Clinical Outcome of 500 Consecutive Cases Undergoing Descemet's Membrane Endothelial Keratoplasty

Purpose: To evaluate the clinical outcome of 500 consecutive cases after Descemet's membrane endothelial keratoplasty (DMEK) and the effect of technique standardization. Design: Prospective, interventional case series at a tertiary referral center. Participants: A total of 500 eyes of 393 patients who underwent DMEK for Fuchs' endothelial corneal dystrophy, bullous keratopathy, or previous corneal transplant failure. Methods: Best-corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications were evaluated before and 1, 3, and 6 months after DMEK. Main Outcome Measures: Comparison between 2 groups (group I: cases 1-250, outcome of early surgeries during transition to technique standardization; group II: cases 251-500, outcome of late surgeries after technique standardization). Results: At 6 months, 75% of eyes reached a BCVA of >= 20/25 (>= 0.8), 41% of eyes achieved >= 20/20 (>= 1.0), and 13% of eyes achieved >= 20/18 (>= 1.2) (n = 418) when excluding eyes with ocular comorbidities (n = 57). When including all available eyes at 6 months (n = 475), 66% of eyes reached a BCVA of >= 20/25 (>= 0.8), and 36% of eyes achieved >= 20/20 (>= 1.0). Mean ECD decreased by 37% (+/- 8%) to 1600 (+/- 490) cells/mm(2) (n = 447) at 6 months (P < 0.001). Postoperative pachymetry averaged 525 (+/- 46) mu m compared with 667 (+/- 92) mu m preoperatively (P < 0.001). None of these parameters differed among the 2 groups (P > 0.05). (Partial) graft detachment presented in 79 eyes (15.8%), and 26 eyes (5.2%) required a secondary surgery within the first 6 months (re-bubbling in 15, secondary keratoplasty in 11). With technique standardization, the postoperative complication rate decreased from 23.2% to 10% (P < 0.001) and the rate of secondary surgeries decreased from 6.8% to 3.6% (P = 0.10). Conclusions: In comparison with earlier endothelial keratoplasty techniques, DMEK may consistently give higher visual outcomes and faster visual rehabilitation. When used for the extended spectrum of endothelial pathologies, DMEK proved feasible with a relatively low risk of complications. Technique standardization may have contributed to a lower graft detachment rate and a relatively low secondary intervention rate. As such, DMEK may become the first choice of treatment in corneal endothelial disease. (C) 2015 by the American Academy of Ophthalmology.