Outcomes Of Dsaek In Complex Corneal Cases: A Resident’S Perspective

Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) has become a preferred technique for endothelial dysfunction, offering faster recovery and better tectonic stability compared to penetrating keratoplasty (PKP).However, performing DSAEK in complex cases  such as post-PKP eyes, aphakic eyes, and corneal decompensation following Toxic Anterior Segment Syndrome (TASS) — presents unique surgical challenges including irregular anatomy, poor anterior chamber stability, and compromised host tissues.This case series aims to evaluate the feasibility, visual outcomes, and complications of DSAEK in such high-risk eyes.

Retrospective interventional case series in a tertiary care centre

Sample Size: 6 eyes of 6 patients were include

• Standard DSAEK with microkeratome-prepared donor tissue was performed by single trainee surgeon
• Donor insertion was done using Busin glide under fluid using anterior chamber maintainer
• Air or gas tamponade with 80–90% anterior chamber fill was done
• Microscope integrated OCT aided in identifying interface fluid and intraoperative graft attachment
• Modifications such as non scoring of host Descemet membrane in Post PKP cases, removal of membrane from angle of anterior chamber in TASS related cases and additional anterior vitrectomy with suture aided graft attachment was done in aphakic case.

         Mean duration of followup was 9 months 

Results: Anatomical success (graft attachment) was achieved in all 6 cases. Second surgical intervention -rebubbling for partial graft detachment was required in one case (Aphakic decompensation). All patients who underwent DSAEK had significant improvement in visual acuity compared to their preoperative visual acuity. Secondary glaucoma was noticed in two TASS related decompensation cases. The intraoperative modifications were based on the complexity of these cases.

Preoperative planning and anticipation of challenges with timely modification if steps in DSAEK of such complex cases helps achieve anatomical and functional success even in trainee surgeons.Intraoperative challenges such as poor visibility, incomplete removal of host Descemet membrane, unstable anterior chamber, peripheral anterior synechiae, fibrin membrane at the angle of AC, unstable intraocular lens, poor wounds of previous surgery and hypotony are to be kept in mind during preoperative planning.Anatomical and functional success is achievable by trainee surgeons in such complex cases with prior planning and modification of routine steps of DSAEK.