Introduction For almost 100 years, penetrating keratoplasty (PK) was the mainstay of therapy for patients with corneal endothelial disorders.1 That changed in 1998 with the introduction of posterior lamellar keratoplasty (PLK),2–4 later popularized in the United States as deep lamellar endothelial keratoplasty (DLEK).5–7 Selectivity was the new technique’s primary advantage. By replacing only the inner aspect of the cornea, many of the suture, astigmatism, and wound healing problems of PK disappeared. But while effective, DLEK ultimately proved too technically challenging for widespread adoption. So, the surgery was simplified, giving rise to Descemet stripping (automated) endothelial keratoplasty (DS(A)EK).8-11 And within five years, this modified technique became the global treatment of choice for corneal endothelial disorders. Still, few patients after DS(A)EK achieved best corrected visual acuities (BCVAs) exceeding 20/25. Probably, the graft’s layer of attached stroma was to blame, which thickened the cornea and seemed to undermine its optical performance.12-16 A stroma-less graft was the solution, arriving in 2006 in the form of Descemet membrane endothelial keratoplasty (DMEK).17-19 With a transplant composed solely of isolated Descemet membrane (and its endothelium), DMEK slashed graft thickness by 75 % compared to DS(A)EK, from 80 microns down to twenty. The results were dramatic: almost 80 % of patients reached ≥20/25 within six months after surgery.12,20,21 Recently, DMEK has been refined into a standardized ‘no-touch’ procedure, ready for the typical corneal surgeon in any clinical setting and at low cost.22 Compared to its predecessors (DSEK, DLEK, and their variations), DMEK provides better and faster visual recovery, usually with no additional complications. It is therefore poised to become the first-line option for corneal endothelial disorders worldwide.23 Preoperative Preparation of the DMEK Graft Ideally, DMEK grafts are prepared in an eye bank, 1–2 weeks before surgery. There, the tissue undergoes several rounds of additional screening. Principally, this consists of evaluating the cell density and morphology of the donor endothelium. Grafts which appear abnormal under the microscope—those with scarce or atypical cells, suspicious for being dysfunctional—are discarded, raising the quality of the pool of tissue for transplant. Preparing the grafts weeks in advance also adds convenience: it saves time and safeguards against unexpected tissue shortage on the day of surgery.24 On the other hand, some ophthalmologists may prefer to create the grafts themselves, in the operating room, just before surgery.25 This is especially true in the United States, where few eye banks currently supply ready-to-use DMEK tissue. Each graft takes 30 minutes to prepare, and all the steps are the same, whether in the operating room or the eye bank. The initially described DMEK graft harvesting technique consisted of stripping Descemet membrane from a corneo-scleral rim submerged in saline. This method was proven safe and reproducible, with <5 % tissue loss due to inadvertent tearing, and—surprisingly—no significant endothelial cell damage.24-28 Recently, the process was upgraded to a ‘no-touch’ procedure, making the preparation both safer and easier.29 As a bonus, the anterior portion of the corneas left over from creating the DMEK grafts (with the Descemet membrane stripped off, but otherwise intact) can be used for deep anterior lamellar keratoplasty (DALK). This added benefit applies only to DMEK, because DS(A)EK preparation – by incorporating some of the posterior stroma into the graft – mangles the corneal remains, leaving them less suitable for transplant.29-31
Descemet Membrane Endothelial Keratoplasty—A Review
US Ophthalmic Review, 2013;6(1):29-32 DOI: http://doi.org/10.17925/USOR.2013.06.01.29
Abstract:Descemet membrane endothelial keratoplasty (DMEK) is the most recent step forward in the evolution of endothelial keratoplasty toward thinner grafts and more natural, anatomic corneal restoration. Offering unprecedented visual results and requiring no special or expensive equipment, DMEK has the potential to become the first line treatment for corneal endothelial disorders. The surgery’s perceived shortcomings (primarily technical difficulty) have mostly been addressed by new ‘no-touch’ procedures for both graft preparation and graft unfolding in the recipient eye. And as a result, DMEK has been gaining traction with ophthalmologists the world over. Now, in its most recent formulation, DMEK is ready for the typical corneal surgeon, in any clinical setting, and at low cost.
Keywords: Descemet membrane endothelial keratoplasty (DMEK), posterior lamellar keratoplasty, corneal transplantation, endothelium, surgical technique
Disclosure: Dr Melles is a consultant for D.O.R.C. International/ Dutch Ophthalmic USA, all remaining autors have no conflicts of interest to declare.
Received: April 20, 2012 Accepted November 30, 2012
Correspondence: Gerrit RJ Melles, MD PhD, Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands E: email@example.com, W: www.niios.com
- Terry MA, Endothelial keratoplasty: why aren’t we all doing descemet membrane endothelial keratoplasty?, Cornea, 2012;31:469–71.
- Melles GRJ, Eggink FAGJ, Lander F, et al., A surgical technique for posterior lamellar keratoplasty, Cornea, 1998;17:618–26.
- Melles GR, Lander F, Beekhuis WH, et al., Posterior lamellar keratoplasty for a case of pseudophakic bullous keratopathy, Am J Ophthalmol, 1999;127:340–1.
- Melles GR, Lander F, Nieuwendaal C, Sutureless, posterior lamellar keratoplasty: A case report of a modified technique, Cornea,2002;21:325–7.
- Terry MA, Ousley PJ, Deep lamellar endothelial keratoplasty in the first United States patients: early clinical results, Cornea, 2001;20:239–43.
- Terry MA, Ousley PJ, Deep lamellar endothelial keratoplasty visual acuity, astigmatism, and endothelial survival in a large prospective series, Ophthalmology, 2005;112:1541–8.
- Ousley PJ, Terry MA, Stability of vision, topography, and endothelial cell density from 1 year to 2 years after deep lamellar endothelial keratoplasty surgery, Ophthalmology, 2005;112:50–7.
- Melles GR, Wijdh RH, Nieuwendaal CP, A technique to excise the Descemet membrane from a recipient cornea (descemetorhexis), Cornea, 2004;23:286–8.
- Price FW Jr, Price MO, Descemet’s stripping with endothelial keratoplasty in 50 eyes: a refractive neutral corneal transplant, J Refract Surg, 2005;21:339–45.
- Azar DT, Jain S, Sambursky R, Strauss L, Microkeratome-assisted posterior keratoplasty, J Cataract Refract Surg, 2001;27:353–6.
- Gorovoy MS, Descemet-stripping automated endothelial keratoplasty, Cornea,2006;25:886–9.
- Dapena I, Ham L, Melles GRJ, Endothelial Keratoplasty: DSEK/DSAEK or DMEK – the thinner the better?, Curr Opin Ophthalmol,2009;20:299–307.
- Bahar I, Kaiserman I, McAllum P, et al., Comparison of posterior lamellar keratoplasty techniques to penetrating keratoplasty, Ophthalmology,2008;115:1525–33.
- Chen ES, Terry MA, Shamie N, et al., Descemet-stripping automated endothelial keratoplasty: six month results in a prospective study of 100 eyes, Cornea,2008;27:514–20.
- Mearza AA, Qureshi MA, Rostron CK, Experience and 12-month results of Descemet-stripping endothelial keratoplasty (DSEK) with a small-incision technique, Cornea,2007;26:279–83.
- Terry MA, Shamie N, Chen ES, et al., Precut tissue for Descemet’s stripping automated endothelial keratoplasty: Vision, astigmatism, and endothelial survival, Ophthalmology, 2009;116:248–56.
- Melles GR, Lander F, Rietveld FJ, Transplantation of Descemet’s membrane carrying viable endothelium through a small scleral incision, Cornea,2002;21:415–8.
- Melles GR, Ong TS, Ververs B, van der Wees J, Descemet membrane endothelial keratoplasty (DMEK), Cornea, 2006;25:987–90.
- Melles GR, Ong TS, Ververs B, van der Wees J, Preliminary clinical results of Descemet membrane endothelial keratoplasty, Am J Ophthalmol,2008;145:222–7.
- Melles GR, Posterior lamellar keratoplasty: DLEK to DSEK to DMEK, Cornea,2006;25:879–81.
- Fernandez MM, Afshari NA, Endothelial Keratoplasty: From DLEK to DMEK, Middle East Afr J Ophthalmol,2010;17:5–8.
- Dapena I, Moutsouris K, Droutsas K, et al, Standardized ‘no touch’ technique for Descemet membrane endothelial keratoplasty (DMEK),Arch Ophthalmol,2011;129:88–94.
- Dirisamer M, Ham L, Dapena I, et al, Efficacy of Descemet membrane endothelial keratoplasty (DMEK): Clinical outcome of 200 consecutive cases after a ‘learning curve’ of 25 cases, Arch Ophthalmol, 2011;129:1435–43.
- Lie JT, Birbal R, Ham L et al., Donor tissue preparation for Descemet membrane endothelial keratoplasty, J Cataract Refract Surg,2008;34:1578–83.
- Kruse FE, Laaser K, Cursiefen C, et al., A stepwise approach to donor preparation and insertion increases safety and outcome of Descemet membrane endothelial keratoplasty, Cornea, 2011;30:580–7.
- Price MO, Giebel AW, Fairchild KM, Price FW Jr, Descemet’s membrane endothelial keratoplasty: prospective multicenter study of visual and refractive outcomes and endothelial survival, Ophthalmology,2009; 116:2361–8.
- Zhu Z, Rife L, Yiu S, et al, Technique for preparation of the corneal endothelium-Descemet membrane complex for transplantation, Cornea,2006;25:705–8.
- Ignacio TS, Nguyen TT, Sarayba MA, et al, A technique to harvest Descemet’s membrane with viable endothelial cells for selective transplantation, Am J Ophthalmol, 2005;139:325–30.
- Groeneveld-van Beek E, Lie J, van der Wees J, et al., Standardized ‘no-touch’ donor tissue preparation for DALK and DMEK: Harvesting undamaged anterior and posterior transplants from the same donor cornea, Acta Ophthalmol, 2012 Jun 6.[Epub ahead of print].
- Heindl LM, Riss S, Laaser K, et al, Split cornea transplantation for 2 recipients - review of the first 100 consecutive patients, Am J Ophthalmol,2011;152:523–32.
- Lie JT, Groeneveld-van Beek EA, Ham L, et al., More efficient use of donor corneal tissue with Descemet membrane endothelial keratoplasty (DMEK): two lamellar keratoplasty procedures with one donor cornea, Br J Ophthalmol, 2010;94:1265–6.
- Kymionis GD, Yoo SH, Diakonis VF, et al, Automated donor tissue preparation for Descemet membrane automated endothelial keratoplasty (DMAEK): An Experimental Study, Ophthalmic Surg Lasers Imaging,2011;42:158–61.
- McCauley MB, Price FW, Price MO, Descemet membrane automated endothelial keratoplasty: hybrid technique combining DSAEK stability with DMEK visual results, J Cataract Refract Surg, 2009;35:1659–64.
- Studeny P, Farkas A, Vokrojova M, et al, Descemet membrane endothelial keratoplasty with a stromal rim (DMEK-S), Br J Ophthalmol, 2010;94:909–14.
- Guerra FP, Anshu A, Price MO, et al, Descemet’s membrane endothelial keratoplasty prospective study of 1-Year visual outcomes, graft survival, and endothelial cell loss, Ophthalmology,2011;118:2368–73.
- McCauley MB, Price MO, Fairchild KM, et al, Prospective study of visual outcomes and endothelial survival with Descemet membrane automated endothelial keratoplasty, Cornea, 2011;30:315–9.
- Williams KA, Muehlberg SM, Lewis RF, et al., How successful is corneal transplantation? A report from the Australian Corneal Graft Register, Eye, 1995;9:219–27.
- Ham L, Dapena I, van der Wees J, Melles GR, Secondary DMEK for poor visual outcome after DSEK: donor posterior stroma may limit visual acuity in endothelial keratoplasty, Cornea, 2010;29:1278–83.
- Guerra FP, Anshu A, Price MO, Price FW, Endothelial keratoplasty: fellow eyes comparison of Descemet stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty, Cornea,2011;30:1382–6.
- Dapena I, Dapena L, Dirisamer M, et al, Visual acuity and endothelial cell density following Descemet membrane endothelial keratoplasty (DMEK), Arch Soc Esp Oftalmol, 2011;86:395–401.
- Ham L, Dapena I, van der Wees J, Melles GR, Endothelial cell density after Descemet membrane endothelial keratoplasty: 1- to 3-year follow-up, Am J Ophthalmol,2010;149:1016–7.
- Parker J, Dirisamer M, Naveiras M, et al, Endothelial cell density after Descemet membrane endothelial keratoplasty: 4-year follow-up, Am J Ophthalmol, 2011;151:1107.
- Price MO, Fairchild KM, Price DA, et al., Descemet’s stripping endothelial keratoplasty five-year graft survival and endothelial cell loss, Ophthalmology, 2011;118:725–9.
- Price FW Jr, Price MO, Does endothelial cell survival differ between DSEK and standard PK?, Ophthalmology, 2009;116:367–8.
- Price MO, Price FW Jr, Endothelial cell loss after Descemet stripping with endothelial keratoplasty influencing factors and 2-year trend, Ophthalmology, 2008;115:857–65.
- Borderie VM, Boëlle PY, Touzeau O, et al, Predicted longterm outcome of corneal transplantation, Ophthalmology, 2009;116:2354–60.
- Patel SV, David O, Hodge MS, Bourne WM, Corneal endothelium and postoperative outcomes 15 years after penetrating keratoplasty, Am J Ophthalmol, 2005;139:311–9.
- Ing JJ, Ing HH, Nelson LR, et al., Ten-year postoperative results of penetrating keratoplasty, Ophthalmology,1998;105:1855–65.
- Busin M, Bhatt PR, Scorcia V, A modified technique for Descemet membrane stripping automated endothelial keratoplasty to minimize endothelial cell loss, Arch Ophthalmol, 2008;126:1133–7.
- Koenig SB, Covert DJ, Early results of small-incision Descemet stripping and automated endothelial keratoplasty, Ophthalmology, 2007;114:221–6.
- Terry MA, Shamie N, Chen ES, et al., Endothelial keratoplasty a simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block, Ophthalmology, 2008;115:1179–86.
- Dapena I, Moutsouris K, Ham L, Melles GR, Graft detachment rate, Ophthalmology, 2010;117:847.
- Dirisamer M, van Dijk K, Dapena I, et al., Prevention and management of graft detachment in Descemet membrane endothelial keratoplasty (DMEK), Arch Ophthalmol, 2012;130:280–91.
- Dapena I, Ham L, Droutsas K, et al., Learning curve in Descemet’s membrane endothelial keratoplasty: First series of 135 consecutive cases, Ophthalmology, 2011;118:2147–54.
- Laaser K, Bachmann BO, Horn FK, et al., Donor tissue culture conditions and outcome after descemet membrane endothelial keratoplasty, Am J Ophthalmol,2011;151:1007–18.
- Anshu A, Price MO, Price FW Jr, Risk of corneal transplant rejection significantly reduced with Descemet’s membrane endothelial keratoplasty, Ophthalmology, 2012;119:536–40.
- Dapena I, Ham L, Netukova M, et al., Incidence of early allograft rejection following Descemet membrane endothelial keratoplasty (DMEK), Cornea, 2011;30:1341–45.
- Li JY, Terry MA, Goshe J, et al., Graft rejection after Descemet’s stripping automated endothelial keratoplasty: graft survival and endothelial cell loss, Ophthalmology, 2012;119:90–4.
- Vajaranant TS, Price MO, Price FW, Visual acuity and intraocular pressure after Descemet’s stripping endothelial keratoplasty in eyes with and without preexisting glaucoma, Ophthalmology, 2009; 116:1644–50.
- Erdurmus M, Cohen EJ, Yildiz EH, et al., Steroid-induced intraocular pressure elevation or glaucoma after penetrating keratoplasty in patients with keratoconus or Fuchs dystrophy, Cornea,2009;28:759–64.
- Greenlee EC, Kwon YH, Graft failure: III. glaucoma escalation after penetrating keratoplasty, Int Ophthalmol,2008;28:191–207.
- Allen MB, Lieu P, Mootha VV, et al, Risk factors for intraocular pressure elevation after Descemet stripping automated endothelial keratoplasty, Eye Contact Lens, 2010;36:223–7.
- Naveiras M, Dirisamer, Parker J, et al., Causes of glaucoma after Descemet membrane endothelial keratoplasty (DMEK), Am J Ophthalmol,2012;153:958–66.
- Dapena I, Ham L, Tabak S, et al, Phacoemulsification after Descemet membrane endothelial keratoplasty, J Cataract Refract Surg, 2009;35:1314-5.
- Parker J, Dirisamer M, Naveiras M, et al,Outcomes of Descemet membrane endothelial keratoplasty in phakic eyes, J Cataract Refract Surg,2012;38:871–7.
- Price FW Jr, Price MO, Comment on ‘Spontaneous corneal clearance despite graft detachment after descemet membrane endothelial keratoplasty’, Am J Ophthalmol,2010;149:173-4; author reply 174-5.
- Zafirakis P, Kymionis GD, Grentzelos MA, Livir-Rallatos G, Corneal graft detachment without corneal edema after Descemet stripping automated endothelial keratoplasty, Cornea,2010;29:456–8.
- Jacobi C, Zhivov A, Korbmacher J, et al, Evidence of endothelial cell migration after Descemet membrane endothelial keratoplasty, Am J Ophthalmol, 2011;152:537–42.
- Lagali N, Stenevi U, Claesson, M, et al., Donor and recipient endothelial cell population of the transplanted human cornea: a two-dimensional imaging study, Invest Ophthalmol Vis Sci, 2010;51:1898–1904.
- Stewart RM, Hiscott PS, Kaye SB, Endothelial migration and new Descemet membrane after endothelial keratoplasty, Am J Ophthalmol, 2010;149:683; author reply 683–4.
- Dirisamer M, Yeh RY, van Dijk K, et al, Recipient endothelium may relate to corneal clearance in descemet membrane endothelial transfer, Am J Ophthalmol; 2012;154:290–6.
- This figure has been published previously in Dapena et al., Arch Ophthalmol, 2011;129(1):88–94].
Keywords: Descemet membrane endothelial keratoplasty (DMEK), posterior lamellar keratoplasty, corneal transplantation, endothelium, surgical technique