Descemet’s Stripping Automated Endothelial Keratoplasty

  • Robert A. CopelandJr
  • Usiwoma Abugo
  • Young-Joo Lee


In the past, a penetrating keratoplasty (PK) was the mainstay of treatment for corneal endothelial disease. It involves the replacement of full-thickness corneal host tissue by a full-thickness donor. The procedure is relatively simple compared to posterior lamellar procedures, but good visual outcomes are often limited. This is secondary to high or irregular astigmatism. Many months are required to achieve visual stability due to suture-dependent corneal curvature and astigmatism. It can be related to ocular surface and suture-related problems. Globe instability is a major concern with PKs, leading to devastating expulsive hemorrhages intraoperatively or postoperatively secondary to ocular trauma and wound dehiscence [1]. In the 1960s, Barraquer proposed a method to selectively replace the diseased endothelium with an anterior approach via a corneal flap. This was not adopted secondary to vascular in growth at the host-donor interface and technique-induced astigmatism [2].


Anterior Chamber Donor Graft Endothelial Cell Density Penetrate Keratoplasty Anterior Segment Optical Coherence Tomography 
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  1. 1.
    Grottone GT, Pereira NC, Gomes JA. Endothelial keratoplasty: evolution and horizons. Arq Bras Oftalmol. 2012;75(6):439–46.CrossRefPubMedGoogle Scholar
  2. 2.
    Culbertson WW. Endothelial replacement: flap approach. Ophthalmol Clin North Am. 2003;16(1):113–8, vii.CrossRefPubMedGoogle Scholar
  3. 3.
    Melles GR, Eggink FA, Lander F, et al. A surgical technique for posterior lamellar keratoplasty. Cornea. 1998;17(6):618–26.CrossRefPubMedGoogle Scholar
  4. 4.
    Terry MA, Ousley PJ. Deep lamellar endothelial keratoplasty in the first united states patients: early clinical results. Cornea. 2001;20(3):239–43.CrossRefPubMedGoogle Scholar
  5. 5.
    Melles GR, Wijdh RH, Nieuwendaal CP. A technique to excise the descemet membrane from a recipient cornea (descemetorhexis). Cornea. 2004;23(3):286–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Price Jr FW, Price MO. Descemet’s stripping with endothelial keratoplasty in 50 eyes: a refractive neutral corneal transplant. J Refract Surg. 2005;21(4):339–45.PubMedGoogle Scholar
  7. 7.
    Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea. 2006;25(8):886–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Terry MA, Shamie N, Chen ES, et al. Endothelial keratoplasty for fuchs’ dystrophy with cataract: complications and clinical results with the new triple procedure. Ophthalmology 2009;116(4):631–9.Google Scholar
  9. 9.
    Khor WB, Teo KY, Mehta JS, Tan DT. Descemet stripping automated endothelial keratoplasty in complex eyes: results with a donor insertion device. Cornea. 2013;32(8):1063–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Puri S, Robinson SB, Wang J, Sikder S. Vision-related impact on quality of life in an elderly patient population after corneal transplantation. Cornea. 2014;33(2):119–24.CrossRefPubMedGoogle Scholar
  11. 11.
    Ang M, Mehta JS, Anshu A, Wong HK, Htoon HM, Tan D. Endothelial cell counts after descemet’s stripping automated endothelial keratoplasty versus penetrating keratoplasty in Asian eyes. Clin Ophthalmol. 2012;6:537–44.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Ang M, Mehta JS, Lim F, Bose S, Htoon HM, Tan D. Endothelial cell loss and graft survival after descemet’s stripping automated endothelial keratoplasty and penetrating keratoplasty. Ophthalmology. 2012;119(11):2239–44.CrossRefPubMedGoogle Scholar
  13. 13.
    Nanavaty MA, Wang X, Shortt AJ. Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy. Cochrane Database Syst Rev. 2014;2, CD008420.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Arnalich-Montiel F, Hernandez-Verdejo JL, Oblanca N, Munoz-Negrete FJ, De Miguel MP. Comparison of corneal haze and visual outcome in primary DSAEK versus DSAEK following failed DMEK. Graefes Arch Clin Exp Ophthalmol. 2013;251(11):2575–84.CrossRefPubMedGoogle Scholar
  15. 15.
    Goldich Y, Artornsombidth P, Avni-Zauberman N, et al. Fellow eye comparison of corneal thickness and curvature in descemet membrane endothelial keratoplasty and descemet stripping automated endothelial keratoplasty. Cornea. 2014;33(6):547–50.CrossRefPubMedGoogle Scholar
  16. 16.
    Pineda 2nd R, Jain V, Shome D, Hunter DC, Natarajan S. Descemet’s stripping endothelial keratoplasty: Is it an option for congenital hereditary endothelial dystrophy? Int Ophthalmol. 2010;30(3):307–10.CrossRefPubMedGoogle Scholar
  17. 17.
    Sharma N, Sachdev R, Pandey RM, et al. Study of factors for unsuitability of DSAEK in cases of corneal decompensation following cataract surgery. Int Ophthalmol. 2012;32(4):313–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Cleary C, Liu Y, Tang M, Li Y, Stoeger C, Huang D. Excimer laser smoothing of endothelial keratoplasty grafts. Cornea. 2012;31(4):431–6.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Boynton GE, Woodward MA. Eye-bank preparation of endothelial tissue. Curr Opin Ophthalmol. 2014;25(4):319–24.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Esquenazi S, Rand W. Effect of the shape of the endothelial graft on the refractive results after descemet’s stripping with automated endothelial keratoplasty. Can J Ophthalmol. 2009;44(5):557–61.CrossRefPubMedGoogle Scholar
  21. 21.
    Jun B, Kuo AN, Afshari NA, Carlson AN, Kim T. Refractive change after descemet stripping automated endothelial keratoplasty surgery and its correlation with graft thickness and diameter. Cornea. 2009;28(1):19–23.CrossRefPubMedGoogle Scholar
  22. 22.
    Lombardo M, De Santo MP, Lombardo G, et al. Surface quality of femtosecond dissected posterior human corneal stroma investigated with atomic force microscopy. Cornea. 2012;31(12):1369–75.CrossRefPubMedGoogle Scholar
  23. 23.
    Mootha VV, Heck E, Verity SM, et al. Comparative study of descemet stripping automated endothelial keratoplasty donor preparation by moria CBm microkeratome, horizon microkeratome, and intralase FS60. Cornea. 2011;30(3):320–4.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Moshirfar M, Imbornoni LM, Muthappan V, et al. In vitro pilot analysis of uniformity, circularity, and concentricity of DSAEK donor endothelial grafts prepared by a microkeratome. Cornea. 2014;33(2):191–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Rauen MP, Goins KM, Sutphin JE, Kitzmann AS, Schmidt GA, Wagoner MD. Impact of eye bank lamellar tissue cutting for endothelial keratoplasty on bacterial and fungal corneoscleral donor rim cultures after corneal transplantation. Cornea. 2012;31(4):376–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Scorcia V, Matteoni S, Scorcia GB, Scorcia G, Busin M. Pentacam assessment of posterior lamellar grafts to explain hyperopization after descemet’s stripping automated endothelial keratoplasty. Ophthalmology. 2009;116(9):1651–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Vetter JM, Butsch C, Faust M, et al. Irregularity of the posterior corneal surface after curved interface femtosecond laser-assisted versus microkeratome-assisted descemet stripping automated endothelial keratoplasty. Cornea. 2013;32(2):118–24.CrossRefPubMedGoogle Scholar
  28. 28.
    Waite A, Davidson R, Taravella MJ. Descemet-stripping automated endothelial keratoplasty donor tissue preparation using the double-pass microkeratome technique. J Cataract Refract Surg. 2013;39(3):446–50.CrossRefPubMedGoogle Scholar
  29. 29.
    Woodward MA, Titus M, Mavin K, Shtein RM. Corneal donor tissue preparation for endothelial keratoplasty. J Vis Exp. 2012;(64):e3847. doi(64):e3847.Google Scholar
  30. 30.
    Cheng YY, Kang SJ, Grossniklaus HE, et al. Histologic evaluation of human posterior lamellar discs for femtosecond laser descemet’s stripping endothelial keratoplasty. Cornea. 2009;28(1):73–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Daoud YJ, Munro AD, Delmonte DD, et al. Effect of cornea donor graft thickness on the outcome of descemet stripping automated endothelial keratoplasty surgery. Am J Ophthalmol. 2013;156(5):860–6.e1.CrossRefPubMedGoogle Scholar
  32. 32.
    Phillips PM, Phillips LJ, Maloney CM. Preoperative graft thickness measurements do not influence final BSCVA or speed of vision recovery after descemet stripping automated endothelial keratoplasty. Cornea. 2013;32(11):1423–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Wisse RP, Achterberg JA, Van der Lelij A. DSAEK: Practical approach to choose the microkeratome head on the basis of donor cornea pachymetry. Cornea. 2014;33(3):230–4.CrossRefPubMedGoogle Scholar
  34. 34.
    Terry MA, Li J, Goshe J, Davis-Boozer D. Endothelial keratoplasty: the relationship between donor tissue size and donor endothelial survival. Ophthalmology. 2011;118(10):1944–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Price MO, Baig KM, Brubaker JW, et al. Randomized, prospective comparison of precut vs surgeon-dissected grafts for descemet stripping automated endothelial keratoplasty. Am J Ophthalmol 2008;146(1):36–41.Google Scholar
  36. 36.
    Tan GS, He M, Tan DT, Mehta JS. Correlation of anterior segment optical coherence tomography measurements with graft trephine diameter following descemet stripping automated endothelial keratoplasty. BMC Med Imaging. 2012;12:19-2342-12-19.Google Scholar
  37. 37.
    Mehta JS, Por YM, Poh R, Beuerman RW, Tan D. Comparison of donor insertion techniques for descemet stripping automated endothelial keratoplasty. Arch Ophthalmol. 2008;126(10):1383–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Khor WB, Han SB, Mehta JS, Tan DT. Descemet stripping automated endothelial keratoplasty with a donor insertion device: Clinical results and complications in 100 eyes. Am J Ophthalmol. 2013;156(4):773–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Mehta JS, Por YM, Beuerman RW, Tan DT. Glide insertion technique for donor cornea lenticule during descemet’s stripping automated endothelial keratoplasty. J Cataract Refract Surg. 2007;33(11):1846–50.CrossRefPubMedGoogle Scholar
  40. 40.
    Ang M, Saroj L, Htoon HM, Kiew S, Mehta JS, Tan D. Comparison of a donor insertion device to sheets glide in descemet stripping endothelial keratoplasty: 3-year outcomes. Am J Ophthalmol. 2014;157(6):1163–9.e3.CrossRefPubMedGoogle Scholar
  41. 41.
    Bahar I, Kaiserman I, Sansanayudh W, Levinger E, Rootman DS. Busin guide vs forceps for the insertion of the donor lenticule in descemet stripping automated endothelial keratoplasty. Am J Ophthalmol. 2009;147(2):220–6.e1.CrossRefPubMedGoogle Scholar
  42. 42.
    Inserters reduce EK-related endothelial cell loss. Date published online: May 2010. Date accessed: 11/2/2016.
  43. 43.
    Chen ES, Terry MA, Shamie N, Phillips PM, Friend DJ, McLeod SD. Descemet-stripping automated endothelial keratoplasty: Insertion using a novel 40/60 underfold technique for preservation of donor endothelium. Cornea. 2008;27(8):941–3.CrossRefPubMedGoogle Scholar
  44. 44.
    Koenig SB, Meisler DM, Dupps WJ, Rubenstein JB, Kumar R. External refinement of the donor lenticule position during descemet’s stripping and automated endothelial keratoplasty. Ophthalmic Surg Lasers Imaging. 2008;39(6):522–3.CrossRefPubMedGoogle Scholar
  45. 45.
    Wylegala E, Nowinska AK, Wroblewska-Czajka E, Janiszewska D. Donor disc attachment assessment with intraoperative spectral optical coherence tomography during descemet stripping automated endothelial keratoplasty. Indian J Ophthalmol. 2013;61(9):511–3.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Sng CC, Luengo Gimeno F, Mehta JS, Htoon HM, Tan DT. Intraoperative use of spectral-domain optical coherence tomography during descemet’s stripping automated endothelial keratoplasty. Clin Ophthalmol. 2012;6:479–86.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Terry MA, Saad HA, Shamie N, et al. Endothelial keratoplasty: the influence of insertion techniques and incision size on donor endothelial survival. Cornea. 2009;28(1):24–31.CrossRefPubMedGoogle Scholar
  48. 48.
    Ivarsen A, Hjortdal J. Recipient corneal thickness and visual outcome after descemet’s stripping automated endothelial keratoplasty. Br J Ophthalmol. 2014;98(1):30–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Hindman HB, Huxlin KR, Pantanelli SM, et al. Post-DSAEK optical changes: a comprehensive prospective analysis on the role of ocular wavefront aberrations, haze, and corneal thickness. Cornea. 2013;32(12):1567–77.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Price MO, Price Jr FW. Descemet’s stripping with endothelial keratoplasty: comparative outcomes with microkeratome-dissected and manually dissected donor tissue. Ophthalmology. 2006;113(11):1936–42.CrossRefPubMedGoogle Scholar
  51. 51.
    Mearza AA, Qureshi MA, Rostron CK. Experience and 12-month results of descemet-stripping endothelial keratoplasty (DSEK) with a small-incision technique. Cornea. 2007;26(3):279–83.CrossRefPubMedGoogle Scholar
  52. 52.
    Basak SK. Descemet stripping and endothelial keratoplasty in endothelial dysfunctions: three-month results in 75 eyes. Indian J Ophthalmol. 2008;56(4):291–6.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Kobayashi A, Yokogawa H, Sugiyama K. Descemet stripping with automated endothelial keratoplasty for bullous keratopathies secondary to argon laser iridotomy – preliminary results and usefulness of double-glide donor insertion technique. Cornea. 2008;27 Suppl 1:S62–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Bahar I, Sansanayudh W, Levinger E, Kaiserman I, Srinivasan S, Rootman D. Posterior lamellar keratoplasty – comparison of deep lamellar endothelial keratoplasty and descemet stripping automated endothelial keratoplasty in the same patients: a patient’s perspective. Br J Ophthalmol. 2009;93(2):186–90.CrossRefPubMedGoogle Scholar
  55. 55.
    Sarnicola V, Toro P. Descemet-stripping automated endothelial keratoplasty by using suture for donor insertion. Cornea. 2008;27(7):825–9.CrossRefPubMedGoogle Scholar
  56. 56.
    Oster SF, Ebrahimi KB, Eberhart CG, Schein OD, Stark WJ, Jun AS. A clinicopathologic series of primary graft failure after descemet’s stripping and automated endothelial keratoplasty. Ophthalmology. 2009;116(4):609–14.CrossRefPubMedGoogle Scholar
  57. 57.
    Ang M, Htoon HM, Cajucom-Uy HY, Tan D, Mehta JS. Donor and surgical risk factors for primary graft failure following descemet’s stripping automated endothelial keratoplasty in Asian eyes. Clin Ophthalmol. 2011;5:1503–8.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Mehta JS, Chua J, Poh R, Beuerman RW, Tan D. Primary graft failure after descemet-stripping automated endothelial keratoplasty: clinico-pathological study. Cornea. 2008;27(6):722–6.PubMedGoogle Scholar
  59. 59.
    Suh LH, Dawson DG, Mutapcic L, et al. Histopathologic examination of failed grafts in descemet’s stripping with automated endothelial keratoplasty. Ophthalmology. 2009;116(4):603–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Liu YC, Alvarez Paraz CM, Cajucom-Uy HY, et al. Risk factors for donor endothelial loss in eye bank-prepared posterior lamellar corneal tissue for descemet stripping automated endothelial keratoplasty. Cornea. 2014;33(7):677–82.CrossRefPubMedGoogle Scholar
  61. 61.
    Kanellopoulos AJ, Asimellis G. Anterior-segment optical coherence tomography investigation of corneal deturgescence and epithelial remodeling after DSAEK. Cornea. 2014;33(4):340–8.CrossRefPubMedGoogle Scholar
  62. 62.
    Wells 4th JA, Aldave AJ, Tsui I. Surgical technique: hand-over-hand retrieval of a posteriorly dislocated DSAEK graft in an eye with an iris reconstruction lens. Ophthalmic Surg Lasers Imaging Retina. 2013;44(6):569–71.CrossRefPubMedGoogle Scholar
  63. 63.
    Hood CT, Woodward MA, Bullard ML, Shtein RM. Influence of preoperative donor tissue characteristics on graft dislocation rate after descemet stripping automated endothelial keratoplasty. Cornea. 2013;32(12):1527–30.CrossRefPubMedGoogle Scholar
  64. 64.
    Sng CC, Mehta J, Tan DT. Posterior dislocation and immediate retrieval of a descemet stripping automated endothelial keratoplasty graft. Cornea. 2012;31(4):450–3.CrossRefPubMedGoogle Scholar
  65. 65.
    Wong RK, Greene DP, Shield DR, Eberhart CG, Huang JJ, Shayegani A. 5-fluorouracil for epithelial downgrowth after descemet stripping automated endothelial keratoplasty. Cornea. 2013;32(12):1610–2.CrossRefPubMedGoogle Scholar
  66. 66.
    Chhadva P, Cabot F, Ziebarth N, Kymionis GD, Yoo SH. Persistent corneal opacity after descemet stripping automated endothelial keratoplasty suggesting inert material deposits into the interface. Cornea. 2013;32(11):1512–3.CrossRefPubMedGoogle Scholar
  67. 67.
    Bradley JC, McCartney DL. Descemet’s stripping automated endothelial keratoplasty in intraoperative floppy-iris syndrome: suture-drag technique. J Cataract Refract Surg. 2007;33(7):1149–50.CrossRefPubMedGoogle Scholar
  68. 68.
    Jangi AA, Ritterband DC, Wu EI, Mehta VV, Koplin RS, Seedor JA. Descemet stripping automated endothelial keratoplasty after failed penetrating keratoplasty. Cornea. 2012;31(10):1148–53.CrossRefPubMedGoogle Scholar
  69. 69.
    Yoo SH, Kymionis GD, Deobhakta AA, et al. One-year results and anterior segment optical coherence tomography findings of descemet stripping automated endothelial keratoplasty combined with phacoemulsification. Arch Ophthalmol. 2008;126(8):1052–5.CrossRefPubMedGoogle Scholar
  70. 70.
    Ang M, Li L, Chua D, et al. Descemet’s stripping automated endothelial keratoplasty with anterior chamber intraocular lenses: complications and 3-year outcomes. Br J Ophthalmol. 2014;98(8):1028–32.CrossRefPubMedGoogle Scholar
  71. 71.
    Mehta JS, Hantera MM, Tan DT. Modified air-assisted descemetorhexis for descemet-stripping automated endothelial keratoplasty. J Cataract Refract Surg. 2008;34(6):889–91.CrossRefPubMedGoogle Scholar
  72. 72.
    Fahd DF, Allemann N, Chamon W, Azar D. History of cornea surgery. In: Copeland R, Afshari NA, editors. Copeland and Afshari’s principles and practice of cornea, vol. 2. New Delhi: Jaypee Brothers; 2013. p. 906.Google Scholar
  73. 73.
    O’Brien PD, Lake DB, Saw VP, et al. Endothelial keratoplasty: case selection in the learning curve. Cornea 2008;27(10):1114–8.Google Scholar

Copyright information

© Springer India 2016

Authors and Affiliations

  • Robert A. CopelandJr
    • 1
  • Usiwoma Abugo
    • 1
  • Young-Joo Lee
    • 2
  1. 1.Department of OpthalmologyHoward University HospitalWashingtonUSA
  2. 2.Louis Stokes Health Sciences LibraryHoward UniversityWashingtonUSA

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