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Comment & Response
June 2015

Descemet Membrane Endothelial Keratoplasty—Reply

Author Affiliations
  • 1Netherlands Institute for Innovative Ocular Surgery (NIIOS), Rotterdam, the Netherlands
  • 2Melles CorneaClinic Rotterdam, Rotterdam, the Netherlands
  • 3Amnitrans Eyebank Rotterdam, Rotterdam, the Netherlands
JAMA Ophthalmol. 2015;133(6):725. doi:10.1001/jamaophthalmol.2015.0486

In Reply We thank Shanbhag et al for commenting on our study. In short, they question whether, based on our article describing the learning curve for 18 novel DMEK surgeons,1 the procedure would be a better alternative to DSEK and PK. The main concerns expressed are that the study does not contain reliable data on best-corrected visual acuity, the decrease in endothelial cell density would be higher than in earlier techniques, and about one-fifth of eyes required a secondary intervention. Furthermore, according to long-term studies PK would still be preferable over endothelial keratoplasty, and unless technique improvements are reached, DMEK may not hold potential to become a preferred method for treatment of endothelial disorders.2

From their comment it is our understanding that they compared learning curve results of DMEK with large PK and DSEK study groups described by experienced surgeons. However, to get more accurate information on all of these techniques, it would seem mandatory to compare either learning curve results with each other or large study groups by established centers (instead of short-term learning curve outcomes with long-term results of experienced surgeons). Expanding on this, the cited publications in Ophthalmology read different to us: recently introduced techniques for lamellar keratoplasty showed better outcomes than PK in single-center studies,2-4 but these results would not (yet) be reached by nationwide evaluations. In other words, DMEK as a technique may have been shown to surpass DSEK and PK, but the results on a larger-scale implementation lag behind.

We have learned from techniques previously designed by us, like deep lamellar endothelial keratoplasty and DSEK, that starting with a new technique may be more challenging than one would anticipate. Therefore, we have tried to standardize as much as possible the surgical technique for DMEK as well as its technique for donor tissue preparation, into what we now refer to as “standardized no-touch DMEK.”5,6 Still, surgeons in various countries will be facing challenges as a result of different clinical settings, such as surgical facilities, donor tissue availability, or support of an eye bank or lack thereof. In an attempt to better identify these problems, we performed our retrospective study that may aid corneal surgeons in starting with DMEK, while it allowed us to fine-tune our educational program. So to answer the question in the title of whether “to do or not to do” DMEK, since additional training in the various techniques may be obtained through instructional courses at international meetings, wetlab courses, textbooks on DMEK, or live-surgery video-streaming sessions, we encourage all our colleagues to consider DMEK for the management of corneal endothelial disorders.

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Article Information

Corresponding Author: Gerrit R. J. Melles, MD, PhD, Netherlands Institute for Innovative Ocular Surgery (NIIOS), Laan op Zuid 88, 3071 AA Rotterdam, the Netherlands (research@niios.com).

Published Online: April 2, 2015. doi:10.1001/jamaophthalmol.2015.0486.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Melles is a consultant for DORC International/Dutch Ophthalmic USA and SurgiCube International. No other disclosures were reported.

References
1.
Monnereau  C, Quilendrino  R, Dapena  I,  et al.  Multicenter study of descemet membrane endothelial keratoplasty: first case series of 18 surgeons.  JAMA Ophthalmol. 2014;132(10):1192-1198.PubMedGoogle ScholarCrossref
2.
Coster  DJ, Lowe  MT, Keane  MC, Williams  KA; Australian Corneal Graft Registry Contributors.  A comparison of lamellar and penetrating keratoplasty outcomes: a registry study.  Ophthalmology. 2014;121(5):979-987.PubMedGoogle ScholarCrossref
3.
Guerra  FP, Anshu  A, Price  MO, Giebel  AW, Price  FW.  Descemet’s membrane endothelial keratoplasty: prospective study of 1-year visual outcomes, graft survival, and endothelial cell loss.  Ophthalmology. 2011;118(12):2368-2373.PubMedGoogle ScholarCrossref
4.
Rodríguez-Calvo-de-Mora  M, Quilendrino  R, Ham  L,  et al.  Clinical outcome of 500 consecutive cases undergoing Descemet's membrane endothelial keratoplasty [published online October 22, 2014].  Ophthalmology. doi:10.1016/j.ophtha.2014.09.004.Google Scholar
5.
Dapena  I, Moutsouris  K, Droutsas  K, Ham  L, van Dijk  K, Melles  GR.  Standardized “no-touch” technique for descemet membrane endothelial keratoplasty.  Arch Ophthalmol. 2011;129(1):88-94.PubMedGoogle ScholarCrossref
6.
Groeneveld-van Beek  EA, Lie  JT, van der Wees  J, Bruinsma  M, Melles  GR.  Standardized ‘no-touch’ donor tissue preparation for DALK and DMEK: harvesting undamaged anterior and posterior transplants from the same donor cornea.  Acta Ophthalmol. 2013;91(2):145-150.PubMedGoogle ScholarCrossref
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