corneal Endothelial Cells. Tissue Eng Part A 2020; 26:1158-1168. [PMID: 32495687 DOI: 10.1089/ten.tea.2020.0047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Corneal endothelial dysfunction is a major cause of corneal blindness and is mainly treated by corneal transplantation. However, the global shortage of donor cornea hampers its application. Intracameral injection of cultured primary corneal endothelial cells (CECs) was recently confirmed in clinical trials. However, abnormal adhesion of the grafted CECs affects the application of this strategy. In this study, we explored if laminin 511 (LN511) improves the therapeutic function of the intracameral CEC injection for corneal endothelial dysfunction. To mimic the late stage of corneal endothelial diseases, intense scraping was developed to remove CECs and extracellular matrix of the posterior Descemet's membrane (DM) without DM removal in rabbits. Then, Dulbecco's phosphate-buffered saline (DPBS) and LN511 were intracamerally injected as the control and intervention groups, respectively. We found that the injected LN511 could settle and form a coating on the posterior surface of DM. After CEC transplantation, corneal clarity of rabbits in the LN511 group was rapidly recovered within 7 days, whereas the corneal recovery took 14 days in the DPBS group. Corneal thickness of LN511 group decreased to 413.3 ± 20.8 μm 7 days after operation, which was significantly lower than 1086.3 ± 78.6 μm of DPBS group (p < 0.01). Moreover, for the grafted CECs, LN511 promoted the rapid adhesion, tight junction formation, and expression of Na+/K+-ATPase and ZO-1. In vitro analysis revealed that the functions of LN511 on the cultured human CECs mechanistically depended on the cell density and the nuclear-cytoplasmic translocation of the Yes-associated protein. Our study demonstrated that LN511 precoating promoted the adhesion of the transplanted CECs and enhanced the functional regeneration of the corneal endothelium. Thus, our data suggested that the strategy of LN511 precoating and CECs' intracameral injection could be a potential method for the therapy of corneal endothelial dysfunction. Impact statement Intracameral injection of cultured corneal endothelial cells (CECs) is a potential alternative therapy for corneal endothelial dysfunction and has been proven to be effective in clinical trials. However, abnormal adhesion of the grafted CECs affects its application. In this study, intense scraping was developed to remove CECs and extracellular matrix of the posterior Descemet's membrane (DM) without DM removal for the therapy of late stage of corneal endothelial diseases. Laminin 511 was intracamerally injected to form a coating, improve the posterior DM, enhance the adhesion of the grafted CECs, and promote the functional regeneration of CEC transplantation through Yes-associated protein signaling.
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Affiliation(s)
- Can Zhao
- Department of Medicine, Qingdao University, Qingdao, China.,Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Qingjun Zhou
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Haoyun Duan
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Xin Wang
- Department of Medicine, Qingdao University, Qingdao, China.,Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Yanni Jia
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China.,Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
| | - Yajie Gong
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Wenjing Li
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Chunxiao Dong
- Department of Medicine, Qingdao University, Qingdao, China.,Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Zongyi Li
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Weiyun Shi
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China.,Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
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18
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de Oliveira RC, Wilson SE. Descemet's membrane development, structure, function and regeneration. Exp Eye Res 2020; 197:108090. [PMID: 32522478 DOI: 10.1016/j.exer.2020.108090] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
Basement membranes are layers of extracellular matrix which anchor the epithelium or endothelium to connective tissues in most organs. Descemet's membrane- which is the basement membrane for the corneal endothelium- is a dense, thick, relatively transparent and cell-free matrix that separates the posterior corneal stroma from the underlying endothelium. It was historically named Descemet's membrane after Jean Descemet, a French physician, but it is also known as the posterior limiting elastic lamina, lamina elastica posterior, and membrane of Demours. Normal Descemet's membrane ultrastructure in humans has been shown to consist of an interfacial matrix that attaches to the overlying corneal stroma, an anterior banded layer and a posterior non-banded layer-upon which corneal endothelial cells attach. These layers have been shown to have unique composition and morphology, and to contribute to corneal homeostasis and clarity, participate in the control of corneal hydration and to modulate TGF-β-induced posterior corneal fibrosis. Pathophysiological alterations of Descemet's membrane are noted in ocular diseases such as Fuchs' dystrophy, bullous keratopathy, keratoconus, primary congenital glaucoma (Haab's striae), as well as in systemic conditions. Unrepaired extensive damage to Descemet's membrane results in severe corneal opacity and vision loss due to stromal fibrosis, which may require penetrating keratoplasty to restore corneal transparency. The purpose of this article is to highlight the current understanding of Descemet's membrane structure, function and potential for regeneration.
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19
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Wilson SE, Torricelli AAM, Marino GK. Corneal epithelial basement membrane: Structure, function and regeneration. Exp Eye Res 2020; 194:108002. [PMID: 32179076 DOI: 10.1016/j.exer.2020.108002] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/04/2020] [Accepted: 03/09/2020] [Indexed: 12/28/2022]
Abstract
Basement membranes are highly specialized extracellular matrices. More than providing scaffolds, basement membranes are recognized as dynamic and versatile structures that modulate cellular responses to regulate tissue development, function, and repair. Increasing evidence suggests that, in addition to providing structural support to adjacent cells, basement membranes serve as reservoirs and modulators of growth factors that direct and fine-tune cellular functions. Since the corneal stroma is avascular and has a relatively low keratocyte density, it's likely that the corneal BM is different in composition from the BMs in other tissues. BMs are composed of a diverse assemblage of extracellular molecules, some of which are likely specific to the tissue where they function; but in general they are composed of four primary components-collagens, laminins, heparan sulfate proteoglycans, and nidogens-in addition to other components such as thrombospondin-1, matrilin-2, and matrilin-4 and fibronectin. Severe injuries to the cornea, including infection, surgery, and trauma, may trigger the development of myofibroblasts and fibrosis in the normally transparent connective tissue stroma. Ultrastructural studies have demonstrated that defective epithelial basement membrane (EBM) regeneration after injury to the cornea underlies the development of myofibroblasts from both bone marrow- and keratocyte-derived precursor cells. Defective EBM permits epithelium-derived and tear-derived transforming growth factor beta (TGF-β), platelet-derived growth factor (PDGF), and possibly other modulators, to penetrate the stroma at sustained levels necessary to drive the development and persistence of vimentin + alpha-smooth muscle actin + desmin+ (V + A + D+) mature myofibroblasts. A recent discovery that has contributed to our understanding of haze development is that keratocytes and corneal fibroblasts produce critical EBM components, such as nidogen-1, nidogen-2 and perlecan, that are essential for complete regeneration of a normal EBM once laminin secreted by epithelial cells self-polymerizes into a nascent EBM. Mature myofibroblasts that become established in the anterior stroma are a barrier to keratocyte/corneal fibroblast contributions to the nascent EBM. These myofibroblasts, and the opacity they produce, often persist for months or years after the injury. Transparency is subsequently restored if the EBM is fully regenerated, myofibroblasts are deprived of TGF-β and undergo apoptosis, and keratocytes reoccupy the anterior stroma and reabsorb the disordered extracellular matrix.
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20
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Wilson SE. Coordinated Modulation of Corneal Scarring by the Epithelial Basement Membrane and Descemet's Basement Membrane. J Refract Surg 2020; 35:506-516. [PMID: 31393989 DOI: 10.3928/1081597x-20190625-02] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/25/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE To provide an overview of the importance of the coordinated role of the epithelial basement membrane (EBM) and Descemet's basement membrane (DBM) in modulating scarring (fibrosis) in the cornea after injuries, infections, surgeries, and diseases of the cornea. METHODS Literature review. RESULTS Despite their molecular and ultrastructural differences, the EBM and DBM act in a coordinated fashion to modulate the entry of transforming growth factor beta (TGF-β) and other growth factors from the epithelium/tear film and aqueous humor, respectively, into the corneal stroma where persistent levels of these modulators trigger the development and persistence of myofibroblasts that produced disordered, opaque extracellular matrix not usually present in the corneal stroma. The development of these myofibroblasts and the extracellular matrix they produce is often detrimental to visual function of the cornea after penetrating keratoplasty, LASIK buttonhole flaps, persistent epithelial defects, microbial keratitis, Descemet stripping automated endothelial keratoplasty, or Descemet membrane endothelial keratoplasty, while being beneficial in other situations such as the scarred edge of LASIK flaps and donor-recipient interface in penetrating keratoplasty. Efforts to modulate the repair or replacement of the EBM and DBM, and thereby the development or disappearance of myofibroblasts, should be a major emphasis of treatments provided by refractive and corneal surgeries, infections, trauma, or diseases of the cornea. CONCLUSIONS The EBM and DBM are critical modulators of the localization of profibrotic growth factors, such as TGF-β, that modulate the development and persistence of myofibroblasts that produce corneal scars (stromal fibrosis). Therapeutic efforts to regenerate or repair EBM and/or DBM, and interfere with the development of myofibroblasts or facilitate their disappearance are often the key to clinical outcomes. [J Refract Surg. 2019;35(8):506-516.].
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21
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Alió del Barrio JL, Montesel A, Ho V, Bhogal M. Descemet Membrane Endothelial Keratoplasty Under Failed Penetrating Keratoplasty Without Host Descemetorhexis for the Management of Secondary Graft Failure. Cornea 2019; 39:13-17. [DOI: 10.1097/ico.0000000000002046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Medeiros CS, Saikia P, de Oliveira RC, Lassance L, Santhiago MR, Wilson SE. Descemet's Membrane Modulation of Posterior Corneal Fibrosis. Invest Ophthalmol Vis Sci 2019; 60:1010-1020. [PMID: 30884531 PMCID: PMC6424532 DOI: 10.1167/iovs.18-26451] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/07/2019] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the effect of removal of Descemet's basement membrane and endothelium compared with removal of the endothelium alone on posterior corneal fibrosis. Methods Twelve New Zealand White rabbits were included in the study. Six eyes had removal of the Descemet's membrane-endothelial complex over the central 8 mm of the cornea. Six eyes had endothelial removal with an olive-tipped cannula over the central 8 mm of the cornea. All corneas developed stromal edema. Corneas in both groups were cryofixed in optimum cutting temperature (OCT) formula at 1 month after surgery. Immunohistochemistry (IHC) was performed for α-smooth muscle actin (SMA), keratocan, CD45, nidogen-1, vimentin, and Ki-67, and a TUNEL assay was performed to detect apoptosis. Results Six of six corneas that had Descemet's membrane-endothelial removal developed posterior stromal fibrosis populated with SMA+ myofibroblasts, whereas zero of six corneas that had endothelial removal alone developed fibrosis or SMA+ myofibroblasts (P < 0.01). Myofibroblasts in the fibrotic zone of corneas that had Descemet's membrane-endothelial removal were undergoing both mitosis and apoptosis at 1 month after surgery. A zone between keratocan+ keratocytes and SMA+ myofibroblasts contained keratocan-SMA-vimentin+ cells that were likely CD45- corneal fibroblasts and CD45+ fibrocytes. Conclusions Descemet's basement membrane has an important role in modulating posterior corneal fibrosis after injury that is analogous to the role of the epithelial basement membrane in modulating anterior corneal fibrosis after injury. Fibrotic areas had myofibroblasts undergoing mitosis and apoptosis, indicating that fibrosis is in dynamic flux.
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Affiliation(s)
- Carla S. Medeiros
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
- Department of Ophthalmology, University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Luciana Lassance
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Marcony R. Santhiago
- Department of Ophthalmology, University of Sao Paulo, Sao Paulo, Brazil
- Department of Ophthalmology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Ophthalmology, University of Southern California, Los Angeles, California, United States
| | - Steven E. Wilson
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
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Brockmann T, Pilger D, Brockmann C, Maier AKB, Bertelmann E, Torun N. Predictive Factors for Clinical Outcomes after Primary Descemet's Membrane Endothelial Keratoplasty for Fuchs' Endothelial Dystrophy. Curr Eye Res 2018; 44:147-153. [PMID: 30339062 DOI: 10.1080/02713683.2018.1538459] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study is to identify predictors for the best-corrected visual acuity (BCVA), central corneal thickness (CCT), and the endothelial cell density (ECD) after primary Descemet's membrane endothelial keratoplasty (DMEK). METHODS In a prospective observational study, 108 eyes with Fuchs' endothelial dystrophy underwent a primary DMEK. Preoperative data, histologic parameters from host's Descemet's membrane, and follow-up data of the first eye were analyzed in regard to BCVA, CCT, and ECD, 12 months after surgery. RESULTS Overall, 12 months postoperative, the BCVA improved to 0.11 ± 0.11 logMAR, the CCT declined to 529 ± 42 µm, and the ECD measured 1675 ± 418 cells/mm2. A significant influence of the preoperative CCT on postoperative BCVAs and CCTs was observed (r = 0.299, p = 0.014 and r = 0.507, p < 0.001, respectively). Especially eyes with a CCT <625 µm demonstrated a better BCVA (0.05 ± 0.07 logMAR) than eyes with a CCT ≥625 µm (0.13 ± 0.11 logMAR, p = 0.002). Furthermore, the identification of eyes with an early visual restitution was possible by considering follow-up data of the first eye. A preoperative CCT ≥625 µm was also sensitive to identify eyes with a persistent corneal swelling. The anterior banded layer thickness, which was obtained histologically, correlated to the preoperative CCT and the frequency of graft detachments (r = 0.601, p = 0.023 and r = 0.652, p = 0.041, respectively). Furthermore, a graft's baseline ECD ≤2100 cells/mm2 was found to be a risk factor for an ECD deterioration under 1000 cells/mm2 (1.8% vs. 15.8%, p = 0.020). CONCLUSIONS Simple clinical parameters, such as the preoperative CCT, the course of visual restitution of the first eye, and the graft's baseline ECD, are efficient predictors for relevant outcome parameters after DMEK and therefore may be used for stratification. Furthermore, our findings indicate that a DMEK should be performed in eyes with Fuchs' endothelial corneal dystrophy, if possible, before the CCT exceeds 625 µm to maintain good clinical results.
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Affiliation(s)
- Tobias Brockmann
- a Department of Ophthalmology , Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health , Berlin , Germany.,b Berlin Institute of Health (BIH) , Berlin , Germany
| | - Daniel Pilger
- a Department of Ophthalmology , Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health , Berlin , Germany.,b Berlin Institute of Health (BIH) , Berlin , Germany
| | - Claudia Brockmann
- a Department of Ophthalmology , Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health , Berlin , Germany.,b Berlin Institute of Health (BIH) , Berlin , Germany
| | - Anna-Karina B Maier
- a Department of Ophthalmology , Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health , Berlin , Germany
| | - Eckart Bertelmann
- a Department of Ophthalmology , Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health , Berlin , Germany
| | - Necip Torun
- a Department of Ophthalmology , Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health , Berlin , Germany
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24
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Descemet Membrane Endothelial Keratoplasty for Failed Penetrating Keratoplasty: Visual Outcomes and Graft Survival. Cornea 2018; 38:151-156. [DOI: 10.1097/ico.0000000000001763] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Jia Y, Li W, Duan H, Li Z, Zhou Q, Shi W. Mini-Sheet Injection for Cultured Corneal Endothelial Transplantation. Tissue Eng Part C Methods 2018; 24:474-479. [DOI: 10.1089/ten.tec.2018.0077] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Yanni Jia
- Department of Medicine, Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Wenjing Li
- Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Haoyun Duan
- Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Zongyi Li
- Department of Medicine, Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Qingjun Zhou
- Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Weiyun Shi
- Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
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Brockmann T, Brockmann C, Maier AKB, Schroeter J, Bertelmann E, Torun N. Primary Descemet’s Membrane Endothelial Keratoplasty for Fuchs Endothelial Dystrophy versus Bullous Keratopathy: Histopathology and Clinical Results. Curr Eye Res 2018; 43:1221-1227. [DOI: 10.1080/02713683.2018.1490773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Tobias Brockmann
- Department of Ophthalmology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Claudia Brockmann
- Department of Ophthalmology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Anna-Karina B. Maier
- Department of Ophthalmology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jan Schroeter
- Institute of Transfusion Medicine, University Tissue Bank, Charité – Universitätsmedizin Berlin, corporatemember of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eckart Bertelmann
- Department of Ophthalmology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Necip Torun
- Department of Ophthalmology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Berlin, Germany
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Abstract
PURPOSE To describe Descemet membrane endothelial keratoplasty (DMEK) complications and strategies for their prevention and management. METHODS Five hundred consecutive eyes with DMEK of 393 patients were reviewed in this retrospective study for intraoperative and postoperative complications up to 2 years and for corresponding management. RESULTS Intraoperative challenges (difficult graft unfolding/positioning, high vitreous pressure, iris root hemorrhage, and Descemet membrane remnants) were encountered in 81 eyes (16.2%). Visually significant graft detachment was the main postoperative complication (34 eyes, 6.8%). Graft failure occurred in 8 eyes (1.6%). Other postoperative complications were an increase of intraocular pressure/decompensated glaucoma in 48 eyes (9.6%), significant cataract in 11 of 124 phakic eyes (8.9%), allograft rejection in 7 eyes (1.4%), cystoid macular edema in 5 eyes (1.0%), microbial keratitis in 2 eyes (0.4%), and retinal detachment in 1 eye (0.2%). Different strategies for prevention and management of these complications have been identified. CONCLUSIONS DMEK shows acceptable rates of complications up to 2 years after surgery, which can be managed successfully. Anticipation of potential challenges and difficulties may aid in modifying intraoperative strategies for predisposed eyes. This knowledge may further minimize complications, in particular, when performing DMEK for an extended spectrum of corneal endothelial disorders.
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Descemet's Membrane Endothelial Keratoplasty. Indication, technique chirurgicale, gestion postopératoire et revue de la littérature. J Fr Ophtalmol 2018; 41:368-381. [DOI: 10.1016/j.jfo.2017.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/20/2017] [Indexed: 11/20/2022]
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Outcome and Histopathology of Secondary Penetrating Keratoplasty Graft Failure Managed by Descemet Membrane Endothelial Keratoplasty. Cornea 2018; 36:777-784. [PMID: 28350625 DOI: 10.1097/ico.0000000000001180] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the clinical outcome and histopathology of Descemet membrane endothelial keratoplasty (DMEK) performed for secondary graft failure after penetrating keratoplasty (PK). METHODS A total of 11 eyes from 10 patients who underwent DMEK for secondary PK graft failure at a tertiary referral center were included in this retrospective study. Best-corrected visual acuity, endothelial cell density, and central pachymetry were evaluated before and at regular time intervals up to 36 months after DMEK and complications were recorded; 1 post mortem cornea was available for light microscopy. RESULTS At their last follow-up visit (on average, 16 months after DMEK), 7 of 11 transplanted corneas were clear. In the 7 eyes with clear grafts, 5 had a best-corrected visual acuity of ≥20/25 (≥0.8), central pachymetry averaged 535 (±70) μm, and endothelial cell density averaged 1045 (±500) cells/mm. Of the 11 eyes, 4 required rebubbling in the early postoperative phase; 1 eye was left with a small (<1/3) detachment. Light microscopy of the pathology specimen showed complete attachment of the DMEK graft onto the preexisting PK posterior stroma, with interface scarring over DMEK graft folds and underneath the graft area that had initially been detached. CONCLUSIONS DMEK may be a viable option to manage secondary PK graft failure with acceptable outcomes in many cases. Rebubbling for graft detachment may be anticipated, especially because of preexisting glaucoma conditions (severe decompensation, hypotony, and tubes from glaucoma-draining devices). Graft reattachment may occur through interface scarring.
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Santander-García D, Dapena I, Baydoun L, Melles GRJ. DMEK complications: current treatment and recommendations. EXPERT REVIEW OF OPHTHALMOLOGY 2018. [DOI: 10.1080/17469899.2018.1429917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Diana Santander-García
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
| | - Isabel Dapena
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
| | - Lamis Baydoun
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
| | - Gerrit R. J. Melles
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
- Amnitrans Eye Bank Rotterdam, Rotterdam, The Netherlands
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Lin X, Wu Y, Fu Y, Dai Q. Spontaneous reattachment of Descemet membrane detachment after deep anterior lamellar keratoplasty: A case report. Medicine (Baltimore) 2018; 97:e0032. [PMID: 29465543 PMCID: PMC5841960 DOI: 10.1097/md.0000000000010032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE To report a case of late spontaneous reattachment of Descemet membrane (DM) detachment after deep anterior lamellar keratoplasty (DALK). PATIENT CONCERNS A 50-year-old woman with stromal corneal scarring underwent a DALK with the big bubble technique. The DM detachment and double anterior chamber were observed on the first day after operation. DIAGNOSES Descemet membrane detachment after deep anterior lamellar keratoplasty [Oculus Dexter (OD), indicates right eye]. INTERVENTIONS Sterile air injection was unsuccessful. Conservative observation was performed. OUTCOMES During the follow-up, the donor cornea kept transparent and no edema was observed. The DM reattached spontaneously at the fifth months post-DALK. LESSONS The present case suggests that the retained host DM may result in DM detachment after DALK. For the DM detachment without roll rim, the detachment may spontaneously reattach in several months after surgery.
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Affiliation(s)
- Xiaolei Lin
- School of Ophthalmology and Optometry, Eye Hospital, Wenzhou Medical University Key Laboratory of Vision Science, Ministry of Health, Wenzhou, Zhejiang, China
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Affiliation(s)
| | - Pankaj Gupta
- University Hospitals Eye Institute and Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio 44106;,
| | - Jonathan Lass
- University Hospitals Eye Institute and Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio 44106;,
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Parekh M, Leon P, Ruzza A, Borroni D, Ferrari S, Ponzin D, Romano V. Graft detachment and rebubbling rate in Descemet membrane endothelial keratoplasty. Surv Ophthalmol 2017; 63:245-250. [PMID: 28739402 DOI: 10.1016/j.survophthal.2017.07.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 07/13/2017] [Accepted: 07/17/2017] [Indexed: 11/18/2022]
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is a selective replacement of dysfunctional endothelium with healthy donor Descemet membrane and endothelium. Although the donor preparation and surgical methods still remain a challenge, DMEK is gaining popularity in terms of early rehabilitation and visual outcomes. New and improved donor preparation techniques like prestripped DMEK tissues are being taken up rapidly because of less manipulation that is required in the surgical theatre. Donor graft delivery in the recipient eye has also been improved because of new products like prestripped and preloaded membranes. As DMEK is at its budding stage, only early outcomes have been known so far. Early graft detachment, rebubbling rates, and primary failures are still being studied in DMEK. As there are different techniques that are currently used for preparation and injection of the graft, it becomes difficult to judge the results based on specific inclusion and exclusion criteria. Graft detachment and rebubbling rates have been a huge challenge both during the surgery and also while reporting postoperative data. We highlight the importance of defining graft detachment and rebubbling rates and their surgical relevance, which may also have an impact on graft preparation and insertion techniques.
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Affiliation(s)
- Mohit Parekh
- International Center for Ocular Physiopathology, The Veneto Eye Bank Foundation, Mestre, Venice, Italy; Department of Molecular Medicine, School of Biomedicine, University of Padova, Padova, Italy.
| | - Pia Leon
- Department of Ophthalmology, SS Giovanni and Paolo Hospital, Venice, Italy; Department of Ophthalmology, Villa Igea Hospital, Forli, Italy; Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Alessandro Ruzza
- International Center for Ocular Physiopathology, The Veneto Eye Bank Foundation, Mestre, Venice, Italy
| | - Davide Borroni
- Department of Ophthalmology, Riga Stradins University, Riga, Latvia; Department of Genetics, Riga Stradins University, Riga, Latvia
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, The Veneto Eye Bank Foundation, Mestre, Venice, Italy
| | - Diego Ponzin
- International Center for Ocular Physiopathology, The Veneto Eye Bank Foundation, Mestre, Venice, Italy
| | - Vito Romano
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Air Pump-Assisted Graft Centration, Graft Edge Unfolding, and Graft Uncreasing in Young Donor Graft Pre-Descemet Endothelial Keratoplasty. Cornea 2017; 36:1009-1013. [PMID: 28481833 DOI: 10.1097/ico.0000000000001225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess an air pump-assisted technique for graft centration, graft edge unfolding, and graft uncreasing while performing pre-Descemet endothelial keratoplasty (PDEK) using young donor grafts. METHODS Continuous pressurized air infusion was used for graft centration, graft edge unfolding, and graft unwrinkling. RESULTS Ten eyes of 10 patients underwent PDEK with donors aged below 40 years. In all eyes, the donor scrolled into tight scrolls. In all cases, the air pump-assisted technique was effective in positioning and centering the graft accurately and in straightening infolded graft edges and smoothing out graft creases and wrinkles. Endothelial cell loss was 38.6%. Postoperative best-corrected visual acuity at 6 months was 0.66 ± 0.25 in decimal equivalent. Continuous pressurized air infusion acted as a third hand providing a continuous pressure head that supported the graft and prevented graft dislocation as well as anterior chamber collapse during intraocular maneuvering. Adequate maneuvering space was available in all cases, and bleeding, if any, was tamponaded successfully in all cases. CONCLUSIONS Although very young donor grafts may be used for PDEK, they are difficult to center and unroll completely before floating against host stroma. An air pump-assisted technique using continuous pressurized air infusion allows successful final graft positioning even with very young donor corneas. It thus makes surgery easier as several key steps are made easier to handle. It additionally helps in tamponading hemorrhage during peripheral iridectomy, increasing surgical space, preventing fluctuations in the anterior chamber depth, and promoting graft adherence.
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35
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Clinical Outcome of Rebubbling for Graft Detachment After Descemet Membrane Endothelial Keratoplasty. Cornea 2017; 36:771-776. [DOI: 10.1097/ico.0000000000001220] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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