Femto-DSAEK for deep posterior stromal opacity: a lamellar alternative to PK in failed DMEK

To describe the feasibility of femtosecond laser-assisted stromal dissection combined with Descemet stripping automated endothelial keratoplasty (femto-DSAEK) as an alternative to penetrating keratoplasty (PK) in case of deep posterior stromal scarring following failed Descemet membrane endothelial keratoplasty (DMEK). A 58-year-old male with history of failed DMEK in right eye for Fuchs’ endothelial dystrophy was referred at our department for posterior stromal scarring. On examination, the posterior stromal opacity, localized at 501 μm from the epithelium, had a thickness of 80 μm. In view of the above, planning a second DMEK was not expected to yield satisfactory visual outcomes. A femtosecond laser-assisted deep stromal dissection (80 μm depth, 7.50 mm diameter) was performed to selectively remove the posterior stroma, Descemet membrane, and dysfunctional endothelium in a single-step approach. A 7.00 mm pre-cut DSAEK graft, of 82 μm thickness, was subsequently implanted. The procedure resulted in rapid visual recovery and corneal clearing (BCVA improved from 1.00 to 0.10 logMAR), without complications. Femto-DSAEK offers a streamlined approach for managing failed DMEK with posterior stromal scarring. By enabling precise removal of diseased posterior tissue and immediate endothelial replacement, it may enhance graft adherence, optimize visual rehabilitation, and provide an effective alternative to PK in complex cases.