Comparative Outcomes of Conservative Management Versus Descemet Membrane Endothelial Keratoplasty for Early-Stage Fuchs Dystrophy

Abstract

Background Fuchs endothelial corneal dystrophy (FECD) is a progressive corneal disorder that can significantly impair visual function and quality of life. Conservative management with hypertonic saline and observation has traditionally been employed in early-stage disease, whereas Descemet membrane endothelial keratoplasty (DMEK) is generally reserved for advanced cases. However, increasing evidence suggests that earlier surgical intervention may offer superior outcomes. Despite growing interest in this approach, the comparative effectiveness of early DMEK versus conservative management remains incompletely understood. Objective To systematically evaluate whether early DMEK provides superior visual and quality-of-life outcomes compared with conservative management in patients with mild to moderate FECD. Methods A systematic review was conducted in accordance with PRISMA guidelines. Comprehensive searches were performed in PubMed, Scopus, Web of Science, and the Cochrane Library. Studies comparing early DMEK with conservative treatment involving hypertonic saline and observation in adults with mild to moderate FECD were included. Randomized controlled trials, cohort studies, and comparative observational studies were considered. Data extraction and risk-of-bias assessment were independently performed by two reviewers using standardized tools. A qualitative synthesis of findings was undertaken. Results  A total of 742 records were identified, of which eight studies involving 1,124 patients met the eligibility criteria. Across the included studies, early DMEK consistently demonstrated superior improvements in best-corrected visual acuity, corneal clarity, and vision-related quality of life compared with conservative management. Disease progression rates were lower among surgically treated patients, while postoperative complications were generally infrequent and manageable. Overall, the evidence favored early DMEK for achieving better functional and patient-centered outcomes. Conclusion Early DMEK appears to provide meaningful clinical benefits over conservative management in patients with mild to moderate FECD, particularly with respect to visual rehabilitation, quality of life, and prevention of disease progression. Although the overall evidence is supportive, further large-scale randomized studies with long-term follow-up are needed to establish definitive recommendations regarding optimal timing of intervention