REVIEW

CURRENT
OPINION Refractive surgery after Descemet’s stripping
endothelial keratoplasty
Jessica Prince and Roy S. Chuck

Purpose of review
Descemet’s stripping endothelial keratoplasty (DSEK) has become a preferred surgical correction for
endothelial dysfunction. Patient dissatisfaction secondary to refractive error is emerging as a significant
complaint after anatomically successful DSEK. This article reviews refractive surgeries after DSEK to address
this problem.
Recent findings
There are various surgical options available to treat refractive compromise following DSEK. Cataract
extraction with intraocular lens (IOL) implantation is a well tolerated option to restore visual acuity after
DSEK in cases with significant lens opacities. Laser in-situ keratomileusis (LASIK) and photorefractive
keratectomy (PRK) can otherwise successfully correct simple refractive errors. Phototherapeutic keratectomy
(PTK) may be employed in cases wherein visually significant subepithelial fibrosis and scarring become
evident after DSEK.
Summary
To obtain maximum visual rehabilitation, patients undergoing DSEK may require further refractive surgeries.
Cataract extraction, LASIK, PRK, PTK, and various combination procedures have been shown to optimize
corneal clarity and visual acuity in patients who previously had successful DSEK with subsequent refractive
errors. Technological advancements and continued research are necessary to perfect optimal timing and
outcomes of these secondary refractive surgeries.
Keywords
Descemet’s stripping endothelial keratoplasty, refractive error, refractive surgery

INTRODUCTION including hyperopic shift, visually significant lens

Descemet’s stripping endothelial keratoplasty
(DSEK) may be superior to penetrating keratoplasty
for visual rehabilitation in patients with endothelial
dysfunction, including but not limited to Fuchs’
endothelial dystrophy and pseudophakic bullous
&
keratopathy [1,2,3 ,4]. It has been well documented
as successful not only as a primary modality for
endothelial dysfunction, but also as a recovery pro-
&
cedure for failed penetrating keratoplasty [5 ]. Rapid
recovery, early suture removal, and decreased long-
term topical corticosteroid use are among the
&
advantages of DSEK [1,2,4,5 ,6–10]. However, DSEK
does not come without its limitations including
hyperopic shift and potential for cataract formation
and subepithelial fibrosis. This review discusses
refractive surgeries to correct for these limitations.
INDICATIONS
There are various reasons for refractive surgery
after DSEK. Unacceptable refractive compromise
opacities, and central subepithelial opacity can limit
maximum visual acuity in the postoperative period.
These potential complications following DSEK con-
tribute to patient dissatisfaction, motivating phys-
icians to address these issues.
Refractive error
Previous studies have reported hyperopic refractive
shift after DSEK [2,8,9,11–18]. Enhancement of
Department of Ophthalmology and Visual Sciences, Albert Einstein
College of Medicine, Montefiore Medical Center, Bronx, New York, USA
Correspondence to Roy S. Chuck, MD, PhD, Department of Ophthal-
mology and Visual Sciences, Albert Einstein College of Medicine, Mon-
tefiore Medical Center, 3332 Rochambeau Avenue, 3rd Floor, Bronx, NY
10467, USA. Tel: +1 718 920 6665; fax: +1 718 881 5439; e-mail:
rchuck@montefiore.org
Curr Opin Ophthalmol 2012, 23:242–245
DOI:10.1097/ICU.0b013e3283543b79

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Number 4
July 2012

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Descemet’s stri pping endothelial keratoplasty Prince and Chuck
KEY POINTS

Descemet’s stripping endothelial keratoplasty (DSEK) is
increasingly the preferred treatment modality for
endothelial dysfunction.

Refractive surgeries can successfully be performed after
DSEK to improve visual acuity and related
patient satisfaction.

Further research is necessary to optimize primary DSEK
outcomes, secondary refractive surgery outcomes, and
timing of these secondary revisions.
posterior corneal k-readings, posterior corneal
astigmatism, and corneal volume are a few postu-
lated etiologies for this hyperopic shift [13,15,19–
23]. The difference in central and peripheral donor
corneal graft thickness may also be responsible for
&
this refractive shift. Hwang et al. [24 ] developed
an early mathematical model to predict refractive
error after DSEK. Changes in the posterior corneal
curvature and the distance between different planes
of the cornea and lens contribute to the equation.
This model places strong emphasis on variables
including the ratio between central and peripheral
&
graft thickness and central cornea thickness [24 ].
They concluded that small central and peripheral
ratios and large corneal graft thicknesses result
in larger hyperopic shifts. The potential for an
estimation of hyperopic shifts before surgery can
allow better approximation of emmetropia after
surgery, especially in cases of combined DSEK and
cataract surgery, or in cases of imminent cataract
&
surgery [24 ]. Of course, myopic and symmetric
astigmatic error may also be addressed using refrac-
tive surgery.
Cataract
There is a reported increased rate of cataract for-
mation in the 5-year postoperative period following
penetrating keratoplasty; however, little research
had been performed to evaluate the rate of cataract
formation and extraction following endothelial
&& &&
keratoplasty [25 ]. Price et al. [25 ] explored this
topic in a retrospective review of 80 eyes that
remained phakic following primary DSEK. Cataracts
&&
formed postoperatively in 26 eyes (43%) [25 ].
The rates of cataract formation and extraction
increased over time after DSEK; both were found
&&
to be statistically significant [25 ]. Of note, this
study did not have record of lens opacities prior
to DSEK. There were also numerous patients who
required repositioning of grafts and regrafting
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with simultaneous or sequential cataract extraction,
&&
potentially confounding results [25 ]. All patients
were treated with topical corticosteroids in the
perioperative period, also possibly contributing
to the increased rate of cataract formation. The
researchers concluded that age and DSEK accele-
rated the rates of cataract formation and extraction
&&
[25 ].
Anterior corneal opacity
In cases wherein anterior corneal opacities exist
with concurrent endothelial dysfunction and fail-
ure, rather than a full penetrating graft, DSEK fol-
lowed by phototherapeutic keratectomy (PTK) may
be considered [26 ].
&&
TREATMENT MODALITIES
There is currently no standard protocol directing
physicians to address these potential complications
as they arise in the post-DSEK period. However,
numerous studies have been published employing
various refractive surgical techniques to correct
hyperopic refractive error, cataracts, and subepithelial
fibrosis.
Laser-assisted in-situ keratomileusis and
photorefractive keratectomy
&&
Ratanasit and Gorovoy [27 ] reported on five
pseudophakic patients who had laser-assisted in-
situ keratomileusis (LASIK) (3) or photorefractive
keratectomy (PRK) (2) after DSEK for correction of
hyperopic refractive error. The goal of LASIK or PRK
in these patients was to provide an opportunity to be
spectacle free because their postoperative refractive
error was unacceptable. The mean time between
DSEK and secondary refractive surgery in this retro-
spective case series was 14 months (11–17 month
&&
range) [27 ]. There were no complications reported
after LASIK or PRK and final examination revealed
clear corneal grafts without need for further enhance-
ment procedures. In all patients, uncorrected
visual acuity (UCVA) significantly improved from
post-DSEK (20/80–20/200) to the postoperative
period after LASIK or PRK (20/20–20/40). These
results allowed patients to reach their goals of
decreasing refractive error and becoming spectacle
&&
free [27 ].
Phototherapeutic keratectomy
&&
Hongyok et al. [26 ] published two case reports
of patients who underwent PTK after DSEK. The
www.co-ophthalmology.com 243
 Refractive surgery
first patient experienced corneal endothelial
decompensation after cataract surgery as a result
of Fuchs’ endothelial dystrophy. After successful
DSEK, an anterior corneal opacity was revealed.
PTK with mitomycin C (MMC) was performed
to remove this anterior pathology without
incidence. At the 1-year follow-up, this patient’s
best spectacle-corrected visual acuity (BSCVA)
was 20/40 without recurrent endothelial or anterior
&&
corneal pathology [26 ]. The second patient
had a similar surgical course, requiring DSEK
after cataract extraction due to endothelial dysfunc-
tion. This patient had known subepithelial fibrosis
that became more visually significant after DSEK.
PTK with MMC allowed this patient to obtain
BSCVA 20/40 without recurrence of the anterior
&&
fibrosis [26 ].
Combination of Descemet’s stripping
endothelial keratoplasty with lens-based
surgery
Studies have been reported combining DSEK with
phacoemulsification and intraocular lens (IOL)
&
implantation [28 ]. In one study with a 6-month
follow-up, 21 eyes had phacoemulsification and
posterior chamber IOL implantation followed by
&
DSEK [28 ]. BSCVA significantly improved in this
patient subset. Limitations to such triple procedure
surgery include improper IOL power calculation,
surgery through a hazy cornea, and longer recovery
& &
periods [28 ]. Shah et al. [29 ] evaluated the surgical
outcomes of patients undergoing DSEK in which
anterior chamber IOL (ACIOL) was exchanged for
posterior chamber IOL (PCIOL) compared with
DSEK alone wherein the PCIOL was left in place.
There was no difference in the rates of dislocation,
graft failure, or pupillary block in the two study
groups. There was a statistically significant differ-
ence in BSCVA (P ¼ 0.01) with the study group mean
of 20/48 after 6 months and the comparison group
&
20/34 [29 ]. This finding emphasizes the need for
additional research evaluating optimal time for sec-
ondary surgical procedures after DSEK and evaluat-
ing the benefit of concurrent versus sequential
refractive surgeries.
Descemet’s membrane endothelial
keratoplasty as an alternative to Descemet’s
stripping endothelial keratoplasty to reduce
postoperative refractive shifts
Descemet’s membrane endothelial keratoplasty
(DMEK) has become an alternative to DSEK, trans-
planting Descemet’s membrane and endothelium
244 www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
without stroma. Some suppose that a better visual
outcome is reached with DMEK when compared
with DSEK. DMEK is hypothesized to be superior
because the additional thicker, posterior stromal
layer in a DSEK graft may cause a reduction in
&
potential of visual acuity [30 ]. DMEK grafts are
thinner potentially eliminating this problem. Case
reports have been published describing complete
visual rehabilitation with DMEK after failed DSEK
&
[30 ]. In one particular study, patients’ BSCVA
approached 20/25 following DMEK, placing empha-
sis on the importance of corneal graft thickness as a
&
contributor to final visual outcome [30 ]. Although
recent reports reveal a faster recovery with DMEK, its
limitations include fragility of the graft and diffi-
culty of graft placement. As with DSEK, a mild
hyperopic shift may also occur with DMEK. Of note,
&
Ham et al. [30 ] stated that this shift may result from
reversal of a preexisting myopic shift secondary to
stromal swelling in patients with endothelial dis-
ease. This situation is in comparison to the hyper-
opic shift in DSEK due to the increased posterior
corneal power from the donor lenticule shape [16–
&
18,28 ].
CONCLUSION
Despite its numerous advantages, DSEK can fall
short of providing consistent and excellent visual
rehabilitation for its patients. Secondary refractive
surgeries including LASIK, PRK, PTK, and lens-based
surgery have successfully brought patients closer to
their postoperative visual goals after DSEK. Improve-
ments in mathematical models to predict refractive
error will better allow physicians to plan preoper-
atively for anticipated hyperopic changes. Anterior
corneal opacities before and after DSEK can now be
treated safely without having to resort to penetrat-
ing keratoplasty. Finally, current literature and
future randomized, controlled trials comparing con-
current triple procedure therapies to sequential
surgeries will also better allow physicians to opti-
mize care and timing for additional lens-based pro-
cedures when indicated. For these reasons, DSEK is
quickly becoming the modality of choice to treat
endothelial dysfunction with successful options for
further revisions through secondary refractive
surgeries.
Acknowledgements
Research to Prevent Blindness for an unrestricted core
grant to Albert Einstein College of Medicine.
Conflicts of interest
There are no conflicts of interest.
Volume 23
Number 4
July 2012
 Descemet’s stri pping endothelial keratoplasty Prince and Chuck
REFERENCES AND RECOMMENDED
READING
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& of special interest
&& of outstanding interest
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A mathematical model was formulated to predict hyperopic shifts after DSEK,
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Two case reports of DSAEK followed by PTK with MMC for treatment of
endothelial diseases with visually significant subepithelial fibrosis revealing favor-
able results.
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&& fractive keratectomy after Descemet stripping Automated endothelial kera-
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This retrospective case series reported on five patients who successfully under-
went LASIK or PRK after DSAEK to correct refractive error.
28. Covert DJ, Koenig SB. New triple procedure: Descemet’s stripping and
& automated endothelial keratoplasty combined with phacoemulsification and
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This 6 month follow-up case series demonstrated that phacoemulsification with
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This retrospective case series evaluated complications and outcomes of DSAEK
with IOL exchanges compared with DSAEK alone. The study concluded that
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graft failure, dislocation, or pupillary block. However, vision was limited with the
combination procedure when compared to DSAEK alone.
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outcome. DMEK after DSEK proved successful in all three patients, with BCVA of
20/25, stable anterior corneal curvature, and variable posterior corneal refractive
changes.
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