Non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK) for Late Endothelial Failure After Mushroom Keratoplasty: A Retrospective Analysis of Visual and Anatomical Outcomes
Abstract
1. Introduction
2. Materials and Methods
2.1. Patient Selection
2.2. Clinical Evaluation and Measurements
2.3. nDSAEK Procedure
2.4. Re-Bubbling
2.5. Statistical Analysis
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Busin, M.; Arffa, R.C. Microkeratome-assisted mushroom keratoplasty with minimal endothelial replacement. Am. J. Ophthalmol. 2005, 140, 138–140. [Google Scholar] [CrossRef]
- Yu, A.C.; Spena, R.; Fusco, F.; Dondi, R.; Myerscough, J.; Fabbri, F.; Bovone, C.; Busin, M. Long-Term Outcomes of Two-Piece Mushroom Keratoplasty for Traumatic Corneal Scars. Am. J. Ophthalmol. 2022, 236, 20–31. [Google Scholar] [CrossRef]
- Moramarco, A.; Fontana, L.; di Geronimo, N.; Rapezzi, G.; Savini, G.; Viola, P.; Mete, M.; Romano, V. A Pilot Case Series on the Use of a Large Mushroom-Shaped Corneal Graft for the Surgical Management of Post-Penetrating Keratoplasty Ectasia and Endothelial Failure. J. Clin. Med. 2025, 14, 343. [Google Scholar] [CrossRef]
- Williams, K.A.; Roder, D.; Esterman, A.; Muehlberg, S.M.; Coster, D.J. Factors predictive of corneal graft survival. Report from the Australian Corneal Graft Registry. Ophthalmology 1992, 99, 403–414. [Google Scholar] [CrossRef]
- Thompson, R.W.; O Price, M.; Bowers, P.J.; Price, F.W. Long-term graft survival after penetrating keratoplasty. Ophthalmology 2003, 110, 1396–1402. [Google Scholar] [CrossRef] [PubMed]
- Wu, J.; Wu, T.; Li, J.; Wang, L.; Huang, Y. DSAEK or DMEK for failed penetrating keratoplasty: A systematic review and single-arm meta-analysis. Int. Ophthalmol. 2021, 41, 2315–2328. [Google Scholar] [CrossRef] [PubMed]
- Jacobi, C.; Zhivov, A.; Korbmacher, J.; Falke, K.; Guthoff, R.; Schlötzer-Schrehardt, U.; Cursiefen, C.; Kruse, F.E. Evidence of endothelial cell migration after descemet membrane endothelial keratoplasty. Am. J. Ophthalmol. 2011, 152, 537–542.e2. [Google Scholar] [CrossRef]
- Böhringer, D.; Böhringer, S.; Poxleitner, K.; Birnbaum, F.; Schwartzkopff, J.; Maier, P.; Sundmacher, R.; Reinhard, T. Long-term graft survival in penetrating keratoplasty: The biexponential model of chronic endothelial cell loss revisited. Cornea 2010, 29, 1113–1117. [Google Scholar] [CrossRef]
- Feizi, S. Corneal endothelial cell dysfunction: Etiologies and management. Ther. Adv. Ophthalmol. 2018, 10, 2515841418815802. [Google Scholar] [CrossRef]
- Barraquer, R.I.; Pareja-Aricò, L.; Gómez-Benlloch, A.; Michael, R. Risk factors for graft failure after penetrating keratoplasty. Medicine 2019, 98, e15274. [Google Scholar] [CrossRef]
- Amouzegar, A.; Chauhan, S.K.; Dana, R. Alloimmunity and Tolerance in Corneal Transplantation. J. Immunol. Baltim. 2016, 196, 3983–3991. [Google Scholar] [CrossRef]
- Ventura, A.C.S.; Wälti, R.; Böhnke, M. Corneal thickness and endothelial density before and after cataract surgery. Br. J. Ophthalmol. 2001, 85, 18–20. [Google Scholar] [CrossRef]
- Da Silva, F.; Linhares, J.M.M.; Lira, M. What intrinsic factors affect the central corneal thickness? Ophthalmic Physiol. Opt. J. Br. Coll. Ophthalmic Opt. Optom. 2025, 45, 315–332. [Google Scholar] [CrossRef]
- Doughty, M.J.; Zaman, M.L. Human corneal thickness and its impact on intraocular pressure measures: A review and meta-analysis approach. Surv. Ophthalmol. 2000, 44, 367–408. [Google Scholar] [CrossRef]
- Wu, Y.; Liu, Y.; Feng, Y.; Li, X.; Lu, Z.; Gu, H.; Li, W.; Hill, L.J.; Ou, S. Evolution of therapeutic strategy based on oxidant-antioxidant balance for fuchs endothelial corneal dystrophy. Ocul. Surf. 2024, 34, 247–261. [Google Scholar] [CrossRef]
- Busin, M.; Madi, S.; Scorcia, V.; Santorum, P.; Nahum, Y. A Two-Piece Microkeratome-Assisted Mushroom Keratoplasty Improves the Outcomes and Survival of Grafts Performed in Eyes with Diseased Stroma and Healthy Endothelium (An American Ophthalmological Society Thesis). Trans. Am. Ophthalmol. Soc. 2015, 113, T1. [Google Scholar]
- Wang, F.; Zhang, T.; Kang, Y.W.; He, J.L.; Li, S.-M.; Li, S.-W.; Shukla, D. Endothelial keratoplasty versus repeat penetrating keratoplasty after failed penetrating keratoplasty: A systematic review and meta-analysis. PLoS ONE 2017, 12, e0180468. [Google Scholar] [CrossRef]
- Keane, M.C.; A Galettis, R.; Mills, R.A.D.; Coster, D.J.; A Williams, K.; For Contributors to the Australian Corneal Graft Registry. A comparison of endothelial and penetrating keratoplasty outcomes following failed penetrating keratoplasty: A registry study. Br. J. Ophthalmol. 2016, 100, 1569–1575. [Google Scholar] [CrossRef] [PubMed]
- del Barrio, J.L.A.; Montesel, A.; Ho, V.; Bhogal, M. Descemet Membrane Endothelial Keratoplasty Under Failed Penetrating Keratoplasty Without Host Descemetorhexis for the Management of Secondary Graft Failure. Cornea 2020, 39, 13–17. [Google Scholar] [CrossRef] [PubMed]
- Pavlovic, I.; Shajari, M.; Herrmann, E.; Schmack, I.; Lencova, A.; Kohnen, T. Meta-Analysis of Postoperative Outcome Parameters Comparing Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Automated Endothelial Keratoplasty. Cornea 2017, 36, 1445–1451. [Google Scholar] [CrossRef] [PubMed]
- Romano, D.; Aiello, F.; Parekh, M.; Levis, H.J.; Gadhvi, K.A.; Moramarco, A.; Viola, P.; Fontana, L.; Semeraro, F.; Romano, V. Incidence and management of early postoperative complications in lamellar corneal transplantation. Graefes Arch. Clin. Exp. Ophthalmol. Albrecht Von Graefes Arch. Klin. Exp. Ophthalmol. 2023, 261, 3097–3111. [Google Scholar] [CrossRef]
- Mitry, D.; Bhogal, M.; Patel, A.K.; Lee, B.S.; Chai, S.M.; Price, M.O.; Price, F.W.; Jun, A.S.; Aldave, A.J.; Mehta, J.S.; et al. Descemet stripping automated endothelial keratoplasty after failed penetrating keratoplasty: Survival, rejection risk, and visual outcome. JAMA Ophthalmol. 2014, 132, 742–749. [Google Scholar] [CrossRef]
- Covert, D.J.; Koenig, S.B. Descemet stripping and automated endothelial keratoplasty (DSAEK) in eyes with failed penetrating keratoplasty. Cornea 2007, 26, 692–696. [Google Scholar] [CrossRef]
- Yamazaki, R.; Nejima, R.; Ichihashi, Y.; Miyata, K.; Tsubota, K.; Shimmura, S. Descemet stripping and automated endothelial keratoplasty (DSAEK) versus non-Descemet stripping and automated endothelial keratoplasty (nDSAEK) for bullous keratopathy. Jpn. J. Ophthalmol. 2020, 64, 585–590. [Google Scholar] [CrossRef] [PubMed]
- Kobayashi, A.; Yokogawa, H.; Sugiyama, K. Non-descemet stripping automated endothelial keratoplasty for endothelial dysfunction secondary to argon laser iridotomy. Am. J. Ophthalmol. 2008, 146, 543–549.e1. [Google Scholar] [CrossRef]
- Mohamed, Y.H.; Uematsu, M.; Inoue, D.; Kitaoka, T. First experience of nDSAEK with heads-up surgery: A case report. Medicine 2017, 96, e6906. [Google Scholar] [CrossRef]
- Moramarco, A.; di Geronimo, N.; Airaldi, M.; Gardini, L.; Semeraro, F.; Iannetta, D.; Romano, V.; Fontana, L. Intraoperative OCT for Lamellar Corneal Surgery: A User Guide. J. Clin. Med. 2023, 12, 3048. [Google Scholar] [CrossRef] [PubMed]
- Matthaei, M.; Sandhaeger, H.; Hermel, M.; Adler, W.; Jun, A.S.; Cursiefen, C.; Heindl, L.M. Changing Indications in Penetrating Keratoplasty: A Systematic Review of 34 Years of Global Reporting. Transplantation 2017, 101, 1387–1399. [Google Scholar] [CrossRef]
- Xiao, G.B.; Tsou, B.C.B.; Soiberman, U.S.; Prescott, C.R.; Srikumaran, D.; Woreta, F.A. Keratoplasty in the United States: Trends and Indications from 2015 to 2020. Cornea 2023, 42, 1360–1364. [Google Scholar] [CrossRef] [PubMed]
- Wilhelm, T.I.; Gauché, L.; Böhringer, D.; Maier, P.; Heinzelmann, S.; Glegola, M.; Betancor, P.K.; Reinhard, T. Ten-year outcomes after DMEK, DSAEK, and PK: Insights on graft survival, endothelial cell density loss, rejection and visual acuity. Sci. Rep. 2025, 15, 1249. [Google Scholar] [CrossRef]
- Ting, D.S.J.; Rana-Rahman, R.; Chen, Y.; Bell, D.; Danjoux, J.-P.; Morgan, S.J.; Ghosh, S.; Baylis, O. Effectiveness and safety of accelerated (9 mW/cm2) corneal collagen cross-linking for progressive keratoconus: A 24-month follow-up. Eye 2019, 33, 812–818. [Google Scholar] [CrossRef]
- Lim, L.; Lim, E.W.L. Current perspectives in the management of keratoconus with contact lenses. Eye 2020, 34, 2175–2196. [Google Scholar] [CrossRef]
- Moramarco, A.; Gardini, L.; Di Mola, I.; di Geronimo, N.; Iannetta, D.; Romano, V.; Hannush, S.B.; Fontana, L. Big-bubble DALK: A technique in evolution. Ocul. Surf. 2024, 34, 418–429. [Google Scholar] [CrossRef] [PubMed]
- Reinhart, W.J.; Musch, D.C.; Jacobs, D.S.; Lee, W.B.; Kaufman, S.C.; Shtein, R.M. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the American academy of ophthalmology. Ophthalmology 2011, 118, 209–218. [Google Scholar] [CrossRef] [PubMed]
- Kiel, M.; Bu, J.B.; Gericke, A.; Vossmerbaeumer, U.; Schuster, A.K.; Pfeiffer, N.; Wasielica-Poslednik, J. Comparison of DMEK and DSAEK in Eyes With Endothelial Decompensation After Previous Penetrating Keratoplasty. Cornea 2021, 40, 1218–1224. [Google Scholar] [CrossRef]
- Roberts, H.W.; de Benito-Llopis, L. Comparison of repeat penetrating keratoplasty, DSAEK and DMEK for the management of endothelial failure of previous PK. Eye Lond. Engl. 2023, 37, 3596–3601. [Google Scholar] [CrossRef]
- Inoue, K. A 10-year review of penetrating keratoplasty. Jpn. J. Ophthalmol. 2000, 44, 139–145. [Google Scholar] [CrossRef]
- Price, F.W.; Price, M.O. Endothelial keratoplasty to restore clarity to a failed penetrating graft. Cornea 2006, 25, 895–899. [Google Scholar] [CrossRef]
- Omoto, T.; Toyono, T.; Inoue, T.; Shirakawa, R.; Yoshida, J.; Miyai, T.; Yamagami, S.; Usui, T. Comparison of 5-Year Clinical Results of Descemet and Non-Descemet Stripping Automated Endothelial Keratoplasty. Cornea 2020, 39, 573–577. [Google Scholar] [CrossRef]
- Kamiya, K.; Asato, H.; Shimizu, K.; Kobashi, H.; Igarashi, A.; Lin, H. Effect of intraocular forward scattering and corneal higher-order aberrations on visual acuity after descemet’s stripping automated endothelial keratoplasty. PLoS ONE 2015, 10, e0131110. [Google Scholar] [CrossRef]
- Kobayashi, A.; Yokogawa, H.; Sugiyama, K. In vivo laser confocal microscopy after non–descemet’s stripping automated endothelial keratoplasty. Ophthalmology 2009, 116, 1306–1313. [Google Scholar] [CrossRef]
- Kobayashi, A.; Mawatari, Y.; Yokogawa, H.; Sugiyama, K. In vivo laser confocal microscopy after descemet stripping with automated endothelial keratoplasty. Am. J. Ophthalmol. 2008, 145, 977–985.e1. [Google Scholar] [CrossRef] [PubMed]
- Lehman, R.E.; Copeland, L.A.; Stock, E.M.; Fulcher, S.F. Graft Detachment Rate in DSEK/DSAEK After Same-Day Complete Air Removal. Cornea 2015, 34, 1358–1361. [Google Scholar] [CrossRef] [PubMed]
- Masaki, T.; Kobayashi, A.; Yokogawa, H.; Saito, Y.; Sugiyama, K. Clinical evaluation of non-Descemet stripping automated endothelial keratoplasty (nDSAEK). Jpn. J. Ophthalmol. 2012, 56, 203–207. [Google Scholar] [CrossRef] [PubMed]
- Price, M.O.; Calhoun, P.; Kollman, C.; Price, F.W.; Lass, J.H. Descemet Stripping Endothelial Keratoplasty: Ten-Year Endothelial Cell Loss Compared with Penetrating Keratoplasty. Ophthalmology 2016, 123, 1421–1427. [Google Scholar] [CrossRef]
- Wajima, H.; Hayashi, T.; Kobayashi, A.; Nishino, T.; Mori, N.; Yokogawa, H.; Yamagami, S.; Sugiyama, K. Graft rejection episodes after keratoplasty in Japanese eyes. Sci. Rep. 2023, 13, 2635. [Google Scholar] [CrossRef]
Variable | Mean ± SD |
---|---|
Number of patients (n) | 18 |
Age (mean years ± SD) | 39.9 ± 13.5 |
Gender (Male/Female) | 8 (44%)/10 (56%) |
Indications for MPK: | |
| 14 (77.7%) |
| 3 (16.7%) |
| 1 (5.6%) |
Interval between MPK and nDSAEK (mean months ± SD) | 37.2 ± 23.9 |
Follow-up duration (mean months) | 18.6 * |
Variable | Preoperative (Mean ± SD) | Postoperative at 3 Months (Mean ± SD) | Postoperative at 6 Months (Mean ± SD) | Postoperative at 12 Months (Mean ± SD) | p-Value |
---|---|---|---|---|---|
BCVA (LogMAR mean ± SD) | 1.40 ± 0.42 | 0.57 ± 0.23 | 0.48 ± 0.19 | 0.46 ± 0.19 | <0.05 |
CCT (µm mean ± SD) | 721 ± 70.12 | 624 ± 45.97 | 611 ± 50.43 | 616 ± 52.80 | <0.05 |
ECD (cells/mm2 mean ± SD) | Not measurable | 1809 ± 82 | 1780 ± 96 | 1748 ± 100 | - |
Variable | Total | Re-Bubbling | No Re-Bubbling |
---|---|---|---|
No. of patients (n) | 18 | 2 (11.1%) | 16 (88.9%) |
BCVA at 12 months (logMAR mean ± SD) | 0.46 ± 0.19 | 0.51 ± 0.27 | 0.46 ± 0.19 |
CCT at 12 months (µm mean ± SD) | 616 ± 52.80 | 641 ± 26.16 | 613 ± 54.94 |
ECD at 12 months (cells/mm2 mean ± SD) | 1748 ± 100 | 1612 ± 28 | 1765 ± 92 |
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Moramarco, A.; di Geronimo, N.; Zimbru, M.S.; Grendele, A.; Biagini, F.; Mete, M.; Romano, V.; Fontana, L. Non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK) for Late Endothelial Failure After Mushroom Keratoplasty: A Retrospective Analysis of Visual and Anatomical Outcomes. J. Clin. Med. 2025, 14, 5568. https://doi.org/10.3390/jcm14155568
Moramarco A, di Geronimo N, Zimbru MS, Grendele A, Biagini F, Mete M, Romano V, Fontana L. Non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK) for Late Endothelial Failure After Mushroom Keratoplasty: A Retrospective Analysis of Visual and Anatomical Outcomes. Journal of Clinical Medicine. 2025; 14(15):5568. https://doi.org/10.3390/jcm14155568
Chicago/Turabian StyleMoramarco, Antonio, Natalie di Geronimo, Marian Sergiu Zimbru, Arianna Grendele, Francesco Biagini, Maurizio Mete, Vito Romano, and Luigi Fontana. 2025. "Non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK) for Late Endothelial Failure After Mushroom Keratoplasty: A Retrospective Analysis of Visual and Anatomical Outcomes" Journal of Clinical Medicine 14, no. 15: 5568. https://doi.org/10.3390/jcm14155568
APA StyleMoramarco, A., di Geronimo, N., Zimbru, M. S., Grendele, A., Biagini, F., Mete, M., Romano, V., & Fontana, L. (2025). Non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK) for Late Endothelial Failure After Mushroom Keratoplasty: A Retrospective Analysis of Visual and Anatomical Outcomes. Journal of Clinical Medicine, 14(15), 5568. https://doi.org/10.3390/jcm14155568