Low rejection rate after DMEK spurs clinicians to evaluate low-dose steroid management

  • Ocular Surgery News Europe Edition, September 2012

ROME — Descemet’s membrane endothelial keratoplasty is showing superior results over time compared to Descemet’s stripping endothelial keratoplasty in terms of optical quality and rejection rate with low-dose steroids in internationally published data, according to a specialist.

“In my nearly 3 years of experience, I have learned to increasingly appreciate the advantages of DMEK, which has now become my favorite approach,” José Güell, MD, said at the joint Refractive.online and SICCSO meeting.

José G</strong><strong>üell

José Güell

Güell now uses DSEK only in aphakic eyes or eyes with anterior chamber IOLs.

“In the near future, as the technique evolves, also these limitations may be overcome,” he said.

Tissue preparation, insertion and handling in the eye are crucial aspects that still need improvement to preserve endothelial cell integrity and lower the detachment rate.

“We are doing better with the new inserters that reduce donor manipulation, but at least in my country, we are experiencing problems due to the learning curve of eye banks in preparing the tissue,” Güell said.

A study recently published by Price and colleagues showed that the rejection rate was considerably lower with DMEK compared to DSEK, with a proportion of 1:8 at 1 year and 1:12 at 2 years.

“In consideration of this low rejection rate, we are now starting to evaluate a low-dose steroid regimen following DMEK,” Güell said.

  • Disclosure: Güell has no relevant financial disclosures.

Perspective

  • At a recent meeting, José L. Güell, MD, underlined that DMEK has become his favorite procedure for endothelial keratoplasty. Indeed, recent studies demonstrated better visual outcomes and lower rejection rates with lower steroid doses after DMEK compared with DSEK. It is probably true that the best anatomical and functional results should be obtained by exchanging the single injured corneal layer.

    However, the surgical learning curve is much more important in the case of DMEK than for DSEK. The endothelium loading and injection are much more complicated in DMEK than in DSEK procedures, implying a second corneal button available in the operating room for rescue in the case of injection failure. This option is not possible in many centers where patients have to wait a long time before a corneal transplant. Furthermore, the re-bubbling rate after DMEK injection is much more important than after DSEK, implying a careful follow-up, multiplying the risk of acute glaucoma when the bubble pass behind the iris, collapsing the anterior chamber.

    I agree with Güell that tissue preparation, insertion and handling remain crucial aspects that need improvement in the future.

    • David Touboul, MD
    • CHU de Bordeaux, CRNK Bordeaux, France
  • Disclosures: Touboul has no relevant financial disclosures.

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