Femto -Dsaek For Deep Posterior Stromal Opacity: A Lamellar Alternative To Pk In Failed Dmek
Published 2026 - 44th Congress of the ESCRS
Reference: CC03.06 | Type: Case Report | DOI: 10.82333/bpwz-sm06
Authors: Dr Luca Lucchino* 1 , Dr Davide Romano 2 , Dr Sabrina Vaccaro 3 , Dr Antonio Moramarco 4 , A/Prof. Francesco Semeraro 3 , A/Prof. Luigi Fontana 4 , A/Prof. Vito Romano 3
1Department of Sense Organs,Sapienza University of Rome,Rome,Italy;Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia,Eye Unit,Brescia,Italy, 2Department of Corneal Diseases, Royal Liverpool University Hospital,St. Paul's Eye Unit,Liverpool,United Kingdom, 3Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia,Eye Unit,Brescia,Italy, 4Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum University of Bologna,Ophthalmology Unit,Bologna,Italy
Purpose
To describe the feasibility of femtosecond laser-assisted stromal dissection combined with Descemet stripping automated endothelial keratoplasty (femto-DSAEK) as an alternative to penetrating keratoplasty (PK) in case of deep posterior stromal scarring following failed Descemet membrane endothelial keratoplasty (DMEK).
Setting
Tertiary referral cornea service, Eye Unit, Brescia, Italy
Report of case
A 58-year-old male with a history of failed DMEK for Fuchs’ endothelial dystrophy was referred for reduced visual acuity associated with posterior stromal scarring. Anterior segment OCT showed an 80 µm hyperreflective posterior stromal opacity located at 501 µm from the epithelium, with a central corneal thickness (CCT) of 581 µm. Due to the presence of deep posterior stromal opacity, repeat DMEK was considered unlikely to achieve satisfactory visual outcomes and PK was initially considered.
To avoid full-thickness transplantation, femtosecond laser-assisted posterior stromal dissection followed by DSAEK (Femto-DSAEK) was performed. Stromal dissection was carried out using a low-energy femtosecond laser platform (FEMTO LDV Z8, Ziemer, Switzerland) with intraoperative OCT guidance. The procedure was performed in two steps: a horizontal lamellar cut at 501 µm depth (7.50 mm diameter), centered on the visual axis and corresponding to the level of the stromal scar, followed by a posterior-to-anterior vertical dissection reaching the lamellar plane, enabling en bloc removal of the posterior stromal disc, DM, and dysfunctional endothelium. A 7.00 mm precut DSAEK graft (82 µm thickness) was subsequently implanted.
Postoperatively, rapid corneal clearing and visual recovery were observed, with BCVA improving from 1.00 to 0.10 logMAR at 3 months. No intraoperative or postoperative complications, graft detachment, or interface haze occurred, and CCT was 513 µm at final follow-up.
Conclusion/Take home message
Femto-DSAEK offers a streamlined surgical approach for managing failed DMEK with posterior stromal scarring. By enabling precise removal of diseased posterior tissue with immediate endothelial replacement in a single session, it may enhance graft adherence, facilitate rapid visual rehabilitation, and provide an effective tissue-sparing alternative to PK in complex cases.