Descemet Stripping With Endothelial Keratoplasty Research Articles

Graft stability after endothelial keratoplasty.

BACGROUND/AIM: Techniques for replacing the corneal endothelium have been improved. The host-graft interface is the key to graft adhesion and visual recovery. The aim of this study was to establish graft stability after Descemet stripping with endothelial keratoplasty (DSEK), compare it to the graft stability after endothelial keratoplasty with the intact posterior corneal layers (nDSEK) in the rabbit cornea, and to investigate the nature of wound healing. Adult white rabbits (n = 20) were divided in two experimental groups: ten rabbits underwent monocular DSEK, and ten rabbits underwent endothelial keratoplasty without Descemet stripping (nDSEK). On the second postoperative day a horizontal dislocation of the graft was tried using the Lindstrom roller in each animal. Corneas were processed for the light microscopy study. Rolling the Lindstrom instrument over the corneal surface did not cause horizontal dislocation in any of the operated eyes. In the DSEK group light microscopy revealed the lack of inflammation and fibrosis at the clearly distinctive donor-recipient interface (DRI). Retrocorneal membrane was found in two eyes. In nDSEK group, the host Descemet's membrane (DM) was intact without endothelial cells, with good graft apposition, without inflammation, fibrosis, or retrocorneal membrane. This study suggests that there is no difference in graft stability in DSEK compared to nDSEK in rabbit corneas. Wounds healed at DRI by hypocellular scarring only in both experimental groups.

Intraocular Pressure Measured With Goldmann, Noncontact, Schiøtz, and Dynamic Contour Tonometry After DSEK

To compare intraocular pressure (IOP) measurements with various tonometers after Descemet stripping with endothelial keratoplasty (DSEK) and to measure the change in IOP during the follow-up period. A total of 28 eyes of 28 patients having undergone DSEK for bullous keratopathy by a single surgeon from June 2008 to November 2011 were enrolled in this study. IOP values, which were measured with Goldmann applanation tonometry (GAT), noncontact tonometry (NCT), Schiøtz indentation tonometry (SIT), and dynamic contour tonometry, and central corneal thickness values were reviewed and analyzed up to 3 years after DSEK (range, 1 months-3 years). Different tonometers measured the IOP after DSEK differently. NCT showed the lowest IOP values, although GAT and NCT showed the smallest intertonometry difference. SIT showed extreme variation in IOP measurements. The dynamic contour tonometry values were higher than those of NCT or GAT. Central corneal thickness did not correlate with any of the IOP measurements. Only 2 episodes of IOP elevation greater than 30 mm Hg were detected. IOP measured with NCT or GAT may be lower than the real IOP after DSEK. SIT is not a reliable tonometry measurement after DSEK. Additional IOP measurements using different methods and consideration of other clinical signs may be the best method for ocular evaluation after DSEK.

Corneal Haze Determined by Confocal Microscopy 2 Years After Descemet Stripping With Endothelial Keratoplasty for Fuchs Corneal Dystrophy

To quantify corneal light scatter and its relationship to vision after Descemet stripping with endothelial keratoplasty (DSEK). Eyes with Fuchs corneal dystrophy were examined before and 1, 3, 6, 12, and 24 months after DSEK. Outcome measures were high- and low-contrast visual acuity, contrast sensitivity, and forward light scatter. Corneal reflectivity (backscatter), expressed in scatter units (SU), was quantified using in vivo confocal microscopy. Comparing 49 study eyes with 35 normal eyes, the mean (SD) corneal subepithelial layer was more reflective than normal before (2325 [613] vs 1208 [287] SU, P<.001) and through 24 months after DSEK (1760 [432] SU, P<.001). Interface reflectivity remained higher than in normal stroma through 24 months (1228 [287] vs 827 [188] SU, P<.001). At 1 year, forward light scatter correlated with subepithelial reflectivity (r=0.28, P=.01) but not interface reflectivity. Recipient age was correlated with improvement in subepithelial reflectivity at 12 months (r=–0.41, P=.01, 34 eyes) and 24 months (r=–0.36, P=.02, 26 eyes) after DSEK, and the improvement of subepithelial haze in eyes of participants aged 62 years or younger was correlated with improvement in forward light scatter at 12 months (r=0.52, P=.008) and 24 months (r=0.62, P=.004). In Fuchs corneal dystrophy, the corneal subepithelial region is a more important source of forward light scatter than the DSEK interface. Subepithelial haze improves more in younger patients and is associated with improvement in forward light scatter. Visual function after DSEK is affected by residual haze in the anterior host cornea more so than the surgical interface. Haze, which likely is experienced as glare disability, improves after surgical intervention but improves more in younger patients.

Endothelial Image Quality After Descemet Stripping With Endothelial Keratoplasty: A Comparison of Three Microscopy Techniques

To determine corneal endothelial image quality after descemet stripping with endothelial keratoplasty (DSEK) as recorded by three different microscopy techniques: noncontact specular microscopy, noncontact confocal microscopy, and contact confocal microscopy. The corneal endothelium of 52 eyes after DSEK and 20 normal eyes was photographed by the three microscopy techniques during a single encounter. Image quality was graded by two masked observers according to the proportion of countable contiguous cells visible in the image; disagreements in grading were adjudicated by a third observer. Endothelial cell density was compared among the three techniques. After DSEK, image quality was better with contact confocal microscopy than with noncontact confocal microscopy (P = 0.01) and better with noncontact confocal microscopy than with noncontact specular microscopy (P < 0.001). With noncontact specular microscopy, 42% of images after DSEK were uncountable. In normal corneas, all images were countable, and although image quality was better with contact confocal microscopy than with noncontact confocal (P = 0.03) and noncontact specular (P < 0.001) microscopy, the difference was not clinically important. For countable images, the mean differences in endothelial cell density between microscopy methods were close to zero after DSEK and in normal corneas. Confocal optics enable better image quality of the corneal endothelium in corneas with high backscatter, such as those after DSEK. When images were countable, there was a good agreement for endothelial cell density measured by the three microscopy techniques.

Making the transition from PK to DSEK: experiences during the learning curve

To report our experiences during the transition from penetrating keratoplasty to Descemet's stripping with endothelial keratoplasty (DSEK). All patients undergoing DSEK during the period of April 2008 to April 2009 were included in this study. All grafts were attached and clear at both the 6- and 12 -month follow-up examinations. Mean best-corrected visual acuity was 0.6 at 6 months and 0.7 at 12 months for patients without other ocular comorbidity. With adequate attention to detail, DSEK seems to be a safe and successful treatment for corneal endothelial disease, also during the surgeon's learning curve.

One cornea for two patients: case report

Case reporting the use of one donor cornea for two transplantation procedures: deep anterior lamellar keratoplasty (DALK) in a case of an imminent corneal perforation caused by herpetic stromal necrosis, and Descemet stripping with endothelial keratoplasty (DSEK) in an eye with pseudophakic bullous keratopathy (PBK). Descemet's membrane (DM), denuded by stromal necrosis, served as the starting point for dissection plane and creation of the recipient bed for DALK. The next steps were excision of the diseased stroma along the edge of trephination, and transplantation of a 400-450 microm thick, manually dissected lamellar graft. The remaining posterior layers of the donor cornea, 100-150 microm thick, were used as a graft in the DSEK procedure for PBK. The integrity of the globe was saved, and best-corrected visual acuity (BCVA) of 20/40 was reached after DALK in the eye with an imminent corneal perforation. A subnormal central corneal thickness (CCT) of 430 microm did not interfere with corneal shape (43.50 x 45.50 D) and function. The graft remained attached and clear after DSEK in the eye with PBK, with BCVA of 20/30 and a CCT of 653 microm. One donor cornea can be used for two lamellar keratoplasties, DALK and DSEK. Although the described obstacles may prevent this approach from becoming widely used, it may prove useful when one is confronted with a need for an urgent anterior lamellar keratoplasty, a long list of cases for DSEK, and a shortage of donor corneas.

Three cheers for DSEK (Descemet's stripping with endothelial keratoplasty)!

Three cheers for DSEK (Descemet's stripping with endothelial keratoplasty)!

Intraocular pressure changes following Descemet’s stripping with endothelial keratoplasty

To evaluate the postoperative changes in intraocular pressure (IOP) following Descemet's stripping with endothelial keratoplasty (DSEK). A retrospective chart review of 45 eyes that underwent DSEK for the treatment of corneal edema induced by aphakic or pseudophakic bullous keratopathy (ABK/PBK) and Fuchs' endothelial dystrophy. A mean baseline IOP was obtained at three different preoperative visits using Tono-Pen XL tonometer. This baseline pressure was compared to IOPs obtained at postoperative months 1, 3, 6 and 12. Intraocular pressure increased from a mean preoperative value of 15.6 +/- 4.2 mmHg to 15.9 +/- 5.8 mmHg in the first postoperative month; 17.0 +/- 5.7 mmHg at 3 months; 18.1 +/- 6.2 mmHg at 6 months and 16.8 +/- 4.7 mmHg at 1 year. These pressure differences were considered statistically significant, p = 0.0074 (repeated measures ANOVA). Eyes diagnosed with ABK/PBK (n = 20) showed a significant rise in IOP only noted after the 3(rd) month that peaked at 6 months, p = 0.0001 (repeated measures ANOVA). A subgroup of patients with a diagnosis of Fuchs' endothelial dystrophy (n = 25), showed no statistically significant changes in IOP at 1 year follow-up; p = 0.9103 (repeated measures ANOVA). In a subgroup of eyes with a diagnosis of glaucoma or ocular hypertension (n = 13), a statistically significant increase in IOP was noted after 1 year of follow-up. Mean IOP raised from a preoperative mean value of 16.0 +/- 3.7 mHg to 19.0 +/- 5.3 mmHg at 1 year; p = 0.0074 (repeated measures ANOVA). DSEK induced statistically significant IOP increases in the early postoperative period with a tendency to higher pressures after the 3(rd) month of follow-up. Patients with a preoperative diagnosis of Fuchs' endothelial dystrophy did not show a statistically significant increase in IOP compared to a baseline mean preoperative value. The difference between statistically significant and clinically significant IOP increase is yet to be established.

Confocal microscopy study of donor–recipient interface after Descemet's stripping with endothelial keratoplasty

AimTo evaluate the in vivo confocal microscopic corneal features seen in patients who underwent Descemet's stripping with endothelial keratoplasty (DSEK) and to correlate these findings with the postoperative best spectacle-corrected...

The Effect of Corneal Light Scatter on Vision After Descemet Stripping With Endothelial Keratoplasty

To establish an association between corneal light scatter and vision after Descemet stripping with endothelial keratoplasty (DSEK). Twenty eyes of patients with Fuchs endothelial dystrophy were examined before and at 1, 3, and 6 months after DSEK in a prospective study. Main outcome measures were high-contrast best-corrected visual acuity, intraocular forward light scatter, and corneal backscatter. One eye was excluded because of endothelial graft failure within 1 month. Best-corrected visual acuity improved at 3 months after DSEK (mean [standard deviation], 0.31 [0.20] logarithm of the minimum angle of resolution [logMAR]; Snellen equivalent, 20/41) relative to before DSEK (0.46 [0.26] logMAR; Snellen equivalent, 20/58; P = .03). Posterior corneal backscatter decreased 1 month after DSEK (P < .001), but backscatter from the anterior, middle, and posterior cornea did not return to normal by 6 months (P < or = .02). At 6 months, best-corrected visual acuity correlated with recipient age (r = 0.84, P < .001) and with intraocular forward light scatter (r = 0.67, P < .001); forward light scatter also correlated with recipient age (r = 0.67, P < .001). Six months after DSEK, corneal light scatter remained greater in eyes with Fuchs endothelial dystrophy than in normal eyes and correlated with recipient age and visual acuity. Recipient age might be the best preoperative predictor of vision after DSEK.

Graft rejection episodes after Descemet stripping with endothelial keratoplasty: part one: clinical signs and symptoms

Aim:To investigate characteristics of initial immunological graft rejection after Descemet stripping with endothelial keratoplasty (DSEK).Methods:The incidence, symptoms and clinical characteristics of initial immunological graft rejection episodes were analysed retrospectively in...

Graft rejection episodes after Descemet stripping with endothelial keratoplasty: part two: the statistical analysis of probability and risk factors

Aim:To investigate risk factors and probability of initial immunological graft rejection episodes after Descemet stripping with endothelial keratoplasty (DSEK).Methods:Outcomes of 598 DSEK cases from a single tertiary referral centre were...

Scattered light and visual acuity after Descemet‐stripping with endothelial keratoplasty

Abstract Purpose The lamellar interface and anterior host cornea after posterior lamellar keratoplasty scatter more light than normal corneas. In this study, we examined the relationship between forward‐scattered light, back‐scattered light, and visual function after Descemet‐stripping with endothelial keratoplasty (DSEK). Methods Nineteen eyes of 17 patients received DSEK with the donor prepared by a microkeratome; all eyes were pseudophakic postoperatively. Eyes were examined before and at 6 months after surgery. Best‐corrected high‐contrast visual acuity (HCVA) was measured by electronic‐ETDRS and low‐contrast visual acuity (LCVA) was measured by using a 10% contrast chart. Intraocular forward light scatter was measured by using a stray‐light meter (Oculus C‐Quant) and back‐scattered light was measured in anterior, middle, and posterior thirds of the cornea by using a custom slit‐lamp scatterometer. Generalized estimating equation models were used for statistical analyses to account for possible correlation between fellow eyes of the same patient. Results HCVA improved from 0.46 ± 0.26 logMAR (20/58) before DSEK to 0.28 ± 0.15 logMAR (20/38) at 6 months (p&lt;0.001, n=19), and LCVA improved from 0.88 ± 0.26 logMAR (20/152) before DSEK to 0.62 ± 0.19 logMAR (20/83) at 6 months (p&lt;0.001). At 6 months after DSEK, forward light scatter correlated with HCVA (r=0.67, p&lt;0.001) and with LCVA (r=0.75, p=0.006). Back‐scattered light from the anterior, mid, or posterior cornea were not correlated with forward scatter or with HCVA or LCVA (p&gt;0.2). Conclusion Visual outcomes after DSEK are associated with the forward‐scattered light induced by the host cornea and lamellar interface, although not with the back‐scattered light visible on slit‐lamp examination.

Endothelial Cell Loss after Descemet Stripping with Endothelial Keratoplasty: Influencing Factors and 2-Year Trend

To identify factors correlated with early endothelial cell loss after Descemet stripping with endothelial keratoplasty (DSEK) and to document cell loss over a 2-year period. Cross-sectional and longitudinal retrospective analyses. A series of 263 eyes in 216 patients who were treated with DSEK and were examined at the same center after surgery. Six-month endothelial cell density (ECD) measurements were analyzed by multivariate analysis of variance to identify preoperative, operative, and postoperative factors that significantly influenced early cell loss. In addition, ECD measurements were compared longitudinally at 6, 12, and 24 months after grafting. Central ECD after transplantation. Mean ECD was 2000+/-550 cells/mm(2) 6 months after DSEK, representing cell loss of 34+/-18%. Factors associated with lower 6-month cell loss were use of single-point fixation forceps that compressed the donor tissue only at the tip during graft insertion (P = 0.025) and absence of any secondary donor reattachment procedure (P = 0.035). Six-month cell loss also was significantly less when DSEK was performed as a combined procedure; in combined cases, the graft was inserted through a clear corneal incision, whereas in standard cases, it was inserted through a scleral tunnel incision, which likely exerted more compression. Cell loss was comparable with manual and microkeratome donor dissection techniques (P = 0.91). Postoperative ECD was correlated positively with donor ECD (P<0.0001) and was correlated inversely with donor age (P<0.0001), although these donor characteristics explained only 10% of the total variance in 6-month ECD. Factors not significantly correlated with 6-month ECD or cell loss included donor death-to-preservation time (range, 1-22 hours; P = 0.45), donor death-to-use time (range, 2-8 days; P = 0.86), and recipient demographics. In 34 DSEK eyes analyzed longitudinally, mean ECD was 3100+/-250 cells/mm(2) before surgery, 2000+/-540 cells/mm(2) at 6 months, 1900+/-480 cells/mm(2) at 1 year, and 1800+/-490 cells/mm(2) at 2 years. Cell loss 6 months and 1 year after DSEK was higher than in a recent penetrating keratoplasty series performed at the same center, consistent with more donor tissue manipulation in DSEK. Cell loss was reduced with certain variations in surgical technique.

Descemet Stripping With Endothelial Keratoplasty for Treatment of Iridocorneal Endothelial Syndrome

To describe use of Descemet stripping with endothelial keratoplasty (DSEK) to treat corneal edema associated with iridocorneal endothelial (ICE) syndrome. In this retrospective, consecutive, interventional case series, the corneal endothelium was selectively replaced by the DSEK technique in eyes with ICE syndrome. Three eyes were treated at 1 center between June 2005 and July 2006. Descemet membrane and endothelium were stripped from the recipient and an 8- or 8.5-mm-diameter donor button consisting of posterior stroma and healthy endothelium was folded and implanted through a 5-mm incision. An air bubble was used to press the donor tissue against the recipient cornea, allowing it to attach without sutures. In 1 case with extensive peripheral anterior synechiae (PAS), after the PAS were broken, the anterior chamber was shallow, so a temporary anchor suture was placed in the peripheral edge of the donor tissue to help ensure that it would unfold in the correct orientation. DSEK successfully resolved corneal edema in 3 male patients with unilateral ICE syndrome who were 47 to 67 years of age. Follow-up ranged from 1 to 14 months. Best spectacle-corrected visual acuity at the most recent visit was 20/20 to 20/30, with a mean refractive cylinder of 1.2 D. Selective replacement of dysfunctional endothelium with DSEK can successfully treat corneal edema and associated visual loss and pain caused by ICE syndrome. Visual recovery is rapid and refractive changes are minimal compared with replacement of the full corneal thickness with a traditional penetrating keratoplasty.

Advanced Glycation End Products and Receptors in Fuchs’ Dystrophy Corneas Undergoing Descemet’s Stripping with Endothelial Keratoplasty

To describe the histopathologic features of Descemet's membrane (DM) obtained from Fuchs' endothelial corneal dystrophy (FECD) corneas undergoing Descemet's stripping with endothelial keratoplasty (DSEK) and to assess the presence of advanced glycation end products (AGEs) and their receptors in FECD endothelium and DM. Prospective observational case series. Five eyes of 5 patients undergoing DSEK for FECD and 4 normal control eyebank corneas. Descemet's membrane and corneal endothelium from FECD patients undergoing DSEK were assessed with hematoxylin-eosin staining and immunohistochemistry for AGEs, receptor of AGEs (RAGE), and galectin 3 (AGE-R3). Histopathologic abnormalities and presence of AGEs, RAGE, and AGE-R3 in DSEK specimens. Histopathologic assessment of DSEK specimens from FECD patients disclosed thickening and nodularity of DM and loss of endothelial cells. Immunohistochemical staining of FECD DM for AGE, RAGE, and AGE-R3 showed an abundance of AGEs in the anterior portion of DM, mild positivity for RAGE, and moderate positivity for AGE-R3. Tissue quality after DSEK is sufficient to allow detailed histopathologic analysis. The presence of AGEs, RAGE, and AGE-R3 in DM and corneal endothelium of FECD patients supports a link between accumulation of AGEs, oxidative stress, and corneal endothelial cell apoptosis in the pathogenesis of FECD.

Descemet Stripping with Endothelial Keratoplasty

Corneal transplants are the oldest, most common, and arguably the most successful form of solid tissue transplantation in the world. Since the first full-thickness corneal transplant was performed in 1905 by Eduard Zirm, penetrating keratoplasties (PKs) have been performed to provide a clear, optically functional visual pathway to improve vision, provide tectonic support for an eye, alleviate pain from corneal decompensation, and eliminate an infection in danger of spreading intraocularly. Corneal disease processes requiring transplantation may involve either the anterior cornea (e.g. scars, ectasias) or the posterior cornea (e.g. bullous keratopathy, endothelial dystrophies). In the past 10 years, a new and evolving alternate technique, known as Descemet stripping with endothelial keratoplasty (DSEK), has come about in which only the diseased portion of the posterior cornea is replaced by healthy posterior donor tissue. Important advantages of DSEK over PK are that the host cornea remains structurally intact and more resistant to injury, intra-operative and post-operative suture management issues are non-existent, and concerns about late wound dehiscence after suture removal are virtually absent. Furthermore, the risk of expulsive intra-operative suprachoroidal hemorrhage is minimized because the wound is small and can be closed quickly. Of importance to the patient are the rapid visual recovery, minimal induced astigmatism, and relative safety of topical anesthesia. This article will provide a brief overview of DSEK, an elegant technique for selective replacement of dysfunctional corneal endothelium that is constantly evolving and rapidly revolutionizing corneal transplantation.

Descemet’s Stripping with Endothelial Keratoplasty: Comparative Outcomes with Microkeratome-Dissected and Manually Dissected Donor Tissue

To compare outcomes with 2 donor dissection methods for Descemet's stripping with endothelial keratoplasty (DSEK). Retrospective, comparative, nonrandomized case series. Three hundred thirty consecutive transplants, 114 with manually dissected and 216 with microkeratome-dissected donor tissue. Donor posterior stroma/endothelium was transplanted, after stripping recipient Descemet's membrane/endothelium and dissecting the donor tissue by hand or with a microkeratome. Incidences of donor perforation and donor detachment were compared for all eyes. Visual and refractive outcomes were compared for the first 100 consecutive eyes in each group. Visual recovery was faster with microkeratome-dissected donor tissue, as evidenced by statistically better best spectacle-corrected visual acuity (VA) in that group 1 month after surgery (P = 0.015). Best spectacle-corrected VA was statistically comparable for the 2 groups preoperatively and 3 and 6 months postoperatively. Best spectacle-corrected VA was not correlated significantly with postoperative central corneal thickness (P = 0.25). Corneal thickness was significantly higher in the microkeratome group (690+/-77 mum, compared with 610+/-62 mum after hand dissection; P<0.0001). Mean refractive astigmatism was 1.5 diopters (D) preoperatively and 6 months postoperatively in both groups. Spherical equivalent refraction did not change in the microkeratome group (P = 0.64) but increased by 0.66 D in the hand dissection group (P = 0.0007). Methods designed to remove fluid from the donor/recipient graft interface ultimately reduced the detachment rate to <1% (1 in the last 140 cases). No donor perforations occurred in 216 microkeratome dissections, compared with 5 in 114 hand dissections (P = 0.002). Microkeratome dissection reduced the risk of donor tissue perforation, provided faster visual recovery after DSEK, and did not alter the refractive outcome.

Descemet's stripping with endothelial keratoplasty in 200 eyes

To describe early challenges and techniques to promote donor tissue adherence in Descemet's stripping with endothelial keratoplasty (DSEK). Price Vision Group, Indianapolis, Indiana, USA. The first 200 consecutive cases of DSEK performed by a single surgeon were analyzed retrospectively. Follow-up was 7 to 20 months for 124 eyes and 2 to 6 months for 76 eyes. The surgical technique consisted of stripping Descemet's membrane and endothelium from the recipient's central cornea and transplanting an 8.0 to 9.0 mm disc of donor endothelium and posterior stroma through a 5.0 mm incision, with sutures used only to close the incision. The most frequent challenge was inadequate donor attachment. Using techniques to remove fluid from the donor-recipient graft interface, the donor detachment rate in the last 64 cases was 6%, with half attributable to patient eye rubbing. Detached grafts were reattached by injecting an air bubble to press the donor against the recipient cornea. There were 7 primary graft failures, with only 1 occurring in the second 100 cases, which primarily used microkeratome-dissected donor tissue. Other complications were infrequent and included pupillary block glaucoma (1), aqueous misdirection syndrome (1), and cataract development in 2 of 27 phakic eyes. The DSEK procedure was performed safely before and after laser in situ keratomileusis (1 each). Early outcomes in the initial 200 consecutive DSEK procedures suggest the technique provides significant advantages over penetrating keratoplasty, including more rapid healing, more predictable refractive outcomes, and better retention of corneal strength and integrity. Although donor adherence was more challenging, DSEK was technically easier and should be less traumatic to anterior chamber structures than earlier posterior grafting techniques.

Descemet's Stripping With Endothelial Keratoplasty in 50 Eyes: A Refractive Neutral Corneal Transplant

ABSTRACT PURPOSE: To evaluate early visual and refractive outcomes following treatment of corneal endothelial dysfunction with a corneal transplantation technique, Descemet's stripping with endothelial keratoplasty (DSEK). METHODS: Visual and refractive outcomes of the first 50 consecutive cases of DSEK performed by a single surgeon between December 2003 and July 2004 were analyzed retrospectively. The DSEK technique consisted of stripping Descemet's membrane and endothelium from a recipient cornea and transplanting the posterior stroma and endothelium of a donor cornea through a 5-mm incision. RESULTS: Results are reported for 50 eyes in 47 patients (30 women and 17 men). Mean patient age at surgery was 70±12 years (range: 34 to 89 years). Five eyes were treated for corneal edema or bullous keratopathy and 45 for Fuchs' endothelial dystrophy. Seven eyes were phakic and 43 were Pseudophakic. Six months after surgery, mean manifest cylinder was 1.5±0.94 diopters (D), unchanged from preoperative cylinder of 1.5±1.0 D. Mean manifest spherical equivalent refraction was 0.15 ±1.5 D at 6-month follow-up compared with -0.36±1.4 D preoperatively (P=.10) At 3- and 6-month follow-up, significant improvement was noted in mean best spectacle-corrected visual acuity compared with the preoperative mean of 20/100 (P=.007). At 6-month follow-up, 31 (62%) eyes refracted to ≥20/40 and 38 (76%) eyes saw ≥20/50. CONCLUSIONS: Compared to standard penetrating keratoplasty, DSEK causes minimal refractive change and provides rapid visual recovery for patients with endothelial dysfunction. This technique maintains the structural integrity of the cornea by preserving the recipient's epithelium, Bowman's layer, and entire stromal thickness. [J Refract Surg. 2005;21:339-345.]