gms | German Medical Science

Purpose: To evaluate the clinical outcome of the first 500 consecutive cases after Descemet membrane endothelial keratoplasty (DMEK), as well as the effect of technique standardization, and broadening the scope of indications for DMEK.

Setting/venue: Netherlands Institute for Innovative Ocular Surgery / Tertiary referral center.

Design: Retrospective study of prospectively collected data.

Methods: In five hundred eyes of 393 patients who underwent DMEK for Fuchs endothelial dystrophy, bullous keratopathy or previous corneal transplant failure best corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry and intra- and postoperative complications were evaluated before, and 1, 3 and 6 months after DMEK. The eyes were divided into three groups (Group I: cases 1–125, as the extended learning curve; Group II: cases 126–250, transition to technique standardization; Group III: cases 251–500, surgery with standardized technique) and outcome was compared between these groups.

Results: At six months, 80% of eyes reached a BCVA of ≥20/25 (≥0.8), 44% =20/20 (≥1.0) and 14% =20/18 (≥1.2) (n=394). Mean ECD was 1600 (±490) cells/mm² (n=447), i.e. a decrease of 37 (±18) % compared to preoperative values (P<0.001). Postoperative pachymetry averaged 525 (±46) µm as compared to 667 (±92) µm preoperatively (P<0.001). None of these parameters differed among the three groups (P>0.05). (Partial) graft detachment presented in 79 eyes (15.8%) and 26 eyes (5.2%) required a secondary surgery within the first six months (15 re-bubbling, 3 re-DMEK, 7 secondary DSEK, 1 secondary PKP). With technique standardization, the (partial) detachment rate declined from 24% to 10% and the rate of secondary surgeries from 9.6% to 3.6%.

Conclusions: In comparison to earlier endothelial keratoplasty techniques, DMEK may consistently give higher visual outcomes and faster rehabilitation. When used for the extended spectrum of endothelial pathologies, DMEK proved feasible with a relatively low risk of complications. Technique standardization may have contributed to a lower graft detachment rate and a relatively low number of secondary interventions required. As such, DMEK may become the first choice of treatment in corneal endothelial disease.