DMEK, DSAEK, and repeat PKP for endothelial failure after PKP: systematic review and meta-analysis with a graphical synthesis of clinical decision factors.
Giacomo Beschi, Yousef Youssef, Filippo Lozza et al.
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In 30 seconds
This systematic review and meta-analysis compared DMEK, DSAEK, and repeat penetrating keratoplasty (re-PKP) for endothelial failure after prior PKP in adults. It included 32 studies, predominantly retrospective case series. Pooled graft failure proportions were 0.22 after DMEK, 0.19 after DSAEK, and 0.29 after re-PKP. All procedures improved visual acuity from baseline; DMEK had numerically greater, more sustained improvement and the lowest pooled rejection proportion, but detachment was more frequent. These comparisons are descriptive and should be interpreted cautiously because study populations and follow-up varied.
Key findings
- Pooled graft failure proportions were 0.22 for DMEK, 0.19 for DSAEK, and 0.29 for re-PKP.
- Pooled rejection proportions were 0.07 after DMEK, 0.14 after DSAEK, and 0.15 after re-PKP.
- Detachment was more frequent after DMEK than DSAEK (0.37 vs 0.18).
- All procedures improved visual acuity from baseline; DMEK showed numerically greater, more sustained improvement through 12-13 months.
Why it matters
The findings outline differing outcome profiles for three surgical options after endothelial failure of a prior PKP. In particular, the lower pooled rejection proportion and greater detachment proportion reported with DMEK illustrate why outcomes should be considered together rather than relying on visual improvement alone. The evidence does not establish a definitive procedure-selection framework.
What to keep in mind
Evidence was predominantly from retrospective, non-randomized studies with variable risk of bias. Incomplete reporting of preoperative and graft-related variables, and differences in baseline visual acuity and follow-up, limit comparisons.