Efficacy and safety of Descemet’s membrane endothelial keratoplasty versus Descemet’s stripping endothelial keratoplasty: A systematic review and meta-analysis

PLOS ONE, Nov 2019

Purpose 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). Methods 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 complications 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 postoperative 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 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.

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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 - 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)


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Saiqun Li, Liangping Liu, Wei Wang, Ting Huang, Xingwu Zhong, Jin Yuan, Lingyi Liang. Efficacy and safety of Descemet’s membrane endothelial keratoplasty versus Descemet’s stripping endothelial keratoplasty: A systematic review and meta-analysis, PLOS ONE, 2017, Volume 12, Issue 12, DOI: 10.1371/journal.pone.0182275