Long-Term Outcomes of Descemet Membrane Endothelial Keratoplasty: Effect of Surgical Indication and Disease Severity

Abstract

The aim of this study was to evaluate clinical outcomes and graft survival in a large patient cohort up to 10 years after Descemet membrane endothelial keratoplasty (DMEK) based on surgical indication and Fuchs endothelial corneal dystrophy (FECD) severity. Methods:The cohort in this retrospective study included 750 eyes that underwent DMEK for FECD (86%), bullous keratopathy (BK, 9%), and other indications (5%). Based on the modified Krachmer grading, 186 eyes (29%) had moderate FECD (Krachmer grade 3-4) and 440 eyes (68%) had advanced FECD (Krachmer grade 5-6). Main outcome measures were best-corrected visual acuity (BCVA), central corneal thickness, endothelial cell density (ECD), endothelial cell loss (ECL), postoperative complication rate, and graft survival. Results:The mean 10-year BCVA was 0.08 6 0.28 logMAR (n = 96), and the BCVA remained stable between 5 and 10 years postoperatively (all P . 0.05). The mean ECL at 5 and 10 years was 56% 6 17% (n = 460) and 66% 6 14% (n = 96), respectively (P , 0.05). The 10-year graft survival rate for the total cohort was 0.85 (95% confidence interval, 0.82-0.89). BCVA and ECD differed at 1 to 5 years between eyes with different surgical indications (all P , 0.05), and FECD eyes had higher graft survival compared with BK eyes (0.90 vs. 0.60, P = 0.001). Moderate FECD eyes had better BCVA, ECD, and graft survival outcomes than advanced FECD eyes (all P , 0.05). Minor graft detachment (P = 0.04) and lower donor ECD (P = 0.01) were related to lower 10-year ECD.Conclusions: Long-term outcomes and graft survival after DMEK were better in FECD eyes than BK eyes and were also related to FECD disease severity. Eyes operated for moderate FECD showed the highest graft survival probability and excellent longterm outcomes.

Corneal Guttae After Descemet Membrane Endothelial Keratoplasty

“…23,24 For best-corrected visual acuity, 10 of 11 eyes without graft failure had a bestcorrected visual acuity of 0.9 (decimal) or better at the last available follow-up which is comparable to DMEK outcomes reported earlier. 22,25,26 In conclusion, corneal guttae can occur after DMEK including in eyes operated for indications other than FECD. The postoperative occurrence of guttae is most likely due to guttae on the donor graft that were not detectable by routine slit-lamp and light microscopy evaluation in the eye bank.…”

“…14 In our case series, 2 of 13 grafts (15%) failed, but because this is a small case series, this might not be representative for the actual graft survival probability in the presence of guttae, which might be comparable to the graft survival probability observed in a large DMEK cohort (90% at the 5-year follow-up and 85% at the 10-year follow-up). 22 Corneal guttae are known to affect endothelial cells, 3 but the effect of the observed corneal guttae on postoperative ECD is difficult to quantify because endothelial cell counts on specular microscopy images in the presence of corneal guttae do not tend to be reliable due to a high degree of variability in cell density. 23,24 For best-corrected visual acuity, 10 of 11 eyes without graft failure had a bestcorrected visual acuity of 0.9 (decimal) or better at the last available follow-up which is comparable to DMEK outcomes reported earlier.…”

“…14 In our case series, 2 of 13 grafts (15%) failed, but because this is a small case series, this might not be representative for the actual graft survival probability in the presence of guttae, which might be comparable to the graft survival probability observed in a large DMEK cohort (90% at the 5-year follow-up and 85% at the 10-year follow-up). 22…”

“…23,24 For best-corrected visual acuity, 10 of 11 eyes without graft failure had a best-corrected visual acuity of 0.9 (decimal) or better at the last available follow-up which is comparable to DMEK outcomes reported earlier. 22,25,26…”

Innate Immune Cytokine Levels in Eyes With Late Endothelial Keratoplasty Failure

“…3 Nevertheless, corneal endothelial cell loss occurs faster after any type of keratoplasty, including DMEK, than after routine cataract surgery, and endothelial decompensation is the main cause of longterm DMEK and DSEK failure. 4,5 The aqueous humor (AqH) microenvironment is known to affect corneal graft survival. Certain soluble factors contribute to immune-privileged status, whereas high AqH levels of cytokines associated with increased adaptive T-cellmediated immunity, such as interferon gamma (IFNΥ) and interleukin (IL)-17A, are associated with accelerated endothelial cell loss after keratoplasty.…”