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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, I-2: 0%; p = 0.86); (2) postoperative ECD (-62; -190, 67 cells/mm(2); 4 studies, I-2: 67%; p = 0.35); (3) rebubbling (risks ratio: 1.04; 0.59, 1.85; 4 studies, I-2: 48%; p = 0.89); and primary graft failure rate (risks ratio: 0.91; 0.32, 2.57; 3 studies, I-2: 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.

PURPOSE: To evaluate the 10-year graft survival and clinical outcomes of the first case series after Descemet membrane endothelial keratoplasty (DMEK).DESIGN: Retrospective, interventional case series.METHODS: After excluding the very first 25 DMEK eyes that constitute the technique learning curve, the following 100 consecutive primary DMEK eyes (88 patients) were included. Main outcome parameters (survival, best-corrected visual acuity [BCVA], central endothelial cell density [ECD], and central corneal thickness [CCT]) were evaluated up to 10 years postoperatively, and postoperative complications were documented.RESULTS: At 5 and 10 years after DMEK, 68 and 57 of 100 eyes, respectively, were still available for analysis. Of those eyes, 82% and 89% reached a BCVA of >= 20/25 (decimal VA >= 0.8) at 5- and 10 years postoperatively, respectively. Preoperative donor ECD decreased by 59% at 5 years and 68% at 10 years postoperatively. CCT averaged 668 +/- 74 mu m preoperatively and 540 +/- 33 mu m and 553 +/- 43 mu m at 5 and 10 years, respectively, after surgery. Within 10 years, 4% of eyes developed allograft rejection, no primary graft failures occurred, and 6% of the eyes developed secondary graft failure. Graft survival probability was 0.83 (95% confidence interval [CI], 0.75-0.92) and 0.79 (95% CI, 0.70-0.88) at 5 and 10 years postoperatively, respectively.CONCLUSIONS: Most eyes that underwent surgery in the pioneering phase of DMEK showed excellent and stable clinical outcomes with low postoperative complication rates and promising graft longevity over the first decade after surgery. This suggests that DMEK may be a safe long-term treatment option for corneal endothelial diseases. ((C) 2020 Elsevier Inc. All rights reserved.)

Purpose: To analyze if 6-month endothelial cell density (ECD) affects long-term ECD outcome and graft survival 5 years after Descemet membrane endothelial keratoplasty (DMEK) in eyes with Fuchs endothelial corneal dystrophy (FECD).Design: Retrospective cohort study.Participants: A total of 585 DMEK eyes were included. The study group was divided into 4 groups based on 6-month ECD quartiles: group 1 (n = 146) with 313 to 1245 cells/mm(2), group 2 (n = 148) with 1246 to 1610 cells/mm(2), group 3 (n = 145) with 1611 to 1938 cells/mm(2), and group 4 (n = 146) with 1939 to 2760 cells/mm(2). Group 1 was further split into subgroups 1a (n = 36) with 6-month ECD of

The status of the donor tissue post-keratoplasty (post-transplant), whether full or partial thickness, is currently assessed for health, function, and complications via clinical evaluations. This includes detection of visible signs of graft rejection on slit lamp biomicroscopy such as keratic precipitates or edema. Corneal endothelial cell (EC) images are utilized to indirectly assess the health of the cornea post keratoplasty with evidence that morphometric changes may occur prior to clinical signs of rejection. We extracted over 190 novel quantitative features from EC images acquired 1-12 months prior to patients´ rejection diagnosis date, and used random forest (RF) classifiers to predict future rejection. We automatically segmented the cell borders of 171 EC images using a semi-automated segmentation approach: deep learning U-Net segmentation followed by guided manual correction. Following segmentation, we extracted novel quantitative features that robustly represented the cellular morphology from the EC images. We trained and tested a RF classifier using 5-fold cross validation and minimal Redundancy Maximal Relevance (mRMR) feature selection. From the 5-fold cross validation, we report an area under the receiver operating characteristic curve (AUC) of 0.87 ± 0.03, a sensitivity of 0.86 ± 0.12, and a specificity of 0.86 ± 0.10. The results suggest we can accurately predict a patient’s future graft rejection 1- 12 months prior to diagnosis, enabling clinicians to intervene modifying and/or instituting topical corticosteroid therapy earlier with the possibility of lowering graft rejection failures. Success of this classifier could reduce health care costs, patient discomfort, vision loss and the need for repeat keratoplasty.

Purpose To assess whether combined analysis of specular microscopy and Scheimpflug imaging improves detection of an upcoming allograft rejection following Descemet membrane endothelial keratoplasty (DMEK). Methods Retrospective analysis of 22 eyes that had developed a clinical proven allograft rejection 28 (±22) months (range: 4-84 months) after DMEK. Specular microscopy and Scheimpflug images routinely made after DMEK were retrospectively analysed for changes in endothelial cell morphology (e.g. nuclear activation), cell density (>10%) and pachymetry (>7%), and/or the presence of subclinical keratic precipitates. The same parameters were evaluated for 22 control eyes matched for age, gender and surgery indication. Results A total of 20/22 eyes (91%) showed detectable changes 0.25-75 months before allograft rejection became clinically manifest: 13/22 (59%) showed both specular microscopy and Scheimpflug imaging changes; 5/22 (23%) only had changes on Scheimpflug imaging; and 2/22 (9%) only had specular microscopy changes. In 18/22 (82%) and 14/22 (64%) eyes, subclinical keratic precipitates and endothelial cell morphology changes could be detected, respectively. A total of 11/22 (50%) eyes concurrently showed a >10% drop in endothelial cell density and 4/22 (18%) a >7% pachymetry increase. Of the control eyes, 7/22 (32%) showed changes with specular microscopy but not with Scheimpflug imaging. Conclusions Combined analysis of specular microscopy and Scheimpflug imaging may allow recognizing an upcoming allograft rejection in over 90% of eyes and up to 6 years before rejection becomes clinically manifest. Early recognition of eyes at risk may allow for targeted intensified steroid treatment to prevent endothelial cell damage associated with rejection.

PURPOSE: To evaluate which parameters may affect endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK) by comparing eyes in the low vs high quartile of endothelial cell loss over a follow-up period of 4 years.DESIGN: Retrospective cohort study.METHODS: Donor endothelial cell density (ECD) decline was evaluated for 351 eyes of 275 patients up to 4 years after DMEK for Fuchs endothelial corneal dystrophy (FECD). Eyes with a postoperative endothelial cell loss in the lower quartile at all available follow-up moments were assigned to Group 1 (n = 51) and those in the upper quartile to Group 2 (n = 42). Multinomial regression was used to assess which covariates were related to greater ECD decline.RESULTS: Mean endothelial cell loss as compared to preoperative donor ECD for the entire study group was 33 (+/- 16)%, 36 (+/- 17)%, and 52 (+/- 18)% at 1, 6, and 48 months postoperatively. Endothelial cell loss of Group 1 was 12 (+/- 7)%, 13 (6)%, and 26 (+/- 8)% at, respectively, 1, 6, and 48 months postoperatively, and 59 (+/- 10)%, 64 (+/- 9)%, and 75 (+/- 5)% in Group 2. Partial graft detachment, donor death cause cardiovascular/stroke (vs cancer), postoperative complications other than graft detachment, and severity of preoperative FECD (all P

Purpose To evaluate the clinical outcome of 16 eyes undergoing Descemet membrane endothelial transfer (DMET). Methods In this retrospective cohort study, a consecutive series of 16 eyes from 16 patients was evaluated after subtotal detachment of the Descemet graft after a Descemet membrane endothelial keratoplasty procedure (n = 8) or intended DMET (n = 8) for either Fuchs endothelial dystrophy (n = 10) or bullous keratopathy (BK; n = 6). Results All 8 Descemet membrane endothelial keratoplasty procedures were complicated by subtotal detachment of the donor graft. The remaining 8 eyes that underwent a DMET procedure were uneventful and no postoperative complications occurred, except 1 eye with BK that experienced a postoperative wound leak. Throughout all postoperative time points, the partially attached status of all Descemet grafts was maintained. Although all eyes operated on for Fuchs endothelial dystrophy showed initial central corneal clearance, no eye operated for BK demonstrated any degree of corneal deturgescence. Ultimately, all 16 corneas decompensated and 15 of the 16 patients elected retransplantation, while 1 patient declined further surgery for health reasons. Retransplantation was performed on average 10.3 (±7.4) months (range, 3-31 mo) postoperatively. Conclusions Ultimately, regardless of the etiology of endothelial dysfunction, DMET fails to provide satisfactory results in the long term; durable corneal clearance may therefore require the presence of a nearly completely attached Descemet graft.

Purpose of review Descemet membrane endothelial keratoplasty (DMEK) has become a first-line treatment in corneal endothelial diseases because of its exceptional clinical outcomes and low complication rates. Because of its improved refractive predictability, DMEK is now also considered for managing cases with endothelial decompensation following previous refractive procedures, or in combination with those. This article reviews the clinical outcomes in these cases and discusses the possibility of refractive interventions following DMEK. Recent findings DMEK has been successfully performed in eyes after laser in-situ keratomileusis, eyes after anterior chamber intraocular lens (IOL) implantation and aphakic eyes. Often, DMEK is combined with cataract surgery (triple-DMEK). Initial reports on reducing the refractive cylinder by toric IOL implantation are available. Although there are some reports on phacoemulsification and IOL implantation after phakic DMEK, reports on laser refractive procedures following DMEK are lacking. Summary In contrast to earlier keratoplasty techniques, DMEK induces on average only mild refractive shifts owing to the 'natural' restoration of the cornea. As such, DMEK may be ideal in managing corneal decompensation in refractive patients. However, further studies are required to assess the safety and efficacy of DMEK after refractive treatment and of refractive procedures following DMEK.

To evaluate the clinical outcome of 500 consecutive cases up to 2 years after Descemet membrane endothelial keratoplasty (DMEK) and to assess which parameters may have influenced the clinical outcome.From a group of 500 eyes (393 patients), which underwent DMEK for Fuchs endothelial corneal dystrophy (FECD), bullous keratopathy, failed corneal transplants and other indications, clinical outcomes [best-corrected visual acuity (BCVA), central endothelial cell density (ECD), and central corneal thickness] were evaluated before, and at 6, 12, and 24 months after DMEK and postoperative complications were documented.At 12 months postoperatively, 81% of eyes reached a BCVA of ≥20/25 (≥0.8), 49% ≥20/20 (≥1.0), and 15% ≥20/18 (≥1.2) (n = 396) and remained stable up to 24 months (P = 0.828). Compared with preoperative ECD, mean postoperative ECD decreased by 37 (±18)%, 40 (±18)%, and 45 (±18)% at 6, 12, and 24 months, respectively (P0.05 for all time points). Surgery indication and graft attachment status were related to postoperative BCVA and ECD results. Eyes with FECD and attached grafts showed better BCVA outcomes and higher ECD (P0.05). Central corneal thickness decreased by 20 (±11)% to 525 (±46) μm from preoperative to 6 months postoperatively and remained stable thereafter (P0.05). Within the study period, retransplantation was required in 32 eyes (6.4%). Principal longer-term complications were secondary graft failure (1.4%) and allograft rejection (1.4%).Clinical outcomes remain excellent up to 2 years after DMEK, in particular for eyes operated on for FECD and with completely attached grafts.

PURPOSE: To analyze 6-month results of 1000 consecutive Descemet membrane endothelial keratoplasty (DMEK) cases, and to evaluate if outcomes are influenced by surgical indication and preoperative lens status.DESIGN: Retrospective, interventional case series.METHODS: A series of 1000 eyes (738 patients) underwent DMEK mainly for Fuchs endothelial corneal dystrophy (FECD; 85.3%) or bullous keratopathy (BK; 10.5%). Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density, postoperative complications, and retransplantations.RESULTS: At 6 months after DMEK, there was no difference in BCVA outcome between FECD and BK eyes (P = .170), or between phakic and pseudophakic FECD eyes (P = .066) after correcting for patient age and preoperative BCVA. Endothelial cell loss at 6 months postoperatively was similar for phakic and pseudophakic FECD eyes (39%; P = .852), but higher for BK eyes than for FECD eyes (46% vs 39%, P = .001). Primary and secondary graft failure occurred in 3 (0.3%) and 2 eyes (0.2%), respectively, and 7 eyes developed allograft rejection (0.7%). Eighty-two eyes (8.2%) received rebubbling for graft detachment and retransplantation was performed in 20 eyes (2.0%). Rebubbling was more often required in eyes treated for BK vs FECD eyes (12.4% vs 7.4%, P = .022).CONCLUSION: DMEK consistently provides excellent short-term results, with similar high visual acuity levels for both FECD and BK eyes. As preoperative lens status did not influence DMEK outcomes, for phakic FECD eyes with a still relatively clear crystalline lens, lens preservation may be preferable in a selected group of younger patients, who may still benefit from their residual accommodative capacity. (C) 2019 Elsevier Inc. All rights reserved.

Purpose:To report clinical outcomes of the first Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK) case series performed for central Fuchs endothelial corneal dystrophy.Methods:This is a prospective, interventional case series analyzing the clinical outcomes of 19 eyes of 19 patients with central Fuchs endothelial corneal dystrophy, that is, with guttae predominantly in the 6- to 7-mm optical zone, who underwent unilateral Quarter-DMEK at a tertiary referral center. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications. Included eyes had up to 2 years of postoperative follow-up.Results:At 6 months postoperatively, all eyes reached a BCVA of >= 20/40 (>= 0.5): 18 of 19 eyes (95%) with >= 20/25 (>= 0.8) and 9 of 19 eyes (42%) with >= 20/20 (>= 1.0). Thereafter, BCVA remained stable up to 2 years postoperatively. The mean donor ECD decreased from 2842 139 cells/mm(2) (n = 19) before implantation to 913 +/- 434 cells/mm(2) (-68%) at 6 months (n = 19), 869 +/- 313 cells/mm(2) (-70%) at 12 months (n = 18), and 758 +/- 225 cells/mm(2) (-74%) at 24 months (n = 13) after Quarter-DMEK. Visually significant graft detachment requiring rebubbling occurred in 8 of 19 eyes (42%).Conclusions:Quarter-DMEK surgery yields visual outcomes similar to those of conventional DMEK and may potentially quadruple the availability of endothelial grafts. Further modifications of the graft preparation and the surgical technique may improve clinical outcomes in terms of lower ECD decrease and fewer graft detachments.

PURPOSE To study the influence of different intraoperative air tamponade times on graft adherence after Descemet membrane endothelial keratoplasty (DMEK). METHODS In this interventional case series, we evaluated 117 eyes with Fuchs endothelial corneal dystrophy (FECD) that underwent DMEK using intraoperative air tamponade times of 60 minutes (group I; n = 39), 45 minutes (group II; n = 39), or 30 minutes (group III; n = 39). At 1 and 6 months postoperatively, graft adherence status, endothelial cell density, central pachymetry, and postoperative complications were recorded. RESULTS At 1 month, 19 of the 117 eyes (16.2%) showed a clinically significant detachment (>1/3 of the graft surface area and affecting visual axis): 6 eyes in group I (15.4%), 5 eyes in group II (12.8%), and 8 eyes in group III (20.5%) (P = 0.82). A minor detachment (

Introduction: In the last 20 years the treatment of endothelial dysfunction has evolved dramatically. Nowadays, Descemet membrane endothelial keratoplasty (DMEK) allows for an anatomical replacemen...

Purpose To investigate in vitro central and peripheral corneal endothelial cell (EC) migration from Quarter–Descemet membrane endothelial keratoplasty (Quarter‐DMEK) grafts. Methods Quarter‐DMEK grafts were obtained from 10 corneas ineligible for transplantation but with intact and viable ECs. Ten Quarter‐DMEK grafts were ‘sandwiched’ between two glass slides and cultured over 1 week in a humidified atmosphere at 37 °C and 5% CO2. Cell migration was evaluated by light microscopy at standardized time intervals. In addition, immunohistochemistry analyses were performed to assess the detailed structural organization of ECs in the corneal centre and far periphery. Results Endothelial cell (EC) migration occurred from the radial cut graft edges, but not from the far peripheral area. Cell migration followed three different migration patterns: (1) individual cell migration, (2) uncoordinated cell migration of cell clusters and (3) collective migration in which ECs moved as a sheet. Immunostaining showed the presence of ECs up to the far periphery but with different expression patterns of phenotypical markers ZO‐1, Na+/K+ ‐ATPase and vimentin compared to central ECs. Conclusion In vitro EC migration from Quarter‐DMEK grafts occurs along the radial cut edges with a decrease in migration activity towards the corneal far periphery. No migration occurred along the outer peripheral corneal edge possibly due to a different anatomical matrix in the far periphery. Hence, ECs from the far periphery may not contribute to corneal clearance of the adjacent bare area after Quarter‐DMEK surgery, but these cells may constitute a valuable cellular reserve on the graft.

Penetrating and – to some extent, Deep anterior lamellar keratoplasty (PK and DALK, respectively) – represent the ‘old’ generation of treatments for keratoconus (KC). Increasingly, they are being replaced by newer, less invasive techniques, like ultra-violet corneal crosslinking (UV-CXL) and intracorneal ring segment (ICRS) implantation. Even more recently, Bowman layer (BL) transplantation has been introduced for patients with advanced KC; the operation is designed to stiffen, strengthen, and flatten the recipient cornea into a more normal, stable configuration and thereby prevent or delay the need for more invasive treatment. Here, we provide an overview and history of this new technique, and relay the operation’s mid-term surgical results.

Purpose To describe the use of 360-degree Scheimpflug imaging as a diagnostic tool for detection and documentation of subtle corneal changes preceding upcoming allograft rejection after Descemet membrane endothelial keratoplasty (DMEK). Methods A total of 17 eyes (16 patients) were diagnosed with clinically manifest allograft rejection 2 to 42 months after DMEK. 360-degree Scheimpflug images of consecutive follow-up examinations (from 3-60 mo) of "asymptomatic" eyes before, during, and after rejection were retrospectively analyzed, to determine which abnormalities could be detected before allograft rejection became clinically manifest. The images were compared with DMEK control eyes (without rejection episode). Results Scheimpflug images at the time of rejection showed keratic precipitates as distinct retrocorneal nodular elevations and/or a significant increase in pachymetry of ≥7%. More subtle changes could be identified retrospectively in 9/17 eyes (53%) on an average at 8 (±5) months before rejection became clinically manifest; in all eyes, these subtle changes were not recognized at routine slit-lamp examinations by various ophthalmologists as inflammatory changes heralding allograft rejection. Secondary graft failure occurred in 4/17 eyes (24%). None of the control eyes showed relevant abnormalities with Scheimpflug imaging. Conclusions By screening the posterior corneal surface with 360-degree Scheimpflug imaging, subtle inflammatory retrocorneal deposits can be detected and recorded during consecutive follow-up visits. Hence, Scheimpflug imaging may have the potential to become a diagnostic tool for early detection of upcoming allograft rejection in asymptomatic DMEK eyes, that is, before the immune response becomes clinically manifest and before substantial endothelial cell damage occurs.

Purpose To describe specific maneuvers and technical modifications to the standardized "no-touch" technique of Descemet membrane endothelial keratoplasty (DMEK) to successfully handle the presence of a glaucoma drainage device (GDD) tube in the anterior chamber of an eye with a failed primary penetrating keratoplasty (PK) graft. Methods A 42-year-old male patient underwent DMEK because of a failed primary PK graft in his phakic right eye. The patient was then evaluated at 3 and at 6 months after surgery. Results A modified no-touch DMEK technique proved a feasible treatment option for a decompensated primary PK graft in the presence of a long GDD tube. Conclusions With specific technical modifications DMEK can be successfully performed in eyes with decompensated primary PK grafts in the presence of a long GDD tube. The very thin DMEK graft allows positioning between the GDD tube and the failed PK graft, leaving the tube in place.

Background To evaluate the efficacy of manual mid-stromal dissection in stabilizing progressive keratoconus. Methods Surgeries were performed in 16 eyes of 14 patients with progressive keratoconus. All eyes were examined before and at 1 day, 1 week, 1, 3, 6 and 12 months after surgery, and every 6 months thereafter. Pentacam (simK, Kmax and pachymetry), best corrected visual acuity (BCVA) and subjective refraction were recorded up to the latest follow-up visit (mean follow-up time 6.6 ± 2.4 years). Results All surgeries were uneventful, and no postoperative complications occurred. Keratometry values (n = 15) stabilized in 6/11 eyes (55%) with a preoperative Kmax 60 D showed continued progression. In 11/15 eyes (73%) pachymetry was unchanged. BCVA with spectacles remained stable in 7/12 eyes (58%) and improved ≥2 Snellen lines in 5/12 eyes (42%). BCVA with a contact lens remained stable in 4/9 eyes (44%), improved ≥2 Snellen lines in 3/9 eyes (33%) and deteriorated in 2/9 eyes (22%). Conclusions Manual mid-stromal dissection was effective in 50% of keratoconic corneas with Kmax values

Purpose To report an unusual presentation of iridocorneal endothelial (ICE) syndrome associated with band keratopathy and its management with ethylenediamine-tetraacetic acid (EDTA) chelation and Descemet membrane endothelial keratoplasty (DMEK). Methods A 57-year-old female patient presented with unilateral progressive painless visual impairment, corneal band keratopathy, and morphological corneal endothelial changes without corneal edema or any previous ophthalmic, medical, or family history. Routine specular and confocal microscopy imaging, as well as biomicroscopy, best-corrected visual acuity, and pachymetry measurements were performed before and after the surgical procedures. Histopathologic and immunohistochemical evaluations of the surgically excised diseased DM-endothelium were performed. Results Superficial epithelial keratectomy with EDTA chelation was performed. After an initial period of a few months of corneal clearance, the patient presented with recurrence of visually significant band keratopathy. After 1 year, she underwent retreatment with superficial epithelial keratectomy and EDTA chelation, followed by DMEK. Histopathologic and immunohistochemical analysis showed ICE syndrome. Two years after DMEK surgery, the cornea was still clear and band keratopathy had not recurred. Conclusions To the best of our knowledge, this is the first case in the literature that reports the association of ICE syndrome with band keratopathy. As band keratopathy recurred shortly after EDTA chelation, endothelial keratoplasty (DMEK) may be indicated to successfully treat such cases.

PURPOSE To report the mid-term outcomes of hemi-Descemet membrane endothelial keratoplasty (hemi-DMEK) performed for Fuchs endothelial corneal dystrophy (FECD). METHODS In this prospective, interventional case series, we evaluated clinical outcomes of 10 eyes from 10 patients who underwent hemi-DMEK for FECD. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), central pachymetry, and postoperative complications. RESULTS At 1 year postoperatively, 7/7 eyes (excluding 2 eyes with low visual potential) reached a BCVA of ≥20/40 (≥0.5), 6/7 (86%) ≥20/25 (≥0.8), 4/7 (57%) ≥20/20 (≥1.0), and 2/7 (29%) 20/17 (≥1.2). BCVA remained stable until 2 years postoperatively (P ≥ 0.05) and further improved thereafter (P < 0.05). Mean ECD decreased from 2740 (±180) cells/mm preoperatively to 850 (±300) cells/mm (n = 9) at 1 year (P ≤ 0.05) and showed an annual decrease of on average 6% to 7% thereafter (P ≥ 0.05 between consecutive follow-ups). Pachymetry decreased from preoperatively 745 (±153) μm to 533 (±63) μm (n = 9) and 527 (±35) μm (n = 8) at 1 and 3 years postoperatively, respectively. Within the first 6 postoperative months, 4/10 eyes underwent rebubbling for visually significant graft detachment. One eye received secondary circular DMEK for persistent graft detachment 1 month postoperatively; another eye developed secondary graft failure 2.5 years postoperatively, and 1 eye was suspected for an allograft reaction 1.5 years postoperatively. CONCLUSIONS Hemi-DMEK may render visual outcomes comparable to those achieved by conventional DMEK. Despite low ECD counts by 6 months, ECD levels remain fairly stable thereafter. Hence, hemi-DMEK may become a potential alternative technique for treatment of FECD while increasing the yield of the endothelial tissue pool.

PURPOSE To assess aqueous flare as a measure of subclinical inflammation after Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy. METHODS In this prospective cross-sectional and longitudinal case series at a tertiary referral center, 173 DMEK eyes of 169 patients and 19 age-matched healthy control eyes were included. Aqueous flare [photon count per millisecond (ph/ms)] was assessed by laser flare photometry at 1 day, 1 week, and 1 month after DMEK in group I (evaluation of postsurgical blood-aqueous barrier recovery; n = 25) and on average 28 (±19) months (range, 3-86 months) after DMEK in group II (evaluation of long-term inflammation; n = 148). RESULTS In group I, flare levels decreased from 1 day to 1 week [25.1 (±9.1) ph/ms vs. 13.4 (±4.8) ph/ms; P = 0.003] and remained stable up to 1 month after DMEK [12.1 (±3.2) ph/ms; P = 0.387]. However, average flare at 1 month was higher than that in healthy controls (P < 0.001). The long-term flare value after DMEK (group II) was 9.6 (±4.2) ph/ms and was higher in eyes associated with allograft rejection (n = 6) versus those without rejection [16.7 (±7.8) ph/ms vs. 9.3 (±3.8) ph/ms, respectively, P < 0.001]. All eyes associated with rejection had flare values above 10 ph/ms. CONCLUSIONS Aqueous flare after DMEK quickly decreased within the first postoperative month, indicating fast recovery of the blood-aqueous barrier. Long-term flare levels were higher in eyes associated with rejection, suggesting persistent subclinical inflammation. A flare level above 10 ph/ms may be used as a threshold for identifying eyes associated with or at risk of allograft rejection after DMEK.

PURPOSE To evaluate endothelial cell density (ECD) in the first 6 months after Descemet membrane endothelial keratoplasty (DMEK) by eliminating method error as a confounding variable. METHODS From 24 DMEK eyes operated for Fuchs endothelial corneal dystrophy, from which specular microscopy images could be taken at 1 day and 6 months postoperatively, ECD values were compared between these 2 time points. RESULTS Using the 1-day ECD measurement as baseline, mean ECD decreased from 1913 (±326) cells/mm to 1524 (±393) cells/mm at 6 months, a decline of -18 (±19)%. With the 1-week ECD as baseline [1658 (±395) cells/mm], the decline at 6 months was -6 (±19)% and when using preoperative ECD as baseline [2521 (±122) cells/mm], the decline was -39 (±16)% at 6 months. CONCLUSIONS After DMEK, ECD shows an in vivo decline of 18% from 1 day to 6 months postoperatively, with a sharp 13% drop in the first week, and a slower decrease thereafter. The remaining difference of 20% from preoperative ECD values may be attributed to a measurement error in the eye bank with an overestimation of the graft's viable endothelial cell population and/or intraoperative trauma to the graft.

Fuchs endothelial corneal dystrophy is a common disorder characterized by the progressive thickening of Descemet membrane (DM), manifesting as guttae and leading to a decrease in endothelial cells and corneal clearance. Numerous studies have tried to better characterize the genetics of Fuchs endothelial corneal dystrophy, and suggest that it is a complex heterogenic disorder with an array of variants in severity and disease progression. Currently the most effective treatment for replacing diseased endothelium is endothelial keratoplasty (EK). In the last decade, EK has evolved into selective transplantation of an isolated DM and its endothelium, referred to as Descemet membrane endothelial keratoplasty (DMEK), which enables near normal anatomical and visual outcomes after surgery. Unexpected observations after DMEK, however, may bring new insights on endothelial cell wound healing, potentially allowing novel ‘non-keratoplasty’ surgical approaches like Descemet membrane endothelial transfer, endothelial ce...

Phake Patienten mit gleichzeitiger Fuchs Endotheldystrophie (FED) stellen eine Herausforderung hinsichtlich der Entscheidung uber Zeitpunkt und Reihenfolge einer Descemet Membran Endothelkeratoplastik (DMEK) und/oder Katarakt-Operation dar. Klinischer Erfahrungsbericht basierend auf mehr als 500 konsekutiven DMEK-Operationen, die in unserer Klinik durchgefuhrt wurden. Patienten mit signifikanter Katarakt profitieren primar von einer Katarakt-Operation im ersten Schritt und bei unzureichender Visusverbesserung infolge einer signifikanten Hornhautdekompensation von einer DMEK im zweiten Schritt. Bei Patienten mit inzipienter Katarakt ist eine Identifikation der Hauptursache der Sehverschlechterung (Hornhaut oder Linse) unter Berucksichtigung der subjektiven Beschwerden und der objektiven Diagnostik hilfreich. Auf der anderen Seite profitieren insbesondere junge emmetrope Patienten mit signifikanter FED aber noch relativ klarer Linse von einer alleinigen DMEK, wobei das Risiko postoperativ eine signifikante Katarakt zu entwickeln, relativ gering ist. Bei phaken Patienten ist, abhangig vom Ausmasβ der Linsentrubung und der gleichzeitigen endothelialen Hornhautdystrophie individuell zu entscheiden, ob und in welcher Reihenfolge eine Katarakt-Operation und/oder DMEK zur signifikanten und zufriedenstellenden Visusbesserung am wahrscheinlichsten beitragen wird.

Purpose To describe the clinical outcome and complications of repeat Descemet membrane endothelial keratoplasty (re-DMEK). Design Retrospective case series study at a tertiary referral center. Participants From a series of 550 consecutive DMEK surgeries with ≥6 months follow-up, 17 eyes underwent re-DMEK for graft detachment after initial DMEK (n = 14) and/or endothelial graft failure (n = 3). The outcomes were compared with an age-matched control group of uncomplicated primary DMEK surgeries. Methods The re-DMEK eyes were evaluated for best-corrected visual acuity (BCVA), densitometry, endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications. Main Outcome Measures Feasibility and clinical outcome of re-DMEK. Results In all eyes, re-DMEK was uneventful. At 12 months, 12 of 14 eyes (86%) achieved a BCVA of ≥20/40 (≥0.5); 8 of 14 eyes (57%) achieved ≥20/25 (≥0.8), 3 of 14 eyes (21%) achieved ≥20/20 (≥1.0), and 1 eye (7%) achieved 20/17 (1.2); 5 eyes were fitted with a contact lens. Average donor ECD decreased from 2580±173 cells/mm 2 before to 1390±466 cells/mm 2 at 6 months after surgery, and pachymetry from 703±126 μm to 515±39 μm, respectively. No difference in densitometry could be detected between re-DMEK and control eyes ( P = 0.99). Complications after re-DMEK included primary graft failure (n = 1), secondary graft failure (n = 2), graft detachment requiring rebubbling (n = 1), secondary glaucoma (n = 2), cataract (n = 1), and corneal ulcer (n = 1). One eye received tertiary DMEK. Conclusions In the management of persistent graft detachment and graft failure after primary DMEK, re-DMEK proved a feasible procedure. Acceptable BCVA may be achieved, albeit lower than after DMEK in virgin eyes, and some cases may benefit from contact lens fitting. Complications after re-DMEK may be better anticipated than after primary DMEK because graft detachment and graft failure tended to recur, suggesting that intrinsic properties of the host eye play a role in graft adherence and graft failure.

To report the 6-month clinical outcomes of a large cohort of Descemet membrane endothelial keratoplasty (DMEK) eyes operated by 55 starting or experienced surgeons.This is a retrospective, multicenter, interventional, cohort study with a total of 2485 eyes. Best-corrected visual acuity (BCVA), endothelial cell density (ECD) decrease, and intra- and post-operative complications were evaluated. Three groups based on case order were compared: group I (cases 1-24), group II (cases 25-99), and group III (cases ≥100). Forty-nine percent of the surgeons were in their learning curve (25 cases), representing 10.4% of the surgeries.Six months after DMEK, BCVA improved in 90.5% of eyes, remained unchanged in 4.6%, and deteriorated in 4.9% (n = 1936); 75.4% of eyes reached a BCVA of ≥20/40 (≥0.5), 45.4% ≥20/25 (≥0.8), and 25.8% ≥20/20 (≥1.0) (n = 1959) and ECD decreased by 40% (±19) (n = 1272, P0.05). BCVA and ECD outcomes did not differ between groups I and III (P0.05). Intraoperative complications were reported for 9.4% of eyes, whereas graft detachment was the main postoperative complication (27.4%), with lower intra- and post-operative complication rates in group III than group I (P0.05). Rebubbling was performed in 20.1% of eyes; 13.8% required secondary keratoplasty within 6 months.DMEK is applicable for surgeons in various settings with good clinical outcomes. After an arbitrary learning curve (25 cases), virtually all transplant-related complications declined with experience. Notably, surgeons with a higher annual caseload may pass faster through their learning curve than surgeons performing their first surgeries over an extended period.

Background/aimTo assess the clinical outcome of the first series of Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK), a potential hybrid technique between ‘descemetorhexis only’ and conventional, circular DMEK.MethodsProspective interventional case series at a tertiary referral centre. Twelve eyes of 12 patients with central Fuchs endothelial corneal dystrophy underwent Quarter-DMEK, that is, transplantation of one quadrant of a full-diameter DMEK graft, and were evaluated for best-corrected visual acuity (BCVA), endothelial cell density (ECD) and complications up to 6 months postoperatively.ResultsAt 6 months postoperatively, all eyes reached a BCVA of ≥20/40 (≥0.5), 11/12 (92%) of ≥20/25 (≥0.8) and 6/12 (50%) of ≥20/20 (≥1.0). Mean central ECD decreased from 2867 (±161) cells/mm2before to 1255 (±514) cells/mm2at 1 month, 1058 (±455) cells/mm2at 3 months and 968 (±427) cells/mm2at 6 months after surgery. Rebubbling was performed in 4/12 eyes (33%) within the first two months.ConclusionsQuarter-DMEK may be a feasible procedure that allows for visual outcomes similar to conventional, circular DMEK. The relatively large drop in ECD within the first month may have resulted from more extensive endothelial cell migration and/or measurement error (at the graft edges). If longer-term outcomes would resemble those of conventional DMEK, Quarter-DMEK may potentially quadruple the availability of endothelial grafts.

Purpose To evaluate the clinical significance of dark spots in the donor endothelial cell layer as observed with specular microscopy, in patients who underwent Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy (FED). Methods Specular microscopy images of 83 consecutive eyes up to 7 years after DMEK were retrospectively reviewed in a masked fashion for the presence of dark spots and morphologic changes in the endothelial cell layer and processed for endothelial cell density (ECD) measurements. Results A normal endothelial cell layer was found in 52/83 eyes (62.7%) (group 0). In the remaining 31/83 eyes, various dark discolorations with or without altered endothelial cell morphology were categorized into 4 groups. Dark spots were classified as artifacts in 10/83 (12.0%) eyes (group I) and as "superimposed" dots in 10/83 (12.0%) eyes (group II), that is, optical irregularities slightly anterior to a healthy endothelial cell layer. In 11/83 (13.3%) eyes, endothelial stress was characterized by dark grayish discolorations and/or nuclear activation (group III). Most of the latter eyes also had a significant ECD decrease; 3 of these eyes later developed secondary graft failure, of which one was preceded by allograft rejection. None of the eyes showed recurrent guttae typical for FED (group IV). Conclusions Dark endothelial spots after DMEK for FED may not represent a recurrent disease, but tissue irregularities just anterior to the graft. However, if associated with changes in endothelial cell morphology, nuclear activation and/or ECD decrease, dark discolorations may reflect "cellular stress" heralding secondary graft failure or (subclinical) allograft rejection.

To evaluate changes in maximum keratometry (Kmax), corneal higher-order aberrations (HOAs), and densitometry (backscattered light) up to 1 year after UV cross-linking and their possible relation with changes in the visual outcome.Retrospective cohort study on 18 eyes of 16 patients, who underwent UV cross-linking after the Dresden protocol for progressive keratoconus or ectasia after laser-assisted in situ keratomileusis. Corrected distance visual acuity (CDVA), Scheimpflug-based corneal tomography, mean image brightness (corneal densitometry) from the anterior 120 μm of the midcornea, and posterior 60 μm of the central 6 mm of the cornea, and HOAs were evaluated.Kmax at 1 month (59.7 ± 6.0D) after UV cross-linking resembled preoperative Kmax (59.3 ± 6.4D, P = 0.368), decreased until 3 months postoperatively (58.3 ± 6.3D, P = 0.002), and stabilized thereafter (P0.227). All postoperative corneal densitometry values were higher than preoperative values in all measured depths (P0.05). One-month anterior and total corneal HOAs (4.28 ± 1.64 μm and 3.87 ± 1.62 μm, respectively) resembled preoperative values (4.10 ± 1.70 μm and 3.67 ± 1.62 μm, respectively; P0.221) and then decreased until 12 months postoperatively (3.86 ± 1.84 μm and 3.40 ± 1.80 μm, respectively; P0.005). Thinnest point thickness decreased from before (442 ± 25 μm) to 3 months postoperatively (427 ± 25 μm, P0.001), with no difference at 12 months postoperatively compared with preoperative values (437 ± 29 μm, P = 0.149). CDVA and endothelial cell density remained unchanged (P0.345 and P0.257, respectively). No relations were found between CDVA and the evaluated parameters (P0.05).One year after UV cross-linking, the observation of stable CDVA and thinnest point thickness, together with reduced Kmax suggests no ectasia progression within the study period in these cases. Although HOAs showed a trend toward improvement, corneal densitometry remained elevated.

To describe Descemet membrane endothelial keratoplasty (DMEK) complications and strategies for their prevention and management.Five hundred consecutive eyes with DMEK of 393 patients were reviewed in this retrospective study for intraoperative and postoperative complications up to 2 years and for corresponding management.Intraoperative challenges (difficult graft unfolding/positioning, high vitreous pressure, iris root hemorrhage, and Descemet membrane remnants) were encountered in 81 eyes (16.2%). Visually significant graft detachment was the main postoperative complication (34 eyes, 6.8%). Graft failure occurred in 8 eyes (1.6%). Other postoperative complications were an increase of intraocular pressure/decompensated glaucoma in 48 eyes (9.6%), significant cataract in 11 of 124 phakic eyes (8.9%), allograft rejection in 7 eyes (1.4%), cystoid macular edema in 5 eyes (1.0%), microbial keratitis in 2 eyes (0.4%), and retinal detachment in 1 eye (0.2%). Different strategies for prevention and management of these complications have been identified.DMEK shows acceptable rates of complications up to 2 years after surgery, which can be managed successfully. Anticipation of potential challenges and difficulties may aid in modifying intraoperative strategies for predisposed eyes. This knowledge may further minimize complications, in particular, when performing DMEK for an extended spectrum of corneal endothelial disorders.

Purpose To assess the clinical outcome after successful rebubbling procedures for visually significant graft detachment after Descemet membrane endothelial keratoplasty (DMEK). Methods From a total of 760 consecutive DMEK surgeries, 41 eyes required rebubbling. Of those, 33 eyes of 31 patients were successful and were included in our retrospective outcome analysis study. Main outcome measures were compared with those of matched controls with uneventful primary DMEK (attached DMEK grafts without rebubbling). Rebubbling was performed on average 25 (±20) days (range 7-91 days) after DMEK. All eyes were evaluated for best-corrected visual acuity, endothelial cell density (ECD), pachymetry, and complications up to 6 months after rebubbling. Results At 6 months after DMEK, best-corrected visual acuity in rebubbled eyes did not differ from that in control eyes (P = 0.514). The mean ECD decrease was higher in rebubbled than in control eyes (54% vs. 35%, respectively, P = 0.001). Pachymetry did not differ between both groups (P = 0.153). After rebubbling, one buphthalmic eye showed temporary intraocular pressure elevation and 5 eyes had minor graft edge detachment that did not require further treatment. Conclusions Rebubbling for DMEK graft detachment may result in similar visual outcomes as in uncomplicated DMEK, when performed within the first 6 to 8 postoperative weeks. However, rebubbled eyes may have lower ECD, which may be attributed to additional air bubble trauma and/or selection bias through more extensive manipulation during initial DMEK or higher risk of graft detachment in more complicated eyes.

To monitor refractive changes after Descemet membrane endothelial keratoplasty (DMEK) and to determine what may influence these changes and the time point of stabilization.From 67 pseudophakic DMEK eyes operated on for Fuchs endothelial dystrophy at a tertiary referral center, biomicroscopy, visual acuity, subjective refraction, and Scheimpflug-based corneal tomography data were obtained before and up to 2 years postoperatively. Visual acuity and changes in spherical equivalent (SE), mean anterior and posterior simulated keratometry (Km), and central pachymetry were analyzed.At 3 months postoperatively, both hyperopic (28/67 eyes) and myopic (21/67 eyes) shifts were observed; 18/67 eyes showed no SE change. The mean change in SE at 3 months was +0.33 diopters (D) (95% confidence interval = [0.11, 0.54], P = 0.028), which stabilized thereafter (P0.466). Initial flattening of mean anterior Km by 0.66D (95% confidence interval = [-0.81, -0.51], P0.001) at 3 months was followed by a slow steepening, which became significant between 1 and 2 years postoperatively (P0.001). Posterior Km stabilized after 3 months (P0.252). Preoperative to 3 months postoperative absolute changes in anterior Km were positively related to preoperative backscattered light from the central anterior cornea (P = 0.035), and the presence of partial graft detachment postoperatively (P = 0.013).After DMEK, SE and posterior corneal curvature were on average stable at 3 months after surgery, whereas the mean anterior corneal curvature showed an ongoing gradual change. Changes in anterior corneal curvature may be related to preoperative anterior corneal densitometry or postoperative partial graft detachment.

Background/aims To evaluate the clinical outcome of a full-diameter, untrephined, semicircular Descemet graft in a consecutive series of Descemet membrane endothelial keratoplasty (hemi-DMEK), potentially allowing the harvesting of two grafts from a single donor corneoscleral rim. Methods Interventional case series of 10 eyes of 10 patients with Fuchs endothelial dystrophy. Best corrected visual acuity (BCVA), endothelial cell density (ECD) and central corneal thickness (CCT) were evaluated up to 6 months postoperatively, and intraoperative and postoperative complications were recorded. Results Hemi-DMEK was successful in 9 out of 10 eyes; one eye showed persistent graft detachment despite rebubbling and underwent a secondary DMEK. BCVA improved in all successful hemi-DMEK eyes: at 6 months 100% of eyes (n=7) reached ≥20/40 (≥0.5), 86% (n=6) ≥20/25 (≥0.8), 29% (n=2) ≥20/20 (≥1.0) and 14% (n=1) reached 20/17 (≥1.2). Two eyes were excluded from visual analysis due to low visual potential. Preoperative donor ECD declined from 2744 (±181) cells/mm 2 to 940 (±380) cells/mm 2 centrally at 6 months postoperatively (n=9), with (donor and/or host) endothelial cell redistribution over bare stromal areas adjacent to the graft. Average CCT decreased from 745 (±153) µm preoperatively to 520 (±37) µm at 6 months. Four eyes required rebubbling for visually significant graft detachment. No other complications occurred throughout the study period. Conclusions Hemi-DMEK may give visual outcomes similar to those in conventional DMEK. If ECD decrease and graft detachment rate would prove acceptable in larger series, hemi-DMEK could have the potential to double the availability of donor tissue for endothelial keratoplasty.