Descemet Membrane Endothelial Keratoplasty: Challenges and Lessons Learned After First 10 Cases
Narrative Responses:
Purpose
Descemet's membrane endothelial keratoplasty (DMEK) is a relatively new technique in endothelial keratoplasty. Corneal surgeons have been hesitant to adopt this technique owing to its reported technical difficulty. Our purpose is to report on our experiences with our initial ten cases of DMEK, including lessons learned and technique modifications.
Methods
Ten initial and consecutive DMEK cases were included. All patients had a preoperative diagnosis of Fuchs’ endothelial dystrophy or pseudophakic bullous keratopathy. Preoperative, intraoperative, and postoperative management experiences are discussed in detail. We further report on how we have modified our technique based on these lessons learned.
Results
Preoperative challenges include patient selection, which entails gauging the extent of host corneal edema, assessing iridectomies, iris defects, and glaucoma valve implants to minimize the chance of tissue loss, and selecting donor tissue of the appropriate age. Intraoperative challenges include selecting the appropriate donor preparation technique, assessing the amount of Descemet's stripping needed to achieve good graft adherence, managing air in vitrectomized and filtered eyes, and facilitating the unrolling of the DMEK scroll. Postoperative challenges and lessons learned include re-bubbling detached tissue, using anterior segment OCT to guide decision-making, and managing graft failure.
Conclusion
The available literature shows that DMEK is a superior surgical alternative to DSAEK with faster visual recovery, comparable endothelial cell loss, and lower rates of graft rejection. This report of our early experience may facilitate the learning curve of adopting this technique in endothelial keratoplasty.