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Allograft rejection risk may be reduced with DMEK
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The risk of corneal transplant rejection was reduced among patients who had undergone Descemet’s membrane endothelial keratoplasty compared with those who had undergone Descemet’s stripping endothelial keratoplasty or penetrating keratoplasty, according to a study.
“Patients undergoing DMEK had a significantly reduced risk of experiencing a rejection episode within 2 years after surgery compared with DSEK and PK performed for similar indications using the same corticosteroid regimen,” the researchers said.
The comparative case series evaluated the risk of immunologic rejection episode in patients who had undergone DMEK, DSEK or PK between February 2008 and September 2010 at a tertiary referral center. The patients all had similar demographics, follow-up duration and indications for surgery.
One patient in the DMEK group experienced a rejection episode compared with 54 in the DSEK group and five in the PK group. This resulted in an absolute rejection rate of 0.7% for DMEK, 9% for DSEK and 17% for PK.
Results also showed that patients had a 15 times lesser risk of experiencing a rejection episode after DMEK than after DSEK (P = .008) and 20 times lower risk after DMEK than PK (P = .006).
“This study confirms our hypothesis that DMEK is associated with a significantly reduced risk of graft rejection compared with DSEK and PK,” the researchers said.
Perspective
Back to TopIra J. Udell, MD
The introduction of DSEK has transformed the management of endothelial disease requiring keratoplasty. Anshu and colleagues have reported on the incidence of rejection in a case series of DMEK, DSEK and PK. The take-home message from these data is that the incidence of DMEK rejection was 0.7%, DSEK 9% and PK 17%. The Kaplan-Meier cumulative probability of rejection episodes at 1 and 2 years was 1% and 1% respectively for DMEK; 8% and 12% respectively for DSEK; and 14% and 18% respectively for PK.
The implications of the study are important if they are substantiated by other investigators. The technical hurdles in DMEK have inhibited widespread conversion of DSEK surgeons to DMEK, as pointed out recently in an editorial by Mark Terry, MD, in the journal Cornea (Cornea. 2012;31(5):469-471).
Thirteen corneal surgeons from the Northeast Cornea Society participated in a retrospective review of DSEK rejection data with nearly 2,500 cases evaluated at 2 years postop. These data were submitted for presentation at the last AAO meeting. The overall incidence of rejection was 2% with a range of 1.3% to 9.5%. Importantly, 87% of the rejections were reversed with topical steroid.
Clearly more studies are needed before we can conclude that DMEK has a statistically significant superior rejection rate and lower graft loss rate profile then DSEK.
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