Different Course of Immune Reactions and Endothelial Cell Loss after Penetrating Low-Risk Keratoplasty and Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Dystrophy

Abstract

Background The aim of this study was to compare the incidence of immune reactions and endothelial cell loss after penetrating keratoplasty (PKP) vs. Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial dystrophy (FED).

Patients and Methods In the present retrospective study, a total of 962 surgeries (225 excimer laser PKP and 727 DMEK) of 700 patients performed between 28.06.2007 and 27.08.2020 in the Department of Ophthalmology at Saarland University Medical Center UKS were statistically evaluated. On the one hand, the prevalence and the temporal course of the immune reactions that occurred were analysed using the Kaplan-Meier method, as well as the effect of the immune reactions on the endothelial cells and corneal thickness. Secondly, endothelial cell density, pleomorphism, and polymegethism of the endothelial cells were evaluated for the time points U1 = preoperative, U2 = 6 weeks postoperative, U3 = 6 to 9 months postoperative, U4 = 1 to 2 years postoperative, and U5 = 5 years postoperative. In addition, statistical tests were carried out for differences between the two types of surgery and in the longitudinal course.

Results A total of 54 immune reactions occurred during the observed period, whereby the probability of such a reaction was significantly greater in the PKP group with 8.9% than in the DMEK group with 4.5% (p = 0.011). The comparison of the two Kaplan-Meier curves also showed a significant difference between the two surgical techniques in the log-rank test (p = 0.012). The endothelial cell loss due to the immune reaction was only significant in PKP (p = 0.003). For all surgical procedures, endothelial cell density decreased significantly with time in both surgical techniques (p < 0.0001 in each case), but more strongly with DMEK than with PKP (p < 0.0001). Furthermore, this cell density was significantly higher with PKP than with DMEK for the whole observation time (p < 0.0001). Polymegethism decreased significantly in the DMEK group (p < 0.0001). Pleomorphism was significantly higher, on average, in DMEK than in PKP (p < 0.0001).

Conclusion The prognosis of DMEK in patients with FED seems to be more favourable after immune reactions than that of PKP, as not only were immune reactions less frequent, but they were also milder. However, endothelial cell density was significantly higher in the PKP group during the entire follow-up.

Fazitbox

Bereits bekannt

• Die DMEK löst die PKP in Bezug auf die Indikation FED immer mehr als OP-Technik der Wahl ab.

• Bisweilen wurden einige Vorteile der DMEK gegenüber der PKP beschrieben: Im Allgemeinen treten weniger Immunreaktionen auf und der chronische Endothelzellverlust ist geringer.

Neu beschrieben

• Immunreaktionen treten bei FED nach PKP signifikant häufiger auf als nach DMEK. Außerdem verlaufen die Abstoßungsreaktionen nach DMEK in Bezug auf den Endothelzellverlust milder.

• Die Endothelzelldichte der Gesamtkohorte sinkt ausgehend von der Spenderendothelzelldichte sowohl nach PKP als auch nach DMEK signifikant ab. In dieser Studie war die Endothelzelldichte allerdings überraschenderweise im gesamten postoperativen Beobachtungszeitraum bei der PKP signifikant höher als bei der DMEK und der Zellverlust verlief nach DMEK steiler als nach PKP.

Conclusion Box

Already known:

• DMEK is increasingly replacing PKP as the surgical technique of choice for the indication of FED.

• Some advantages of DMEK over PKP have sometimes been described: In general, fewer immune reactions occur and chronic endothelial cell loss is lower.

Newly described:

• Immune reactions occur significantly more frequently in FED after PKP than after DMEK. In addition, the rejection reactions after DMEK are milder with regard to endothelial cell loss.

• The endothelial CD of the total cohort decreases significantly from the donor endothelial CD after both PKP and DMEK. In this study, however, endothelial CD was surprisingly significantly higher with PKP than with DMEK throughout the postoperative observation period and cell loss was steeper after DMEK than after PKP.

Key words

Fuchs endothelial dystrophy - penetrating keratoplasty - Descemet membrane endothelial keratoplasty - endothelial cell density - immune reaction

Publikationsverlauf

Eingereicht: 27. Juli 2022

Angenommen: 28. Februar 2023

Artikel online veröffentlicht:
05. Mai 2023

• References/Literatur

• 1 Maghsoudlou P, Sood G, Akhondi H. Cornea Transplantation. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2022. Im Internet (Stand: 19.01.2022): https://www.ncbi.nlm.nih.gov/books/NBK539690/
• 2 Flockerzi E, Maier P, Böhringer D. et al. Trends in Corneal Transplantation from 2001 to 2016 in Germany: A Report of the DOG–Section Cornea and its Keratoplasty Registry. Am J Ophthalmol 2018; 188: 91-98
• 3 Seitz B, Daas L, Flockerzi E. et al. „Descemet membrane endothelial keratoplasty“ DMEK – Spender und Empfänger Schritt für Schritt. Ophthalmologe 2020; 117: 811-828
• 4 Vendomèle J, Khebizi Q, Fisson S. Cellular and Molecular Mechanisms of Anterior Chamber-Associated Immune Deviation (ACAID): What We Have Learned from Knockout Mice. Front Immunol 2017; 8: 1686
• 5 Chen SY, Terry M. Step-by-step Descemetʼs membrane endothelial keratoplasty surgery. Taiwan J Ophthalmol 2019; 9: 18-26
• 6 Liu M, Hong J. Risk Factors for Endothelial Decompensation after Penetrating Keratoplasty and Its Novel Therapeutic Strategies. J Ophthalmol 2018; 2018: 1389486
• 7 Pleyer U, Bertelmann E. Differenzialdiagnose und Therapie der Transplantatabstoßung nach Keratoplastik. Klin Monbl Augenheilkd 2005; 222: 863-869
• 8 Molter Y, Milioti G, Langenbucher A. et al. Zeitpunkt, Rezidive und Prognose der immunologischen Abstoßungsreaktion nach Keratoplastik. Ophthalmologe 2020; 117: 548-556
• 9 Moshirfar M, Somani AN, Vaidyanathan U. et al. Fuchs Endothelial Dystrophy. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. 2022 Jan. Im Internet (Stand: 02.11.2021): https://www.ncbi.nlm.nih.gov/books/NBK545248/
• 10 Akanda Z, Naeem A, Russell E. et al. Graft Rejection Rate and Graft Failure Rate of Penetrating Keratoplasty (PKP) vs. Lamellar Procedures: A Systematic Review. PLoS One 2015; 10: e0119934
• 11 Woo JH, Ang M, Htoon HM. et al. Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty. Am J Ophthalmol 2019; 207: 288-303
• 12 Hos D, Tuac O, Schaub F. et al. Incidence and Clinical Course of Immune Reactions after Descemet Membrane Endothelial Keratoplasty. Ophthalmology 2017; 124: 512-518
• 13 Seitz B, Langenbucher A, Diamantis A. et al. Immunreaktionen nach perforierender Keratoplastik – Eine prospektive randomisierte Vergleichsstudie zwischen Excimerlaser- und Motortrepanation. Klin Monbl Augenheilkd 2001; 218: 710-719
• 14 Musch DC, Schwartz AE, Fitzgerald-Shelton K. et al. The Effect of Allograft Rejection After Penetrating Keratoplasty on Central Endothelial Cell Density. Am J Ophthalmol 1991; 111: 739-742
• 15 Fiorentzis M, Viestenz A, Viestenz A. et al. Intracameral Dexamethsaone Injection as Adjuvant Therapy in Endothelial Immune Reaction After Penetrating and Posterior Lamellar Keratoplasty: A retrospective Clinical Observation. Adv Ther 2017; 34: 1928-1935
• 16 Brand J, Langenbucher A, Zemova E. et al. Prä- und intraoperative Einflussgrößen auf die Endothelzellentwicklung in der Früh- und Spätphase nach perforierender Keratoplastik. Klin Monbl Augenheilkd 2021; 238: 904-911
• 17 Langenbucher A, Nguyen NX, Seitz B. Predictive donor factors for chronic endothelial cell loss after nonmechanical penetrating keratoplasty in a regression model. Graefes Arch Clin Exp Ophthalmol 2003; 241: 975-981
• 18 Seitz B, Langenbucher A, Zagrada D. et al. Hornhautdimensionen bei verschiedenen Hornhautdystrophien und ihre Bedeutung für die perforierende Keratoplastik. Klin Monbl Augenheilkd 2000; 217: 152-158
• 19 Heinzelmann S, Böhringer D, Eberwein P. et al. Outcomes of Descemet membrane endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty and penetrating keratoplasty from a single centre study. Graefes Arch Clin Exp Ophthalmol 2016; 254: 515-522
• 20 Seitz B, Langenbucher A, Naumann GOH. Die perforierende Keratoplastik. Ophthalmologe 2005; 102: 1128-1139
• 21 Hayashi T, Schrittenlocher S, Siebelmann S. et al. Risk factors for endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK). Sci Rep 2020; 10: 11086
• 22 Aljundi W, Abdin A, Suffo S. et al. Descemet Membrane Endothelial Keratoplasty (DMEK) in Previously Vitrectomized Eyes: Complications and Clinical Outcomes. Klin Monbl Augenheilkd 2021; 238: 1101-1107
• 23 Heidemann DG, Dunn SP, Chow CY. Comparison of Deep Lamellar Endothelial Keratoplasty and Penetrating Keratoplasty in Patients With Fuchs Endothelial Dystrophy. Cornea 2008; 27: 161-167
• 24 Tóth G, Butskhrikidze T, Seitz B. et al. Endothelial cell density and corneal graft thickness following excimer laser vs. femtosecond laser-assisted penetrating keratoplasty – a prospective randomized study. Graefes Arch Clin Exp Ophthalmol 2019; 257: 975-981
• 25 Langenbucher A, Seitz B, Nguyen NX. et al. Corneal endothelial cell loss after nonmechanical penetrating keratoplasty depends on diagnosis: a regression analysis. Graefes Arch Clin Exp Ophthalmol 2002; 240: 387-392
• 26 Lekhanont K, Pisitpayat P, Cheewaruangroj N. et al. Outcomes of Descemet Membrane Endothelial Keratoplasty in Bangkok, Thailand. Clin Ophthalmol 2021; 15: 2239-2251
• 27 Arslan OS, Dogan C, Mergen B. Six-Month Results of Descemet Membrane Endothelial Keratoplasty in 100 Eyes: First Clinical Results from Turkey. Turk J Ophthalmol 2019; 49: 235-242