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The management of corneal endothelial dysfunction has undergone a paradigm shift in the last decade, from the gold standard of penetrating keratoplasty (PK) through to pure endothelial cell transplantation. Posterior lamellar keratoplasty,1 2 deep lamellar endothelial keratoplasty (DLEK),3 Descemet's stripping endothelial keratoplasty (DSEK),4 Descemet's stripping automated endothelial keratoplasty (DSAEK)5 and Descemet's membrane endothelial keratoplasty (DMEK)6 are all variations on the theme of replacing diseased recipient endothelium with healthy donor endothelium, and are collectively referred to as endothelial keratoplasty (EK).
The major advantage of EK over PK is the rapid visual recovery, with minimal change in corneal shape and refraction. Bahar et al found that many patients undergoing EK achieved stable postoperative best corrected visual acuity (BCVA) as early as 1 month after surgery.7 DSEK or DSAEK causes little or no change in corneal topography or mean refractive cylinder compared with PK, which also stabilises quickly, hence accounting for a faster visual recovery.8
With refinement of the techniques of EK, better BCVA outcomes have been reported. While only 49% of the earlier series of DLEK cases of Terry and Ousley achieved 20/40 or better,9 Chen et al, more recently, reported a mean BCVA of 20/30 in DSAEK patients without visual comorbidity.10 Visual outcome results after DSAEK or DSEK are now comparable to, or exceed, those …