Standardized pachymetry-assisted manual lamellar dissection for Descemet stripping endothelial keratoplasty

To present an alternative technique (Pachy-DSEK) for the manual preparation of thin endothelial lamellae in Descemet stripping endothelial keratoplasty (DSEK), as well as to evaluate its visual and anatomic outcomes.

A retrospective chart review was conducted in 15 cases who underwent DSEK at a private eye clinic in Brazil (INOB, Brasília) from June 2017 to December 2019. All patients had ocular comorbidities and relative contraindications to Descemet membrane endothelial keratoplasty (DMEK). All endothelial lamellae were manually prepared by using a standardized technique. Best corrected visual acuity (BCVA), tomographic parameters and graft's thickness were evaluated preoperatively and at 6 months. Endothelial cell counts were evaluated preoperatively and at 12 to 24 months.

During preparation there was one case (6%) of peripheral tear and no tissue was lost. At 6 months, the median BCVA improved from 1.60 to 0.40 logMAR (p = 0.0009). There was no significant change in anterior (p = 0.507) and posterior astigmatism (p = 0.483), anterior (p = 0.683) and posterior mean keratometry (p = 0.767), and total corneal power (p = 0.952). The median central graft thickness at 6 months was 80 µm. Ultrathin grafts (<130 µm) were achieved in 80% of cases. At 12 to 24 months endothelial cell count decreased significantly. Graft's detachment occurred in two cases (13%) and endothelial rejection in one case (6%).

By using ultrasonic pachymetry intra-operatively and standardizing graft preparation, most manually dissected endothelial lamellae were ultrathin. Pachy-DSEK was safe and effective for treating endothelial disfunction in eyes with ocular comorbidities. It may be a cost-effective alternative to automated dissection methods.