Favourable Technique Bubbles to Surface

Better visual outcomes with DMEK than UT-DSAEK, but more rebubbling with DMEK. Roibeárd O’hÉineacháin reports.

Roibeard O’hEineachain

Posted: Sunday, May 1, 2022

Better visual outcomes with DMEK than UT-DSAEK, but more rebubbling with DMEK. Roibeárd O’hÉineacháin reports.

Descemet membrane endothelial keratoplasty (DMEK) results in superior visual acuity rates with quicker recovery compared to Ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). However, UT-DSAEK has a more favourable complication profile, particularly regarding lower rates of rebubbling, according to a systematic review and meta-analysis presented by Daire Hurley MB, MCh.

“Both are valuable options in [treating] corneal endothelial disease, and choice of procedure may depend on surgical expertise,” Dr Hurley said.

Dr Hurley conducted a comprehensive search on Medline, Embase, and Cochrane Library databases to identify studies reporting comparative results of UT-DSAEK versus DMEK. Of 135 studies reviewed, seven met the inclusion criteria for the meta-analysis, namely, best-corrected visual acuity (BCVA), endothelial cell density (ECD; cells/mm2), central corneal thickness (CCT), and complications.

Altogether, a total of 306 patients were included in the analysis, 161 of whom underwent UT-DSAEK and 147 DMEK. Their average age was 71 years, and 68.9% were female. For 90% of cases, Fuchs’ endothelial dystrophy was the indication for surgery. The baseline visual acuity, endothelial cell density, and central corneal thickness were similar in the two cohorts. The average donor graft thickness in the UT-DSAEK group was 80.7 microns.

The study showed patients who underwent DMEK had significantly better BCVA than those who underwent UT-DSAEK at three months (logMAR 0.13 versus 0.23) postoperatively and one year postoperatively (logMAR 0.10 versus 0.19), roughly a difference of one line of BCVA.

“DMEK resulted in superior visual acuity rates with quicker recovery compared to UT-DSAEK. This is likely due to improved restoration of anatomy in the DMEK procedure because of the use of a thinner graft with no lamellae and the lack of a stromato-stroma graft interface,” Dr Hurley said.

Patients undergoing DMEK also had significantly greater reductions in CCT, with an average reduction at one year of 117.3 μm (18%) compared to a reduction of only 50.4 μm (7.8%) in the UT-DSAEK groups. The one-year postoperative CCT values were also significantly higher in the UT-DSAEK group (592.0 μm versus 524.8 μm).

There were no significant differences between the DMEK and UT-DSAEK groups in terms of postoperative ECD at one year, which were 1,705.3 cells/mm2 and 1,673.8 cells/mm2, respectively. Nor was there any significant difference between the two groups in terms of endothelial cell loss, which were 36.7% and 38.6%, respectively, at one year.

On the other hand, UT-DSAEK resulted in significantly lower total complications (23.2% versus 57.3%, p = 0.0001) and rates of rebubbling (11.0% versus 33.7%). The most common complication was the need for rebubbling, which occurred in 30 patients in the DMEK group compared to only 10 patients in the UT-DSAEK group. Raised IOP was the next most common complication, which occurred in seven eyes in the UT-DSAEK group and eight in the DMEK group. There was one graft failure in each group.

“Previous studies have shown DMEK to have less rejection compared to traditional DSAEK. As UT-DSAEK uses less donor tissue, this may result in rejection rates closer to those of DMEK,” Dr Hurley added.

Dr Hurley presented the study during the ESCRS Virtual Winter Meeting 2022.

Daire Hurley MB, MCh is a Senior House Officer in the Department of Ophthalmology, Mater Misericordiae University Hospital, Dublin, Ireland.

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