Descemet Membrane Endothelial Keratoplasty (DMEK) Anesthesia Analysis

Abstract

Purpose Comparison of safety and clinical results of Descemet membrane endothelial keratoplasty (DMEK) in topical, peribulbar, or general anesthesia.

Methods Retrospective, post hoc matched study of 346 patients who received DMEK surgery with different types of anesthesia (n = 54 topical, n = 137 peribulbar, n = 155 general anesthesia). Outcome criteria were intraoperative complications, endothelial cell count (ECC), central corneal thickness (CCT) and graft rejection rate, rebubbling rate, and visual acuity (VA). Mean follow-up time was 9.4 ± 2.8 months.

Results The group with topical anesthesia showed intraoperative difficulties such as vitreous pressure (p = 0.01) and difficult graft unfolding (p = 0.4), possibly leading to a higher rebubbling rate (p = 0.03) and therefore graft failure (p = 0.39). However, rebubbling and graft failure occurred more often when the graft preparation was more difficult (p = 0.2, p = 0.13, respectively), which was independent of anesthesia. All three groups achieved comparable functional results regarding VA, ECC, and CCT after 6 months.

Conclusion DMEK under topical anesthesia is feasible and shows comparable final visual outcomes but should be limited to selected cooperative patients and performed by experienced surgeons due to the potential for increased intraoperative challenges.

Zusammenfassung

Fragestellung Vergleich von Tropf-, Parabulbär- und Allgemeinanästhesie im Rahmen einer Descemet-Membran-Endothel-Keratoplastik (DMEK) im Hinblick auf Sicherheit und klinisches Outcome.

Methoden Retrospektive, post-hoc-gematchte Studie von 346 Patienten, bei denen eine DMEK mittels verschiedener Anästhesieverfahren erfolgte (n = 54 Tropfenanästhesie, n = 137 Parabulbäranästhesie, n = 155 Allgemeinanästhesie). Entscheidende und berücksichtigte Faktoren für das schlussfolgernde Outcome waren dabei intraoperative Komplikationen, die Endothelzellzahl, die zentrale Hornhautdicke, sowie die Abstoßungsrate, Re-Bubbling-Rate und bester korrigierter Visus. Der durchschnittliche Beobachtungszeitraum nach erfolgter DMEK betrug 9,4 ± 2,8 Monate.

Ergebnisse Intraoperative Komplikationen wie erhöhter Druck aus dem Glaskörperraum (Vis-à-tergo) (p = 0,01) und erschwerte Transplantatentfaltung (p = 0,4) traten in der Gruppe der in Tropfenanästhesie operierten Patienten auf, was möglicherweise zu einer höheren Rate an Re-Bubbling- (p = 0.03) und Transplantatversagen (p = 0,39) führte. Insgesamt traten ein Re-Bubbling oder ein Transplantatversagen häufiger bei erschwerter Transplantatpräparation auf (respektiv p = 0,2, p = 0,13), wobei die Transplantatpräparation insgesamt unabhängig von der gewählten Anästhesieform war. Unter Berücksichtigung von Visus, Endothelzellzahl und zentraler Hornhautdicke zeigten alle 3 Anästhesiegruppen nach 6 Monaten vergleichbare Ergebnisse.

Fazit Die DMEK ist unter Tropfenanästhesie durchführbar und zeigt letztendlich vergleichbare Visus-Ergebnisse mit DMEKs unter Parabulbär- und Allgemeinanästhesie. Dennoch sollte die Tropfenanästhesie aufgrund des höheren Risikos für intraoperative Komplikationen ein Verfahren für besonders kooperative Patienten und erfahrene Operateure bleiben.

Conclusion Box

Already known:

• Technical refinements such as no-touch preparation techniques, clear cornea cartridge implantation, and bimanual irrigation to ensure stable intraocular pressure have made DMEK a minimally invasive procedure.

Newly described:

• Topical anesthesia is feasible for DMEK and yields comparable visual results when compared with other more invasive forms of anesthesia.

• Intraoperative difficulties such as vitreous pressure and difficult graft unfolding occurred more often with topical anesthesia.

• We recommend performing DMEK with topical anesthesia only in selected cooperative patients and solely by very experienced surgeons.

Keywords

DMEK - Descemet membrane endothelial keratoplasty - anesthesia - vitreous pressure - graft failure

Schlüsselwörter

DMEK - Descemet-Membran Endothel-Keratoplastik - Anästhesie - Vis-à-tergo - Transplantatversagen

Publication History

Received: 20 October 2023

Accepted: 31 January 2024

Article published online:
04 April 2024

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