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Purpose: To describe how to approach eyes with phakic or pseudophakic bullous keratopathy that have an anterior chamber intraocular lens (AC IOL) using thin Descemet-stripping endothelial keratoplasty (thin-DSEK) or Descemet membrane endothelial keratoplasty (DMEK) with or without AC IOL removal., Setting: Tertiary referral center., Design: Comparative case series., Methods: Descemet membrane endothelial keratoplasty or thin-DSEK was performed in pseudophakic eyes with iris-claw AC IOLs (Group 1) or in phakic eyes with angle-supported AC IOLs (Group 2). In both groups, DMEK was routinely performed except in eyes with insufficient corneal transparency or a high risk for graft detachment. Preoperative surgical considerations, postoperative corrected distance visual acuity (CDVA), endothelial cell density, and complications were documented., Results: In Group 1, all AC IOLs were left in situ. In Group 2, AC IOLs were removed in 90% of cases. At 6 months, the CDVA was 20/40 (≥0.5 decimal) or better in 36% of eyes in Group 1 and 90% in Group 2. Graft detachment occurred in 20% of eyes and de novo or glaucoma exacerbation in 29%., Conclusions: Bullous keratopathy treatment in eyes with an AC IOL was feasible with DMEK. Intraocular lens removal may be required if postoperative complications are anticipated, but not to facilitate surgery. Overall, the surgical approach may aim to minimize postoperative complications; that is, thin-DSEK in eyes with low visual potential and/or concomitant pathology and DMEK in eyes with a phakic AC IOL and normal visual potential., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the various causes of unexpected incomplete visual rehabilitation at 6 months postoperative after Descemet membrane endothelial keratoplasty (DMEK)., Design: Retrospective study of prospectively collected data at a tertiary referral center., Methods: From a larger group of 400 consecutive DMEK surgeries, the last 200 consecutive eyes were reviewed for visual discomfort despite a best-corrected visual acuity (BCVA) of ≥20/25 (≥0.8) or unexpected subnormal BCVA (≤20/28; ≤0.7) at 6 months after DMEK. Biomicroscopy, funduscopy, Pentacam imaging, noncontact specular microscopy, anterior segment optical coherence tomography, and surgical videos were used to determine the causes of incomplete visual rehabilitation., Results: A total of 69 eyes out of 178 eyes that were included in the analysis (38.8%) presented with incomplete visual rehabilitation after DMEK, further categorized as "primarily patient-related" in 40 of 178 (22.5%), "primarily graft-related" in 21 of 178 (11.8%), and a combination of "patient-/graft-related" in 8 of 178 cases (4.5%). Unrecognized pre-existing ocular pathology and/or posterior segment disease in 19 of 178 eyes (10.7%), clinically significant corneal irregularities and/or central corneal scarring often secondary to long-standing preoperative corneal edema in 14 of 178 eyes (7.9%), or (partial) graft detachment in 20 of 178 eyes (11.2%) were the main causes of unexpected incomplete visual rehabilitation. Transient or persistent monocular ghost images or diplopia occurred in 10 of 178 eyes (5.6%), sometimes requiring contact lens fitting., Conclusions: In contrast to earlier endothelial keratoplasty techniques that may frequently be associated with undefined transplant-related subnormal visual outcomes, incomplete visual rehabilitation after DMEK may virtually always be explained by concomitant ocular pathology or evident graft failure., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To report the outcomes of Descemet membrane endothelial keratoplasty (DMEK) using a large diameter graft in the management of endothelial decompensation in buphthalmic eyes., Methods: Four eyes of 4 adults (1 man, 3 women) with bullous keratopathy and buphthalmos secondary to congenital glaucoma were treated with DMEK using posterior lamellar grafts with diameters ranging from 10 to 12 mm. The mean age was 31 (±9) years (range, 20-38 years). Mean follow-up time was 13.5 (±7.5) months (range, 6-24 months). Main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP), pachymetry, endothelial cell density, and complications after surgery., Results: In all eyes, there was improved corneal clarity with decrease in pachymetry. The final postoperative BCVA improved in most eyes. There was no significant change in IOP, with 3 eyes needing additional antiglaucoma medication. Endothelial cell loss ranged from 37% to 42%. Postoperative complications were early partial graft detachment in 2 eyes, one resolving spontaneously without intervention and the other requiring a rebubbling, and cataract formation requiring phacoemulsification in 1 eye., Conclusions: DMEK using a large or even full diameter Descemet membrane graft may be an effective treatment for bullous keratopathy in buphthalmic eyes. Partial graft detachment after surgery may be the main complication. Postoperative IOP control is mandatory, and BCVA may vary with ocular comorbidity unrelated to the transplanted cornea.

Purpose: To describe corneal clearance after re-endothelialization of the recipient posterior stroma through Descemet membrane endothelial transfer (DMET) (ie, a "free-floating" donor Descemet graft in the recipient anterior chamber after descemetorhexis), in managing corneal endothelial disorders., Design: Nonrandomized prospective study at a tertiary referral center., Methods: Twelve eyes enrolled in our study, 7 suffering from Fuchs endothelial dystrophy and 5 with bullous keratopathy. The clinical outcome was monitored by biomicroscopy, optical coherence tomography, confocal microscopy, endothelial cell density, and pachymetry measurements., Results: All eyes operated on for Fuchs endothelial dystrophy showed corneal clearance, with pachymetry values returning to normal (533 ±47 μm). The denuded recipient stroma re-endothelialized with an average endothelial cell density of 797 (± 743) cells/mm(2) at 6 months after surgery. In contrast, none of the bullous keratopathy eyes showed any improvement throughout the follow-up period., Conclusion: DMET may be effective in the management of Fuchs endothelial dystrophy (primarily a Descemet membrane disorder), but not in bullous keratopathy (primarily an endothelial depletion). Apparently, the indication for surgery (ie, a "dystrophy" vs a "depletion" of recipient endothelial cells) relates to the capacity of the cornea to clear. This suggests that the remaining rim of recipient endothelium (after descemetorhexis) is involved in the re-endothelialization of the recipient posterior stroma after DMET., (Copyright © 2012 Elsevier Inc. All rights reserved.)