Indications and Decision-Making for Endothelial Keratoplasty

Since its introduction in the early 2000s, endothelial keratoplasty (EK) has quickly become the treatment of choice for patients with all types of corneal endothelial dysfunction. Using techniques that are readily adoptable by corneal surgeons, EK provides more rapid visual recovery with fewer intra- and postoperative complications than the alternative full-thickness penetrating keratoplasty (PK). The Eye Bank Association of America’s 2018 Statistical Report documents an exponential rise in the number of EK procedures performed within the United States over the past decade, from 1398 cases in 2005 up to 30,336 cases in 2018. Since 2012, the number of EK procedures performed in the United States has surpassed the number of PK procedures, with PK numbers on the decline. These trends reflect the many advantages of EK over PK.

Indications for Endothelial Keratoplasty

Candidates for EK procedures include patients with any type of endothelial dysfunction, including endothelial dystrophies such as Fuchs endothelial dystrophy, posterior polymorphous dystrophy (PPMD) or congenital hereditary endothelial dystrophy (CHED), pseudophakic or aphakic bullous keratopathy, iridocorneal endothelial (ICE) syndrome, endothelial decompensation from trauma or prior ocular surgery ( Fig. 128.1 ), or a late endothelial failure of a prior penetrating keratoplasty ( Fig. 128.2 and Table 128.1 ).

TABLE 128.1

Indications for Endothelial Keratoplasty

Indications Endothelial dystrophy CHED, Fuchs, posterior polymorphous Bullous keratopathy pseudophakic, aphakic Endothelial failure from trauma, previous surgery, angle closure, glaucoma drainage devices Iridocorneal endothelial (ICE) syndrome Failed penetrating keratoplasty (if acceptable refractive result was achieved)

Contraindications Stromal opacity or scarring that limits visual potential Keratoconus, ectasia Hypotony/pre-phthisical eye

Assessment of anterior chamber space and specialized techniques advised in eyes with: Anterior synechiae Glaucoma drainage devices Iris abnormalities Anterior chamber intraocular lens

CHED , Congenital hereditary endothelial dystrophy.

EK is not an appropriate option for patients with healthy endothelium, such as those with keratoconus or corneal ectasia (see Table 128.1 ). Similarly, EK may not be the optimal choice in patients with significant vision-limiting corneal subepithelial or stromal scarring. Depending on the patient’s visual needs and goals, a full-thickness penetrating keratoplasty or anterior lamellar keratoplasty may be a better choice in those cases.