Cystoid Macular Edema Following DMEK
Cystoid Macular Edema Following DMEK
Background To determine the incidence and potential risk factors of cystoid macular oedema (CMO) following Descemet membrane endothelial keratoplasty (DMEK) with or without simultaneous cataract surgery.
Methods In this study, 155 eyes of 88 patients suffering from Fuchs endothelial dystrophy (81%), bullous keratopathy (17.6%) or other corneal diseases (1.4%) underwent DMEK. 52% were pseudophacic (DMEK) and 48% received simultaneous cataract surgery (DMEK combined with cataract surgery (Triple-DMEK)) at the Eye Center at Albert Ludwigs University of Freiburg between May 2011 and June 2013. Spectral-domain optical coherence tomography (SD-OCT) was performed 6 weeks, 3 months and 6 months following (Triple-)DMEK and in unscheduled visits due to limited or decreased visual acuity. The medical records were reviewed for pre-existing comorbidities limiting visual acuity. Patients with a history of macular oedema were excluded. We estimated the incidence of CMO using the Kaplan–Meier method. Potential risk factors for CMO were analysed with a Cox regression analysis and Pearson's correlation. The Cox model included the following variables: patient age and axial length, simultaneous cataract surgery, rate of rebubbling, donor age and donor endothelial cell density.
Results 13% of all eyes developed a single episode of CMO at the end of the follow-up. After 6 months, 13.3% of eyes following Triple-DMEK and 12.5% of eyes following DMEK showed CMO. There was a statistically significant correlation between CMO development and best spectacle corrected visual acuity. Long axial length had a protective effect on CMO development (HR=0.3; p=0.03). Under medical therapy, central foveal thickness decreased in all patients. CMO did not have a relevant effect on long-term visual acuity.
Conclusions CMO is a frequent complication following DMEK in phacic and pseudophacic eyes. The prognosis is excellent given medical treatment. We recommend regular SD-OCT monitoring during the first 6 months following DMEK.
The treatment of corneal endothelial disorders such as Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK) has changed greatly during the last few years. Compared with penetrating keratoplasty (PK), posterior lamellar keratoplasty techniques such as Descemet stripping automated endothelial keratoplasty (DSAEK) or Descemet membrane endothelial keratoplasty (DMEK) allow a faster and refractively neutral visual rehabilitation and have a reduced risk of rejection. This seems especially true for DMEK. However, this surgical technique is not as standardised as DSAEK or PK. The most frequent complication following DMEK is graft dislocation, which can be treated with a repeated air fill of the anterior chamber. However, the complete spectrum of complications is not yet well characterised.
Cystoid macular oedema (CMO) is a well-known complication following intraocular surgery. However, the pathophysiology is not completely understood. It can be measured by various methods, including fluorescence angiography or different kinds of optical coherence tomography (OCT). The incidence of angiographically proven CMO is about 10-fold higher than the incidence measured by OCT. As OCT is the less invasive procedure and known to show clinically significant CMO, it is often used for screening or the diagnosis of CMO. The incidence of CMO following uneventful cataract surgery is 0.1%–2.4%. After complicated cataract surgery (ie, posterior capsule rupture with or without vitreous loss or after laser capsulotomy), the risk can increase 10 times up to 21% during the first month. In patients with pre-existing systemic diseases such as diabetes mellitus, CMO is reported to occur in up to 28.6% of cases after cataract surgery within the first postoperative year.
We hypothesise that CMO can also occur following DMEK because of the intraoperative manipulation inside the anterior chamber. To determine the incidence of CMO following DMEK (with or without combined cataract surgery), we performed repeated optical coherence tomographies following DMEK in a large consecutive case series.
Abstract and Introduction
Abstract
Background To determine the incidence and potential risk factors of cystoid macular oedema (CMO) following Descemet membrane endothelial keratoplasty (DMEK) with or without simultaneous cataract surgery.
Methods In this study, 155 eyes of 88 patients suffering from Fuchs endothelial dystrophy (81%), bullous keratopathy (17.6%) or other corneal diseases (1.4%) underwent DMEK. 52% were pseudophacic (DMEK) and 48% received simultaneous cataract surgery (DMEK combined with cataract surgery (Triple-DMEK)) at the Eye Center at Albert Ludwigs University of Freiburg between May 2011 and June 2013. Spectral-domain optical coherence tomography (SD-OCT) was performed 6 weeks, 3 months and 6 months following (Triple-)DMEK and in unscheduled visits due to limited or decreased visual acuity. The medical records were reviewed for pre-existing comorbidities limiting visual acuity. Patients with a history of macular oedema were excluded. We estimated the incidence of CMO using the Kaplan–Meier method. Potential risk factors for CMO were analysed with a Cox regression analysis and Pearson's correlation. The Cox model included the following variables: patient age and axial length, simultaneous cataract surgery, rate of rebubbling, donor age and donor endothelial cell density.
Results 13% of all eyes developed a single episode of CMO at the end of the follow-up. After 6 months, 13.3% of eyes following Triple-DMEK and 12.5% of eyes following DMEK showed CMO. There was a statistically significant correlation between CMO development and best spectacle corrected visual acuity. Long axial length had a protective effect on CMO development (HR=0.3; p=0.03). Under medical therapy, central foveal thickness decreased in all patients. CMO did not have a relevant effect on long-term visual acuity.
Conclusions CMO is a frequent complication following DMEK in phacic and pseudophacic eyes. The prognosis is excellent given medical treatment. We recommend regular SD-OCT monitoring during the first 6 months following DMEK.
Introduction
The treatment of corneal endothelial disorders such as Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK) has changed greatly during the last few years. Compared with penetrating keratoplasty (PK), posterior lamellar keratoplasty techniques such as Descemet stripping automated endothelial keratoplasty (DSAEK) or Descemet membrane endothelial keratoplasty (DMEK) allow a faster and refractively neutral visual rehabilitation and have a reduced risk of rejection. This seems especially true for DMEK. However, this surgical technique is not as standardised as DSAEK or PK. The most frequent complication following DMEK is graft dislocation, which can be treated with a repeated air fill of the anterior chamber. However, the complete spectrum of complications is not yet well characterised.
Cystoid macular oedema (CMO) is a well-known complication following intraocular surgery. However, the pathophysiology is not completely understood. It can be measured by various methods, including fluorescence angiography or different kinds of optical coherence tomography (OCT). The incidence of angiographically proven CMO is about 10-fold higher than the incidence measured by OCT. As OCT is the less invasive procedure and known to show clinically significant CMO, it is often used for screening or the diagnosis of CMO. The incidence of CMO following uneventful cataract surgery is 0.1%–2.4%. After complicated cataract surgery (ie, posterior capsule rupture with or without vitreous loss or after laser capsulotomy), the risk can increase 10 times up to 21% during the first month. In patients with pre-existing systemic diseases such as diabetes mellitus, CMO is reported to occur in up to 28.6% of cases after cataract surgery within the first postoperative year.
We hypothesise that CMO can also occur following DMEK because of the intraoperative manipulation inside the anterior chamber. To determine the incidence of CMO following DMEK (with or without combined cataract surgery), we performed repeated optical coherence tomographies following DMEK in a large consecutive case series.
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