Steroid Response In Descemet Membrane Endothelial Keratoplasty (Dmek): A 7-Year Longitudinal Study Of 993 Non-Glaucomatous Eyes

To identify the incidence and risk factors for steroid response in a large cohort of low-risk patients who underwent routine descemet membrane endothelial keratoplasty (DMEK) or combined phacoemulsification and DMEK (phaco-DMEK) surgery

Tertiary referral centre at Moorfields Eye Hospital NHS Foundation Trust, London

A retrospective review of 1032 eyes which had undergone DMEK or combined phaco-DMEK surgery between January 2014 and December 2020 was performed and a total of 993 eyes were included. Eyes with pre-existing ocular hypertension, glaucoma or post-operative pupillary block were excluded. Incidence of steroid response and the time interval to the onset of steroid response were determined. Association between different surgical and post-operative risk factors and steroids response, such as agents for graft tamponade (air vs SF6), types of topical steroids and the need for re-bubbling were analyzed. Treatment outcomes of steroid response in this cohort were also examined.

Overall incidence of steroid response was 12.69% (126/993) across 7 years, of which 13.72% (79/576) for DMEK alone and 11.27% (47/417) for phaco-DMEK but the difference was not significant (p>0.05). Majority of steroid response developed within 4-6 months (42.7%) compared to other post-operative periods (26.0% 1-3 months, 16.7% 7-9 months, 14.6% >9 months; p<0.01). 95% were on topical dexamethasone when steroid response was detected. Re-bubbling increased the risk (OR 1.48, 95% CI 0.07-1.65). There was no statistical difference between air vs SF6 tamponade and the risk of steroid response (p>0.05). Majority (94.8%) responded well to topical intraocular pressure treatment and change of topical steroid formulation without developing glaucoma.

The incidence of steroid response can be higher than expected even for low-risk DMEK patients with no pre-existing history of raised intraocular pressure but a majority of these cases responded well to topical treatment. Change in topical immunosuppression to a lower potency steroid formulation should be considered at around 6 months post-operatively in low-risk DMEK grafts. Patients who require DMEK re-bubbling should be monitored more closely for steroid response.