COMPARISON OF PHACO-DWEK AND PHACO-DMEK IN PATIENTS WITH CATARACT AND EARLY-TO-MODERATE FUCHS ENDOTHELIAL DYSTROPHY

To compare the clinical outcomes of phacoemulsification combined with Descemetorhexis without endothelial keratoplasty (Phaco-DWEK) versus phacoemulsification combined with Descemet membrane endothelial keratoplasty (Phaco-DMEK) in patients with cataract and Fuchs endothelial corneal dystrophy (FECD).

Ophthalmology Department in a Tertiary Hospital in Lisbon

Retrospective study of 42 eyes (36 patients) operated between 2018–2023: 13 Phaco-DWEK and 29 Phaco-DMEK. Phaco-DWEK was offered for stage 1 FECD (central guttae < 5 mm, no edema, peripheral ECD > 1500 cells/mm², CCT < 600 µm). Phaco-DMEK was indicated for stage 2 disease (stromal edema, CCT > 600 µm, risk of decompensation). Exclusion criteria: previous ocular surgery, complicated cataract, other ocular pathology, epithelial edema and baseline best-corrected visual acuity (BCVA) <0.2 decimal (for Phaco-DWEK group). Baseline variables included age, sex, and BCVA. Outcomes: time to corneal clearance, BCVA at 3 and 6 months, endothelial cell density (ECD) and central corneal thickness (CCT) at 6 months, secondary interventions, and complications. Kaplan–Meier with log-rank test compared clearance times; other variables were analyzed using parametric/non-parametric and Fisher’s exact tests.

Mean age (70.2 ± 6.6 vs 70.3 ± 9.3 years; p=0.99) and sex (p=0.66) were comparable. Preoperative BCVA was worse in Phaco-DMEK (0.70 [0.50–1.00] vs 0.40 [0.30–0.46] logMAR; p=0.0003). Corneal clearance occurred significantly faster with Phaco-DMEK (median 12 vs 60 days; HR = 4.1, 95% CI 2.1–7.9; p<0.0001). Postoperative BCVA was similar at 3 (p=0.90) and 6 months (p=0.22). At 6 months, ECD was higher in Phaco-DMEK (1760 vs 992 cells/mm²; p<0.0001) while CCT was comparable (547 vs 542 µm; p=0.73). Secondary keratoplasty was required in 30% of Phaco-DWEK (n=4) versus 3% in Phaco-DMEK (n=1), though 21% (n=6) of Phaco-DMEK required rebubbling. Iatrogenic stromal haze occurred more often after Phaco-DWEK (38.5% vs 10.3%, p=0.08). No immunologic rejection or corticosteroid-related complications were observed.

Phaco-DMEK achieved faster corneal recovery, superior endothelial preservation, and lower failure rates than Phaco-DWEK, with equivalent visual outcomes at 6 months. Phaco-DMEK should be favored for FECD stage 2, while Phaco-DWEK may be considered in carefully selected early-stage cases.