Purpose: To compare visual outcomes, complications and vision-related quality-of-life (QoL) following micro-thin Descemet stripping automated endothelial keratoplasty (MT-DSAEK) versus Descemet membrane endothelial keratoplasty (DMEK) for the management of corneal endothelial dysfunction in Fuchs dystrophy. Design: Prospective, double-blinded randomized controlled clinical trial Methods: Patients with visually significant endothelial decompensation from Fuchs dystrophy were prospectively randomized to receive MT-DSAEK or DMEK surgery. The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 12 months. Secondary outcomes included refraction, keratometry, endothelial cell count, complications and vision-related QoL at 6 and 12 months postoperatively.Results: A total of 56 eyes of 56 patients were enrolled, 28 in each group. Post-operatively, LogMAR mean BSCVA in the MT-DSAEK group was 0.17±0.08 and 0.11±0.09 at 6 and 12 months compared to 0.09±0.13 and 0.04±0.13 following DMEK (p=0.03, p=0.002 respectively) with the DMEK cohort achieving 3.5logMAR letters better BSCVA at 1 year compared to MT-DSAEK. Complication rates were similar with 3.5% rebubbling rate in both groups, 1 primary graft failure in DMEK and a single endothelial rejection in the MT-DSAEK arm. Vision-related QoL was comparable at 6 and 12 months post-operatively and no eyes demonstrated loss of vision from pre-operative BSCVA.Conclusion: DMEK surgery resulted in significantly better BSCVA at 1, 3, 6 and 12 months post-operatively compared to MT-DSAEK. Patient satisfaction was similar with no differences reported in vision-related QoL scores, as was the complications profile between groups. Thus, our results favor DMEK as the better choice procedure for eyes with Fuchs-related corneal decompensation without ocular comorbidities.

Significant variability in the number of cases performed and the efficiency of patient flow were found between different institutions. Time and motion studies identified requirements for high-volume models and factors relating to performance. Supporting the surgeon with sufficient AHPs and tasks performed by AHPs could improve surgical efficiency up to approximately double productivity over conventional theatre models.

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