Preparation of Donor Tissue in Descemet Membrane Endothelial Keratoplasty (DMEK): Impact of Pseudophacic Donor Status on Clinical Outcomes

Abstract

Purpose To evaluate whether the lens status of donor eyes (phakic vs. pseudophakic) influences graft preparation, graft handling, and postoperative outcomes in Descemet membrane endothelial keratoplasty (DMEK).

Methods Retrospective analysis of 1171 DMEK cases, comparing phakic (n = 870) and pseudophakic (n = 301) donor eyes. Graft preparation characteristics, surgical complications, and postoperative outcomes including endothelial cell count (ECC), visual acuity (VA), central corneal thickness (CCT), rebubbling and repeat keratoplasty rates were assessed with a three-year follow-up.

Results Pseudophakic donor tissue was significantly more difficult to prepare, with higher rates of tissue tears and need for manual dissection (both p < 0.001), though preparation times did not differ significantly. These challenges were linked to increased repeat keratoplasty risk (p = 0.041) and lower postoperative ECC (p = 0.047 at 1 year), while CCT and VA remained comparable. Intraoperative difficulties in graft manipulation occurred more frequently during implantation in the pseudophakic group (p = 0.14) and were associated with a significantly lower endothelial cell count after one year (p = 0.08) as well as a significantly higher risk of graft failure (p = 0.028). Overall, rebubbling (37% vs. 26%, p < 0.001) and repeat keratoplasty (12% vs. 7%, p = 0.045) were significantly more frequent in the pseudophakic group. Despite these complications, both groups showed comparable and significant visual improvement (p < 0.001).

Conclusion Although pseudophakic donor tissue increases the technical complexity of DMEK resulting in significantly higher rates of rebubbling and repeat keratoplasty, successful grafts yield comparable visual outcomes to those from phakic donors. Pseudophakic corneas should therefore be considered a valuable additional donor source in times of tissue scarcity, provided that preparation and implantation are performed by experienced surgeons.

Zusammenfassung

Hintergrund Es sollte untersucht werden, ob der Linsenstatus des Spenderauges (phak vs. pseudophak) einen Einfluss auf die Transplantatpräparation, die intraoperative Handhabung des Transplantats und die postoperativen Ergebnisse der Descemet-Membran-Endothel-Keratoplastik (DMEK) hat.

Methoden Retrospektive Analyse von 1171 DMEK-Fällen, wobei phake (n = 870) und pseudophake (n = 301) Spenderaugen verglichen wurden. Die Charakteristika der Transplantatpräparation, chirurgische Komplikationen und postoperative Ergebnisse, einschl. der Anzahl der Endothelzellen (ECC), der Sehschärfe (VA), der zentralen Hornhautdicke (CCT), der Rebubbling- und Re-Keratoplastik-Raten wurden mit einem 3-jährigen Follow-up bewertet.

Ergebnisse Pseudophakes Spendergewebe war signifikant schwieriger zu präparieren, mit höheren Raten von Geweberissen und der Notwendigkeit einer manuellen Dissektion (beide p < 0,001), obwohl sich die Präparationszeiten nicht signifikant unterschieden. Diese Schwierigkeiten waren mit einem erhöhten Risiko für eine erneute Keratoplastik (p = 0,041) und einer geringeren postoperativen ECC (p = 0,047 nach 1 Jahr) verbunden, während CCT und VA vergleichbar blieben. Schwierigkeiten bei der Handhabung des Transplantats traten während der Implantation häufiger in der pseudophaken Gruppe auf und waren signifikant mit einer niedrigeren ECC (p = 0,08 nach 1 Jahr) und einem höheren Risiko für ein Transplantatversagen (p = 0,028) verbunden. Insgesamt traten in der pseudophaken Gruppe signifikant häufiger erneutes Rebubbling (37% vs. 26%, p < 0,001) und eine erneute Keratoplastik (12% vs. 7%, p = 0,045) auf. Trotz dieser Komplikationen zeigten beide Gruppen eine vergleichbare und signifikante Sehverbesserung (p < 0,001).

Schlussfolgerung Obwohl pseudophakes Spendergewebe die technische Komplexität der DMEK erhöht, was zu deutlich höheren Raten von Rebubbling und wiederholten Keratoplastiken führt, erzielen erfolgreiche Transplantate vergleichbare Sehergebnisse wie solche von phaken Spendern. Pseudophake Hornhäute sollten daher in Zeiten der Gewebeknappheit als wertvolle zusätzliche Spenderquelle betrachtet werden, vorausgesetzt, dass die Vorbereitung und Implantation von erfahrenen Chirurgen durchgeführt werden.

Conclusion Box

Already known:

• Pseudophakic donor tissues may pose a greater challenge during preparation due to adhesions at prior incision sites

• Failures in preparation can have severe consequences with increased endothelial cell loss and primary graft failure

Newly described:

• Pseudophakic donor tissue showed significantly more frequent tearing and challenging liquid-bubble preparation, often requiring a switch to manual techniques.

• Independent of donor lens status, difficult preparation or implantation was strongly associated with increased endothelial cell loss, higher rebubbling rates, and a greater likelihood of graft failure.

• Despite higher rates of rebubbling and repeat keratoplasty, successfully implanted pseudophakic grafts achieved comparable long-term visual outcomes to phakic grafts.

Keywords

Descemet membrane endothelial keratoplasty (DMEK) - corneal donor graft preparation - corneal transplant

Schlüsselwörter

Descemet Membrane Endothelial Keratoplasty (DMEK) - Präparation Hornhautspende - Gewebespende

Publication History

Received: 08 May 2025

Accepted: 27 November 2025

Article published online:
12 February 2026

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