Ultra-thin DSAEK delivers better results than standard DSAEK

Take home message: Ultrathin Descemet’s stripping automated endothelial keratoplasty (DSAEK) is associated with faster visual recovery and better visual acuity in a study compared ultrathin with standard DSAEK.

By Vanessa Caceres

Patients treated with ultrathin Descemet’s stripping automated endothelial keratoplasty (DSAEK) achieve faster visual recovery and better visual outcomes compared with patients who undergo standard DSAEK, said Mor. M. Dickman, MD, University Eye Clinic Maastricht, the Netherlands.

Dr. Dickman discussed the preliminary results of a Netherlands-based prospective randomized multicenter study that included four tertiary care medical centers. He and fellow researchers wanted to further investigate ultrathin DSAEK as DSAEK itself has become more popular because it is associated with less astigmatism, less ocular surface disease, less rejection, and greater tectonic stability compared with penetrating keratoplasty. However, visual acuity following standard DSAEK remains suboptimal, with only a small percentage of patients achieving 20/20 vision.

The 65 patients who participated in the Netherlands study were randomly assigned to receive precut ultrathin DSAEK defined as 100 µm or less versus precut standard DSAEK, defined as thinner than 200 µm. The primary outcome measure was ETDRS best-corrected visual acuity (BCVA) at 12 months postoperatively. The secondary outcome measures were complication profile, quality of vision, and vision-related quality of life, Dr. Dickman said.

Patients included were 18 years or older and had endothelial dysfunction. Patients were excluded if they had prior corneal transplantation, ocular comorbidity other than cataract, human leukocyte antigen typed transplantation, or were unable to communicate.

Patient and donor demographics were similar between both study groups, Dr. Dickman said.

Mean posterior lamellar thickness measured 209 µm in the standard group and 101 µm in the ultrathin group. Dr. Dickman and fellow researchers found a highly significant difference in visual acuity between the two groups, with a 1 ETDRS line advantage in favor of the ultra-thin group. At 3 months, the ultrathin group had an average BCVA of 0.17 logMAR compared with 0.28 logMAR in the standard DSAEK group. At 6 months, average BCVA was 0.14 logMAR in the ultrathin group compared with 0.24 logMAR in the standard group.

Patients in both groups had a significant hyperopic shift, suggesting hyperopic shift is linked to factors other than central graft thickness, Dr. Dickman reported.

Endothelial cell loss also was comparable between both groups, measuring ~40% after 3 months and stabilizing thereafter. Regarding complications, donor dislocation requiring air reinjection measured 15% in both groups. There was one primary graft failure in the ultrathin group that required a re-transplant. No graft rejection occurred during the follow up period.

“The preliminary results show that ultra-thin DSAEK provides faster and better visual recovery, with similar hyperopic shift, endothelial cell density and complication profile compared to standard DSAEK,” Dr. Dickman said.

Endothelial keratoplasties are now common in the U.S., Dr. Dickman said, citing statistics from the Eye Bank Association of America that showed 23,465 DSAEKs and 1,522 Descemet's membrane endothelial keratoplasties were performed in the U.S. in 2013.

“The last decade has seen a revolution in corneal transplantation with endothelial keratoplasty replacing full-thickness grafts as the most common corneal transplantation surgery,” he said.

Mor M. Dickman, MD

E: mor.dickman@mumc.nl ; rudy.nuijts@mumc.nl

This article was adapted from Dr. Dickman’s presentation during the World Cornea Congress meeting held in San Diego earlier this year. The presentation was entitled “Preliminary results of a multicenter prospective randomized controlled trial comparing ultra-thin and standard DSAEK.”