Non stripping descemet membrane endothelial keratoplasty in difficult cases: A case series

Endothelial keratoplasty (EK) has been increasingly used instead of penetrating keratoplasty (PK) in the management of post PK graft rejection. Both DSAEK and DMEK involve the surgical removal of the diseased host endothelial cell layer and Descemet's membrane (DM) (descemetorhexis) before transplantation, a technically challenging step, especially in post-PK eyes. Understandably, interest arose when non-stripping DMEK (nDMEK) was described in 2013, and recent studies suggested encouraging results without increased early postoperative failures or complications requiring rebubbling. The purpose of our series was to further study the feasibility and safety of nDMEK and to compare the results with traditional DMEK. This is a single center case series of 3 eyes which underwent nDMEK performed by experienced surgeons (C.P, A.M). Two eyes had nDMEK as a secondary procedure following a failed/rejected PK, while the third case underwent nDMEK on a virgin eye. Undiseased donor DM and a regular host endothelium were required to be eligible for nDMEK. The average change in CCT at last follow-up was -21.2% (±13.3). All required intracameral air injection (rebubbling) within the first few days, with a mean of 2.33 rebubblings per eye, the first one occurring at 6.33±2.52 days after surgery. Non-stripping DMEK surgery appears to be a feasible option, and results are satisfactory at mid to long term. However, in our series, the immediate postoperative period was marked by an increased rebubbling rate. While foreseeable particularly in high-risk cases, surgeons considering this technique should expect a higher risk of early rejection.