After endothelial keratoplasty, plan pressure surveillance: OHT 9% after DMEK, 34% after DSAEK

Design

Systematic review and meta-analysis of 33 studies

Population

5,235 glaucoma-naive adult eyes after DMEK or DSAEK

Primary outcome

De novo glaucoma and ocular hypertension

Effect

Glaucoma 3% vs 11%; ocular hypertension 9% vs 34%; rate ratio for OHT 0.31 (95% CI 0.14 to 0.71)

A systematic review in the American Journal of Ophthalmology (published 22 September) pooled 33 studies of 5,235 adult eyes without previous glaucoma having Descemet membrane endothelial keratoplasty (DMEK) or Descemet stripping automated endothelial keratoplasty (DSAEK).

De novo glaucoma occurred in 3% after DMEK and 11% after DSAEK, ocular hypertension in 9% versus 34%, and starting or escalating pressure-lowering medication in 6% versus 20%. Glaucoma surgery was uncommon (1.0% vs 2.5%). DSAEK cohorts were followed about twice as long, but rate ratios adjusted for time still favoured DMEK for ocular hypertension (0.31, 95% CI 0.14 to 0.71). Greater steroid exposure was independently linked to ocular hypertension. Certainty was low, and randomised head-to-head comparisons did not reach significance.

The practical point is less about choosing a technique than about follow-up: a raised pressure is common after either procedure, often driven by the steroids needed to protect the graft. Pressure checks should be built into the post-keratoplasty schedule, with steroid potency and duration tailored to the patient.

• Schedule regular pressure checks after every endothelial keratoplasty, especially during steroid treatment.
• Expect ocular hypertension in about one in ten eyes after DMEK and about one in three after DSAEK.
• Consider a lower-potency steroid or shorter course where graft risk allows.
• Counsel patients that a pressure rise may need drops and occasionally surgery.
• Weigh the lower pressure-related risk of DMEK when choosing a technique, alongside surgeon experience.

Why it matters

Post-keratoplasty glaucoma threatens both the optic nerve and the graft, and much of it is predictable from the procedure and steroid regimen.

Don't overread it

Certainty was low, glaucoma definitions varied, and randomised head-to-head comparisons were not significant.

The statistics, in plain English

A Poisson rate ratio of 0.31 means DMEK eyes developed ocular hypertension at about a third of the DSAEK rate per year of follow-up. When glaucoma was restricted to optic nerve or field damage, the difference shrank (5.0% vs 8.1%) and was not significant, so part of the gap is in pressure, not proven damage.

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