Low-dose steroids effective after DMEK

This prospective, randomized study found a remarkably low rejection rate after Descemet membrane endothelial keratoplasty (DMEK) in patients given either prednisolone acetate 1% or fluorometholone 0.1% during the first postoperative year. The results suggest the feasibility of reducing postoperative topical corticosteroid strength and therefore the risk of steroid-related IOP elevation without increasing the risk of immunologic graft rejection.

The authors randomized 325 eyes undergoing DMEK to prednisolone acetate 1% for one month postoperatively plus either prednisolone or fluorometholone for months two through 12. Dosing was four times daily in months one to three, three times daily in month four, twice daily in month five, and once daily in months six to 12.

Eyes given prednisolone acetate 1% had no graft rejection episodes compared to a 1.4% rejection rate (two eyes) in the fluorometholone 0.1% group. However, significantly more eyes on prednisolone had IOP elevation during the first year (22% vs. 6%) and required initiation of or increase in glaucoma medications (17% vs. 5%; P = 0.0003).

The most frequent reasons for discontinuing the assigned therapy were problems with IOP management (13 eyes assigned to prednisolone) or inflammation (3 eyes assigned to fluorometholone). One-year endothelial cell loss was comparable in both arms (30% vs. 31%; P = 0.50).

This study is important since it demonstrates the low rate of rejection episodes for DMEK procedures regardless of steroid strength. As a result, surgeons may be able to avoid some of the complications related to long-term prednisolone acetate 1% use after DMEK by switching patients to fluorometholone 0.1%.