Using DSAEK to Treat Corneal Perforations

Every procedure comes with a cost, and corneal perforation management is a perfect example, with each treatment option carrying its shortcomings.

“Traditional measures used in the management of corneal perforation like glue, amniotic membrane transplantation, conjunctival flaps, and therapeutic penetrating keratoplasty (PK) have significant disadvantages. These include high astigmatism, poor visual outcomes, and the risk of operating on a hot eye,” said Swetha Ravichandran MD.

Dr Ravichandran believes there is a better alternative to these procedures: the mini Descemet stripping automated endothelial keratoplasty (DSAEK), a technique developed by James Myerscough MB, a consultant ophthalmologist and clinical lead at the Mid and South Essex Hospital Trust.

According to Dr Ravichandran, using this procedure can help reduce suture-related complications, shorten surgery time, and spare the visual axis. In some cases, it could also reduce the need for further surgery.

“We pull a mini-DSAEK graft into the eye from a Busin glide via a limbal wound and place it just under the perforation, with subsequent air tamponade,” she explained. “We intentionally microkeratome a thicker graft than in conventional DSAEK to increase the stromal rigidity of the graft and reduce the risk of postoperative prolapse through the perforation.”

To confirm her position, Dr Ravichandran presented a review of five-year outcomes in the first 20 eyes treated using the mini DSAEK technique. Some of the patients, treated across four National Health Service (NHS) sites, had a maximum follow-up of five years; five had undergone a primary DSAEK, while 15 initially received glue before subsequently requiring a tectonic DSAEK.

Perforation size ranged from 0.5 mm to 5.0 mm, graft thickness from 130 μm to 500 μm, and graft diameter from 4.0 mm to 9.0 mm. The surgical procedure was as follows: automated microkeratome (approximately 300 μm), graft trephination (4.0–6.0 mm), tangential trimming to maintain a clear visual axis if required, pull through from Busin glide, anterior chamber air tamponade, and sutureless closure.

This contrasts with other reported tectonic DSAEK techniques, in which the graft is delivered directly through the corneal perforation into the anterior chamber. Such a manoeuvre may enlarge the perforation, requiring subsequent sutures, thus defeating the very premise of using an internal approach.

“The thickness of the graft and its shape, which includes placing a crescentic graft if it is occluding the visual axis, helps to customise it. Regarding tissue conservation, harvest the graft from unused donor material,” Dr Ravichandran said.

She reported that 19 of 20 eyes surveyed in the review had achieved tectonic closure, 16 of which did so without the need for revision. Five patients subsequently underwent mushroom penetrating keratoplasty (PK) to improve their visual outcomes, and 75% of those involved in the review achieved “preoperative or better best-corrected visual acuity.”

“Mini/tectonic DSAEK is a safe, effective, and sutureless option for corneal perforation originating from a range of aetiologies, and the technique is reproducible across independent NHS sites. It spares the visual axis and enables later optical rehabilitation via mushroom PK or deep anterior lamellar keratoplasty on DSAEK,” Dr Ravichandran said.

“Tissue can be harvested pragmatically from unused donor material such as the anterior lamella remaining after a DMEK peel, which is important given national shortages. Prospective multicentre studies are warranted, and microkeratome availability does remain a concern to be addressed.”

Dr Ravichandran presented at the 2026 EuCornea Annual Congress in Porto, Portugal.

Swetha Ravichandran FRCOphth is Locum Consultant Ophthalmologist Corneal at the Mid and South Essex Hospital Trust, UK. swetha.ravichandran@nhs.net