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    DSEK or DMEK? Choosing the best for patients with corneal edema

    Proper surgical course should depend on the patients, their condition, timing of each case

    Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK) are the two primary endothelial keratoplasty procedures. However, they are not interchangeable, and one might outstrip the other under varying conditions.

    Choosing the most beneficial procedure for each patient with a corneal degeneration is paramount. Before that step is taken, surgeons must determine the optimal timing of the surgery.

    “We advise our patients to undergo surgery when there is a significant decrease in their everyday activities due to the presence of glare or reduced visual acuity [VA],” said Claus Cursiefen, MD, PhD.

    Dr. Cursiefen first recommends early surgical intervention because the visual recovery achieved with the modern lamellar techniques is exceptionally good and occurs rapidly and, secondly, because some evidence exists that there is a correlation between the preoperative and postoperative visual acuity levels.

    Limited visual recovery seems to be associated with anterior stromal changes that increase over time, he pointed out.  Therefore, surgery should be performed as early as necessary.

    Dr. Cursiefen is chairman and professor, Department of Ophthalmology, University of Cologne, Germany, and adjunct associate scientist, Schepens Eye Research Institute, Harvard Medical School, Boston.

    DMEK versus DSEK

    When a patient presents with corneal edema and 20/40 vision, Dr. Cursiefen said that at the University of Cologne where about 600 graft procedures are performed each year, about 75% of the surgeries are posterior lamellar procedures, of which most are DMEKs. (Editor's Note: A previous version of this article incorrectly stated this number about 65%.)

    “We still perform DSEK, but most procedures are DMEK because the final visual acuity is so good, with most patients achieving 20/25 or better in the absence of any other comorbidities,” Dr. Cursiefen said. “The visual recovery is rapid. When several studies have compared the speed of the visual recovery with the final visual acuity between DMEK and DSEK, DMEK was found to be associated with faster recovery and better vision.”

    Specifically, these findings are related to so-called normal DMEK procedures, he added. However, the quality of the results associated with ultra-thin DSEK remains to be determined.

    Another reason for performing DME is the substantially lower graft rejection rate that is about 1%. “This represents higher safety compared with DSEK,” Dr. Cursiefen said.

    Another consideration when choosing a particular surgical procedure is the degree of the corneal edema at presentation, Dr. Cursiefen explained. The most important factor to be determined is the location of the edema. Is it in the epithelial or stromal layer?

    In the case of the former, it can be removed easily during the surgery by corneal abrasion, and good visualization of the anterior chamber  (AC) can be obtained. In the case of the latter, which can be identified on optical coherence tomography (OCT) images obtained preoperatively, it might be more difficult to evaluate the unrolling of the DMEK tissue in the anterior chamber.

    In this case, DMEK performed with intraoperative OCT might be the preferred option.

    Microscopes equipped with OCT are commercially available. The surgeons have both the view provided by the surgical microscope as well as the OCT images.

    With this technology, the surgeon can see from the side into the AC despite the presence of a high degree of stromal edema and perform the surgical procedure, which normally would not be possible. He explained that when OCT is unavailable and there is a high degree of corneal edema and other risk factors, he recommended DSEK.

    DSEK might be preferable when the eyes are considered complicated, such as in patients with hypotony or silicone oil.

    “Technically, DMEK can be performed; however, based on the surgical corollary and considering the endothelium, DSEK is a better choice,” Dr. Cursiefen explained. “In infant eyes, which have very small ACs, DSEK is much less traumatic to the graft than DMEK.”

    Dr. Cursiefen recounted the findings of DSEK in infant eyes. One study found that DSEK facilitated the rapid restoration of transparency and visual acuity.

    Infant eyes

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