Concerns remain about long-term graft survival in DMEK
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Descemet’s membrane endothelial keratoplasty has changed the management of endothelial pathologies. It is now widely adopted and well managed by most surgeons, but concerns remain about long-term graft survival, according to one specialist.
“Fuchs’ patients are now operated on earlier, so we need to know more about long-term results,” Marc Muraine, MD, said at the European Society of Cataract and Refractive Surgeons winter meeting.
Preloaded grafts have led to rapid adoption of DMEK since 2015. Data from the French Eye Bank in Paris show that its relative percentage within all graft procedures went up from 15% to 60%. While the number of corneal transplant surgeries for keratoconus or keratitis has remained unchanged, DMEK for Fuchs’ dystrophy increased from 60 procedures in 2010 to 150 in 2015 and 550 in 2020.
“Since the incidence of the pathology has not increased, the main explanation is that patients are transplanted more easily and earlier in the evolution of the pathology,” Muraine said.
Graft survival rate was estimated to be between 90% and 95% at 5 years by Melles and other groups, and first results at 10 years are beginning to be reported. Weller and Kruse evaluated the outcomes at 8 to 10 years and found 80% survival. Melles reported similar outcomes, with 79% graft survival at 10 years.
“These good results should not make us forget that 20% of the patients had to be regrafted. In addition, in both series, more than half of the patients were lost to follow-up,” Muraine said.
Other series were suggestive of potentially lower rates of graft survival in the long term. Beek reported only 60% clear grafts at 7 years when patients during the learning curve were included. Alio reported 85% graft survival at 8 years but only 40% clear grafts at 10 years.
Additionally, preloaded grafts in a series by Romano were shown to have comparable outcomes to surgeon-prepared grafts but a much higher rate of rebubbling, 48% as compared with 15%, suggesting decreased adhesion forces in bank-prepared tissue.
The current debate about DMEK is no longer about the technique, which is now well established and confidently managed by most surgeons, Muraine said.
“My concerns are on whether grafting Fuchs’ patients early, as we do now, is the best option. We need to know more about the long-term survival rate of DMEK in Fuchs’ and the survival rate of a regraft. Let’s not forget that visual acuity after a failed graft is much lower than visual acuity before surgery,” he said.
References:
- Beek NK, et al. Int Ophthalmol. 2022;doi:10.1007/s10792-021-02078-4.
- Ham L, et al. Am J Ophthalmol. 2016;doi:10.1016/j.ajo.2016.08.038.
- Montesel A, et al. Eur J Ophthalmol. 2021;doi:10.1177/1120672120947592.
- Romano V, et al. Br J Ophthalmol. 2022;doi:10.1136/bjophthalmol-2020-317608.
- Vasiliauskait I, et al. Am J Ophthalmol. 2020;doi:10.1016/j.ajo.2020.04.005.
- Weller JM, et al. Int Ophthalmol. 2022;doi:10.1007/s10792-021-02176-3.
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Muraine M. Update on DMEK. Presented at: European Society of Cataract and Refractive Surgeons winter meeting; Feb. 18-20, 2022 (virtual meeting).
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