Systematic Review and Meta-analysis: Outcomes After Descemet Membrane Endothelial Keratoplasty Versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty

doi:10.1016/j.ajo.2022.09.013

American Journal of Ophthalmology

Volume 245, January 2023, Pages 222-232

https://doi.org/10.1016/j.ajo.2022.09.013 Get rights and content

Purpose

To compare the efficacy and safety of ultrathin Descemet stripping (automated) endothelial keratoplasty (UT-DS(A)EK) versus Descemet membrane endothelial keratoplasty (DMEK) for the treatment of Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK).

Design

Systematic review and meta-analysis.

Methods

Literature containing DMEK and UT-DSAEK were searched in the Cochrane Database of Systematic Reviews, PubMed, EMBASE, LILACS, and through manual reference searching. Studies were included that measured the outcome of interventions—including best corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications, especially graft detachment with the need of re-bubbling, graft rejection, graft failure, and postoperative elevated intraocular pressure (IOP)—in patients with FED and BK. Included outcomes were pooled as standardized mean differences (SMD) or risk ratios (RR) using random effects models. Inter-study heterogeneity was assessed using the Q-test and I² statistic.

Results

Seven (of 163) studies met all the inclusion and exclusion criteria. Meta-analysis showed a significantly better BCVA 12 months postoperatively, but an increased re-bubbling rate in eyes after DMEK compared with eyes after UT-DS(A)EK (BCVA: SMD = 0.50 [95% CI 0.27-0.74] and re-bubbling rate: RR = 0.33 [95% CI 0.16-0.67]). All other parameters did not differ significantly between both interventions, although estimates were imprecise (graft failure: RR = 0.65 [95% CI 0.18-2.30], graft rejection: RR = 1.40 [95% CI 0.27-7.30], and postoperative intraocular pressure elevation: RR = 1.14 [95% CI 0.60-2.18]). Postoperative SMDs of ECD could not be evaluated due to significant heterogeneity between studies.

Conclusions

Although the improvement in BCVA was higher after UT-DS(A)EK than after conventional DS(A)EK, the BCVA after DMEK was still superior. The complication rates were comparable for both procedures, except for the higher rate of re-bubbling after DMEK.

Section snippets

INTRODUCTION

Diseases of the corneal endothelium, especially Fuchs endothel dystrophy (FED) and bullous keratopathy (BK), affect people all over the world and often cause visual problems up to vision loss and/or pain. The main surgical interventions for these diseases are the posterior lamellar surgical techniques, Descemet stripping (automated) endothelial keratoplasty (DS(A)EK), and Descemet membrane endothelial keratoplasty (DMEK). In contrast to the DS(A)EK technique—where the diseased endothelium and

SELECTION CRITERIA

This study included any study: (i) comparing DMEK and UT-DS(A)EK in patients with FED and BK, with respect to best corrected visual acuity (BCVA in logMAR), endothelial cell density (ECD), and postoperative complications, especially graft detachment with the need of re-bubbling, graft rejection, graft failure, and postoperative intraocular pressure (IOP) elevation; (ii) with a minimum follow-up time after intervention of 6 months; and (iii) with the study protocol and outcome of the

SEARCH RESULTS

The literature search identified a total of 163 potentially eligible publications (Figure 1). Of these, 11 met the inclusion criteria after screening of title and abstracts, and were subjected to a full-text review. The following four studies were excluded after quality assessment:28, 29, 30, 31 the study by Machalinska and associates reported statistically significant baseline differences between the two treatment groups, which affected the interpretability of the postoperative visual acuity.²⁸

DISCUSSION

In this comprehensive, systematic review comparing the postoperative results between UT-DS(A)EK and DMEK, evidence was provided that DMEK provides superior postoperative BCVA than UT-DS(A)EK. Except for a higher re-bubbling rate after DMEK, the postoperative risks between both procedures did not differ.

Although several studies have shown that a thinner graft can improve BCVA after DS(A)EK and that UT-DS(A)EK results in a better postoperative visual acuity than conventional DS(A)EK,20, 21, 22, 23

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Cost Drivers of Endothelial Keratoplasty: A Time-Driven Activity-Based Costing Analysis
2023, Ophthalmology
To determine cost drivers of endothelial keratoplasty (EK) through evaluation of surgical costs and procedure length based on type of EK, use of preloaded grafts, and performance of simultaneous cataract surgery.
This study was an economic analysis of EKs at a single academic institution using time-driven activity-based costing (TDABC) methodology.
Endothelial keratoplasty surgical cases, including Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK), at the University of Michigan Kellogg Eye Center from 2016 to 2018 were included in the analysis.
Data and inputs were obtained via the electronic health record (EHR) and from prior literature. Simultaneous cataract surgeries were included and separately categorized for analysis. Endothelial keratoplasty expenses were determined with TDABC, a method for cost calculation that incorporates the time that key resources are used and each resource’s associated cost rate.
Main outcome measures included surgery length (in minutes) and day-of-surgery costs.
There were 559 EKs included: 355 DMEKs and 204 DSAEKs. Fewer DSAEKs had simultaneous cataract extraction (47; 23%) than DMEK (169; 48%). Of the DMEKs, 196 (55%) used preloaded corneal grafts. Descemet membrane endothelial keratoplasty cost $392.31 less (95% confidence interval, $251.05–$533.57; P < 0.0001) than DSAEK and required 16.94 fewer minutes (14.16–19.73; P < 0.0001). Descemet membrane endothelial keratoplasty cases that used preloaded corneal grafts cost $460.19 less ($316.23–$604.14; P < 0.0001) and were 14.16 minutes shorter (11.39–16.93; P < 0.0001). In multivariate regression, preloaded graft use saved $457.19, DMEK (compared with DSAEK) saved $349.97, and simultaneous cataract surgery added $855.17 in day-of-surgery costs.
Cost analysis of TDABC identified a day-of-surgery cost and surgical time reduction associated with the use of preloaded grafts for DMEK, DMEK compared with DSAEK, and isolated EK compared with EK combined with cataract surgery. This study provides an improved understanding of surgical cost drivers and margin incentivization, which may explain trends and indirectly influence patient care decisions in cornea surgery practices.
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Comment on: Systematic Review and Meta-Analysis: Outcomes After Descemet Membrane Endothelial Keratoplasty Versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty
2023, American Journal of Ophthalmology
Reply to comment on: Systematic Review and Meta-Analysis: Outcomes After Descemet Membrane Endothelial Keratoplasty Versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty
2023, American Journal of Ophthalmology
Successful restoration of corneal surface integrity with a tissue-engineered allogeneic implant in severe keratitis patients
2023, Biomedicine and Pharmacotherapy
Corneal diseases are among the main causes of blindness, with approximately 4.6 and 23 million patients worldwide suffering from bilateral and unilateral corneal blindness, respectively. The standard treatment for severe corneal diseases is corneal transplantation. However, relevant disadvantages, particularly in high-risk conditions, have focused the attention on the search for alternatives.
We report interim findings of a phase I-II clinical study evaluating the safety and preliminary efficacy of a tissue-engineered corneal substitute composed of a nanostructured fibrin-agarose biocompatible scaffold combined with allogeneic corneal epithelial and stromal cells (NANOULCOR). 5 subjects (5 eyes) suffering from trophic corneal ulcers refractory to conventional treatments, who combined stromal degradation or fibrosis and limbal stem cell deficiency, were included and treated with this allogeneic anterior corneal substitute.
The implant completely covered the corneal surface, and ocular surface inflammation decreased following surgery. Only four adverse reactions were registered, and none of them were severe. No detachment, ulcer relapse nor surgical re-interventions were registered after 2 years of follow-up. No signs of graft rejection, local infection or corneal neovascularization were observed either. Efficacy was measured as a significant postoperative improvement in terms of the eye complication grading scales. Anterior segment optical coherence tomography images revealed a more homogeneous and stable ocular surface, with complete scaffold degradation occurring within 3–12 weeks after surgery.
Our findings suggest that the surgical application of this allogeneic anterior human corneal substitute is feasible and safe, showing partial efficacy in the restoration of the corneal surface.
Effects of Autologous Serum and Platelet-Rich Plasma on Human Corneal Endothelial Cell Regeneration: A Comparative Study
2024, Eye and Contact Lens
Comparison of immunogenic and crystalline endothelial deposits after Descemet membrane endothelial keratoplasty (DMEK)—a report of two cases
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