ORIGINAL ARTICLE  
Descemet Stripping Automated Endothelial  
Keratoplasty (DSAEK)  
Zaman Shah1, Ibrar Hussain2, Sadia Sethi3, Bakht Samar Khan4, Tajamul Khan5  
1-5Department of Ophthalmology, Khyber Teaching Hospital, Peshawar  
ABSTRACT  
Purpose: The purpose of this study to analyze the visual outcome and complications of DSAEK with their  
management.  
Study Design: Interventional case series.  
Place and Duration of Study: Department of ophthalmology Khyber Teaching Hospital Peshawar, from January  
2017 to April 2019.  
Material and Methods: Twenty-one patients were selected by convenient sampling method from the outpatient  
department of Khyber Teaching Hospital Peshawar. Informed written consent was obtained from all patients.  
Ethical approval of the study was obtained from institutional review board (IRB) of Khyber Medical College, in  
accordance with the declaration of Helsinki. All cases of DSAEK were performed by a single surgeon. We  
received the precut DSAEK tissue and then endoglide was used in 5 (23.8%) and Busin Glide in 16 (76.19%) of  
cases. The unfolding of the donor tissue was performed by preplaced anterior chamber maintainer using balance  
salt solution. Any complication either intra operative or post-operative, which happened, was recorded and  
managed either medically, or by appropriate surgical means.  
Results: The average visual acuity before surgery was CF-1m. After DSAEK procedure, average best-corrected  
visual acuity was 6/36. Per-operative complications included incomplete stripping of the Descemet membrane and  
loss of donor button during mounting in glide. Complications in the early post-operative period were pupillary  
block glaucoma in 3 eyes and donor tissue dislocation in 2 eyes. Late post-operative complications included  
edema and non-attachment after re-bubbling, late secondary glaucoma, cystoid macular edema (CME) and  
interface opacification.  
Conclusion: DSAEK is a promising alternative to penetrating Keratoplasty for corneal endothelial de-  
compensation.  
Key Words: DSAEK, Keratoplasty, Lamellar Keratoplasty, Endothelial Keratoplasty.  
How to Cite this Article: Shah Z, Hussain I, Sethi S, Khan BS, Khan T. Descemet Stripping Automated  
Endothelial Keratoplasty (DSAEK). Visual Outcome, Complications and Their Management, Pak J Ophthalmol.  
2020, 36 (2): 103-108.  
Doi: 10.36351/pjo.v36i2.977  
INTRODUCTION  
In Descemet stripping automated endothelial  
keratoplasty (DSAEK), the diseased endothelium is  
It is a good alternative to penetrating keratoplasty  
replaced with healthy donor endothelium, Descemet  
membrane and part of the thin posterior corneal tissue.  
(PKP) in cases of endothelial decompensation.  
In literature, DSAEK appears similar to PKP in  
Correspondence to: Zaman Shah, Assistant Professor  
terms of graft clarity, visual acuity, surgical risk,  
complications rate and endothelial cell loss but it  
seems to be superior to PKP in terms of early visual  
Department of Ophthalmology, Khyber Teaching Hospital,  
Peshawar  
Email: zamanshah73@hotmail.com  
103  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 103-108  
Descemet Stripping Automated Endothelial Keratoplasty (DSAEK). Visual Outcome, Complications and Their Management  
recovery,  
refractive  
stability,  
post-operative  
after surgery and late complications were those, which  
happened after 2 months of surgery. Any complication  
either intra operative or post-operative, were managed  
either medically, or by appropriate surgical means.  
The data was analysed using SPSS version 20 and P  
value of < 0.05 was considered significant.  
astigmatism wound and suture related complications  
and intraoperative risk1. Some surgeons are using  
automated micro keratome for the preparation of donor  
endothelial graft, mounted on artificial anterior  
chamber. The procedure is known as DSAEK. At the  
same time many surgeons are still using manual  
dissection for preparation of donor tissue mounted on  
artificial anterior chamber and the procedure is termed  
RESULTS  
Total 21 patients were included in the study, which  
comprised of 5 males (23.8%) and 16 females  
(76.2%). The median age of these patients was 51.5  
years (range 40-65). All patients had pseudophakic  
corneal edema/bullous keratopathy. 20 (95.23%) out  
the total had posterior chamber intraocular lens and  
only one (4.7%) had anterior chamber intraocular lens.  
as  
DSEK  
(Descemet  
stripping  
endothelial  
keratoplasty).  
Some of the donor tissue complications are  
inability to separate newly prepared donor tissue from  
the anterior layer, excessively thickened donor  
posterior lenticule, donor tissue perforation and  
2
inadvertent slipping of the tissue inside of the eye .  
The most frequent complication encountered in  
DSAEK is donor lenticule dislocation, which can be  
resolved with repositioning of the graft and re-  
bubbling3. The proposed causes of graft detachment  
include patient eye rubbing and poor donor tissue  
dissection technique. There are reports on air induced  
pupillary block, primary graft failure and interface  
infection in early post-operative period3. In the late  
post-operative period, the most important reported  
complications are secondary glaucoma and graft  
rejection4.  
All 21 patients had VA less than 5/60 (0.08) with  
most of the patients having VA of CF-1m (0.04). The  
average VA before surgery was CF-1m (0.03). After  
DSAEK procedure the best corrected VA in 8  
(38.09%) patients was 6/60 (0.1) and in 5 (23.8%)  
patients, it was 6/24 (0.25). The overall average  
BCVA after DSAEK was 6/36 (0.17). On paired  
sample t-test the P value was 0.001. Table 1 shows  
per-operative complications. In 2 (9.52%) cases,  
incomplete stripping of the Descemet membrane  
occurred. In these cases, the remaining un-stripped  
tissue was left as such and donor graft applied. The  
two most common early post-operative complications  
were pupillary block glaucoma in 3 (14.28%) eyes and  
donor graft dislocation in 2 (9.52%) eyes. Air induced  
pupillary block cases were initially treated with  
The purpose of this study is to evaluate the visual  
outcome and to analyze the per-operative and post-  
operative complications of DSAEK with their possible  
management.  
MATERIAL AND METHODS  
Table 1: Complications of DAESK.  
This study was performed in the Department of  
Ophthalmology Khyber Teaching Hospital Peshawar,  
from Jan 2017 to April 2019. All cases of DSAEK  
were performed by a single surgeon. The informed  
written consent was obtained from all patients. Ethical  
approval of the study was obtained from institutional  
review board (IRB) of Khyber Medical College, in  
accordance with the declaration of Helsinki.  
No of  
Cases  
Complications  
%age  
Intra-operative Complications  
Incomplete stripping of DM  
DSAEK detachment  
Loss of button in glide  
Early post-operative Complications  
Donor Dislocation  
Air induced Pupillary glaucoma  
Partial donor non-attachment  
Blood in interface  
2
9.52  
2
1
9.52  
4.76  
1
3
2
1
1
4.76  
14.28  
9.52  
4.76  
4.76  
The procedures were performed using the similar  
technique. We received the precut DSAEK tissue and  
then endoglide was used in 5 (23.8%) and Busin Glide  
in 16 (76.19%) cases. The unfolding of the donor  
tissue was performed by preplaced anterior chamber  
maintainer using balance salt solution.  
Decentration  
Late Post-operative Complications  
Edema and non attachment after re-  
bubbling in donor dislocation  
Late secondary glaucoma  
Cystoid macular edema  
Interface opacification  
1
4.76  
1
1
2
4.76  
4.76  
9.52  
Early post operation complications were defined  
as the complications that occurred within 2 months  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 103-108  
104  
Zaman Shah, et al  
Table 2: Comparison of “Tan endoglide” Vs “Busin Glide”.  
No.  
%age  
Delivery of Donor Tissue  
Site of Incision  
Iris Prolapsed  
Incision Size  
Tan endoglide  
Busin Glide  
5
16  
23.8%  
76.19%  
Difficult  
Comparatively easy  
Scleral  
Corneal  
None  
None  
4.5mm  
4 mm  
intravenous injection of mannitol and oral  
acetozolamide 250 mg – four times a day and pupillary  
dilatation. Air bubble was not removed in any of the  
cases. In our case series, one donor graft dislocation  
happened in a case with AC IOL. This case was  
managed by pupillary dilatation, repositioning and re-  
bubbling on first post-operative day. The second case  
was treated by repositioning and re-bubbling.  
Decentration occurred in one (4.76%) case, which was  
also managed with repositioning and re-bubbling.  
Percentage  
25  
20  
15  
10  
5
23.2  
20.3  
16.7  
0
0
The  
most  
common  
late  
post-operative  
Pre-operative  
6 Months  
1 Year  
18 Months  
complication was corneal edema and non attachment  
of DSAEK tissue in one (4.76%) case. The other  
important complication was late secondary glaucoma  
in one (4.76%) case, cystoid macular edema (CME)  
occurred in one (4.76%) eye and interface  
opacification in 2 (9.52%) eyes. CME was treated with  
sub-tenon injection of triamcinolone acetonide and  
Nepafenec eye drop 3 times a day for 3 months. There  
was an improvement in vision with resolution of  
macular edema. In this study the rate of complications  
was more in cases where venting incision was done.  
Edema and non-attachment after re-bubbling was seen  
in one (4.76%) case of venting incision. While these  
complications were not seen in non-venting cases.  
Post-operative scarring at the venting site and  
epithelial ingrowths were not seen in any case.  
Fig. 1: Endothelial Cell Loss in % Age with Time.  
DISCUSSION  
The DSAEK offers an effective and efficient  
alternative to traditional PKP for the treatment of  
corneal endothelial dysfunctions. The different  
complications of DSAEK are pupillary block by air,  
donor dislocation, graft failure, secondary glaucoma  
and graft rejection. The potential causes of donor  
dislocation include; presence of interface viscous fluid  
or air, patient squeezing and eye rubbing. There are  
complications with preparation, handling and insertion  
of donor lamellar tissue into the anterior chamber of  
the recipient. Most of the reported complications are  
with automated dissection of the donor tissue but  
evidence is lacking about management of these  
complications.  
Table 2 shows comparison of Busin glide and Tan  
endoglide in the DSAEK procedure. We did 5 (23.8%)  
cases with Tan endoglide which was found difficult  
for delivery and time consuming and 16 (76.19%)  
cases were performed with Busin glide which was  
comparatively easy and less time consuming. The site  
for incision was selected as 4.5 mm scleral with Tan  
endoglide and 4.00 mm corneal for Busin glide. No  
iris prolapse occurred with any of the two glides.  
As previously described, pupillary block by air is  
an important complication of DSAEK procedure. The  
reported incidence of pupillary block varies between  
0.5% and 13% in different series5. This is due to the  
displacement of an excessively large air bubble. In our  
series, the overall frequency was 4.76%. This  
complication can be prevented by placing a freely  
mobile air bubble and putting a drop of cycloplegic at  
the end of surgery.  
The overall medium endothelial cell loss (ECL)  
after 6 months was 16.7%. It was 20.3%, 32.2% after  
12 months and 18 months follow-up (Figure 1).  
However, the ECL has not been analyzed  
independently with different groups of patients and  
with or without complications.  
Donor dislocation is one of the most important  
complications and the rate varies from 0% to 82%,  
with an average dislocation rate of 14.5%. The graft  
dislocation may represent either fluid in the interface  
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Descemet Stripping Automated Endothelial Keratoplasty (DSAEK). Visual Outcome, Complications and Their Management  
of an otherwise well positioned graft or complete  
one (4.76%) eye, which resolved with topical non-  
steroidal anti-inflammatory agent and sub-tenon  
triamcinolone acetonide injection. This is again  
comparable with the previous reports15.  
dislocation into the anterior chamber. It is interesting  
to notice that the incidence of this unique complication  
is reduced with experience and the same author had  
reported 8% dislocation rate in 20086. Price reported a  
dislocation rate of 50% on the first 10 eyes undergoing  
DSAEK, which was reduced to 13% in the next 126  
cases after changing the procedure to include face up  
position after surgery and smoothening of the corneal  
surface7. With experience and time, the dislocation  
rate is reduced. The results of dislocation management  
are also satisfactory with a success rate of 72.3% that  
is comparable with other published series8.  
Late secondary donor failure due to chronic  
endothelial cell loss is a question in DSAEK  
procedure. The reported late graft failure varies  
between 0 and 45 % after 01 year with an average of  
6% in first year16. In our series the study duration is up  
to 18 months and the endothelial cell loss was 23.2%.  
Late graft failure was more in pseudophakic eye with  
AC IOLs than with PC IOL (11.7% versus 2.4%).  
Previous studies have also shown that endothelial cell  
loss (ECL) in DSAEK in Pseudophakic eyes with AC  
IOLs is higher and the graft failure was 16% with up  
to 30 months follow up15. Therefore, DSAEK surgery  
in patients with AC IOL remains controversial. As the  
published report of DSAEK beyond 5 years are few in  
number, so long term graft clarity with DSAEK is yet  
to be determined. Retanasi et al showed that only four  
(7.8%) eyes had a late donor failure among 5% cases  
in their longest follow up of more than 5 years16. The  
author states that long term results of DSAEK were  
excellent. The grafts were clear despite lower than  
normal endothelial cell count. The total graft failure in  
this large series was 31 (7.2%) eyes. The failed  
DSAEK cases, early or late can be managed by redo  
procedure in majority (54.8%) of cases.  
The published studies showed rate of primary graft  
failure (PGF) from 0% to 29%, with an average PGF  
rate of 5%9. PGF has been linked with poor surgical  
technique of DSAEK and related excessive iatrogenic  
intraoperative manipulation of donor endothelial  
cells10. In our series, no case of PGF was recorded,  
probably due to less manipulation of DSAEK button.  
Published reports on secondary glaucoma after  
DSAEK are between 0% and 15%, with an average of  
3%1. In our series, the incident of secondary glaucoma  
was 4.76% and the commonest cause of this late  
secondary glaucoma was topical corticosteroid.  
Among reviewed studies the endothelial rejections  
rates varied from 0% to 45%, with an average  
rejections rate of 10% with the follow-up ranging from  
3 to 24 months10. In our series the rejection rate was  
0%.  
The infection following DSAEK procedure, either  
in the form of interface kerititis and endophthalmitis in  
early post operative period or delayed kerititis after 03  
months is always serious17-19. In our study, at the end  
of 18 months follow up, not a single case of infection  
was seen. As a fairly new procedure the relative  
experience of surgeons in earlier cases may account  
for more graft manipulation and ECL during surgery.  
In addition, the DSAEK in certain indications have  
more complications then clear case of PC IOL related  
Pseudophakic Bullous Keratopathy or Fuchs  
endothelial dystrophy. The different conditions are  
aphakic AC IOL related pseudophakic bullous  
keratopathy (PBK); post penetrating keratoplasty  
(PKP) failed graft, congenital hereditary endothelial  
dystrophies (CHED) and irido-corneal endothelial  
syndrome (ICES). In aphakic cases there are reports of  
posterior dislocation of the donor disc into the vitreous  
cavity with or without retinal detachment20. Other  
difficult cases include vitreous in anterior chamber,  
previous large peripheral iridectomy, large YAG laser  
capsulotomy even in the presence of PC IOL and a  
Epithelial ingrowths, interface opacification and  
interface hemorrhage are less common complications  
in our series and these are comparable with reported  
studies11,12. Among theses, interface opacity is one of  
the important reasons for repeat endothelial  
keratoplasty reported by Letko et al, following 1050  
consecutive DSAEK cases in 5 years13. Interface  
fibrosis was also described histopathologically in  
failed DSAEK cases where PKP procedure was  
performed later on.  
The incomplete removal of DM as a cause of  
partial graft detachment in DSAEK has been  
reported14. In our series, partial donor detachment  
happened in two cases and with time they attached  
completely, which was because of incomplete  
stripping of DM in two cases. In both cases the graft  
was initially attached in more than two third areas.  
Postoperative cystoid macular edema developed in  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 103-108  
106  
Zaman Shah, et al  
DALK): a laboratory based surgical solution to  
dislocation in 100 consecutive DSEK cases. Cornea,  
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required in these difficult cases.  
5. Koenig SB, Covert DJ. Early results of small-incision  
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keratoplasty. Ophthalmology, 2007; 114: 221–6.  
6. Basak SK. Descemet stripping and endothelial  
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9. Shih CY, Ritterband DC, Rubino S. Visually  
significant and non-significant complications arising  
from Descemet stripping automated endothelial  
keratoplasty. Am J Ophthalmol. 2009; 148: 837–43.  
10. Ashar JN, Madhavi Latha K, Vaddavalli PK.  
Descemet’s stripping endothelial keratoplasty (DSEK)  
for children with congenital hereditary endothelial  
dystrophy: Surgical challenges and 1-year outcomes.  
Graefes Arch Clin Exp Ophthalmol. 2012; 250: 1341–  
5.  
CONCLUSION  
In conclusion, the DSAEK is an exciting and  
promising alternative to the traditional PKP. Like  
other corneal transplantation surgeries, the learning  
curve is steep and the potential for complication is  
significant during first few cases. Both operative and  
post-operative complications do occur in DSAEK and  
increase with the long postoperative follow up, but all  
are within an acceptable limit. The re-DSAEK can be  
easily performed in most of the failed cases with  
satisfactory results.  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
Conflict of Interest  
Authors declared no conflict of interest  
Author’s Designation and Contribution  
Dr. Zaman Shah; Assistant Professor: Research  
design, Data collection, Manuscript writing, Final  
review  
Dr. Ibrar Hussain; Head of Department of  
Ophthalmology: Research design, Final review  
11. Ku BI, Hsieh YT, Hu FR, Wan IJ, Chen WL, Hou  
YC. Endothelial cell loss in penetrating keratoplasty,  
endothelial keratoplasty, and deep anterior lamellar  
keratoplasty. Taiwan J Ophthalmol. 2017; 7 (4): 199–  
204. Doi:10.4103/tjo.tjo_55_17  
12. Schmitt AJ, Feilmeier MR, Piccoli FV. Interface  
blood after Descemet stripping automated endothelial  
keratoplasty. Cornea, 2011; 30: 815–7.  
13. Letko E, Price DA, Lindoso EM. Secondary graft  
failure and repeat endothelial keratoplasty after  
Dr. Sadia Sethi; Professor: Research design, Final  
review  
Dr. Bakht Samar Khan; Associate Professor: Research  
design, Final review  
Dr. Tajamul Khan; Associate Professor: Research  
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Cornea, 2011; 30: 1414–8.  
17. Sengupta J, Khetan A, Saha S. Bacterial keratitis after  
manual Descemet stripping endothelial keratoplasty–a  
design, Final review.  
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