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Descemet 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, donor tissue including Descemet’s membrane, endothelium, and posterior stroma replace the host’s Descemet’s membrane 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 their standard protocol. After preparation, the tissue is safely transported to the surgery center and further prepared for the patient.

If the DSEK is being performed in conjunction with cataract surgery, the cataract is removed and an intraocular lens is inserted prior to the corneal graft. Using a laser, a peripheral iridotomy is made in the host iris to allow for proper aqueous movement in the eye. The host tissue endothelium and Descemet’s membrane are stripped from the posterior cornea and removed from the eye. Prior to inserting the graft, the tissue 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 an appropriate position 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 in the adherence of the graft tissue to the posterior cornea. After the bubble is safely placed in the patient’s eye, the IOP is checked, thus completing the surgical process.

Post Op

Drop protocol is 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 until the bottle runs out.

  • Vigamox: instill 1 drop 4 times per day for 1 week or until 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

  • Elevated intraocular pressure (IOP). In the first week, if a patient experiences a significantly sore/achy eye, headache around the eye, feels nauseated or vomits, 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)

  • Graft rejection

    • What to look for:

      • Decreased vision

      • Photophobia

      • Corneal edema

      • Keratic precipitates