Descemet Stripping Automated Endothelial Keratoplasty Research Articles

Factors Influencing Corneal Endothelial Cell Density after Descemet Stripping Automated Endothelial Keratoplasty

Purpose: To identify determinants of corneal endothelial cell density at 12 months after Descemet stripping automated endothelial keratoplasty (DSAEK).Methods: This study included patients with bullous keratopathy who underwent DSAEK with internationally sourced donor corneas from March 2021 to March 2022. We assessed various preoperative factors in recipients (age, cause of bullous keratopathy, intraocular pressure, visual acuity, anterior chamber volume, depth and angle, pupil size, white-to-white corneal diameter, and preoperative corneal endothelial cell density) and donors (age, death to preservation time, preservation to transplantation time, death to transplantation time, corneal endothelial cell density, trephine size, and precut tissue thickness). We analyzed factors influencing corneal endothelial cell density up to 12 months after keratoplasty.Results: This study involved 53 patients, with an average recipient age of 65.9 ± 14.6 years prior to surgery. Donor corneas had an average endothelial cell density of 2,871.6 ± 271.6 cells/mm<sup>2</sup>. At 6 and 12 months postoperatively, endothelial cell densities had decreased by 36.9% and 47.2%, respectively, compared with preoperative levels. Multivariate linear regression analysis indicated that endothelial cell densities at 3 and 12 months postoperatively were linked to recipient age and anterior chamber depth.Conclusions: Corneal endothelial cell density after DSAEK typically stabilized after initial decline; higher densities were found in older recipients and individuals with shallower anterior chambers.

Graft detachment rates in surgeon-cut and pre-cut tissue for DSAEK transported in different mediums.

To analyse graft detachment rates after Descemet stripping automated endothelial keratoplasty (DSAEK) using surgeon-cut grafts and pre-cut grafts transported in different mediums. A retrospective study of graft detachment rates including 265 surgeries (240 patients) performed between 2019 and 2023. The DSAEK grafts were either surgeon-cut (n = 135) or pre-cut and transported in a dextran-containing medium (n = 82) or in a dextran-free medium (n = 48). All surgeries were performed by a single surgeon (I.G.). The surgeries were categorised according to whether the recipients' eyes had, or did not have, factors associated with an increased risk of graft detachment. Detachment rates were compared for all patients receiving the different kinds of graft, and only for those without risk factors. A significantly higher detachment rate was found among patients receiving pre-cut grafts transported in a dextran-containing medium (32.9%), compared to surgeon-cut grafts (14.1%, p = 0.002), and pre-cut grafts transported in a dextran-free medium (6.3%, p = 0.002) for all recipients (those with and without risk factors for graft detachment). When analysing recipients without risk factors for graft detachment, the detachment rate was still significantly higher with pre-cut tissue transported in a dextran-containing medium (26.9%), compared to surgeon-cut tissue (8.3%, p = 0.002) and pre-cut tissue transported in a dextran-free medium (3.6%, p = 0.01). The use of pre-cut DSAEK tissue transported in a dextran-containing medium significantly increases the risk of graft detachment requiring re-bubbling.

Endothelial Keratoplasty Following Glaucoma Filtration Surgery: A UK Tertiary Eye Care Referral Centre Experience.

Purpose: To compare the postoperative complications and clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with previous glaucoma filtering surgery. Methods: In this retrospective comparative case series, we analysed postoperative visual acuity and intraocular pressure, graft survival, rate of graft detachment and/or dislocation, number of rebubbling and/or graft repositioning procedures, and graft rejection or failure (primary and secondary). Results: Sixteen eyes with DMEK and 80 eyes with DSAEK with previous glaucoma surgery were studied. The results were recorded at 3 and 12 months postoperatively. No statistically significant differences in postoperative visual acuity were found between the two groups at any stage of the follow-up. Intraocular pressure was lower in the DMEK group at the follow-up stage of 3 (p = 0.0022) and 12 months (p = 0.0480). Visually significant graft detachment was recorded in 31.3% and 22.5% of DMEK and DSAEK cases, respectively (p = 0.4541). All DMEK detachments (n = 5) were managed with slit-lamp rebubbling. Out of 18 graft detachments in the DSAEK group, 2 grafts were observed due to small graft detachment, 6 large graft detachments underwent rebubbling performed in the operating theatre, and 10 eyes needed primary graft repositioning for graft dislocation. Conclusions: DMEK is a feasible option to treat endothelial failure in complex eyes with previous glaucoma surgery. In the DMEK group, visual acuity outcomes and possibly postoperative intraocular pressure control were better compared with the DSAEK group.

Changing indications for keratoplasty: monocentric analysis of the past two decades

Abstract Purpose Over the past two decades, lamellar keratoplasty procedures, such as Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) and Descemet's Membrane Endothelial Keratoplasty (DMEK) as well as Deep Anterior Lamellar Keratoplasty (DALK), have become an integral part of clinical practice. With advances in contact lens fitting for keratoconus management and the implementation of UVA-Riboflavin Crosslinking (CXL), the landscape of keratoplasty indications is undergoing changes. Procedures and indications in a single tertiary care center over the past two decades are reviewed in this retrospective analysis. Methods: Retrospective analysis utilized anonymized electronic data from the LIONS cornea bank Baden-Württemberg, Eye Center Freiburg, spanning from beginning of 2004 to end of 2023. The primary focus was on surgical procedures and indications for keratoplasty. Results The study encompassed a comprehensive analysis of 7130 corneal transplants. Penetrating keratoplasty (PK) exhibited a significant decline from 95% (n = 206, 2004) to 11% (n = 46, 2023), while DMEK increased from 48% (n = 157, 2012) to 82% (n = 347, 2023). Fuchs endothelial dystrophy (FED) emerged as the dominant indication, witnessing a significant increase from 24% (2004, n = 39) to 72% (2023, n = 288). Conversely, keratoconus (KC) showed a reciprocal change from 25% (2004, n = 40) to 4% (2023, n = 17). PK demonstrated a noteworthy indication shift in descending order from Bullous Keratopathy (BK), FED, and KC in 2004 to KC, graft failure, corneal scars, and ulcers in 2023. Repeat keratoplasty following DMEK remained rare, but a discernible upward trend was observed for PK. Conclusion This retrospective analysis highlights significant changes in both keratoplasty indications and techniques over the past two decades. DMEK has emerged as a successful intervention for treating endothelial diseases, while PK retains its qualitative indispensability for a wide range of indications. Modern corneal banks are urged to maintain a robust supply of grafts for all surgical techniques in anticipation of potential increased demand in the future, particularly for repeat keratoplasties. Key messages What is known • Over the past two decades, lamellar keratoplasty procedures such as DSAEK and DMEK have increasingly replaced penetrating keratoplasty (PK) in clinical practice due to their improved outcomes and reduced complications for certain indications. New Findings • Our study reveals a significant shift in keratoplasty indications, with Fuchs endothelial dystrophy (FED) emerging as the predominant indication, increasing from 24% in 2004 to 72% in 2023, while keratoconus (KC) declined from 25 to 4% during the same period. • Penetrating keratoplasty (PK) has shown a marked decline in use, dropping from 95% of keratoplasties in 2004 to 11% in 2023, whereas DMEK has grown to represent 82% of procedures in 2023. • Despite the rise of DMEK, PK remains vital for a broad spectrum of indications, highlighting the necessity for corneal banks to maintain a versatile supply of grafts to meet diverse clinical needs, particularly in cases of repeat keratoplasties.

Giant corneal keloid following Descemet stripping automated endothelial keratoplasty for the treatment of corneal decompensation secondary to trauma

PurposeThis report aims to present a case of corneal keloid caused by chronic corneal insult after trauma and Descemet stripping automated endothelial keratoplasty (DSAEK).Case presentationA 35-year-old male with a history of vision loss in the right eye was referred to our hospital. The patient underwent Ahmed Glaucoma Valve Implantation to alleviate elevated intraocular pressure after ocular trauma to the same eye. One year following the procedure, the eye developed endothelial failure, leading to the performance of Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) with repositioning of the shunt tube. Upon initial examination, a well-circumscribed elevated white opaque lesion involving the central corneal surface of the RE was observed. Based on the patient’s clinical history, slit lamp examination, and UBM findings, the diagnosis of corneal keloid was established. Superficial keratectomy was performed. Histopathological analysis confirmed the diagnosis of corneal keloid. Following the procedure, BCVA improved slightly. However, 3 months later, the patient underwent a penetrating keratoplasty for visual rehabilitation.ConclusionCorneal keloids should be considered following any form of ocular trauma, particularly in cases involving ocular surgery. Diagnosing corneal keloids can sometimes be challenging due to the variety of potential differentials; however, by carefully evaluating the patient’s medical history and clinical presentation, we can effectively narrow down the differential diagnosis of corneal conditions.

Trends in infectious adverse events after elective optical keratoplasty (PK, EK, and ALK) - Ten years' analysis from an eye bank.

To report the clinical profile and donor characteristics of post-optical keratoplasty adverse events notified at an eye bank. Between January 2013 and December 2022, 37,041 donor corneas were utilized for keratoplasty, of which 16,531 were used for penetrating keratoplasty (PK), 12,171 for endothelial keratoplasty (EK), and 1356 for anterior lamellar keratoplasty (ALK). EK included 10,956 Descemet stripping automated endothelial keratoplasty (DSAEK) and 1215 Descemet membrane endothelial keratoplasty (DMEK). The adverse events reported within the first 6 weeks of optical keratoplasty were analyzed for donor-related parameters. A total of 41 (0.11%) recipients had post-keratoplasty infections. Of these, 33 occurred after EK (29 after DSAEK, and four after DMEK), two after ALK, and six after PK. The clinical presentation was keratitis alone in 16 eyes and associated with endophthalmitis in 25 eyes. The organisms isolated were gram-negative bacteria in 26 eyes, fungus in eight eyes, gram-positive bacteria in four eyes, mixed infection in five eyes, and microbiology inconclusive in seven eyes. The majority (78%) of the gram-negative infections were due to multidrug-resistant organisms. Most (88%) donor corneas were harvested from hospital premises. The most common cause of donor mortality was trauma. The median duration of presentation from surgery was 4.46 (range: 1-30) days. The death to preservation time was 4.18 (1.5-7.65) hours. The death to utilization time was 3 (2-4.7) days. The overall risk of infectious adverse events after keratoplasty was 0.11%, ranging from 0.08% to 0.36%. Most (80.4%) of the adverse events occurred after EK. The majority (78.9%) of the adverse events were of bacterial etiology, of which gram-negative infections (68.4%) were the most common. The trends and microbiological spectrum of organisms associated with infections should be thoroughly documented in eye banks to gain insights and formulate guidelines on the management of adverse events.

Assessment of Generative Artificial Intelligence (AI) Models in Creating Medical Illustrations for Various Corneal Transplant Procedures.

This study aimed to task and assess generative artificial intelligence (AI) models in creating medical illustrations for corneal transplant procedures such as Descemet's stripping automated endothelial keratoplasty (DSAEK), Descemet's membrane endothelial keratoplasty (DMEK), deep anterior lamellar keratoplasty (DALK), and penetrating keratoplasty (PKP). Methods: Six engineered prompts were provided to Decoder-Only Autoregressive Language and Image Synthesis 3 (DALL-E 3) and Medical Illustration Manager (MIM) to guide these generative AI models in creating a final medical illustration for each of the four corneal transplant procedures. Control illustrations were created by the authors for each transplant technique for comparison. A grading system with five categories with a maximum score of 3 points each (15 points total) was designed to objectively assess AI's performance. Four independent reviewers analyzed and scored the final images produced by DALL-E 3 and MIM as well as the control illustrations. All AI-generated images and control illustrations were then provided to Chat Generative Pre-Trained Transformer-4o (ChatGPT-4o), which was tasked with grading each image with the grading system described above. All results were then tabulated and graphically depicted. The control illustration images received significantly higher scores than produced images from DALL-E 3 and MIM in legibility, anatomical realism and accuracy, procedural step accuracy, and lack of fictitious anatomy (p<0.001). For detail and clarity, the control illustrations and images produced by DALL-E 3 and MIM received statistically similar scores of 2.75±0.29, 2.19±0.24, and 2.50±0.29, respectively (p=0.0504). With regard to mean cumulative scores for each transplant procedure image, the control illustrations received a significantly higher score than DALL-E 3 and MIM (p<0.001). Additionally, the overall mean cumulative score for the control illustrations was significantly higher than DALL-E 3 and MIM (14.56±0.51 (97.1%), 4.38±1.2 (29.2%), and 5.63±1.82 (37.5%), respectively (p<0.001)). When assessing AI's grading performance, ChatGPT-4o scored the images produced by DALL-E 3 and MIM significantly higher than the average scores of the independent reviewers (DALL-E 3: 10.0±0.0 (66.6%) vs. 4.38±1.20 (29.2%),p<0.001; MIM: 10.0±0.0 (66.6%) vs. 5.63±1.82 (37.5%), p<0.001). However, mean scores for the control illustrations between ChatGPT-4o and the independent reviewers were comparable (15.0±0.0 (100%) vs. 14.56±0.13 (97.1%); p>0.05). AI is an extremely powerful and efficient tool for many tasks, but it is currently limited in producing accurate medical illustrations for corneal transplant procedures. Further development is required for generative AI models to create medically sound and accurate illustrations for use in ophthalmology.

Blocking Air in the Filtering Bleb: Effects on Graft Adhesion After Descemet's Stripping Automated Endothelial Keratoplasty.

To evaluate the outcome of Descemet's stripping automated endothelial keratoplasty (DSAEK) with "blocking air" in the filtering bleb in patients with previous trabeculectomy. In total, 299 eyes in 283 patients who underwent DSAEK were retrospectively reviewed. Endothelial graft adhesion, intraocular pressure (IOP), and air volume in the anterior chamber with (group A) or without (group B) a filtering bleb were compared between the groups. Group A was divided into two subgroups according to the presence (group A1) or absence (group A2) of air in the filtering bleb; the same three factors were compared between the subgroups. The graft detachment rate was significantly higher in group A (14.3%) than in group B (6.5%) (p = 0.04). IOP was significantly lower in group A than in group B before surgery (p = 0.01), at the end of surgery (p = 0.04), at three hours (p < 0.001), and one week postoperatively (p = 0.02). The graft detachment rate did not significantly differ between groups A1 and A2. There were no differences in IOP at each follow-up time, whereas there was a statistically significant increase in IOP from the preoperative measurement to the end of surgery in group A1 (21.0±7.0 mmHg) compared with group A2 (14.2±8.6 mmHg) (p = 0.02). The presence of blocking air in the filtering bleb helps ensure increased IOP during the early postoperative period but had no significant effect on graft detachment rates.

Determining Risk Factors for Detachment After Endothelial Keratoplasties: Nine-Year Review of a Single Institution.

To determine roles of patient history, donor tissue characteristics, tissue preparation methods, and surgeon technique for graft detachment requiring rebubbling after Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) procedures. Retrospective analysis of all eyes undergoing first-time DSAEK or DMEK at the study institution between 2013 and 2022. Data were collected regarding recipients' history, donors' medical history, tissue preparation methods, intraoperative details, and postoperative clinical outcomes. Multivariate statistical analysis was conducted to identify risk factors for graft detachment necessitating rebubbling. Of 1240 eyes meeting inclusion criteria, 746 (60.2%) underwent DSAEK, and 494 (39.8%) underwent DMEK. DSAEK procedures had 12.5% rebubbling rate, whereas DMEK procedures had 18.4% rebubbling rate (P = 0.005). Sub50-DSAEK (<50 μm) grafts had 16.0% rebubble rate, whereas sub100-DSAEK (51-99 μm) and >100 μm DSAEKs had rebubble rate of 9.9% and 9.5%, respectively (P = 0.006). Significant risk factors for DSAEK graft detachment included history of retinal surgery (OR = 2.59), preloaded tissue (OR = 2.70), forceps insertion (OR = 2.33), use of sub50-DSAEK lenticules versus sub100-DSAEK (OR = 2.44) and >100 μm DSAEK (OR = 2.38) lenticules, and donor history of noninsulin-dependent diabetes mellitus (OR = 4.18). DMEK risk factors included recipient history of cancer (OR = 2.51) and use of higher SF6 gas concentration (OR = 1.09). Although rebubbled DMEK eyes had comparable refractive outcomes to nonrebubbled eyes (P >0.05), rebubbled DSAEK eyes had worse refractive outcomes at all time points (P < 0.05). Graft detachments in DSAEK and DMEK are influenced by various factors, including donor tissue characteristics, tissue preparation, and surgical technique. Identifying and understanding these factors can potentially improve postoperative outcomes.

Simple Modification of a DSAEK Carrier Enables Graft Insertion by Injection Without Compromising Endothelial Cell Viability.

We evaluate the quality and feasibility of preloading Descemet stripping automated endothelial keratoplasty (DSAEK) grafts into a modified EndoGlide Ultrathin system for graft injection. DSAEK grafts were prepared by experienced processing technicians at 2 separate locations, loaded into a modified EndoGlide Ultrathin, and placed in storage media. Grafts processed at one location were shipped cross-country overnight to the other location and were examined on arrival for positioning within the modified EndoGlide Ultrathin. All grafts were ejected and analyzed for endothelial cell loss (ECL) with calcein acetoxymethyl staining and FIJI segmentation. A subset of grafts was measured by optical coherence tomography for graft thickness 1 hour after cut, 1 hour after loading, and 1 day after loading. No grafts were displaced from the modified carrier over 3 shipping events (n = 9), and all grafts (n = 18) were successfully ejected. Grafts loaded into the modified carrier and ejected exhibited no more cell loss than grafts loaded into the standard carrier and removed by pull-through (14.0% ± 2.8% vs. 12.2% ± 3.4%, respectively, P = 0.24). Carrier modification skills can be successfully transferred as grafts loaded by a processing technician new to carrier modification were within the acceptable limit of 25% ECL for transplant DSAEK grafts. Graft thickness increased significantly (P < 0.05) between the postcut and 1-hour postload measurement and the postcut and 24-hour postload measurement. The EndoGlide Ultrathin can be modified to enable its use for graft injection while not compromising the ability to use the pull-through method for graft delivery. Preloaded DSAEK grafts swell significantly during the 24-hour storage period, and patterns of ECL may be linked to swelling.

Microkeratome versus manually dissected donor tissue for Descemet stripping endothelial keratoplasty: A randomized prospective study.

To compare the visual outcomes, postoperative complications, and graft asymmetry between precut and manually dissected donor tissues for Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet stripping endothelial keratoplasty (DSEK) procedures, respectively. Seventy eyes of 70 patients undergoing DSEK/DSAEK at a tertiary eyecare center in eastern India were included in this prospective randomized control study. The 70 eyes were divided equally into two groups. Group A (n = 35) and Group B (n = 35) underwent DSEK and DSAEK procedures, respectively. the operating surgeons prepared the manually dissected corneal grafts using lamellar dissectors. the eye bank technicians prepared the precut corneal grafts using a microkeratome. The patients were investigated postoperatively after 1 day, 1 week, 1 month, 3 months, and 6 months. The data were compared for visual outcomes [uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), spherical and cylindrical refraction, and spherical equivalent], incidence of postoperative complications, and pachymetry. The mean age was 56.5 (±17.8) years, and the male-to-female ratio was 1.3:1. The most common indications were pseudophakic bullous keratopathy (45.71%, 32/70), failed graft (32.86%, 23/70), and Fuchs' endothelial corneal dystrophy (10%, 7/70). The indications for surgery (P = 0.732) and donor (P = 0.258) and host pachymetry (P = 0.986) were comparable between both groups. There was no significant difference in change of UCVA, BCVA, and postoperative refraction (mean spherical refraction, P = 0.849; mean cylindrical refraction, P = 0.516; spherical equivalent, P = 0.518) between the two groups. Postoperative complications like graft detachment (P = 0.179), graft failure (P = 0.513), graft infiltrate (P = 0.428), and endophthalmitis (P = 0.493) were higher in the DSAEK group; however, the difference between the groups was insignificant. The graft asymmetry index was higher in DSAEK than in DSEK; the difference was significant till the 1-month follow-up (P = 0.005). The outcome was similar in both groups. Therefore, manual donor dissection can be an alternative for microkeratome-assisted dissection in low-resource centers and countries to achieve good results.

Comparative Analysis of Endothelial Cell Density and Central Thickness of Corneas Used for Endothelial Keratoplasty Procedures Using Various Storage Solutions.

The goal of this study was to evaluate the effect of various Food and Drug Administration-approved storage solutions on endothelial cell density (ECD) and central corneal thickness (CCT). We analyzed 6220 tissues used for endothelial keratoplasty procedures between January 2022 and June 2023 that were stored in either Life4°C, Optisol-GS, Kerasave, or Eusol-C under hypothermic conditions. We analyzed preprocessing CCT, success rate of meeting surgeon's Descemet stripping automated endothelial keratoplasty (DSAEK) thickness preferences, and preprocessing and postprocessing ECD. Results were analyzed using one-way analysis of variance, followed by multiple pairwise comparisons using the Tukey test. Mean preprocessing CCT was significantly lower in the Life4°C group (532 μm) than in Optisol-GS (549 μm), Kerasave (582 μm), and Eusol-C (589 μm) groups (all P < 0.0001). Preprocessing CCT in the Optisol-GS group was significantly lower than in Kerasave and Eusol-C groups (F (3, 3273) = 153.1, all P < 0.0001). Success rate of meeting surgeon DSAEK preferences was statistically similar among all 4 groups. Preprocessing ECD of the Kerasave group (2821 cells/mm2) was numerically higher than of the Eusol-C (2791 cells/mm2), Life4°C (2759 cells/mm2), and Optisol-GS (2768 cells/mm2) groups (P = 0.3232, 0.0004, and 0.0015, respectively). Corneal tissues stored in Kerasave and Eusol-C are significantly thicker than those in Life4°C and Optisol-GS. However, the success rate of meeting surgeon DSAEK preferences is similar among all 4 storage solutions.

A Functional and Immunologic Point of View on Corneal Endothelial Transplantation: A Systematic Review and Meta-Analysis.

Background: To systematically review and meta-analyze the immunologic aspects and outcomes of various endothelial keratoplasty (EK) techniques, specifically comparing Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK), Ultra-Thin Descemet's Stripping Automated Endothelial Keratoplasty (UT-DSAEK), and Descemet's Membrane Endothelial Keratoplasty (DMEK). Methods: Systematic review and meta-analysis. Main outcomes were the proportion of patients achieving a best spectacle-corrected visual acuity (BSCVA) of 20/20 at 6 months after keratoplasty, rejection rate one year after surgery, BSCVA at last follow up, and postoperative immunomodulating regimen. Results: A higher proportion of DMEK patients achieved a BSCVA of 20/20 after 6 months. UT-DSAEK and DMEK showed similar rejection rates with a lower risk of re-bubbling for UT-DSAEK (4% vs. 20%). Conclusions: DMEK showed faster visual recovery than UT-DSAEK but a similar rejection rate and long-term visual acuity. One-year postoperative slow tapering steroid regimen has a positive but not (yet) significant effect on rejection risk and visual outcomes.

Combined DSAEK With Cataract Surgery in a Patient With Fuchs Endothelial Corneal Dystrophy and Keratoconus After Corneal Crosslinking

Purpose: To report a combined Descemet stripping automated endothelial keratoplasty (DSAEK) with cataract surgery in a case of Fuchs endothelial corneal dystrophy (FECD) and keratoconus after corneal crosslinking combined with photorefractive keratectomy. Methods: We report a case of a 56-year-old woman with a history of subclinical keratoconus who underwent corneal crosslinking (CXL) plus 7 years ago. At presentation, the patient complained of blurry vision, which was more prominent in the morning over the past few years, and frequent changes of spectacle prescription ever since the initial treatment with CXL plus. Post-CXL plus corneal tomographies revealed progressive corneal flattening of 6.20 diopters (D) and 6.50 D in the right (OD) and left (OS) eye, respectively, in terms of mean keratometry values over a period of 7 years, which resulted in significant hyperopia. Corrected distance visual acuity (CDVA) at presentation was 20/50 in the OD and 20/200 in the OS. Slit-lamp examination revealed guttae (diagnosis of FECD) with associated posterior corneal edema and advanced nuclear sclerotic cataracts in both eyes. Combined DSAEK with cataract surgery was performed on the left eye. Results: One year after the combined procedure, CDVA improved to 20/25, with the correction of (−0.25, −4.25 × 25). Slit-lamp examination revealed a clear cornea without evidence of corneal edema or scarring. Corneal tomography indicated discontinuation of the corneal flattening in the left eye while the fellow eye continued to flatten. Conclusions: Combined DSAEK with cataract surgery provides an effective surgical option for patients with FECD after CXL plus procedures for keratoconus, offering fast visual rehabilitation and functional visual outcomes.

Changes in the Visual Field Test after Descemet Stripping Automated Endothelial Keratoplasty in Advanced Glaucoma.

Background: To evaluate changes in the visual field (VF) after Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with advanced glaucoma and previous trabeculectomy. Methods: Changes in VF, best-corrected visual acuity (BCVA), intraocular pressure (IOP), and number of glaucoma medications were analyzed before and after DSAEK in 19 eyes. The VFs were evaluated using the 10-2 program of the Humphrey Field Analyzer (HFA) and/or Goldmann perimetry (GP). Results: In nine eyes, the MD improved from -22.24 ± 6.5 dB to -18.36 ± 5.1 dB in HFA. In five out of nine eyes, postoperative MD improved >1 dB compared to preoperative MD. In GP testing, 10 out of 15 eyes showed an improvement, that is, greater than 20° in VF enlargement by the isopter of I-4e and/or new detection of a smaller or darker isopter. Overall, improvement in VF with the HFA and/or GP test was observed in 12/19 (63.2%) eyes after DSAEK. Postoperative BCVA improved by more than two lines in logMAR VA in 18 of 19 (94.7%) eyes. There were no significant differences between the preoperative and postoperative IOP and the number of glaucoma medications. Conclusions: DSAEK may produce subjective improvement in the visual field as well as improved visual acuity, even in advanced glaucomatous eyes.

Modified Method for Nanothin Descemet Stripping Automated Endothelial Keratoplasty.

The purpose of this study was to describe a method to achieve a high success rate for nanothin (NT, ≤50 μm) Descemet stripping automated endothelial keratoplasty (DSAEK) graft preparation using anterior chamber pressurizer (ACP) with a modified setting and evaluate its postoperative efficacy. A prospective cohort (study group) of 24 patients with corneal endothelial dysfunction was consecutively enrolled and received DSAEK grafts using the modified ACP method from December 2021 to May 2022. The control group included 24 historical patients who received DSAEK grafts using conventional ACP procedure. Central graft thickness (CGT), graft regularity (3-mm and 5-mm diameter zones), best spectacle-corrected visual acuity, and endothelial cell density (ECD) were compared between 2 groups. A 100% ultrathin (UT, ≤100 μm) DSAEK rate and 62.5% NT-DSAEK rate was achieved at 3 months postsurgery in the study group, with a 51.3 ± 14.8 μm CGT, while a 70.8% UT-DSAEK rate and 4.2% NT-DSAEK rate was achieved in the control group, with an 89.0 ± 15.4 μm CGT (P <0.001). At 3-month postoperative follow-up, the regularity of graft thickness was significantly better in the study group (central-to-peripheral thickness difference: P = 0.044 and 0.014 for 3-mm and 5-mm diameter zones, respectively, graft thickness uniformity: P <0.001 and 0.012, respectively). There was no statistical difference in the best spectacle-corrected visual acuity (P = 0.170) or ECD (P = 0.833) between 2 groups at 3-month postoperative follow-up. DSAEK grafts harvested using modified ACP method were thinner and more regular compared with the conventional ACP method.

Glaucoma drainage device implantation and cyclophotocoagulation in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty.

To compare the surgical outcomes of glaucoma drainage device implantation (GDI) and trans-scleral neodymium:YAG cyclophotocoagulation (CPC) in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty (DSAEK). This retrospective study on observational case series enrolled 29 patients who underwent DSAEK and posterior anti-glaucoma surgery (15 with GDI and 14 with CPC). The main outcome measures were intraocular pressure (IOP), glaucoma surgery success rate (defined as IOP of 6-21 mm Hg without additional anti-glaucoma operation), number of glaucoma medications, endothelial graft status, and best-corrected visual acuity (BCVA). The mean follow-up time was 34.1 and 21.0mo for DSAEK or glaucoma surgeries, both for the GDI and CPC groups. Both groups showed significant IOP reduction after glaucoma surgery. The GDI group presented a significantly higher success rate in IOP control than the CPC group (60% vs 21.4%, P=0.03). Both procedures significantly decreased the number of glaucoma medications (P=0.03). Forty percent and 57% of cases in the GDI and the CPC group, respectively, experienced endothelial graft failure during follow-up (P=0.36). Significantly worse BCVA after surgery was observed in the CPC group but not in the GDI group. Both GDI and CPC significantly decrease IOP in eyes with glaucoma after DSAEK. GDI is preferable to CPC in refractory glaucoma cases after DSAEK, as it manifests a significantly higher success rate for IOP control, similar endothelial graft failure rate, and relatively preserves BCVA than CPC.

Anatomical and functional results of femtosecond laser-assisted descemet stripping automated endothelial keratoplasty compared to microkeratome-assisted descemet stripping automated endothelial keratoplasty

Abstract Introduction: Femtosecond laser devices have been praised for their precision in corneal surgery; however, their performance in endothelial corneal graft surgery is still in development compared to the standard microkeratome technique. The purpose of this study is to describe the anatomical and functional differences in surgical outcomes between microkeratome (mk) and femtosecond laser (fs) assisted Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: This is an analytic, observational, pilot study of patients who underwent mk-DSAEK or fs-DSAEK. The data were obtained from the clinical records and the institutional transplant registry with a focus on graft measurements, survival, transparency, visual acuity and was further analyzed. Results: A total of 37 participants were included in the study with 70.3% (n = 26) of them being female and 29.7% of them being male (n = 11). Of the 37 eyes, 23 (62.2%) of them underwent mk-DSAEK and 14 (37.8%) of them underwent fs-DSAEK. Optimized femtosecond laser parameters are reported. There was a statistically significant difference in donor graft thickness which was thinner in the fs-DSAEK group with a median of 110 mm interquartile range (IQR) (102.25–117.5) versus a median of 233 mm IQR (219–243.75) P = 0.00 in the mk-DSAEK group. There were no significant differences for other variables between techniques. Conclusion: Fs-DSAEK allowed significantly thinner graft obtention in comparison to mk-DSAEK; however, there were no significant differences between mk-DSAEK and fs-DSAEK in terms of transparency, graft survival, or visual acuity.

Descemet stripping automated endothelial keratoplasty via a frown incision.

To assess the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) via a sclerocorneal frown incision. Retrospective comparative study. The outcomes of Descement stripping endothelial keratoplasty (DSAEK) were retrospectively compared between 36 patients (36 eyes) who underwent surgery via a 3.8-mm frown incision (frown incision group) and 20 patients (20 eyes) who underwent surgery via a 4.6-mm straight incision (straight incision group). In all patients, an NS Endo-Inserter was used as the graft inserter and the incision for a frown incision was via the superior sclerocorneal site and for the straight incision via the temporal cornea. DSAEK was performed by the standard technique, except for the incision. At 1 year after surgery, the two groups were compared with respect to the visual acuity, decrease of corneal endothelial cell density, the severity of corneal astigmatism (diopters), the number of sutures for wound closure, and intraoperative/postoperative complications. There was no significant difference between the two groups in terms of postoperative visual acuity, corneal astigmatism, and intraoperative/postoperative complications one year after surgery. On the other hand, the number of sutures required for wound closure was 1.13±0.42 in the frown incision group, whereas in the straight incision group, it was 3.20±0.40, showing a significant difference (P<0.001). In addition, there was no decreased corneal endothelial cell density associated with the reduction in incision width. A sclerocorneal frown incision is useful for performing DSAEK with an NS Endo-Inserter as it does not affect endothelial cell loss despite its short incision width.

Change in posterior astigmatism with degree of decentring graft in patients with descemet stripping automated endothelial keratoplasty

Aims/Purpose: Aligning the center of grafts in patients with Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) is difficult but important process. We investigated how the graft centring affected posterior astigmatism in patients.Methods: This study analysed 63 patients (63 eyes) who received DSAEK. Postoperative posterior astigmatism of patients was measured using pentacam, and the decentring of the graft was measured by using the distance between the patient's optic centre and the centre of the graft. Correlation analysis was performed on the relationship between graft decentring and posterior astigmatism. In addition, the spherical aberration of the cornea before and after surgery was analysed and investigated.Results: The average posterior astigmatism of the patients before surgery was 1.70 ± 2.25, and the average posterior astigmatism was 0.66D ± 0.43, confirming a decrease in posterior astigmatism after surgery (p &lt; 0.05). The mean decentring of graft was 0.45 ± 0.33 mm. Preoperative spherical aberration was 0.192 ± 0.53 and postoperative spherical aberration was 0.044 ± 0.37, and these differences were not statistically significant (p &gt; 0.05). Analysis of the relationship between graft decentring and postoperative posterior astigmatism showed no statistically significant correlation (p &gt; 0.05).Conclusions: In this study, no significant correlation was found between centring of the graft and posterior astigmatism after surgery. However, centring of the graft in DSAEK plays an important role in graft survival and postoperative prognosis, surgeons should pay attention to centring well during surgery.