CORNEA EWAP JUNE 2023 33 choice for uncomplicated Fuchs dystrophy and bullous keratopathy. The EBAA Statistical Report showed that about 64% of keratoplasties in the U.S. in 2021 were DMEK or DSAEK, and 52% of DSAEK and DMEK done in the U.S. were done for endothelial dystrophy. The 52% is probably an underestimate given that some surgeons don’t accurately report indications for surgery, and some EKs are done to replace a failing graft that was previously done for Fuchs dystrophy.” Dr. Venkateswaran said experience with DMEK or DSAEK for those in training depends on the patient population they see and the technique with which attending ophthalmologists are more comfortable. “If you have a clinic where you are predominately seeing patients with Fuchs dystrophy or pseudophakic bullous keratopathy in otherwise healthy eyes, I think the majority of cornea surgeons are trending toward performing DMEK. It’s the least invasive lamellar keratoplasty technique [and has] lower risks of rejection with improved vision outcomes compared to DSAEK. It’s an enjoyable surgical technique to learn and perform as well. But you can also have a cohort of eyes that aren’t going to necessarily shine with DMEK,” Dr. Venkateswaran said, noting that she did a lot of DSAEK in residency and a lot of DMEK in fellowship based on what surgical option was best for the patients she was caring for. Dr. Venkateswaran and Dr. Chamberlain think there is still a place for DSAEK in cornea practice. “DSAEK still has a solid role in corneal transplantation, and therefore techniques and training emphasis are important. One of the driving forces for DMEK is the result of two randomized controlled trials that demonstrated that DMEK outperformed ultrathin DSAEK in patients with Fuchs and bullous keratopathy in terms of vision at 1 year and recovery time. 1 One of those trials showed DMEK still giving better visual acuity at 2 years after surgery than ultrathin DSAEK, 2” Dr. Chamberlain said. He noted, however, that the trials focused on less complicated eyes. “There are fewer high-standard publications rigorously assessing DMEK’s long-term performance in more complicated eyes. These eyes create surgical challenges for successfully completing DMEK, and therefore DSAEK may still be the best approach.” Dr. Venkateswaran said this is how she approaches her cases. “In my straightforward cases with endothelial dysfunction (i.e., Fuchs dystrophy or pseudophakic bullous keratopathy), I will perform DMEK. But since I practice in a tertiary care referral center where I’m comanaging very sick eyes with multiple ocular comorbidities and previous ocular surgeries (i.e., prior glaucoma surgeries, prior vitrectomies, iris defects, scleral fixated or anterior chamber IOL placement), I tend to perform more DSAEK as I think these complex eyes fare better with a DSAEK procedure as compared to DMEK,” Dr. Venkateswaran said. She said she tried to learn all the different insertion techniques for DSAEK tissue, including using multiple injection devices and suturing techniques, when she was in training because she wasn’t sure what tools would be available to her when she started practice. “We have excellent visual outcomes, low graft rejection rates, and less rebubbling rates with advanced DSAEK techniques,” Dr. Venkateswaran said. “I think there are some advantages to DSAEK when you’re considering your patient population, too. The higher chance of needing a rebubbling Loading of DSAEK graft onto EndoSerter (CorneaGen). Attached DSAEK graft with air bubble. Removal of failed DSAEK graft. Source (all): Nandini Venkateswaran, MD
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