Objectives: To analyze the outcomes and complications of Descemet‘s membrane endothelial keratoplasty (DMEK) performed without prophylactic peripheral iridotomy (PI). Methods: Design: Retrospective study. Setting: Institutional, tertiary care eye hospital. Study Population: All patients who underwent DMEK or DMEK combined with phacoemulsification (DMEK triple) for Fuchs endothelial dystrophy, using a standardized protocol between August 2016 and July 2021, were included. Previous glaucoma surgery, laser PI, aphakia, or complicated pseudophakia were excluded. Main outcome measures: Primary outcomes: Incidence of pupillary block (PB). Secondary outcomes: Graft detachment (GD), rebubbling rates, uncorrected (UCDVA) and best corrected logMAR distance visual acuity (BCDVA), and endothelial cell loss (ECL) at six months. Data were analyzed using the chi-square test and stepwise backward regression analysis. Results: 104 eyes of 72 patients were included. Four eyes (3.8%) developed PB; in two of these cases, standard protocol was not followed. Overall minor GD occurred in 43.2% (n = 45); significant GD was present only in 7 eyes (6.6%). Overall slit lamp rebubbling rate was 30% (n = 35), though only four patients were rebubbled in theatre (3.8%). PB, GD, and rebubbling rates did not vary with the surgeon, surgery, or tamponade (air or SF6 gas). UCDVA, BCDVA, and ECL at 6 months were 0.29 ± 0.31, 0.20 ± 0.28, and 40.46 ± 20.36%, respectively. Conclusions: Compared to previously reported outcomes of DMEK with PI, our results of PI less DMEK using a standardized protocol have a similar incidence of pupillary block, graft detachment, and rebubbling, with comparable visual acuity and endothelial cell loss.

BACKGROUND: Morbidity and Mortality meetings (M&Ms) are a fundamental element of surgical practice. However, there has been little investigation into best practices, to maximise education and improvement outcomes. OBJECTIVE: Create a new, evidence-based M&M methodology, that facilitates standardised analysis of errors in a non-judgemental fashion, and highlights areas for improvement. METHODS: A Quality Improvement (QI) methodology was used. This project encompassed a literature review and two sequential QI cycles. A literature review and initial survey highlighted best practice and identified areas for improvement. From this information, a new standardised format was created, which centred around a new modified Fishbone framework, incorporating the London Protocol methodology. The project then sequentially tested new formats, with feedback collected for every new format. RESULTS: The literature review and surveys guided improvement of the M&M. The need for standardisation was highlighted. The new PowerPoint template and modified Fishbone ensured presentations and analysis were consistent and systematic. Participants reported that M&Ms were more engaging, interactive and structured, ensuring improved discussion of errors. The modified Fishbone framework reinforced a blame-free, system-focused analysis. CONCLUSION: M&Ms are a critical aspect of patient safety. This project utilised simple QI tools to encourage collaborative reflection, learning and improvement.

Objectives To analyze the outcomes and complications of Descemet's Membrane Endothelial Keratoplasty (DMEK) performed without prophylactic peripheral iridotomy (PI). Methods Design: Retrospective study. Setting: institutional, tertiary care eye hospital Study Population: All patients who underwent DMEK or DMEK combined with phacoemulsification (DMEK triple) for Fuch's Endothelial Dystrophy, using a standardized protocol between Aug 2016 to July 2021, were included. Previous glaucoma surgery, laser PI, aphakia or complicated pseudophakia were excluded. Main Outcome Measures:Primary outcomes: incidence of the pupillary block (PB). Secondary outcomes: graft detachment (GD), rebubbling rates, uncorrected (UCDVA) & best corrected LogMAR distance visual acuity (BCDVA) and endothelial cell loss (ECL) at six months. Data were analyzed using the chi-square test and stepwise backward regression analysis. Results 104 eyes of 72 patients were included. Four eyes (3.8%) developed PB. In two of these cases of PB, standard protocol was not followed; in the other two, there was an inadequate release of gas and aqueous on day 1. Significant GD occurred in 7 eyes (6.6%), and rebubbling in theatre was needed in 4 eyes (3.8%). PB, GD and rebubbling rates did not vary with the surgeon, surgery, or tamponade (air or SF6 gas). UCDVA, BCDVA and ECL at 6 months were 0.29±0.31, 0.20±0.28 and 40.46±20.36%, respectively. Conclusions Compared to previously reported outcomes of DMEK with PI, our results of PI less DMEK using a standardized protocol have a similar incidence of pupillary block, graft detachment, and rebubbling, with comparable visual acuity and endothelial cell loss.

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