Abstract
Purpose :
To determine the clinical and ultrastructural characteristics of secondary graft failure after Descemet membrane endothelial keratoplasty (DMEK).
Methods :
Retrospective, single-center case series of eyes with failed DMEK grafts undergoing repeat DMEK between December 2020 and November 2023 at the Department of Ophthalmology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany. Main outcome parameters were initial indication for DMEK, rate of rebubbling procedures after DMEK, comorbidities (glaucoma, pseudoexfoliation syndrome, macular edema), and history of filtering surgery or vitrectomy. Transmission electron microscopy of excised Descemet’s membranes was used to detect ultrastructural alterations related to secondary graft failure after DMEK.
Results :
Among 1837 DMEKs, 65 surgeries were repeat DMEKs (3.5%), whereof 20 were classified as primary graft failure, and 45 as secondary graft failures. Only secondary graft failures were analyzed in this study. At time of repeat DMEK, mean age of the patients was 74 ± 10 years. Mean interval between first and repeat DMEK was 59 ± 27 months (range 25-130 months).
In eyes with secondary graft failure, indication for the first DMEK surgery had been Fuchs endothelial corneal dystrophy in 73% (n=33), and pseudophakic bullous keratopathy in 27% (n=12). In 38% the initial surgery had been DMEK alone, in 62% DMEK with combined cataract surgery. 31% of eyes undergoing repeat DMEK had required air injections after the first DMEK because of graft detachment, compared to 11% in the entire DMEK cohort (p<0.05).
Among eyes with secondary graft failure, 40% (n=18) had open-angle glaucoma, compared to 2.1% of the primary DMEK cohort (p<0.05). 13% (n=6) of these eyes had pseudoexfoliation syndrome, 18% (n=8) previous filtering surgery, 18% (n=8) previous vitrectomy. In n=13 eyes (29%), recurrent or persistent cystoid macular edema had been diagnosed. Ultrastructural alterations in Descemet’s membrane were detected by electron microscopy.
Conclusions :
Eyes with secondary graft failure after DMEK had a significantly higher rate of rebubbling procedures after the first DMEK. The glaucoma rate was 40% in these eyes, confirming that glaucoma is a major risk factor for late graft failure after DMEK.
This abstract was presented at the 2024 ARVO Annual Meeting, held in Seattle, WA, May 5-9, 2024.