CLINICAL SCIENCE Descemet Stripping Automated Endothelial Keratoplasty Using Donor Corneas With Previous Laser In Situ Keratomileusis or Photorefractive Keratectomy: A Case Series and Donor Cap Histopathology Majid Moshirfar, MD,* Yousuf M. Khalifa, MD,† Don Davis, MD,* Carlton R. Fenzl, BS,* Ladan Espandar, MD,* JoAnn C. Chang, MD,* Nick Mamalis, MD,* and Mark D. Mifflin, MD† Purpose: To report outcomes in Descemet stripping automated endothelial keratoplasty (DSAEK) using donor tissue from eyes that have had previous refractive surgery and to report histopathology of the donor free cap. Methods: Retrospective case series. Preoperative and postoperative data were collected on each patient, and donor information was collected. Histopathologic evaluation was carried out on donor caps to determine the stability of the laser in situ keratomileusis (LASIK) flap and smoothness of the microkeratome cut during preparation of the donor. Results: DSAEK was performed on 7 eyes using donors that had undergone photorefractive keratectomy (PRK) or LASIK. One patient received PRK donor tissue, had no interface haze, and had improvement in vision. All but one patient who received LASIK donor tissue had improvement in vision, and that patient had severe graft folds noted intraoperatively that persisted. Histopathologic examination of 3 donor caps showed mild to moderate dehiscence of the LASIK flap, but the cut interface was consistent with normal donor tissue preparation histopathology. Conclusions: We report the first case of DSAEK using PRK donor tissue, which was successful. Our experience with LASIK donor tissue was comparable to nonrefractive donor tissue with the exception of the persistent donor macrofolds in one patient. Key Words: DSAEK, LASIK, PRK, Fuchs dystrophy, endothelial transplantation, endothelial dystrophy (Cornea 2012;31:533–537) D escemet stripping automated endothelial keratoplasty (DSAEK) is quickly becoming the treatment of choice for patients suffering from endothelial dysfunction. 1 The Eye Bank Association of America reports that the donor tissue used in endothelial keratoplasty procedures increased from 1429 in 2005 to 17,468 in 2008. 2 Donors with a history of corneal refractive surgery were considered substandard for corneal transplantation before the widespread acceptance of the endothelial keratoplasty techniques, and it is fortuitous that the increase in endothelial keratoplasty procedures is con- comitant with the likely increase in the donor pool of corneas that have undergone laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK). Preparation of the DSAEK button with donor corneas that previously underwent LASIK has been reported in the literature, and no significant difference in the preoperative pre- paration and postoperative results of endothelial keratoplasty using these donors were reported. 3,4 We report the first case of DSAEK using a PRK donor cornea and 6 cases of DSAEK using LASIK donor cornea along with histopathology of 3 LASIK donor caps from DSAEK microkeratome preparation. MATERIALS AND METHODS Surgical Technique For the DSAEK donor preparation, a Moria ALTK- CBm artificial chamber maintainer (Doylestown, PA) with the available microkeratome heads (300 and 350 mm) was used. The LASIK flap hinge was identified in the viewing chamber (Fig. 1) and marked with a surgical marking pen before mounting on the anterior chamber maintainer. After adequate pressures were maintained, pachymetry was performed cen- trally. Microkeratome cuts were started at the hinge site to minimize the shearing forces on the LASIK flap. The free cap was then removed and submitted in formalin for histopathol- ogy analysis. The residual stromal bed was measured, and the donor tissue was punched with a corneal punch. The DSAEK surgery then proceeded as described previously. 1 Pathology Evaluation Anterior donor free caps were submitted in formalin for histopathology evaluation. Specimens were dehydrated with graded alcohol baths culminating in a xylene bath and Received for publication September 17, 2009; revision received June 30, 2010; accepted August 10, 2010. From the *Moran Eye Center, University of Utah, Salt Lake City, UT; and †Flaum Eye Institute, University of Rochester, Rochester, NY. Supported in part by an unrestricted educational grant from Allergan, Inc, Irvine, CA, and Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology and Visual Sciences at the John A. Moran Eye Center, University of Utah, Salt Lake City, UT. Reprints: Majid Moshirfar, Moran Eye Center, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT (e-mail: majid.moshirfar@hsc.utah.edu). Copyright Ó 2012 by Lippincott Williams & Wilkins Cornea  Volume 31, Number 5, May 2012 www.corneajrnl.com | 533