Name

272 - DMEK dans l'herpes oculaire

To describe functional outcome, complications and complication management of Descemet’s membrane endothelial keratoplasty (DMEK) in corneal decompensation secondary to herpetic eye disease (HED). 

In this retrospective case series we report on DMEK surgery that was performed in patients with HED whenever endothelial decompensation was the major component of visual loss. Patients received a complete ophthalmological examination, including anterior segment OCT, preoperatively and postoperatively at day 1, day 2, every week for the first month and thereon on a monthly basis. Follow-up times were at least 6 months. 

17 eyes of 17 patients were included. Mean follow-up time was 11.1±5.9 months (range: 6-27). Corrected-distance visual acuity improved from 1.16±0.46 logMAR to 0.62±0.44 logMAR (p=0.001). Pachymetry significantly decreased from 695±53µm at day 1 to 631±54µm at week 1 (p=0.001) and further to 569±88µm at two months (p=0.009). Postoperative complications included primary graft failure (2 eyes), endothelitis (5 eyes), neurotrophic ulcers (6 eyes) and Irvine Gass syndrome (3 eyes). Median delay until complications was 2.5 months following surgery with a general complication risk decreasing after 5 months.

In our study group, rejection rates were higher than in DMEK subsequent to different indications, but similar to penetrating keratoplasty following herpes simplex keratitis. In 30% of eyes an endothelitis developed in the follow-up time. The rate of these complications seems to be higher than in PKP and in full-bed deep anterior lamellar keratoplasty (DALK). The high level of endothelitis observed in our patient cohort may be due to the irritation of the uveal tissue after direct and indirect manipulation during surgery and to the fact eyes that already had an endothelial decompensation are expected to be more prone to develop keratouveitis and endothelitis when compared to eyes with only corneal scarring secondary to epithelial keratitis. In DMEK, contrary to PKP or DALK, corneal nerves are preserved. Therefore, one would expect the rate of neurotrophic ulcer to be lower. However, with 35% of cases, the rate of neurotrophic ulcer was found to be relatively high in our study group. Overall this risk profile strongly suggests that patients receiving DMEK for endothelial decompensation secondary to HED must be closely monitored and recurrence of herpetic infections must be avoided by all means. Patients should therefore be kept on a full dose of valacyclovir for as long as they are treated with corticosteroids.

DMEK surgery significantly improved CDVA in patients with an endothelial decompensation due to HED with limited stromal scarring. Complications occurred at a higher rate than expected and mainly developed in the short postoperative period. Close follow-up should be performed and patients should be kept on oral valacyclovir. Threshold should be low for hospitalization and intravenous antiviral treatment in case of disease recurrence.