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What Is Endothelial Keratoplasty (DSAEK/DMEK)?

Endothelial keratoplasty is a partial-thickness corneal transplant that replaces the diseased corneal endothelium and Descemet's membrane while leaving most of the front cornea intact. The two common forms are Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). These procedures are used when endothelial failure causes corneal swelling and blurry vision, such as in Fuchs endothelial corneal dystrophy. Compared with full-thickness transplantation, they often provide faster visual recovery and less change to the front corneal surface.

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What Is Endothelial Keratoplasty (DSAEK/DMEK)?

Endothelial keratoplasty is a partial-thickness corneal transplant that replaces the diseased corneal endothelium and Descemet's membrane while leaving most of the front cornea intact. The two common forms are Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). These procedures are used when endothelial failure causes corneal swelling and blurry vision, such as in Fuchs endothelial corneal dystrophy. Compared with full-thickness transplantation, they often provide faster visual recovery and less change to the front corneal surface.

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DSAEK vs DMEK

Both procedures replace unhealthy endothelium, but they differ in how much donor tissue is transplanted. DSAEK uses donor endothelium plus a thin layer of donor stroma, which can make the graft easier to handle but slightly thicker. DMEK transplants only Descemet's membrane and endothelium, which can provide sharper visual outcomes in many patients but can be more technically demanding. Choice depends on eye anatomy, surgeon experience, and clinical goals.

  • DSAEK uses a thin stromal layer
  • DMEK uses only Descemet's membrane and endothelium
  • Both target endothelial failure

How the Surgery Works

The surgeon removes the damaged Descemet's membrane and endothelium from the recipient cornea and inserts the donor graft into the anterior chamber. An air or gas bubble is used to press the graft into place so it can adhere to the back of the cornea. The incision is usually smaller than in penetrating keratoplasty, and stitches may be minimal depending on the approach. Drops are prescribed to prevent infection, control inflammation, and protect the graft.

Recovery and Positioning

Patients are often asked to lie on their back for a period after surgery so the air or gas bubble supports graft attachment. Vision may be blurry at first due to the bubble and early corneal edema, then improves as swelling clears. Follow-up visits confirm graft attachment and monitor eye pressure, since pressure can rise after surgery. If the graft partially detaches, a rebubbling procedure may be needed to improve adherence.

Risks and Complications

Potential complications include graft detachment, primary graft failure, increased eye pressure, infection, and rejection, although rejection rates are generally lower than penetrating keratoplasty. Because DMEK tissue is thinner and more delicate, early detachment and handling-related issues can occur and may require rebubbling. Long-term, ongoing monitoring helps detect pressure problems and late graft changes. Seek urgent care for redness, pain, light sensitivity, discharge, or sudden vision decrease.

FAQs on Endothelial Keratoplasty

What conditions are treated with endothelial keratoplasty?

It is used for diseases that damage the endothelium and cause corneal edema, such as Fuchs endothelial corneal dystrophy and pseudophakic bullous keratopathy. It may also be used for some endothelial failures after prior eye surgery. Your surgeon will confirm whether the corneal swelling is primarily due to endothelial dysfunction.

How long does the air bubble last after surgery?

The bubble gradually absorbs over days to weeks depending on the gas type and volume used. While it is present, vision can be temporarily blurred and you may see a moving line in your vision. Your surgeon will advise on positioning and any restrictions, including when air travel is not allowed if a longer-acting gas was used.

Can the graft detach after DSAEK or DMEK?

Yes. Detachment is one of the more common early issues and may require a rebubbling procedure to reattach the graft. Prompt follow-up helps detect detachment early and protect visual outcomes.

Is rejection still possible with endothelial keratoplasty?

Yes, but it is generally less common than with full-thickness transplants. Because donor endothelium is transplanted, the immune system can react, so monitoring and anti-inflammatory drops remain important. Contact your eye doctor urgently if rejection symptoms appear.

References

Descemet Membrane Endothelial Keratoplasty. EyeWiki. https://eyewiki.org/Descemet_Membrane_Endothelial_Keratoplasty. Date Accessed February 4 2026.

Corneal Endothelial Transplantation. StatPearls (National Library of Medicine, National Institutes of Health). https://www.ncbi.nlm.nih.gov/books/NBK562265/. Date Accessed February 4 2026.

Current Concepts and Recent Trends in Endothelial Keratoplasty. PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC11886285/. Date Accessed February 4 2026.

How Endothelial Keratoplasty Has Revolutionized Current Corneal Transplantation. Taylor & Francis Online. https://www.tandfonline.com/doi/full/10.1080/17469899.2024.2305433. Date Accessed February 4 2026.

Emerging Concepts in Corneal Transplantation. Cataract & Refractive Surgery Today Europe. https://crstodayeurope.com/articles/nov-dec-2023/emerging-concepts-in-corneal-transplantation/. Date Accessed February 4 2026.