This prospective study compared 5-year outcomes between Descemet stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) in Asian eyes.

Utilizing 20 years of data from the Singapore Cornea Transplant Registry, the authors examined 828 consecutive cases with Fuchs’ endothelial dystrophy or bullous keratopathy. All patients were pseudophakic.

The main outcome measures were BSCVA with astigmatism (cylinder) and spherical equivalent (SE).

Over 5 years of follow-up, DSAEK patients had better BSCVA, lower astigmatism, and lower spherical equivalent (all P<0.001). Of note, Fuchs’ patients fared better than bullous keratopathy patients, with the better BSCVA at 4 years (P=0.006).

In addition, DSAEK cases with better baseline vision had better BSCVA at the end of follow-up (P<0.05).

The authors did not randomize the cohort, which, as the authors state, resulted in the PK group having worse preoperative VA. This could influence the results given that the clinically worse corneas (i.e., higher degrees of scarring) were those that underwent PK.

Surgery was performed by 8 surgeons with varying experience, including supervised fellows, which could have skewed the findings.

This paper further bolsters the role of lamellar surgery, particularly DSAEK, in the treatment of corneal endothelial disease. Early intervention in DSAEK cases appears to be associated with better visual outcomes. The authors also provide further evidence for the visual and astigmatic benefits of lamellar endothelial surgery in select cases.