Phacoemulsification After Descemet Membrane Endothelial Keratoplasty: Incidence and Influence on Endothelial Cell Density

Comparison of Pre- and Post-DMEK Keratometry and Total Keratometry Values for IOL Power Calculations in Eyes Undergoing Triple DMEK

PURPOSE

To evaluate prediction accuracy of pre- and post-DMEK keratometry (K) and total keratometry (TK) values for IOL power calculations in Fuchs endothelial corneal dystrophy (FECD) eyes undergoing DMEK with cataract surgery (triple DMEK).

METHODS

Retrospective cross-sectional multicenter study of 55 FECD eyes (44 patients) that underwent triple DMEK between 2019 and 2022 between two centers in USA and Europe. Swept-source optical coherence tomography biometry (IOLMaster 700) was used for pre- and post-DMEK measurements. K and TK values were used for power calculations with ten formulae (Barrett Universal II (BUII), Castrop, Cooke K6, EVO 2.0, Haigis, Hoffer Q, Hoffer QST, Holladay I, Kane, and SRK/T). Mean error, mean absolute error (MAE), standard deviation, and percentage of eyes within ±0.50/±1.00 diopters (D) were calculated. Studied formulae were additionally adjusted using a method published previously (IOLup1D Method), which increases the IOL power by 1D. While both eyes from the same patient were considered for descriptive statistics, we restricted to one eye per individual (44 eyes for statistical comparisons.

RESULTS

MAEs for all formulae were lower for post-DMEK K and TK than pre-DMEK K and TK by an average of 0.24 and 0.47 D, respectively. The lowest MAE was 0.49 D for Kane using post-DMEK TK, and the highest MAE was 1.05 D for BUII using pre-DMEK TK. Most IOLup1D formulae had lower MAEs than pre-DMEK K and TK formulae.

CONCLUSIONS

The IOLup1D Method should be used instead of pre-DMEK K and TK values for triple DMEK in FECD eyes. Using post-DMEK TK values for cataract surgery after DMEK provides better refractive accuracy than any of the three studied methods used for triple DMEK procedures.

Combined or sequential DMEK in cases of cataract and Fuchs endothelial corneal dystrophy-A systematic review and meta-analysis

To compare the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed after phacoemulsification and intraocular lens (IOL) implantation (sequential DMEK) and DMEK combined with phacoemulsification and IOL implantation (combined DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and cataract. Systematic literature review and meta-analysis performed according to the PRISMA guidelines and registered in PROSPERO. Literature searches were conducted in Medline and Scopus. Comparative studies reporting sequential DMEK and combined DMEK in FECD patients were included. The main outcome measure of the study was the corrected distance visual acuity (CDVA) improvement. Secondary outcomes were postoperative endothelial cell density (ECD), rebubbling rate and primary graft failure rate. Bias risk was assessed and a quality appraisal of the body of evidence was completed using the Cochrane Robin-I tool. A total of 667 eyes (5 studies) were included in this review, 292 eyes (43.77%) underwent a combined DMEK, while 375 (56.22%) eyes underwent a sequential DMEK surgery. We found no evidence of a difference between the two groups (mean difference, 95% CI) regarding: (1) CDVA improvement (-0.06; -0.14, 0.03 LogMAR; 3 studies, I2 : 0%; p = 0.86); (2) postoperative ECD (-62; -190, 67 cells/mm2 ; 4 studies, I2 : 67%; p = 0.35); (3) rebubbling (risks ratio: 1.04; 0.59, 1.85; 4 studies, I2 : 48%; p = 0.89); and primary graft failure rate (risks ratio: 0.91; 0.32, 2.57; 3 studies, I2 : 0%; p = 0.86). Of all the 5 non-randomized studies, all (100%) were graded as low quality. The overall quality of the analysed studies was low. Randomized controlled trials are needed to confirm no difference or superiority of one approach in terms of CDVA, endothelial cell count and postoperative complication rate between the two arms.

Risk Factors for Repeat Keratoplasty after Endothelial Keratoplasty - an IRIS® Registry Analysis

PURPOSE

To assess risk factors for repeat keratoplasty after endothelial keratoplasty (EK).

DESIGN

Retrospective cohort study METHODS: : EK procedures performed between 2013-2018 in the IRIS® Registry (Intelligent Research in Sight) were identified.

STUDY POPULATION

Patients aged 18 years and older who underwent EK.

MAIN OUTCOME MEASURES

1) Risk factors for repeat keratoplasty, and 2) complication rates after EK. A Kaplan-Meier survival analysis was used to determine the probability of repeat keratoplasty. A multivariable shared frailty survival model was used to assess risk factors.

RESULTS

59,344 procedures were identified in the registry, of which 30,600 EK procedures met the inclusion criteria for the analysis. The probability of repeat keratoplasty was 17.4% (95% CI:16.7-18.0%) at five years. Risk factors for repeat keratoplasty include post-operative re-bubbling procedure (HR 2.24, 95% CI:2.05-2.45); prior failed graft (HR 2.07, 95% CI:1.84-2.32) or bullous keratopathy (HR 1.47, 95% CI:1.33-1.61) versus Fuchs dystrophy as surgical indication; subsequent routine cataract surgery (HR 1.61, 95% CI:1.45-1.79); as well as subsequent (HR 1.53, 95% CI:1.39-1.69) and prior/concurrent (HR 1.23, 95% CI:1.11-1.36) glaucoma surgery or history of glaucoma (HR 1.24, 95% CI:1.14-1.35). Medicaid (HR 1.47, 95% CI:1.13-1.92), military/government (HR 1.29, 95% CI:1.03-1.60), Medicare Fee-for-Service (HR 1.17, 95% CI:1.05-1.31) or Medicare Managed (HR 1.17, 95% CI:1.01-1.36) insurances versus private insurance, as well as Black versus White race (HR 1.25, 95% CI:1.11-1.40) and smoking (HR 1.16, 95% CI:1.05-1.27) were also associated with an increased risk of undergoing repeat keratoplasty.

CONCLUSIONS

Black race, government-based insurance plans, and smoking were identified as independent factors associated with repeat keratoplasty in addition to history of glaucoma, glaucoma surgery, and prior graft failure or bullous keratopathy as surgical indication.

Cataract surgery and intraocular lens placement in patients with Fuchs corneal dystrophy: a review of the current literature

PURPOSE OF REVIEW

Late-onset Fuchs endothelial corneal dystrophy (FECD) is seen in approximately 4% of individuals over the age of 40. With the growing population of adults over the age of 65, ophthalmologists need to be aware of the preoperative, perioperative, and postoperative considerations involved in cataract surgery in Fuchs patients.

RECENT FINDINGS

Management of cataract patients with FECD requires preoperative assessment of endothelial cell size, density, and morphology. Considerations for perioperative endothelial cell loss include patients with hyperopia and shallow anterior chambers, phacoemulsification technique, transfer of ultrasonic energy to the cornea, corneal-protective perioperative agents, as well as thermal and mechanical damage.

SUMMARY

Ophthalmologists performing cataract surgery on patients with FECD must carefully consider the risks of endothelial cell loss during surgery and minimize the risk of corneal decompensation after surgery. Preoperative management should evaluate the severity of the FECD as well as individual factors such as cataract density, the health and thickness of the cornea, and the anterior chamber depth. Perioperative techniques, adjustments to biometry calculations, and intraocular lens (IOL) selection may help optimize visual outcomes and recovery time.