Prescription patterns in DMEK: European survey

Abstract

Purpose: To assess current prescription patterns in Descemet membrane endothelial keratoplasty (DMEK) in Europe.

Setting: Countries affiliated with the European Cornea and Cell Transplantation Registry and the European Vision Institute Clinical Research Network.

Design: Cross-sectional study (European survey).

Methods: An electronic survey was distributed to 16 national societies to gather data on prescription patterns for DMEK. Responses were categorized by 3 clinical goals: prevention of postoperative endophthalmitis, graft rejection, and pupillary block and glaucoma.

Results: Responses from 136 surgeons revealed that medication protocols mainly came from departmental protocols (54%) or personal experiences (48%) rather than national guidelines (22%) (multiple answers were allowed). Infection prevention primarily relied on intraoperative (72%) and postoperative (92%) antibiotics, with preoperative use less common (18%). Steroids were the mainstay for rejection prevention, used intraoperatively (59%), postoperatively (100%), and occasionally preoperatively (13%). Steroids were typically tapered to once daily after 6 months (46%) and discontinued after varying durations (65%). Dexamethasone was the preferred steroid. For high-risk DMEK, the most common approach was adding another topical (30%) or systemic immunosuppressive drug (24%), such as cyclosporine or mycophenolate. For graft rejection, most respondents increased topical steroid frequency (85%) or added (peri)bulbar steroid injections (42%). Pupillary block and glaucoma prophylaxis mainly involved intraoperative mydriatics (34%); intraocular pressure-lowering agents were rarely used (0.7% to 2.2%). For steroid-induced ocular hypertension, the common approach was switching to a lower-potency steroid (40%) or reducing steroid frequency (43%).

Conclusions: Current prescription patterns in routine and high-risk DMEK vary significantly, reflecting the lack of standardized guidelines.

Figure 1.

Distribution of annual routine DMEK procedures performed by surveyed corneal surgeons (A) and their affiliated institutes in 2023 (B). The percentage (%) of respondents is indicated next to each segment of the pie chart.

Figure 2.

Distribution of medications prescribed before, during, and after DMEK procedures (A). Route of administration of medications during routine DMEK surgery (B). The percentage (%) of respondents is indicated above each bar.

Figure 3.

Distribution of steroid tapering regimen to once daily (A) and discontinuation of steroid prescription (B) after DMEK. The percentage (%) of respondents is indicated next to each segment of the pie chart.

Figure 4.

Distribution of the preferred step-by-step approach in case of graft rejection signs (A) and steroid-induced IOP elevation (B). The percentage (%) of respondents is indicated next to each bar.