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DSEK (Descemet's Stripping Endothelial Keratoplasty)


DSEK surgery is the newest and most advanced method for corneal transplantation and has been around since 2004. The motivation behind the development of this type of surgery is to speed up visual recovery and improve patient safety as compared to a traditional corneal transplant. DSEK offers multiple advances over the traditional full-thickness corneal transplant, or penetrating keratoplasty (“PK”). DSEK can be performed through a 4 mm self-sealing incision, eliminating the need for sutures (stitches).

A typical PK has 20 to 30 sutures that anchor the full thickness corneal graft into place. These sutures can irritate the eye and cause pain and tearing for 3 to 6 weeks after surgery. Because of the sutures and the large healing response induced from a full-thickness transplant, most eyes yield large amounts of astigmatism and/or nearsightedness post-operatively. The sutures must be left in the cornea until it completely heals which is often a year or longer, and glasses may not be fit until 9 to 12 months after surgery. After traditional PK, around 30% of patients will require a hard contact lens to see their best, and another 60% will require thick glasses.

Utilizing DSEK

Endothelial Dysfunction

Some corneal diseases only affect the back layer of the cornea, known as the endothelial layer. The endothelial layer is important in pumping water out of the cornea to keep it clear. Most people don't even realize that they have a cover over their iris and pupil because of its crystal clear appearance. When the endothelial layer stops working, the cornea swells with water (corneal edema) and turns cloudy or “foggy.” If a large amount of water accumulates, it results in blisters on the surface of the eye that cause pain and tearing when they "pop." This is known as Bullous Keratopathy (BK) and it is the end-stage disease process of endothelial dysfunction.

You are born with the maximum number of endothelial cells that you will ever have. They exist in a single layer (like tiles) on the back of the cornea. The natural aging process causes some of these cells to die off each year and they are not replaced and won’t grow back. That leaves more work (fluid pumping) for the remaining cells. When there are too few cells to do the job correctly, the cornea begins to swell.

Fuchs' Dystrophy

Some people are born with too few cells and/or they lose them at a more rapid rate, a condition described by German physician, Ernest Fuchs in 1900. Fuchs' endothelial dystrophy patients tend to lose their vision in their late 60s or 70s with continued deterioration and blindness by their 80s or 90s. However, some cases can be very advanced in an individual’s mid to late 40s. Additional insults or trauma (such as cataract or glaucoma surgery) can accelerate the process. Fuchs' dystrophy tends to run in families and is more common in women.

Endothelial Trauma

Complicated eye surgery or multiple intraocular surgeries can cause a rapid loss of these cells even in patients without Fuchs' dystrophy. The final stage of the disease is always the same with severe swelling, loss of vision (even blindness) and pain (BK).

The DSEK Procedure

Since the back layer of the cornea is the problem for patients with corneal edema, BK, or Fuchs', only the back layer needs to be replaced. This involves a “partial corneal transplant” since not all the layers are being transplanted. In DSEK, the Dr. Walter shaves down a donor cornea to the back layer, which contains healthy donor endothelial cells. This extremely thin disc of tissue is placed into a special insertion device known as the EndoSerter® (invented by Dr. Walter) and placed through a 4 mm self-sealing corneal incision. Dr. Walter prepares the patient's eye by "stripping" away the back layer of unhealthy endothelial cells in a process known as Descemetorhexis. The donor tissue is then unfolded into the patient’s eye and "floated" into position with a cushion of air. This air bubble holds the donor tissue into position until the endothelial cells start working. These new donor endothelial cells start pumping out the extra water, causing swelling to decrease and vision to improve. Most patients have little or no pain after surgery and begin to see as soon as the bubble dissolves over the next 2 to 3 days. The majority of patients regain their vision after 8 to 12 weeks. Minor prescription changes in glasses may be required.

After your operation, you will be asked to lie flat on your back (or in a recliner with your nose pointed at the ceiling) for 22 out of the first 24 hours. This will keep the small air bubble underneath the new transplant in the proper position. You are allowed to get up to go to the bathroom or eat, but for only 10 to 15 minutes at a time. The next day you will return to Dr. Walter’s office for the first post-operative check. The remainder of the week you will be asked to “take it easy.”

Retina Chart

Advantages of DSEK over traditional Penetrating Keratoplasty (PK):

  • Quicker visual recovery – three (3) months for DSEK versus twelve (12) months for PK.
  • No sutures, resulting in less pain.
  • Little or no astigmatism and/or extreme nearsightedness.
  • Hard contact lenses aren't required for your best post-surgery vision.
  • Stronger corneal wound, meaning you are less likely to rupture your eye with minor trauma.
  • You are less likely to reject the corneal transplant.
  • Less risk to the patient during surgery (e.g., expulsive hemorrhage, infection or retinal detachment).