Deep anterior lamellar keratoplasty after descemet stripping automated endothelial keratoplasty

Purpose: To report, using 2 illustrative cases, a new technique in which deep anterior lamellar keratoplasty (DALK) is performed after Descemet stripping automated endothelial keratoplasty (DSAEK) for cases of residual stromal opacity after the resolution of corneal endothelial failure. Method: DSAEK was performed in 2 eyes with endothelial failure and stromal opacities of uncertain visual significance. After surgery, visual acuity failed to adequately improve. Residual stromal opacities were present in each case. Best-corrected visual acuity after DSAEK was 20/100 in case 1 and 20/200 in case 2. Subsequently, both cases underwent DALK. Results: Surgeries and postoperative courses were uneventful in each case. After DALK, best-corrected visual acuity improved to 20/30 (-1.0/-4.0 Ã 90 degrees) at 9 months in case 1 and remained stable during a total of 24 months. In case 2, best-corrected visual acuity increased to 20/40 at 6 months (+2.00/-6.00 Ã 40 degrees). Conclusions: A new approach has been used to preserve the healthy DSAEK graft in these eyes with significant residual corneal opacities after the resolution of endothelial failure. Corneal clarity was reestablished by substituting the host central corneal stroma in its entire thickness with donor tissue, thus performing a DALK in addition to a DSAEK and avoiding a second intraocular surgery.