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Kladny AMS, Glatz A, Lieberum JL, Zander DB, Siegel H, Jiang J, Brandi-Dohrn F, Maier PC, Lapp T, Lang SJ, Heinzelmann-Mink S, Böhringer D, Reinhard T, Wacker K. Supine Positioning for Graft Attachment After Descemet Membrane Endothelial Keratoplasty: A Randomized Controlled Trial. Am J Ophthalmol 2024; 263:117-125. [PMID: 38070634 DOI: 10.1016/j.ajo.2023.11.021] [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: 08/09/2023] [Revised: 10/12/2023] [Accepted: 11/22/2023] [Indexed: 03/25/2024]
Abstract
PURPOSE The Supine Positioning for Descemet Membrane Endothelial Keratoplasty Attachment (SUPER-DMEK) trial assessed the efficacy of prolonged supine head positioning on graft attachment. DESIGN Randomized controlled trial. METHODS Participants with Fuchs' dystrophy were randomized to 5 days of supine head positioning (intervention) or to 1 day (control). Participants, surgeons, and investigators were masked until the day after surgery. Adherence to the allocated intervention was monitored using a head sensor. Main outcome measures were area and volume of graft detachment (coprimary end points) 2 weeks after surgery quantified using a validated neural network for image segmentation on anterior segment optical coherence tomography images, and repeat air injection (rebubbling), subjective visual function, and adverse events (secondary end points). RESULTS A total of 86 participants received the allocated intervention (35 eyes intervention and 51 eyes control). In the intention-to-treat analysis, the mean area of graft detachment was 28.6% in the intervention arm and 27.5% in the control arm (adjusted between-arm difference, 1.3; 95% CI, -8.7 to 11.4; P = .80). Results for volume of detachment and as-treated analyses based on head position sensor data indicated no potentially clinically relevant effect of prolonged supine positioning on graft attachment. Results were not compatible with a relevant treatment effect on rebubbling or subjective visual function. Adverse events, most commonly back pain, were more common and more severe with the intervention. CONCLUSIONS In this randomized controlled trial, graft attachment was not improved with prolonged supine head positioning. Prolonged supine positioning frequently caused back pain. Prolonged supine positioning after Descemet membrane endothelial keratoplasty for Fuchs' dystrophy may not be needed in routine practice.
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Affiliation(s)
- Anne-Marie S Kladny
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Andreas Glatz
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Judith-Lisa Lieberum
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Daniel B Zander
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Helena Siegel
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jana Jiang
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Franziska Brandi-Dohrn
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Philip C Maier
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thabo Lapp
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Stefan J Lang
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Sonja Heinzelmann-Mink
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Daniel Böhringer
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Reinhard
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Katrin Wacker
- From the Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
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Kladny AMS, Glatz A, Böhringer D, Zander DB, Lieberum JL, Reinhard T, Wacker K. 3D Mapping of the DMEK Detachment Area from OCT Scans of the Anterior Segment of the Eye - Clinical Applications. Klin Monbl Augenheilkd 2024; 241:727-733. [PMID: 38688303 DOI: 10.1055/a-2219-1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Graft detachment is the most common complication after Descemet membrane endothelial keratoplasty (DMEK). To assess the amount of graft detachment, precision is limited when using slit-lamp biomicroscopy. Detachment of DMEK grafts can be assessed automatically on anterior segment optical coherence tomography (AS OCT) images and allows visualization of the area and volume of detachment using 3D maps. This article provides an overview of its applications such as accurately assessing the course of natural graft attachment, identification of potential risk factors for detachment and evaluation of the long-term effect of graft detachment. The 3D map of DMEK detachment may support researchers and clinicians in precise quantification of the area and volume of graft detachment even in large data sets, and the intuitive, fast and reliable evaluation.
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Affiliation(s)
| | | | - Daniel Böhringer
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
| | | | | | - Thomas Reinhard
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
| | - Katrin Wacker
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
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Lockington D, Brown G, Pearce C, Kaczmarczyk L. Evaluating the forces involved in bubble management in DMEK surgery: mathematical and computational model with clinical implications. J Cataract Refract Surg 2024; 50:78-83. [PMID: 37718512 DOI: 10.1097/j.jcrs.0000000000001309] [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: 07/01/2023] [Accepted: 09/04/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE To model postoperative forces involved in Descemet membrane endothelial keratoplasty (DMEK) tissue adherence and bubble management, including the impact of surface tension on graft support, with a view towards clinical applications. SETTING Tennent Institute of Ophthalmology, Glasgow, and James Watt School of Engineering, University of Glasgow, Glasgow, United Kingdom. DESIGN Mathematical modelling and computer simulation. METHODS Theoretical modelling of biphasic flow and interaction of gas, liquid and tissue within the anterior chamber for static horizontal scenario A (adherent DMEK with mobile bubble) and dynamic vertical scenario B (release of bubble due to pupil block following DMEK). RESULTS The model assumed incompressibility for both fluids within realistically achievable pressure ranges. Cahn-Hilliard Navier-Stokes equations were discretised through the application of the Finite Element Method. Mathematical modelling and computer simulation showed bubble size, corneal curvature and force intensity influences surface tension support for DMEK tissue in scenario A. Scenario B demonstrated complex, uneven distribution of surface pressure on the DMEK graft during uncontrolled bubble release. Uneven pressure concentration can cause local tissue warping, with air/fluid displacement via capillary waves generated on the fluid-air interface adversely impacting DMEK support. CONCLUSIONS We have quantitatively and qualitatively modelled the forces involved in DMEK adherence in normal circumstances. We have shown releasing air/gas can abruptly reduce DMEK tissue support via generation of large pressure gradients at the liquid/bubble/graft interfaces, creating negative local forces. Surgeons should consider these principles to reduce DMEK graft dislocation rates via optimised bubble size to graft size, longer acting bubble support and avoiding rapid decompression where possible.
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Affiliation(s)
- David Lockington
- From the Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, United Kingdom (Lockington, Brown); James Watt School of Engineering, University of Glasgow, Glasgow, United Kingdom (Pearce, Kaczmarczyk)
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Vasiliauskaite I, Kocaba V, van Dijk K, Baydoun L, Lanser C, Lee D, Jager MJ, Melles GRJ, Oellerich S. Long-Term Outcomes of Descemet Membrane Endothelial Keratoplasty: Effect of Surgical Indication and Disease Severity. Cornea 2023; 42:1229-1239. [PMID: 36731083 DOI: 10.1097/ico.0000000000003130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/16/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate clinical outcomes and graft survival in a large patient cohort up to 10 years after Descemet membrane endothelial keratoplasty (DMEK) based on surgical indication and Fuchs endothelial corneal dystrophy (FECD) severity. METHODS The cohort in this retrospective study included 750 eyes that underwent DMEK for FECD (86%), bullous keratopathy (BK, 9%), and other indications (5%). Based on the modified Krachmer grading, 186 eyes (29%) had moderate FECD (Krachmer grade 3-4) and 440 eyes (68%) had advanced FECD (Krachmer grade 5-6). Main outcome measures were best-corrected visual acuity (BCVA), central corneal thickness, endothelial cell density (ECD), endothelial cell loss (ECL), postoperative complication rate, and graft survival. RESULTS The mean 10-year BCVA was 0.08 ± 0.28 logMAR (n = 96), and the BCVA remained stable between 5 and 10 years postoperatively (all P > 0.05). The mean ECL at 5 and 10 years was 56% ± 17% (n = 460) and 66% ± 14% (n = 96), respectively ( P < 0.05). The 10-year graft survival rate for the total cohort was 0.85 (95% confidence interval, 0.82-0.89). BCVA and ECD differed at 1 to 5 years between eyes with different surgical indications (all P < 0.05), and FECD eyes had higher graft survival compared with BK eyes (0.90 vs. 0.60, P = 0.001). Moderate FECD eyes had better BCVA, ECD, and graft survival outcomes than advanced FECD eyes (all P < 0.05). Minor graft detachment ( P = 0.04) and lower donor ECD ( P = 0.01) were related to lower 10-year ECD. CONCLUSIONS Long-term outcomes and graft survival after DMEK were better in FECD eyes than BK eyes and were also related to FECD disease severity. Eyes operated for moderate FECD showed the highest graft survival probability and excellent long-term outcomes.
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Affiliation(s)
- Indre Vasiliauskaite
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - Viridiana Kocaba
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
- Amnitrans EyeBank Rotterdam, Rotterdam, The Netherlands
- Tissue and Cell Therapy Group, Singapore Eye Research Institute, Singapore
| | - Korine van Dijk
- 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
- University Eye Hospital Munster, Munster, Germany; and
- ELZA Institute Dietikon/Zurich, Switzerland
| | - Charlotte Lanser
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
| | - Demi Lee
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
| | - Martine J Jager
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerrit R J Melles
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
- Melles Cornea Clinic Rotterdam, Rotterdam, The Netherlands
- Amnitrans EyeBank Rotterdam, Rotterdam, The Netherlands
| | - Silke Oellerich
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
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Kladny AMS, Zander DB, Lieberum JL, Glatz A, Brandi-Dohrn F, Reinhard T, Wacker K. Graft Detachment after Descemet Membrane Endothelial Keratoplasty with and without Cataract Surgery. OPHTHALMOLOGY SCIENCE 2022; 2:100194. [PMID: 36531572 PMCID: PMC9754956 DOI: 10.1016/j.xops.2022.100194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/27/2022] [Accepted: 06/29/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE To evaluate graft detachment after Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic eyes and DMEK combined with cataract surgery (triple DMEK). DESIGN Analysis of 3 single-center prospective cohort studies and 1 randomized controlled trial. PARTICIPANTS Participants with Fuchs' endothelial corneal dystrophy. METHODS A validated neural network for image segmentation quantified graft detachment on anterior segment OCT (AS-OCT) images 3 days after DMEK and at the 2-week postoperative visit. Area and volume of graft detachment were compared between DMEK only and triple DMEK using generalized estimating equation models and adjusting for participant age and the size of the air bubble. MAIN OUTCOME MEASURES Area and volume of DMEK graft detachment. RESULTS Among 207 participants with 270 eyes included, 75 pseudophakic eyes had DMEK only and 195 eyes had triple DMEK. A total of 147 eyes had less than one third of detachment at day 3. In 139 of these eyes (95%), detachment was still less than one third at the 2-week scan, indicating that postoperative graft detachment at 2 weeks occurred mainly in eyes with early detachment. When superimposing all 3-dimensional maps from 2 weeks after surgery, the central graft was mainly attached and detachment was located at the graft margin. The mean area of graft detachment decreased from 28% in DMEK only and 38% in triple DMEK to 16% in DMEK only and 25% in triple DMEK at the 2-week postoperative visit. At 2 weeks, the mean area of detachment was 1.85-fold higher (95% confidence interval [CI], 1.34-2.56) and the mean volume was 2.41-fold higher (95% CI, 1.51-3.86) in triple DMEK compared with DMEK. A total of 46 eyes received rebubbling procedures, with 7 eyes (9%) in the DMEK group and 39 eyes (20%) in the triple DMEK group (adjusted risk ratio, 3.1; 95% CI, 1.3-7.1), indicating that rebubbling was more common in eyes undergoing triple DMEK. CONCLUSIONS Automated segmentation of AS-OCT images allowed precise quantification of graft detachment over time and identified DMEK combined with cataract surgery as a risk factor. Frequency of operative follow-up might be guided by extent of detachment in the first postoperative days after DMEK.
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Affiliation(s)
| | | | | | | | | | | | - Katrin Wacker
- Correspondence: Katrin Wacker, MD, Eye Center, University of Freiburg, Killianstr. 5, 79106 Freiburg im Breisgau, Germany.
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Zander DB, Jiang J, Reinhard T, Wacker K. Corneal Oedema: Aetiology, Diagnostic Testing, and Treatment. Klin Monbl Augenheilkd 2022; 239:752-759. [DOI: 10.1055/a-1759-3834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractCorneal oedema results from an underlying pathology, which can be diverse in origin, and may be mechanical, dystrophic, or inflammatory, and affect any layer of the cornea. Diagnostic tools
such as Scheimpflug imaging and anterior segment optical coherence tomography have standardised quantification of corneal oedema and have become important aids in clinical practice. Timely
diagnosis and treatment are key to preventing irreversible damage to the corneal ultrastructure, such as anterior corneal fibrosis or endothelial cell damage. The oedema usually resolves
quickly when the underlying cause has been addressed. Symptomatic treatment using hyperosmolar agents has failed to show any benefits in oedema resolution or improvement in visual acuity
compared to placebo. In contrast, rho-associated protein kinase (ROCK) inhibitors offer a promising option for medical treatment in cases of endothelial dysfunction, but their safety and
efficacy must be further validated in large scale clinical trials. Until then, endothelial or penetrating keratoplasties remain the mainstay treatment where structural changes to the cornea
have occurred.
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Affiliation(s)
| | - Jana Jiang
- Eye Center, Medical Center – University of Freiburg, Freiburg, Germany
| | - Thomas Reinhard
- Eye Center, Medical Center – University of Freiburg, Freiburg, Germany
| | - Katrin Wacker
- Eye Center, Medical Center – University of Freiburg, Freiburg, Germany
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