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  • Is DMEK Posturing Necessary?

    By Lynda Seminara
    Selected by Richard K. Parrish II, MD
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    Journal Highlights

    American Journal of Ophthalmology, August 2022

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    Graft detachment is a common complication of Descemet membrane endothelial keratoplasty (DMEK) that often requires rebubbling or regrafting. It is believed that placing the patient in a supine position postoperatively may reduce the risk of graft detachment, but patients may be uncomfortable main­taining this position for long periods. Moreover, there is no consensus on which posturing regimen (with regard to length of time) is best. Given the lack of data on DMEK without posturing, Roberts et al. performed a retrospective review to explore the risk of graft de­tachment when post-op posturing does not take place. They found that the rate of this complication was low.

    This interventional case series in­cluded 134 consecutively treated eyes (101 patients) that required DMEK for endothelial failure of any cause. DMEK was performed with an intraoperative inferior peripheral iridotomy. After unscrolling and centration of the graft, the anterior chamber was filled almost completely with 20% sulfur hexaflu­oride (SF6). After filling, there was no intraoperative tamponade period or postoperative posturing. Main out­comes were the rates of graft detach­ment, rebubbling, and rejection; rates of primary and secondary failure; intra­operative and postoperative complica­tions; and VA at months 3 and 12.

    Postoperatively, all patients received topical preservative-free moxifloxacin .5% or chloramphenicol .5% four times daily for seven days. Detachment occurred in more than a third of the graft area in five eyes (3.7%) and in less than a third of the graft area in 19 eyes (14.2%). Rebubbling was required in 19 eyes (14.2%), and primary failure occurred in six eyes (4.5%). Graft survival lasted through 12 months in 122 eyes (91%). Nine eyes (6.7%) had an episode of endothelial rejection, and the average time to rejection was 9.5 months (range, 1-20 months). Two eyes (1.5%) had pupil blockage that re­quired partial evacuation of the bubble; both occurred within post-op day 1. Among the eyes without a visually sig­nificant comorbidity, 96.6% had VA of 20/40 or better by three months; 30.3% had VA of 20/20 or better at this time. Within one year, VA was 20/20 or better in 98.5% and at least 20/20 in 39.4%.

    Rebubbling rates in published liter­ature range from .2% to 76% (mean, 28.8%). The low rate of rebubbling in the present study suggests that routine postoperative posturing may not be necessary, but further research is need­ed, said the authors. They recommend prospective direct comparisons of postured and posture-less DMEK.

    The original article can be found here.