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Spelta S, Micera A, Gaudenzi D, Niutta M, Surico PL, De Vincentis A, Coassin M, Di Zazzo A. A Functional and Immunologic Point of View on Corneal Endothelial Transplantation: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3431. [PMID: 38929958 PMCID: PMC11204674 DOI: 10.3390/jcm13123431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/04/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background: To systematically review and meta-analyze the immunologic aspects and outcomes of various endothelial keratoplasty (EK) techniques, specifically comparing Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK), Ultra-Thin Descemet's Stripping Automated Endothelial Keratoplasty (UT-DSAEK), and Descemet's Membrane Endothelial Keratoplasty (DMEK). Methods: Systematic review and meta-analysis. Main outcomes were the proportion of patients achieving a best spectacle-corrected visual acuity (BSCVA) of 20/20 at 6 months after keratoplasty, rejection rate one year after surgery, BSCVA at last follow up, and postoperative immunomodulating regimen. Results: A higher proportion of DMEK patients achieved a BSCVA of 20/20 after 6 months. UT-DSAEK and DMEK showed similar rejection rates with a lower risk of re-bubbling for UT-DSAEK (4% vs. 20%). Conclusions: DMEK showed faster visual recovery than UT-DSAEK but a similar rejection rate and long-term visual acuity. One-year postoperative slow tapering steroid regimen has a positive but not (yet) significant effect on rejection risk and visual outcomes.
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Affiliation(s)
- Sara Spelta
- Department of Ophthalmology, University Campus Bio-Medico, 00128 Rome, Italy; (S.S.); (D.G.); (M.N.); (P.L.S.); (M.C.)
- Fondazione Policlinico Campus Bio-Medico, 00128 Rome, Italy
| | - Alessandra Micera
- Research and Development Laboratory for Biochemical, Molecular and Cellular Applications in Ophthalmological Sciences, IRCCS–Fondazione Bietti, 00184 Rome, Italy;
| | - Daniele Gaudenzi
- Department of Ophthalmology, University Campus Bio-Medico, 00128 Rome, Italy; (S.S.); (D.G.); (M.N.); (P.L.S.); (M.C.)
- Fondazione Policlinico Campus Bio-Medico, 00128 Rome, Italy
| | - Matteo Niutta
- Department of Ophthalmology, University Campus Bio-Medico, 00128 Rome, Italy; (S.S.); (D.G.); (M.N.); (P.L.S.); (M.C.)
- Fondazione Policlinico Campus Bio-Medico, 00128 Rome, Italy
| | - Pier Luigi Surico
- Department of Ophthalmology, University Campus Bio-Medico, 00128 Rome, Italy; (S.S.); (D.G.); (M.N.); (P.L.S.); (M.C.)
- Fondazione Policlinico Campus Bio-Medico, 00128 Rome, Italy
| | - Antonio De Vincentis
- Fondazione Policlinico Campus Bio-Medico, 00128 Rome, Italy
- Internal Medicine, University Campus Bio-Medico, 00128 Rome, Italy
| | - Marco Coassin
- Department of Ophthalmology, University Campus Bio-Medico, 00128 Rome, Italy; (S.S.); (D.G.); (M.N.); (P.L.S.); (M.C.)
- Fondazione Policlinico Campus Bio-Medico, 00128 Rome, Italy
| | - Antonio Di Zazzo
- Department of Ophthalmology, University Campus Bio-Medico, 00128 Rome, Italy; (S.S.); (D.G.); (M.N.); (P.L.S.); (M.C.)
- Fondazione Policlinico Campus Bio-Medico, 00128 Rome, Italy
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Perone JM, Goetz C, Zevering Y, Derumigny A. Principal Component Analysis of a Real-World Cohort of Descemet Stripping Automated Endothelial Keratoplasty and Descemet Membrane Endothelial Keratoplasty Cases: Demonstration of a Powerful Data-Mining Technique for Identifying Areas of Research. Cornea 2024:00003226-990000000-00569. [PMID: 38830189 DOI: 10.1097/ico.0000000000003584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/24/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Principal component analysis (PCA) is a descriptive exploratory statistical technique that is widely used in complex fields for data mining. However, it is rarely used in ophthalmology. We explored its research potential with a large series of eyes that underwent 3 keratoplasty techniques: Descemet membrane endothelial keratoplasty (DMEK), conventional Descemet stripping automated endothelial keratoplasty (ConDSAEK), or ultrathin-DSAEK (UT-DSAEK). METHODS All consecutive DMEK/DSAEK cases conducted in 2016 to 2022 that had ≥24 months of follow-up were included. ConDSAEK and UT-DSAEK were defined as preoperative central graft thickness ≥130 and <130 μm, respectively. Seventy-six patient, disease, surgical practice, and temporal outcome variables were subjected to PCA, including preoperative anterior keratometry, the use of sulfur hexafluoride gas (SF6) versus air for primary tamponade, and postoperative best corrected visual acuity and endothelial cell density. Associations of interest that were revealed by PCA were assessed with the Welch t test or Pearson test. RESULTS A total of 331 eyes were treated with DMEK (n = 165), ConDSAEK (n = 95), or UT-DSAEK (n = 71). PCA showed that ConDSAEK and UT-DSAEK clustered closely, including regarding postoperative best corrected visual acuity, and were clearly distinct from DMEK. PCA and follow-up univariate analyses suggested that in DMEK, 1) flatter preoperative anterior keratometry (average, K1, and K2) associated with more rebubbling (P = 0.004-0.089) and graft detachment (P = 0.007-0.022); 2) graft marking did not affect postoperative ECD; and 3) lower postoperative endothelial cell density associated with SF6 use (all P > 0.001) and longer surgery (P = 0.005-0.091). All associations are currently under additional investigation in our hospital. CONCLUSIONS PCA is a powerful technique that can rapidly reveal clinically relevant associations in complex ophthalmological datasets.
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Affiliation(s)
- Jean-Marc Perone
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| | - Christophe Goetz
- Clinical Research Support Unit, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France; and
| | - Yinka Zevering
- Clinical Research Support Unit, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France; and
| | - Alexis Derumigny
- Department of Applied Mathematics, Delft University of Technology, Delft, the Netherlands
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Madsen MBM, Ivarsen A, Hjortdal J. Visual function after ultrathin Descemet's stripping automated endothelial keratoplasty or Descemet's membrane endothelial keratoplasty combined with cataract surgery: a randomised controlled clinical trial. Br J Ophthalmol 2024; 108:654-661. [PMID: 37290822 DOI: 10.1136/bjo-2023-323304] [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: 01/24/2023] [Accepted: 05/29/2023] [Indexed: 06/10/2023]
Abstract
AIMS To compare best-corrected visual acuity (BCVA), contrast sensitivity and endothelial cell density (ECD) after ultrathin Descemet's stripping automated endothelial keratoplasty (UT-DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK). METHODS A randomised, single-blinded, single-centre design was used. 72 patients with Fuchs' endothelial dystrophy and cataract were randomised to UT-DSAEK or DMEK combined with phacoemulsification and lens implantation. 27 patients with cataract were included in a control group and treated with phacoemulsification and lens implantation. The primary outcome was BCVA at 12 months. RESULTS Compared with UT-DSAEK, DMEK resulted in better BCVA with mean differences of 6.1 early treatment diabetic retinopathy study (ETDRS) (p=0.001) after 3 months, 7.4 ETDRS (p<0.001) after 6 months and 5.7 ETDRS (p<0.001) after 12 months. The control group obtained significantly better BCVA with a mean difference of 5.2 ETDRS (p<0.001) compared with DMEK 12 months postoperatively. Compared with UT-DSAEK, contrast sensitivity was significantly better 3 months after DMEK with a mean difference of 0.10 LogCS (p=0.03). However, our study found no effect after 12 months (p=0.08). ECD was significantly lower after UT-DSAEK compared with DMEK with mean differences of 332 cells/mm2 (p<0.01) after 3 months, 296 cells/mm2 (p<0.01) after 6 months and 227 cells/mm2 (p=0.03) after 12 months. CONCLUSIONS Compared with UT-DSAEK, DMEK resulted in better BCVA 3, 6 and 12 months postoperatively. Twelve months postoperatively, DMEK had a higher ECD than UT-DSAEK; however, no difference in contrast sensitivity was found. TRIAL REGISTRATION NUMBER NCT04417959.
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Affiliation(s)
| | - Anders Ivarsen
- Department of Ophthalmology, Aarhus University Hospital, Aarhus N, Denmark
| | - Jesper Hjortdal
- Department of Ophthalmology, Aarhus University Hospital, Aarhus N, Denmark
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Flockerzi E, Turner C, Seitz B, Collaborators GSG. Descemet's membrane endothelial keratoplasty is the predominant keratoplasty procedure in Germany since 2016: a report of the DOG-section cornea and its keratoplasty registry. Br J Ophthalmol 2024; 108:646-653. [PMID: 37586835 PMCID: PMC11137454 DOI: 10.1136/bjo-2022-323162] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/12/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND/AIMS This retrospective multicentric panel study provides absolute numbers, types of and indications for corneal transplantation in Germany from 2011 to 2021 and sets them into the international context. METHODS A questionnaire was sent to the 104 German ophthalmologic surgery departments and 93 (89%) provided their data. RESULTS The number of reported keratoplasties more than doubled from 2011 (n=4474) to 2021 (n=8998). Lamellar keratoplasties (49% posterior (n=2883), 4% anterior (n=231)) surpassed penetrating keratoplasty (PKP, 47%, n=2721) for the first time in 2014. Since 2016, Descemet's membrane endothelial keratoplasty (DMEK) has become the predominant keratoplasty procedure in Germany. Its number increased by 1.5-fold from 3850 (2016) to 5812 (2021). Main indications in 2021 were Fuchs' endothelial corneal dystrophy (FECD, 43%), pseudophakic corneal decompensation (12%), repeated keratoplasty (11%), infections (7%), keratoconus (6%) and corneal scarring (4%, others: 9%). The PKP percentage decreased from 70.2% in 2011 (n=3141) to 31.7% in 2021 (n=2853). Descemet's stripping (automated) endothelial keratoplasties (DSAEKs) decreased to 1% in 2021 (n=74). 98.6% of all posterior lamellar keratoplasties were DMEKs in Germany in 2021. The number of deep anterior lamellar keratoplasties (DALKs) remained comparable from 2011 (n=269) to 2021 (n=251, 2.8%). CONCLUSION Main indications for corneal transplantation in Germany (2021) were FECD and pseudophakic corneal decompensation. DMEK is by far the predominant corneal transplantation procedure since 2016 followed by PKP, whose absolute number decreased only slightly during the decade from 2011 to 2021. DALK proportions remain low, but stable, whereas DSAEK decreased annually and plays a minor role in Germany. TRIAL REGISTRATION NUMBER NCT03381794.
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Affiliation(s)
- Elias Flockerzi
- Department of Ophthalmology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Christina Turner
- Department of Ophthalmology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - GeKeR Study Group Collaborators
- Department of Ophthalmology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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Fu L, Hollick EJ. Comparison of Long-Term Outcomes of DSEK and DMEK in Fuchs Endothelial Dystrophy. Cornea 2024; 43:184-189. [PMID: 37170402 DOI: 10.1097/ico.0000000000003310] [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: 01/10/2023] [Accepted: 04/11/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE This study aimed to compare the long-term endothelial cell loss, graft survival, and clinical outcomes in patients with Fuchs endothelial dystrophy (FED) after Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK) using a standardized surgical protocol. METHODS Three hundred and six consecutive DSEK and DMEK grafts of 223 patients with FED performed by 8 surgeons between January 2006 and August 2022 were analyzed. The primary outcome measures were graft survival, endothelial cell loss, and best spectacle-corrected visual acuity. RESULTS At 5 years, graft survival was 96% for both DSEK and DMEK eyes. The mean percentage of endothelial cell loss was 57.7 ± 17.1 in DSEK and 56.8 ± 15.2 in DMEK eyes ( P = 0.430). The mean best spectacle-corrected visual acuity was 0.13 ± 0.14 logMAR in DSEK and 0.01 ± 0.18 logMAR in DMEK grafts ( P <0.00001) at 5 years postoperatively. Rebubbling was performed in 7.8% DSEK and 2.1% DMEK grafts ( P = 0.441). Cox regression identified rejection episodes (HR 6.5; 95% CI: 1.70-24.8; P = 0.0062) as a significant contributing factor for graft failure. CONCLUSIONS DMEK had superior visual acuity outcomes compared with DSEK in these patients up to 5 years after surgery. At 5 years, there was no significant difference in graft survival or endothelial cell loss between DSEK and DMEK eyes with FED. We propose that our standardized technique reduces the need for rebubbling.
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Affiliation(s)
- Lanxing Fu
- Department of Ophthalmology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
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Moura-Coelho N, Papa-Vettorazzi R, Reyes A, Cunha JP, Güell JL. Ultrathin DSAEK versus DMEK - Review of systematic reviews. Eur J Ophthalmol 2023:11206721231214605. [PMID: 37964555 DOI: 10.1177/11206721231214605] [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: 11/16/2023]
Abstract
The efficacy and safety of Descemet's membrane endothelial keratoplasty (DMEK) and ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) have been recently compared in several systematic reviews (SRs). The aim of this study was to assess the evidence quality of such SRs, in order to obtain a scientifically rigorous comparison between the two techniques. We performed a systematic review of SRs and meta-analyses comparing the efficacy and safety between UT-DSAEK and DMEK up to 24th March 2023, using 3 electronic databases (PubMed, Cochrane Library, Google Scholar) plus manual reference search. Specific outcomes analyzed included best-corrected visual acuity (BCVA), endothelial cell density (ECD), rebubbling rate, and other postoperative complications. Of 90 titles/abstracts screened, four SRs met the inclusion criteria. All SRs adequately analyzed potential bias of the included studies. One SR raised concern for potential literature search bias and two SRs have heterogeneity in some outcomes analyzed. All SRs found higher BCVA after DMEK, but one SR reported significant heterogeneity. All SRs found significant heterogeneity in ECD analysis, with one SR providing inconsistent analysis of this outcome. Three SRs analyzed rebubbling rates, favoring UT-DSAEK over DMEK. Three SRs concluded a higher overall complication rate after DMEK, although rebubbling may be a confounding factor. This systematic review clarifies the strengths and weaknesses of published SRs and reinforces the conclusion that DMEK leads to superior visual outcomes compared to UT-DSAEK, with the trade-off of higher rebubbling rates and possibly other postoperative complications. Studies with longer follow-up are needed to ascertain these differences between procedures.
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Affiliation(s)
- Nuno Moura-Coelho
- Cornea and Refractive Surgery Unit, Instituto de Microcirugía Ocular (IMO) Barcelona Grupo Miranza, Barcelona, Spain
- NOVA Medical School (NMS) - Universidade Nova de Lisboa, Lisbon, Portugal
- European School for Advanced Studies in Ophthalmology (ESASO), Lugano, Switzerland
| | - Renato Papa-Vettorazzi
- Cornea and Refractive Surgery Unit, Instituto de Microcirugía Ocular (IMO) Barcelona Grupo Miranza, Barcelona, Spain
- Anterior Segment Unit, Clínica Visualiza Guatemala, Guatemala, Guatemala
| | - Alonso Reyes
- Cornea and Refractive Surgery Unit, Instituto de Microcirugía Ocular (IMO) Barcelona Grupo Miranza, Barcelona, Spain
| | - João Paulo Cunha
- Ophthalmology, Hospital CUF Cascais, Lisbon, Portugal
- Escola Superior de Tecnologia da Saúde de Lisboa (ESTeSL), Lisbon, Portugal
| | - José Luis Güell
- Cornea and Refractive Surgery Unit, Instituto de Microcirugía Ocular (IMO) Barcelona Grupo Miranza, Barcelona, Spain
- European School for Advanced Studies in Ophthalmology (ESASO), Lugano, Switzerland
- Ophthalmology, Universidad Autónoma de Barcelona, Barcelona, Spain
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7
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Vaiano AS, Greco A, Greco A, Toro ME, Leto MG, Savini G. Efficacy and safety of UT-DSAEK combined with Carlevale's sutureless scleral fixation IOL. Eur J Ophthalmol 2023; 33:2201-2209. [PMID: 36976933 DOI: 10.1177/11206721231166558] [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: 03/30/2023]
Abstract
PURPOSE To evaluate a novel surgical combination of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and sutureless scleral fixation for Carlevale intraocular lens (SSF-Carlevale IOL) implantation to manage corneal endothelial decompensation when there is a concomitant need for secondary IOL fixation. METHODS Clinical data collected from 10 eyes of 9 patients with bullous keratopathy (BK) who underwent combined UT-DSAEK and SSF-Carlevale IOL implantation in a single procedure were retrospectively analyzed. Anterior chamber IOL (4 cases), aphakia (4 cases, 1 of which associated with PEX), and previous trauma (2 cases) were the conditions responsible for BK. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell density (ECD), central corneal thickness (CCT), graft thickness (GT) and complications were recorded over a 12-month follow-up period. RESULTS In 90% (9/10) of eyes graft clarity was maintained during follow-up. The mean CDVA improved significantly (p < 0.0001) from 1.78 ± 0.76 logMAR preoperatively to 0.53 ± 0.3 logMAR at 12 months. ECD on average decreased from 2575 ± 125.3 cells/mm2 (donor tissue) to 1697 ± 133.3 cells/mm2 in 12 months. The mean CCT decreased from 870 ± 200 µm to 650 µm ± 9 at 12 months (ANOVA, p = 0.0005). CONCLUSIONS Combined UT-DSAEK and SSF-Carlevale IOL implantation was associated with good corneal graft survival and IOP control, with few complications. These findings suggest that this surgical approach is a practical option for patients requiring both treatment for corneal endothelial dysfunction and secondary IOL implantation.
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Affiliation(s)
- Agostino S Vaiano
- Institute of Ophthalmology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Antonio Greco
- Institute of Ophthalmology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Andrea Greco
- Institute of Ophthalmology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Maria E Toro
- Institute of Ophthalmology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Marco G Leto
- Institute of Ophthalmology, Santa Croce e Carle Hospital, Cuneo, Italy
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Sela TC, Iflah M, Muhsen K, Zahavi A. Descemet membrane endothelial keratoplasty compared with ultrathin Descemet stripping automated endothelial keratoplasty: a meta-analysis. BMJ Open Ophthalmol 2023; 8:e001397. [PMID: 37914389 PMCID: PMC10626808 DOI: 10.1136/bmjophth-2023-001397] [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: 07/14/2023] [Accepted: 10/13/2023] [Indexed: 11/03/2023] Open
Abstract
AIMS This study aims to compare the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) and ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) in patients with corneal endothelial dysfunction due to Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy. METHODS We conducted a meta-analysis using a literature search of Embase, PubMed, Cochrane CENTRAL, ClinicalTrials.gov and WHO ICTRP databases. We included randomised controlled trials (RCTs) and cohort studies that compared DMEK and UT-DSAEK (graft<130 µm), with a follow-up of ≥12 months, published until 20 February 2022. We used the Revised Cochrane risk-of-bias tool for RCTs and the Risk of Bias in Non-Randomised Studies-of Interventions system for cohort studies. RESULTS Out of 144 records, 8 studies (3 RCTs, 2 fellow-eye studies and 3 cohort studies) were included, encompassing 376 eyes, (N=187 DMEK vs N=189 UT-DSAEK). The 12-month logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) was better post-DMEK (mean difference -0.06 (95% CI -0.10 to -0.02)), but with higher rebubbling risk: OR 2.76 (95% CI 1.46 to 5.22). Heterogeneity was significant I2=57%. Findings were consistent when excluding retrospective studies, including only studies with low risk of bias or RCTs only. An analysis of studies with mean DSAEK grafts <70 µm showed no significant difference in BCVA between the procedures. Publication bias was found in the BCVA analysis (Egger's test p=0.023). CONCLUSIONS Post-DMEK BCVA is superior to post-UT-DSAEK when using <130 µm grafts. DSAEK grafts <70 µm may not significantly differ from DMEK. The higher risk of rebubbling with DMEK necessitates an appropriate selection of patients. PROSPERO REGISTRATION NUMBER CRD42022340805.
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Affiliation(s)
- Tal Corina Sela
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moti Iflah
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Zahavi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel
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9
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Hurley DJ, Murtagh P, Guerin M. Ultrathin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK) versus Descemet Membrane Endothelial Keratoplasty (DMEK)-a systematic review and meta-analysis. Eye (Lond) 2023; 37:3026-3032. [PMID: 36934158 PMCID: PMC10516931 DOI: 10.1038/s41433-023-02467-2] [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: 09/24/2022] [Revised: 01/29/2023] [Accepted: 02/24/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND/OBJECTIVES Endothelial keratoplasty (EK) is a commonly performed transplant procedure used in the treatment of corneal endothelial dysfunction. The aim of this systematic review and meta-analysis is to evaluate the differences in visual acuity outcomes, endothelial cell density (ECD) and complications between two forms of EK, ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). METHODS A literature search of MEDLINE, Embase and Cochrane Library was conducted to identify studies reporting comparative results of UT-DSAEK versus DMEK. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for search strategy. Of 141 titles, 7 studies met the inclusion criteria; best corrected visual acuity (BCVA) (LogMAR), ECD (cells/mm2), and complications were compared, with all statistical analysis performed using Review Manager. RESULTS A total of 362 eyes were included for analysis. DMEK resulted in significantly better BCVA at 3 months (0.14 vs 0.22, p = 0.003), 6 months (0.08 vs 0.18, p = 0.005) and 1 year post-op (0.07 vs 0.14, p = 0.0005). UT-DSAEK resulted in significantly lower total complications (25.2% vs 57.3%, p = 0.0001) and rates of re-bubbling (11.0% vs 33.7%, p = 0.004). No differences were found in ECD between the two procedures (1541 vs 1605, p = 0.77). CONCLUSIONS DMEK results in superior visual acuity rates with quicker recovery. However, UT-DSAEK has a more favourable complication profile, particularly regarding lower rates of re-bubbling. Both are valuable options in the treatment of corneal endothelial disease and choice of procedure may depend on surgical expertise.
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Affiliation(s)
- Daire J Hurley
- Department of Ophthalmology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - Patrick Murtagh
- Department of Ophthalmology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - Marc Guerin
- Department of Ophthalmology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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de Bruyn B, Ní Dhubhghaill S, Claerhout I, Claes K, Deconinck A, Delbeke H, Huizing M, Krolo I, Muijzer M, Oellerich S, Roels D, Termote K, Van den Bogerd B, Van Gerwen V, Verhaegen I, Wisse R, Wouters K, Consortium TBC, Duchesne B, Koppen C. Belgian Endothelial Surgical Transplant of the Cornea (BEST cornea) protocol: clinical and patient-reported outcomes of Ultra-Thin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK) versus Descemet Membrane Endothelial Keratoplasty (DMEK) - a multicentric, randomised, parallel group pragmatic trial in corneal endothelial decompensation. BMJ Open 2023; 13:e072333. [PMID: 37714670 PMCID: PMC10510864 DOI: 10.1136/bmjopen-2023-072333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/31/2023] [Indexed: 09/17/2023] Open
Abstract
OBJECTIVES Corneal blindness is the third most frequent cause of blindness globally. Damage to the corneal endothelium is a leading indication for corneal transplantation, which is typically performed by lamellar endothelial keratoplasty. There are two conventional surgical techniques: Ultra-Thin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK) and Descemet Membrane Endothelial Keratoplasty (DMEK). The purpose of this study is to compare both techniques. METHODS AND ANALYSIS The trial compares UT-DSAEK and DMEK in terms of clinical and patient reported outcomes using a pragmatic, parallel, multicentric, randomised controlled trial with 1:1 allocation with a sample size of 220 participants across 11 surgical centres. The primary outcome is the change in best-corrected visual acuity at 12 months. Secondary outcomes include corrected and uncorrected vision, refraction, proportion of high vision, quality of life (EQ-5D-5L and VFQ25), endothelial cell counts and corneal thickness at 3, 6 and 12 months follow-up appointments. Adverse events will also be compared 12 months postoperatively. ETHICS AND DISSEMINATION The protocol was reviewed by ethical committees of 11 participating centres with the sponsor centre issuing the final definitive approval. The results will be disseminated at clinical conferences, by patient partner groups and open access in peer-reviewed journals. GOVERNANCE OF THE TRIAL Both, trial management group and trial steering committee, are installed with representatives of all stakeholders involved including surgeons, corneal bankers, patients and external experts. TRIAL REGISTRATION NUMBER NCT05436665.
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Affiliation(s)
- Barbara de Bruyn
- Ophthalmology, University Hospital Antwerp, Edegem, Belgium
- Faculty of Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Sorcha Ní Dhubhghaill
- Ophthalmology, University Hospital Antwerp, Edegem, Belgium
- Ophtalmology, UZ Brussel, Brussel, Belgium
| | - Ilse Claerhout
- Ophtalmology, AZ Maria Middelares, Sint-Niklaas, Belgium
- Faculty of Health Sciences, Ghent University, Gent, Belgium
| | - Kim Claes
- Ophthalmology, University Hospital Antwerp, Edegem, Belgium
| | - Ann Deconinck
- Clinical Research Centre, University Hospital Antwerp, Edegem, Belgium
| | - Heleen Delbeke
- Ophthalmology, KU Leuven University Hospitals, Leuven, Belgium
- Health Sciences, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Manon Huizing
- Cell and Tissue Bank, University Hospital Antwerp, Edegem, Belgium
- Faculty of Health Sciences, University Hospital Antwerp, Edegem, Belgium
| | - Iva Krolo
- Ophtalmology, UZ Brussel, Brussel, Belgium
| | - Marc Muijzer
- Ophtalmology, University Medical Centre, Utrecht, The Netherlands
| | - Silke Oellerich
- Ophthalmology, Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands
| | - Dimitri Roels
- Faculty of Health Sciences, Ghent University, Gent, Belgium
- Ophthalmology, University Hospital Ghent, Gent, Belgium
| | - Karolien Termote
- Ophtalmology, UZ Brussel, Brussel, Belgium
- Ophthalmology, Imelda Hospital, Bonheiden, Belgium
| | | | - Veerle Van Gerwen
- Clinical Research Centre, University Hospital Antwerp, Edegem, Belgium
| | - Iris Verhaegen
- Clinical Trial Centre, Antwerp University Hospital, Edegem, Belgium
| | - Robert Wisse
- Ophtalmology, University Medical Centre, Utrecht, The Netherlands
| | - Kristien Wouters
- Clinical Research Centre, University Hospital Antwerp, Edegem, Belgium
| | | | - Bernard Duchesne
- Ophtalmology, Central University Hospital, Liege, Belgium
- Faculty of Health Sciences, University of Liege, Liege, Belgium
| | - Carina Koppen
- Ophthalmology, University Hospital Antwerp, Edegem, Belgium
- Faculty of Health Sciences, University of Antwerp, Antwerp, Belgium
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11
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van Rooij J, Engel A, Steijger-Vermaat P, Molenaar A, Vigueras-Guillén JP, Wubbels RJ. Donor lamella thickness after ultrathin Descemet stripping automated endothelial keratoplasty and its relation to postoperative visual acuity and pre-operative lamella measures. BMC Ophthalmol 2023; 23:265. [PMID: 37308898 DOI: 10.1186/s12886-023-03019-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 06/05/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND To accurately measure ultrathin Descemet stripping automated endothelial keratoplasty (DSAEK) donor lamella thickness during the first postoperative year and to correlate this with pre-operative and other postoperative measurements. METHODS Donor lamella thickness in 41 eyes undergoing DSAEK for Fuchs endothelial dystrophy (FED) was measured using the Tomey Casia OCT directly after graft preparation and at 1 week and 1, 3, 6 and 12 months postoperatively. Visual acuity and endothelial cell density were measured as the secondary parameters. RESULTS Individual graft thickness profiles were shown to be fairly regular within the optically relevant area. There was a strong and highly significant correlation between the pre- and postoperative lamellar thicknesses at all time points (p < 0.0001). Compared with the measurements directly after preparation at the cornea bank, the lamella thickness decreased by 12% after 12 months. Between 1 and 12 months postoperatively, the lamella thickness (mean ± SD) changed from 112 ± 27 μm to 101 ± 21 μm. Best spectacle-corrected visual acuity (BSCVA) changed from 0.46 ± 0.30 logMAR pre-operatively through 0.36 ± 0.33 at 1 month to 0.13 ± 0.16 at 1 year postoperatively. The endothelial cell counts were comparable to those reported in previous studies. CONCLUSIONS Thickness profiles of individual grafts were fairly regular within the optically relevant area. A strong relationship between pre- and postoperative graft thicknesses was detected, and ultrathin DSAEK grafts prepared using methods similar to that applied in this study are expected to show a deswelling of around 12% during the first postoperative year. No correlation was detected between graft thickness and BSCVA.
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Affiliation(s)
- Jeroen van Rooij
- Rotterdam Eye Hospital, Schiedamse Vest 180, Rotterdam, 3011 BH, The Netherlands
| | - Angela Engel
- Rotterdam Ophthalmic Institute, Schiedamse Vest 160, Rotterdam, 3011 BH, The Netherlands
| | | | - Annemieke Molenaar
- Cornea Department, ETB-BISLIFE, Markt 58, Beverwijk, 1941 BM, The Netherlands
| | | | - René J Wubbels
- Rotterdam Ophthalmic Institute, Schiedamse Vest 160, Rotterdam, 3011 BH, The Netherlands.
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12
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Azuara-Blanco A, Carlisle A, O'Donnell M, Jayaram H, Gazzard G, Larkin DFP, Wickham L, Lois N. Design and Conduct of Randomized Clinical Trials Evaluating Surgical Innovations in Ophthalmology: A Systematic Review. Am J Ophthalmol 2023; 248:164-175. [PMID: 36565904 DOI: 10.1016/j.ajo.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Surgical innovations are necessary to improve patient care. After an initial exploratory phase, novel surgical technique should be compared with alternative options or standard care in randomized controlled trials (RCTs). However, surgical RCTs have unique methodological challenges. Our study sought to investigate key aspects of the design, conduct, and reporting of RCTs of novel surgeries. DESIGN Systematic review. METHODS The protocol was prospectively registered in PROSPERO (CRD42021253297). RCTs evaluating novel surgeries for cataract, vitreoretinal, glaucoma, and corneal diseases were included. Medline, EMBASE, Cochrane Library, and Clinicaltrials.gov were searched. The search period was January 1, 2016, to June 16, 2021. RESULTS A total of 52 ophthalmic surgery RCTs were identified in the fields of glaucoma (n = 12), vitreoretinal surgery (n = 5), cataract (n = 19), and cornea (n = 16). A description defining the surgeon's experience or level of expertise was reported in 30 RCTs (57%) and was presented in both control and intervention groups in 11 (21%). Specification of the number of cases performed in the particular surgical innovation being assessed prior to the trial was reported in 10 RCTs (19%) and an evaluation of quality of the surgical intervention in 7 (13%). Prospective trial registration was recorded in 12 RCTs (23%) and retrospective registration in 13 (25%); and there was no registration record in the remaining 28 (53%) studies. CONCLUSIONS Important aspects of the study design such as the surgical learning curve, surgeon's previous experience, quality assurance, and trial registration details were often missing in novel ophthalmic surgical procedures. The Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) framework aims to improve the quality of study design.
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Affiliation(s)
| | - Aaron Carlisle
- From the Centre for Public Health (A.A.-B., A.C., M.O.D.), Belfast, UK; Belfast Health and Social Care Trust (A.C.), Belfast, UK
| | - Matthew O'Donnell
- From the Centre for Public Health (A.A.-B., A.C., M.O.D.), Belfast, UK
| | - Hari Jayaram
- NIHR Biomedical Research Centre & Glaucoma Service at Moorfields Eye Hospital NHS Foundation Trust (H.J., G.G.), London, UK; Institute of Ophthalmology (H.J., G.G.), University College London, UK
| | - Gus Gazzard
- NIHR Biomedical Research Centre & Glaucoma Service at Moorfields Eye Hospital NHS Foundation Trust (H.J., G.G.), London, UK; Institute of Ophthalmology (H.J., G.G.), University College London, UK
| | - Daniel F P Larkin
- Cornea & External Diseases Service (D.F.P.L.), Moorfields Eye Hospital, London, UK
| | - Louisa Wickham
- Vitreo-retinal Service (L.W.), Moorfields Eye Hospital, London, UK
| | - Noemi Lois
- Wellcome-Wolfson Institute for Experimental Medicine (N.L.), Queen's University, Belfast, UK
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13
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Spaniol K, Hellmich M, Borgardts K, Girbardt C, Maier P, Reinhard T, Torun N, Maier AK, Thaler S, Bartz-Schmidt KU, Wiedemann P, Seitz B, Daas L, Schrittenlocher S, Cursiefen C, Bachmann B, Geerling G. DMEK outcome after one year - Results from a large multicenter study in Germany. Acta Ophthalmol 2023; 101:e215-e225. [PMID: 36178238 DOI: 10.1111/aos.15257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 06/08/2022] [Accepted: 09/03/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Descemet membrane endothelial keratoplasty (DMEK) accounts for >50% of all corneal transplants in Germany. So far, no data from such a large multicenter study have been published. METHODS This retrospective study included 3200 DMEKs at seven departments performed for Fuchs endothelial corneal dystrophy (FECD) or bullous keratopathy (BK). We evaluated best corrected visual acuity (BCVA, logMAR), endothelial cell density (ECD, cells/mm2 ), minimal corneal thickness (CT, μm), rebubbling-, primary transplant failure- and immune reaction-rate. Changes over time were evaluated by linear mixed models for repeated measures and correlation with case number by center by weighted linear regression. RESULTS For patients without vision-limiting comorbidities (74% of all analysed eyes, n = 2270), mean BCVA improved from 0.6 ± 0.4 logMAR to 0.2 ± 0.2 logMAR 6 months (p < 0.001, n = 1441) and 0.1 ± 0.2 logMAR 12 months (p = 0.001, n = 1402) postoperatively. BK- had a worse BCVA compared to FECD-patients (0.3 ± 0.5 vs. 0.1 ± 0.2 logMAR [p < 0.001] at 1 year). ECD declined from 2465 ± 259 cells/mm2 (n = 2876 preoperatively) to 1587 ± 433 cells/mm2 after 12 months (p < 0.001, n = 1237). Mean rebubbling rate was 0.4 ± 0.7/eye. 784 eyes (25%) received at least one rebubbling. More rebubblings correlated with a lower ECD, a worse BCVA, a higher CT, and higher transplant failure and rejection rates (p < 0.001, p = 0.013 for BCVA at 12 months). A single rebubbling did not influence the BCVA (p = 0.785). Graft failure rate was 3% (n = 67), rejection rate 1.5% (n = 48). CONCLUSION Descemet membrane endothelial keratoplasty increases visual acuity with low transplant failure- and rejection-rates. FECD has a better outcome than BK. Since a quarter of all patients need a rebubbling, this should be included in the informed consent. Remarkably, one rebubbling has no influence on the outcome.
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Affiliation(s)
- Kristina Spaniol
- Department of Ophthalmology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Klara Borgardts
- Department of Ophthalmology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Girbardt
- Department of Ophthalmology, University Hospital Leipzig, Leipzig, Germany
| | - Philip Maier
- Eye Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Reinhard
- Eye Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Necip Torun
- Department of Ophthalmology, Charité Universitätsmedizin - Berlin, Corporate Member of Freie Universität Berlin, Humbolt-Universität zu Berlin und Berlin Institute of Health, Berlin, Germany
| | - Anna-Karina Maier
- Department of Ophthalmology, Charité Universitätsmedizin - Berlin, Corporate Member of Freie Universität Berlin, Humbolt-Universität zu Berlin und Berlin Institute of Health, Berlin, Germany
| | - Sebastian Thaler
- Department of Ophthalmology, University Hospital Tübingen, Tübingen, Germany
| | | | - Peter Wiedemann
- Department of Ophthalmology, University Hospital Leipzig, Leipzig, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | | | - Claus Cursiefen
- Department of Ophthalmology, University Hospital Cologne, Cologne, Germany
| | - Björn Bachmann
- Department of Ophthalmology, University Hospital Cologne, Cologne, Germany
| | - Gerd Geerling
- Department of Ophthalmology, University Hospital Düsseldorf, Düsseldorf, Germany
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14
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Maier AKB, Milek J, Joussen AM, Dietrich-Ntoukas T, Lichtner G. Systematic Review and Meta-analysis: Outcomes After Descemet Membrane Endothelial Keratoplasty Versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty. Am J Ophthalmol 2023; 245:222-232. [PMID: 36220351 DOI: 10.1016/j.ajo.2022.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/25/2022] [Accepted: 09/29/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To compare the efficacy and safety of ultrathin Descemet stripping (automated) endothelial keratoplasty (UT-DS(A)EK) versus Descemet membrane endothelial keratoplasty (DMEK) for the treatment of Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK). DESIGN Systematic review and meta-analysis. METHODS Literature containing DMEK and UT-DSAEK were searched in the Cochrane Database of Systematic Reviews, PubMed, EMBASE, LILACS, and through manual reference searching. Studies were included that measured the outcome of interventions-including best corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications, especially graft detachment with the need of re-bubbling, graft rejection, graft failure, and postoperative elevated intraocular pressure (IOP)-in patients with FED and BK. Included outcomes were pooled as standardized mean differences (SMD) or risk ratios (RR) using random effects models. Inter-study heterogeneity was assessed using the Q-test and I2 statistic. RESULTS Seven (of 163) studies met all the inclusion and exclusion criteria. Meta-analysis showed a significantly better BCVA 12 months postoperatively, but an increased re-bubbling rate in eyes after DMEK compared with eyes after UT-DS(A)EK (BCVA: SMD = 0.50 [95% CI 0.27-0.74] and re-bubbling rate: RR = 0.33 [95% CI 0.16-0.67]). All other parameters did not differ significantly between both interventions, although estimates were imprecise (graft failure: RR = 0.65 [95% CI 0.18-2.30], graft rejection: RR = 1.40 [95% CI 0.27-7.30], and postoperative intraocular pressure elevation: RR = 1.14 [95% CI 0.60-2.18]). Postoperative SMDs of ECD could not be evaluated due to significant heterogeneity between studies. CONCLUSIONS Although the improvement in BCVA was higher after UT-DS(A)EK than after conventional DS(A)EK, the BCVA after DMEK was still superior. The complication rates were comparable for both procedures, except for the higher rate of re-bubbling after DMEK.
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Affiliation(s)
- Anna-Karina B Maier
- From Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Ophthalmology, Berlin, Germany (A-K.B.M, J.M., A.M.J., T.D-N.).
| | - Jonas Milek
- From Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Ophthalmology, Berlin, Germany (A-K.B.M, J.M., A.M.J., T.D-N.)
| | - Antonia M Joussen
- From Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Ophthalmology, Berlin, Germany (A-K.B.M, J.M., A.M.J., T.D-N.)
| | - Tina Dietrich-Ntoukas
- From Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Ophthalmology, Berlin, Germany (A-K.B.M, J.M., A.M.J., T.D-N.)
| | - Gregor Lichtner
- Universitätsmedizin Greifswald, Department of Anesthesia, Critical Care, Emergency and Pain Medicine, Greifswald, Germany (G.L.)
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15
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A Randomized Controlled Trial Comparing Microthin Descemet Stripping Automated Endothelial Keratoplasty With Descemet Membrane Endothelial Keratoplasty: Two-Year Report. Cornea 2022; 41:1519-1524. [DOI: 10.1097/ico.0000000000003024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/05/2022] [Indexed: 11/09/2022]
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16
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Abstract
PURPOSE OF REVIEW Corneal graft rejection has been reported after coronavirus disease 2019 (COVID-19) vaccination. The purpose of this review is to evaluate the literature regarding corneal graft rejection after vaccination, including rejection rates and risk factors. We aim to create a framework to identify patients who are at higher risk for graft rejection and may warrant consideration of prophylactic interventions. RECENT FINDINGS Graft rejection has been reported following administration of mRNA, viral vector, and inactivated whole-virion COVID-19 vaccines. Most cases had additional risk factors associated with rejection. Vaccination increases circulation of proinflammatory cytokines, CD4+ and CD8+ T-cell responses, and antispike neutralizing antibody, all of which may contribute to graft rejection. Two prospective studies have found no relationship between recent vaccination and rejection but 20% of cornea specialists report to have seen a vaccine-associated rejection and 22% recommend delaying vaccination in certain circumstances. Many specialists recommend prophylactic topical corticosteroids before and after vaccination to mitigate rejection risk but there is no evidence to support this practice on a wider scale. SUMMARY Our framework identified 96.8% of penetrating keratoplasty patients with vaccine-associated rejection as higher risk. Further research is needed in order to develop evidence-based guidelines.
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Affiliation(s)
- Sarah P Dugan
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
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17
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Abstract
PURPOSE OF REVIEW To review the current literature on Descemet membrane endothelial keratoplasty (DMEK) in complex eyes. RECENT FINDINGS DMEK surgery has become a standardized procedure in Fuchs endothelial dystrophy and simple bullous keratopathy. But eyes with more complex disease present unique intraoperative and postoperative challenges to the DMEK surgeon. Poor visualization during surgery, complex anterior segment anatomy, altered anterior chamber dynamics, glaucoma shunts, and congenital or iatrogenic missing or altered iris and lens make DMEK surgery extremely difficult to accomplish. SUMMARY DMEK is feasible in complex eyes, including advanced bullous keratopathy, eyes with history of glaucoma or vitreoretinal surgery, previous penetrating keratoplasty, uveitis, pediatric, and congenital anterior segment disorders. The tools and methods reported in the literature to accomplish DMEK in complex eyes vary widely with no particular consensus or standardization of techniques. The outcomes noted for some of these conditions demonstrate the difficulty of the surgery and the uncertainty of long-term graft survival in complex eyes. Both surgical standardization and randomized prospective data will better help elucidate DMEK's role in the corneal rehabilitation of complex eyes.
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Affiliation(s)
- Aazim Siddiqui
- Division of Cornea and Refractive Surgery, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
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18
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Magnier F, Dutheil F, Pereira B, Watson SL, Baker JS, Chiambaretta F, Navel V. Preventive treatment of allograft rejection after endothelial keratoplasty: A systematic review and meta-analysis. Acta Ophthalmol 2022; 100:e1061-e1073. [PMID: 35411680 DOI: 10.1111/aos.15154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 02/10/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy of preventive treatment against allograft rejection after endothelial keratoplasty (EK), we conducted a systematic review and meta-analysis. METHOD PubMed, Cochrane Library, Embase and ScienceDirect databases were searched until May 2021. We computed a random-effect meta-analysis on graft rejection rate stratified by the intervention (i.e. Descemet membrane EK (DMEK) and Descemet stripping (Automated) EK (DS(A)EK) or ultrathin (UT)-DSAEK), and postoperative treatment. Meta-regressions were performed to compare intervention, treatment and influence of putative confusion factors. RESULTS We included 49 studies and 12 893 EK (6867 DMEK and 6026 DS(A)EK/UT-DSAEK). Topical steroids were merged in two efficacy regimens: standard steroids (prednisolone acetate 1% or dexamethasone 0.1%) and soft steroids (fluorometholone 0.1% or loteprednol etabonate 0.5%). Globally, DMEK had a lower graft rejection rate than DS(A)EK/UT-DSAEK (coefficient - 3.3, 95 CI, -4.60 to -1.90; p < 0.001). No significant differences were observed between standard and soft steroids to prevent graft rejection after DMEK. After EK, the rate of ocular hypertension was 20% (95 CI, 14 to 26%) with the use of standard steroids and 7% (5 to 9%) with soft steroids. Comparisons of treatments were not feasible in DS(A)EK/UT-DSAEK due to a lack of studies. CONCLUSIONS Descemet membrane endothelial keratoplasty (DMEK) has less risk of graft rejection compared with DS(A)EK/UT-DSAEK. Furthermore, soft steroids seemed to be a valuable alternative to standard steroids to prevent graft rejection after DMEK, involving a safe profile against ocular hypertension. Further studies are needed to compare other drugs in the prevention of graft rejection after EK.
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Affiliation(s)
- Florent Magnier
- Ophthalmology, CHU Clermont‐Ferrand University Hospital of Clermont‐Ferrand Clermont‐Ferrand France
| | - Frédéric Dutheil
- CNRS, LaPSCo, Physiological and Psychosocial Stress, University Hospital of Clermont‐Ferrand, CHU Clermont‐Ferrand, Preventive and Occupational Medicine Université Clermont Auvergne Clermont‐Ferrand France
| | - Bruno Pereira
- Biostatistics, CHU Clermont‐Ferrand University Hospital of Clermont‐Ferrand (CHU) Clermont‐Ferrand France
| | - Stephanie L. Watson
- Discipline of Ophthalmology, Save Sight Institute, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Sydney Eye Hospital Sydney New South Wales Australia
| | - Julien S. Baker
- Department of Sport, Physical Education and Health, Center for Health and Exercise Science Research Hong Kong Baptist University Kowloon Tong Hong Kong
| | - Frédéric Chiambaretta
- Translational Approach to Epithelial Injury and Repair, CNRS, INSERM, GReD, University Hospital of Clermont‐Ferrand, CHU Clermont‐Ferrand, Ophthalmology Université Clermont Auvergne Clermont‐Ferrand France
| | - Valentin Navel
- Translational Approach to Epithelial Injury and Repair, CNRS, INSERM, GReD, University Hospital of Clermont‐Ferrand, CHU Clermont‐Ferrand, Ophthalmology Université Clermont Auvergne Clermont‐Ferrand France
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19
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Efficacy of Thin and Ultrathin Descemet Stripping Automated Endothelial Keratoplasty and Influence of Graft Thickness on Postoperative Outcomes: Systematic Review and Meta-analysis. Am J Ophthalmol 2022; 240:170-186. [PMID: 35346623 DOI: 10.1016/j.ajo.2022.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/08/2022] [Accepted: 03/17/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE To conduct a systematic review and meta-analysis on the efficacy of thin and ultrathin Descemet stripping automated endothelial keratoplasty (T-DSAEK and UT-DSAEK, with graft thickness <130 and <100 µm, respectively), depending on graft thickness. DESIGN Systematic review and meta-analysis. METHOD PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and ScienceDirect databases were searched until October 1, 2021. We computed random-effect meta-analysis on postoperative outcomes of T/UT-DSAEK, stratified by graft thickness (<80 μm, 80-100 μm, and 100-130 μm). The main postoperative outcome was visual acuity (logarithm of the minimum angle of resolution [logMAR]). Secondary outcomes were pachymetry (μm), endothelial cell count (cell/mm2), spherical equivalent (diopter [D]), rebubbling rate (%), and rejection rate (%). Meta-regressions compared postoperative outcomes depending on graft thickness and search for putative confusion factors. RESULTS We included 47 articles for a total of 2141 eyes of 2040 patients. T/UT-DSAEK globally improved visual acuity (effect size = -0.38 logMAR [95% confidence interval {CI} -0.46 to -0.30 logMAR]), without difference depending on graft thickness. Overall, pachymetry improved (-60.6 µm [95% CI -101 to -19.7 µm]), endothelial cell count decreased (-1039 cells/mm2 [95% CI -1209 to -868 cells/mm2), spherical equivalent resulted in a hyperopic shift (0.74 D [95% CI -0.50 to 1.97 D), the graft rejection rate was 0.2% (95% CI -0.1% to 0.4%), and the rebubbling rate was 8.7% (95% CI 6.8%-10.5%). Grafts >100 μm induced a hyperopic shift. Metaregressions did not demonstrate differences between the 3 groups (<80 μm, 80-100 μm, or 100-130 μm) in any outcomes. CONCLUSION All T/UT-DSAEK thickness groups provided similar visual acuity, pachymetry, endothelial cell count, rejection rate, and rebubbling rate regardless of graft thickness. A hyperopic shift was induced by grafts >100 μm.
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20
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Weisenthal RW, Yin HY, Jarstad AR, Wang D, Verdier DD. Long-term Outcomes in Fellow Eyes Comparing DSAEK and DMEK for Treatment of Fuchs Corneal Dystrophy. Am J Ophthalmol 2022; 233:216-226. [PMID: 34157279 DOI: 10.1016/j.ajo.2021.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/12/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare the long-term results of Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK) in fellow eyes for treatment of Fuchs endothelial corneal dystrophy. METHODS This study is a 2-centered, retrospective case series of 64 patients (128 eyes) with DSAEK followed by DMEK. The main outcomes measured were best spectacle-corrected visual acuity (BSCVA) and duration of time to achieve BSCVA as well as eye preference. RESULTS Preoperative median logarithm of the minimum angle of resolution (logMAR) BSCVA was similar in eyes receiving DMEK 0.36 ± 0.26 and DSAEK 0.42 ± 0.34 (P = .266). The average follow-up time needed for the DMEK eyes to achieve BSCVA was faster than that of DSAEK (277 days vs 490 days, P = .0014). With long-term follow-up, the BSCVA of the DMEK eyes [0.09 ± 0.10 logMAR] and DSAEK eyes [0.11 ± 0.16 logMAR] did not show a statistically significant difference (P = .069). Twenty-two of the 64 preferred the DMEK eye, 17 patients preferred the DSAEK eye (P = .423), and 25 patients did not have a preference. In the DMEK group, the average spherical equivalent was -0.08 compared with the DSAEK group at 0.06 (P = .2854). CONCLUSION In our fellow eye study with long-term follow-up, DMEK and DSAEK had comparable levels of BSCVA and patient satisfaction. The DMEK eyes reached their BSCVA sooner, whereas the DSAEK eyes improved over a longer time frame. A greater number of patients had 20/25 and 20/20 vision in the DMEK group; however, the difference was not statistically significant. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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Affiliation(s)
- Robert W Weisenthal
- Department of Ophthalmology, SUNY Upstate Medical University, Syracuse, New York.
| | - Han Y Yin
- Department of Ophthalmology, SUNY Upstate Medical University, Syracuse, New York; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Allison R Jarstad
- Department of Ophthalmology, SUNY Upstate Medical University, Syracuse, New York
| | - Dongliang Wang
- Department of Ophthalmology, SUNY Upstate Medical University, Syracuse, New York
| | - David D Verdier
- Department of Surgery, Ophthalmology Division Michigan State University College of Human Medicine Eye Grand Rapids Michigan Verdier Center, Grand Rapid, Michigan, USA
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