DSEK and DMEK: Advanced Corneal Transplant Techniques

Moussa Al-Rufayie

Corneal transplantation has seen significant advancements in recent years, with Descemet’s Stripping Endothelial Keratoplasty (DSEK) and Descemet’s Membrane Endothelial Keratoplasty (DMEK) at the forefront. These techniques offer improved outcomes and faster recovery times compared to traditional full-thickness corneal transplants (1). This article explores the differences between DSEK and DMEK, highlighting their respective advantages and applications.

DSEK involves the removal of the damaged endothelial layer of the cornea along with a portion of the stroma. A donor graft, consisting of Descemet’s membrane, endothelium, and a thin layer of posterior stroma, is then inserted into the patient’s eye. This technique preserves more of the patient’s corneal structure compared to full-thickness transplants. Studies have shown that DSEK can significantly improve visual acuity and reduce graft rejection rates compared to older methods (2).

DMEK is a more refined procedure that involves transplanting only the Descemet’s membrane and endothelial cells without any stromal tissue. By excluding the stromal layer, DMEK can offer even better visual outcomes and faster recovery times. Research indicates that DMEK patients experience fewer optical aberrations and higher quality vision post-surgery (3).

In DSEK, the donor tissue preparation is relatively straightforward, involving the removal of the endothelial layer with a thin layer of stroma. The graft is then folded and inserted through a small incision (4). In contrast, DMEK requires more meticulous preparation, as the donor tissue consists solely of the Descemet’s membrane and endothelium, making it thinner and more delicate. This graft is typically rolled into a scroll and inserted through a small incision (5).

The DSEK graft, being slightly thicker, is easier to manipulate and position within the eye. It unfolds naturally and adheres to the host cornea with minimal manipulation. Conversely, the DMEK graft, due to its thinness, requires precise handling and careful unrolling within the anterior chamber. Air or gas is often used to help the graft adhere properly. While both techniques promote rapid healing, DMEK patients may experience faster visual recovery due to the absence of stromal tissue (5).

Visual Outcomes

DMEK generally offers superior visual outcomes compared to DSEK. The absence of stromal tissue in DMEK reduces optical aberrations, resulting in clearer and sharper vision for the patient. Studies have shown that patients undergoing DMEK achieve better visual acuity and contrast sensitivity (6).

Complication Rates

Both DSEK and DMEK have low rates of complications, but there are differences in the types of risks associated with each procedure. DSEK carries a slightly higher risk of graft detachment, although this can often be managed effectively. DMEK, while having a lower overall complication rate, requires greater surgical expertise and has a steeper learning curve, potentially leading to initial challenges in graft handling and positioning (7).

Conclusion

DSEK and DMEK represent significant advancements in corneal transplantation, each offering distinct advantages. DSEK, with its easier graft preparation and insertion, remains a robust choice for many patients. DMEK, with its superior visual outcomes and faster recovery, is increasingly becoming the preferred option for patients requiring endothelial keratoplasty. Both techniques underscore the importance of personalised patient care and the ongoing evolution of ophthalmic surgery.

References

  1. Tandon R, Singh R, Gupta N, Vanathi M. Corneal transplantation in the modern era. Indian Journal of Medical Research [Internet]. 2019;150(1):7. Available from: http://www.ijmr.org.in/temp/IndianJMedRes15017-5918131_162621.pdf  
  2. Price FW, Price MO. Descemet’s Stripping With Endothelial Keratoplasty in 50 Eyes: A Refractive Neutral Corneal Transplant. 2005 Jul 1;21(4):339–45. Available from: https://journals.healio.com/doi/10.3928/1081-597X-20050701-07
  3. Trindade BLC, Eliazar GC. Descemet membrane endothelial keratoplasty (DMEK): an update on safety, efficacy and patient selection. Clinical Ophthalmology (Auckland, NZ) [Internet]. 2019 Aug 16;13:1549–57.  
    Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6701611   
  4. Price MO, Bidros M, Gorovoy M, Price FW, Benetz BA, Menegay HJ, et al. Effect of incision width on graft survival and endothelial cell loss after DSAEK. Cornea [Internet]. 2010 May 1 [cited 2024 Jun 17];29(5):523–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860043/
  5. Terry M, Chen SY. Step-by-step Descemet’s membrane endothelial keratoplasty surgery. Taiwan Journal of Ophthalmology. 2019;9(1):18. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432849/
  6. Dunker SL, Dickman MM, Wisse RPL, Siamak Nobacht, Wijdh RHJ, Bartels MC, et al. Quality of vision and vision‐related quality of life after Descemet membrane endothelial keratoplasty: a randomized clinical trial. Acta ophthalmologica (2008 Print). 2021 Jan 12;99(7). Available from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8597030/
  7. Phillips PM, Phillips LJ, Muthappan V, Maloney CM, Carver CN. Experienced DSAEK Surgeon’s Transition to DMEK: Outcomes Comparing the Last 100 DSAEK Surgeries With the First 100 DMEK Surgeries Exclusively Using Previously Published Techniques. Cornea. 2016 Dec 1;36(3):275–9. Available from: https://pubmed.ncbi.nlm.nih.gov/27918355/
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