Descemet Stripping Endothelial Keratoplasty Surgery Research Articles

Successful YAG Laser Treatment for Epithelial Ingrowth in Descemet Stripping Endothelial Keratoplasty Interface

Purpose: To present a case of epithelial ingrowth in the graft–host interface after Descemet stripping endothelial keratoplasty (DSEK) surgery that was successfully treated with an Nd:YAG Laser. Methods: A 79-year-old Caucasian female underwent a repeat DSEK 9 months after a prior DSEK graft rejection and subsequent failure. At her regularly scheduled 1-month follow-up visit, an asymptomatic dense white interface opacity was observed within the stromal interface, with an appearance consistent with epithelial ingrowth. The depth and location was confirmed by anterior segment optical coherence tomography. After initial observation, the opacity was noted to be growing over 2 months. The epithelial ingrowth cells were then treated with an Nd:YAG Laser. Results: The patient remained stable 12 months post laser treatment with no recurrence of epithelial ingrowth. Focal stromal pits were noted at the site of Nd:YAG Laser treatment within the DSEK graft stromal interface, but were not visually significant. Conclusions: Nd:YAG laser treatment is a safe and effective way to treat early-stage epithelial ingrowth in the interface after DSEK surgery.

Clinical outcomes of Descemet’s stripping endothelial keratoplasty using a manual or automated procedure at Undaan Eye Hospital Surabaya, Indonesia: with one-year follow up

Background: Endothelial keratoplasty (EK) is a selective lamellar corneal transplantation technique that replaces damaged endothelium while preserving the patient's corneal stroma. Donor graft preparation can be done using Descemet stripping endothelial keratoplasty (DSEK) or Descemet stripping automated endothelial keratoplasty (DSAEK). Research on EK in Indonesia is currently underreported, but it is crucial for developing strategies to treat corneal blindness in the future. This study aimed to present visual acuity, graft survival, and complications after DSEK or DSAEK at Undaan Eye Hospital Surabaya. Methods: This study involved 17 eyes, treated with DSEK or DSAEK surgery between 2017 and 2022. Patients with other ocular diseases and incomplete medical records were excluded. Best corrected visual acuity (BCVA) was documented before the surgery, and at 1 day, 1, 3, 6 months, and 1 year after. Data in this study were analyzed using multiple techniques, including Wilcoxon, Kaplan-Meier survival, and bivariate logistic regression analysis. Results: The postoperative mean BCVA significantly increased to 1.36 ± 0.57 logMAR (p=0.012) at 1 day, 1.02 ± 0.62 logMAR (p=0.002) at 1 month, 0.94 ± 0.66 logMAR (p=0.002) at 3 months, 0.72 ± 0.66 logMAR at 6 months (p=0.000), and 0.74 ± 0.74 logMAR (p=0.001) at 1-year compared to preoperative BCVA of 1.84 ± 0.39 logMAR. The graft could survive 100% within 1 day to 6 months and 76% within 1 year after surgery. Bivariate logistic regression showed donor origin had a statistically significant effect with p-value = 0.031 and odds ratio = 1.8, 95% confidence interval (CI) = 1.003 - 3.229. Corneal edema was the most common complication in the early and late postoperative periods. Conclusion: DSEK or DSAEK surgery is safe, effective, and viable. It shows good visual outcomes and becomes the most used EK treatment for corneal endothelial dysfunction.

Incidence and risk factors for glaucoma development and progression after corneal transplantation.

To assess the cumulative incidence and risk factors for glaucoma development and progression within 1-2 years following corneal transplant surgery. Retrospective cohort study. Patients undergoing penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK), Descemet stripping endothelial keratoplasty (DSEK), Descemet membrane endothelial keratoplasty (DMEK), Boston keratoprosthesis type I (KPro) implantation, or endothelial keratoplasty (DSEK or DMEK) under previous PK (EK under previous PK) at one academic institution with at least 1 year of follow-up were included. Primary outcome measures were cumulative incidence of glaucoma development and progression after corneal transplant, in patients without and with preoperative glaucoma, respectively. Risk factors for glaucoma development and progression were also assessed. Four hundred and thirty-one eyes of 431 patients undergoing PK (113), DALK (17), DSEK (71), DMEK (168), KPro (35) and EK under previous PK (27) with a mean follow-up of 22.9 months were analyzed. The 1-year cumulative incidence for glaucoma development and progression was 28.0% and 17.8% in patients without and with preoperative glaucoma, respectively. In a Cox proportional hazards analysis, DSEK surgery, KPro implantation, average intraocular pressure (IOP) through follow-up and postoperative IOP spikes of ≥30 mmHg were each independently associated with glaucoma development or progression (p < 0.04 for all). A significant proportion of patients developed glaucoma or exhibited glaucoma progression within 1 year after corneal transplantation. Patient selection for DSEK may partly explain the higher risk for glaucoma in these patients. Postoperative IOP spikes should be minimized and may indicate the need for co-management with a glaucoma specialist.

Gonioscopic angle evaluation and its correlation with graft survival and post-operative ocular hypertension in patients of Descemet's stripping endothelial keratoplasty.

To evaluate the gonioscopic changes in patients receiving Descemet's stripping endothelial keratoplasty (DSEK) without pre-existing ocular hypertension (OHT) and to report its correlation with post-surgery OHT, graft survival, and visual outcomes. Adult patients who underwent DSEK surgery from April 2014 to March 2018 with at least 2 years of follow-up were analyzed in this retrospective study. Demographic details, indication of DSEK, necessary anterior and posterior segment findings, and the post-DSEK OHT details were documented. A total of 58 patients (23 males and 35 females) with a mean age of 61.44 ± 8.8 years were included in the study. The most common etiology for DSEK surgery was pseudophakic bullous keratopathy in 47 eyes (81.03%). A total of 22.41% (13/58) eyes showed elevated intra-ocular pressure (IOP) following DSEK surgery. The most common cause of IOP elevation was steroid-induced OHT in seven eyes (12.06%). Gonioscopy examination revealed areas of peripheral anterior synechiae (PAS) in 17 (29.3%) eyes. OHT was found in 4/17 (23.5%) eyes having PAS. Three of these cases required trabeculectomy + goniosynechiolysis (GSL), and the fourth case required GSL alone to control IOP. These four cases also required repeat DSEK for failed grafts. The mean pre-operative best corrected visual acuity was 1.62 logMAR (range 1.17-1.77), which gradually improved to 0.79 logMAR (range 0.3-1.77) after 2 years (p < 0.00001). PAS was found to be an important factor associated with post-DSEK ocular hypertension in our study. OHT in PAS cases required definitive surgical treatments to control IOP. It adversely affected the graft survival and in turn affected visual outcomes also.

Peripheral iridectomy in descemet stripping endothelial keratoplasty: to do or not to do

Background: The purpose of the research was to study role of peripheral iridectomy (PI) in alleviating intra ocular pressure (IOP) spike due to retained air in patients of pseudophakic bullous keratopathy (PBK) undergoing descemet stripping endothelial keratoplasty (DSEK).Methods: A retrospective case review was done for patients undergoing DSEK at tertiary care eye centre from January 2017 to December 2018. Patients were divided into two groups based on whether they have undergone PI during DSEK surgery or not. Total 25 patients were included in the study. Group 1 consisted of 15 patients who hadn’t undergone PI and group 2 consisted of 10 patients who had undergone PI. Study of post-operative IOP spike was done in all cases and role of PI was evaluated. The primary outcome measure was role of PI in alleviating IOP rise. Statistical analysis was done using statistical package for social sciences (SPSS) statistical software version 26.0.Results: All patients in group 1 had developed an IOP spike on first post-operative day. The mean IOP on day 1 in group 1 patients were 29±2.9 mm of Hg (range 24-34 mm of Hg) and in group 2 were 19±1.49 mm of Hg (range 17-21 mm of Hg). Almost all patients in group 1 required anti glaucoma medications. Group 2 had better post-operative results as compared to group 1in terms of best corrected visual acuity (BCVA) as well as graft clarity. Three patients in group 1 had to undergo repeat DSEK.Conclusions: DSEK surgery causes increase in IOP post operatively due to retained air in anterior chamber (AC), probably causing pupillary block. PI definitely has some role in alleviating this IOP spike and increasing graft survival in long term.

A Multicenter Study Evaluating the Risk Factors and Outcomes of Repeat Descemet Stripping Endothelial Keratoplasty.

Descemet stripping endothelial keratoplasty (DSEK), currently the most common procedure for managing corneal endothelial dysfunction, may be repeated following DSEK failure from a variety of causes. This multicenter study reports the risk factors and outcomes of repeat DSEK. This was an institutional review board-approved multicenter retrospective chart review of patients who underwent repeat DSEK. Twelve surgeons from 5 Midwest academic centers and 3 private practice groups participated. The Eversight Eye Bank provided clinical indication and donor graft data. We also assessed the role of the learning curve by comparing cohorts from the first and second 5-year periods. A total of 121 eyes from 121 patients who underwent repeat DSEK were identified. The average age of the patients was 70 ± 12 years. The most common indication for repeat DSEK was late endothelial graft failure without rejection (58%, N = 63). Average preoperative and 12-month postoperative repeat DSEK corrected distance visual acuities were 20/694 and 20/89, respectively. Visual acuity outcomes, endothelial cell density, and cell loss did not significantly vary between the 2 cohorts. Initial graft rebubble rates for the first and second cohorts were 51% and 25%. The presence of glaucoma, prior glaucoma surgery, or a history of penetrating (full thickness) keratoplasty did not significantly affect visual outcomes. The median, mean, and range of intraocular pressures before repeat DSEK were 15.0, 15.7, and 6 to 37 mm Hg, respectively. Patients with higher intraocular pressures before repeat DSEK had improved postoperative corrected distance visual acuities. Repeating DSEK improves vision following failed or decompensated DSEK surgery. Higher preoperative repeat DSEK IOPs were associated with improved visual outcomes, and initial graft rebubble rates, which decreased over time, were likely due to surgeon experience.

Opacification of the Intraocular Lens After Descemet Stripping Endothelial Keratoplasty.

To report the incidence of opacification of the intraocular lens (IOL) after Descemet stripping endothelial keratoplasty (DSEK) in an academic ophthalmology clinic. In this retrospective case series, all patients who underwent DSEK between 2003 and 2013 were included. In 2008, the first patient presented with reduced vision as a result of opacification of the IOL in our clinic. The period between DSEK surgery and diagnosis of IOL opacification, Snellen corrected distance visual acuity before and after the appearance of IOL opacification, IOL specifications, and incidence of IOL exchange were assessed. A total of 160 eyes were operated on. Opacification was seen in 8 eyes (5%) and was diagnosed between 4 and 24 months after DSEK (mean, 9.6; SD, 6.3; range, 4-24 months). The mean Snellen corrected distance visual acuity was 0.6 (SD, 0.2; range, 0.2-0.8) before opacification and 0.3 (SD, 0.2; range, 0.02-0.6) after opacification of the IOL occurred. The IOL material was hydrophilic acrylic in all patients. In 4 eyes, IOL exchange was performed. Opacification of the IOL can be a vision-threatening late complication after DSEK and was seen in 8 of 160 eyes.

Descemet Stripping Endothelial Keratoplasty in Iridocorneal Endothelial Syndrome: Postoperative Complications and Long-Term Outcomes.

To determine the long-term outcomes of Descemet stripping endothelial keratoplasty (DSEK) in iridocorneal endothelial (ICE) syndrome. Retrospective review of a consecutive series of 4 eyes of 4 patients with ICE syndrome treated by DSEK surgery at a single institution with follow-up between 2 and 7 years. Mean follow-up after initial DSEK surgery was 55 months (range, 24-95 months). One eye required 1 repeat DSEK, and 2 eyes required 2 repeat DSEKs for a total of 9 DSEK operations across the 4 eyes. There were no graft dislocations and no primary graft failures. Seven of 9 grafts achieved a visual acuity of 6/12 or better by 6 months. Mean endothelial cell loss at 3, 6, 12, and 24 months was 55 ± 14%, 78 ± 5%, 80 ± 6%, and 83 ± 9%, respectively. Long-term graft survival was poor with 7 of 9 grafts suffering late endothelial failure by a mean of 18 ± 7 months (range, 12-28 months). Mean graft survival on Kaplan-Meier analysis was 19 months (95% confidence interval, 14-24 months). DSEK has the potential to provide good short-term visual outcomes in eyes with ICE syndrome. However, long-term graft survival beyond 2 years is poor because of late endothelial failure. Patients with ICE considering DSEK surgery should be warned about the high probability of repeat surgery.

Endothelial keratoplasty combined with cataract surgery or alone using polyethylene glycol hydrogel sealant for closure of corneal incisions

We present a surgical technique in which polyethylene glycol hydrogel is used to seal corneal incisions and maintain air in the anterior chamber. This technique was used in 11 eyes that had Descemet-stripping endothelial keratoplasty (DSEK). In 2 cases, DSEK was combined with cataract extraction and intraocular lens implantation. In all cases, the anterior chamber was well formed with no leakage and the donor graft remained attached following surgery. The use of polyethylene glycol hydrogel in DSEK and combined DSEK-cataract surgery may shorten surgery, decrease suture-induced corneal astigmatism, and prevent the need for suture removal. Neither author has a financial or proprietary interest in any material or method mentioned.

Correlation of Corneal Parameters and Visual Acuity Outcomes after Descemet Stripping Endothelial Keratoplasty

Purpose: To assess a potential relationship between visual acuity and corneal haze and thickness after Descemet Stripping Endothelial Keratoplasty (DSEK). Methods: Retrospective review of patients who underwent DSEK surgery with at least 3 months of post-operative follow up. Best-spectacle corrected visual acuity (BSCVA) and ultrasonic pachymetry were measured, and a Pentacam scan was performed for each study eye. Pentacam images were analyzed to determine the surface, host stromal, interface, and graft light scattering levels, which were used as markers of corneal haze. The central donor graft and overall central thicknesses were also measured from the Pentacam. Pearson correlation coefficients were calculated for each of the parameters and post-operative BSCVA to identify any potential associations. A multivariate analysis was performed using a linear regression model predicting visual acuity for each of the significant parameters from the univariate analysis adjusting for patient age and pre-operative acuity. Results: Results are reported for 41 eyes of 36 patients. Pearson correlation coefficients showed a statistically significant positive correlation between post-operative BSCVA and age (r=0.36, P=0.020), interface-stromal scattering (r=0.44, P=0.004), and interface-graft scattering (r=0.36, P=0.022). No correlation was found between BSCVA and surface scattering (r=0.04, P=0.78), host stromal scattering (r=-0.15, P=0.35), mean interface scattering (r=0.18, P=0.25), or graft scattering (r=-0.14, P=0.38). A trend towards a positive correlation between BSCVA and central donor graft thickness was noted on the exploratory scatter plot but this was not statistically significant (r=0.27, P=0.085). A linear regression analysis controlling for age and pre-operative acuity was performed for the above parameters and the correlation between BSCVA and the difference between interface and host stromal scattering remained statistically significant (β=0.00375, P=0.0195). Conclusion: Eyes with better BSCVA after DSEK tend to have lower differences between interface and stromal light scattering. However, no relationship was found between BSCVA and the other measures of corneal light scattering or corneal thickness. Additional prospective studies using techniques such as in vivo confocal microscopy to supplement the present methods could be performed to validate the relative impact of regional differences in corneal haze on visual acuity outcomes after DSEK.

Intraocular pressure after descemet stripping endothelial keratoplasty (DSEK)

To assess the incidence of elevated intraocular pressure (IOP) after descemet stripping endothelial keratoplasty (DSEK). Retrospective case series. From the start of the technique in our hospital in 2003 until the middle of 2010, 73 eyes underwent DSEK, of which 66 (90.5 %) had a clear graft 1 year after surgery. IOP data pre- and postoperatively were analyzed. Follow-up was 1-5 years (mean 3.8, SD 1.3). Mean age was 71 years (SD 11, range 43-89). Three eyes (4.5 %) had a history of glaucoma before DSEK. Mean pre-operative IOP was 12.4 mmHg (SD ± 4.3). Mean IOP 1 day post-operatively was 16.4 mmHg (±9.2). Mean IOP after 1 and 6 months, and 1, 3, and 5 years were, respectively, 13.9 (±5.3), 14.7 (±5.6), 14.2 (±5.4), 13.8 (±3.7), and 12.6 (±3.5). Seventeen percent (11 eyes) had a postoperative rise in IOP which needed medical or surgical intervention: 8 % (5 eyes) had a rise in IOP 1 day after DSEK, of which 1 underwent a trabeculectomy 7 months after DSEK surgery; 6 % (4 eyes) had a rise in IOP later in the postoperative period, which could all be managed medically; and 3 % (2 eyes) had increased IOP 1 day after DSEK and later in the postoperative period, both eyes underwent a trabeculectomy 5 and 24 months, respectively, after DSEK surgery. An increase in IOP was encountered in 17 % of DSEK patients. Checking the IOP in the short and long postoperative period is necessary.

Severe and Recurrent Interface Hemorrhage after Endothelial Keratoplasty

To report the occurrence and management of recurrent hemorrhage after Descemet stripping endothelial keratoplasty (DSEK) in a patient with pseudophakic bullous keratopathy. An 84-year-old Chinese woman on two oral antiplatelet drugs underwent DSEK in her left eye. Preoperative best-corrected visual acuity was 20/30 OD and 14/200 OS. Intraoperative bleeding was noted from the iris root. Surgery was completed uneventfully, and interface was thoroughly irrigated in the end. Slit lamp examination on the first postoperative day showed a dense interface hemorrhage and an intraocular pressure of 24 mm Hg. Repeat interface irrigation was carried out on postoperative day 4, but the hemorrhage appeared again on the following day. Donor lenticule was well apposed to the corneal stroma, and visual acuity was hand motions in the operated eye. No further surgical interventions were performed. Corticosteroid eye drops were continued four times a day in the operated eye, and the patient was advised weekly follow-up. Over the next 4 weeks, the interface blood gradually started to clear from the central cornea. At the end of 4 months postoperatively, the interface hemorrhage disappeared completely. A final best-corrected visual acuity of 20/80 was achieved. Specular microscopy revealed an endothelial cell density of 1375 cells/mm2. Interface hemorrhage is a known complication after DSEK surgery. Recurrent hemorrhage may be expected in patients on oral antiplatelet treatment. In cases without associated graft dislocation, conservative management can still result in good visual outcome.

Outcomes of Repeat Endothelial Keratoplasty in Patients With Failed Descemet Stripping Endothelial Keratoplasty

To report the outcomes of repeat endothelial keratoplasty (EK) in patients with failed Descemet stripping endothelial keratoplasty (DSEK). The clinical records of patients with failed DSEK who underwent repeat EK surgery at a single institution were reviewed. A total of 20 eyes of 20 patients (8 men and 12 women) were included. The mean age at initial DSEK surgery was 69.9 ± 11.9 years (range, 41-83 years). The causes of DSEK failure included progressive endothelial failure (8 eyes; 40%), primary graft failure (8 eyes; 40%), and endothelial rejection (4 eyes; 20%). The mean duration from primary DSEK to repeat EK was 13.1 ± 10.3 months (range, 2-33 months). Removal of the failed DSEK donor disc was performed in all eyes. Mean preoperative corrected distance visual acuity (logMAR) before repeat EK surgery was 1.76, and this improved to 0.5 (P < 0.001) at the final follow-up at 27 months. Three eyes had limited corrected distance visual acuity secondary to ocular comorbidities (age-related macular degeneration and advanced glaucomatous optic neuropathy). Repeat EK in patients with DSEK failure is an effective treatment modality. This is the preferred management option compared with penetrating keratoplasty because the advantages of EK surgery are maintained with repeat EK surgery.

Refractive Changes after Descemet Stripping Endothelial Keratoplasty: A Simplified Mathematical Model

To develop a mathematical model that can predict refractive changes after Descemet stripping endothelial keratoplasty (DSEK). A mathematical formula based on the Gullstrand eye model was generated to estimate the change in refractive power of the eye after DSEK. This model was applied to four DSEK cases retrospectively, to compare measured and predicted refractive changes after DSEK. The refractive change after DSEK is determined by calculating the difference in the power of the eye before and after DSEK surgery. The power of the eye post-DSEK surgery can be calculated with modified Gullstrand eye model equations that incorporate the change in the posterior radius of curvature and change in the distance between the principal planes of the cornea and lens after DSEK. Analysis of this model suggests that the ratio of central to peripheral graft thickness (CP ratio) and central thickness can have significant effect on refractive change where smaller CP ratios and larger graft thicknesses result in larger hyperopic shifts. This model was applied to four patients, and the average predicted hyperopic shift in the overall power of the eye was calculated to be 0.83 D. This change reflected in a mean of 93% (range, 75%-110%) of patients' measured refractive shifts. This simplified DSEK mathematical model can be used as a first step for estimating the hyperopic shift after DSEK. Further studies are necessary to refine the validity of this model.

Technique for Air Bubble Management During Endothelial Keratoplasty in Eyes After Penetrating Glaucoma Surgery

Our purpose was to develop a technique for maintaining air within the anterior chamber during endothelial keratoplasty in eyes that have previously undergone trabeculectomy or a glaucoma drainage implant. Whole human globes and rabbits underwent penetrating glaucoma surgery to develop the technique. Without the aid of any additional device or manipulation, continuing to inject air into the anterior chamber as it escapes through the sclerostomy or tube eventually fills the subconjunctival space and allows for back pressure. This allows for a full anterior chamber air fill and brief elevation of intraocular pressure. We employed this overfilling technique on 3 patients with previous incisional glaucoma surgery to perform successful Descemet stripping endothelial keratoplasty without complication. We recommend using the overfilling technique when performing Descemet stripping endothelial keratoplasty surgery in eyes with previous penetrating glaucoma surgery because it is a simple technique without the need for pre- or postoperative manipulation.

Confocal Microscopy After Descemet Stripping Endothelial Keratoplasty: A Case Report

To evaluate the clinical findings, visual outcomes, and confocal microscopic corneal features after Descemet stripping endothelial keratoplasty (DSEK) technique in Fuchs endothelial dystrophy. A 70-year-old female patient with pseudophakia and Fuchs endothelial dystrophy underwent small-incision DSEK surgery. Best spectacle-corrected visual acuity was 1.30 (20/400) logarithm of the minimum angle of resolution (Snellen) before treatment. Confocal microscopy (ConfoScan 4; Nidek Technologies, Padova, Italy) was performed before surgery, after 7 days, at 1 month, and 6 months after descemet stripping endothelial keratoplasty. Images of corneal structures, including endothelium, donor stroma, and recipient stroma, were obtained. Best spectacle-corrected visual acuity improved to 0.3 (20/40) logarithm of the minimum angle of resolution (Snellen) at 6 months. Endothelial cell density was 850 cells per square millimeter 6 months after surgery. Interface and donor stroma reflectivity were highest, 7 days postoperative showing progressive decrease over time. The DSEK procedure represents a promising alternative to conventional penetrating keratoplasty for patients with Fuchs endothelial dystrophy. Confocal microscopy is able to detect interface morphological characteristics, to improve therapeutic choice, and to understand the pathophysiology of visual recovery.

Histologic Evidence of Retained Fetal Layer of the Descemet Membrane After Presumed Total Removal for Endothelial Keratoplasty

This is, to our knowledge, the first report of histology after failed Descemet-stripping endothelial keratoplasty (DSEK) surgery in a patient. We describe the interface histology found in a case of donor nonadherence and subsequent graft failure in a patient after DSEK. An 83-year-old woman with a history of Fuchs dystrophy underwent DSEK surgery and subsequently underwent full-thickness penetrating keratoplasty (PKP) because of nonadherence of the donor disc and presumed graft failure. Specimens from the initial stripping of the Descemet membrane, the failed donor disc, and the full thickness of the patient's remaining cornea containing the recipient bed after her DSEK and PKP procedures were histologically evaluated by light microscopy. Microscopic examination of the initial stripped recipient Descemet membrane revealed a "delamination" of the Descemet membrane involving the fetal layer. After PKP, histopathologic study of the recipient button revealed residual fetal Descemet membrane retained on the recipient DSEK interface. Examination of the failed donor disc showed healthy tissue. In DSEK surgery, there are multiple reasons that the donor graft button may fail to adhere to the recipient posterior corneal surface. In this instance, histologic study revealed that the Descemet membrane was split by the stripping, and the fetal layer of the Descemet membrane was retained on the central part of the patient's posterior cornea. Despite histologically normal donor endothelial cells, the inability of the donor tissue to adhere may have been caused by the coating of the central recipient bed with retained fetal Descemet membrane.

Histology of Dislocations in Endothelial Keratoplasty (DSEK and DLEK)

Laboratory studies were performed to evaluate the histologic differences between the recipient bed after deep lamellar endothelial keratoplasty (DLEK) surgery and Descemet's-stripping endothelial keratoplasty (DSEK) surgery. Relevant new surgical strategies to prevent dislocation in DSEK surgery were initiated in our first 100 consecutive clinical cases. Ten pairs of cadaver eyes had a DLEK in 1 eye and a DSEK in the fellow eye, and the posterior stromal surface was analyzed by scanning electron microscopy at x50 magnification. Based on the findings in these cadaver eyes, our DSEK procedure was modified to include surgical roughening in the peripheral recipient bed in 100 consecutive eyes. One hundred percent of these eyes were followed for at least 60 days after surgery to determine the rate of donor dislocation. In all 10 pairs of cadaver eyes, the DSEK stromal interface showed a smoother surface than DLEK eyes, without the presence of cut stromal fibrils. The DLEK surface was less smooth than the DSEK eyes, but with the presence of uniformly cut fibrils over the entire surface. Subsequent surgical modifications to the DSEK procedure to include scraping and roughening of the recipient peripheral bed in humans resulted in only a 4% (4/100) dislocation rate of the donor tissue into the anterior chamber. One of these 4 dislocated donors was seen on the first postoperative day and was the only primary graft failure in the series. The other 3 cases were fully attached on the first postoperative day with no interface fluid, but they dislocated later on postoperative days 2, 3, and 4. The high rate of dislocation of the donor disc in DSEK may be caused by the absence of recipient stromal fibrils to initially bind to the donor stromal fibrils. Clinical success with a surgical technique of selectively scraping the peripheral recipient bed to promote donor edge adhesion (while leaving the central bed untouched for vision) may aid in the prevention of donor dislocation in DSEK surgery. Reduction of dislocation in DSEK surgery has also been associated with a reduced rate of iatrogenic primary graft failure (PGF) to 1%.