Determinants of visual quality after endothelial keratoplasty

Abstract

Endothelial keratoplasty is now favored over full-thickness penetrating keratoplasty for corneal decompensation secondary to endothelial dysfunction. Although endothelial keratoplasty has evolved as surgeons strive to improve outcomes, fewer patients than expected achieve best corrected visual acuity of 20/20 despite healthy grafts and no ocular comorbidities. Reasons for this remain unclear, with theories including anterior stromal changes, differences in graft thickness and regularity, induced high order aberrations, and the nature of the graft-host interface. Newer iterations of endothelial keratoplasty such as thin manual DSEK, ultrathin DSAEK, and DMEK have achieved rates of 20/20 acuity of approximately 50%, comparable to modern cataract surgery , and it may be that a ceiling exists, particularly in the older age group of patients. Establishing the relative contribution of the factors that determine visual quality following endothelial keratoplasty will help drive further innovation, optimising visual and patient-reported outcomes while improving surgical efficacy and safety.

Fuchs’ endothelial corneal dystrophy: a controlled prospective study on visual recovery after endothelial keratoplasty

“…In a recent review, it was concluded that the limiting factor of vision after DSAEK remains unknown (Turnbull et al. ). Here, we used a prospective design and a repeated‐measures mixed model that incorporated data from all time‐points.…”

“…A recent review concluded that the reason for limited visual outcome after DSAEK remains uncertain (Turnbull et al. ).…”

A review of the evidence for in vivo corneal endothelial regeneration

“…145 Despite all these advantages, the visual results in some patients may be less than optimal even with fully functional grafts with no ocular comorbidities, suggesting that there is a ceiling on what can be achieved in some cases. 134…”

“…It is also possible that simple corneal endothelial stripping, if successful, could address some of the limiting factors in achieving the highest visual outcomes seen in EK surgery. 134 Reforming the endothelial barrier without the use of donor tissue could reduce the higher order aberrations and light scatter that are known to reduce visual acuity after DSAEK as well as remove any scatter caused by a donor-host interface. 107 On the other hand, the prolonged edema that persists until the endothelium closes could induce anterior corneal stromal changes that may be more detrimental to long-term visual acuity.…”

Fuchs' endothelial corneal dystrophy: pathology and treatment outcome

“…In a recent review on the matter, it was concluded that the limiting factor of vision after DSAEK remains unknown (Turnbull et al. ).…”