DMEK vs DSAEK: what is the latest?

Experience of operating surgeon often determines choice of procedure

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Descemet stripping automated endothelial keratoplasty (DSAEK) remains the more popular choice in cataract surgery on diseased corneas, but the use of Descemet’s membrane endothelial keratoplasty (DMEK) is increasing and has certain advantages, Frank Larkin MD, FRCOphth, UK, told the 37th Congress of the ESCRS in Paris, France. Addressing the joint ESCRS/EuCornea Symposium: ‘Cataract Surgery in Eyes with Diseased Corneas’, Dr Larkin gave a considered overview on when to use DSAEK or DMEK in combination with cataract surgery, with surgeon experience and pre-cut graft availability being key considerations. While discussing meta-analyses and the data reported to date, he said there remains a scarcity of controlled clinical trials and lack of information in particular on longer-term visual outcomes, and complication rates with/without adjustment for surgeon inexperience. Dr Larkin listed the advantages of DSAEK as the donor graft being prepared in advance (faster operating lists and no uncertainty about donor availability), easier graft handling in the anterior chamber, more versatile technique (it can be used in a wider variety of anterior segment disorders and dimensions), and lower complication rates. With regards to DMEK, advantages include faster visual recovery, better visual acuity and quality in the earlier months post-surgery, and a probable lower risk of allograft rejection – “if this is confirmed in prospective studies it may mean needing to use less steroids”. Dr Larkin quoted UK registry data on EK for all indications since 2001 which shows the significant rise in its usage; from just eight procedures in 2001 to over 2,000 procedures in 2018. DSAEK was by far the most popular choice of EK initially, but DMEK has rapidly caught up in the last five years, with 630 DMEK procedures performed in 2018 in the UK. He also highlighted data showing that DSAEK outcomes in Fuchs’ cases are improving over time. However, Dr Larkin also cited results from a 2019 analysis of 88 UK ophthalmic surgeons, which showed that the majority (51) had performed fewer than 20 DMEK procedures, so surgeon experience in the procedure still needs to improve. Summarising the UK registry outcome data to date, he said DSAEK and DMEK outcomes are comparable after accounting for surgeon learning, adjusting for post-DMEK failure and surgeon experience. Concluding, Dr Larkin said DMEK is becoming more established among high-volume surgeons and centres for uncomplicated endothelial replacement with cataract surgery. In the future in such centres DSAEK will remain the preferred procedure in patients with comorbidities, but more detailed studies and longer-term data are needed, he said. Frank Larkin: frank.larkin@moorfields.nhs.uk 
Tags: dmek, dsaek, EuCornea