To evaluate whether primary graft failure (PGF) rates and endothelial cell loss (ECL) differ between surgeon-trephined/loaded and eye bank-preloaded Descemet-stripping automated endothelial keratoplasty (DSAEK) grafts. Tertiary care academic center. Retrospective case series and ex vivo laboratory study. Single-center review of 69 eyes undergoing DSAEK (2020-2023) divided into 3 groups based on graft preparation and eye bank source: (1) eye bank-preloaded in EndoSerter (PL-ES), (2) eye bank-preloaded in glass tube (PL-GT), and (3) surgeon-trephined/loaded in EndoSerter (SL-ES). The primary clinical outcome was PGF (persistent corneal edema >3 months despite medical therapy). Secondary outcomes included visual outcomes and clinical complications (cystoid macular edema [CME] and rebubbling rate [RR]). The primary outcome of the laboratory study was percentage ECL (%ECL). All lenticules were ≤80 μm. PGF was significantly higher in the PL-ES group (8/20; 40%) and the PL-GT group (4/7; 57%) compared with the SL-ES group (1/42; 2%) ( P < .0001). Grafts requiring rebubbling were more likely to experience PGF ( P = .0176). PGF eyes were regrafted with SL-ES DSAEK; none experienced subsequent PGF. There were no significant differences in CME, RR, corrected distance visual acuity, and spherical equivalent. The ex vivo study included 9 PL-ES, 6 PL-GT, and 6 SL-ES grafts. %ECL was higher in both preloaded groups than SL-ES ( P = .0354), although significance was not demonstrated on post hoc analysis. Fluorescent imaging revealed more cell loss in preloaded grafts. Preloading and storage of DSAEK grafts may affect PGF rates clinically and ECL ex vivo.

Combined Descemet stripping automated endothelial keratoplasty and intraocular lens exchange using intrascleral haptic fixation (Yamane technique)-Clinical outcomes and literature review.

ABSTRACT Purpose To investigate current trends in corneal transplantation in South Korea by integrating data from the Korean Ophthalmological Society (KOS) and Eversight Eye Bank, focusing on surgical preferences, donor demographics, and evolving practices between 2021 and 2023. Methods This retrospective epidemiological study reviewed data from annual KOS surveys of government-registered transplantation centers and records from the Eversight Eye Bank. Surgical categories included penetrating keratoplasty (PKP), anterior lamellar keratoplasty (ALK), Descemet’s stripping automated endothelial keratoplasty (DSAEK), Descemet’s membrane endothelial keratoplasty (DMEK), and keratolimbal allograft (KLA). Variables collected included types of surgery, donor demographics, sources of donor corneas, time from death to corneal preservation, and endothelial cell density (ECD). For endothelial keratoplasty (EK), additional graft-specific parameters were collected, including graft diameter, thickness, preloading status, and loading materials. Results A total of 2636 corneal transplantations were identified. While PKP remained most commonly performed procedure (49.5% in 2023), the proportion of EK steadily increased. DMEK nearly doubled from 8.4% in 2021 to 15.2% in 2023. The proportion of imported donor tissue rose, reaching 74.5% by 2023. Donor age was significantly higher for DMEK (60.9 ± 6.0 years) than for PKP (48.0 ± 14.1 years) or DSAEK (50.7 ± 12.9 years). There was a clear trend toward greater use of preloaded grafts, smaller diameters, and novel loading techniques. Conclusion Corneal transplantation in South Korea is shifting toward EK, especially DMEK, driven by limited domestic donations and changes in surgical preferences. These findings highlight the importance of enhancing local donation systems and maintaining robust data infrastructure to guide policy and clinical decision-making.

This study aims to evaluate the long-term outcomes of Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) at a tertiary care center in Saudi Arabia over a 15-year period, focusing on the graft survival, visual improvement, complications rates, and graft insertion techniques. This is a retrospective study that included all patients who underwent DSAEK at King Abdulaziz University Hospital (KAUH), Riyadh, between 2009 and 2024. Data were collected on demographics, surgical details, visual acuity, graft survival, and complications. Primary and secondary graft failures were clarified, and risk factors were analyzed using univariate and multivariate Cox regression. Kaplan-Meier survival curves were used to represent the grafts survival, and surgical techniques (Lens Glide vs. Busin Glide) were compared. A total of 179 eyes from 163 patients were included. The overall graft survival rate was 69.3%, with cumulative survival of 81.0% at 1 year, 63.8% at 3 years, and 51.7% at 5 years. Visual acuity improved in 46.9% of patients, and 22.0% achieved 20/40 or better. Postoperative complications occurred in 38.5% of cases, with endothelial rejection being the leading cause of graft failure (49.1%). In multivariate analysis, postoperative complications were the only independent risk factor for failure (HR = 2.67, 95% CI: 1.71-4.18, p < 0.001). Although not statistically significant, a trend toward decreasing survival rates was evident with repeated DSAEK. Among surgical techniques, the lens glide group had no primary failures in the single-surgeon subgroup and demonstrated higher success rates than busin glide (p = 0.026). DSAEK provides favorable long-term outcomes, though prior surgeries, glaucoma, and postoperative complications, specifically endothelial rejection, can negatively impact graft survival. Surgical technique may influence early failure rates, emphasizing the importance of gentle tissue handling and surgeon expertise.

To evaluate the outcomes of Simultaneous Double Lamellar Keratoplasty (SDLK) as a surgical alternative to repeat penetrating keratoplasty (PK) for cases involving both stromal pathology and endothelial graft failure. Three patients with failed PK and evidence of both stromal and endothelial pathology underwent SDLK. The procedure combined deep anterior lamellar keratoplasty (DALK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in a single operation. Outcome measures included uncorrected and corrected distance visual acuity (UDVA and CDVA), topographic astigmatism, and postoperative complications, assessed over a 24-month follow-up period. All patients achieved significant improvements in visual acuity and reduced astigmatism. Final CDVA ranged from 0.04 to 0.30 logMAR. One patient had an intraoperative microperforation, which was successfully managed. Postoperative complications included 1 case of partial DSAEK detachment, resolved with rebubbling. No graft rejections were observed. The combination of DALK and DSAEK restored corneal clarity and improved astigmatism while minimizing the risks associated with open-sky surgery. SDLK offers a viable alternative to repeat PK for managing combined stromal and endothelial failure. This approach preserves structural integrity, provides superior refractive outcomes, and facilitates future lamellar interventions. Further studies are warranted to validate these findings in larger cohorts.

PurposeTo evaluate the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) combined with complete vitreous chamber fluid-air exchange via pars plana in vitrectomized patients with unstable compartmentalization between the anterior and posterior segment.MethodsThis case series presents a modified (full-filling) DSAEK technique, involving complete fluid-air exchange via pars plana, in six eyes with endothelial dysfunction and corneal edema who had undergone prior vitrectomy and lacked stable anterior-posterior segment compartmentalization (aphakic, iris-claw IOL, scleral fixed IOL, IOL in the ciliary sulcus). Preoperative and postoperative data, including visual acuity, corneal thickness, and endothelial cell density, were collected. The primary outcome was single-surgery graft adhesion; secondary outcomes included complications, re-bubbling rate, and visual acuity improvement.ResultsThe full-filling DSAEK technique achieved complete graft adhesion in all cases at all follow-up visits, with improved visual acuity and decreased corneal thickness. No major complications were recorded, including donor graft dislocation and need of rebubbling.ConclusionWhen performing DSAEK, completely filling the ocular cavity with air via pars plana is a safe and effective technique in poorly compartmentalized vitrectomized eyes to achieve graft adhesion and improving surgical success.

Introduction: This case report seeks to document a rare case of posterior dislocation of Descemet stripping automated endothelial keratoplasty (DSAEK) graft in a patient with subluxed intraocular lens one day post-operation. Case Report: A 70-year-old man with a background of subluxed intraocular lens in a non-vitrectomized eye with pseudophakic bullous keratopathy underwent DSAEK. Review on post-operative day one noted a dislocated graft. Graft re-bubbling in the clinic with air displaced the graft into the posterior segment. Graft retrieval, repositioning, and intraocular lens removal were done on the same evening without complications. Conclusion: This case report shows the possibility of DSAEK graft dislocation post-operation in a non-vitrectomized eye but with compromised barrier between anterior and posterior chambers of the eye. The uniqueness of this case report is retrieving a DSAEK graft in the posterior segment and successfully using the same graft to achieve a clear cornea the day after the original surgery.

To investigate current practice patterns among corneal specialists performing Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). An online questionnaire was distributed via the Canadian Ophthalmological Society and Kera-net (Cornea Society listserv) for the period from March to May 2025. The survey collected data on demographics, clinical practice, and intra/postoperative management strategies related to DSAEK and DMEK, including use of perioperative assistive techniques, tamponade strategies, postoperative positioning, and follow-up protocols. There were 70 respondents. All performed DSAEK while 82.9% performed DMEK. Most had over 5-year experience with DSAEK (85.7%) and DMEK (77.6%). Donor tissue marking was common (82.5% for DMEK; 72.9% for DSAEK), as were peripheral iridotomy/iridectomy (70.2% for DMEK; 37.1% for DSAEK), and intra/postoperative dilation (45.6% for DMEK; 61.4% for DSAEK). Intraoperative anterior segment optical coherence tomography was used by 15.8% (DMEK) and 12.9% (DSAEK) of respondents. Sulfur hexafluoride (SF6) gas is the preferred tamponade agent for routine DMEK (55.2%) but less so for DSAEK (7.1%). Intraoperative tamponade was more frequent in DSAEK (90.0%) than DMEK (67.2%). Full/near-full air/gas fills were left in 42.9% of routine DSAEK and 50.0% of DMEK. Same-day postoperative review was performed by 74.1% (DMEK) and 67.2% (DSAEK). Many surgeons discharged routine cases from corneal services by postoperative year 1 (53.4% for DMEK; 51.4% for DSAEK). This study sheds insights into the current endothelial keratoplasty practices among corneal specialists. Further research is needed to examine how these technique variations correlate with clinical outcomes.

Background/Objectives: To evaluate the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with glaucoma and to investigate if the usage of the prostaglandin analog latanoprost increases the risk of graft rejection. Methods: This study retrospectively reviewed 65 eyes of 61 patients with glaucoma who underwent DSAEK at King Abdulaziz University Hospital between 2009 and 2024. The risk factors for graft rejection were identified using Kaplan–Meier survival analysis and univariate and multivariate Cox regression models. Results: The graft survival rates among patients with glaucoma at 1, 3, and 5 years were 72.4%, 23.1%, and 11.5%, respectively. Latanoprost use was significantly associated with graft failure (71.4% vs. 28.6%, p = 0.024). The graft failure was mostly secondary failure (80%, p = 0.015) and was often linked to endothelial rejection episodes (62.5%). Other antiglaucoma medications were not associated with graft failure. Conclusions: Glaucoma decreases graft longevity after DSAEK. Latanoprost use may further increase the risk of graft rejection by enhancing inflammatory or immune responses. Prospective studies are warranted to confirm these findings.

To present a case of a dislocated posterior lamellar graft into the vitreous cavity in an eye that was post pars plana vitrectomy. Retrospective case report. A middle-aged man underwent pars plana vitrectomy (PPV), pars plana lensectomy (PPL), and SSIOL fixation following a traumatic eye injury. The patient required subsequent Descemet stripping automated endothelial keratoplasty (DSAEK) for corneal edema, and the posterior lamellar graft was lost intraoperatively into the posterior segment. The graft was surgically retrieved one week later, followed by a successful placement of a new posterior lamellar graft. Histopathological examination of the retrieved graft after one week in the vitreous cavity revealed viable endothelial cells, a novel finding in a posteriorly dislocated DSAEK graft. The newly placed graft remained attached and healed well, with the patient achieving a visual acuity (VA) of 20/80 at three months post-operatively. Posteriorly dislocated grafts may be suitable for transplantation to the corneal stroma following prompt retrieval from the vitreous cavity. Prompt retrieval and appropriate surgical techniques are critical for optimizing outcomes in such clinical scenarios.

Relevance. Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) is one of the modern surgical approaches used to treat endothelial corneal diseases, including Fuchs' dystrophy and bullous keratopathy. However, the success of surgery depends directly on the correct choice of technique for inserting the donor Descemet's membrane and endothelium. Currently, there is no standardized method for endothelial graft insertion. The technique is chosen by the surgeon based on individual factors, which may lead to variability in outcomes. Research objective. Comprehensive evaluation of the effectiveness of various methods of endothelial transplant administration in DSEK surgery and assessment of the morphofunctional state. Materials and Methods. The study included 15 patients with Fuchs' dystrophy and endothelial dysfunction (5 patients per each of the three techniques). Results and Conclusion. The insertion technique significantly affects DSAEK outcomes. Long-term observations showed that forceps are a classic yet most traumatic method for the endothelium; the Busin Glide offers technical stability, although some uncertainties remain; the TransplantREADY™ DSAEK system is the most convenient, safe, and efficient, providing the best endothelial cell preservation. Keywords: DSAEK, endothelial forceps, Busin Glide, TransplantREADY, endothelial cells, keratoplasty. The drug was developed by the Lions EYE Institute (USA) and is available in Uzbekistan through official cooperation with this institute.

Descemet's stripping automated endothelial keratoplasty (DSAEK) is the method of choice in the treatment of Fuchs' endothelial dystrophy and pseudophakic bullous keratopathy. The use of a femtosecond laser allows for the rapid and atraumatically formation of thin and ultra-thin corneal grafts. Objective: to analyze the results of surgical treatment of patients with endothelial dystrophy and pseudophakic bullous keratopathy using femtosecond laser-assisted Descemet's stripping automated endothelial keratoplasty with thin corneal grafts. Materials and methods: an analysis of the treatment results was performed in 31 patients who underwent surgery in 2022–2024 at the Irkutsk branch of S. Fyodorov “Eye microsurgery” Federal State Institution using femtosecond laser-assisted Descemet's stripping automated endothelial keratoplasty (FS-DSAEK) with 110–120 μm thick corneal grafts. Uncorrected (UCVA) and best corrected (BCVA) visual acuity, IOP, corneal thickness, corneal graft thickness and endothelial cell density (ECD) were assessed. The observation period was before surgery, 3, 6, 12 months after surgery. Results: an increase in UCVA from 0.03±0.02 to 0.29±0.14 and BCVA from 0.20±0.15 to 0.37±0.16 was noted 12 months after surgery. During the observation period, IOP was compensated – 12.25±3.99 mm Hg. The average corneal thickness 12 months after surgery was 659.67±34.73 μm, and the graft thickness in the center was 95.43±11.11 μm. The PEC in the postoperative period decreased slightly and 12 months after surgery was 1190.67±106.61 per mm2. Conclusion: the use of thin grafts for femtosecond assisted Descemet's stripping automated endothelial keratoplasty allowed obtaining an improvement in visual functions in patients with Fuchs’ endothelial dystrophy and pseudophakic bullous keratopathy within a year after surgical treatment. Complete anatomical adhesion of the graft was noted, the thickness of which did not exceed 100 μm in the center with a sufficient density of endothelial cells. Keywords: Descemet's stripping automated endothelial keratoplasty, Fuchs' dystrophy, bullous keratopathy, FS-DSAEK.

Cost-utility analysis of cultured human corneal endothelial cells for corneal edema secondary to endothelial dysfunction: a Monte Carlo simulation model.

To investigate the association between preoperative aqueous humor (AqH) cytokines and mid-term endothelial cell density (ECD) after Descemet stripping automated endothelial keratoplasty (DSAEK). This prospective study included 80 eyes: 47 eyes undergoing DSAEK and 33 cataract surgery eyes as controls. AqH samples were collected at the beginning of surgery. The levels of cytokines [interleukins (ILs)-1α, -1β, -4, -6, -8, -10, -12p70, -17A, monocyte chemotactic protein-1, interferon-α, IFN-γ, E-selectin, P-selectin, and soluble intercellular adhesion molecule-1 (sICAM-1)] in the AqH were measured using a multiplex beads immunoassay. Total protein levels in the AqH were measured independently using the detergent compatible (DC) Protein Assay. DSAEK subjects were divided into 2 groups by 36 months ECD: group 1 (ECD <1200 cells/mm2 or graft failure, n = 29 eyes) and group 2 (ECD ≥1200, n = 18 eyes). The ECD reduction per year was significantly correlated with preoperative levels of total protein (r = 0.44; P = 0.002) and sICAM-1 (r = 0.46; P = 0.002). Group 1 exhibited significantly higher levels of sICAM-1 compared with group 2 (P = 0.001). Although not statistically significant, trends were observed between graft failure and levels of total protein (P = 0.003), IL-17A (P = 0.04), and sICAM-1 (P = 0.003). Elevated AqH levels of total protein and sICAM-1 are associated with mid-term ECD reduction and graft failure after DSAEK. Pathological alterations of the AqH microenvironment may critically affect corneal endothelial cells and graft survival after DSAEK.

To analyze the outcomes of phacoemulsification with intraocular lens (IOL) implantation in patients with Axenfeld-Rieger syndrome (ARS). This was a retrospective observational study. Patients with ARS who underwent cataract surgery and had a minimum postoperative follow-up of 6 weeks were included. Visual outcomes after cataract surgery and complications were evaluated in these patients. All patients underwent uneventful cataract surgery. A total of 12 eyes of 11 patients were included, 6 males and 5 females. The mean age was 45.3 ± 10.5 years, and the mean follow-up period was 21.6 months. The mean best-corrected visual acuity (BCVA) preoperatively was 0.9 ± 0.3 Log MAR and postoperatively was 0.4 ± 0.3 LogMAR (P = 0.0043). Eleven patients had secondary glaucoma requiring surgical intervention in 6/12 eyes (50%). Two patients required Descemet stripping automated endothelial keratoplasty (DSAEK) postcataract surgery for corneal decompensation. No significant intraoperative complications occurred in these patients. Cataract surgery and intraocular lens implantation in patients with ARS is safe, but visual improvement depends on comorbid conditions.

PurposeTo report Descemet stripping automated endothelial keratoplasty (DSAEK) outcomes for pediatric Descemet membrane detachment (DMD) with diffuse corneal edema.MethodsThis study included seven cases of pediatric DMD presented at Peking University Third Hospital during October 2017 and April 2022. The collected data included patient demographics, etiology, configuration of the DMD, preoperative and postoperative vision and central corneal pachymetry, surgical outcomes, and complications.ResultsThe mean age of the children was 3.27 ± 4.73 (range: 0.33–13) years old. Etiologies included cataract surgeries, glaucoma surgeries, and forceps-related injuries. In all cases, the central areas of the corneas were involved. Three patients had received Descemetopexy at first but failed. DSAEK was successfully performed in all eyes. Compared to the preoperative visual acuity (LogMAR 2.57 ± 0.23), postoperative visual acuity (LogMAR 0.78 ± 0.25) was significantly improved (P < 0.01). Postoperative central corneal pachymetry measured within a month after DSAEK (850 ± 163 μm) showed satisfactory improvement when compared to the preoperative one (1,304 ± 234 μm, P = 0.005). Early postoperative complications included graft dislocation in one case and was successfully managed with air bubbling.ConclusionPediatric DMD might suffer a lower success rate of Descemetopexy due to the anatomical peculiarity. Reconstructing visual pathway to promote early visual development justifies more aggressive treatment like DSAEK, which has demonstrated satisfactory results.

Background/Objectives: This study assessed outcomes between penetrating keratoplasty (PK) and Descemet’s stripping automated endothelial keratoplasty (DSAEK) when combined with cataract surgery as part of the triple procedure. Methods: Retrospective analysis of 727 triple procedures (525 PK and 202 DSAEK) from 2007–2023. Graft survival, visual acuity, and refractive outcomes were analyzed. Kaplan–Meier and Cox regression were used for survival and prognostic analysis. Results: No statistically significant difference in survival was found (PK—42 months; DSAEK—47 months). DSAEK had better visual acuity improvement and refractive stability. PK had higher astigmatism and variability in refractive error. Conclusions: While graft survival was comparable, DSAEK offers superior visual rehabilitation, supporting its use when refractive predictability is important.

For many corneal diseases, transplantation is the gold standard for curative treatment and restoration of vision. Penetrating keratoplasty (PKP), performed by Zirm in 1905, was the first successful corneal transplantation procedure. Since then, relentless advancement in the field has occurred, most importantly with the development of deep anterior lamellar keratoplasty (DALK), Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK), which have been rapidly increasing in usage and are poised to take over PKP in prevalence and effectiveness in treating specific stromal and endothelial pathologies. The biggest issues currently facing this field are the lack of availability of donor corneas and lack of accessibility of the procedure to many areas of the world. Recent and future advancements are focused on substitutes to increase the amount of graft material for use and technological developments to streamline keratoplasty techniques, making them more effective, easier to perform and associated with less complications. Bio-engineered corneas, cell-based therapies and regenerative medicine can create grafts through various mechanisms: acellular, synthetic scaffolds and medical therapies to promote endogenous cell regeneration or exogenous cultivation of corneal tissues from stem-cells. Keratoplasty has also been refined by the introduction of femtosecond laser (FSL), which when combined with intra-operative optical coherence tomography (iOCT) allows for finer cuts and novel techniques which can improve the outcomes from PKP, DALK and DMEK.

Background: Textural interface opacities (TIOs) following Descemet's stripping automated endothelial keratoplasty (DSAEK) have become a significant postoperative concern. Studies have explored possible links such as stromal irregularities and viscoelastic usage, but the exact cause of TIOs remains unclear. PURPOSE: To evaluate the relationship between microkeratome dissection parameters and the development of textural interface opacities in DSAEK grafts utilizing the "M-TIO" grading scale for standardized assessment. Methods: Optical coherence tomography (OCT) images of DSAEK-processed corneal grafts, prepared with the same microkeratome and technique for transplantation at Bascom Palmer Eye Institute, underwent blinded analysis using a newly developed grading scale termed "M-TIO". This analysis aimed to evaluate and categorize the occurrence of TIO, explore its potential correlation with graft characteristics prior to DSAEK preparation, and assess specific stages of the DSAEK dissection process. Data collected included the size of the microkeratome head used, the difference between the head and the actual stromal cut, and the difference between the pre-cut graft thickness and post-cut DSAEK lenticule thickness. Results: The study retrospectively included 422 donor corneas transplanted from 2019 to 2023. Variables associated with TIO in the final multivariable ordinal logistic model included the difference between the pre-cut graft thickness and the post-cut DSAEK lenticule thickness (OR: 1.57 [99% CI: 1.22 to 2.06] per 50 µm) and microkeratome head (OR: 6.95 [99% CI: 1.04 to 36.60] 300 µm, OR: 4.39 [99% CI: 0.76 to 19.00] 350 µm, and OR: 18.86 [99% CI: 2.35 to 175.91] 400 µm vs 450 or 500 µm, respectively). Conclusions: This study identified a statistically significant association between TIOs and the microkeratome DSAEK preparation, proposing several factors that could help prevent its occurrence. Specifically, creating an ultra-thin DSAEK lenticule from an initially thick graft using a smaller microkeratome head with the slow single-pass technique may increase the risk of TIOs. In contrast, utilizing a larger microkeratome head can improve stromal thickness consistency, reduce technical challenges during graft preparation, and lower the risk of TIOs.

Background and Objectives: Descemet stripping automated endothelial keratoplasty (DSAEK) is a widely used surgical technique for treating corneal endothelial dysfunctions such as Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK). This study aimed to investigate the association between postoperative visual acuity and various corneal morphological and optical parameters, including corneal densitometry (CD) and higher-order aberrations (HOAs), measured using the Pentacam (OCULUS Optikgeräte GmbH, Wetzlar, Germany), as well as graft thickness, which was assessed by anterior segment optic coherence tomography (AS-OCT), (Optovue Inc., Fremont, CA, USA), and corneal thickness, assessed by both AS-OCT and Pentacam. Materials and Methods: This prospective, observational cohort study included 17 eyes from 13 patients who underwent DSAEK. Data on preoperative visual acuity were collected, while postoperative parameters were assessed during follow-up visits. Corneal measurements included the total corneal and corneal graft thickness, corneal densitometry in 20 defined subregions, and corneal higher-order aberrations. Associations between these parameters and postoperative visual acuity were evaluated using nonparametric statistical tests. Results: The postoperative visual acuity improved significantly (p < 0.001). Strong correlations were found between poorer visual acuity and higher CD values. The strongest correlations with visual acuity were found for CD 2-6 mm total (Rho = 0.795; p < 0.001), CD central 2-6 mm (Rho = 0.791; p < 0.001), and CD central 0-2 mm (Rho = 0.730; p < 0.001). Significant associations were also observed with anterior and posterior HOAs (Rho = 0.624, p = 0.01; and Rho = 0.556, p = 0.02, respectively). No correlation was found between visual outcomes and graft thickness measured by AS-OCT (Rho = 0.051; p = 0.85), nor with total corneal thickness measured by AS-OCT (Rho = -0.227; p = 0.38) or Pentacam (Rho = -0.369; p = 0.14). Conclusions: This study demonstrates that CD and HOAs are more strongly associated with postoperative visual acuity after DSAEK than traditionally monitored parameters such as graft or corneal thickness. The results highlight the value of detailed corneal imaging and support the use of advanced optical diagnostics in postoperative evaluation.