Perceived difficulties and barriers to uptake of Descemet's membrane endothelial keratoplasty among surgeons

Figures & data

Table 1 Characteristics of corneal surgeons who participated in the survey

DMEK participants (n=22)	n (%)
Time since formal DMEK wet-lab course  Within 6 months  Between 6 months and 1 year  Between 1 and 2 years  Between 2 and 3 years  Between 3 and 4 years  Between 4 and 5 years  >5 years	1 (4.6) 2 (9.1) 10 (45.5) 3 (13.6) 2 (9.1) 1 (4.6) 3 (13.6)
Current level of practice  Surgeon in practice	22 (100)
Place of practice  Academic/university setting  Private practice  Combination of academic and private  Other  Public hospital	9 (40.9) 8 (36.4) 3 (13.6) 2 (9.1)
Region of practice  Within the US  Outside the US	4 (18.2) 18 (81.8)
Formal surgical training in DMEK  Yes  No  Other^a	0 20 (90.9) 2 (9.1)

Note: ^aAnother day course.

Abbreviation: DMEK, Descemet's membrane endothelial keratoplasty.

Table 2 Surgical case volume of participants

Surgeries performed, n (%)	0	1–10	11–50	51–100	101–500	≥501
Penetrating keratoplasty	0	1 (4.6)	3 (13.6)	3 (13.6)	7 (31.8)	8 (36.4)
DSAEK/DSEK	5 (22.7)	1 (4.6)	5 (22.7)	2 (9.1)	6 (27.3)	3 (13.6)
DMEK	3 (13.6)	10 (45.5)	4 (18.2)	2 (9.1)	3 (13.6)	0

Abbreviations: DSAEK, Descemet's stripping automated endothelial keratoplasty; DSEK, Descemet's stripping endothelial keratoplasty; DMEK, Descemet's membrane endothelial keratoplasty.

Table 3 Barriers limiting surgeon adoption of DMEK

If you have started DMEK surgery, what has been a barrier?^a	n (%)
Finding the right patient	5 (22.7)
Cost associated with DMEK tissue	8 (36.4)
Anxiety about tissue preparation, if preparing yourself	11 (50.0)
Anxiety about tissue quality, if using an eye bank	2 (9.1)
Concern about needing backup DSAEK tissue	8 (36.4)
Anxiety about increased possibility of rebubbling with initial DMEK	9 (40.9)
Anxiety about inserting the tissue incorrectly and needing to regraft	14 (63.6)
Do not believe the challenges associated with DMEK are worth switching from DSAEK	2 (9.1)

Note: ^aPercentages may not add up to 100%, since some participants had multiple responses.

Abbreviations: DMEK, Descemet's membrane endothelial keratoplasty; DSAEK, Descemet's stripping automated endothelial keratoplasty.

Table 4 Self-perceived difficulty with learning different steps of DMEK surgery

How difficult did you find it to learn the following steps of DMEK surgery?
	Not at all difficult	A little difficult	Moderately difficult	Very difficult	Total
Selecting the right patient	13 61.90%	7 33.33%	1 4.76%	0 0	21
Selecting the right tissue source if pre-prepared	11 57.89%	4 21.05%	3 15.79%	1 5.26%	19
Preparing the DMEK graft	1 4.76%	4 19.05%	8 38.10%	8 38.10%	21
Performing descemetorhexis	10 45.45%	7 31.82%	4 18.18%	1 4.55%	22
Preparing the DMEK tissue for insertion	5 22.73%	7 31.82%	10 45.45%	0 0	22
Inserting the DMEK tissue	7 31.82%	6 27.27%	8 36.36%	1 4.55%	22
Unfolding the DMEK tissue	3 13.64%	3 13.64%	7 31.82%	9 40.91%	22
Counselling the patient postoperatively	11 50	7 31.82%	4 18.18%	0 0	22
Managing complications	3 14.29%	7 33.33%	8 38.10%	3 14.29%	21

Abbreviation: DMEK, Descemet's membrane endothelial keratoplasty.

Table 5 Self-reported surgeon competence regarding different steps of DMEK surgery

How competent do you currently feel about performing each of the following steps of surgery?
	Level 1: Not competent	Level 2: Able to do with moderate coaching from a more experienced surgeon	Level 3: Able to do with minimal input from a more experienced surgeon	Level 4: Able to do without input from a more experienced surgeon	Total
Selecting the right patient	0	0	6 27.27%	16 72.73%	22
Selecting the right tissue source if prepared	0	4 18.18%	4 18.18%	14 63.64%	22
Preparing the DMEK graft	3 13.64%	4 18.18%	8 36.36%	7 31.82%	22
Performing descemetorhexis	1 4.55%	2 9.09%	5 22.73%	14 63.64%	22
Preparing the DMEK tissue for insertion	1 4.55%	2 9.09%	7 31.82%	12 54.55%	22
Inserting the DMEK tissue	2 9.09%	2 9.09%	6 27.27%	12 54.55%	22
Unfolding the DMEK tissue	3 13.64%	5 22.73%	4 18.18%	10 45.45%	22
How competent do you feel in DMEK surgery overall?	2 9.1%	2 9.1%	8 36.4%	10 45.5%	22
In order to reach level 4 competence for DMEK surgery overall, how many procedures did you need?				n (%)
0–5				5 (22.7)
6–10				3 (13.6)
11–20				9 (40.9)
21–30				3 (13.6)
31–50				2 (9.1)
50+				0

Abbreviation: DMEK, Descemet's membrane endothelial keratoplasty.

Table 6 Utility of various educational resources in improving surgeons' skills

Rate the value of the following learning methods in building your surgical skills
	Not helpful		A little helpful		Moderately helpful		Very helpful		Did not do		Total
Lecture	0	0	9.09%	2	50	11	40.91%	9	0	0	22
Small-group case-based discussion	0	0	0	0	27.27%	6	45.45%	10	27.27%	6	22
Independent reading	0	0	9.09%	2	50	11	40.91%	9	0	0	22
Interactive computer-based modules	0	0	9.09%	2	31.82%	7	18.18%	4	40.91%	9	22
Independent time in a practice lab	0	0	9.09%	2	22.73%	5	45.45%	10	22.73%	5	22
One-on-one interaction with faculty in the practice lab	0	0	0	0	22.73%	5	59.09%	13	18.18%	4	22
One-on-one interaction with faculty in the OR	0	0	0	0	18.18%	4	59.09%	13	22.73%	5	22
Watching videos of other surgeons by myself	0	0	0	0	40.91%	9	59.09%	13	0	0	22
Watching my own surgical videos by myself	0	0	4.55%	1	36.36%	8	54.55%	12	4.55%	1	22
Watching videos (my own or other) with an attending	0	0	0	0	13.64%	3	45.45%	10	40.91%	9	22
Reviewing my own surgical outcomes	0	0	0	0	40.91%	9	59.09%	13	0	0	22
Attending wet-lab training course	0	0	4.55%	1	36.36%	8	59.09%	13	0	0	22