Descemet's Stripping Without Endothelial Keratoplasty

Daniel Garcerant; Nino Hirnschall; Nicholas Toalster; Meidong Zhu; Li Wen; Gregory Moloney

Disclosures

Curr Opin Ophthalmol. 2019;30(4):275-285. 

In This Article

Background

Although recent publications have given surgeons renewed confidence to attempt Descemet's stripping for Fuchs' Dystrophy, the idea itself was described in detail decades ago by Paufique.[22] The technique was clearly not widely adopted and the reference all but lost, discovered by chance in the library of the Massachusetts Eye and Ear Infirmary (R Pineda – personal communication). In more recent years the observation of corneal clearance after iatrogenic trauma was noted by several authors (Table 1).[23–33]

With the evolution of endothelial keratoplasty, the deliberate stripping of Descemet's membrane has become commonplace. The Melles group reported clearance of corneas with nonattached Descemet's grafts, with this subsequently tried deliberately in a technique dubbed Descemet's membrane endothelial transfer.[8,9,10,11] Several reports emerged at a similar time describing deliberate removal of Descemet's membrane without grafting for Fuchs' Dystrophy.[30,34,35,36]

Early reports of the success of this strategy were mixed at best (Table 2). Bleyen et al.[34] described failure in seven of eight cases after stripping Descemets membrane with a diameter of 8 mm. Price[35] reported mixed outcomes in a series of three cases with a 6–6.5-mm Descemetorhexis, two clearing with one case having residual edema. Concerns were held in all cases regarding postoperative visual quality and irregular astigmatism. Koenig[37] also reported nonclearance in two cases with a 6 mm descemetorhexis. In reports of inadvertent Descemet's membrane endothelial keratoplasty (DMEK) graft detachment and corneal clearance, all published cases eventually proceeded to DMEK with re-emergence of corneal edema after roughly 24 months.[38,39] Of course in these cases an 8–9-mm descemetorhexis was created.

In cases with a smaller descemetorhexis better clearance rates were reported. Iovieno et al.[43] reported clearance in four of five cases with a 4 mm descemetorhexis but also reported concerns regarding irregular astigmatism. In Borkar's series 10/13 cases with a 4 mm descemetorhexis achieved corneal clearance and in our initial series 9/12 cases with a 3–4 mm descemetorhexis achieved clearance.[36]

The issues affecting the surgery at this point in time were the unpredictability of corneal clearance, both who would achieve it, and how long it would take, but also the quality of vision conferred even if clearance was achieved. Colby coined the useful terminology – 'fast, slow and nonresponders' to the technique.[36] Clearly a strategy was required to preselect the fast responders presurgery or convert the slow and nonresponders postsurgery. It is reasonable to assume that a patient's response to this surgery is either due to innate, possibly genetic characteristics of the anterior segment, or iatrogenic factors at the time of surgery.

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