Re: Busin et al.: The ongoing debate: Descemet membrane endothelial keratoplasty versus ultrathin Descemet stripping automated endothelial keratoplasty (Ophthalmology. 2020;127:1160–1161)

We read the commentary by Busin et al1Busin M. Yu A.C. The ongoing debate: Descemet membrane endothelial keratoplasty versus ultrathin stripping automated keratoplasty.Ophthalmology. 2020; 127: 1160-1161Abstract Full Text PDF PubMed Scopus (3) Google Scholar on debate regarding (ultrathin DSAEK) (DMEK). Although randomized controlled trials (RCTs) are designed to decrease or eliminate bias, they cannot variability. Multiple RCTs needed get closer true value of an effect. Therefore, it is great importance that there now 2 comparing DSAEK and DMEK. al pointed out some differences may underlie disagreement in best-corrected visual acuity (BCVA) between Endothelial Thickness Comparison Trial (DETECT) our study.2Dunker S.L. Dickman M.M. Wisse R.P.L. al.Descemet keratoplasty: a multicenter clinical trial.Ophthalmology. 1152-1159Abstract (17) Scholar,3Chamberlain W. Lin C.C. Austin A. thickness comparison trial: trial with 2019; 126: 19-26Abstract (48) In addition technical issues, such as graft regularity, methodologic differences, inclusion pseudophakic eyes only, both studies also differed terms eligibility patients corneal edema, fellow eyes, masking. Nonetheless, interesting 1 year after surgery were no significant clinically relevant BCVA (measured standardized manner) treatment arms study DETECT (DMEK arm 0.08 ± 0.14 vs 0.04 0.12; P = 0.3; 0.15 0.11 0.16 0.18 logarithm minimum angle resolution [logMAR], 0.8; respectively; independent-samples t test using mean, standard deviation, sample size). outcome particular interest; 73 12 μm 101 25 study. prospective 155 51 μm, (also measured was logMAR at continued improvement through 5 years.4Wacker K. Baratz K.H. Maguire L.J. for fuchs' dystrophy: five-year results study.Ophthalmology. 2016; 123: 154-160Abstract (65) these 3 found within letters each other over wide range thickness, suggesting not play major role long-term outcomes; even diminish time. Indeed, end points be limited extent which context (including timing). It will see if any short-term either carry forward. from suggest modern techniques approaching upper limit high-contrast BCVA. Disease-specific measures glare disability low-contrast Fuchs dystrophy can assess domains beyond acuity, patient-reported outcomes increasingly placed heart value-based health care. Similar BCVA, we faster recovery DMEK, but comparable surgery. Neither RCT vision-related quality life. However, underpowered regard secondary used generic life questionnaires. Future consider disease-specific measures, V-FUCHS, primary outcome.5Wacker Bourne W.M. al.Patient-reported Fuchs' function status instrument.Ophthalmology. 2018; 125: 1854-1861Abstract (14) DMEK anatomically different procedure (whether standard, ultrathin, nanothin). donor stroma adds irregularity posterior surface transplantation, might influence more than thickness. complex vision-limiting comorbidities, technique probably matters little vision achieving maximum potential survival functional minimizing intraoperative complications postoperative detachments requiring rebubbling. similar rebubbling rate reported (24%) American Academy Ophthalmology Ophthalmic Technology Assessment (29%) provides evidence common effects currently unknown, report increased cell loss, lead earlier failure. Both show sets high bar outcomes, whether future novel therapies. still has important surgical management especially anatomy previous trauma provide highly thicknesses. Ongoing Debate: Membrane Keratoplasty Versus Ultrathin Stripping Automated KeratoplastyOphthalmologyVol. 127Issue 9PreviewThe success popularity (DMEK) related its rapid speed excellent several studies.1–3 practice, best candidates include normal ocular good potential. trifolded endothelium-in successfully performed complicated cases,1 prefer (DSAEK) poor view, anatomy, lower potential, when fellows-in-training. Full-Text ReplyOphthalmologyVol. 128Issue 5PreviewIn trials, inherent variability due known unknown sources bias. Consequently, although means various seem converge value, note variations represented relatively size (n trials). An analysis averages alone tell whole story, regards overall asymmetry.