Long-Term Results Of Steroid-Induced Intraocular Pressure Elevation And Glaucoma After Descemet Membrane Endothelial Keratoplasty

To evaluate the long-term incidence of steroid-induced intraocular pressure (IOP) elevation and post-Descemet Membrane Endothelial Keratoplasty (DMEK) glaucoma following DMEK and DMEK combined with phacoemulsification, with emphasis on the type of topical corticosteroid used.

Single-center, retrospective, consecutive case series.

Fully anonymized data were collected from 168 eyes undergoing DMEK or DMEK triple procedures for Fuchs endothelial dystrophy at Sussex Eye Hospital, United Kingdom, between 2017 and 2023. After exclusions for pre-existing glaucoma/ocular hypertension, repeat DMEK, primary graft failure, or inadequate follow-up, 98 eyes (mean age 70.7 ± 10.4 years) were analyzed. Postoperative regimens included topical dexamethasone 0.1% for four weeks, followed by loteprednol 0.5%. IOP measurements were recorded at 12 months and at the last follow-up (mean 47 ± 21.5 months). Steroid response was defined as IOP ≥22 mmHg or an increase of ≥5 mmHg from baseline. Post-DMEK glaucoma required IOP elevation plus glaucomatous optic disc or visual field changes.

The overall steroid response incidence was 17.4% (17/98 eyes). Of steroid responders, 88.2% (15/17) were receiving topical dexamethasone at onset (mean time 7.7 months), while 11.8% (2/17) were receiving loteprednol (mean time 6.5 months). Rejection occurred in 2.0% (2/98) of cases, with equal distribution between dexamethasone and loteprednol groups. Post-DMEK glaucoma developed in 5.1% (5/98) of eyes. Six patients required ongoing anti-glaucoma medications; no patient required glaucoma surgery. Rebubbling rates were 44% among steroid responders versus 30% among normal eyes (p=0.52).

Steroid-induced IOP elevation remains a significant complication after DMEK, predominantly associated with dexamethasone use. The majority of steroid responders were receiving dexamethasone at the time of IOP elevation. Early transition to lower-potency corticosteroids, such as loteprednol etabonate, after the first postoperative month may reduce the risk of steroid response while maintaining adequate immunosuppression in low-risk DMEK cases.