To review the published literature on safety and outcomes of Descemet's stripping
endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases
of the cornea.
Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library
with the most recent search in February 2009. The searches yielded 2118 citations
in English-language journals. The abstracts of these articles were reviewed and 131
articles were selected for possible clinical relevance, of which 34 were determined
to be relevant to the assessment objectives.
The most common complications from DSEK among reviewed reports included posterior
graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection
(mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic
glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular
microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and
from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected
Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66.
A review of postoperative refractive results found induced hyperopia ranging from
0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from
-0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found
that clear grafts at 1 year ranged from 55% to 100% (mean, 94%).
The evidence reviewed is supportive of DSEK being a safe and effective treatment for
endothelial diseases of the cornea. In terms of surgical risks, complication rates,
graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar
to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier
visual recovery, refractive stability, postoperative refractive outcomes, wound and
suture-related complications, and intraoperative and late suprachoroidal hemorrhage
risk. The most common complications of DSEK do not appear to be detrimental to the
ultimate vision recovery in most cases. Long-term endothelial cell survival and the
risk of late endothelial rejection are beyond the scope of this assessment.
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