Deep lamellar endothelial keratoplasty - Visual acuity, astigmatism, in a large prospective series

Purpose: To report the 6-month results for the treatment of enclothelial dysfunction in a large, prospective series of deep lamellar enclothelial keratoplasty (DLEK) procedures. Design: Prospective, noncomparative, interventional case series. Participants: One hundred eyes of 88 patients with corneal edema from Fuchs' dystrophy and pseudophakia. Methods: A limbal, scleral, partial-depth incision provided access for a deep lamellar corneal pocket dissection. Two eyes were converted to penetrating keratoplasty (PK) at the time of DLEK surgery because of poor dissections. Of the 98 eyes that had completed DLEK surgeries, 36 eyes received a large-incision technique (9-mm scleral access incision) and 62 eyes received a small-incision technique (5-mm scleral access incision). A 7.5- to 8.0-mm posterior lamellar disc of recipient tissue then was excised and replaced through the pocket with a similar size donor disc containing healthy endothelium. A temporary air bubble in the anterior chamber was used for donor tissue adherence, and no surface corneal incisions or sutures were necessary. Main Outcome Measures: Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction (MR) astigmatism, and enclothelial cell density (ECD) were evaluated prospectively. Results: At 6 months after surgery, all 98 DLEK corneas were clear and the grafts were healed in good position. The mean BSCVA was 20/46, with a range between 20/20 and 20/400. The average MR astigmatism was 1.34 +/- 0.86 diopters (D), representing an average change in astigmatism from before surgery of +0.28 +/- 1.08 D (P = 0.013). The average ECD at 6 months was 2140 +/- 427 cells/mm(2), representing a mean cell loss from preoperative donor cell measurements of 25%. Conclusions: The DLEK procedure, with its absence of corneal surface incisions and sutures, preserves the normal corneal topography, minimizes astigmatism, and provides a healthy donor enclothelial cell count and function. The DLEK procedure represents a reasonable alternative to PK, and compared with historical PK data, offers superior refractive outcomes in the treatment of enclothelial dysfunction.