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dc.contributor.authorOng, Hon Shingen_US
dc.contributor.authorHtoon, Hla M.en_US
dc.contributor.authorAng, Marcusen_US
dc.contributor.authorMehta, Jodhbir Singhen_US
dc.identifier.citationOng, H. S., Htoon, H. M., Ang, M. & Mehta, J. S. (2022). "Endothelium-Out" and "Endothelium-In" descemet membrane endothelial keratoplasty (DMEK) graft insertion techniques: a systematic review with meta-analysis. Frontiers in Medicine, 9, 868533-.
dc.description.abstractBackground: We evaluated the visual outcomes and complications of “endothelium-out” and “endothelium-in” Descemet membrane endothelial keratoplasty (DMEK) graft insertion techniques. Materials and Methods: Electronic searches were conducted in CENTRAL, Cochrane databases, PubMed, EMBASE, Study designs included clinical trials, comparative observational studies, and large case series (≥25 eyes). PRISMA guidelines were used for abstracting data and synthesis. Random-effects models were employed for meta-analyses. Results: 21,323 eyes (95 studies) were included. Eighty-six studies reported on “endothelium-out” techniques; eight studies reported on “endothelium-in” techniques. One study compared “endothelium-out” to “endothelium-in” techniques. Eighteen “endothelium-out” studies reported that 42.5–85% of eyes achieved best-corrected visual acuity (BCVA) ≥20/25 at 6 months; pooled proportion of eyes achieving BCVA ≥20/25 at 6 months was 58.7% (95% CI 49.4–67.7%,15 studies). Three “endothelium-in” studies reported that 44.7–87.5% of eyes achieved BCVA of ≥20/25 at 6 months; pooled proportion of eyes achieving BCVA ≥20/25 at 6 months was 62.4% (95% CI 33.9–86.9%). Pooled mean endothelial cell loss was lower in the “endothelium-in” studies (28.1 ± 1.3%, 7 studies) compared to “endothelium-out” studies (36.3 ± 6.9%,10 studies) at 6 months (p = 0.018). Graft re-bubbling rates were higher in the “endothelium-out” studies (26.2%, 95% CI 21.9–30.9%, 74 studies) compared to “endothelium-in” studies (16.5%, 95% CI 8.5–26.4%, 6 studies), although statistical significance was not reached (p = 0.440). Primary graft failure rates were comparable between the two groups (p = 0.552). Quality of evidence was considered low and significant heterogeneity existed amongst the studies. Conclusion: Reported rates of endothelial cell loss were lower in “endothelium-in” DMEK studies at 6 months compared to “endothelium-out” studies. Outcomes of “endothelium-in” techniques were otherwise comparable to those reported in “endothelium-out” studies. Given the technical challenges encountered in “endothelium-out” procedures, surgeons may consider “endothelium-in” techniques designed for easier intra-operative DMEK graft unfolding. “Endothelium-in” studies evaluating outcomes at longer time points are required before conclusive comparisons between the two techniques can be drawn.en_US
dc.relation.ispartofFrontiers in Medicineen_US
dc.rightsCopyright © 2022 Ong, Htoon, Ang and Mehta. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.en_US
dc.title"Endothelium-Out" and "Endothelium-In" descemet membrane endothelial keratoplasty (DMEK) graft insertion techniques: a systematic review with meta-analysisen_US
dc.typeJournal Articleen
dc.contributor.schoolSchool of Materials Science and Engineeringen_US
dc.contributor.organizationSingapore National Eye Centreen_US
dc.contributor.organizationSingapore Eye Research Instituteen_US
dc.contributor.organizationDuke-NUS Medical Schoolen_US
dc.description.versionPublished versionen_US
dc.subject.keywordsEndothelial Keratoplastyen_US
dc.subject.keywordsDescemet’s Membrane Endothelial Keratoplastyen_US
dc.description.acknowledgementThe costs of publication of this article was funded by a grant from SingHealth Fund-SNEC (SHF-SNEC).en_US
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