Purpose: To compare the safety and efficacy profiles of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in adult patients with Fuchs’ endothelial dystrophy. Methods: Electronic database search on MEDLINE and CENTRAL from inception to August 2017. We included all comparative studies of DMEK versus DSAEK in patients with diagnosed Fuchs’ endothelial dystrophy. Studies assessing rescue procedures were excluded to minimize bias. Primary outcome: mean difference in best-corrected visual acuity (BCVA) at 3, 6, and 12 months postoperatively. Secondary outcomes: rates of graft primary failure, rejection, and rebubbling; other graft-related issues; mean difference in endothelial cell density; subjective visual outcomes; and patient satisfaction. Results: A total of 10 retrospective studies of moderate methodological quality were included (n = 947 eyes, 646 DMEK). BCVA was better with DMEK at all evaluated time points (0.16 logMAR at 12 months) comparing to DSAEK (0.30 logMAR; p < 0.001). DMEK had a 60% lower rate of rejection (risk ratio (RR) 0.4, 95% CI (0.24, 0.67), p = 0.0005), but required more rebubblings (RR = 2.48, 95% CI (1.32, 4.64), p = 0.005). DMEK had more primary graft failures and less endothelial cell density loss, but statistical difference was not reached. More patients were satisfied after DMEK (odds ratio = 10.29, 95% CI (3.55, 29.80), p < 0.0001). Conclusion: DMEK showed better postoperative results regarding BCVA, patient satisfaction, and graft-related issues. However, the small number of studies with short follow-up times and other methodological issues prompt us to interpret these results carefully.

Purpose: To compare intracameral 20% sulfur hexafluoride (SF₆) versus 100% air as tamponade for graft attachment in Descemet membrane endothelial keratoplasty (DMEK). Methods: Using an electronic database search on MEDLINE and CENTRAL from inception to December 2017, we performed a literature review and meta-analysis including all comparative studies of SF₆ at a 20% concentration (20% SF₆) versus pure air (100% air) for anterior chamber tamponade in DMEK. The primary outcome was the rebubbling rate at the final observation. The secondary outcomes were 1) the graft detachment rate, 2) mean difference (MD) in best-corrected visual acuity (BCVA), 3) manifest refraction spherical equivalent, 4) central corneal thickness (CCT), 5) percentage of endothelial cell loss (ECL), and 6) rate of pupillary block by the final observation. Statistical analysis was performed using RevMan5.3 software. Results: Five retrospective studies were included, assessing 1195 eyes (SF₆ 277; air 918). The main indication for surgery was Fuchs endothelial dystrophy (SF₆ 85.2%; air 86.2%) and bullous keratopathy (SF₆ 10.8%; air 10.0%). Overall, studies were of moderate to good methodological quality. Patients in the SF₆ group required 58% less rebubbling procedures (risk ratio 0.42, 95% confidence interval (CI), 0.31–0.56, P < 0.0001). No differences were found regarding BCVA improvement (MD 0.03, 95% CI, −0.05 to 0.11, P = 0.49). SF₆ was associated with a minor hyperopic shift (MD 0.37 D, 95% CI, −0.95 to −0.21, P = 0.21). No differences were found regarding CCT, ECL, and rate of pupillary block (P > 0.05). Conclusions: In DMEK, 20% SF₆ tamponade and longer postoperative time supine were associated with 58% fewer rebubbling procedures, and an ECL not statistically different from using 100% air.

Background: Diabetic retinopathy (DR) is a leading cause of blindness due to diabetic macular edema (DME) or complications of proliferative diabetic retinopathy (PDR). Optical coherence tomography (OCT) is a noninvasive imaging technique well established for DME but less used to assess neovascularization in PDR. Developments in OCT imaging and the introduction of OCT angiography (OCTA) have shown significant potential in PDR. Objectives: To describe the tomographic features of PDR, namely of neovascularization, both of the optic disc (NVD) and elsewhere (NVE), intraretinal microvascular abnormalities (IRMA), retinal nonperfusion areas (NPA), status of the posterior vitreous, vitreoschisis and vitreous and subhyaloid/sub-ILM hemorrhages. Data sources: Electronic database search on PubMed and EMBASE, last run on December 19th 2019. Study eligibility criteria, participants and interventions: Publications assessing OCT and/or OCTA findings in PDR patients. All study designs were allowed except for case-reports, conference proceedings and letters. Study appraisal: Newcastle–Ottawa Scale for observational studies was used for purposes of risk of bias assessment. Results: From the 1300 studies identified, 283 proceeded to full-text assessment and 60 were included in this comprehensive review. OCT was useful in detecting NVD and NVE, such as in characterizing disease activity and response to laser and/or anti-VEGF therapies. The absence of posterior vitreous detachment seemed determinant for neovascular growth, with the posterior hyaloid acting as a scaffold. OCTA allowed a more detailed characterization of the neovascular complexes, associated NPA and disease activity, allowing the quantification of neovessel area and flow index. However, changes in OCTA blood flow signal following local therapies did not necessarily correlate with structural regression. Widefield and ultra-widefield OCTA were highly sensitive in the detection of PDR, adding value to disease staging and monitoring. Compared to fluorescein angiography, OCTA was more sensitive in detecting microvascular changes indicating disease progression. Limitations: Publication languages were restricted. Most included studies were observational and non-comparative. Risk of bias regarding case representativeness. Conclusions: OCT-based retinal imaging technologies are advancing rapidly and the trend is to be noninvasive and wide-field. OCT has proven invaluable in diagnosing, staging and management of proliferative diabetic disease with daily application in clinical and surgical practices.

BACKGROUND AND OBJECTIVE: To compare complete internal limiting membrane (ILM) peeling with the inverted flap technique for macular hole (MH) surgery. PATIENTS AND METHODS: An electronic database search on PubMed, CENTRAL, and ClinicalTrials.gov was performed. Inclusion criteria were comparative prospective/retrospective studies including patients with MH of any size with at least 6 months of follow-up. The primary outcome was MH closure rate. Secondary outcomes were best-corrected visual acuity improvement and surgery-related adverse events. RESULTS: Sixteen papers enrolling 1,403 eyes were included (733 ILM peeling, 670 inverted flap). MH mean minimum diameter and time of symptomatic evolution were higher in the inverted flap group (531.1 μm ± 188.8 μm vs. 602.8 μm ± 223.8 μm; 10.4 ± 20.2 months vs. 12.0 ± 18.4 months; P < .01). Overall, MH closure rate was superior with the inverted flap technique (risk-ratio [RR]: 1.25; 95% confidence interval [CI], 1.14–1.38; P < .0001), as well as in all subgroups: idiopathic large MH (n = 362; RR: 1.12; 95% CI, 1.05–1.20; P < .001), myopic MH without retinal detachment (n = 133; RR: 1.35; 95% CI, 1.14–1.59; P < .001), and MH retinal detachment (n = 198; RR: 1.89; 95% CI, 1.31–2.73; P < .001). CONCLUSION: This meta-analysis suggests the inverted flap technique is more effective in achieving MH closure. [ Ophthalmic Surg Lasers Imaging Retina . 2020;51:187–195.]