{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,26]],"date-time":"2026-10-26T20:29:33Z","timestamp":1793046573230,"version":"4.5.0"},"reference-count":144,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,6,14]],"date-time":"2022-06-14T00:00:00Z","timestamp":1655164800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>We evaluated the visual outcomes and complications of \u201cendothelium-out\u201d and \u201cendothelium-in\u201d Descemet membrane endothelial keratoplasty (DMEK) graft insertion techniques.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>Electronic searches were conducted in CENTRAL, Cochrane databases, PubMed, EMBASE, <jats:ext-link>ClinicalTrials.gov<\/jats:ext-link>. Study designs included clinical trials, comparative observational studies, and large case series (\u226525 eyes). PRISMA guidelines were used for abstracting data and synthesis. Random-effects models were employed for meta-analyses.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>21,323 eyes (95 studies) were included. Eighty-six studies reported on \u201cendothelium-out\u201d techniques; eight studies reported on \u201cendothelium-in\u201d techniques. One study compared \u201cendothelium-out\u201d to \u201cendothelium-in\u201d techniques. Eighteen \u201cendothelium-out\u201d studies reported that 42.5\u201385% of eyes achieved best-corrected visual acuity (BCVA) \u226520\/25 at 6 months; pooled proportion of eyes achieving BCVA \u226520\/25 at 6 months was 58.7% (95% CI 49.4\u201367.7%,15 studies). Three \u201cendothelium-in\u201d studies reported that 44.7\u201387.5% of eyes achieved BCVA of \u226520\/25 at 6 months; pooled proportion of eyes achieving BCVA \u226520\/25 at 6 months was 62.4% (95% CI 33.9\u201386.9%). Pooled mean endothelial cell loss was lower in the <jats:italic>\u201cendothelium-in\u201d<\/jats:italic> studies (28.1 \u00b1 1.3%, 7 studies) compared to <jats:italic>\u201cendothelium-out\u201d<\/jats:italic> studies (36.3 \u00b1 6.9%,10 studies) at 6 months (<jats:italic>p<\/jats:italic> = 0.018). Graft re-bubbling rates were higher in the \u201cendothelium-out\u201d studies (26.2%, 95% CI 21.9\u201330.9%, 74 studies) compared to \u201cendothelium-in\u201d studies (16.5%, 95% CI 8.5\u201326.4%, 6 studies), although statistical significance was not reached (<jats:italic>p<\/jats:italic> = 0.440). Primary graft failure rates were comparable between the two groups (<jats:italic>p<\/jats:italic> = 0.552). Quality of evidence was considered low and significant heterogeneity existed amongst the studies.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Reported rates of endothelial cell loss were lower in \u201cendothelium-in\u201d DMEK studies at 6 months compared to \u201cendothelium-out\u201d studies. Outcomes of \u201cendothelium-in\u201d techniques were otherwise comparable to those reported in \u201cendothelium-out\u201d studies. Given the technical challenges encountered in \u201cendothelium-out\u201d procedures, surgeons may consider \u201cendothelium-in\u201d techniques designed for easier intra-operative DMEK graft unfolding. \u201cEndothelium-in\u201d studies evaluating outcomes at longer time points are required before conclusive comparisons between the two techniques can be drawn.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fmed.2022.868533","type":"journal-article","created":{"date-parts":[[2022,6,14]],"date-time":"2022-06-14T05:02:05Z","timestamp":1655182925000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":16,"title":["\u201cEndothelium-Out\u201d and \u201cEndothelium-In\u201d Descemet Membrane Endothelial Keratoplasty (DMEK) Graft Insertion Techniques: A Systematic Review With Meta-Analysis"],"prefix":"10.3389","volume":"9","author":[{"given":"Hon Shing","family":"Ong","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hla M.","family":"Htoon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcus","family":"Ang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jodhbir S.","family":"Mehta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2022,6,14]]},"reference":[{"key":"B1","year":"2018","journal-title":"The Australian Graft Registry 2018 Report."},{"key":"B2","year":"2020","journal-title":"Eye Banking Statistical Report 2019."},{"key":"B3","doi-asserted-by":"publisher","first-page":"2432","DOI":"10.1016\/j.ophtha.2015.08.017","article-title":"Keratoplasty in the United States: a 10-year review from 2005 through 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