Comparison of posterior lamellar keratoplasty techniques to penetrating keratoplasty

Purpose: To describe the visual outcomes and intraoperative and postoperative complications after penetrating keratoplasty (PK), deep lamellar endothelial keratoplasty (DLEK), Descemet stripping endothelial keratoplasty (DSEK), and Descemet stripping automated endothelial keratoplasty (DSAEK) and to compare the results with those of previously reported series. Design: Prospective, comparative, nonrandomized study. Participants: One hundred seventy-seven eyes of 161 consecutive patients who had corneal edema resulting from Fuchs endothelial dystrophy, pseudophakic bullous keratopathy, aphakic bullous keratopathy, failed graft or iridocorneal endothelial syndrome. Methods: All patients underwent either PK, DLEK, DSEK, or DSAEK at the Cornea Service of the Toronto Western Hospital. Main Outcome Measures: Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, corneal endothelial counts, and postoperative complications. Results: The average 12-month postoperative BSCVA was 20/53 in the PK group, 20/80 in the DLEK group, 20/56 in the DSEK group, and 20/44 in the DSAEK group. The mean spherical equivalent was similar between groups, but tended toward hyperopia in the DSEK and DSAEK groups. The average refractive astigmatism was 3.78 +/- 1.91 diopters (D) in the PK group and 1.61 +/- 1.26 D, 1.86 +/- 1.1 D, and 1.36 +/- 0.92 D in the DLEK, DSEK, and DSAEK groups, respectively (P<0.0001). Early postoperative donor disc dislocations occurred in 6 (8.8%) patients in the DLEK group, 2 (12.5%) in the DSEK group, and 7 (15.6%) in the DSAEK group (P = 0.0004). Detached grafts were reattached and repositioned by injecting an air bubble to press the donor against the recipient cornea. Primary graft failure occurred in 1 (2.1%) of the PK cases, 2 (2.9%) of the DLEK cases, and 1 (2.2%) of the DSAEK cases; all underwent the same procedure successfully. Average cell loss at 1 year after surgery was 40.11 % and was similar in the 4 groups. Conclusions: The DSAEK surgery enabled rapid and better UCVA and BSCVA when compared with PK, DLEK, and DSEK, with significantly lower astigmatism. Endothelial cell loss was similar, but the dislocation rate was significantly higher in the DSAEK group.