Optimizing outcomes with Descemetʼs membrane endothelial keratoplasty

PURPOSE OF REVIEWTo review recent advances in posterior lamellar keratoplasty and to describe strategies that enhance the outcome of Descemetʼs membrane endothelial keratoplasty (DMEK) and should lead to a more widespread use of this technique. RECENT FINDINGSDMEK offers significant advantages over Descemetʼs stripping automated endothelial keratoplasty (DSAEK) such as less immune reaction and better visual acuity because of less higher order aberrations. Donor selection should exclude donors under 50 years because of tissue elasticity; several advanced techniques now allow donor preparation from both cold and organ-cultured tissue in about 99% minimizing the risk of graft loss. Oversizing the area of Descemetʼs stripping in relationship to graft size enhances graft attachment and use of a standardized approach for graft delivery. Air bubble-driven nontouch unfolding techniques and, possibly, gas tamponade in the anterior chamber further enhance graft attachment and reduce surgery-induced endothelial cell loss. Graft orientation is made earlier by marking, slit beam and optical coherence tomography. Novel understanding of the functional anatomy of Descemetʼs membrane as well as migration of endothelial cells will allow to further refine DMEK and improve its outcome. SUMMARYAlthough the superiority of DMEK over Descemetʼs stripping automated endothelial keratoplasty in terms of safety and functionality had been further elucidated, remarkable progress has been made in the recent past regarding tissue preparation, insertion and intraoperative manipulation that will foster the more widespread use of DMEK among corneal surgeons.