DMEK: Probleme vermeiden, erkennen, lösen

Zusammenfassung

Seit der ersten erfolgreichen Descemet Membrane endothelial Keratoplasty (DMEK) vor über 10 Jahren hat sich diese Technik in vielen Regionen zu einem Routineeingriff entwickelt, der mittlerweile einen festen Platz im ophthalmochirurgischen Armamentarium bei der Behandlung von Hornhautendothelerkrankungen einnimmt. Im Vergleich mit der etwas älteren Methode der Descemetʼs Stripping (automated) endothelial Keratoplasty (DS[A]EK), bei der das Transplantat im Gegensatz zur DMEK noch eine Stromalamelle besitzt, wird bei der DMEK eine schnellere und bessere Visuserholung erzielt und gleichzeitig ist das Risiko der Abstoßungsreaktion deutlich reduziert. Dennoch birgt die Technik einige Schwierigkeiten, die ein besonderes Vorgehen zur Vermeidung intra- und postoperativer Komplikationen notwendig machen. Hierzu zählen Strategien zur Vermeidung von Endothelschädigungen während der Präparation, die richtige Spender-Patienten-Allokation ist wichtig für eine schonende Entfaltung der Transplantatrolle in der Vorderkammer, die Verwendung von SF₆-Gas zur Transplantatanlage vermindert die Transplantatablösungsrate und damit die Notwendigkeit erneuter Vorderkammertamponaden (Rebubblings), und die richtige postoperative Behandlung mit topischen Steroiden hat maßgeblichen Einfluss auf die Entwicklung von zystoidem Makulaödem und Abstoßungsreaktionen. Durch die weitere Standardisierung, aber auch Individualisierung der DMEK kann sie mittlerweile auch bei Patienten mit schwierigen anatomischen Voraussetzungen des vorderen Augenabschnitts (anteriore Synechien, größere Irisdefekte, Glaukomdrainageimplantate) regelmäßig durchgeführt werden, wodurch gerade solche Patienten mit tendenziell erhöhtem Risiko von Wundheilungsstörungen und Abstoßungsreaktionen im Übermaß profitieren.

Abstract

Descemet membrane endothelial keratoplasty (DMEK) has evolved into a routine surgical procedure for posterior lamellar keratoplasty. After its introduction more than 10 years ago, several modifications in grafting technique and postoperative treatment regimen helped to improve its safety and reproducibility. Although DMEK offers faster and better improvements in visual acuity, as well as less graft rejections when compared to Descemetʼs stripping (automated) endothelial keratoplasty (DS[A]EK), difficulties when implementing this technique hamper the widespread use in many areas. However, different strategies help to reduce the rate of intra- and postoperative complications, making DMEK the method of choice for most patients with corneal endothelial diseases. Certain techniques help to reduce the endothelial damage during graft preparation; correct matching of donor age and recipientʼs anterior chamber depth eases intracameral unfolding of the DMEK graft, the use of SF₆ gas for anterior chamber tamponade reduces the need for additional rebubblings, and the correct frequency and duration of postoperative topical steroid treatment helps to reduce the development of cystoid macular edema and graft rejections. Further standardization, but also individualization, of DMEK helps to offer this treatment option to patients with more complex anterior segment situations like anterior synechia, larger iris defects and glaucoma drainage devices.

Schlüsselwörter

DMEK - DSAEK - Hornhautendothel - Fuchs-Endotheldystrophie

Key words

DMEK - DSAEK - corneal endothelium - Fuchsʼ endothelial dystrophy

• Literatur

• 1 Maier P, Reinhard T, Cursiefen C. Descemet stripping endothelial keratoplasty – rapid recovery of visual acuity. Dtsch Arztebl Int 2013; 110: 365-371
• 2 Rudolph M, Laaser K, Bachmann BO. et al. Corneal higher-order aberrations after Descemetʼs membrane endothelial keratoplasty. Ophthalmology 2012; 119: 528-535
• 3 Anshu A, Price MO, Price jr. FW. Risk of corneal transplant rejection significantly reduced with Descemetʼs membrane endothelial keratoplasty. Ophthalmology 2012; 119: 536-540
• 4 Weller JM, Tourtas T, Kruse FE. et al. Descemet membrane endothelial keratoplasty as treatment for graft failure after Descemet stripping automated endothelial keratoplasty. Am J Ophthalmol 2015; 159: 1050-1057.e2
• 5 Schaub F, Simons HG, Enders P. et al. [Corneal donation: Dilemma between growing demand and declining donor rate]. Ophthalmologe 2016; 113: 1058-1065
• 6 Melles GR, Ong TS, Ververs B. et al. Descemet membrane endothelial keratoplasty (DMEK). Cornea 2006; 25: 987-990
• 7 Kruse FE, Laaser K, Cursiefen C. et al. A stepwise approach to donor preparation and insertion increases safety and outcome of Descemet membrane endothelial keratoplasty. Cornea 2011; 30: 580-587
• 8 Van Dooren BT, Beekhuis WH, Pels E. Biocompatibility of trypan blue with human corneal cells. Arch Ophthalmol 2004; 122: 736-742
• 9 Siebelmann S, Matthaei M, Hörster M. et al. A lutein and brilliant blue-based dye for donor preparation and transplantation in Descemet membrane endothelial keratoplasty (DMEK). Cornea 2017; 36: 440-444
• 10 Bachmann B, Cursiefen C. Intra- and postoperative Complications and their Management in DMEK (including Re-DMEK). In: Cursiefen C, Jun AS. eds. Current Treatment Options for Fuchs endothelial Dystrophy. Cham: Springer; 2017: 153-164
• 11 Müller TM, Lavy I, Baydoun L. et al. Case report of Quarter-Descemet membrane endothelial keratoplasty for Fuchs endothelial dystrophy. Cornea 2017; 36: 104-107
• 12 Tourtas T, Heindl LM, Kopsachilis N. et al. Use of accidentally torn descemet membrane to successfully complete Descemet membrane endothelial keratoplasty. Cornea 2013; 32: 1418-1422
• 13 Schlötzer-Schrehardt U, Bachmann BO, Laaser K. et al. Characterization of the cleavage plane in Descemetʼs membrane endothelial keratoplasty. Ophthalmology 2011; 118: 1950-1957
• 14 Schlötzer-Schrehardt U, Bachmann BO, Tourtas T. et al. Reproducibility of graft preparations in Descemetʼs membrane endothelial keratoplasty. Ophthalmology 2013; 120: 1769-1777
• 15 Schlötzer-Schrehardt U, Bachmann BO, Tourtas T. et al. Ultrastructure of the posterior corneal stroma. Ophthalmology 2015; 122: 693-699
• 16 Dua HS, Faraj LA, Branch MJ. et al. The collagen matrix of the human trabecular meshwork is an extension of the novel pre-Descemetʼs layer (Duaʼs layer). Br J Ophthalmol 2014; 98: 691-697
• 17 Dua HS, Faraj LA, Said DG. et al. Human corneal anatomy redefined: a novel pre-Descemetʼs layer (Duaʼs layer). Ophthalmology 2013; 120: 1778-1785
• 18 Bachmann BO, Laaser K, Cursiefen C. et al. A method to confirm correct orientation of descemet membrane during Descemet membrane endothelial keratoplasty. Am J Ophthalmol 2010; 149: 922-925.e2
• 19 Steven P, Le Blanc C, Velten K. et al. Optimizing descemet membrane endothelial keratoplasty using intraoperative optical coherence tomography. JAMA Ophthalmol 2013; 131: 1135-1142
• 20 Schaub F, Enders P, Zachewicz J. et al. Impact of donor age on Descemet membrane endothelial keratoplasty outcome: evaluation of donors aged 17–55 years. Am J Ophthalmol 2016; 170: 119-127
• 21 Stanzel T, Ersoy L, Sansanayudh W. et al. Immediate postoperative intraocular pressure changes after anterior chamber air fill in Descemet membrane endothelial keratoplasty (DMEK). Cornea 2016; 35: 14-19
• 22 Heindl LM, Schlötzer-Schrehardt U, Cursiefen C. et al. Myofibroblast metaplasia after Descemet membrane endothelial keratoplasty. Am J Ophthalmol 2011; 151: 1019-1023.e2
• 23 Guell JL, Morral M, Gris O. et al. Comparison of sulfur hexafluoride 20 % versus air tamponade in Descemet membrane endothelial keratoplasty. Ophthalmology 2015; 122: 1757-1764
• 24 Hoerster R, Stanzel TP, Bachmann BO. et al. Intensified topical steroids as prophylaxis for macular edema after posterior lamellar keratoplasty combined with cataract surgery. Am J Ophthalmol 2016; 163: 174-179.e2
• 25 Heinzelmann S, Maier P, Böhringer D. et al. Cystoid macular oedema following Descemet membrane endothelial keratoplasty. Br J Ophthalmol 2015; 99: 98-102
• 26 Maier PC, Heinzelmann S, Böhringer D. et al. [Intraocular lens opacification following posterior lamellar keratoplasty]. Klin Monatsbl Augenheilkd 2015; 232: 976-981
• 27 Schrittenlocher S, Penier M, Schaub F. et al. Intraocular lens calcifications after (triple-) DMEK surgery. Am J Ophthalmol 2017; 179: 129-136
• 28 Girbardt C, Oertel N, Adamek-Dyk J. et al. [Refractive changes in triple Descemet membrane endothelial keratoplasty]. Ophthalmologe 2016; 113: 217-222
• 29 Girbardt C, Wiedemann P, Nestler A. [Triple Descemet membrane endothelial keratoplasty. Indications, variations and results]. Ophthalmologe 2016; 113: 213-216
• 30 Laaser K, Bachmann BO, Horn FK. et al. Descemet membrane endothelial keratoplasty combined with phacoemulsification and intraocular lens implantation: advanced triple procedure. Am J Ophthalmol 2012; 154: 47-55.e2
• 31 Ham L, Dapena I, Moutsouris K. et al. Refractive change and stability after Descemet membrane endothelial keratoplasty. Effect of corneal dehydration-induced hyperopic shift on intraocular lens power calculation. J Cataract Refract Surg 2011; 37: 1455-1464
• 32 Cursiefen C, Heiligenhaus A. [Endothelial immune reactions in times of lamellar corneal transplant surgery: mission completed?]. Klin Monatsbl Augenheilkd 2013; 230: 484-485
• 33 Steven P, Hos D, Heindl LM. et al. [Immune reactions after DMEK, DSAEK and DALK]. Klin Monatsbl Augenheilkd 2013; 230: 494-499
• 34 Price MO, Price jr. FW, Kruse FE. et al. Randomized comparison of topical prednisolone acetate 1 % versus fluorometholone 0.1 % in the first year after descemet membrane endothelial keratoplasty. Cornea 2014; 33: 880-886
• 35 Price MO, Feng MT, Scanameo A. et al. Loteprednol etabonate 0.5 % gel vs. prednisolone acetate 1 % solution after Descemet membrane endothelial keratoplasty: prospective randomized trial. Cornea 2015; 34: 853-858
• 36 Price MO, Scanameo A, Feng MT. et al. Descemetʼs membrane endothelial keratoplasty: risk of immunologic rejection episodes after discontinuing topical corticosteroids. Ophthalmology 2016; 123: 1232-1236