DMEK in 'super' seniors: feasible treatment, realistic expectations

This article was reviewed by Philip W. Dockery, MD, MPH

Patients older than 90 years are physically capable of withstanding an ocular surgery such as Descemet’s membrane endothelial keratoplasty (DMEK).

Outcomes may be less than optimal because of patients’ physical limitations or pre-existing ocular problems.

DMEK, the gold standard for treating endothelial dysfunction, produces consistently better results compared with Descemet’s stripping endothelial keratoplasty (DSAEK), including a faster, more complete visual recovery, according to Philip W. Dockery, MD, MPH.

Related: DMEK vs. DSAEK: Debate goes on

Because DMEK is a relatively new procedure compared with DSAEK or penetrating keratoplasty, there is a lack of complete information available regarding its outcomes in various populations.

In light of that, Dockery and colleagues evaluated how very elderly patients fared after DMEK.

The study and results
Investigators evaluated patients from 2 institutions (Netherlands Institute for Innovative Ocular Surgery, Rotterdam, and Parker Cornea, Birmingham, Alabama) from 2009 to 2019.

The study included 20 eyes of 17 patients, all of whom were older than 90 years (mean, 92.6) at the time of the procedure.

The main outcome measures were the best-corrected visual acuity (BCVA); changes in corneal curvature, and endothelial cell density (ECD), and central corneal thickness (CCT); and any intraoperative or postoperative complications, such as graftdetachment.

All patients underwent a standard DMEK procedure.

Related: Teaching AI algorithms to identify corneal pathology: The future is now

It is noteworthy, Dockery said, that this patient group had a high number of ocular comorbidities, Dockery said. Specifically, more than 30% of eyes had each of the following: macular pathology, glaucoma, or anterior stromal scarring.

“These comorbidities in these eyes made the visual potential substantially less than what might be expected in a younger population,” Dockery said.

Only half the eyes could be followed for up to 1 year or more. In the other cases, the patients either died or had physical or psychological factors that prevented their attendance at follow-up evaluations.

The median preoperative visual acuity was 20/200, which increased to 20/60 at 1 month, 20/55 at 6 months, and 20/50 at 12 months. Just 10% of eyes had 20/40 or better preoperatively, but 50% had 20/40 or better at the final visit.

Dockery emphasized 2 major findings regarding the VA: All eyes had an improvement in at 12 months, and none reached 20/20. He noted that the latter result is rare in evaluation of DMEK outcomes.

Related: ASCRS 2020: Returning to baseline post-corneal collagen crosslinking for keratoconus

When considering ECD and CCT, Dockery explained that the cornea thins after DMEK and becomes clear. A difference in this very elderly population was that the corneal thinning seemed to happen slower compared with the eyes of younger patients.

Investigators found increased rates of complications intraoperatively and postoperatively in this population compared with younger patients. The most serious complication was 1 case of intraoperative suprachoroidal hemorrhage.

Postoperatively, the most frequently seen problem was partial graft detachment requiring rebubbling in 6 eyes, a rate 2- to 3-fold higher than in DMEK performed in younger patients.

Complications occurring in 1 eye each were secondary graft failure that required retransplantation with DSAEK, chronic corneal epithelial defects, and cystoid macular edema.

Investigators concluded that the increased rate of graft detachment could have been associated with the difficulty elderly patients may have with supine posturing.

Related: Hardware, software offer surgeons a window to cornea diagnosis

The worse postoperative VAs were likely to be associated with high rates of ocular comorbidities such as age-related macular degeneration and corneal scarring; however, Dockery pointed out that compared with DMEK performed in younger eyes, corneal deturgescence and ECD trends are similar. In addition, all eyes had improved BCVA postoperatively.

The very elderly depend on others for transportation to appointments. Supine posturing may be problematic, and the ability to self-administer eye drops may be compromised.

Read more by Lynda Charters

----

Philip W. Dockery, MD, MPH
e:phildock2020@gmail.com
Dockery has no financial interest in this subject matter. He is an intern at Wills Eye Hospital in Philadelphia, Pennsylvania, and an affiliate of Parker Cornea in Birmingham, Alabama.