Causes of Glaucoma After Descemet Membrane Endothelial Keratoplasty

PURPOSE: To describe the incidence and causes of glaucoma after Descemet membrane endothelial keratoplasty (DMEK). DESIGN: Nonrandomized prospective cohort study at a tertiary referral center. METHODS: The incidence of glaucoma was evaluated in the first 275 consecutive eyes that underwent DMEK for Fuchs endothelial dystrophy (260 eyes) or bullous keratopathy (15 eyes). Glaucoma was defined as a postoperative intraocular pressure (IOP) elevation of >= 24 mm Hg, or >= 10 mm Hg from the preoperative baseline. If possible, the cause of glaucoma was identified, and best-corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative course were documented, with a mean follow-up of 22 (+/- 13) months. RESULTS: Overall, 18 eyes (6.5%) showed postoperative glaucoma after DMEK. Seven eyes (2.5%) had an exacerbation of a pre-existing glaucoma. Eleven eyes (4%) presented with a de novo TOP elevation, associated with air bubble induced mechanical angle closure (2%), steroid response (0.7%), or peripheral anterior synechiae (0.4%), or without detectable cause (0.7%). Two eyes (0.7%) required glaucoma surgery after DMEK. At 6 months, all eyes had a BCVA of >= 20/40 (>= 0.5), and 81% reached >= 20/25 (>= 0.8) (n = 16); mean ECD was 1660 (+/- 554) cells/mm(2) (n = 15) (P > .1). CONCLUSION: Glaucoma after DMEK may be a relatively frequent complication that could be avoided by reducing the residual postoperative air bubble to 30% in phakic eyes, applying a population-specific steroid regime, and avoiding decentration of the Descemet graft. Eyes with a history of glaucoma may need close TOP monitoring in the first postoperative months, especially in eyes with an angle-supported phakic intraocular lens. (Am J Ophthalmol 2012;153:958-966. (C) 2012 by Elsevier Inc. All rights reserved.)