Who Benefits From Descemet Stripping Only? A Topographic Predictive Model

Descemet’s stripping only (DSO) relies on migration of peripheral endothelial cells to repopulate the central cornea and offers advantages including avoidance of donor tissue and immunological rejection. However, outcomes are variable and recovery may be prolonged, largely due to the absence of standardized selection criteria. Although DSO is generally reserved for early central Fuchs endothelial corneal dystrophy (FECD), objective predictors of success remain unclear. This study aimed to identify preoperative corneal tomographic features that predict clinical outcomes following DSO in patients with FECD.

This was a retrospective observational study conducted at the Cambridge Eye Unit, Addenbrooke’s Hospital, United Kingdom, between December 2021 and December 2024.

This retrospective observational study included patients with visually symptomatic central FECD without overt clinical corneal oedema. Topographic markers of subclinical oedema assessed included loss of parallel isopachs within central 4mm, displacement of the thinnest corneal point, and focal posterior depression. Parameters were graded on a 3-point scale: isopachs (mild, moderate, severe), thinnest point displacement (within 3 mm, 3–5 mm, outside 5 mm), and posterior depression (≤−15 µm, −16 to −30 µm, >−30 µm). All eyes underwent DSO without Rho-kinase inhibitors. Outcomes included best-corrected visual acuity (BCVA), and time to oedema resolution. Surgical success was defined as BCVA improvement with oedema resolution within 3 months.

Eight eyes of eight patients were included. Four eyes with DSO failure or late success scored ≥6 points, reflecting marked loss of parallel isopachs, displacement of thinnest corneal point beyond central 3 mm, and posterior depression >-15 µm. Of these, three eyes failed to achieve corneal clearance and required DMEK, while one eye with late success cleared at 12 months. In contrast, four eyes with early success (<3 months) scored ≤5 points, most scoring 3 points, with mild isopach irregularity, thinnest point within 3 mm, and posterior depression <-15 µm. Among the 3 parameters, displacement of thinnest point was most predictive, with all early success eyes showing displacement within central 3 mm and all failed cases beyond central 3 mm.

Scheimpflug-derived markers of subclinical corneal oedema can reliably predict outcomes following DSO in patients with visually symptomatic central FECD without overt clinical oedema. Displacement of the thinnest corneal point was the most predictive parameter, with greater displacement associated with failure. Eyes with early topographic changes are suitable candidates, whereas advanced subclinical oedema is linked to poor outcomes. These simplified criteria may guide patient selection and improve predictability of DSO outcomes. Larger studies are needed to validate these findings.