Descemet membrane endothelial keratoplasty in patients after radiation therapy for uveal melanoma

Descemet membrane endothelial keratoplasty in patients after radiation therapy for uveal melanoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Descemet membrane endothelial keratoplasty in patients after radiation therapy for uveal melanoma Anna-Karina B. Maier, Dhoksina Papa, Aline Riechardt, Jens Heufelder, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8329664/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Apr, 2026 Read the published version in BMC Ophthalmology → Version 1 posted 10 You are reading this latest preprint version Abstract PURPOSE : To evaluate the visual outcomes and postoperative complications after Descemet membrane endothelial keratoplasty (DMEK) in patients after radiation therapy for uveal melanoma. METHODS : In this retrospective observational study, 9 eyes of 9 patients after radiation therapy for uveal melanoma who received DMEK surgery at the Charité – Universitätsmedizin Berlin were included. Preoperative patients` characteristics were analyzed. Postoperative results including visual acuity and endothelial cell density and complications were evaluated. RESULTS : Best-corrected visual acuity improved 3, 12 and 24 months after DMEK (preoperative: 0.88±0.47 logMAR, after 3 months: 0.52±0.30 (p=0.049), after 12 months: 0.60±0.35 logMAR (p=0.66), after 24 months: 0.60±0.45 logMAR (p=0.357)) compared to preoperatively. Endothelial cell density decreased 3 and 12 months after DMEK (preoperative: 2327±242 cells/mm 2 , after 3 months: 1831±384 cells/mm 2 (p=0.068), after 12 months: 1350±996 cells/mm 2 (p=0.180)). Re-bubbling was performed in 55.6% of eyes after DMEK. One patient developed a postoperative macular edema, and another one a distant metastasis of the liver 20 years after last tumor treatment. Two-year-incidence of graft rejection was 0%, of graft failure 25.0% (95%KI -17.5%, 67.5%), of IOP-elevation 55.6% (95% KI 12.1%, 99.1%) and post-DMEK glaucoma 16.7% (95%KI -13.1%, 46.5%). CONCLUSIONS : Our results confirm that DMEK surgery is feasible and improves the visual acuity in patients with local control of uveal melanoma after radiation therapy. However, the complications rate is high - including graft failure, postoperative IOP elevation and post-DMEK glaucoma - and complications of the radiation treatment limit the achievable visual acuity. DMEK uveal melanoma proton beam therapy brachytherapy INTRODUCTION Uveal melanoma is the most common primary intraocular tumor in adults with an age adjusted risk of 5 per 1 million [ 1 ]. It includes melanoma of the iris, choroid and ciliary body. Resection, radiation therapy, and enucleation are the first-line treatment options for uveal melanomas currently. Radiation therapy includes brachytherapy with episcleral plaques (eg, 125 I or 106 Ru), teletherapy with heavy charged particles (proton beam therapy, helium ion therapy), and CyberKnife radiotherapy. As radiation therapies for the treatment of uveal melanoma improved in recent years and allow an eye preservation, other vision-impairing eye diseases, that occur coincidently, or vision-impairing complications of the treatment play a more important role in the postoperative course [ 2 ]. Once local tumor control has been achieved, treatment of these vision-impairing eye diseases and complications can be considered. This also includes corneal endothelial disorders like Fuchs endothelial corneal dystrophy (FECD), bullous keratopathy or graft failure after previous keratoplasty. These diseases can be treated very successfully by Descemet membrane endothelial keratoplasty (DMEK), because it enables a fast visual rehabilitation, reduction of corneal edema and reduction of corneal thickness and bullae [ 3 – 7 ]. Because only an isolated Descemet membrane and its endothelium are transplanted, a near-normal anatomic corneal restoration is possible. The excellent results of visual acuity in the literature suggest that it is also an option for the treatment of posterior corneal endothelial disorders in patients after radiation therapy for uveal melanoma [ 2 ]. Because many different complications as result of the uveal melanoma and its treatment such as secondary glaucoma, corneal neuropathy, corneal decompensation, limbal stem cell failure, radiation retinopathy and radiation optic neuropathy, retinal detachment and maculopathy can occur, DMEK in those patients may be more advanced and results may be less favourable [ 8 – 13 ]. Therefore, we investigated the pre-, intra- and postoperative results of DMEK surgery in patients after radiation therapy for uveal melanoma. MATERIALS AND METHODS Patients In this retrospective observational study, we enrolled eyes from patients after radiation therapy for uveal melanoma, that underwent DMEK surgery at the Department of Ophthalmology, Charité – Universitätsmedizin Berlin, Campus Virchow Klinikum, between January 2013 and December 2020 performed by three experienced surgeons (N.T., A.-K. M., T.D-N.) after screening of 2188 DMEK surgeries performed during this time period. This study adhered to the ethical standards of the Declaration of Helsinki. Institutional ethical approval was obtained by the Ethics Committee of the Charité – Universitätsmedizin Berlin (EA4/167/16) and (EA2/108/12). For this retrospective, single-center study formal consent was not required; the Ethikkommission, Charité – Universitätsmedizin Berlin approved the waiver of consent. The patients gave their consent to the surgery in the usual manner after being informed about the surgical procedure. Preoperative and postoperative evaluation Examinations were performed preoperatively and one, three, 12 and 24 months after DMEK surgery, including a complete ophthalmologic evaluation containing objective refraction using an auto refractometer (RM-8900 Auto Kerato-Refractometer, Topcon Corporation, Itabashi-ku, Tokyo, Japan), best corrected visual acuity (BCVA) tested with a Snellen chart, endothelial cell density (NIDEK CEM-530, specular microscope, NIDEK Co., LTD, Gamagori, Aichi, Japan), slit-lamp examination and central corneal thickness (CCT) (NIDEK CEM-530, specular microscope, NIDEK Co., LTD, Gamagori, Aichi, Japan). Graft and Surgical technique All patients underwent single DMEK procedure with a graft with minimum endothelial cell density of 2000 cells/mm 2 . The graft and surgical technique and the postoperative regime, especially the re-bubbling, have been described in detail in previous studies [14]. Definitions of IOP-elevation, post-DMEK glaucoma, graft rejection and graft failure were used as defined in detail by Maier AB et al. [15]. Statistical methods Normality was tested for all outcome measures and the appropriate statistical test was used. Descriptive statistics were expressed as median and range or mean ± standard deviation (SD). We used Kaplan-Meier survival analysis to estimate incidences for graft rejection, graft failure, IOP-elevation and post-DMEK glaucoma. Differences were considered statistically significant when P values were less than 0.05. RESULTS After screening of 2188 DMEK surgeries performed between January 2013 and December 2020, 9 eyes from 9 patients were included in this retrospective study. In these eyes uveal melanoma was diagnosed and treated before DMEK surgery. Data of the included patients (6 female and 3 male) were summarized in table 1 and supplement table 1. Two patients with pre-existing secondary glaucoma were treated by trabeculectomy with mitomycin C before DMEK and in one case additional cyclophotocoagulation. One of these two patients needed an additional glaucoma surgery, cyclophotocoagulation, after DMEK surgery to control intraocular pressure (IOP). Table 1 Preoperative data of included patients Visual acuity and endothelial cell density Visual acuity improved 3, 12 and 24 months after DMEK (preoperative: 0.88 ± 0.47 logMAR, after 3 months: 0.52 ± 0.30 (p = 0.049), after 12 months: 0.60 ± 0.35 logMAR (p = 0.66), after 24 months: 0.60 ± 0.45 logMAR (p = 0.357)) compared to preoperatively. Endothelial cell density decreased 3 and 12 months after DMEK (endothelial cell density of the graft: 2327 ± 242 cells/mm 2 , after 3 months: 1831 ± 384 cells/mm 2 (p = 0.068), after 12 months: 1350 ± 996 cells/mm 2 (p = 0.180)). Complications Additional application of intracameral air, so called re-bubbling, was performed in 55.6% of eyes after DMEK, once in 4 eyes and twice in one eye. One patient showed a postoperative macular edema, which disappeared after a few months. This patient had epiretinal gliosis as a risk factor for macular edema. No patient developed local recurrence of the tumor during the follow-up after DMEK. One patient developed a distant metastasis of the liver 18 months after Re-DMEK, 5 years and 9 months after first DMEK, performed because of a graft failure after perforating keratoplasty, and 23 years and 9 months after ruthenium-applicator brachytherapy of choroidal melanoma of the iris, and 20 years after proton beam therapy of melanoma recurrence. Two-year-incidence of graft rejection was 0%, of graft failure 25.0% (95% KI -17.5%, 67.5%), of IOP-elevation 55.6% (95% KI 12.1%, 99.1%) and post-DMEK glaucoma 16.7% (95% KI -13.1%, 46.5%). No donor tissue was lost during DMEK preparation in this study. DISCUSSION Our results show that DMEK surgery improves the visual acuity in patients with local control of uveal melanoma after radiation therapy, but results are limited by other complications after radiation treatment. The two-year incidences of graft failure, postoperative IOP elevation and post-DMEK glaucoma are high. In our study, the proportion of patients with localization of the melanoma in the iris was greater than in the choroid, although iris melanoma is the most uncommon of all uveal melanomas (2% versus 90% choroidal) [ 16 ]. As described by Riechardt et al., the risk of a corneal decompensation and necessity of a keratoplasty is high in patients with a proton beam therapy of the whole anterior segment treating iris melanoma [ 2 ]. However, the most common reason for DMEK in our study was the coincidence of FED and uveal melanoma and not corneal decompensation due to radiation. It is also possible that patients with corneal decompensation after radiation treatment of uveal melanoma were not even considered for DMEK because they had other vision-limiting diseases or an involvement of other corneal layers, so that a perforating keratoplasty seemed more appropriate, or because local tumor control was not achieved. The results of mean visual acuity show an improvement after 3, 12 and 24 months after DMEK surgery, but these remain significantly lower than those normally achieved after DMEK [ 3 , 5 – 7 ]. Only two patients showed a visual acuity of 0.1 logMAR in the postoperative course, in all others visual acuity improved, but stayed limited. This is due to multiple complications like radiation optic neuropathy, glaucomatous optic neuropathy, radiation retinopathy, retinal detachment and maculopathy, but also corneal changes from dry eye syndrome to limbal stem cell failure, that occur as result of the uveal melanoma or of the radiation treatment of the tumor [ 10 – 13 , 17 ], which also limit the results concerning visual acuity. Two-year-incidences of graft failure, IOP elevation and post-DMEK glaucoma are higher in these patients than usual in patients after DMEK [ 3 – 7 , 14 ]. Here, the multiple complications of the tumor and its radiation therapy play also a role. Cohen et al presented that having a complicated anterior segment including previous glaucoma surgery, post-penetrating keratoplasty, peripheral anterior synechia, previous pars-plana vitrectomy, aniridia, aphakia, anterior chamber intraocular lens and iris-fixated intraocular lens increases risk for graft failure [ 18 ]. This is also represented in our study collective with patients presenting with previous glaucoma surgery, after pars-plana vitrectomy and after penetrating keratoplasty. For IOP elevation and post-DMEK glaucoma, it has been also shown that a pre-existing glaucoma and the diagnosis bullous keratopathy and graft failure (versus FED) increased the risk for these complications [ 14 ]. Additionally, the risk of graft failure is higher in eyes with pre-existing glaucoma, especially in patients with glaucoma diagnosis classified as all others except primary open-angle / primary angle-closure glaucoma and pseudoexfoliative glaucoma [ 14 , 15 , 19 , 20 ]. Secondary glaucoma in patients with uveal melanoma after radiation therapy is probably more difficult to treat, has a higher risk for complications and shows additional structural changes of the anterior chamber and higher inflammatory response increasing the risk of developing postoperative graft failure [ 12 , 21 ]. In our experience, consistent treatment of IOP elevation is particularly necessary, while no adjustment to the standard regime after DMEK was necessary with regard to anti-inflammatory and lubrication therapy. Re-bubbling rate was higher in our study collective compared to re-bubbling rates using the same treatment strategies [ 14 , 15 ]. Here, as mentioned for the other complications above, the underlying diagnoses such as post-graft failure or pre-existing glaucoma, but also structural changes of the anterior chamber and tissues due to the tumor and its treatment resulting in changes of the posterior corneal surface may play a role [ 22 , 23 ]. In none of the patients a local tumor recurrence occurred after DMEK and none of the patients presented with inoculation metastasis as a consequence of the DMEK. However, one patient developed distant metastases 20 years after the last tumor treatment. Since this is repeatedly reported in the literature, regular semi-annular liver ultrasound examinations are recommended until the end of life, as distant metastases typically occur there first [ 24 – 26 ]. The main limitations were the small sample size and the retrospective character due to the rare coincidence of DMEK and local tumor control after radiation therapy of uveal melanoma. Additionally, treatment therapies to achieve local tumor control of uveal melanomas and complications of the treatment differ between the included patients. However, this corresponds to the real-world data available for the treatment of uveal melanoma. Our results confirm that DMEK surgery is feasible and improves the visual acuity in patients with local control of uveal melanoma after radiation therapy. However, the complication rate, especially graft failure, postoperative IOP elevation and post-DMEK glaucoma, is high and other complications of the radiation treatment limit the achievable results concerning visual acuity. Therefore, early DMEK should be considered if indicated and if local tumor control was achieved. However, this is recommended in specialized centers and under appropriate close monitoring, particularly with attention to IOP control. Declarations Consent to Publish declaration Not applicable. Human Ethics and Consent to Participate declarations This study adhered to the ethical standards of the Declaration of Helsinki. Institutional ethical approval was obtained by the Ethics Committee of the Charité – Universitätsmedizin Berlin (EA4/167/16) and (EA2/108/12). For this retrospective, single-center study formal consent was not required; the Ethikkommission, Charité – Universitätsmedizin Berlin approved the waiver of consent. The patients gave their consent to the surgery in the usual manner after being informed about the surgical procedure. Funding Declaration No funding received . Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests Authors' contributions DP, JH and AKM collected and complied the data. AKM, DP and AR analyzed and interpreted the patient data. AKM, AR and TDN were the major contributors in writing the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable References Singh AD, Turell ME, Topham AK. Uveal melanoma: trends in incidence, treatment, and survival. Ophthalmology 2011; 118(9):1881–1885. Riechardt AI, Klein JP, Cordini D, et al. Salvage proton beam therapy for recurrent iris melanoma: outcome and side effects. 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Cohen E, Mimouni M, Sorkin N, et alRisk Factors for Repeat Descemet Membrane Endothelial Keratoplasty Graft Failure. Am J Ophthalmol. 2021 Jun;226:165-171. Reinhard T, Kallmann C, Cepin A, et al. The influence of glaucoma history on graft survival after penetrating keratoplasty. Graefes Arch Clin Exp Ophthalmol 1997;235(9):553-7. Anshu A, Price MO, Price FW. Descemet's stripping endothelial keratoplasty: long-term graft survival and risk factors for failure in eyes with preexisting glaucoma. Ophthalmology 2012;119(10):1982-87. Sharkawi E, Oleszczuk JD, Bergin C, Zografos L. Baerveldt shunts in the treatment of glaucoma secondary to anterior uveal melanoma and proton beam radiotherapy. Br J Ophthalmol 2012;96: 1104–1107. Kilian R, Crincoli E, Lammer J, et al. Predictive factors for re-bubbling after DMEK: focus on the posterior corneal surface. Graefes Arch Clin Exp Ophthalmol. 2024 Jul;262(7):2181-2187. Wykrota AA, Hamon L, Daas L, Seitz B. Descemet Membrane Endothelial Keratoplasty after failed penetrating keratoplasty- case series and review of the literature. BMC Ophthalmol. 2024 Jan 8;24(1):15. Shields CL, Kaliki S, Furuta M, et al. Clinical spectrum and prognosis of uveal melanoma based on age at presentation in 8,033 cases. Retina. 2012 Jul;32(7):1363-72. Rantala ES, Hernberg MM, Piperno-Neumann S, et al. Metastatic uveal melanoma: The final frontier. Prog Retin Eye Res. 2022 Sep;90:101041. Kujala E, Mäkitie T, Kivelä T. Very long-term prognosis of patients with malignant uveal melanoma. Invest Ophthalmol Vis Sci. 2003 Nov;44(11):4651-9. Additional Declarations No competing interests reported. Supplementary Files Supplementtable.docx Cite Share Download PDF Status: Published Journal Publication published 02 Apr, 2026 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 08 Feb, 2026 Reviews received at journal 07 Feb, 2026 Reviews received at journal 01 Feb, 2026 Reviewers agreed at journal 26 Jan, 2026 Reviewers agreed at journal 11 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor assigned by journal 30 Dec, 2025 Editor invited by journal 29 Dec, 2025 Submission checks completed at journal 28 Dec, 2025 First submitted to journal 28 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8329664","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":572813960,"identity":"1158a6b5-3240-4383-aba7-354e8763ee61","order_by":0,"name":"Anna-Karina B. 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It includes melanoma of the iris, choroid and ciliary body. Resection, radiation therapy, and enucleation are the first-line treatment options for uveal melanomas currently. Radiation therapy includes brachytherapy with episcleral plaques (eg, \u003csup\u003e125\u003c/sup\u003eI or \u003csup\u003e106\u003c/sup\u003eRu), teletherapy with heavy charged particles (proton beam therapy, helium ion therapy), and CyberKnife radiotherapy. As radiation therapies for the treatment of uveal melanoma improved in recent years and allow an eye preservation, other vision-impairing eye diseases, that occur coincidently, or vision-impairing complications of the treatment play a more important role in the postoperative course [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Once local tumor control has been achieved, treatment of these vision-impairing eye diseases and complications can be considered. This also includes corneal endothelial disorders like Fuchs endothelial corneal dystrophy (FECD), bullous keratopathy or graft failure after previous keratoplasty. These diseases can be treated very successfully by Descemet membrane endothelial keratoplasty (DMEK), because it enables a fast visual rehabilitation, reduction of corneal edema and reduction of corneal thickness and bullae [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Because only an isolated Descemet membrane and its endothelium are transplanted, a near-normal anatomic corneal restoration is possible. The excellent results of visual acuity in the literature suggest that it is also an option for the treatment of posterior corneal endothelial disorders in patients after radiation therapy for uveal melanoma [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Because many different complications as result of the uveal melanoma and its treatment such as secondary glaucoma, corneal neuropathy, corneal decompensation, limbal stem cell failure, radiation retinopathy and radiation optic neuropathy, retinal detachment and maculopathy can occur, DMEK in those patients may be more advanced and results may be less favourable [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, we investigated the pre-, intra- and postoperative results of DMEK surgery in patients after radiation therapy for uveal melanoma.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective observational study, we enrolled eyes from patients after radiation therapy for uveal melanoma, that underwent DMEK surgery at the Department of Ophthalmology, Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin, Campus Virchow Klinikum, between January 2013 and December 2020 performed by three experienced surgeons (N.T., A.-K. M., T.D-N.) after screening of 2188 DMEK surgeries performed during this time period. This study adhered to the ethical standards of the Declaration of Helsinki. Institutional ethical approval was obtained by the Ethics Committee of the Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin (EA4/167/16) and (EA2/108/12). For this retrospective, single-center study formal consent was not required; the Ethikkommission, Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin approved the waiver of consent. The patients gave their consent to the surgery in the usual manner after being informed about the surgical procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative and postoperative evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExaminations were performed preoperatively and one, three, 12 and 24 months after DMEK surgery, including a complete ophthalmologic evaluation containing objective refraction using an auto refractometer (RM-8900 Auto Kerato-Refractometer, Topcon Corporation, Itabashi-ku, Tokyo, Japan), best corrected visual acuity (BCVA) tested with a Snellen chart, endothelial cell density (NIDEK CEM-530, specular microscope, NIDEK Co., LTD, Gamagori, Aichi, Japan), slit-lamp examination and central corneal thickness (CCT) (NIDEK CEM-530, specular microscope, NIDEK Co., LTD, Gamagori, Aichi, Japan).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGraft and Surgical technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent single DMEK procedure with a graft with minimum endothelial cell density of 2000 cells/mm\u003csup\u003e2\u003c/sup\u003e. The graft and surgical technique and the postoperative regime, especially the re-bubbling, have been described in detail in previous studies [14]. Definitions of IOP-elevation, post-DMEK glaucoma, graft rejection and graft failure were used as defined in detail by Maier AB et al. [15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNormality was tested for all outcome measures and the appropriate statistical test was used. Descriptive statistics were expressed as median and range or mean \u0026plusmn; standard deviation (SD). We used Kaplan-Meier survival analysis to estimate incidences for graft rejection, graft failure, IOP-elevation and post-DMEK glaucoma. Differences were considered statistically significant when P values were less than 0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAfter screening of 2188 DMEK surgeries performed between January 2013 and December 2020, 9 eyes from 9 patients were included in this retrospective study. In these eyes uveal melanoma was diagnosed and treated before DMEK surgery. Data of the included patients (6 female and 3 male) were summarized in table 1 and supplement table 1. Two patients with pre-existing secondary glaucoma were treated by trabeculectomy with mitomycin C before DMEK and in one case additional cyclophotocoagulation. One of these two patients needed an additional glaucoma surgery, cyclophotocoagulation, after DMEK surgery to control intraocular pressure (IOP).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 Preoperative data of included patients\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1768243994.png\" width=\"751\" height=\"960\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVisual acuity and endothelial cell density\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVisual acuity improved 3, 12 and 24 months after DMEK (preoperative: 0.88 \u0026plusmn; 0.47 logMAR, after 3 months: 0.52 \u0026plusmn; 0.30 (p = 0.049), after 12 months: 0.60 \u0026plusmn; 0.35 logMAR (p = 0.66), after 24 months: 0.60 \u0026plusmn; 0.45 logMAR (p = 0.357)) compared to preoperatively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEndothelial cell density decreased 3 and 12 months after DMEK (endothelial cell density of the graft: 2327 \u0026plusmn; 242 cells/mm\u003csup\u003e2\u003c/sup\u003e, after 3 months: 1831 \u0026plusmn; 384 cells/mm\u003csup\u003e2\u003c/sup\u003e (p = 0.068), after 12 months: 1350 \u0026plusmn; 996 cells/mm\u003csup\u003e2\u003c/sup\u003e (p = 0.180)).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional application of intracameral air, so called re-bubbling, was performed in 55.6% of eyes after DMEK, once in 4 eyes and twice in one eye. One patient showed a postoperative macular edema, which disappeared after a few months. This patient had epiretinal gliosis as a risk factor for macular edema.\u003c/p\u003e\n\u003cp\u003eNo patient developed local recurrence of the tumor during the follow-up after DMEK. \u0026nbsp;One patient developed a distant metastasis of the liver 18 months after Re-DMEK, 5 years and 9 months after first DMEK, performed because of a graft failure after perforating keratoplasty, and 23 years and 9 months after ruthenium-applicator brachytherapy of choroidal melanoma of the iris, and 20 years after proton beam therapy of melanoma recurrence.\u003c/p\u003e\n\u003cp\u003eTwo-year-incidence of graft rejection was 0%, of graft failure 25.0% (95% KI -17.5%, 67.5%), of IOP-elevation 55.6% (95% KI 12.1%, 99.1%) and post-DMEK glaucoma 16.7% (95% KI -13.1%, 46.5%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo donor tissue was lost during DMEK preparation in this study. \u003cstrong\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur results show that DMEK surgery improves the visual acuity in patients with local control of uveal melanoma after radiation therapy, but results are limited by other complications after radiation treatment. The two-year incidences of graft failure, postoperative IOP elevation and post-DMEK glaucoma are high.\u003c/p\u003e \u003cp\u003eIn our study, the proportion of patients with localization of the melanoma in the iris was greater than in the choroid, although iris melanoma is the most uncommon of all uveal melanomas (2% versus 90% choroidal) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. As described by Riechardt et al., the risk of a corneal decompensation and necessity of a keratoplasty is high in patients with a proton beam therapy of the whole anterior segment treating iris melanoma [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, the most common reason for DMEK in our study was the coincidence of FED and uveal melanoma and not corneal decompensation due to radiation. It is also possible that patients with corneal decompensation after radiation treatment of uveal melanoma were not even considered for DMEK because they had other vision-limiting diseases or an involvement of other corneal layers, so that a perforating keratoplasty seemed more appropriate, or because local tumor control was not achieved.\u003c/p\u003e \u003cp\u003eThe results of mean visual acuity show an improvement after 3, 12 and 24 months after DMEK surgery, but these remain significantly lower than those normally achieved after DMEK [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Only two patients showed a visual acuity of 0.1 logMAR in the postoperative course, in all others visual acuity improved, but stayed limited. This is due to multiple complications like radiation optic neuropathy, glaucomatous optic neuropathy, radiation retinopathy, retinal detachment and maculopathy, but also corneal changes from dry eye syndrome to limbal stem cell failure, that occur as result of the uveal melanoma or of the radiation treatment of the tumor [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], which also limit the results concerning visual acuity.\u003c/p\u003e \u003cp\u003eTwo-year-incidences of graft failure, IOP elevation and post-DMEK glaucoma are higher in these patients than usual in patients after DMEK [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Here, the multiple complications of the tumor and its radiation therapy play also a role. Cohen et al presented that having a complicated anterior segment including previous glaucoma surgery, post-penetrating keratoplasty, peripheral anterior synechia, previous pars-plana vitrectomy, aniridia, aphakia, anterior chamber intraocular lens and iris-fixated intraocular lens increases risk for graft failure [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This is also represented in our study collective with patients presenting with previous glaucoma surgery, after pars-plana vitrectomy and after penetrating keratoplasty. For IOP elevation and post-DMEK glaucoma, it has been also shown that a pre-existing glaucoma and the diagnosis bullous keratopathy and graft failure (versus FED) increased the risk for these complications [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, the risk of graft failure is higher in eyes with pre-existing glaucoma, especially in patients with glaucoma diagnosis classified as all others except primary open-angle / primary angle-closure glaucoma and pseudoexfoliative glaucoma [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Secondary glaucoma in patients with uveal melanoma after radiation therapy is probably more difficult to treat, has a higher risk for complications and shows additional structural changes of the anterior chamber and higher inflammatory response increasing the risk of developing postoperative graft failure [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our experience, consistent treatment of IOP elevation is particularly necessary, while no adjustment to the standard regime after DMEK was necessary with regard to anti-inflammatory and lubrication therapy.\u003c/p\u003e \u003cp\u003eRe-bubbling rate was higher in our study collective compared to re-bubbling rates using the same treatment strategies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Here, as mentioned for the other complications above, the underlying diagnoses such as post-graft failure or pre-existing glaucoma, but also structural changes of the anterior chamber and tissues due to the tumor and its treatment resulting in changes of the posterior corneal surface may play a role [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn none of the patients a local tumor recurrence occurred after DMEK and none of the patients presented with inoculation metastasis as a consequence of the DMEK. However, one patient developed distant metastases 20 years after the last tumor treatment. Since this is repeatedly reported in the literature, regular semi-annular liver ultrasound examinations are recommended until the end of life, as distant metastases typically occur there first [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main limitations were the small sample size and the retrospective character due to the rare coincidence of DMEK and local tumor control after radiation therapy of uveal melanoma. Additionally, treatment therapies to achieve local tumor control of uveal melanomas and complications of the treatment differ between the included patients. However, this corresponds to the real-world data available for the treatment of uveal melanoma.\u003c/p\u003e \u003cp\u003eOur results confirm that DMEK surgery is feasible and improves the visual acuity in patients with local control of uveal melanoma after radiation therapy. However, the complication rate, especially graft failure, postoperative IOP elevation and post-DMEK glaucoma, is high and other complications of the radiation treatment limit the achievable results concerning visual acuity. Therefore, early DMEK should be considered if indicated and if local tumor control was achieved. However, this is recommended in specialized centers and under appropriate close monitoring, particularly with attention to IOP control.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adhered to the ethical standards of the Declaration of Helsinki. Institutional ethical approval was obtained\u0026nbsp;by\u0026nbsp;the Ethics Committee of the Charit\u0026eacute;\u0026nbsp;\u0026ndash;\u0026nbsp;Universit\u0026auml;tsmedizin Berlin\u0026nbsp;(EA4/167/16) and (EA2/108/12).\u0026nbsp;For this retrospective, single-center study formal consent was not required;\u0026nbsp;the\u0026nbsp;Ethikkommission, Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin\u0026nbsp;approved the waiver of consent.\u0026nbsp;The patients gave their consent to the surgery in the usual manner after being informed about the surgical procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding received\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eDP, JH and AKM collected and complied the data. AKM, DP and AR analyzed and interpreted the patient data. AKM, AR and TDN were the major contributors in writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSingh AD, Turell ME, Topham AK. Uveal melanoma: trends in incidence, treatment, and survival. Ophthalmology 2011; 118(9):1881\u0026ndash;1885.\u003c/li\u003e\n \u003cli\u003eRiechardt AI, Klein JP, Cordini D, et al. Salvage proton beam therapy for recurrent iris melanoma: outcome and side effects. Graefes Arch Clin Exp Ophthalmol. 2018 Jul;256(7):1325-1332.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSchlogl A, Tourtas T, Kruse FE, Weller JM. Long-term Clinical Outcome After Descemet Membrane Endothelial Keratoplasty. Am J Ophthalmol. 2016;169:218-26.\u003c/li\u003e\n \u003cli\u003ePrice MO, Kanapka L, Kollman C, et al. Descemet Membrane Endothelial Keratoplasty: 10-Year Cell Loss and Failure Rate Compared With Descemet Stripping Endothelial Keratoplasty and Penetrating Keratoplasty. Cornea. 2024 Nov 1;43(11):1403-1409.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eVasiliauskaite I, Kocaba V, van Dijk K, et al. Long-Term Outcomes of Descemet Membrane Endothelial Keratoplasty: Effect of Surgical Indication and Disease Severity. Cornea. 2023 Oct 1;42(10):1229-1239.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZwingelberg SB, B\u0026uuml;scher F, Schrittenlocher S, et al. Long-Term Outcome of Descemet Membrane Endothelial Keratoplasty in Eyes With Fuchs Endothelial Corneal Dystrophy Versus Pseudophakic Bullous Keratopathy. Cornea. 2022 Mar 1;41(3):304-309.\u003c/li\u003e\n \u003cli\u003eWeller JM, Kruse FE, Tourtas T. Descemet membrane endothelial keratoplasty: analysis of clinical outcomes of patients with 8-10\u0026nbsp;years follow-up. Int Ophthalmol. 2022 Jun;42(6):1789-1798.\u003c/li\u003e\n \u003cli\u003eBanou L, Tsani Z, Arvanitogiannis K, et al. Radiotherapy in Uveal Melanoma: A Review of Ocular Complications. Curr Oncol. 2023 Jul 3;30(7):6374-6396.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZemba M, Dumitrescu OM, Gheorghe AG, et al. Ocular Complications of Radiotherapy in Uveal Melanoma. Cancers (Basel). 2023 Jan 4;15(2):333.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEibenberger K, Heimann H, Gatchalian L, et al. Side Effects of Proton Beam Radiotherapy Treatment on Iris Melanoma. Ophthalmology. 2023 Sep;130(9):958-965.\u003c/li\u003e\n \u003cli\u003eSeibel I, Cordini D, Hager A, et al. Predictive risk factors for radiation retinopathy and optic neuropathy after proton beam therapy for uveal melanoma. Graefes Arch Clin Exp Ophthalmol. 2016 Sep;254(9):1787-92.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRiechardt AI, Cordini D, Rehak M, et al. Trabeculectomy in patients with uveal melanoma after proton beam therapy. Graefes Arch Clin Exp Ophthalmol. 2016 Jul;254(7):1379-85.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEspensen CA, Kiilgaard JF, Appelt AL, et al. Dose-Response and Normal Tissue Complication Probabilities after Proton Therapy for Choroidal Melanoma. Ophthalmology. 2021 Jan;128(1):152-161.\u003c/li\u003e\n \u003cli\u003eMaier AB, Pilger D, Gundlach E, et al. Long-term Results of Intraocular Pressure Elevation and Post-DMEK Glaucoma After Descemet Membrane Endothelial Keratoplasty\u003cem\u003e. Cornea.\u003c/em\u003e 2021 Jan;40(1):26-32\u003c/li\u003e\n \u003cli\u003eMaier AB, Pilger D, Gundlach E, et al. Graft failure rate and complications after Descemet membrane endothelial keratoplasty in eyes with pre-existing glaucoma. Graefes Arch Clin Exp Ophthalmol. 2023 Feb;261(2):467-476.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShields CL, Manalac J, Das C, et al. Choroidal melanoma: clinical features, classification, and top 10 pseudomelanomas. Curr Opin Ophthalmol 2014 25:177\u0026ndash;185.\u003c/li\u003e\n \u003cli\u003eSeibel I, Vollhardt D, Riechardt AI, et al. Influence of Ranibizumab versus laser photocoagulation on radiation retinopathy (RadiRet) - a prospective randomized controlled trial. Graefes Arch Clin Exp Ophthalmol. 2020 Apr;258(4):869-878.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCohen E, Mimouni M, Sorkin N, et alRisk Factors for Repeat Descemet Membrane Endothelial Keratoplasty Graft Failure. Am J Ophthalmol. 2021 Jun;226:165-171.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eReinhard T, Kallmann C, Cepin A, et al. The influence of glaucoma history on graft survival after penetrating keratoplasty. Graefes Arch Clin Exp Ophthalmol 1997;235(9):553-7.\u003c/li\u003e\n \u003cli\u003eAnshu A, Price MO, Price FW. Descemet\u0026apos;s stripping endothelial keratoplasty: long-term graft survival and risk factors for failure in eyes with preexisting glaucoma. Ophthalmology 2012;119(10):1982-87.\u003c/li\u003e\n \u003cli\u003eSharkawi E, Oleszczuk JD, Bergin C, Zografos L. Baerveldt shunts in the treatment of glaucoma secondary to anterior uveal melanoma and proton beam radiotherapy. Br J Ophthalmol 2012;96: 1104\u0026ndash;1107.\u003c/li\u003e\n \u003cli\u003eKilian R, Crincoli E, Lammer J, et al. Predictive factors for re-bubbling after DMEK: focus on the posterior corneal surface. Graefes Arch Clin Exp Ophthalmol. 2024 Jul;262(7):2181-2187.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWykrota AA, Hamon L, Daas L, Seitz B. Descemet Membrane Endothelial Keratoplasty after failed penetrating keratoplasty- case series and review of the literature. BMC Ophthalmol. 2024 Jan 8;24(1):15.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShields CL, Kaliki S, Furuta M, et al. Clinical spectrum and prognosis of uveal melanoma based on age at presentation in 8,033 cases. Retina. 2012 Jul;32(7):1363-72.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRantala ES, Hernberg MM, Piperno-Neumann S, et al. Metastatic uveal melanoma: The final frontier. Prog Retin Eye Res. 2022 Sep;90:101041.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKujala E, M\u0026auml;kitie T, Kivel\u0026auml; T. Very long-term prognosis of patients with malignant uveal melanoma. Invest Ophthalmol Vis Sci. 2003 Nov;44(11):4651-9.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"DMEK, uveal melanoma, proton beam therapy, brachytherapy","lastPublishedDoi":"10.21203/rs.3.rs-8329664/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8329664/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePURPOSE\u003c/strong\u003e: To evaluate the visual outcomes and postoperative complications after Descemet membrane endothelial keratoplasty (DMEK) in patients after radiation therapy for uveal melanoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e: In this retrospective observational study, 9 eyes of 9 patients after radiation therapy for uveal melanoma who received DMEK surgery at the Charité – Universitätsmedizin Berlin were included. Preoperative patients` characteristics were analyzed. Postoperative results including visual acuity and endothelial cell density and complications were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e: Best-corrected visual acuity improved 3, 12 and 24 months after DMEK (preoperative: 0.88±0.47 logMAR, after 3 months: 0.52±0.30 (p=0.049), after 12 months: 0.60±0.35 logMAR (p=0.66), after 24 months: 0.60±0.45 logMAR (p=0.357)) compared to preoperatively. Endothelial cell density decreased 3 and 12 months after DMEK (preoperative: 2327±242 cells/mm\u003csup\u003e2\u003c/sup\u003e, after 3 months: 1831±384 cells/mm\u003csup\u003e2\u003c/sup\u003e (p=0.068), after 12 months: 1350±996 cells/mm\u003csup\u003e2\u003c/sup\u003e (p=0.180)).\u003c/p\u003e\n\u003cp\u003eRe-bubbling was performed in 55.6% of eyes after DMEK. One patient developed a postoperative macular edema, and another one a distant metastasis of the liver 20 years after last tumor treatment. Two-year-incidence of graft rejection was 0%, of graft failure 25.0% (95%KI -17.5%, 67.5%), of IOP-elevation 55.6% (95% KI 12.1%, 99.1%) and post-DMEK glaucoma 16.7% (95%KI -13.1%, 46.5%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSIONS\u003c/strong\u003e: Our results confirm that DMEK surgery is feasible and improves the visual acuity in patients with local control of uveal melanoma after radiation therapy. However, the complications rate is high - including graft failure, postoperative IOP elevation and post-DMEK glaucoma - and complications of the radiation treatment limit the achievable visual acuity.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Descemet membrane endothelial keratoplasty in patients after radiation therapy for uveal melanoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 18:54:27","doi":"10.21203/rs.3.rs-8329664/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-09T04:33:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-07T18:23:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-01T17:50:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80134030349493310007562857250091054851","date":"2026-01-26T17:19:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133512953367412241020962368234319811528","date":"2026-01-11T17:57:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T16:28:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-30T14:16:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-29T13:44:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-28T15:58:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-12-28T15:51:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cbf4bee5-4038-4d1f-bbdd-dd2e8058e553","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:15:34+00:00","versionOfRecord":{"articleIdentity":"rs-8329664","link":"https://doi.org/10.1186/s12886-026-04787-9","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2026-04-02 15:58:58","publishedOnDateReadable":"April 2nd, 2026"},"versionCreatedAt":"2026-01-12 18:54:27","video":"","vorDoi":"10.1186/s12886-026-04787-9","vorDoiUrl":"https://doi.org/10.1186/s12886-026-04787-9","workflowStages":[]},"version":"v1","identity":"rs-8329664","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8329664","identity":"rs-8329664","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}