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Original Investigation |

Endothelial Survival After Descemet Membrane Endothelial Keratoplasty Effect of Surgical Indication and Graft Adherence Status

Lamis Baydoun, MD1,2,3; Lisanne Ham, PhD1,2,3; Vincent Borderie, MD, PhD4; Isabel Dapena, MD, PhD1,2; Jingzhen Hou, MD3; Laurence E. Frank, PhD1,5; Silke Oellerich, PhD1; Gerrit R. J. Melles, MD, PhD1,2,3
[+] Author Affiliations
1Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands
2Melles Cornea Clinic Rotterdam, Rotterdam, the Netherlands
3Amnitrans Eye Bank, Rotterdam, the Netherlands
4Department of Ophthalmology, Centre Hospitalier National d’Ophtalmologie des XV-XX, UPMC University of Paris, Paris, France
5Department of Methodology and Statistics, Utrecht University, Utrecht, the Netherlands
JAMA Ophthalmol. 2015;133(11):1277-1285. doi:10.1001/jamaophthalmol.2015.3064.
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Importance  This study evaluates the longevity of Descemet membrane endothelial keratoplasty (DMEK) grafts in terms of endothelial survival and endothelial failure.

Objective  To determine endothelial survival and its association with the indication for surgery and/or partial graft detachment in DMEK.

Design, Setting, and Participants  Retrospective cross-sectional study of data collected from August 8, 2006, until June 17, 2015, at a tertiary referral center. A total of 352 eyes were evaluated up to 8 years after DMEK for Fuchs endothelial corneal dystrophy (FECD; n = 314), bullous keratopathy (BK; n = 31), and failed previous endothelial graft (n = 7), of which 314 eyes had complete graft attachment and 38 eyes had partial graft detachment (one-third of the graft surface area or less). Endothelial cell density was measured with specular microscopy, and Kaplan-Meier survival estimates were based on eyes with endothelial failure. Endothelial survival was followed up to 8 years after DMEK.

Main Outcomes and Measures  Endothelial cell density, endothelial failure, and endothelial survival.

Results  Endothelial cell density decreased to a mean (SD) of 952 (366) and 771 (321) cells/mm2 at 7 and 8 years postoperatively, respectively. Higher endothelial cell densities were found in eyes with FECD compared with those with BK (estimated mean difference, 261 cells/mm2; 95% CI, 118-404; P = .003) and in eyes with attached grafts compared with those with partially detached grafts (estimated mean difference, 330 cells/mm2; 95% CI, 208-452; P < .001), until 8 years. In 11 eyes (3.1%) that had concomitant ocular pathology, endothelial failure occurred within 4 years after DMEK. The overall graft survival probability was 0.96 at 5 and 8 years (95% CI, 0.94-0.99). At 8 years, better survival rates were found in eyes with FECD than in those with BK (survival probability, 0.97 [95% CI, 0.95-0.99] vs 0.84 [95% CI, 0.70-0.99], respectively); until the same follow-up, survival probabilities in eyes with attached and partially detached grafts were 0.97 (95% CI, 0.95-0.99) and 0.91 (95% CI, 0.82-0.99), respectively.

Conclusions and Relevance  Endothelial decay was higher in eyes with a partial graft detachment than in those with attached grafts and lower in eyes with FECD than in those with BK. Endothelial failure only occurred in eyes with concomitant ocular pathology. These results suggest that eyes with DMEK that have undergone surgery for FECD with a completely attached graft may have an excellent prognosis.

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Figure 1.
Mean Endothelial Cell Density (ECD) Up to 8 Years After Descemet Membrane Endothelial Keratoplasty

A, Mean ECD by cross-sectional analysis of the entire cohort for each follow-up point and longitudinal analysis from 6 months until 5-year follow-up. B, Mean ECD by preoperative indication of Fuchs endothelial corneal dystrophy vs bullous keratopathy. C, Mean ECD by graft adherence status of attached grafts vs partially detached grafts. Error bars indicate standard deviation.

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Figure 2.
Kaplan-Meier Survival Curves Up to 8 Years After Descemet Membrane Endothelial Keratoplasty

A-C, Survival probabilities and 95% confidence intervals for the overall group (A), for those with preoperative indication of Fuchs endothelial corneal dystrophy vs bullous keratopathy (B), and for those with attached grafts vs partially detached grafts (C).

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