Descemet membrane endothelial keratoplasty (DMEK)

Summary of Evidence

Descemet membrane endothelial keratoplasty (DMEK) vs Descemet’s Stripping Endothelial Keratoplasty (DSEK)

Meta-analysis of 11 prospective and retrospective studies comparing DMEK vs DSAEK showed:

No significant difference in endothelial cell loss
Significantly higher partial detachment rate with DMEK
DMEK was superior in best-corrected visual acuity after 6 months, subjective evaluation of visual acuity, patient satisfaction, and was the method preferred by patients {Pavlovic I, Shajari M, Herrmann E, Schmack I, Lencova A, Kohnen T. Meta-Analysis of Postoperative Outcome Parameters Comparing Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Automated Endothelial Keratoplasty. Cornea. 2017 Dec;36(12):1445-1451.}

Evidence

1. Background

Review

2019 Godinho & Mian

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2019
Review

Update on DMEK{Godinho JV, Mian SI. Update on Descemet membrane endothelial keratoplasty. Curr Opin Ophthalmol. 2019 Jul;30(4):271-274.}:

Preloaded DMEK grafts allow optimization of DMEK surgery time and reduce costs of the procedure.
Hemi-DMEK and quarter-DMEK have shown similar outcomes to conventional DMEK with respect to corneal transparency and visual acuity.
Three-year follow-up of hemi-DMEK has also shown stability in endothelial cell count while maintaining corneal transparency.

Review

2018 Deng et.al.

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2018
Review

Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology: {Deng SX, Lee WB, Hammersmith KM, Kuo AN, Li JY, Shen JF, Weikert MP, Shtein RM. Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology. Ophthalmology. 2018 Feb;125(2):295-310.}

The evidence reviewed supports DMEK as a safe and effective treatment for endothelial failure.
With respect to visual recovery time, visual outcomes, and rejection rates, DMEK seems to be superior to DSEK and to induce less refractive error with similar surgical risks and EC loss compared with DSEK.
The rate of air injection and repeat keratoplasty were similar in DMEK and DSEK after the learning curve for DMEK.

1.1 DMEK and glaucoma

Review

2018 Ang & Sng

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2018
Review

Review of DMEK and glaucoma{Ang M, Sng CCA. Descemet membrane endothelial keratoplasty and glaucoma. Curr Opin Ophthalmol. 2018 Mar;29(2):178-184.}:

Glaucoma after DMEK is a serious complication that may cause permanent visual loss, affect donor endothelial cells and graft survival.
The mechanisms of raised intraocular pressure (IOP) after DMEK include reverse pupillary block in the early postoperative period, and steroid response in the late phase.
The reduced risk of immunogenic graft rejection after DMEK necessitates a shorter duration of steroids, which may in turn reduce the risk of steroid response.
On the other hand, eyes with preexisting glaucoma that undergo DMEK may have a poorer prognosis than those without glaucoma.

2. Techniques

2.1 Sulfur Hexafluoride 20% Versus Air 100% for Anterior Chamber Tamponade

Meta-analysis

2018 Marques et.al.

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2018
Meta-analysis

Meta-analysis of 5 retrospective studies comparing intracameral 20% sulfur hexafluoride (SF6) versus 100% air as tamponade for graft attachment in DMEK showed patients in the SF6 group required 58% less rebubbling procedures (risk ratio 0.42. No differences were found regarding BCVA improvement, central corneal thickness, endothelial cell loss and rate of pupillary block. {Marques RE, Guerra PS, Sousa DC, Ferreira NP, Gonçalves AI, Quintas AM, Rodrigues W. Sulfur Hexafluoride 20% Versus Air 100% for Anterior Chamber Tamponade in DMEK: A Meta-Analysis. Cornea. 2018 Jun;37(6):691-697.}

3. Outcomes

3.1 DMEK vs DSAEK/DSEK

3.1.1 Primary

Meta-analysis

2019 Marques et.al.

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2019
Meta-analysis

Meta-analysis of 10 retrospective studies comparing DMEK vs DSAEK for Fuchs’ endothelial dystrophy showed DMEK had better postoperative results regarding BCVA, patient satisfaction, and graft-related issues. {Marques RE, Guerra PS, Sousa DC, Gonçalves AI, Quintas AM, Rodrigues W. DMEK versus DSAEK for Fuchs’ endothelial dystrophy: A meta-analysis. Eur J Ophthalmol. 2019 Jan;29(1):15-22.}

BCVA was better with DMEK at all evaluated time points
DMEK had a 60% lower rate of rejection but required more rebubblings (RR = 2.48)
DMEK had more primary graft failures and less endothelial cell density loss, but statistical difference was not reached.

Meta-analysis

2017 Pavlovic et.al.

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2017
Meta-analysis

Meta-analysis of 11 prospective and retrospective studies comparing DMEK vs DSAEK showed: {Pavlovic I, Shajari M, Herrmann E, Schmack I, Lencova A, Kohnen T. Meta-Analysis of Postoperative Outcome Parameters Comparing Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Automated Endothelial Keratoplasty. Cornea. 2017 Dec;36(12):1445-1451.}

No significant difference in endothelial cell loss
Significantly higher partial detachment rate with DMEK
DMEK was superior in best-corrected visual acuity after 6 months, subjective evaluation of visual acuity, patient satisfaction, and was the method preferred by patients

3.1.2 After previous penetrating keratoplasty

Meta-analysis

2021 Wu et.al.

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2021
Meta-analysis

Review

2021 Barrio et.al.

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2021
Review

Review of incidence and risk factors of graft failure for penetrating and lamellar (stromal and endothelial) corneal transplants. Discussion of the various surgical alternatives currently available to rescue such failed grafts, with a focus on the reported outcomes and limitations.{Alió Del Barrio JL, Bhogal M, Ang M, Ziaei M, Robbie S, Montesel A, Gore DM, Mehta JS, Alió JL. Corneal transplantation after failed grafts: Options and outcomes. Surv Ophthalmol. 2021 Jan-Feb;66(1):20-40.}

Case series

2021 Kiel et.al.

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2021
Case series

Retrospective review of 30 patients who underwent DMEK or DSAEK for endothelial decompensation after previous penetrating keratoplasty showed similar rates of lamellar graft survival, loss of endothelial cells, and mean rebubbling rates in both groups at 12 months. {Kiel M, Bu JB, Gericke A, Vossmerbaeumer U, Schuster AK, Pfeiffer N, Wasielica-Poslednik J. Comparison of DMEK and DSAEK in Eyes With Endothelial Decompensation After Previous Penetrating Keratoplasty. Cornea. 2021 Sep 1;40(9):1218-1224.}

3.2 Graft detachment and rebubbling

Review

2018 Parekh et.al.

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2018
Review

Review

2017 Rapoport & Veldman

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2017
Review

Rapoport & Veldman
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3.3 Postoperative Endothelial Cell Density and graft survival

Retrospective study

2021 Vasiliauskaite et.al.

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2021
Retrospective study

Six-month ECD is associated with DMEK graft survival. High early cell loss after DMEK negatively affects long-term ECD outcome and graft survival. Grafts in the lowest 6-month ECD subgroup (≤828 cells/mm²) are at higher risk of failure within 5 years after DMEK.{Vasiliauskaitė I, Quilendrino R, Baydoun L, van Dijk K, Melles GRJ, Oellerich S. Effect of Six-Month Postoperative Endothelial Cell Density on Graft Survival after Descemet Membrane Endothelial Keratoplasty. Ophthalmology. 2021 Dec;128(12):1689-1698. }

References

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Descemet membrane endothelial keratoplasty (DMEK)

Summary of Evidence

Evidence

1. Background

1.1 DMEK and glaucoma

2. Techniques

2.1 Sulfur Hexafluoride 20% Versus Air 100% for Anterior Chamber Tamponade

3. Outcomes

3.1 DMEK vs DSAEK/DSEK

3.1.1 Primary

Details

3.1.2 After previous penetrating keratoplasty

3.2 Graft detachment and rebubbling

3.3 Postoperative Endothelial Cell Density and graft survival

References

Comments