Endothelial keratoplasty, most commonly Descemet’s stripping endothelial keratoplasty (DSEK), has become the procedure of choice for endothelial diseases. DSEK provides many unique advantages compared to traditional penetrating keratoplasty; these includes smaller risk of suprachoroidal hemorrhage during the surgery, minimal to no induced astigmatism, lower chance of wound dehiscence, and lower rates of rejection. However, DSEK carries its own set of specific risks and complications. Most common complications of DSEK surgery are posterior graft dislocation, glaucoma, and endothelial graft rejection. Other complications include graft folds, graft interface opacity, decentered graft, epithelial downgrowth, and endophthalmitis. Some of these complications may be encountered more frequently with certain surgical techniques. For example, a large clear corneal incision carries a higher risk of induced astigmatism and epithelial downgrowth than a more peripheral scleral tunnel incision. The risk of epithelial downgrowth is also increased if corneal venting incisions are made. There may be a greater risk of endothelial damage in bifold and push through techniques compared to when special insertion devices are used during the surgery . In this chapter, we will explore some of the more frequently encountered complications in DSEK that may occur in various stages of the surgery as well as in the postoperative course. Predisposing factors that lead to complications and ways to prevent them will also be discussed. In addition, appropriate management of the complications when they do occur will be described.
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