CLINICAL SCIENCE

Incidence of Cystoid Macular Edema After Descemet

Membrane Endothelial Keratoplasty
Viridiana Kocaba, MD,*† Romain Mouchel, MD,* Jacques Fleury, MD,* Anne-Sophie Marty, MD,*
Hélène Janin-Manificat, MD,* Delphine Maucort-Boulch, MD, PhD,†‡§ and Carole Burillon, MD*†

Conclusions: Although CME frequently occurred after DMEK, no

Purpose: The incidence of and risk factors for cystoid macular CME risk factors were identified. In addition, CME did not
edema (CME) after Descemet membrane endothelial keratoplasty significantly affect long-term visual outcomes when it was
(DMEK) remain uncertain. This study examines the incidence of and appropriately treated.
risk factors for CME after DMEK.
Key Words: cornea, cystoid macular edema, Descemet membrane
Methods: This retrospective, single-center study included patients endothelial keratoplasty, surgical complication
with no history of CME who had undergone DMEK. Patients were
examined weekly for 1 month after surgery and at 3 and 6 months (Cornea 2018;37:277–282)
after surgery. Follow-up examinations included visual acuity (VA)
assessment, pachymetry, anterior segment optical coherence tomog-
raphy, biomicroscopy, intraocular pressure measurement, and fundo-
scopy. Eyes suspected of having CME (reduced VA and/or abnormal
fundoscopic findings) underwent macular optical coherence tomog-
D escemet membrane endothelial keratoplasty (DMEK) is
a relatively new partial thickness corneal grafting tech-
nique that is used to treat corneal endothelial disorders, most
raphy. Potential risk factors for CME examined included age, axial commonly Fuchs corneal endothelial dystrophy. The DMEK
length, anterior chamber rebubbling, not using a topical nonsteroidal procedure was first proposed by Melles et al in 2006.1,2 Since
antiinflammatory after surgery, and concurrent DMEK and cataract that time, advancements in the DMEK technique have been
surgery (triple-DMEK). made, and the procedure has become popular among corneal
specialists, largely because functional and anatomical outcomes
Results: Eighty eyes (74 subjects) were included. Eleven eyes are superior to those of Descemet stripping automated endo-
(13.8%) developed CME within 6 months after undergoing DMEK. thelial keratoplasty and penetrating keratoplasty.3–5 A number
Univariate analyses did not identify any significant CME risk factors. of research teams are currently studying DMEK outcomes and
Interestingly, the triple-DMEK procedure did not put subjects at risk DMEK-associated complications. The largest of these studies to
for developing CME (P = 0.184). Visual prognosis after medical date (n = 500 eyes) showed that common complications of
treatment for CME was excellent, and subjects with and without DMEK include graft detachment (15.8%), rebubbling (3.0%),
CME had comparable VA at 6 months [CME: logarithm of graft failure (0.4%), cataract (0.4%), graft rejection (0.2%), and
the minimum angle of resolution (logMAR) VA = 0.3 (first–third retinal detachment (0.2%).6 However, that study did not assess
quartile: 0.1–1.0), 20/40; no CME: logMAR VA = 0.3 (0.1–0.5), the incidence of cystoid macular edema (CME) after DMEK.
20/40; P = 0.391]. Postoperative CME frequently occurs after ocular surgery
through inflammatory pathophysiological mechanisms. More
specifically, phospholipase A2 activation occurs, which leads to
Received for publication May 26, 2017; revision received November 9, 2017; inner blood–retinal barrier rupture and a subsequent increase in
accepted November 11, 2017. Published online ahead of print January 2,
2018.
perifoveal vessel permeability.7,8 The risk factors for CME
From the *Ophthalmology Centre, Edouard Herriot Hospital, Lyon, France; development after cataract surgery (Irvine–Gass syndrome)
†Claude Bernard Lyon 1 University, Villeurbanne, France; ‡Biostatistics include age, history of uveitis, diabetes, retinal vein occlusion,
Service, Lyon Public Hospitals Network, Lyon, France; and §Laboratory of prostaglandin eye drop use, and intraoperative complications
Biometrics and Evolutionary Biology, Health Biostatistics Team, Villeur-
banne, France.
(eg, posterior capsular rupture).9,10
No funds were received for the conduct of this study. The proofreading of this Five research groups have previously investigated CME
article was funded by the Lyon Internship Scientific Library and the Lyon after DMEK. Heinzelmann et al11 and Hoerster et al12 reported
Public Hospital Network. similar CME incidences of 13% (20 of 155 eyes) and 12% (9
The authors have no conflicts of interest to disclose. of 75 eyes), respectively. By contrast, Flanary et al,13 Dapena
Correspondence: Viridiana Kocaba, MD, Department of Ophthalmology,
Edouard Herriot Hospital—Claude Bernard Lyon 1 University, 5 Place et al,14 and Chaurasia et al15 reported an incidence of 7.5% (13
d’Arsonval, 69003 Lyon, France (e-mail: viridiana_k@yahoo.fr). of 173 eyes), 0.7% (1 of 135 eyes), and 1% (3 of 292 eyes),
Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. respectively, in eyes that underwent DMEK. In addition,
This is an open-access article distributed under the terms of the Creative Chaurasia et al15 observed a CME incidence of 1.5% (3 of
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
200 eyes) in eyes that underwent concurrent DMEK/cataract
work provided it is properly cited. The work cannot be changed in any surgery. The current study further examined CME incidence
way or used commercially without permission from the journal. after DMEK and investigated risk factors for developing CME.

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Kocaba et al Cornea  Volume 37, Number 3, March 2018

METHODS trypan blue 0.06% staining (2 baths, 4 minutes each),

This study was reviewed and approved by the Edouard scrolling, and drawing it into a glass injector (G-38635,
Herriot University Hospital Institutional Review Board single use; Geuder AG, Heidelberg, Germany). The graft was
(Lyon, France). Because this was a retrospective study, the then injected into the anterior chamber and deployed by
requirement for obtaining study informed consent was gently tapping on the corneal surface. After placement
waived. However, all subjects provided written informed verification, the clear corneal incision was hydrated to ensure
consent to undergo standard-of-care DMEK or DMEK/ self-sealing, and air was injected into the anterior chamber to
cataract surgery according to our hospital’s standard proce- seat the graft.
dures. All study conduct adhered to the tenets of the Patients undergoing both DMEK and cataract surgery
Declaration of Helsinki. had cataract surgery performed first using phacoemulsifica-
tion through a 2.2-mm corneal incision. After cataract
extraction, an intraocular lens was implanted into the
Study Subjects posterior chamber, and Miochol-E (1:100, acetylcholine
This retrospective study included all patients who chloride intraocular solution; Bausch & Lomb, Rochester,
underwent DMEK alone or DMEK with concurrent cataract NY) was injected to induce miosis for peripheral iridotomy
surgery (triple-DMEK) at the Edouard Herriot University before the DMEK procedure. All patients received a subcon-
Hospital (Lyon, France) between March 2014 and December junctival corticosteroid injection at the end of surgery.
2015. Patients were excluded from analyses if they had Postoperative medication use included artificial tears
a history of macular edema (regardless of the origin) before (Celluvisc; Allergan France, Courbevoie, France), a cortico-
DMEK surgery. steroid antiinflammatory agent (dexamethasone/neomycin
suspension, Alcon; 4 times a day for month 1, 3 times
a day for months 2 and 3, twice a day for months 4–8, and
Surgical Techniques once a day for months 9–12), and a miotic agent [Europhtal
Donor corneal tissue was obtained from the Lyon (pilocarpine 1%), Vidal France, Issy-les-Moulineaux,
Cornea Bank at Edouard Herriot Hospital in all cases. All France]. Patients who underwent a triple procedure also used
DMEK procedures were performed by 2 corneal specialists a topical nonsteroidal antiinflammatory drop (NSAID) [indo-
(V.K. and A.S.M.) using the same surgical techniques. methacin (indocollyre) 0.1%, Chauvin, France, 4 times a day
Procedures were performed under general or local anesthesia, for 5 weeks]. Patients were required to remain in a supine
as per the surgeons’ discretion. position until the anterior chamber air bubble disappeared. All
patients remained hospitalized for 3 days after surgery. The
Graft Preparation anterior chamber was rebubbled if graft detachment occurred,
All DMEK grafts were harvested at the cornea bank or regardless of the detachment size.
in the operating room using the “no touch” technique.16 First,
the endothelium was stained with trypan blue 0.06% (BCC;
Croma-Pharma GmbH, Leobendorf, Austria) for approxi- Study Examinations
mately 4 minutes. Next, the Descemet membrane and All subjects attended follow-up visits as per standard
endothelium were incised along the trabecular meshwork, protocols. Postoperative examinations occurred at weeks 1, 2,
elevated along the periphery (for approximately 2 mm) using 3, and 4 and at months 3 and 6. Examinations at each visit
a corneal epithelium spatula (MMSU 1113; Malosa Medical, included corrected and uncorrected visual acuity (VA)
Halifax, United Kingdom), and detached from the stroma by assessment [logarithm of the minimum angle of resolution
pulling upward with Kocaba DMEK forceps (MMSU1499S; (logMAR) scale], intraocular pressure measurement, fundo-
Malosa Medical). A corneal trephine (Coronet, NM-51-903- scopy, pachymetry (Pachy-map module, Visante-OCT 1000
8.00, single use; Network Medical Products Ltd, Ripon, system; Carl Zeiss Meditec, Inc, Dublin, CA), and anterior
United Kingdom) was used to cut an 8-mm central segment. segment optical coherence tomography (OCT; Visante-OCT
Last, the trephine (still containing the donor button) was 1000). Patients suspected of having CME (reduced VA
placed in a 0.09% sodium chloride solution to enable despite a clear cornea or abnormal fundoscopic findings) also
endothelium-out graft scrolling. underwent macular OCT imaging (Spectralis-OCT; Sanotek,
Heidelberg, Germany). Macular thickness was automatically
Graft Injection and Positioning measured by the device. Subjects were diagnosed with CME
After standard preparation for ocular surgical proce- if central macular thickness (central 1000 mm) was $300 mm
dures, 4 paracenteses were made using a 15-degree cataract on Spectralis HRA imaging17 or intraretinal (intraretinal
knife (BVI 374891; Beaver Visitec, Milton, United King- edema) or subretinal (serous retinal detachment) fluid was
dom). Iridotomy was then performed using the double-needle detected on OCT.18
technique. Next, air was injected into the anterior chamber to Subjects diagnosed with CME were initially treated
enable performing descemetorhexis, which was done using with a topical NSAID [indomethacin (indocollyre) 0.1%,
a Price hook (17,302; Moria SA, Antony, France). A clear Chauvin, France; 3 times a day for 2 mo] or topical
corneal incision was enlarged using a 2.2-mm slit knife corticosteroids (dexamethasone/neomycin ophthalmic sus-
(8065982265; Alcon, Fort Worth, TX). If not performed at pension, Alcon; 3 times a day for 2 mo) and oral acetazol-
the cornea bank, the graft was prepared for transplantation by amide (Diamox, Sanofi, Paris, France; 3 tablets a day). If

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Cornea  Volume 37, Number 3, March 2018 Incidence of Macular Edema After DMEK

CME did not resolve with treatment, a 0.7-mg dexamethasone

TABLE 1. Characteristics of Patients Who Underwent DMEK
intravitreal implant (DEX implant, Ozurdex; Allergan plc,
Alone and DMEK in Combination With Cataract Surgery
Dublin, Ireland) was placed in the affected eye.
DMEK in
Combination
With Cataract
Data Collection DMEK Alone Surgery All Patients
The following data were retrospectively collected from Characteristic (N = 37 Eyes) (N = 43 Eyes) (N = 80 Eyes) P*
subject medical records: age, sex, laterality, surgical indica- Age (yr) 73.0 69.0 72.0 0.42
tion, ophthalmic history (including uveitis, retinal vein (63.0–80.0) (62.0–78.5) (63.7–79.0)
occlusion, and diabetic macular edema), axial length CME 3 (8.1%) 8 (18.6%) 11 (13.8%) 0.301
(IOLMaster 500; Carl Zeiss Meditec, Jena, Germany), pre- Sex
operative prostaglandin use, intraoperative complications, and Male 21 (56.8%) 13 (30.2%) 34 (42.5%)
proposed postoperative NSAID use. The number of rebub- Female 16 (43.0%) 30 (69.8%) 46 (57.5%) 0.023
blings was also noted. Axial length 23.7 23.8 23,9 0.748
(mm) (22.9–24.3) (22.9–24.8) (22.8–24.7)
Rebubbling 22 (59.5%) 26 (60.5%) 48 (60.0%) .0.999
Statistical Analyses Graft failure 11 (29.7%) 8 (18.6%) 19 (23.8%) 0.297
Qualitative variables are presented as numbers and Subjects 0 (0%) 0 (0%) 0 (0%)
with CME
percentages. Continuous variables are presented as median
History of 4 (10.8%) 3 (7.0%) 7 (8.8%) 0.698
(first and third quartiles). The 2 surgical groups (DMEK and diabetes
DMEK/cataract) were compared using nonparametric tests Subjects 0 (0%) 0 (0%) 0 (0%)
(the Fisher test and Wilcoxon test for qualitative and with CME
continuous variables). Considering the discrete nature of Postoperative 6 (16.2%) 32 (74.4%) 38 (47.5%) ,0.001
follow-up visits, which were identical for all patients, an NSAIDs
ordinal multinomial logistic regression model was used to Subjects 2 (5.4%) 5 (11.6%) 7 (8.8%)
estimate the effect of potential CME risk factors. Statistical with CME
significance was defined as P , 0.05. All data analyses were Indications
performed using R statistical software (version 3.0.2; Fuch 0 (0%) 40 (93.0%) 40 (50.0%)
R Development Core Team, Vienna, Austria). dystrophy
Pseudophakic 24 (64.9%) 0 (0%) 24 (30.0%)
ED
Primary graft 10 (27.0%) 1 (2.3%) 11 (13.8%)
RESULTS failure
A total of 78 patients met all study inclusion criteria. ED after 3 (8.1%) 2 (4.7%) 5 (6.3%)
Four patients were excluded from analyses because of follow- phakic IOL
up loss (3 patients) and retinal detachment development 1
Data are presented as median (first–third quartile) or n (%).
month after surgery (1 patient). Therefore, 80 eyes of 74 *P calculated using a Fisher or Wilcoxon test.
patients were ultimately included in analyses. Median subject ED, endothelial decompensation; IOL, intraocular lens implantation.
age was 72.0 years (63.7–79.0 years), and 34 subjects
(42.5%) were men. Tissue for the DMEK procedure was
prepared at the cornea bank in 27 cases and in the operating subjects who underwent triple-DMEK had an 18.0% (8 of 43
room in 53 cases. eyes) CME incidence (P = 0.184). Subjects who developed
Table 1 summarizes the characteristics of subjects who CME had a median central macular thickness of 467.0 mm
underwent DMEK and triple-DMEK. Indications for surgery (356.0–568.5 mm). The logMAR VA was not significantly
were Fuchs endothelial dystrophy [40 eyes (50.0%)], pseu- different between subjects with and without CME at month 6
dophakic endothelial decompensation [24 eyes (30.0%)], [CME: 0.3 (0.1–1.0); no CME: 0.3 (0.1–0.5); P = 0.93].
primary graft failure [11 eyes (13.8%): perforating kerato- Median logMAR VA at month 6 was also not significantly
plasty (PK) in 1 eye, Descemet stripping automated endothe- different between the DMEK [0.3 (0.1–1.0)] and triple-
lial keratoplasty (DSAEK) in 2 eyes, and DMEK in 8 eyes], DMEK [0.3 (0.1–0.5)] groups (P = 0.391).
and endothelial decompensation after phakic intraocular lens Average CME thickness was 467.2 mm (345–800 mm),
implantation [5 eyes (6.3%)]. Axial length, diabetes history, but CME did not occur in enough patients to compare
rebubbling need, graft failure, and postoperative topical thickness differences between groups. First-line medical
NSAID use/nonuse were not significantly different between therapy sufficiently treated CME, with the exception of 1
surgical groups. All patients who underwent DMEK alone subject in the triple-DMEK group who had a remote history
were pseudophakic and had undergone cataract surgery at of ocular trauma. This subject needed second-line treatment
least 6 months before DMEK. with intravitreal dexamethasone. Three included subjects with
The 6-month incidence of CME was 13.8% (11 of 80 primary open-angle glaucoma were using prostaglandins
eyes) in all included subjects. Most CME appeared between before surgery (2 patients in the triple-DMEK group and 1
M1 and M3, as shown in Figure 1. Subjects who underwent patient in the DMEK group). None of these subjects had
DMEK alone had an 8.0% (3 of 37 eyes) CME incidence, and CME recurrence. Furthermore, univariate analyses revealed

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Kocaba et al Cornea  Volume 37, Number 3, March 2018

FIGURE 1. Plot showing the inci-

dence of CME in the first 6 months
after Descemet membrane auto-
mated endothelial keratoplasty (n =
80 eyes). CME, cystoid macular
edema.

that rebubbling, axial length, postoperative topical NSAID procedure (18.0%). Our results are consistent with previous
use/nonuse, combined surgery, and age were not statistically reports in the literature. In a large prospective study involving
significant risk factors for developing CME (Table 2). 155 eyes, Heinzelmann et al11 reported a post-DMEK CME
Surgical complications included rebubbling [48 eyes incidence of 13%, with no significant difference in the CME
(60.0%)], graft failure [18 eyes (22.5%)], and postoperative incidence after DMEK and triple-DMEK. More recently,
ocular hypertension [1 eye (1.3%)]. Graft failure was not Hoerster et al12 reported a CME incidence of 12% in a study
influenced by the type of surgery performed. All eyes with that included 75 eyes, and Flanary et al13 reported an
graft detachment were rebubbled, regardless of the detach- incidence of 7.5% in a study that included 173 eyes.
ment size. The median number of rebubbles for all included Interestingly, none of the potential risk factors exam-
subjects was 1 (0.0–1.2, maximum = 4). Posterior capsule ined (age, axial length, surgery type, postoperative topical
rupture occurred in 2 eyes in the triple-DMEK group (2.5% of NSAID use/not use, and rebubbling) significantly increased
all eyes, 4.7% of triple-DMEK eyes), none of which the risk of developing CME. However, the incidence of CME
developed postoperative CME. observed after DMEK and triple-DMEK was higher than the
incidence after cataract surgery alone (1%–2%).15 This
suggests that the DMEK procedure itself might be a risk
DISCUSSION factor for postoperative CME. The incidence of CME after
This study found a relatively high CME incidence of cataract surgery has also been shown to be lower than that
13.8% after DMEK. The CME incidence was not signifi- after Descemet stripping automated endothelial keratoplasty
cantly different between patients who underwent only DMEK (5%)19 and penetrating keratoplasty (9%).20
(8.0%) and those who underwent a combined DMEK/cataract Evidence indicates that inflammation plays a large role
in postoperative CME development. Heinzelmann et al11
examined the CME incidence after DMEK and systematically
performed macular OCT during the follow-up period. There-
TABLE 2. Univariate Analyses of Suspected Risk Factors for fore, it is not surprising that they found a higher CME
Developing CME After DMEK incidence than other studies that did not examine all subjects
Risk Factor Odds Ratio (95% CI) P* using OCT. Indeed, in eyes with Irvine–Gass syndrome, OCT
Rebubbling 1.90 (0.50–9.20) 0.373 can be used to detect asymptomatic CME.21 Interestingly,
Axial length 1.17 (0.75–1.77) 0.458 eyes with a short axial length are at greater risk for developing
Postoperative NSAIDs 1.87 (0.52–7.68) 0.349 CME.11 Theoretically, a shorter eyeball would lead to
Combined surgery 2.59 (0.69–12.58) 0.184 a shorter diffusion distance between the cornea and the retina.
Age 0.98 (0.93–1.03) 0.419 This would theoretically facilitate inflammatory cascade
activation and, ultimately, edema development. As already
*P calculated using Fisher and Wilcoxon tests.
CI, confidence interval. shown after cataract surgery, intraoperative iridotomy and the
presence of an anterior chamber bubble can stimulate the iris,

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Cornea  Volume 37, Number 3, March 2018 Incidence of Macular Edema After DMEK

which contributes to increased postoperative inflammation.22 macular leakage in the intermediate phase). Therefore, future
Dapena et al14 performed iridotomy before DMEK and found studies are needed on a larger population to confirm our
a much lower CME incidence of 0.7% after surgery. Their findings. These studies should include scheduled preoperative
rebubbling rate was also very low (5.9%). In our study, in- and postoperative macular imaging (OCT and fluorescein
traoperative iridotomy was associated with a high rate of re- angiography) to rule out CME unrelated to surgery and to
bubbling, which may explain the 13.8% CME incidence improve CME detection. Last, our study population was too
observed here. In agreement with our findings, Heinzelmann small to assess the influence of diabetes, intraocular inflam-
et al11 found that CME development did not significantly mation, and retinal vein occlusion on CME development.
affect long-term visual outcomes and that the majority of In conclusion, our study of 80 eyes (the largest French
CME cases could be successfully treated using topical DMEK case series to date) identified a postoperative CME
medications. As in our study, they had only 1 patient who incidence of 13.8%. This number is consistent with pre-
required intravitreal dexamethasone therapy. viously reported rates. Moreover, our findings suggest that,
Steroid therapy studies further support the large role of when appropriately treated, postoperative CME does not
inflammation in postoperative CME development. Hoerster adversely affect final DMEK visual outcomes.
et al12 directly compared intensive topical steroid therapy
(hourly administration) with standard steroid therapy (admin-
istered 5 times a day) for preventing CME after triple-DMEK.
None of the subjects who received intensive therapy for 1
ACKNOWLEDGMENTS
week developed CME. By contrast, 9 of 75 standard therapy
subjects (12%) developed CME. It should be noted that these The authors would like to thank Editage (www.editage.
findings may not be applicable to all clinical situations com) for English language editing.
because of iatrogenic complication risks and the fact that
only triple-DMEK cases were included in their study. All 9 REFERENCES
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