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Outcomes of Descemet Stripping Automated Endothelial Keratoplasty

Key Concepts Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) provides rapid visual recovery. Postoperative complications can be minimized with careful intraoperative technique. DSEK/DSAEK yields 20/25–20/30 vision 1–3 years after surgery. DSEK/DSAEK causes minimal refractive change. DSEK/DSAEK maintains a physiologic corneal surface with minimal change in astigmatism. Endothelial cell loss following DSEK/DSAEK compares favorably with penetrating keratoplasty over the medium- to long-term. Introduction Endothelial keratoplasty (EK) has evolved…

Intraoperative and Postoperative Complications of Descemet Stripping Automated Endothelial Keratoplasty

Key Concepts To review intraoperative and postoperative complications of Descemet stripping automated endothelial keratoplasty (DSAEK). The authors discuss endothelial keratoplasty trends followed by an outline of complications that may occur during surgery and complications that may occur days to months to years after endothelial keratoplasty. Intraoperative complications of DSAEK include donor tissue preparation issues, tissue damage, bleeding, and tissue and lens implant dislocations. Postoperative complications include…

Nanothin Descemet Stripping Automated Endothelial Keratoplasty

Key Concepts While early studies found conflicting results, most recent studies have concluded better visual acuity outcomes with thinner Descemet stripping automated endothelial keratoplasty (DSAEK) tissue. With a newer preparation technique to produce DSAEK grafts with thickness ≤50 μm, we proposed the term “nanothin DSAEK” to distinguish it from traditional and ultrathin DSAEK. While not a replacement for Descemet membrane endothelial keratoplasty (DMEK), nanothin DSAEK can…

Ultrathin Descemet Membrane Endothelial Keratoplasty

Key Concepts Descemet membrane endothelial keratoplasty (DMEK) is not suitable for all eyes. Central thickness of Descemet stripping automated endothelial keratoplasty (DSAEK) grafts may influence the visual results. A single- or double-pass technique can be used to reproducibly obtain DSAEK grafts of a predetermined thickness and planar profile. Ultrathin (UT) DSAEK can be performed in patients with endothelial decompensation of any etiology. Best spectacle-corrected visual acuity…

Surgical Techniques for Descemet Stripping Automated Endothelial Keratoplasty

Key Concepts Endothelial keratoplasty allows for selective replacement of diseased corneal endothelium, restoring corneal clarity without full-thickness replacement of the entire cornea. One of the most common forms of endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty (DSAEK) involves preparation and insertion of a thin lamella of posterior stroma, Descemet membrane, and endothelium. DSAEK donor insertion techniques have evolved from simple taco folding with forceps, to the…

Eye Bank Preparation of Tissue for Endothelial Keratoplasty

Key Concepts Eye banks have standardized the preparation of donor tissue for Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). Eye bank preparation of donor tissue for endothelial keratoplasty reduces barriers to adopting endothelial keratoplasty techniques and increases operating room efficiency. The Cornea Preservation Time Study (CPTS), a prospective investigation of the effect of preservation time on DSAEK surgery outcomes, determined that…

Indications and Decision-Making for Endothelial Keratoplasty

Key Concepts Endothelial keratoplasty (EK) is the procedure of choice for patients with endothelial dysfunction in both the adult and pediatric population. EK allows for faster visual recovery and decreased intraoperative and postoperative risks compared to penetrating keratoplasty. EK is not an appropriate keratoplasty option for patients with significant vision-limiting anterior corneal scarring. There are several types of EK procedures: Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK),…

Historical Development of Endothelial Keratoplasty

Introduction During the 20th century, replacement of the endothelial layer for patients suffering from corneal edema was accomplished by performing a full-thickness penetrating keratoplasty (PK). This anatomically nonselective method provided a clear corneal window for vision but required corneal sutures to close the fragile, vertical wound of trephination. Despite months and years of healing, PK often left the patient with distortions due to irregular, high astigmatism…

Immunologically High-Risk Penetrating Keratoplasty and Large-Diameter Corneal Grafts

Key Concepts Large-diameter corneal grafts are used for the treatment of uncontrolled corneal ulcers, keratomycoses, and other severe necrotizing corneal conditions that threaten vision or the eye itself. Patients with severe ocular surface disease manifesting as conjunctivalization and superficial neovascularization, which may occur due to limbal stem cell deficiency, are extremely high-risk for immunologic and nonimmunologic graft failure. In these patients, the appropriate strategy is to…

Keratoplasty in Herpes Simplex Infection

Key Concepts Herpes simplex virus (HSV) keratitis is the most frequent cause of unilateral corneal blindness and the most frequent indication for keratoplasty in developed countries. HSV keratitis is a complex, multifaceted disease, and successful treatment requires a clear understanding of the disease, close postoperative follow-up, and proper therapeutic strategy. Control of both inflammation and viral recurrence is mandatory prior to the placement of a corneal…

Pediatric Keratoplasty

Key Concepts Deep phenotyping is essential to classify pediatric corneal opacities to allow for appropriate management algorithm. A new classification of neonatal and congenital corneal opacification may help with surgical planning and intervention. Management options include control of ocular comorbidities (e.g., glaucoma) and systemic comorbidities (e.g., renal or cardiac disease). Management includes penetrating keratoplasty (PKP), deep anterior lamellar keratoplasty (DALK), automated lamellar keratoplasty (ALK), endothelial keratoplasty…

Outcomes of Anterior Lamellar Keratoplasty

Key Concepts Visual and refractive outcomes of deep anterior lamellar keratoplasty (DALK) are comparable to those achieved by penetrating keratoplasty (PK). The residual stromal bed limits visual outcomes following DALK. As a result, techniques that bare the Descemet membrane may be superior to those that do not. Immune rejection of the corneal endothelium cannot occur in DALK; it therefore results in lower rates of graft rejection…

Recovery Techniques in Deep Anterior Lamellar Keratoplasty

Key Concepts The cannula “big bubble” (BB) technique and the bubble test lessen the possibility of deep anterior lamellar keratoplasty (DALK) intraoperative complications. If the air BB fails, the air-visco bubble (AVB) technique can be used. A manual dissection can be employed if bubble separation techniques are not successful. Rescue techniques for cases in which there are intraoperative tears or ruptures in the Descemet membrane differ…

Intraoperative and Postoperative Complications of Anterior Lamellar Keratoplasty

Key Concepts Descemet membrane perforation is the most common intraoperative complication in deep anterior lamellar keratoplasty (DALK). Management of anterior chamber pressure can help avoid irreversible damage to the Descemet membrane. Double anterior chamber is a common postoperative complication in DALK. Air tamponade is effective in treating double anterior chambers, but care is needed to avoid pupillary block. Anterior lamellar keratoplasty can be divided into two…

Techniques of Anterior Lamellar Keratoplasty

Key Concepts Anterior lamella keratoplasty (ALK) techniques allow the surgeon to selectively dissect parts of the diseased corneal stroma while sparing the healthy remaining stroma and endothelium. The stromal dissection has to be deep (residual bed thickness <80 μm) and uniform to provide good visual outcomes comparable with penetrating keratoplasty. Surgical techniques used to be divided into two classes: predescemetic DALK (pdDALK) and descemetic DALK (dDALK);…

Indications for Anterior Lamellar Keratoplasty

Key Concepts Anterior lamellar keratoplasty includes techniques whereby the diseased corneal stroma is partially or totally replaced by donor tissue, provided the endothelium is still healthy. Anterior lamellar keratoplasty induces a low immunologic insult. This allows for larger grafts without increased risk of rejection, as in extreme ectatic disorders, and allows the surgeon to perform a successful transplant in the inflamed eye. Deep anterior lamellar keratoplasty…

Glaucoma After Corneal Transplantation

Key Concepts A history of preexisting glaucoma or glaucoma surgery is a major risk factor for postoperative intraocular pressure (IOP) rise in eyes that have received either PK or Descemet stripping endothelial keratoplasty (DSEK) surgery. Similar mechanisms of IOP rise in post-PK and in post-DSEK eyes occur, such as steroid-related IOP rise, peripheral anterior synechiae, and inflammation. Preexisting glaucoma or glaucoma surgery appears to be a…

Infections After Penetrating Keratoplasty

Key Concepts Infection after penetrating keratoplasty can be a serious complication and can threaten the integrity of the graft. Microbial keratitis in an eye that has undergone penetrating keratoplasty must be recognized early and treated aggressively, as it can progress to endophthalmitis. Suture abscesses require careful and aggressive treatment as they can lead to wound dehiscence and endophthalmitis. Endophthalmitis after penetrating keratoplasty is uncommon but often…

Diagnosis and Management of Corneal Allograft Rejection

Key Concepts Of the approximately 50,000 corneal transplants performed annually in the United States, corneal allograft rejection is still the leading cause of corneal graft failure. Young age, pre- or postoperative vascularization, preoperative inflammation, and iris synechiae to the graft-host junction are risk factors for graft failure after penetrating keratoplasty. Deep anterior lamellar keratoplasty (DALK) avoids the risk for endothelial rejection, but stromal rejection can occur…