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Visual Acuity, Refractive Error, and Endothelial Cell Density Six Months After Descemet Stripping and Automated Endothelial Keratoplasty (DSAEK)

Koenig, Steven B MD*; Covert, Douglas J MD, MPH*; Dupps, William J Jr MD, PhD; Meisler, David M MD

doi: 10.1097/ICO.0b013e3180544902
Clinical Science

Purpose: To evaluate visual acuity, refractive outcomes, and endothelial cell density 6 months after Descemet stripping and automated endothelial keratoplasty (DSAEK).

Methods: We performed an institutional review board-approved prospective study of a surgical case series of 34 patients at 2 institutions undergoing DSAEK for Fuchs endothelial dystrophy, pseudophakic bullous keratopathy, or aphakic bullous keratopathy with or without simultaneous phacoemulsification and intraocular lens implantation. Clinical outcomes, including best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction, and refractive astigmatism and topographic or keratometric astigmatism, were assessed at the 6-month postoperative examination and compared with preoperative values with paired Student t tests. The change in endothelial cell density from the eye bank examination to 6 months after transplantation was similarly evaluated.

Results: BSCVA averaged 20/99 preoperatively and 20/42 postoperatively (P < 0.0001). After DSAEK, 30 (88.2%) of 34 patients showed improved BSCVA, and 21 (61.8%) of the 34 patients achieved a BSCVA of 20/40 or better. For patients not undergoing simultaneous phacoemulsification and intraocular lens implantation, a hyperopic shift in refraction of 1.19 ± 1.32 D was noted. Refractive astigmatism, topographic astigmatism, and keratometry showed no statistically significant change. Endothelial cell density of donor corneas averaged 2826 ± 370 cells/mm2, whereas the mean postoperative density was 1396 ± 440 cells/mm2. This finding corresponded to an average loss of 1426 cells/mm2 (50% loss; P = 0.0001). The first half of cases experienced an average cell loss of 1674 cells/mm2 (59% loss) compared with 1181 (41% loss) in the second half of cases (P = 0.005). Three (9%) of 34 grafts experienced iatrogenic graft failure and required reoperation with new donor tissue. Also, 9 (27%) of 34 grafts experienced dislocation in the early postoperative period and required repositioning.

Conclusions: In this prospective study of DSAEK for bullous keratopathy and Fuchs endothelial corneal dystrophy, improvement of visual acuity was achieved with only a mild tendency toward hyperopic shift and without significant induced astigmatism. Endothelial cell loss was significant, however, and may be related to surgical experience.

From the *Eye Institute, Medical College of Wisconsin, Milwaukee, WI; and the †Cole Eye Institute, Cleveland Clinic, Cleveland, OH.

Received for publication October 11, 2006; revision received January 31, 2007; accepted February 28, 2007.

Supported in part by an unrestricted grant from Research to Prevent Blindness (SBK, DJC), a Research to Prevent Blindness Challenge Grant (WJD, DMM), and NIH 8K12 RR023264, National Center for Research Resources, Multidisciplinary Clinical Research Career Development Programs Grant (WJD).

Reprints: Steven B. Koenig, 925 N. 87th Street, Milwaukee, WI 53226 (e-mail:

© 2007 Lippincott Williams & Wilkins, Inc.