Post-DSAEK optical changes: a comprehensive prospective analysis on the role of ocular wavefront aberrations, haze, and corneal thickness.

Endothelial keratoplasty is now the surgical treatment of choice for endothelial failure. Currently, 89% of patients with Fuchs’ endothelial dystrophy and 55% of patients with post-cataract corneal edema are treated with endothelial keratoplasty. 1 Yet, visual performance is often sub-optimal following Descemet’s stripping with automated endothelial keratoplasty (DSAEK), and efforts aimed at understanding the optical causes of these limitations is ongoing.2 The main causes of optical degradation in the cornea are optical aberrations and light scatter. Because of the change in the corneal contour associated with the addition of the donor lenticule in DSAEK it is not surprising that corneal wavefront aberrations, particularly from those arising from the posterior corneal surface, are increased.3-7 While corneal videokeratography/topography measurements allow for quantification of the anterior and posterior corneal aberrations, any potential aberrations induced by the graft/host interface are missed. Furthermore, the quality of vision ultimately depends not only on the cornea, but on the entire optical system (including the lens and media). As such, when assessing the impact of aberrations on retinal image quality and visual performance, it is more appropriate to study whole eye aberrations. Corneal light scatter has also been reported within anterior stroma and interface post-DSAEK and has thus been implicated as a factor limiting visual performance.8-15 Additionally, there has been great interest in whether corneal thickness plays a role in post-DSAEK visual performance; to date, this remains a point of contention.14, 16-19 Although we know that visual acuity outcomes continue to improve over the first three years post-DSAEK,20 the relative role of aberrations and light scatter in this improvement is poorly understood. We sought to conduct a prospective study, in which operative variables (e.g. surgical technique and graft size) and follow-up time points were controlled, to quantify ocular aberrations, corneal light scatter, and corneal thickness, and to assess their contributions to changing visual performance with time post-DSAEK.