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Descemet’s stripping endothelial keratoplasty (DSEK) is a partial thickness cornea transplant that is commonly used to treat posterior corneal diseases when a DMEK procedure is contraindicated. In DSEK, the donor’s posterior corneal layers, including Descemet’s Membrane (DM), endothelium, and posterior stroma replace host DM and endothelium.
Good candidates for DSEK
Iridocorneal endothelial (ICE) syndrome
Failed endothelial keratoplasty
Complicated anterior chambers, ie: tube shunts
The first step in DSEK is to prepare the graft tissue. This is commonly done by the Eyebank under there standard protocol. After preparation the tissue is safely transported to the surgery center and further prepped for the patient.
If the DSEK graft is being performed in conjunction with cataract surgery, the cataract is removed and an intraocular lens is inserted before the corneal graft. Using a laser, a peripheral iridotomy (a small channel or passage-way) is made in the host iris to allow aqueous movement in the eye. The host tissue endothelium and Descemet’s membrane is stripped from the posterior cornea and removed from the eye. Prior to inserting the stomal-endothelial graft tissue, it is stained with Trypan blue before it is rolled up and placed into an inserter. The graft is injected into the eye and it slowly starts to unfold. The surgeon will manipulate and place the graft into place by using pressure, fluid mechanics and gently tapping on the cornea. Once the graft is in position a gas bubble is injected into the eye to aid the graft tissue in adhering to the posterior cornea. After the bubble is safely placed the patient’s eye, the IOP is checked, which completes the surgical process.
Drop protocol subject to change
Durezol/prednisolone acetate 1%: instill 1 drop 4 times per day for 2 months, then 2 times per day for 4 months, then 1 time per day for 6 months.
Ilevro/Prolensa: instill 1 drop 1 time per day for 1 month or the bottle runs out.
Vigamox: instill 1 drop 4 times per day for 1 week or the bottle runs out.
Side Effects and Post-op Complications
Graft detachment: rates are variable and depend on surgeon experience. Most surgeons agree there is a lower graft detachment rate in DSEK compared to DMEK.
Damage to tissue during preparation or surgery
Upside down grafts
Epithelial defect or erosion
Raised intraocular pressure (IOP). In the first week, if a patient has a real soar/achy eye, a bad headache around the eye, or feels nauseated or like vomiting, the surgeon and his/her team should be called immediately.
Descemet graft folds
Less than 1% risk of anterior synechiae, hypotony, pupillary block, subepithelial haze, and interface pigment deposits.
Cystoid macular edema (CME)
What to look for: