Increased Rate Of Rebubblings, Immune Reactions And Graft Failure After Descemet Membrane Endothelial Keratoplasty (Dmek) In Eyes With Angle-Supported And Iris-Fixated Intraocular Lenses

To evaluate the safety and efficacy of Descemet membrane endothelial keratoplasty (DMEK) in eyes with angle-supported anterior chamber IOL (ACIOL), iris-fixated anterior chamber IOL (IF-ACIOL), or iris-fixated posterior chamber IOL (IF-PCIOL) compared to eyes with a posterior chamber intraocular lens (PCIOL).

Retrospective case control study, Department of Ophthalmology, University Hospital Cologne, Germany, tertiary referral center.

40 patients undergoing pseudophakic DMEK (ACIOL, IF-ACIOL or IF-PCIOL) or a combined procedure of DMEK and IOL implantation (ACIOL or IF-ACIOL) were analyzed and compared to 80 age-matched individuals with PICOL receiving DMEK. Measures of safety (rebubbling, immune reactions, graft failure, regraft) and efficacy (best corrected visual acuity (BCVA), endothelial cell count (ECC), central corneal thickness (CCT), intraocular pressure (IOP)) were compared with a control cohort undergoing DMEK after PCIOL implantation or a triple procedure with PCIOL. Time points analyzed include the preoperative status and 1, 3, 6, 12, 24, and 36 months after the intervention. The data was evaluated with SPSS. Patients undergoing re-DMEKs were excluded.

In the ACIOL and IF-PCIOL group, indication for DMEK include bullous keratopathy (70%), Fuchs dystrophy (12,5%), PEX keratopathy (7,5%), corneal graft failure (7,5%), and Schlichting dystrophy (2,5%). There was an increased risk for rebubblings (OR 2.06), immune reactions (OR 1.72), graft failure (OR 1.58), and regrafts (OR 1.72). A significant improvement in BCVA (logMar) after DMEK was noted in both groups, while the mean BCVA was higher at 1 through 3 years after DMEK (p=0.003; t=2 years) and the mean ECC was lower as of 3 months in the ACIOL/IF-PCIOL group (p=0.004; mixed model analysis). No correlation of ECC and anterior chamber depth was noted. Mean CCT decreased postoperatively and IOP was stable through all timepoints.

DMEK effectively improves visual outcomes postoperatively in eyes with ACIOL and PCIOL as measured by BCVA, ECC, CCT and IOP, although these eyes exhibited an increased risk of adverse events such as increased rebubblings, immune reactions, and graft failure. This may be due to the fact that more diseased eyes with multiple prior surgeries or pathologies are assigned to anterior chamber or iris-fixated IOLs. The higher rate of rebubblings could be attributed to the open access to the vitreus space, which can facilitate the displacement of the anterior chamber gas tamponade posteriorly. In conclusion, DMEK in eyes with ACIOL or IF-PCIOL remains beneficial despite higher risks.