Original article
Descemet Membrane Endothelial Keratoplasty Combined With Phacoemulsification and Intraocular Lens Implantation: Advanced Triple Procedure

https://doi.org/10.1016/j.ajo.2012.01.020Get rights and content

Purpose

To evaluate the functional and morphologic outcome of Descemet membrane endothelial keratoplasty (DMEK) combined with phacoemulsification and intraocular lens implantation in patients suffering from endothelial dysfunction and cataract.

Design

Retrospective, single-center, consecutive case series.

Methods

Triple-DMEK (DMEK with simultaneous cataract surgery) was performed in 61 consecutive eyes of 56 patients using corneal donor tissue pre-stored in either short-term culture (Optisol-GS) at 4 C or organ culture (Dulbecco's modified Eagle's medium, CorneaMax medium) at 34 C. Main outcome measures included the number of air injections necessary for graft attachment as well as best-corrected visual acuity (BCVA [logMAR]), central corneal thickness (CCT), endothelial cell density (ECD), refractive spherical equivalent, refractive cylinder, and topographic cylinder at 1, 3, and 6 months postoperatively.

Results

BCVA increased from 0.6 ± 0.23 logMAR preoperatively (n = 54) to 0.19 ± 0.22 logMAR at 6 months (n = 27) after surgery (P ≤ .05). ECD of donor corneas decreased from 2573 ± 235 cells/mm2 (n = 61) to 1550 ± 326 cells/mm2 (n = 29) after 6 months (P ≤ .05). CCT decreased from 651 ± 69 μm (n = 54) preoperatively to 521 ± 65 μm (n = 27) after 6 months (P ≤ .05). Refractive spherical equivalent was −0.3 ± 2.8 D (n = 27) preoperatively and 0.9 ± 1.5 D 6 months (n = 27) after surgery. A total of 54.5% of eyes were within 1 D of emmetropia (n = 12) and 77.3% were within 2 D of emmetropia (n = 17) 6 months (n = 22) after surgery. Refractive cylinder was −0.9 ± 1.0 D preoperatively (n = 49) and −1.5 ± 1.0 D 6 months (n = 23) after surgery. The change in refractive cylinder within the first month was statistically significant (P ≤ .05; Wilcoxon test). Topographic cylinder was 2.1 ± 1.7 D preoperatively (n = 58) and 1.7 ± 1.1 D 6 months (n = 28) after surgery. Between 3 and 6 months a significant change in topographic cylinder towards lower values was measured (P ≤ 0.05; Wilcoxon test). Optimized spherical results were achieved by selecting intraocular lenses based on a hyperopic shift of −0.75 D.

Conclusion

DMEK combined with cataract surgery (triple procedure) can routinely be performed in cases of endothelial dystrophy and cataract. The addition of cataract surgery to DMEK had no adverse effect on endothelial function or graft adhesion and did not increase the likelihood of postoperative complications.

Section snippets

Patients

Triple-DMEK (DMEK with simultaneous cataract surgery) was performed in 61 consecutive eyes of 56 patients (37 eyes of 34 male patients, and 24 eyes of 22 female patients) aged between 42 and 79 years (mean age 66.3 ± 12.4 years). Indications for surgery were Fuchs endothelial dystrophy (n = 60) and bullous keratopathy after failed DMEK (n = 1). Thirty-two eyes received an isolated endothelium–Descemet membrane layer prepared from a corneoscleral button that had been stored in Optisol-GS (Bausch

Visual Outcome

The BCVA achieved following DMEK is shown in Figure 1. For final analysis 6 patients were excluded because of preexisting conditions limiting visual potential: macular degeneration (n = 3), epiretinal gliosis with cystoid macular edema (n = 1), advanced glaucomatous optic atrophy (n = 1), and prior retinal surgery because of retinal detachment (n = 1). BCVA was 0.6 ± 0.23 logMAR preoperatively (n = 54) and increased to 0.31 ± 0.18 logMAR at 1 month (n = 47), to 0.23 ± 0.23 logMAR at 3 months (n

Discussion

Endothelial keratoplasty such as DSAEK or DMEK has become the procedure of choice in surgical management of corneal endothelial diseases such as Fuchs endothelial dystrophy. There is a consensus about advantages of endothelial keratoplasty compared to penetrating keratoplasties because of faster visual rehabilitation, reduced postsurgical astigmatism, and reduced risk for expulsive hemorrhages.7, 10, 12, 17, 33, 34

In patients with corneal disease and cataract a combined surgical approach

Kathrin Laaser, MD, graduated from Munich Medical School (Technical University) in 2005. Since 2006 she has been a staff member of the Department of Ophthalmology at the University of Erlangen/Nuremberg, Erlangen, Germany. Dr Laaser is currently receiving a fellowship training in corneal diseases at the Department of Ophthalmology, Erlangen University Medical School.

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    Kathrin Laaser, MD, graduated from Munich Medical School (Technical University) in 2005. Since 2006 she has been a staff member of the Department of Ophthalmology at the University of Erlangen/Nuremberg, Erlangen, Germany. Dr Laaser is currently receiving a fellowship training in corneal diseases at the Department of Ophthalmology, Erlangen University Medical School.

    Friedrich E. Kruse, MD, is Professor and Chairman, Department of Ophthalmology, Erlangen University Medical School, Germany since 2004. After graduation from Heidelberg Medical School in 1984, he worked from 1988 to 1991 at the Bascom Palmer Eye Institute, Miami/Florida. His research interests include cellular and molecular biology of the ocular surface corneal transplantation and laser application.

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