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Potential Causes of Incomplete Visual Rehabilitation at 6 Months Postoperative After Descemet Membrane Endothelial Keratoplasty

      Purpose

      To determine the various causes of unexpected incomplete visual rehabilitation at 6 months postoperative after Descemet membrane endothelial keratoplasty (DMEK).

      Design

      Retrospective study of prospectively collected data at a tertiary referral center.

      Methods

      From a larger group of 400 consecutive DMEK surgeries, the last 200 consecutive eyes were reviewed for visual discomfort despite a best-corrected visual acuity (BCVA) of ≥20/25 (≥0.8) or unexpected subnormal BCVA (≤20/28; ≤0.7) at 6 months after DMEK. Biomicroscopy, funduscopy, Pentacam imaging, noncontact specular microscopy, anterior segment optical coherence tomography, and surgical videos were used to determine the causes of incomplete visual rehabilitation.

      Results

      A total of 69 eyes out of 178 eyes that were included in the analysis (38.8%) presented with incomplete visual rehabilitation after DMEK, further categorized as “primarily patient-related” in 40 of 178 (22.5%), “primarily graft-related” in 21 of 178 (11.8%), and a combination of “patient-/graft-related” in 8 of 178 cases (4.5%). Unrecognized pre-existing ocular pathology and/or posterior segment disease in 19 of 178 eyes (10.7%), clinically significant corneal irregularities and/or central corneal scarring often secondary to long-standing preoperative corneal edema in 14 of 178 eyes (7.9%), or (partial) graft detachment in 20 of 178 eyes (11.2%) were the main causes of unexpected incomplete visual rehabilitation. Transient or persistent monocular ghost images or diplopia occurred in 10 of 178 eyes (5.6%), sometimes requiring contact lens fitting.

      Conclusions

      In contrast to earlier endothelial keratoplasty techniques that may frequently be associated with undefined transplant-related subnormal visual outcomes, incomplete visual rehabilitation after DMEK may virtually always be explained by concomitant ocular pathology or evident graft failure.
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      Biography

      Isabel Dapena, MD, PhD, is a cornea specialist in advanced lamellar keratoplasty techniques and works since 2008 as a researcher and corneal surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS) and the Melles Cornea Clinic. Dr Dapena has a vast experience with DMEK surgery and has published over 50 articles in peer-reviewed journals as well as several book chapters.