Endothelial keratoplasty: is Descemet membrane endothelial keratoplasty the way forward? Yes

It is widely accepted that endothelial keratoplasty is the preferable treatment for corneal endothelial disorders. Refinements in the last decade have enabled corneal surgeons to remove the diseased recipient Descemet membrane (DM) and endothelial layer with a descemetorhexis, and specifically replace these posterior layers by means of an endothelial keratoplasty (EK).^{1, 2} Transplanted grafts may include donor stroma of variable thickness, with a tendency towards thinner grafts, thus moving from Descemet stripping (automated) endothelial keratoplasty (DS(A)EK)^{2, 3} to ultrathin DS(A)EK (UT-DS(A)EK)⁴ and finally to Descemet membrane endothelial keratoplasty (DMEK).¹ In DMEK, the transplant consists only of DM and endothelium. Lately, DMEK has been refined into a standardized ‘no-touch’ procedure, ready for the typical corneal surgeon in any clinical setting and at low cost.⁵ Alternative or modified techniques have been also described and standardized in an attempt to make DMEK feasible and successful also in more demanding and complicated cases.^{6, 7, 8}

Following DS(A)EK, the average vision at 6 months is 20/40 (0.5), rarely reaching 20/25 (0.8) or better.⁹ Irregularities in graft thickness and the stromal interface are believed to induce additional optical aberrations compromising the visual outcome.¹⁰ Vision in eyes with irregularities in the DS(A)EK graft thickness or in the stromal interface was shown to improve markedly with a re-operation, replacing the DS(A)EK graft with a DMEK.¹¹ Ultra-thin DSAEK might provide better visual results than standard DSAEK,⁴ but visual rehabilitation still seems to be slower than with DMEK. After DMEK, ≥80% of the eyes without other ocular comorbidities can reach a BCVA of ≥20/40 (0.5) already within the first month after surgery, increasing to ≥95% at 6 months. Moreover, at 6 months postoperatively, 80% of the eyes may achieve a BCVA ≥20/25 (0.8) and almost 50% may even reach 20/20 (1.0).^{12, 13} Visual rehabilitation is usually fast, with most patients reaching their final BCVA within 1–3 months.¹⁴ This may prove extremely helpful in younger, more ‘active’ patients as well as in patients who are practically ‘monoculus’. The proof of DMEK’s superiority comes from the patients themselves, as in a series of patients with one eye operated with DSAEK and the fellow eye with DMEK, overwhelmingly, they prefer the vision in their DMEK eye.¹⁵

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