CORNEA 32 EWAP SEPTEMBER 2023 by Liz Hillman Editorial Co - Director Making Practice Perfect – Special considerations for DMEK in glaucoma patients Contact information Deng: deng@jsei.ucla.edu Sorkin: nir.sorkin@gmail.com It’s not uncommon for cornea specialists to come across a glaucoma patient in need of an endothelial transplant, and the management of these patients from preop through long-term postop has certain nuances. EyeWorld spoke with Sophie Deng, MD, PhD, and Nir Sorkin, MD, for their insights on how to best manage glaucoma patients who need lamellar keratoplasty. Glaucoma and endothelial cell loss A number of studies have looked at glaucoma and associated endothelial cell loss. One suggests that there are several hypotheses for why this can occur, including direct compression of the endothelium due to high IOP and medication toxicity. 1 Dr. Sorkin shared that another reason for decompensation could be due to the prior surgeries these patients might have received to treat their glaucoma (such as cataract surgery, trabeculectomy, or tube shunts). “Multiple procedures may affect their cornea, and that’s when we come into the picture,” Dr. Sorkin said of cornea specialists. When it comes to DMEK or DSAEK, Dr. Sorkin and coauthors published a paper that found the 4-year graft survival rate was similarly low between the two, but DMEK resulted in better visual acuity. 2 For this reason, Dr. Sorkin said he performs DMEK unless otherwise contraindicated for the patient. A study published in 2017 found that eyes with previous trabeculectomy or tubes had good short-term outcomes, with a 0.9% rejection rate over a follow-up of 9.7±7.3 months. 3 Dr. Deng said her success rate in the short term is similar for patients with glaucoma as it is to those without. Long-term graft survival is a different story. In a series of 251 consecutive DMEK procedures performed by Dr. Deng, secondary graft failure at a mean 38.4±11.2 months was 41.5%, 0%, and 2.4% in eyes that had prior glaucoma surgery, eyes with medically treated glaucoma, and eyes without glaucoma, respectively. 4 Endothelial cell loss was higher in prior surgery eyes as well, 63.8%, compared to 47.6% for eyes medically treated for glaucoma and 44.0% for eyes without glaucoma. Preop considerations When assessing a glaucoma patient for lamellar keratoplasty (of which Dr. Sorkin said DMEK is his preference provided there are no other comorbidities that should preclude it), both Dr. Sorkin and Dr. Deng said that ensuring the patient’s IOP is well controlled is the first step. “Often these patients have IOP well above their target IOP, and I send them back to their glaucoma specialist,” Dr. Deng said. Compliance on glaucoma medications is also important, Dr. Sorkin said. This article originally appeared under the title “Special considerations for DMEK in glaucoma patients” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. A patient with prior trab postop week 1 after DMEK. Source: Sophie Deng, MD, PhD
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