Current concepts and recent trends in endothelial keratoplasty

Table 1 Summary of key prospective comparative studies and randomized controlled trials reporting the outcomes of endothelial keratoplasty procedures

Ref.	Publication	n	Study design	Indication	Intervention	Summary
Stuart et al[46], 2016	Cochrane Database of Systematic Reviews	72	Non-randomized, paired, contralateral-eye study	FECD and PBK	DMEK vs DSAEK	DMEK may provide better visual acuity than DSAEK for corneal endothelial failure, but with more graft dislocations
Dunker et al[47], 2020	Ophthalmology (Rochester, Minn)	54	Prospective, multicenter randomized controlled trial	FECD	DMEK vs UT-DSAEK	DMEK and UT-DSAEK corneal endothelial transplantation procedures have similar visual acuity and endothelial cell density outcomes
Dickman et al[48], 2016	Ophthalmology (Rochester, Minn)	66	Multicenter, prospective, double-masked, randomized, controlled clinical trial	FECD	UT-DSAEK vs DMEK	Ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) results in faster and better visual acuity recovery compared to standard DSAEK
Matsou et al[49], 2021	Cornea	56	Prospective, double-blinded randomized controlled clinical trial	FECD	MT-DSAEK vs DMEK	DMEK surgery resulted in significantly better visual acuity compared to MT-DSAEK for treating Fuchs dystrophy-related corneal decompensation
Chamberlain et al[50], 2019	Ophthalmology (Rochester, Minn.)	38	Randomized, controlled, patient- and outcome-masked clinical trial	FECD and PBK	DMEK vs UT-DSAEK	DMEK had superior visual acuity results compared to UT-DSAEK for treating corneal endothelial dysfunction
Shanmugam et al[51], 2023	Cornea	28	Prospective, randomized, interventional study	Corneal Decom-pensation	PDEK vs DMEK	PDEK and DMEK procedures showed comparable visual and graft survival outcomes in endothelial decompensation
Agarwal et al[52], 2017	Canadian Journal of Ophthalmology	6	Prospective, single-centre, interventional case series	PBK	PDEK and DMEK	EK with epithelial debridement performed for the treatment of chronic PBK resulted in significantly improved visual acuity to a functional level, with the clearance of subepithelial fibrosis and anterior stromal scar, in most patients

DMEK: Descemet membrane endothelial keratoplasty; UT-DSAEK: Ultrathin Descemet stripping automated endothelial keratoplasty; DSAEK: Descemet stripping automated endothelial keratoplasty; FECD: Fuchs endothelial corneal dystrophy; PBK: Pseudophakic Bullous Keratopathy; PDEK: Pre-Descemet Endothelial Keratoplasty; MT-DSAEK: Microthin Descemet Stripping Automated endothelial Keratoplasty.

Table 2 Summary of comparative and non-comparative studies reporting the outcomes of corneal endothelial transplant procedures in various clinical scenarios

Ref.	Publication	Study design	Study duration	Study participants	Survival outcomes
Fu et al[43], 2024	Cornea	Retrospective clinical cohort study	10 years	356 (DSEK), Indication: 209 (FECD), 88 (bullous keratopathy), 39 (previous graft failure)	Overall, DSEK has a 79% 10-year graft survival rate (including complex grafts), with higher rates for Fuchs endothelial dystrophy (92%), despite significant endothelial cell loss
Woo et al[53], 2019	American Journal of Ophthalmology – Glaucoma	Retrospective comparative cohort study	27 years	121 eyes (DMEK), 423 eyes (DSAEK), 405 eyes (PK), for a total of 949 eyes from patients with FECD, and BK	DMEK (97.4%) has better long-term graft survival and lower complication rates compared to DSAEK (78.4%) and PK (54.6%)
Price et al[54], 2011	Ophthalmology (Rochester, Minn.)	Retrospective interventional case series	5 years	165 eyes (147) (89%)-FECD and 18 eyes (11%)-PBK and ABK]	Five-year graft survival and endothelial cell loss after Descemet's stripping endothelial keratoplasty are comparable to penetrating keratoplasty
Birbal et al[55], 2020	Cornea	Retrospective interventional case series	5 years	500 eyes of 393 patients. Indications: FECD, Bullous keratopathy, failed grafts	5 Five-year graft survival probability in 0.90 with 82% achieving > 20/25
Deng et al[56], 2018	Ophthalmology (Rochester, Minn.)	Systematic review	Follow-up ranged from 5.7 to 68 months		DMEK is a safe and effective treatment for corneal endothelial dysfunction, with better visual outcomes and lower refractive error compared to DSEK
Kang et al[57], 2019	Journal of Glaucoma	Retrospective case series	Mean follow-up of 36.5 ± 31.4 months	83 patients who underwent 122 DSEK procedures on 85 eyes	DSEK after glaucoma drainage device implantation has high graft failure rates and adverse effects on long-term graft survival
Baydoun et al[58], 2015	JAMA Ophthalmology	Retrospective cross-sectional studies	Approximately 9 years, from August 8, 2006 to June 17, 2015, with endothelial survival followed for up to 8 years after the DMEK procedures	352 eyes, with 314 -FECD, 31 eyes-bullous keratopathy, and 7 eyes -failed previous endothelial grafts	Endothelial survival after Descemet membrane endothelial keratoplasty is better in eyes with Fuchs endothelial corneal dystrophy and completely attached grafts compared to eyes with bullous keratopathy and partially detached grafts

DMEK: Descemet membrane endothelial keratoplasty; DSAEK: Descemet stripping automated endothelial keratoplasty; PBK: Pseudophakic bullous keratopathy; ABK: Aphakic bullous keratopathy; FECD: Fuch’s endothelial corneal dystrophy.

Table 3 Comparison of outcomes of femtolaser-assisted endothelial keratoplasty procedures with conventional manual procedures

Ref.	Topic	Graft survival and graft-related complications	Visual Outcomes
Malyugin et al[87], 2019	FS-DSEK vs DSAEK	The graft survival was 89.5% in the femtosecond laser-assisted DSEK (FS-DSEK) group and 95% in the microkeratome-assisted DSAEK group, but the endothelial cell loss was higher in the FS-DSEK group compared to the DSAEK group at 12 months	The visual acuity outcomes were similar between the two groups at long-term follow-up
Einan-Lifshitz et al[86], 2017	FS-DMEK vs Manual DMEK (M-DMEK)	The graft survival, as indicated by the endothelial cell loss (24% vs 29%) and graft detachment rates (0% vs 20%), was better in the FE-DMEK group compared to the M-DMEK group
Sorkin et al[89], 2020	F-DMEK and M-DMEK	Significantly lower rates of graft detachment (6.25% vs 35.6%) and need for rebubbling (6.25% vs 33.3%) in the F-DMEK group 3) Significantly lower rates of endothelial cell loss in the F-DMEK group at 1 and 2 years, 4) Numerically lower graft failure rate in the F-DMEK group (0% vs 8.9%), though not statistically significant	Comparable visual acuity improvement between F-DMEK and M-DMEK groups over 3 years
Cheng et al[90], 2009	FL-EK and PK	Mean postoperative BCVA was 20/70 ± 2 lines in the FLEK group and 20/44 ± 2 Lines in the PK group (P < 0.001), but the gain in the best corrected visual acuity between the two groups was not significantly different. The endothelial cell loss in the FL-EK and PK group was 65 ± 12% and 23 ± 15% (P < 0.001)	FL-EK reduces postoperative astigmatism but has higher endothelial cell loss compared to PK

FS: Femtosecond; FL: Femtosecond laser; PK: Penetrating keratoplasty; BCVA: Best corrected visual acuity; DMEK: Descemet membrane endothelial keratoplasty; DSAEK: Descemet stripping automated endothelial keratoplasty.