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Vidal-Villegas B, Burgos-Blasco B, Ariño-Gutierrez M, Cuiña Sardiña R, Mendez-Hernandez CD, Torres-Gonzalez JI, Mendez-Fernandez R, Díaz-Valle D, García-Feijóo J. Outcomes of Corneal Transplant in Childhood Glaucoma. J Glaucoma 2023; 32:701-707. [PMID: 37171990 DOI: 10.1097/ijg.0000000000002234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/30/2023] [Indexed: 05/14/2023]
Abstract
PRCIS Childhood glaucoma produces alterations in the postnatal development and function of various ocular structures, including the cornea. Childhood glaucoma patients present lower corneal transplant survival rates. Our series shows outcomes of corneal transplant in childhood glaucoma with survival rates of 29% at 2 years. OBJECTIVE To investigate the surgical outcome of different types of keratoplasty in eyes with childhood glaucoma. PATIENTS AND METHODS A retrospective review was made of the medical records from 17 eyes of 15 patients who were diagnosed with childhood glaucoma and received a corneal transplantation between January 2010 and July 2020. Patient demographics, intraocular pressure, previous ocular surgery, comorbidities, corneal transplant surgery, and follow-up outcome were collected. The primary efficacy endpoint was graft survival (in months) until failure, the latter being considered as irreversible loss of corneal transparency. Secondary efficacy points were the need for an increase in topical hypotensive therapy and the need for additional surgery. RESULTS Seventeen eyes of 15 patients were included, 11 eyes (10 patients) with primary congenital glaucoma and 6 with other types of childhood glaucoma. Corneal transplantation was performed at the mean age of 23.76 ± 14.86 years. At the time of the transplantation, the number of topical medications was 1.35 ± 1.27, intraocular pressure was 15.00 ± 8.34 mm Hg, and patients had received up to 7 glaucoma surgeries. Descemet stripping automated endothelial keratoplasty was performed in 13 eyes (76%) and penetrating keratoplasty in 4 (24%). After surgery, 7 (41%) eyes required increased topical treatment and 2 (12%) glaucoma surgery. Twelve eyes (71%) developed graft failure at 24 months, the mean time of survival being 13.88 ± 8.25 months. CONCLUSIONS Management of corneal decompensation in childhood glaucoma poses a challenge. In this series of childhood glaucoma with corneal transplantations, the survival rate was 29% at 24 months.
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Affiliation(s)
- Beatriz Vidal-Villegas
- Department of Ophthalmology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC)
- Tissue Bank, Hospital Clínico San Carlos
| | - Barbara Burgos-Blasco
- Department of Ophthalmology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC)
- Tissue Bank, Hospital Clínico San Carlos
| | - Mayte Ariño-Gutierrez
- Department of Ophthalmology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC)
- Tissue Bank, Hospital Clínico San Carlos
| | - Ricardo Cuiña Sardiña
- Department of Ophthalmology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC)
| | | | | | - Rosalía Mendez-Fernandez
- Department of Ophthalmology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC)
| | - David Díaz-Valle
- Department of Ophthalmology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC)
- Departamento de Inmunología, Oftalmología y ORL, Facultad de Medicina, Universidad Complutense de Madrid; Madrid, Spain
| | - Julián García-Feijóo
- Department of Ophthalmology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC)
- Departamento de Inmunología, Oftalmología y ORL, Facultad de Medicina, Universidad Complutense de Madrid; Madrid, Spain
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Patel SV, Hodge DO, Winkler NS, Maguire LJ, Baratz KH. Graft Survival, Graft Rejection, and Glaucoma in a Consecutive Series of Descemet Stripping Endothelial Keratoplasty. Cornea 2023; 42:549-556. [PMID: 35543582 DOI: 10.1097/ico.0000000000003050] [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: 01/07/2022] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The goal of this study was to compare outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma and abnormal anatomy to eyes with Fuchs endothelial corneal dystrophy (FECD). METHODS In a retrospective interventional series of all cases of DSEK between April 1, 2006, and November 30, 2015, recipient diagnosis, preoperative glaucoma status, concurrent surgical procedures, and graft outcomes were recorded. Graft survival, risk of rejection, and subsequent glaucoma surgery were estimated by using Kaplan-Meier analysis with risk factors determined by proportional hazard models. RESULTS Of 703 DSEKs in 666 eyes (509 subjects), the main recipient diagnoses were FECD (n = 496), pseudophakic corneal edema (n = 112), and failed graft (n = 83). Glaucoma was present in 150 cases before DSEK. Overall graft survival was 85%, 75%, and 71% at 5, 10, and 12 years, respectively, and for FECD without glaucoma was 95%, 89%, and 87% at 5, 10, and 12 years, respectively. Independent risk factors for graft failure included recipient diagnoses of pseudophakic corneal edema (HR = 8.3, P < 0.001), failed graft (HR = 6.4, P < 0.001), and preoperative medical glaucoma (HR = 7.1, P < 0.001) or surgical glaucoma (HR = 12.3, P < 0.001). Preoperative glaucoma treated by previous surgery resulted in graft survival of 28% at 10 years. Preoperative glaucoma was associated with an increased risk of graft rejection (HR = 6.8, P < 0.001) and subsequent glaucoma surgery (HR > 17.4, P < 0.001). CONCLUSIONS Preoperative glaucoma increases the risk of graft failure, graft rejection, and needing subsequent glaucoma surgery in the first decade after DSEK. With previous glaucoma surgery, DSEK graft survival was more favorable compared with published reports of Descemet membrane endothelial keratoplasty.
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Affiliation(s)
- Sanjay V Patel
- Department of Ophthalmology, Mayo Clinic, Rochester, MN; and
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL
| | | | - Leo J Maguire
- Department of Ophthalmology, Mayo Clinic, Rochester, MN; and
| | - Keith H Baratz
- Department of Ophthalmology, Mayo Clinic, Rochester, MN; and
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3
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Parekh M, Romano D, Wongvisavavit R, Coco G, Giannaccare G, Ferrari S, Rocha-de-Lossada C, Levis HJ, Semeraro F, Calvo-de-Mora MR, Scorcia V, Romano V. DMEK graft: One size does not fit all. Acta Ophthalmol 2023; 101:e14-e25. [PMID: 35751171 DOI: 10.1111/aos.15202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 01/25/2023]
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is a popular procedure for the treatment of corneal endothelial diseases mainly targeting Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK). Although DMEK has multiple advantages, it is challenging in terms of graft preparation and delivery. One of the crucial factors of DMEK graft preparation is determining the size of the graft. Evaluating risks and benefits of transplanting larger or smaller grafts compared with the descemetorhexis performed following a standard DMEK procedure thus becomes important. Advanced techniques like pre-loaded DMEK requires pre-selection of graft diameter without physical examination of the eye making it more challenging. Therefore, recognizing the benefits of graft size and the number of transplanted endothelial cells becomes essential. Smaller DMEK grafts have been preferred and accepted for grafting. Larger diameter grafts have advantages but can be challenging due to higher detachment rates. We thus aim to review the challenges of preparing and delivering DMEK tissues with small or large diameter based on selected descemetorhexis area, discuss the outcomes based on different graft sizes, highlight related complications and suggest which cases may benefit from adopting smaller or larger graft size.
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Affiliation(s)
- Mohit Parekh
- Department of Ophthalmology, Schepens Eye Research Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Davide Romano
- Eye Clinic, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Rintra Wongvisavavit
- Institute of Ophthalmology, University College London, London, UK
- Faculty of Medicine and Public Health, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Giulia Coco
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, Fondazione Banca degli Occhi del Veneto, Venice, Italy
| | - Carlos Rocha-de-Lossada
- Department of Ophthalmology (Qvision), Vithas Virgen del Mar Hospital, Almería, Spain
- Department of Ophthalmology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Departamento de Cirugia, Area de Oftalmologia, Universidad de Sevilla, Sevilla, Spain
| | - Hannah J Levis
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Francesco Semeraro
- Eye Clinic, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marina Rodríguez Calvo-de-Mora
- Department of Ophthalmology (Qvision), Vithas Virgen del Mar Hospital, Almería, Spain
- Department of Ophthalmology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Ophthalmology Department, Hospital Regional Universitario, Málaga, Spain
| | - Vincenzo Scorcia
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Vito Romano
- Eye Clinic, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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4
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Poskute R, Viestenz A, Viestenz A, Huth A, Hammer T. [DMEK-A possibility for endothelial transplant failure after bulbus reconstruction with keratoplasty and artificial iris]. DIE OPHTHALMOLOGIE 2023; 120:79-81. [PMID: 35277745 DOI: 10.1007/s00347-022-01601-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Rasa Poskute
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Augenheilkunde, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
| | - Arne Viestenz
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Augenheilkunde, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
| | - Anja Viestenz
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Augenheilkunde, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
| | - Andrea Huth
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Augenheilkunde, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
| | - Thomas Hammer
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Augenheilkunde, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland. .,Augenzentrum "Frohe Zukunft" Halle (Saale), Halle (Saale), Deutschland.
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Glaucoma in Patients With Endothelial Keratoplasty. Cornea 2022; 41:1584-1599. [DOI: 10.1097/ico.0000000000003122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/09/2022] [Indexed: 11/25/2022]
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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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Liu S, Wong YL, Walkden A. Current Perspectives on Corneal Transplantation. Clin Ophthalmol 2022; 16:631-646. [PMID: 35282172 PMCID: PMC8904759 DOI: 10.2147/opth.s289359] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/20/2022] [Indexed: 12/18/2022] Open
Abstract
Disease of the cornea is the third leading cause of blindness worldwide. Corneal graft surgery is one of the most successful forms of solid organ transplantations in humans, with ever-increasing developments in surgical technique. To date, approximately 4504 corneal transplants are performed in the United Kingdom each year. While full thickness transplantation was the most commonly performed keratoplasty over the last few decades, selective lamellar transplantation of the diseased layers of the cornea has been universally adopted. This comprehensive review aims to provide an updated synthesis on different types of corneal transplantations, their treatment outcomes, and the associated complications of each procedure in both adult and paediatric population. In addition, we also present an up-to-date summary of the emerging therapeutic approaches that have the potential to reduce the demand for donor-dependent keratoplasty.
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Affiliation(s)
- Siyin Liu
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Yee Ling Wong
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Andrew Walkden
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Correspondence: Andrew Walkden, Email
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8
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Fu L, Hollick EJ. Long-term Outcomes of Descemet Stripping Endothelial Keratoplasty: Ten-Year Graft Survival and Endothelial Cell Loss. Am J Ophthalmol 2022; 234:215-222. [PMID: 34416181 DOI: 10.1016/j.ajo.2021.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To determine 10-year outcomes for graft and endothelial cell survival after Descemet stripping endothelial keratoplasty (DSEK), including risk factors for graft failure. DESIGN Retrospective clinical cohort study. METHODS Three hundred fifty-six consecutive DSEK grafts performed by 10 surgeons using a standardized protocol were analyzed. Primary outcomes were cumulative graft survival and percentage endothelial cell loss (ECL) from 6 months to 10 years; secondary outcomes included risk factors for graft failure, postoperative complications, visual outcomes, and central corneal thickness. RESULTS Indications include Fuchs endothelial dystrophy (n = 209), bullous keratopathy (n = 88), and previous graft failure (n = 39). One hundred and four eyes (29%) had preoperative glaucoma. Cumulative graft survival rates of all eyes at 1, 3, 5, and 10 years were 97%, 90%, 85%, and 79%, respectively. Ten-year graft survival for Fuchs endothelial dystrophy was 92%. Mean ± SD percentage ECL of all grafts was 46.6% ± 17.3% at year 1, 54.9% ± 18.7% at year 3, 59.6% ± 17.4% at year 5, and 73.1% ± 9.7% at year 10. Cox regression identified preoperative glaucoma (hazard ratio [HR]: 8.41; 95% CI, 1.30-54.5; P = .026), including previous glaucoma surgery (HR: 3.63; 95% CI: 1.03-12.74; P = .04) and regrafts (HR: 5.29; 95% CI: 2.02-13.89; P = .001) as significant risk factors for graft failure. CONCLUSIONS At 10 years, DSEK survival rate was 79% for all eyes, including complex grafts, and ECL was 73%. For Fuchs endothelial dystrophy, 10-year graft survival rate was 92%. Despite a mean 10-year endothelial cell count of only 692 cells/mm2, graft survival remained high with good vision. DSEK continues to be a viable treatment option, especially in complex eyes with comorbidity.
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Affiliation(s)
- Lanxing Fu
- Department of Ophthalmology, King's College Hospital NHS Foundation Trust, London, UK
| | - Emma J Hollick
- Department of Ophthalmology, King's College Hospital NHS Foundation Trust, London, UK.
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9
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Corneal Endothelial Cell Loss in Glaucoma and Glaucoma Surgery and the Utility of Management with Descemet Membrane Endothelial Keratoplasty (DMEK). J Ophthalmol 2022; 2022:1315299. [PMID: 35637682 PMCID: PMC9148223 DOI: 10.1155/2022/1315299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/10/2022] [Indexed: 01/15/2023] Open
Abstract
The corneal endothelium has a crucial role in maintaining a clear and healthy cornea. Corneal endothelial cell loss occurs naturally with age; however, a diagnosis of glaucoma and surgical intervention for glaucoma can exacerbate a decline in cell number and impairment in morphology. In glaucoma, the mechanisms for this are not well understood and this accelerated cell loss can result in corneal decompensation. Given the high prevalence of glaucoma worldwide, this review aims to explore the abnormalities observed in the corneal endothelium in differing glaucoma phenotypes and glaucoma therapies (medical or surgical including with new generation microinvasive glaucoma surgeries). Descemet membrane endothelial keratoplasty (DMEK) is increasingly being used to manage corneal endothelial failure for glaucoma patients and we aim to review the recent literature evaluating the use of this technique in this clinical scenario.
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10
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Deng S, Le B, Bonnet C, Yung M. Descemet membrane endothelial keratoplasty in eyes with glaucoma. Taiwan J Ophthalmol 2022; 13:13-20. [DOI: 10.4103/2211-5056.361277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 07/17/2022] [Indexed: 11/16/2022] Open
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Alshaker S, Mimouni M, Batawi H, Cohen E, Trinh T, Santaella G, Chan CC, Slomovic AR, Rootman DS, Sorkin N. Four-Year Survival Comparison of Endothelial Keratoplasty Techniques in Patients With Previous Glaucoma Surgery. Cornea 2021; 40:1282-1289. [PMID: 33332901 DOI: 10.1097/ico.0000000000002585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/13/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To compare 4-year survival outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet-stripping automated endothelial keratoplasty (DSAEK) in eyes with previous glaucoma surgery. METHODS This is a retrospective, comparative case series, including patients with previous trabeculectomy or glaucoma drainage device implantation, who later underwent either DMEK (n = 48) or DSAEK (n = 41). Follow-up was limited to 12 to 60 months to prevent bias. Primary outcomes were graft survival and rejection. Secondary outcomes were best spectacle-corrected visual acuity (BSCVA), detachment/rebubble, endothelial cell loss, and intraocular pressure elevations. RESULTS Baseline characteristics, follow-up duration, and preexisting glaucoma parameters did not differ significantly between the groups. Graft survival probability after DMEK and DSAEK was 75% and 75% at 1 year, 63% and 50% at 2 years, 49% and 44% at 3 years, 28% and 33% at 4 years, and 28% and 29% at 5 years, respectively (P = 0.899 between the groups). Graft rejection rates were 20.8% and 19.5%, respectively (P = 1.000). Primary failure, rebubbling, endothelial cell loss, and intraocular pressure elevation did not differ significantly between the groups. Preoperative BSCVA did not differ between the groups (P = 0.821). Postoperative BSCVA was significantly better in the DMEK group at 6, 12, and 24 months (P < 0.001, P = 0.022, and P = 0.047, respectively). In a multivariable model (R2 = 0.576), the type of surgery was the only significant factor affecting postoperative BSCVA, in favor of DMEK (coefficient value -0.518, P = 0.002). CONCLUSIONS In eyes with previous glaucoma surgery, DMEK and DSAEK had comparably low survival and comparably high rejection rates. Postoperative visual acuity might be better after DMEK in this setting.
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Affiliation(s)
| | | | | | - Eyal Cohen
- University of Toronto, Toronto, Canada; and
| | | | | | | | | | | | - Nir Sorkin
- University of Toronto, Toronto, Canada; and
- Department of Ophthalmology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Matsou A, Pujari R, Sarwar H, Rana M, Myerscough J, Thomson SM, Nandakumar G, Zhang J, Rajan MS. Microthin Descemet Stripping Automated Endothelial Keratoplasty Versus Descemet Membrane Endothelial Keratoplasty: A Randomized Clinical Trial. Cornea 2021; 40:1117-1125. [PMID: 33156076 DOI: 10.1097/ico.0000000000002601] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/25/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare visual outcomes, complications, and vision-related quality of life (QoL) after microthin Descemet stripping automated endothelial keratoplasty (MT-DSAEK) versus Descemet membrane endothelial keratoplasty (DMEK) for the management of corneal endothelial dysfunction in Fuchs dystrophy. METHODS This is a prospective, double-blinded randomized controlled clinical trial. Patients with visually significant endothelial decompensation from Fuchs dystrophy were prospectively randomized to receive MT-DSAEK or DMEK surgery. The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 12 months. Secondary outcomes included refraction, keratometry, endothelial cell count, complications, and vision-related QoL at 6 and 12 months postoperatively. RESULTS A total of 56 eyes of 56 patients were enrolled, 28 in each group. Postoperatively, LogMAR mean BSCVA in the MT-DSAEK group was 0.17 ± 0.08 and 0.11 ± 0.09 at 6 and 12 months compared with 0.09 ± 0.13 and 0.04 ± 0.13 after DMEK (P = 0.03, P = 0.002 respectively) with the DMEK cohort achieving 3.5 logarithm of the minimum angle of resolution letters better BSCVA at 1 year compared with MT-DSAEK. Complication rates were similar with 3.5% rebubbling rate in both groups, 1 primary graft failure in DMEK and a single endothelial rejection in the MT-DSAEK arm. Vision-related QoL was comparable at 6 and 12 months postoperatively, and no eyes demonstrated loss of vision from preoperative BSCVA. CONCLUSIONS DMEK surgery resulted in significantly better BSCVA at 1, 3, 6, and 12 months postoperatively compared with MT-DSAEK. Patient satisfaction was similar with no differences reported in vision-related QoL scores, as was the complications profile between groups. Thus, our results favor DMEK as the better choice procedure for eyes with Fuchs-related corneal decompensation without ocular comorbidities.
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Affiliation(s)
- Artemis Matsou
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
| | - Rathin Pujari
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
| | - Hammad Sarwar
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
| | - Mrinal Rana
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
| | - James Myerscough
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
| | - Susan M Thomson
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
| | - Girinath Nandakumar
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
| | - Jufen Zhang
- Vision and Eye Research Institute, School of Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Cambridge, UK
| | - Madhavan S Rajan
- Department of Ophthalmology, Cambridge University Hospitals and Cambridge Eye Research Centre, Cambridge, UK; and
- Vision and Eye Research Institute, School of Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Cambridge, UK
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13
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Mimouni M, Sorkin N, Slomovic J, Kisilevsky E, Mednick Z, Cohen E, Trinh T, Santaella G, Chan CC, Rootman DS, Slomovic AR. Descemet Membrane Endothelial Keratoplasty versus Descemet Stripping Automated Endothelial Keratoplasty in Complicated Vitrectomized Eyes. Curr Eye Res 2021; 46:1283-1290. [PMID: 33657945 DOI: 10.1080/02713683.2021.1892150] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Vitrectomized eyes pose a technical challenge when performing endothelial keratoplasty (EK). The aim of the study was to compare outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in complex eyes undergoing pars plana vitrectomy (PPV) prior to or during surgery. METHODS This retrospective study included consecutive eyes that underwent pars plana infusion-assisted DMEK or pull-through DSAEK which underwent PPV prior to or during the EK at a tertiary center. Included were eyes with at least 1-year follow-up. The main outcome measures were best-corrected visual acuity (BCVA) and serious adverse events. RESULTS Fifty-two eyes (n = 52) with a mean follow-up time of 24.6 ± 7.4 months were included. Both groups were similar in terms of baseline characteristics although the DMEK group had a significantly larger proportion of Fuchs' patients (p = .009). There was no significant difference in postoperative logMAR BCVA between groups at each visit (p > .05 for all). There was a significantly higher proportion of overall serious adverse events (50.0% versus 15.4%, p = .02), retinal detachments (19.2% versus 0.0%, p = .05) and cystoid macular edema (23.1% versus 0.0%, p = .02) following DMEK. Graft detachment occurred more often following DMEK (53.9% versus 11.5%, p = .001) with no significant difference in rebubbling rates (23.1% versus 11.5%, p = .27). CONCLUSIONS A significant and similar improvement in BCVA was achieved following DMEK and DSAEK in complex vitrectomized eyes. Patients should be advised regarding the higher rates of potential serious complications associated with a pars plana infusion DMEK in this situation.
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Affiliation(s)
- Michael Mimouni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Nir Sorkin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada.,Department of Ophthalmology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacqueline Slomovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Eli Kisilevsky
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Zale Mednick
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Eyal Cohen
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Tanya Trinh
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Gisella Santaella
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Clara C Chan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - David S Rootman
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Allan R Slomovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
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14
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Fili S, Perdikakis G, Vastardis I, Müller D, Kohlhaas M. [DMEK in complicated cases of bullous keratopathy after multiple intraocular surgeries]. Ophthalmologe 2020; 118:926-932. [PMID: 33026526 DOI: 10.1007/s00347-020-01240-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/17/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND During the last decade Descemet membrane endothelial keratoplasty (DMEK) has been established as a surgical treatment even for complex cases of bullous keratopathy. MATERIAL AND METHODS In a case series 9 eyes from 8 patients with chronic corneal edema caused by multiple intraocular operations underwent DMEK surgery. It was the sole surgical procedure in three eyes. In one case DMEK was combined with an intravitreal injection of bevacizumab, with opacified intraocular lens exchange in a second case, with transscleral cyclophotocoagulation with Iridex micropulse laser (Iridex, Silicon Valley, CA, USA) and intravitreal injection of bevacizumab in a third case and with the Tutopatch® (DMR srl, Italy) coverage of a scleral perforation in a fourth case. Additionally, DMEK was combined with trimming of the Ahmed valve tube length in two cases. The follow-up period was 12 months. RESULTS Out of 9 eyes 2 showed a persistent partial or total detachment of the graft with concomitant recurrence of bullous keratopathy despite repeated injection of 20% sulfur hexafluoride (SF6) in the anterior chamber. These 2 eyes were treated with penetrating keratoplasty and achieved satisfactory postoperative results including pain relief. Visual acuity did not improve in these 2 eyes due to optic atrophy. Visual acuity and pain improved in the first postoperative month in 7 eyes. Donor endothelial cell density decreased from 2465±147/mm2 to 1295 ± 254/mm2 and 1180 ± 197/mm2 (p < 0.001, n = 7) after 6 and 12 months, respectively. Central corneal thickness decreased from 880 ± 232 μm to 571 ± 15 μm (p = 0.001, n = 7) after 12 months. Multiple rebubblings were performed in 2 of the 9 eyes because of a persistent corneal graft detachment. CONCLUSION Although DMEK is a technically demanding surgical treatment for complicated cases of severe bullous keratopathy, it provides satisfactory results in terms of the improvement of visual acuity, pain relief and a shorter postoperative period.
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Affiliation(s)
- Sofia Fili
- Klinik für Augenheilkunde, St.-Johannes-Hospital in Dortmund, Johannesstr. 9-17, 44137, Dortmund, Deutschland.
| | - Georgios Perdikakis
- Klinik für Augenheilkunde, St.-Johannes-Hospital in Dortmund, Johannesstr. 9-17, 44137, Dortmund, Deutschland
| | - Iraklis Vastardis
- Klinik für Augenheilkunde, St.-Johannes-Hospital in Dortmund, Johannesstr. 9-17, 44137, Dortmund, Deutschland
| | - Deborah Müller
- Klinik für Augenheilkunde, St.-Johannes-Hospital in Dortmund, Johannesstr. 9-17, 44137, Dortmund, Deutschland
| | - Markus Kohlhaas
- Klinik für Augenheilkunde, St.-Johannes-Hospital in Dortmund, Johannesstr. 9-17, 44137, Dortmund, Deutschland
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15
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Four-Year Survival of Descemet Membrane Endothelial Keratoplasty in Patients With Previous Glaucoma Surgery. Am J Ophthalmol 2020; 218:7-16. [PMID: 32446739 DOI: 10.1016/j.ajo.2020.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate 4-year outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with previous glaucoma surgery. DESIGN Retrospective, comparative case series. METHODS Patients with previous trabeculectomy or glaucoma drainage device (GDD) implantation who later underwent DMEK (study group) were matched for follow-up duration with Fuchs dystrophy DMEK patients (control group). The minimum follow-up was 18 months. Primary outcomes included graft survival and rejection rates, and secondary outcomes included rates of detachment/rebubble, endothelial cell loss, best spectacle-corrected visual acuity, intraocular pressure, and glaucoma medications/surgeries. Subgroup analysis compared eyes with and without a GDD. RESULTS Ninety-four eyes of 91 patients were included. There were 51 eyes of 49 patients in the study group (GDD = 32 eyes, no GDD = 19 eyes) and 43 eyes of 42 patients in the control group. The mean follow-up was 37.9 ± 15.2 and 33.8 ± 13.5 months, respectively (P = .322). Graft survival probability of the study group at 12, 24, 36, and 48 months was 75%, 60%, 43%, and 27%, respectively, compared with a consistent 88% in the control group (P < .001). Survival curves of study subgroups (GDD and no GDD) were significantly lower than the control group (P < .001). Rejection rates in the study and control groups were 19.6% and 2.3%, respectively (P = .010). Endothelial cell loss in the study group was 12%-22% higher than the control group at 12, 24, 36, and 48 months (P = .049, P = .027, P = .200, and P = .004). CONCLUSIONS In eyes with previous glaucoma surgery, DMEK has good early outcomes, but longer-term rejection and failure rates are high. Physicians and patients should be cognizant of the high likelihood of graft failure in this setting.
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16
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Bonnet C, Ghaffari R, Alkadi T, Law SK, Caprioli J, Yu F, Deng SX. Long-Term Outcomes of Descemet Membrane Endothelial Keratoplasty in Eyes with Prior Glaucoma Surgery. Am J Ophthalmol 2020; 218:288-295. [PMID: 32619607 DOI: 10.1016/j.ajo.2020.06.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/10/2020] [Accepted: 06/18/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the long-term outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes that had previously undergone trabeculectomy and/or drainage device implantation. DESIGN Retrospective, noncomparative case series. METHODS Medical records of 251 consecutive DMEK procedures performed by 1 surgeon (S.X.D.) from 2013 to 2017 were reviewed. Patients with ≥2 years of follow-up were divided into 3 groups: eyes with prior glaucoma surgery (ST), eyes with medically treated glaucoma (MT), and eyes without glaucoma (NG). Main outcomes measured were visual acuity, endothelial cell count (ECC), rates of secondary graft failure (SGF), and postoperative complications. RESULTS Ninety procedures (87 eyes) met inclusion criteria. The mean follow-up period of all eyes was 38.4 ± 11.2 months (range, 24.2-64.4 months). At last follow-up, the proportion of eyes reaching a vision of ≥20/40 was higher than that before the DMEK procedure in each group (all P < .05). The rate of ECC loss was the highest in the ST group compared to that in the MT and NG groups (63.8% vs 47.6% vs 44.0%, respectively; P < .05) as well as the rate of SGF (41.6% vs 0% vs 2.4%, respectively; P < .05). The rate of SGF of repeat DMEK was higher than that of primary DMEK (P < .05). The rates of postoperative complications were similar among all groups (all P > .05). CONCLUSIONS In eyes with prior glaucoma surgery, DMEK achieved good long-term visual outcomes but experienced a higher rate of SGF than eyes without such comorbidity.
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Affiliation(s)
- Clemence Bonnet
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; Cornea Department, Paris University, Cochin Hospital, Paris, France
| | - Reza Ghaffari
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Turad Alkadi
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Simon K Law
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Joseph Caprioli
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Fei Yu
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Sophie X Deng
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
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17
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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: 68] [Impact Index Per Article: 17.0] [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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18
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Alio JL, Montesel A, El Sayyad F, Barraquer RI, Arnalich-Montiel F, Alio Del Barrio JL. Corneal graft failure: an update. Br J Ophthalmol 2020; 105:1049-1058. [DOI: 10.1136/bjophthalmol-2020-316705] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 11/04/2022]
Abstract
Corneal graft surgery is one of the most successful forms of human solid-tissue transplantation, and nowadays, there is a worldwide expansion of the surgical volume of corneal grafts. This surgery is continuously evolving, with new surgical techniques and postoperative treatments that have considerably increased the chance of survival for the grafts. Despite the high rate of success, corneal transplantation is still complicated by a relevant risk of graft failure. This study investigates the causes that lead to the failure of the different corneal graft surgical techniques and provides an updated synthesis on this topic. A comprehensive review of the main pathological pathways that determine the failure of corneal grafts is provided, analysing the main risk factors and disclosing the survival rates of the principal form of corneal grafts. Our results revealed that penetrating keratoplasty has higher failure rates than lamellar keratoplasty, with immunological rejection being the leading cause of graft failure, followed by late endothelial failure (LEF) and ocular surface disorders. Postoperative glaucoma and dehiscence of the surgical wound represent other important causes of failure. Endothelial keratoplasty showed the lowest rates of failure in the mid-term, with LEF, detachment of the graft and primary graft failure representing the most common pathological reasons for failure.
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Boutin T, Sorkin N, Einan-Lifshitz A, Mednick Z, Mimouni M, Cohen E, Trinh T, Santaella G, Buys YM, Trope G, Chan CC, Rootman DS. Descemet membrane endothelial keratoplasty in patients with prior glaucoma surgery. Eur J Ophthalmol 2020; 31:2121-2126. [PMID: 32605435 DOI: 10.1177/1120672120936178] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To present outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with prior trabeculectomy or a glaucoma drainage device (GDD). METHODS A retrospective case series, including patients that had previously undergone trabeculectomy and/or GDD implantation, who later underwent DMEK between 2013 and 2016 at Toronto Western Hospital and the Kensington Eye Institute. Outcome measures: best spectacle-corrected visual acuity (BSCVA), endothelial cell (EC) density, intraoperative and postoperative complications. RESULTS Twenty-seven eyes of 27 patients were included. All DMEK procedures were uneventful. Mean follow-up time was 14.6 ± 6.1 months. In eyes with no visually limiting comorbidities (n = 16), BSCVA improved from 1.34 ± 0.65 logMAR (Snellen equivalent ~20/440) preoperatively to 0.51 ± 0.24 logMAR (Snellen equivalent ~20/65) and 0.50 ± 0.33 logMAR (Snellen equivalent ~20/65) at 6 and 12 months, respectively (p < 0.001 for both). In eyes with visually limiting comorbidities (n = 11), BSCVA improved from 1.92 ± 0.72 logMAR (Snellen equivalent ~20/1665) preoperatively to 1.43 ± 0.83 logMAR (Snellen equivalent ~20/540) and 1.37 ± 0.99 logMAR (Snellen equivalent ~20/470) at 6 and 12 months, respectively (p = 0.008 and p = 0.037).Graft detachment rate was 24.1% and rebubble rate was 17.2%. Primary and secondary graft failure rates were 3.7% and 10.3%, respectively. Rejection rate was 17.2%. EC-loss rate at 6 months and 12 months was 36.7% and 50.5%, respectively. CONCLUSIONS DMEK performed in eyes with previous trabeculectomy or a GDD is more challenging than conventional DMEK, but has good outcomes. Higher rates of graft rejection and secondary graft failure in this setting should be further evaluated in long-term studies.
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Affiliation(s)
- Tanguy Boutin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Nir Sorkin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada.,Department of Ophthalmology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Einan-Lifshitz
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Zale Mednick
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Michael Mimouni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Eyal Cohen
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Tanya Trinh
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Gisella Santaella
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Yvonne M Buys
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Graham Trope
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Clara C Chan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - David S Rootman
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
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20
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The Impact of Glaucoma Drainage Devices on the Cornea. CURRENT OPHTHALMOLOGY REPORTS 2020. [DOI: 10.1007/s40135-020-00234-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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