Corneal
Endothelial Transplant
(DSAEK, DMEK & DLEK)
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DVD Contents
DSAEK Surgical Techniques
1. Animation M Hodgkin MD
2. Surgery M Gorovoy MD
3. Surgery M Gorovoy MD
4. Surgery M Busin MD
5. Surgery F Price MD
6. Surgery T John MD
7. Donor Cornea T John MD
8. Instruments T John MD
9. Instruments T John MD
10. Instruments T John MD
11. Instruments T John MD
12. Instruments T John MD
13. Instruments T John MD
14. Surgery M Terry MD
Editor
Thomas John MD

Clinical Associate Professor
Loyola University at Chicago, Maywood, Illinois, USA
Visiting Professor, Department of Defense
Military Medical Academy, Belgrade, Serbia
Thomas John Vision Institute, Tinley Park and Oak Lawn, Illinois, USA
Chicago Cornea Research Center, Tinley Park, Illinois, USA
Corneal
Endothelial Transplant
(DSAEK, DMEK & DLEK)
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Corneal Endothelial Transplant (DSAEK, DMEK & DLEK)
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To God of all faiths and religions.
I give all credit to God, Jesus Christ,
without whom I am nobody.
To my wife, Annita and my kids Michelle,
Andrea and Olivia for all their loving support.
To my parents for their love and guidance.
To all the teachers in this world for their
immense contribution to society.

Contributors
Richard L Lindstrom MD
Founder and Attending Surgeon
Minnesota Eye Consultants
Adjunct Professor Emeritus
Department of Ophthalmology
University of Minnesota, Associate
Director, Minnesota Lions Eye Bank, USA
Foreword
Roger F Steinert


MD
Professor of Ophthalmology, Professor of
Biomedical Engineering, Director of
Cornea, Refractive & Cataract Surgery,
Vice Chair of Clinical Ophthalmology,
Department of Ophthalmology
University of California, Irvine, CA, USA
Introduction, Chapter 5
Kenneth R Kenyon MD
Founder, Cornea Consultants
International, Boston, USA, & Munich,
Germany, Associate Clinical Professor of
Ophthalmology, Harvard Medical School,
Boston, MA, USA, Senior Scientist,
Schepens Eye Research Institute, Boston,
MA, USA, Eye Health Vision Centers,
North Dartmouth, MA, USA
Chapter 39
Thomas John

MD
Clinical Associate Professor, Loyola
University at Chicago, Maywood, Illinois,
USA, Thomas John Vision Institute, Tinley
Park and Oak Lawn, Illinois, USA, Chicago
Cornea Research Center, Tinley Park
Illinois, USA
Editor and Chapters 10, 11, 12, 13, 14, 23, 27,
28, 29, 31, 32, 39
Jay S Pepose


MD
,
PhD
Pepose Vision Institute, St. Louis, MO,
USA; Department of Ophthalmology and
Visual Sciences, Washington University
School of Medicine, St. Louis, MO, USA
Chapter 1
Mujtaba A Qazi

MD
Pepose Vision Institute, St. Louis, MO,
USA; Department of Ophthalmology and
Visual Sciences, Washington University
School of Medicine, St. Louis, MO, USA
Chapter 1
Wisam A Shihadeh MD
Assistant Professor/Medical School
Jordan University of Science & Technology
Consultant in Glaucoma, Cornea &
Refractive Surgery
King Abdullah University Hospital
Irbid, Jordan
Chapter 2
Almamoun Abdelkader

MD
Assistant Lecturer of Ophthalmology
Faculty of Medicine, Al-Azhar University

Hospitals, Cairo, Egypt
Chapter 2
Herbert E Kaufman

MD
Byod Professor of Ophthalmology;
Pharmacology & Experimental
Therapeutics; Microbiology, Immunology
& Parasitology
Louisiana State University Health Sciences
Center in New Orleans, LSU Eye Center
New Orleans, LA, USA
Chapter 2
Pedram Hamrah MD
Senior Fellow, Cornea and Refractive
Surgery, Massachusetts Eye & Ear
Infirmary and Department of
Ophthalmology
Harvard Medical School
Boston, MA, USA
Chapter 3
Eric C Amesbury

MD, FACS
Corneal Fellow
Department of Ophthalmology & Visual
Sciences, University of Louisville,
Louisville, KY, USA
Chapter 3
Richard A Eiferman


MD, FACS
Clinical Professor of Ophthalmology
Department of Ophthalmology & Visual
Sciences, University of Louisville,
Louisville, KY, USA
Chapter 3
George Baikoff

MD
Clinique Monticelli, Marseille, France
Chapter 4
Leejee H Suh MD
Assistant Professor of Clinical
Ophthalmology
Cornea and External Diseases
Bascom Palmer Eye Institute
Miami, FL, USA
Chapter 6
William W Culbertson MD
Professor of Ophthalmology
The Lou Higgins Distinguished Chair in
Ophthalmology, Bascom Palmer Eye
Institute, University of Miami School of
Medicine, Cornea and External Diseases,
Miami, FL, USA
Chapter 6
Ronald H Silverman

PhD

Professor of Computer Science in
Ophthalmology
Research Director, Bioacoustic Research
Facility, Department of Ophthalmology
Weill Medical College of Cornell University
New York, NY, USA
Member Research Staff
Frederic L. Lizzi Center for Biomedical
Engineering
Riverside Research Institute
New York, NY, USA
Chapter 7
Monica Patel

MD
Research Fellow, Bioacoustic Research
Facility, Weill Medical College of Cornell
University, New York, NY, USA
Chapter 7
Omer Gal
Research Fellow, Bioacoustic Research
Facility, Weill Medical College of Cornell
University, New York, NY, USA
Chapter 7
Harriet O Lloyd
Research Associate
Department of Ophthalmology
Weill Medical College of Cornell
University,
New York, NY, USA

Chapter 7
D Dan Z Reinstein
MD, MA(Cantab) FRCSC, FRCOphth
London Vision Clinic, London, UK;
Department of Ophthalmology, St.
Thomas’ Hospital - Kings College,
London, UK; Department of
Ophthalmology, Weill Medical College of
Cornell University, NY, USA
Chapter 7
D Jackson Coleman MD, FACS
The John Milton McLean Professor of
Ophthalmology, Chairman Emeritus
Department of Ophthalmology, Weill
Cornell Medical College of Cornell
University, NY, USA
Chapter 7
Jasmeet S Dhaliwal

MD
Henry Ford Health System, Department
of Ophthalmology, Cornea and Refractive
Surgery, Troy, MI, USA
Chapter 8
Auguste G-Y Chiou MD
Clinical Associate Professor
LSU Eye Center, Av.de Montbenon 2
1003 Lausanne, Switzerland
Chapter 8
Stephen C Kaufman


MD,

PhD
Professor and Lyon Endowed Chair of
Ophthalmology
Director of Cornea and Refractive Surgery
University of Minnesota
420 Delaware St. SE, MMC-493
Minneapolis, MN 55455, USA
Chapter 8
Corneal Endothelial Transplant
viii
Ramagopal Rao

PhD
Executive Chairman
3D Vision Systems, LLC
Irvine, CA, USA
Chapter 9
David Miller MD
Associate Clinical Professor of
Ophthalmology, Harvard Medical School
Boston, MA, USA; Founder and Chief
Medical Officer, 3D Vision Systems, LLC
Irvine, CA, USA
Chapter 9
Enrique S Malbran

MD

Director of the Clínica Oftalmológica
Malbran.
President of the Fundación Oftalmológica
Argentina Jorge Malbran.
Chattered Member of the Academia
Nacional de Medicina de Buenos Aires,
Argentina
Chapter 13
Mark A Terry

MD
Director, Devers Eye Institute, Portland,
OR, USA; Scientific Director, Lions Vision
Research Laboratory of Oregon, Portland,
OR, USA; Professor of Clinical
Ophthalmology, Oregon Health Sciences
University, Portland, OR, USA
Chapters 14, 15, 16, 17, 20
Luiz F Regis-Pacheco MD
Cornea and External Disease Service
Department of Ophthalmology
University of the State of Rio de Janeiro
Rio de Janeiro, Brazil
Chapter 14
José G Pecego MD
Cornea Service
Department of Ophthalmology
Federal University of Rio de Janeiro
Rio de Janeiro, Brazil
Chapter 14

Paula J Ousley MT
Past Research Director
Lions Vision Research Laboratory of
Oregon
Portland, Oregon, USA
Chapter 15
Contributors
ix
Ashraf Amayem MD
Consultant Ophthalmologist
Director of Cornea & Refractive Surgery
Unit, Magrabi Eye Center, Jeddah
Saudi Arabia
Chapter 18
Magdi Helal MD
Consultant Ophthalmologist
Director of Glaucoma Unit
Magrabi Eye Center
Jeddah, Saudi Arabia
Chapter 18
Anastasios John Kanellopoulos

MD
Associate Professor of Ophthalmology
NYU Medical School, New York
NY, USA, Director, Laser Vision Institute
Athens, Greece
Chapter 19
Massimo Busin


MD
Head, Department of Ophthalmology
Villa Serena Hospital
Forli, Italy
Professor of Ophthalmology, University
of Bonn, Germany
Clinical Professor of Ophthalmology
University of Catanzaro, Italy
Chapter 21, 37
Vincenzo Scorcia MD
Villa Serena Hospital
Department of Ophthalmology
Forli, Italy
Chapter 21
Marianne O Price

PhD, MBA
Executive Director, Cornea Research
Foundation of America, Indianapolis, IN
USA
Chapter 22
Francis W Price MD
President, Price Vision Group
Indianapolis, IN, USA
Chapter 22
Mark S Gorovoy

MD
Gorovoy
MD

Eye Specialists’ Office
Fort Myers, FL, USA
Chapters 24, 33
Keith A Walter MD
Associate Professor of Ophthalmology
Wake Forest University Eye Center
Winston-Salem, NC, USA
Chapter 25
Marshall E Tyler
Wake Forest Univeristy Eye Center
Winston-Salem
NC, USA
Chapter 25
Ciro Tamburrelli

MD
Head, Ospedale Oftalmico di Roma,
Rome, Italy
Chapter 26
Agostino Salvatore Vaiano

MD
Ophthalmologist
Ospedale Oftalmico di Roma
Rome, Italy
Chapter 26
Emilio Balestrazzi

MD
Head of Ophthalmology Institute, Catholic

University of Rome, Rome, Italy
Chapter 26
Anthony Kuo

MD
Fellow, Cornea and Refractive Surgery
Duke University Eye Center, Durham
NC, USA
Chapter 30
Terry Kim MD
Associate Professor of Ophthalmology
Duke University School of Medicine
Director of Fellowship Programs
Associate Director
Cornea and Refractive Surgery
Duke University Eye Center Durham
NC, USA
Chapter 30
Juan M Castro-Combs

MD
Post-Doctoral Fellow, Cornea and
Refractive Surgery Services, The Wilmer
Ophthalmological Institute, The Johns
Hopkins University School of Medicine
The Johns Hopkins Hospital, Baltimore
MD
, USA
Chapters 34, 35
Naima B Jacobs-El

The Wilmer Eye Institute
The Johns Hopkins University
School of Medicine
Baltimore,
MD
, USA
Chapters 34, 35
Ashley Behrens MD
Assistant Professor of Ophthalmology
Cornea and Refractive Surgery Services
The Wilmer Ophthalmological Institute
The Johns Hopkins University School of
Medicine, The Johns Hopkins Hospital
Baltimore MD, USA
Chapters 34, 35
Corneal Endothelial Transplant
x
Panagiotis Georgoudis MRCOphth
Ophthalmology Resident, St Peter’s
Hospital, Chertsey, Surrey, UK
St Peter’s Hospital
Guildford Road, Chertsey
Surrey, KT16 0PZ, UK
Chapter 36
Michael J Tappin

FRCOphth
Ophthalmic Specialist, St Peter’s Hospital
Chertsey, Surrey, UK
Chapter 36

Jui-Yang Lai

PhD
Assistant Professor, Institute of
Biochemical and Biomedical Engineering
Chang Gung University, Taoyuan
Taiwan, Republic of China; Molecular
Medicine Research Center, Chang Gung
University, Taoyuan, Taiwan
Republic of China
Chapter 38
Ging-Ho Hsiue

PhD
Department of Chemical Engineering
National Tsing Hua University, Hsinchu
Taiwan, Republic of China
Chapter 38
Contributors
xi

Foreword
At the current moment, keratoplasty is undergoing an incredible paradigm shift in surgical
technique. A field dominated by Penetrating Keratoplasty, where advances such as improved
trephination systems, corneal preservation media, and suturing techniques while meaningful,
have clearly been only incremental, is simultaneously going lamellar, minimally invasive,
and sutureless. Lead by the extraordinary success of Deep Lamellar Endothelial Keratoplasty
(DLEK), the concept of transplanting only the corneal layer which is diseased or damaged
and needs replacing is gaining significant traction amongst corneal surgeons worldwide.
Replacing the corneal endothelium only in a patient with Pseudophakic/ Aphakic Bullous

Keratoplasty or Fuchs’ Dystrophy rather than replacing the entire cornea with a full-thickness
Penetrating Keratoplasty has gone from the research interest of a few pioneering surgeons to mainstream in an amazingly
short time. In addition to DLEK, we now have Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)
competing for our attention.
At the same time, the Intralase femtosecond laser is being harnessed in an attempt to make Penetrating Keratoplasty
more precise with the promise of more predictable refractive outcomes. It is truly not only an exciting time for the corneal
surgeon, but also a demanding one requiring the rapid assimilation of new knowledge as well as the development of new
surgical skills.
Fortunately, Thomas John MD has produced for us a timely and outstanding educational offering in his new book
“Corneal Endothelial Transplant (DSAEK, DMEK & DLEK)”. This very comprehensive book includes the history of
lamellar transplantation; an in-depth discussion of the basic science of corneal structure, physiology, biomechanics and
pathology; a primer on advanced corneal imaging; a review of the surgical instrumentation required; and of utmost
importance, detailed instruction by the leaders in the field on the current best practices of surgical technique and
complications management. A final section provides an enticing glimpse to the future.
This book is complete enough to serve the corneal fellow well and advanced enough for even the most accomplished
corneal surgeons to include in their personal library. Thank you, Dr John and colleagues, for providing we corneal
surgeons with such an extraordinary educational resource.
Richard L Lindstrom
MD
Founder and Attending Surgeon
Minnesota Eye Consultants
Adjunct Professor Emeritus
Department of Ophthalmology, University of Minnesota
Associate Director, Minnesota Lions Eye Bank, USA

Preface
This book entitled, Corneal Endothelial Transplant (DSAEK, DMEK & DLEK) is dedicated to the new way of performing
corneal transplantation namely, without the use of corneal sutures and an absence of a full-thickness corneal wound.
Such a move towards advanced corneal replacement surgery eliminates the induction of much disliked corneal astigmatism.
Such a textbook provides the corneal surgeon with a variety of surgical techniques and instrumentation that will be a

useful surgical resource for posterior lamellar keratoplasty procedures.
For several decades, full-thickness penetrating keratoplasty (PKP) has dominated the field of corneal transplantation
and has remained as the gold standard for corneal replacement surgery. However, the time has come when improved
lamellar corneal techniques has re-appeared in the global horizon as a rapidly popular surgical technique and is beginning
to challenge and possibly replace PKP as the gold standard in the times ahead. The editor has previously introduced a
new term namely, Selective Tissue Corneal Transplantation (STCT) which may become the procedure of choice in many
corneal disease processes. Why remove the whole cornea when the pathology may be limited regionally to either the front,
middle or back part of the cornea? I have previously edited two books that covered both anterior and posterior lamellar
keratoplasty, entitled, Surgical Techniques in Anterior and Posterior Lamellar Corneal Surgery, and Step by Step Anterior and
Posterior Lamellar Keratoplasty. Due to the increasing popularity of posterior lamellar keratoplasty among corneal surgeons
all over the world and the rapidly changing and evolving sutureless corneal transplantation techniques, this book
collectively provides the reader with a wide assortment of surgical techniques from world leaders in the field of sutureless
corneal transplantation as we know it today (at the time of writing this book). This book has numerous color photographs
to assist in fully understanding the various surgical techniques described in the text. The editor and contributors have
made it their priority to present the surgical techniques in a way that is easily understood by the readers of this textbook.
This surgical text consists of 11 sections and 39 chapters. In Section 1, new areas of interest such as corneal hysteresis
and biomechanical properties of the normal cornea are described. In addition, corneal physiology is covered. Also described
in this section is the most important layer of the cornea that is responsible for corneal clarity, namely, corneal endothelium,
both in health and in the disease state.
In Section 2, new ways of imaging the human cornea are described. In vivo, real-time imaging of the cornea provides
useful information both before and after surgery. This includes, Optical Coherence Tomography (OCT), Very High Frequency
(VHF) ultrasound and confocal microscopy. The area of imaging covers both the cornea and the anterior segment.
Section 3 presents the new generation operating microscope. This futuristic microscope provides a 3D perspective that
is novel and may change the way we perform ophthalmic surgery in the future. Also included in this section is the use of
intraoperative surgical slit-lamp microscope to assist in lamellar corneal surgery, namely, both anterior and posterior
lamellar keratoplasty.
The next section deals with the various new and useful surgical tools for the corneal surgeon to assist in performing
sutureless corneal transplantation. Much like a paint brush is to an artist, so is the proper surgical instrument to the
surgeon that will help in consistently performing high quality surgical work. It is not enough to have the best microscope
and operating room setup. Equally or more important are the appropriate surgical instruments. This section describes the

various surgical instruments that are commercially available to assist in performing posterior lamellar keratoplasty.
Section 5 deals with an essential and important part of the instrumentation to perform posterior lamellar keratoplasty,
namely, the artificial anterior chamber. A good understanding of the various types of artificial anterior chambers that are
available will help the surgeon doing posterior lamellar keratoplasty. Both non-disposable and disposable types of
artificial anterior chambers are described in this section of the book. This is especially important when the surgeon prefers
to cut his or her own donor corneal tissue in the operating room rather than to use the corneal tissue that are pre-cut by eye
bank technicians and supplied by the various eye banks in the United States for an additional fee. Newly introduced in
the United States is a reimbursement code for surgeons preparing and cutting their own donor corneal disk for DSAEK, in
addition to the DSAEK code for the DSAEK surgery.
Section 6 deals with the definition, various terminologies, and classification of lamellar corneal surgery. This includes
both the anterior and posterior lamellar keratoplasty. A good understanding of these terminologies that are currently in
use will be beneficial to the lamellar surgeon and to all those interested in the field of lamellar corneal surgery.
It is of great interest to go back in time and learn what the pioneers in the field of lamellar keratoplasty had to go through
in order to arrive at the present-day surgical techniques that have simplified the posterior lamellar keratoplasty procedure.
Such improved and simplified posterior lamellar techniques have fuelled the interest in lamellar surgery among corneal
surgeons all over the world and their continued rapid conversion from the familiar, full-thickness penetrating keratoplasty
to the not so familiar sutureless corneal transplantation. In this regard, Section 7 covers the history of lamellar and
penetrating keratoplasty.
Section 8 covers various aspects of Deep Lamellar Endothelial Keratoplasty (DLEK), including the large incision
technique, small incision technique, combined phacoemulsification along with DLEK and there is a final chapter in this
section that describes DLEK along with scleral-fixated posterior chamber intraocular lens implant.
Section 9 is of great interest to all corneal surgeons looking at Descemet’s Stripping Automated Endothelial Keratoplasty
(DSAEK). This section starts off with a chapter on eye banking issues and donor tissue preparation in DSAEK. This is an
important chapter since there are many corneal surgeons who do not “cut” their own donor corneal tissue and instead
elect to use eye bank technician cut donor corneal tissue for their patients. Also, in this section there is a chapter on the use
of eye bank pre-cut donor tissue for DSAEK surgery. Also, in this section, various leading posterior lamellar corneal
surgeons from both the United States and from other parts of the world describe their surgical techniques in performing
posterior lamellar keratoplasty. Armed with this knowledge, the reader can elect to choose the surgical technique that
appeals most to the individual surgeon. The techniques vary from folding the donor corneal disk into a taco-fold, to the
burrito trifold, to no-fold (no taco fold). Varying amounts of donor corneal endothelial cell loss is inevitable at the present

time with all exisiting surgical techniques, and such endothelial cell loss occurs during the handling of the donor corneal
disk, insertion of the donor disk into the patient’s anterior chamber, and subsequent attachment of the disk to the inner
surface of the patient’s cornea. There is a continued search for techniques that will allow for the least amount of endothelial
cell loss in DSAEK surgery. Equally important, is the chapter on the visual and refractive outcomes following DSAEK.
Also of great interest to the lamellar surgeon is the chapter on simplified technique and instrumentation in performing
DSAEK. Also included in this section is the use of femtosecond laser (Intralase) for DSEK surgery. Once posterior lamellar
keratoplasty is performed, the surgeon needs to learn various techniques to keep the donor disk attached to the inner
surface of the patient’s cornea. In this regard, there is a chapter on surgical techniques to facilitate donor disk adherence
to the patient’s cornea. The surgeon can use a single technique or a combination of techniques to decrease the disc
detachment rate following DSAEK surgery. Also included in the same section is a chapter on the management of
complications and a chapter on the unanswered questions in DSAEK.
Section 10 compares the older form of sutureless corneal transplantation technique namely DLEK to the newer technique
of DSAEK surgery. This section also describes the various staining techniques using the commercially available dyes that
will allow better visualization of the donor corneal disk within the patient’s anterior chamber through a cloudy cornea.
Staining in addition to providing better visualization of the donor disk also helps to identify the donor stromal surface
from the donor endothelial surface. Included in the same section is a chapter on the comparative visual recovery in
DSAEK, DLEK and PKP surgeries.
The final section in this book, Section 11 gives a glimpse of what the future holds for posterior lamellar keratoplasty. In
this section there are chapters on the use of tissue adhesive, to a novel approach for corneal endothelial cell transplantation
using Descemet’s membrane as a carrier. There is also a chapter on true endothelial cell (Tencell) transplantation. Also
included is a new technique of Descemet Membrane Endothelial Keratoplasty (DMEK). In addition, there is a chapter on
corneal endothelial reconstruction with a bioengineered cell sheet. The final chapter in this book projects the possible
future of posterior lamellar keratoplasty.
This book is a comprehensive textbook in sutureless posterior lamellar corneal surgery that the reader would enjoy as
he or she travels through this wide landscape of surgical techniques and instrumentation as it relates to the current status
of posterior lamellar corneal surgery. Continued improvements and refinements of the surgical techniques by the ophthalmic
surgeons can only incrementally benefit their patients all over the world.
Thomas John MD
Corneal Endothelial Transplant
xvi

Acknowledgments
I acknowledge all those who contributed to this book on “Corneal Endothelial Transplant,” by taking time from their busy
schedules to write their chapter(s). A collective contribution and passion for their surgical pursuits makes this compilation
valuable for readers all over the world.
I wish to acknowledge all my teachers in the Cornea Service, Massachusetts Eye and Ear Infirmary (MEEI), Harvard
Medical School, Boston, MA, USA, from whom I have learnt immensely both in the clinical and research aspects of
“Cornea”. I am thankful to Drs Kenneth R Kenyon, Claes H Dohlman, C Stephen Foster, Roger F Steinert, Deberoah P
Langston, Mark B Abelson, Michael D Wagoner, Jeffrey P Gilbard, Arthur S Boruchoff, and Ann M Bajart for all their
dedication and effort in teaching surgical and medical skills relating to cornea and external diseases while I was a 2-year
Clinical Cornea Fellow at Harvard. I wish to thank Dr Kenyon, under whose expert guidance I did my research work both
at the Schepens Eye Research Institute and at the Massachusetts Institute of Technology (MIT), in Boston. I am fortunate
to have worked with my colleagues, cornea fellows and residents at MEEI during my fellowship years, to name a few,
Drs Mitchell C Gilbert, Eduardo C Alfonso, Kazuo Tsubota, Scheffer CG Tseng, Dimitri T Azar, John R Wittpenn, and
Oliver D Schein.
Special thanks to Drs James V Aquavella and Gullapalli N Rao for what they taught me in corneal surgery including
epikeratoplasty, refractive surgical procedures, and keratoprosthesis.
I am thankful to all my teachers in my formative years during my ophthalmology residency at the University of
Pennsylvania. Although, not an all inclusive list, special thanks to Drs Ralph C Eagle, Jr, Myron Yanoff, John H Rockey,
Irving M Raber, Alexander J Brucker, David M Kozart, William C Frayer, Harold Scheie, and Madeleine Q Ewing. I am
especially thankful to Ralph C Eagle, Jr, MD, for all his support and professional inspiration, and for teaching me the
various pathological basis of disease processes as it relates to the eye. I thank Myron Yanoff for accepting me into the
ophthalmology residency program at the University of Pennsylvania.
Teachers are one of the greatest assets of any society. I thank all my teachers from kindergarten to completion of my
formal education both in the medical and pre-medical years. Without these teachers, I will be lacking in knowledge and
I am indebted to each and every one of my teachers.
I wish to acknowledge my wife, Annita, and the kids, Michelle, Andrea and Olivia for putting up with my late night
academic work and for all their understanding and loving support.
Thanks to Laura Phelps for the excellent medical illustrations in this book.
To my office staff, for their patience and understanding.
To all my patients, from whom I continue to learn everyday. Learning is a continuous and dynamic process that

stimulates the mind and makes ophthalmology an even more interesting and challenging field in our life’s journey.

Introduction
Sutures have been a necessary evil in most forms of corneal surgery. Sutures have historically
been necessary to obtain a secure incision during the healing phase. The introduction of
sutures in cataract surgery, utilizing large re-usable needles that the surgeon had to thread, in
a manner like a tailor, represented a major breakthrough in rehabilitation after cataract surgery.
As the needles and suture material became smaller and the number of possible sutures in a
single incision increased, the patient rehabilitation time improved dramatically while the
complication rate fell. No longer were cataract patients restricted to bed rest with their heads
stabilized by sand bags, awaiting for healing of a limbal incision secured only by an overlying
conjunctival flap. The problem with sutures in cataract surgery, of course, was the impossibility
of precise control of the suture tension and placement. After prolonged healing, typically lasting several months, the
patient might have high amounts of astigmatism representing either excessively tight or excessively loose sutures. These
issues are now largely a historical footnote, as cataract surgery has come full circle. The drive for smaller incisions in
cataract surgery allowed the creation of a self-sealing “valve” incision that, because of its inherent water tightness and
structural stability, permits surgeons to use no sutures in many cases. In coming full circle and returning to sutureless
cataract surgery, the evolution of the “valve” style incision represented a re-learning of the incision shape that helped
cataract surgeons with sutureless incisions in the early 20th century, because the Graefe knife incisions of that era also
created the same valve effect, unfortunately limited by the extreme width of the incision necessary to perform the whole
lens surgery of that era.
The lessons of sutures in cataract surgery apply even more to corneal surgery. In corneal transplantation, until recently,
sutures have been mandatory to align and stabilize the junction of the donor and the recipient cornea. Because the cornea
is slow to heal, those sutures must be retained much longer than in cataract surgery. In almost all cases, the sutures are
also considerably closer to the optical center and the limbus. This proximity dramatically increases the negative impact of
suture tension.
Despite decades of improvement in suture materials, needles, and ingenious variations in suturing technique and
suture patterns, the problem of distortion and slow healing of corneal incisions has remained as a powerful impediment
to high quality vision after corneal transplantation. Indeed, another of the ironies in this story of sutures in ophthalmology
came with a shift from silk sutures to fine nylon sutures for corneal transplantation. Silk sutures caused intense

inflammation, vascularization, and higher rejection rates as well as patient discomfort. However, if the transplant survived,
the patient benefited by the stimulation of more rapid incision healing and full suture removal much earlier than is
possible with nylon sutures. The use of non-inflammatory material, therefore, caused a further shift in the direction of
prolonged dependency on sutures and vulnerability to the negative impact of those sutures in corneal surgery.
This outstanding text, conceived and edited by Thomas John, MD thoroughly explores the dramatic shift under way
toward corneal transplantation without corneal sutures. The text thoroughly develops the background technologies that
are the foundation of lamellar endothelial transplantation.
Current endothelial transplant surgery typically still involves a few limbal sutures, but the future is clearly in the
direction of transplantation of endothelial cells alone. That will complete the transformation to a completely sutureless
corneal transplantation.
Roger F Steinert

MD
Chair of Ophthalmology
Director of the Gavin Herbert Eye Institute
Professor of Ophthalmology and Biomedical Engineering
Department of Ophthalmology
University of California, Irvine, CA, USA

Perspective
Seems like just a year ago that we witnessed publication of Thomas John’s definitive magnum
opus of lamellar keratoplasty, “Surgical Techniques in Anterior and Posterior Lamellar Corneal
Surgery” (Jaypee Brothers, New Delhi, 2006). Can it really be time for yet another multi-
faceted, multi-authored work on posterior lamellar keratoplasty ??
Answer: Absolutely !!
The Back to the Future of century old anterior lamellar keratoplasty techniques have now
been extended and adapted for posterior corneal application plus technologically enhanced
by current imaging and surgical instrumentation. This Paradigm Shift to Targeted Tissue-
Specific Keratoplasty is clearly the greatest advance in corneal surgery to occur within the last half century (Top 10
Ophthalmic Innovations of the Past 25 Years, Ocular Surgery News, Dec. 2007). Such rapid developments of the past

decade, thanks to Dr. John and several of the nearly 50 international authors contributing to the current treatise, have
propelled Endothelial Keratoplasty to have become the nearly standard approach for the surgical management of corneal
endothelial disease.
Little more than a year ago has passed since my own pilgrimage to Chicago (?or was it Lourdes or perhaps Mecca…?)
to witness and learn from the Master K-Plaster, Tom John, himself. Thusly converted, I can now personally attest to the
Miracle of Posterior Lamellar Keratoplasty. True, this surgery and its variations requires mastery of new surgical skills as
well as problem solving and complication management, as does any novel operative technique. Yet having witnessed the
surgery and its results (including the increasingly long-term published series, as are also included herein), the Bottom
Line is all too obvious: Once you go DSEK, you never go back !
And so it is that Dr. John and friends rapidly push forward and relentlessly expand the frontiers through their current
approaches to the state of the sutureless keratoplasty art. Including sections devoted to corneal basic science, tissue
imaging, surgical instrumentation, basic themes plus multiple variations of endokeratoplasty technique, and future
directions, this opus is a definitive work of equally magnum magnitude which should convince even more conservative
corneal surgeons that the Back to the Future of lamellar keratoplasty is unquestionably now. Finally, I must also express
my personal and professional appreciation to Thomas for both the honor of including me among his illustrious cast of co-
authors but especially for the Epiphany of helping me to Perceive the Light.
Kenneth R Kenyon MD
Founder, Cornea Consultants International
Boston, MA, USA & Munich, Germany
Associate Clinical Professor of Ophthalmology
Harvard Medical School, Boston, MA, USA
Senior Scientist, Schepens Eye Research Institute
Boston, MA, USA