title: Identifying causes for poor visual outcome after DSEK/DSAEK following secondary DMEK in the same eye.
abstract: OBJECTIVE
  To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and to determine whether such eyes can be successfully 'repaired' with a secondary Descemet membrane endothelial keratoplasty (DMEK).
  
  
  METHODS
  Twelve eyes of 12 patients, who underwent secondary DMEK to manage poor visual outcome after initial DSEK/DSAEK, were evaluated with biomicroscopy, Pentacam imaging, and specular and confocal microscopy, before and at 1, 3 and 6 months after DMEK.
  
  
  RESULTS
  Four causes of reduced optical quality of the transplanted host cornea could be identified in DSEK/DSAEK: five eyes (42%) showed large host-Descemet remnants within the visual axis during surgery; six eyes (50%) irregular graft thickness; six eyes subtle 'stromal waves'; and nine eyes (75%) high reflectivity at the donor-to-host interface. After DMEK graft replacement, all corneas cleared and achieved a best corrected visual acuity of ≥20/25 (≥0.8), except for one with a partial Descemet graft detachment. Pachymetry values decreased from 670 (±112) μm before to 517 (±57) μm after secondary DMEK. Higher-order aberrations (Coma and Trefoil) at the posterior surface tended to be lower (p = 0.07) in DMEK grafts than in DSEK/DSAEK grafts.
  
  
  CONCLUSIONS
  Host-Descemet remnants at the donor-to-host interface, interface reflectivity, graft thickness irregularity and donor stromal contraction may contribute to poor visual outcome after DSEK/DSAEK, without causing permanent host corneal damage, as in most cases, complete visual recovery could be achieved by performing a secondary DMEK.
authors.affiliation: The Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands.
authors.forename: Martin
authors.initials: M
authors.lastname: Dirisamer
authors.forename: Jack
authors.initials: J
authors.lastname: Parker
authors.forename: Miguel
authors.initials: M
authors.lastname: Naveiras
authors.forename: Vasilios S
authors.initials: VS
authors.lastname: Liarakos
authors.forename: Lisanne
authors.initials: L
authors.lastname: Ham
authors.forename: Korine
authors.initials: K
authors.lastname: van Dijk
authors.forename: Gerrit R J
authors.initials: GR
authors.lastname: Melles
mesh_terms: D000328:Adult; D000368:Aged; D063171:Corneal Pachymetry; D019781:Corneal Topography; D057111:Descemet Stripping Endothelial Keratoplasty; D005260:Female; D005642:Fuchs' Endothelial Dystrophy / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D018613:Microscopy, Confocal; D008875:Middle Aged; D011183:Postoperative Complications; D019233:Retreatment; D014786:Vision Disorders / Q000209:etiology* / Q000503:physiopathology; D014792:Visual Acuity / Q000502:physiology*