Descemet Membrane Endothelial Keratoplasty Combined With Phacoemulsification and Intraocular Lens Implantation: Advanced Triple Procedure

PURPOSE: To evaluate the functional and morphologic outcome of Descemet membrane endothelial keratoplasty (DMEK) combined with phacoemulsification and intra-ocular lens implantation in patients suffering from endothelial dysfunction and cataract. DESIGN: Retrospective, single-center, consecutive case series. METHODS: Triple-DMEK (DMEK with simultaneous cataract surgery) was performed in 61 consecutive eyes of 56 patients using corneal donor tissue pre-stored in either short-term culture (Optisol-GS) at 4 C or organ culture (Dulbecco's modified Eagle's medium, Cornea Max medium) at 34 C. Main outcome measures included the number of air injections necessary for graft attachment as well as best-corrected visual acuity (BCVA [logMAR]), central corneal thickness (CCT), endothelial cell density (ECD), refractive spherical equivalent, refractive cylinder, and topographic cylinder at 1, 3, and 6 months postoperatively. RESULTS: BCVA increased from 0.6 +/- 0.23 logMAR preoperatively (n = 54) to 0.19 +/- 0.22 logMAR at 6 months (n = 27) after surgery (P <= .05). ECD of donor corneas decreased from 2573 +/- 235 cells/mm(2) (n = 61) to 1550 +/- 326 cells/mm(2) (n = 29) after 6 months (P <= .05). CCT decreased from 651 +/- 69 mu m (n = 54) preoperatively to 521 +/- 65 mu m (n = 27) after 6 months (P <= .05). Refractive spherical equivalent was -0.3 +/- 2.8 D (n = 27) preoperatively and 0.9 +/- 1.5 D 6 months (n = 27) after surgery. A total of 54.5% of eyes were within 1 D of emmetropia (n = 12) and 77.3% were within 2 D of emmetropia (n = 17) 6 months (n = 22) after surgery. Refractive cylinder was -0.9 +/- 1.0 D preoperatively (n = 49) and -1.5 +/- 1.0 D 6 months (n = 23) after surgery. The change in refractive cylinder within the first month was statistically significant (P <= .05; Wilcoxon test). Topographic cylinder was 2.1 +/- 1.7 D preoperatively (n = 58) and 1.7 +/- 1.1 D 6 months (n = 28) after surgery. Between 3 and 6 months a significant change in topographic cylinder towards lower values was measured (P <= 0.05; Wilcoxon test). Optimized spherical results were achieved by selecting intra-ocular lenses based on a hyperopic shift of -0.75 D. CONCLUSION: DMEK combined with cataract surgery (triple procedure) can routinely be performed in cases of endothelial dystrophy and cataract. The addition of cataract surgery to DMEK had no adverse effect on endothelial function or graft adhesion and did not increase the likelihood of postoperative complications. (Am J Ophthalmol 2012;154:47-55. (C) 2012 by Elsevier Inc. All rights reserved.)