Efficacy and safety of Descemet’s membrane endothelial keratoplasty versus Descemet’s stripping endothelial keratoplasty: A systematic review and meta-analysis
December
Efficacy and safety of Descemet's membrane endothelial keratoplasty versus Descemet's stripping endothelial keratoplasty: A systematic review and meta-analysis
Saiqun Li 0 1
Liangping Liu 0 1
Wei Wang 0 1
Ting Huang 0 1
Xingwu Zhong 0 1
Jin Yuan 0 1
Lingyi Liang 0 1
0 State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University , Guangzhou , China , 2 Hainan Eye Hospital, Zhongshan Ophthalmic Center, Sun Yat-sen University , Haikou , China
1 Editor: Wei Li, Xiamen University , CHINA
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Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: Our study was supported by the National
Natural Science Foundation of China (http://www.
nsfc.gov.cn/; (i) award number: 81300739; receipt:
Lingyi Liang; (ii) award number: 81400423; receipt:
Saiqun Li). The funders had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Purpose
Methods
Based on current evidence, the efficiency and safety of Descemet's membrane endothelial keratoplasty (DMEK) was compared with that of Descemet's stripping endothelial keratoplasty (DSEK).
Pubmed, Embase, Web of Science, the Cochrane Database and conference abstracts were
comprehensively searched for studies that compared the efficacy and safety of DMEK and
DSEK. The efficacy outcome was the postoperative best-corrected visual acuity (BCVA).
The safety outcomes included the postoperative endothelial cell density (ECD) and compli
cations such as graft detachment, graft rejection, graft failure, postoperative elevated
intraocular pressure (IOP), tissue loss, etc. The outcomes were pooled using random-effects
models with Stata 13.0 software. Heterogeneity was qualified with Q statistic and I2/H2
statistic. Publication bias was assessed using funnel plot, Begg rank correlation test, and
Egger or Horbard linear regression.
Results
19 articles were eligible, and 1124 eyes and 1254 eyes were included in the DMEK and
DSEK groups, respectively. The overall pooled estimates showed a significantly better post
operative BCVA, a comparable ECD and an increased graft detachment rate in the DMEK
group compared with the DSEK group (BCVA: mean difference (MD) = -0.15, 95% CI =
-0.19 to -0.11, P<0.001; ECD: MD = 14.88, 95% CI = -181.50 to 211.27, P = 0.882; graft
detachment rate: OR = 4.56, 95% CI = 2.43 to 8.58, P<0.001). Except for the postoperative
ECD, which was changed to be higher in the DSEK group than the DMEK group, the learning curve did not have a marked effect on the comparison outcome of the BCVA and graft
Competing interests: The authors have declared
that no competing interests exist.
detachment rate based on the estimates pooled from studies that collected data during the
DMEK learning phase (ECD (learning curve): MD = -361.24, 95% CI = -649.42 to -73.07,
P = 0.014).
Conclusion
Although DMEK is a more technically difficult and challenging procedure, it may represent a safe and more efficient alternative to DSEK for the treatment of corneal endothelial diseases, even during its learning curve.
Introduction
In 2004, corneal transplantation took a great advance by introducing a new technique termed
ªDescemet's stripping endothelial keratoplastyº (DSEK)[1±3]. In this new keratoplasty
procedure, the patient's diseased endothelium and Descemet's membrane are replaced with
posterior corneal stroma, Descemet's membrane and endothelium from the donor cornea[
1, 2, 4
].
Since then, DSEK has been rapidly adopted by surgeons worldwide, and it has gradually
become the standard surgical treatment for corneal endothelial problems, such as Fuchs
corneal dystrophy, pseudophakic bullous keratopathy (PBK) and iridocorneal endothelial (ICE)
syndrome, because of its short learning curve, good clinical outcomes, easier donor
preparation and manipulation, and reproducible results[
5, 6
].
However, the interface opacification, optical irregularities, hyperopic refractive shift and
thicker cornea caused by the extra stromal layers transplanted during the DSEK procedure
may have a negative impact on postoperative visual quality[
7, 8
]. Therefore, to fully retain the
anatomy of the recipient's cornea, endothelial keratoplasty (EK) was used with the
introduction by Melles in 2006 of ªDescemet's membrane endothelial keratoplastyº (DMEK), which
transplants a lamella of Descemet's membrane and endothelium without an adherent donor
corneal stroma[9]. Since its introduction, the number of DMEK cases performed each year in
the United States has doubled every year; however, DSEK is still the dominant surgical
treatment of choice for endothelial diseases[
10
].
DMEK and DSEK both have advantages and disadvantages. Numerous studies have
demonstrated that DMEK results in faster visual rehabilitation and better final visual acuity than
DSEK[11±13]. However, despite the favorable visual outcomes achieved by DMEK, the
technical challenges and (...truncated)