Tissue complications during endothelial keratoplasty

To report 6 cases of apparently inseparable corneal lamellae during intraoperative preparation of tissue for Descemet stripping automated endothelial keratoplasty (DSAEK).

Collection of clinical case reports from an e-mail survey of The Cornea Society and endothelial keratoplasty discussion group participants and Eye Bank Association of America member eye banks.

Five cases involved eye bank precut tissue. Surgery was aborted in 4 of these cases. In the fifth case, a free anterior cap was identified and the posterior lamella was successfully transplanted. In 1 case, in which an incomplete lamellar cut was made in the operating room, the surgery was continued after manual completion of the lamellar dissection.

The most likely causes of inability to separate the lamellae after punching a DSAEK donor cornea are a decentered or incomplete lamellar cut and unsuspected premature separation of the lamellae. Premature separation can occur with an anterior cap that detaches before the central trephination or a posterior lamella that is inadvertently removed from the field after the central trephination. Careful inspection of the donor cornea under the operating microscope can reduce the risk of a decentered cut and can identify the presence of both lamellae. DSAEK may be completed successfully with an intact posterior lamella.