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This is a more recently developed procedure that involves only replacing the innermost layers of the cornea rather than the whole cornea as in a Penetrating Keratoplasty or Full Thickness graft. In conditions such as Fuchs endothelial Dystrophy, the innermost layer , the endothelium is diseased. The rest of the cornea is normal. Previously to replace the valuable endothelial layer the whole central cornea was replaced by performing a Penetrating Keratoplasty. With innovative techniques, we are now able to replace just the innermost layer.
The procedure involves peeling off the inner two layers of the diseased cornea. A donor cornea is then split or dissected to create a flap of the inner two layers and a small portion of stroma (to provide substance for manipulation). This 3 layer donor is then folded and inserted into the eye and floated up to stick onto the inside of the cornea replacing the layers removed earlier.
The procedure is technically challenging, however can be accomplished very quickly often with no stitches at all!
The procedure is becoming more and more popular and will in time become the Gold Standard. We at Centre for Sight and the Corneoplastic Unit perform this procedure regularly and have developed instrumentation to make the process easier.
Advantages
Closed eye surgery
Rapid surgery
Rapid visual recovery
Easily replaceable
Disadvantages
Technically challenging
Grafts can dislocate early requiring further minor intervention
Interface haze can compromise visual clarity
One of the most challenging aspects of DSEK surgery is creating a reproducible donor layer. This can vary considerably and its irregularity could theoretically affect visual outcomes. The Intralase Femtosecond Laser is able to separate the cornea precisely and its use in fashioning precise donor lenticules is currently being investigated. If found to be safe, DSEK and posterior lamellar keratoplasty will become more reproducible which resulting in consistently better outcomes.
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