Endothelial Keratoplasty Techniques and Outcomes

Endothelial keratoplasty has revolutionised the management of corneal endothelial dysfunction by selectively replacing the damaged posterior layers while preserving the host’s anterior stroma. Two principal techniques, Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK), have become standard practice worldwide. DSAEK utilises a donor lenticule comprising posterior stroma, Descemet’s membrane and endothelium, offering relative ease of handling and a lower early graft detachment rate. DMEK transplants only the donor Descemet’s membrane and endothelium, affording superior visual recovery and a reduced immunological barrier but demanding greater surgical skill and presenting a higher rate of rebubbling. Clinical outcomes are assessed primarily by best-corrected visual acuity, endothelial cell density (ECD) and graft survival over time. Advances in preloading and transport protocols, customised tamponade gases, and refined patient selection have collectively improved graft adherence, minimised endothelial cell loss and extended long-term survival. This evolution in techniques has broad global significance, enabling tailored interventions for conditions such as Fuchs endothelial corneal dystrophy and postoperative bullous keratopathy with enhanced safety and visual function.

Research from Nature Portfolio

Detailed analyses of DSAEK outcomes in large cohorts have identified preoperative iris damage and multiple prior intraocular procedures as significant predictors of postoperative ECD decline and graft failure. These studies underscore the importance of comprehensive anterior segment evaluation when selecting candidates for DSAEK. Investigations into DMEK have shown that postoperative rebubbling is the principal modifiable risk factor for long-term cell loss, whereas the choice between air and sulphur hexafluoride tamponade exerts minimal influence on graft viability. Insights from these works guide surgeons in optimising intraoperative technique and postoperative management to preserve endothelial health and enhance graft longevity.

Endothelial Keratoplasty Techniques and Outcomes publication trend

The graph below shows the total number of articles in endothelial keratoplasty techniques and outcomes across all publications each year (not limited to Nature Index journals).

Technical terms

Endothelial keratoplasty: A surgical procedure replacing only the diseased endothelial layer and Descemet’s membrane of the cornea.

DSAEK: Descemet stripping automated endothelial keratoplasty, a lamellar transplant including donor stroma, Descemet’s membrane and endothelium.

DMEK: Descemet membrane endothelial keratoplasty, a transplant of only the donor Descemet’s membrane and endothelium.

Endothelial cell density (ECD): The measurement of endothelial cells per square millimetre, reflecting graft health.

Rebubbling: Injection of gas into the anterior chamber to reattach a partially detached graft.

References

1. Descemet Stripping Automated Endothelial Keratoplasty versus Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy A National Registry-Based Comparison. Ophthalmology (2023).
2. Comparison of preservation and transportation protocols for preloaded Descemet membrane endothelial keratoplasty. British Journal of Ophthalmology (2017).
3. Factors associated with graft survival and endothelial cell density after Descemet’s stripping automated endothelial keratoplasty. Scientific Reports (2016).
4. Efficacy and safety of Descemet’s membrane endothelial keratoplasty versus Descemet’s stripping endothelial keratoplasty: A systematic review and meta-analysis. PLOS ONE (2017).
5. Risk factors for endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK). Scientific Reports (2020).