Repeat Descemet Membrane Endothelial Keratoplasty: Secondary Grafts with Early Intervention Are Comparable with Fellow-Eye Primary Grafts.

Abstract

To evaluate the outcomes of secondary Descemet membrane endothelial keratoplasty (DMEK) after failed primary DMEK. Retrospective, interventional case series. Fifty-five DMEK recipients 42 to 89 years of age. An initial consecutive series of 1655 DMEK surgeries was reviewed to identify cases of secondary DMEK after failed primary DMEK (n = 55). A paired fellow-eye analysis was performed with a subgroup of 29 patients who underwent secondary DMEK in 1 eye and successful primary DMEK in the fellow eye. Corrected distance visual acuity (CDVA), central corneal thickness, and 1-year endothelial cell loss. The median follow-up after DMEK regraft was 18 months (range, 3-61 months). All 55 regrafts cleared, 8 (15%) had air reinjected to promote attachment, 1 eye (2%) with trabeculectomy and progressive synechiae demonstrated late endothelial failure, and no rejection episodes occurred (0%). In the paired analysis, the median duration of endothelial decompensation before the regraft was 21 days (range, 2-133 days). At 1, 3, 6, or 12 months, CDVA did not differ between the primary and secondary grafts in fellow eyes (mean difference, ≤2 Snellen letters; P > 0.05 at all examinations). At 1 year, the visual acuity was ≥20/20 in 61%, ≥20/25 in 81%, and ≥20/40 in 100% of the secondary grafts in the paired analysis, excluding 1 eye with retinal problems. Vision differed by ≤1 line between fellow eyes in all but the 1 patient with the longest time to regraft (133 days), who demonstrated central haze and irregular astigmatism from anterior stromal scarring during that period. At 1 year, CDVA associated with the scarring was 20/40 versus 20/20 for the fellow-eye primary graft. The central corneal thickness was comparable between fellow-eye primary and secondary grafts at 3, 6, and 12 months (mean difference at 1 year, 2 μm; P = 0.57). The 1-year endothelial cell loss was comparable in primary and secondary grafts (27% vs. 31%, respectively; P = 0.58). In patients who received prompt intervention to minimize the duration of central corneal decompensation, the visual outcomes with secondary DMEK matched the fellow-eye visual outcomes with primary DMEK.