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Study: Clinical outcomes better for DMEK than ultrathin DSAEK
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Compared with ultrathin Descemet’s stripping automated endothelial keratoplasty, Descemet’s membrane endothelial keratoplasty had faster recovery, superior visual acuity results and similar complication rates in patients with isolated endothelial dysfunction, according to a study.
The randomized, controlled, patient- and outcome-masked clinical trial included 50 eyes of 38 patients with endothelial dysfunction from Fuchs’ endothelial dystrophy or pseudophakic bullous keratopathy enrolled at Casey Eye Institute at Oregon Health & Science University and Byers Eye Institute at Stanford University.
Patients were randomly assigned to either ultrathin DSAEK or DMEK with standardized surgical techniques. Participants were examined at baseline and at day 1 and months 3, 6 and 12 postoperatively.
On average, study eyes in the DMEK group achieved more rapid and better visual acuity improvement at all time points as compared with the ultrathin DSAEK group. Final outcomes were satisfactory with both techniques, but a difference of approximately 1.5 lines in favor of DMEK remained at 12 months. No differences in the number of adverse events were found between the two groups.
Endothelial cell loss, with 215 fewer cells/mm2 at 12 months postoperatively, as well as the re-bubble rate were slightly higher in DMEK, but the difference was not statistically significant.
“A larger multicenter randomized clinical trial may be able to further clarify differences in rates of need for re-bubble, endothelial cell loss, graft rejection and graft survival over time,” the authors wrote.
Despite the good results shown in many studies, “the majority of corneal surgeons have been slow to adopt DMEK,” the authors noted. In 2017, DMEK represented only 26% of endothelial keratoplasties. The steeper learning curve, which may be anywhere between 20 and 75 cases, might still be a factor that prevents surgeons from switching to DMEK.
“DSAEK has excellent outcomes compared with the prior gold standard penetrating keratoplasty and is a reliable and familiar technique. Therefore, many surgeons may not be motivated to adopt a new technique,” the authors wrote. – by Michela Cimberle
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Jack Parker, MD, PhD
One-and-a-half lines on the eye chart. That is the average amount of visual improvement DMEK provides over and above ultrathin DSAEK. That is not an insignificant difference and — thanks to this study’s scrupulously scientific randomization protocol — cannot be attributed to any other variable, aside from the character of the transplanted tissue.
DSAEK is not dead, and there are many types of eyes in which the operation may still be a reasonable option. But for most eyes, DMEK should be the procedure of choice, and certainly, if you were the patient, this is the operation that you would want performed in your own eye.
The next step is to publish head-to-head trials of DMEK vs. DSAEK in complicated eyes, ie, eyes with glaucoma drainage devices, anterior chamber IOLs, aphakia, prior penetrating grafts, etc. Those are the eyes in which people may have the greatest residual tendency to prefer the comfort of a familiar old operation (DSAEK) instead of challenging themselves further with the new (DMEK). Nevertheless, in these sicker eyes, it may well be the case that, here especially, DMEK should be preferred, with its unparalleled ability to restore the natural anatomy of the eye.
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