CORNEA Long-term follow-up of deep anterior lamellar keratoplasty after Descemet stripping automated endothelial keratoplasty Matthias Fuest 1,2 & Sharita R. Siregar 3,4 & Abdelsattar Farrag 3 & Hla Myint Htoon 1,5 & Donald Tan 1,3,5,6 & Jodhbir S. Mehta 1,3,5,7 Received: 5 December 2017 /Revised: 19 March 2018 /Accepted: 20 April 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Aims To describe the long-term outcomes of deep anterior lamellar keratoplasty (DALK) performed after Descemet stripping automated endothelial keratoplasty (DSAEK) in cases of infection and residual stromal opacity. Methods Ten eyes of nine consecutive patients undergoing DALK after DSAEK at a single tertiary referral center (SNEC) from 2011 to 2016 were analyzed for best spectacle-corrected visual acuity (BSCVA), refraction, spherical equivalent (SE) and cylinder, as well as graft diameters, survival, and complications. Results The mean pre-DSAEK BSCVA was 1.73 ± 0.76 LogMAR. At a mean follow-up of 9.8 ± 7.1 months, visual acuity had improved significantly (p = 0.028) to 1.09 ± 0.55 LogMAR after DSAEK. DALK was performed at 10.3 ± 7.2 months after DSAEK because of residual stromal scarring in nine and a corneal infection in one case. At the last follow-up visit (19.4 ± 13.9 months) after DALK, BSCVA had improved to 0.38 ± 0.6 LogMAR, significantly better than after DSAEK alone (p = 0.015) and before DSAEK (p = 0.018). Spherical equivalent (- 4.8 ± 3.5 D) and cylinder (- 2.5 ± 2.0 D) did not show significant changes compared to after DSAEK (SE p = 0.17; cylinder p = 0.19) or 3 months after DALK (SE p = 0.17; cylinder p = 0.46). One endothelial graft failed 3 months after DALK. Kaplan-Meier estimated average survival for all cases was 45.3 (95% CI 36.6– 54.0) months. The cumulative survival probability for the entire cohort was 90% at 1, 2, and 4 years of follow-up. Conclusions DALK surgery after DSAEK can improve vision in cases of residual host scarring and treat host corneal infection, while avoiding open-sky surgery and sparing a healthy endothelial graft. Keywords Cornea . Wound healing . Vision . Treatment surgery Introduction Endothelial dysfunction is the most frequent indication for cor- neal transplantation [1, 2]. Endothelial keratoplasty (EK) has become the gold standard treatment for corneal endothelial dys- function, as it combines several major advantages over penetrat- ing keratoplasty (PK), including more rapid visual recovery, su- perior postoperative refractive outcomes, reduced rates of rejec- tion, and increased postoperative wound strength [1, 2]. Snellen best spectacle-corrected visual acuity (BSCVA) after Descemet stripping automated endothelial keratoplas- ty (DSAEK) ranges from 20/34 to 20/66 depending on the duration of follow-up [1]. In terms of visual recovery, 38– 100% of eyes achieved 20/40 or better by 20 months after surgery [1], while up to 47% could achieve BCVA 20/20 or better at 36 months [3]. However, this implies that more than 50% of DSAEK eyes with no other comorbidities may not achieve 20/20 vision. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00417-018-3997-6) contains supplementary material, which is available to authorized users. * Jodhbir S. Mehta jodmehta@gmail.com 1 Singapore Eye Research Institute, Singapore, Singapore 2 Department of Ophthalmology, RWTH Aachen University, Aachen, Germany 3 Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, Singapore 4 Jakarta Eye Center, Jakarta, Indonesia 5 Eye-ACP, Duke-NUS Graduate Medical School, Singapore, Singapore 6 Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore 7 School of Material Science and Engineering, Nanyang Technological University, Singapore, Singapore Graefe's Archive for Clinical and Experimental Ophthalmology https://doi.org/10.1007/s00417-018-3997-6