Tissue Complications During Endothelial Keratoplasty

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