The authors report two cases of interface fungal keratitis following Descemet's stripping automated endothelial keratoplasty (DSAEK). Two patients developed culture-proven interface keratitis with Candida albicans and Candida glabrata following DSAEK. Both patients presented with white interface opacities at approximately 1 month after uncomplicated DSAEK. Adjunct confocal microscopy identified fungal elements prior to surgical therapy. A penetrating keratoplasty was performed in both cases after failed medical therapy with fungal elements confirmed by corneal histopathology. Interface fungal keratitis must be recognized as a potential complication of endothelial keratoplasty. Surgeons should consider corneal donor rim cultures on all endothelial keratopathy cases and confocal microscopy on cases with new interface opacities in the early postoperative period. These measures may lead to early identification and treatment of fungal interface infections.

DSAEK is an effective treatment of endothelial dysfunction. Surgical technique is important to limit endothelial cell loss and prevent complications, such as graft dislocation. The injector device has several advantages over the trifold forceps technique, including decreased endothelial cell loss, graft dislocation rate, and graft failure rate, and it reduces the DSAEK learning curve. DSAEK graft injectors likely will have a role in the future of endothelial keratoplasty.

DSAEK is an effective treatment for endothelial dysfunction, but the learning curve is steep. Anterior chamber stability, graft positioning, and small incision insertion are advantages to our technique. Disadvantages include a relatively high endothelial loss and dislocation rate. Minimizing endothelial cell loss and graft dislocation continue to be important goals for successful DSAEK.