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Impact of difficult unfolding and attachment of the graft lamella on the long-term outcome after Descemet membrane endothelial keratoplasty

  • Cornea
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Abstract

Purpose

Unfolding and attachment of the posterior donor lamella may be the most challenging part in Descemet membrane endothelial keratoplasty (DMEK) procedure. We investigated the correlation of the difficulty degrees of this step to the postoperative clinical outcome 6 years after surgery.

Methods

One hundred sixty-nine consecutive DMEKs between September 2012 and August 2013 at the Charité–University Medicine Berlin were graded prospectively into 4 groups according to their grade of difficulty in unfolding and attachment of the graft lamella. Postoperative visual acuity, endothelial cell density, and rate of graft failure were measured after 1 year, after 2 years, and after 6 years and analyzed according to their grading group.

Results

Visual acuity improved significantly in all groups and did not differ significantly between the grading groups at any time point postoperatively. There was a significant decrease of endothelial cell density in all groups with a significantly higher endothelial cell loss in group IV compared with the other groups within the first 24 months after surgery. The graft failure rate was significantly higher in eyes graded III and IV than in groups I and II (p = 0.012).

Conclusion

Although the endothelial cell loss and the graft failure rate increase significantly with a more difficult graft unfolding and attachment, DMEK surgery is a promising procedure with a good long-term postoperative outcome. A direct manipulation of the graft lamella for unfolding and centering by cannula or forceps should be avoided if possible to reduce the risk of an increased endothelial cell loss and a higher graft failure rate.

Trial registration

NCT02020044

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Data availability

The authors have full control of all primary data and agree to allow Graefes Archive for Clinical and Experimental Ophthalmology to review data upon request.

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Acknowledgments

The authors thank Simone Baar and Dirk Scharf for technical support.

Funding

Anna-Karina B. Maier: Financial support was provided by the “Friedrich C. Luft” Clinical Scientist Pilot Program funded by Volkswagen Foundation and Charité Foundation. Enken Gundlach: Financial support was provided by the “Ernst und Bertha Grimmke Stiftung.” Daniel Pilger is a participant in the BIH-Charité Clinician Scientist Program funded by the Charité–University Medicine Berlin and the Berlin Institute of Health.

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Authors and Affiliations

  1. Department of Ophthalmology, Campus Virchow-Klinikum, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – University Medicine Berlin, Berlin, Germany

    Enken Gundlach, Nadiya Spiller, Daniel Pilger, Tina Dietrich-Ntoukas, Antonia M. Joussen, Necip Torun & Anna-Karina B. Maier

Authors
  1. Enken Gundlach
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  2. Nadiya Spiller
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  3. Daniel Pilger
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  4. Tina Dietrich-Ntoukas
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  5. Antonia M. Joussen
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  6. Necip Torun
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  7. Anna-Karina B. Maier
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Contributions

Anna-Karina B. Maier, Necip Torun, and Antonia M. Joussen contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Enken Gundlach, Nadiya Spiller, Daniel Pilger, and Anna-Karina B. Maier. The first draft of the manuscript was written by Enken Gundlach and Anna-Karina B. Maier and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Anna-Karina B. Maier.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

This study followed the ethical standards of the Declaration of Helsinki. Institutional ethical approval was obtained by the Ethics Committee of the Charité–Universitätsmedizin Berlin (EA2/108/12) for this prospective study and clinical trial registration was performed (http://www.clinicaltrials.gov, NCT02020044).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Code availability

(Software application or custom code) SPSS, RRID:SCR_002865

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Gundlach, E., Spiller, N., Pilger, D. et al. Impact of difficult unfolding and attachment of the graft lamella on the long-term outcome after Descemet membrane endothelial keratoplasty. Graefes Arch Clin Exp Ophthalmol 258, 2459–2465 (2020). https://doi.org/10.1007/s00417-020-04852-z

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  • DOI: https://doi.org/10.1007/s00417-020-04852-z

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