Descemetorhexis Without Endothelial Keratoplasty (DWEK)

Summary of Evidence

Outcomes of Descemetorhexis Without Endothelial Keratoplasty

Reported clearance rates following DWEK range from 63 to 100% in recent series, with variation between surgical techniques. Topical Rho-kinase inhibitor has been reported as successfully salvaging failing cases.{Garcerant D, Hirnschall N, Toalster N, Zhu M, Wen L, Moloney G. Descemet’s stripping without endothelial keratoplasty. Curr Opin Ophthalmol. 2019 Jul;30(4):275-285.}

Evidence

1. Background

Review

2021 Spinozzi et.al.

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2021
Review

Review of new developments in corneal endothelial cell replacement, such as cultured corneal endothelial cell sheet transplantation and cell injection. {Spinozzi D, Miron A, Bruinsma M, Dapena I, Kocaba V, Jager MJ, Melles GRJ, Ni Dhubhghaill S, Oellerich S. New developments in corneal endothelial cell replacement. Acta Ophthalmol. 2021 Nov;99(7):712-729.}

Review

2019 Garcerant et.al.

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2019
Review

Reported clearance rates following DWEK range from 63 to 100% in recent series, with variation between surgical techniques. Topical Rho-kinase inhibitor has been reported as successfully salvaging failing cases. {Garcerant D, Hirnschall N, Toalster N, Zhu M, Wen L, Moloney G. Descemet’s stripping without endothelial keratoplasty. Curr Opin Ophthalmol. 2019 Jul;30(4):275-285.}

1.1 Predictive factors for corneal clearance

Case series

2018 Davies et.al.

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2018
Case series

DWEK when performed with a Descemetorhexis technique results in corneal clearance in the majority of cases regardless of baseline demographics, with clearance typically 3 months after the procedure. {Davies E, Jurkunas U, Pineda R 2nd. Predictive Factors for Corneal Clearance After Descemetorhexis Without Endothelial Keratoplasty. Cornea. 2018 Feb;37(2):137-140.}

2. Outcomes

2.1 Primary

Meta-analysis

2019 Franceschino et.al.

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2019
Meta-analysis

Meta-analysis of 11 prospective and retrospective studies on DWEK (+/- phacoemulsification and rho-kinase inhibitor) in Fuchs endothelial corneal dystrophy showed:

DWEK improved visual acuity and pachymetry in early stages of FECD.
A descemetorhexis size ≤4 mm was associated with the best visual outcomes and pachymetry.
DWEK failure was 17%, with 4% for a descemetorhexis size ≤4 mm {Franceschino A, Dutheil F, Pereira B, Watson SL, Chiambaretta F, Navel V. Descemetorhexis Without Endothelial Keratoplasty in Fuchs Endothelial Corneal Dystrophy: A Systematic Review and Meta-Analysis. Cornea. 2021 Dec 8.}

Franceschino et.al.
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2.1.1 DWEK vs DMEK

Case series

2018 Huang et.al.

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2018
Case series

DWEK effectively treats select patients with mild to moderate Fuchs dystrophy with equivalent visual outcomes compared with the current standard of care, DMEK. Although the recovery time may be longer, DWEK patients had reduced adverse events and need for additional procedures and did not require long-term immunosuppression or donor corneal tissue. {Huang MJ, Kane S, Dhaliwal DK. Descemetorhexis Without Endothelial Keratoplasty Versus DMEK for Treatment of Fuchs Endothelial Corneal Dystrophy. Cornea. 2018 Dec;37(12):1479-1483.}

Retrospective comparative cohort study of 27 eyes with mild to moderate Fuchs dystrophy treated with either DMEK or DWEK.
Findings:

	DMEK	DWEK
Average post-operative pinhole visual acuity	20/25-1	20/30+1
Average time to 20/40 vision	2.2 weeks	7.1 weeks
Adverse events	53%	0

2.2 Supplementation with topical rho-kinase inhibitor

Case series

2021 Davies et.al.

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2021
Case series

Netarsudil significantly reduces the time to corneal clearance after DWEK. {Davies E, Jurkunas U, Pineda R 2nd. Pilot Study of Corneal Clearance With the Use of a Rho-Kinase Inhibitor After Descemetorhexis Without Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy. Cornea. 2021 Jul 1;40(7):899-902.}

Comparative cohort study of 20 eyes with Fuchs endothelial corneal dystrophy who had DWEK with cataract surgery.
- For the first eye of each participant, netarsudil was administered immediately after surgery until corneal clearance.
- For the second eye, netarsudil was withheld 2 weeks beyond the time for corneal clearance of the first eye and then administered only if corneal edema was still present.
Findings:
- Average time for corneal clearance in eyes treated with netarsudil immediately after surgery was 4.6 ± 1.7 weeks, which was significantly shorter than eyes not treated with netarsudil immediately at 8 ± 1.9 weeks

	DMEK	DWEK
Average post-operative pinhole visual acuity	20/25-1	20/30+1
Average time to 20/40 vision	2.2 weeks	7.1 weeks
Adverse events	53%	0

Case series

2017 Moloney et.al.

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2017
Case series

In 2 out of 12 eyes treated with DMEK, healing stalled at 3 and 2 months. In both cases, topical ripasudil administered 6 times a day for 2 weeks resulted in complete corneal clearance. {Moloney G, Petsoglou C, Ball M, Kerdraon Y, Höllhumer R, Spiteri N, Beheregaray S, Hampson J, DʼSouza M, Devasahayam RN. Descemetorhexis Without Grafting for Fuchs Endothelial Dystrophy-Supplementation With Topical Ripasudil. Cornea. 2017 Jun;36(6):642-648.}

Retrospective comparative cohort study of 27 eyes with mild to moderate Fuchs dystrophy treated with either DMEK or DWEK.
Findings:

	DMEK	DWEK
Average post-operative pinhole visual acuity	20/25-1	20/30+1
Average time to 20/40 vision	2.2 weeks	7.1 weeks
Adverse events	53%	0

References

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Descemetorhexis Without Endothelial Keratoplasty (DWEK)

Summary of Evidence

Evidence

1. Background

1.1 Predictive factors for corneal clearance

2. Outcomes

2.1 Primary

2.1.1 DWEK vs DMEK

Details

2.2 Supplementation with topical rho-kinase inhibitor

Details

Details

References

Comments