Descemet Stripping Endothelial Keratoplasty (DSEK) is a modern corneal transplant surgery that addresses diseases affecting the inner lining of the eye’s clear front surface. The procedure is classified as a partial-thickness transplant, replacing only the diseased inner layer of the cornea with healthy donor tissue. This technique leaves the majority of the patient’s own corneal structure intact, resulting in a more stable eye and often a faster visual recovery compared to older, full-thickness transplants.
Understanding the Cornea and Endothelium
The cornea is the transparent, dome-shaped outer layer at the front of the eye. It serves as the eye’s primary focusing element, bending light toward the retina. To maintain transparency, the cornea must remain in a slightly dehydrated state.
This delicate balance is maintained by the corneal endothelium, a single, thin layer of specialized cells lining the back surface of the cornea. These cells function like tiny pumps, actively transporting excess fluid out of the corneal tissue. This process ensures the central corneal layer, the stroma, does not swell and become cloudy. When these endothelial cells are damaged or lost, they do not regenerate, causing the cornea to retain water, thicken, and lose clarity, leading to blurred vision.
Primary Reasons for DSEK Surgery
DSEK surgery is performed when endothelial cells fail to maintain corneal transparency, leading to persistent swelling and vision impairment. The most common condition requiring this procedure is Fuchs’ Endothelial Dystrophy, a hereditary disorder causing gradual cell loss. This loss leads to fluid buildup and clouding of the cornea, often resulting in progressively blurry vision, particularly in the morning.
Other indications for DSEK include pseudophakic bullous keratopathy, which is corneal swelling that occurs following cataract surgery. The procedure is also used to treat patients who have experienced the failure or rejection of a previous corneal transplant.
The DSEK Surgical Procedure
The DSEK procedure is typically performed on an outpatient basis and takes approximately 60 to 90 minutes. The surgery begins with the removal of the patient’s diseased Descemet membrane and endothelium, a process referred to as “stripping.” This is done through a small incision at the edge of the cornea, leaving the outer corneal layers undisturbed.
A healthy donor cornea is prepared to create a thin lenticule that includes the endothelium and a small portion of the posterior stroma. This donor tissue is then gently folded and inserted into the eye through the small surgical incision. Once inside the anterior chamber, the surgeon carefully unfolds the delicate donor graft and positions it correctly on the back surface of the patient’s cornea.
The final step involves injecting a sterile air bubble into the eye. This air bubble floats upward, acting as a pneumatic splint that presses the new donor tissue firmly against the recipient’s inner cornea until the layers adhere. The small incision is often self-sealing or requires minimal sutures. This smaller wound contributes to stronger stability and significantly reduced surgically induced astigmatism compared to traditional full-thickness transplants.
Expected Recovery and Post-Operative Care
Immediate post-operative care focuses on ensuring the newly transplanted tissue remains securely in place. Patients are instructed to lie flat on their back, facing the ceiling, often for the first 24 to 48 hours following surgery. This supine positioning allows the air bubble, which holds the donor graft in place, to float up and maintain continuous contact. Maintaining this posture is crucial for initial graft success.
Prescribed eye drops, including steroid and antibiotic medications, are required to prevent infection and minimize the risk of rejection and inflammation. The air bubble naturally absorbs within a few days; vision immediately after surgery is often very blurry, which is normal. Visual improvement begins soon after the air bubble dissipates, with substantial recovery occurring within the first few weeks to months. Patients are advised to avoid strenuous activity, heavy lifting, and swimming for several weeks to protect the healing eye.