Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)

What is DSAEK?

DSAEK or DSEK (Descemet’s Stripping Automated Endothelial Keratoplasty) is a type of endothelial keratoplasty that involves removing the affected Descemet’s membrane and endothelium from the back of the cornea and replacing it with a thin layer from the back of a donor cornea that carries the new Descemet’s membrane and endothelium.

How is DSAEK performed?

This procedure involves stripping the diseased back layer from the recipient cornea and inserting just a thin layer of donor cornea with healthy endothelium into the eye. A bubble of air is placed into the front chamber of the eye to force the donor layer on to the back of the cornea and it will stick there by itself. The healthy endothelium will then start working to pump the swollen cornea clear again.

Endothelial keratoplasty has a number of potential advantages over full-thickness transplants. Healing is much faster and the problem of high degrees of astigmatism and defocus that occurs with full-thickness grafts is avoided. There is also less disturbance to the surface of the eye and fewer dry eye problems and there may be a lower chance of rejection.

DSAEK surgery is done as a daycase or overnight stay procedure under general or local anaesthetic with sedation. The operation takes about an hour. It is often combined with cataract surgery if that has not already been done.

What is the recovery like?

One of the most difficult aspects of the surgery is that it is necessary to lie completely flat afterwards for most of the time afterwards for several days to position the bubble of air in the eye underneath the transplant to allow the graft to stick to the back of your cornea. About one in twenty times the graft does not stick or it slides out of position by the following morning or during the first week. In that case it is necessary to reposition the graft and place another bubble of air in the eye. This may be done in the clinic or back in the operating theatre. Occasionally this has to be repeated. One in a hundred or so cases, the transplanted endothelium does not work or the graft is wrinkled and even it it is in the right position it needs to be removed and replaced with a new graft. A decision about doing this is usually made about a month after the initial surgery.

Often the corneal epithelium (surface cells of the cornea) will be removed during the procedure as it is usually loose and unstable when the cornea is swollen. A bandage contact lens is then placed in the eye at the end of the procedure and this will stay in until the surface has healed (usually a week or so). The surface healing can be more prolonged if the cornea has been swollen for a long time.

Recovery of vision is very variable after endothelial keratoplasty procedures and depends on many factors, e.g. how swollen the cornea was to start with and for how long. Generally, vision takes some weeks to really start improving and then many months to get as good as it is going to. There is continued subtle improvement in vision even between 1 and 2 years after the surgery. It may be 3 to 6 months before vision is stable enough to have glasses changed.

Are there any problems that can occur?

There are many potential problems with corneal transplant surgery of any type.

This is a transplant of living tissue into the eye and your immune system can reject the transplanted tissue. You will be using steroid drops in the eye to prevent this for at least 2 years after surgery. It is very important to keep using these drops. If the transplanted cornea rejects then your cornea will become swollen again and another graft will need to be done.

In some cases, although the transplant is healthy and survives, the interface between the transplant and your own cornea is not clear and the graft needs to be replaced to get good vision.

You do need to be aware that, even though the transplanted tissue is carefully screened, there is a remote risk of having some sort of infection transmitted by the surgery.

How long will it last?

The transplanted cornea will not last forever. It is not yet known how long endothelial grafts will last in general. The full-thickness grafts done for the same reasons can last up to 25 years but many fail before then and the cornea swells up again. About 80 per cent of grafts last at least 5 years. If the graft fails then it can be removed and replaced with another graft.

Experience Life Clearly

Dr. Steven Wiffen is a consultant ophthalmologist subspecialising in cornea, cataract, laser and refractive surgery.