This patient-education article is written by the cornea service at Suraj Eye Institute, Nagpur.

What Are DSAEK and DMEK?

DSAEK and DMEK are modern partial-thickness corneal transplants in which only the diseased inner layer of the cornea — the endothelium — is replaced. They have largely replaced full-thickness penetrating keratoplasty for endothelial diseases such as Fuchs dystrophy and pseudophakic bullous keratopathy. The two procedures differ in what the donor tissue contains:

  • DSAEK (Descemet Stripping Automated Endothelial Keratoplasty) — donor tissue is a thin lenticule of posterior stroma + Descemet membrane + endothelium (approximately 100–150 µm thick).
  • DMEK (Descemet Membrane Endothelial Keratoplasty) — donor tissue is only Descemet membrane + endothelium (approximately 15 µm thick).

Both operations begin in the same way: the diseased Descemet membrane and endothelium are gently stripped from the back of the patient’s cornea through a small clear-corneal incision. The donor tissue is then inserted into the anterior chamber and pressed against the back of the patient’s cornea, where an air bubble holds it in place until natural adhesion takes over.

DSAEK vs DMEK — Anatomical Cross-Section

DSAEK vs DMEK — Only the Back Layer of the Cornea is Replaced

DSAEK (~100 µm graft) Posterior stroma + Descemet + endothelium

Epithelium Bowman Stroma

Donor graft (pink) Air bubble

PATIENT KEEPS FRONT LAYERS

DMEK (~15 µm graft) Descemet membrane + endothelium only

Donor graft (ultra-thin pink) Air bubble

PATIENT KEEPS FRONT LAYERS

Thicker, easier-to-handle graft Slower visual recovery (3–6 months) Preferred in complex eyes

Ultra-thin graft Faster recovery (1–3 months) Technically more demanding

Both: tiny clear-corneal incision · diseased host Descemet stripped · donor inserted · air bubble holds graft on for 24–48 h (patient lies face-up).

Figure 1. Both operations replace only the innermost layer of the cornea. The patient keeps their own epithelium, Bowman layer and most of the stroma (blue). The diseased Descemet membrane and endothelium are stripped away and replaced with donor tissue (pink) attached to the back of the cornea. DSAEK (left) uses a thicker graft of posterior stroma plus Descemet and endothelium (~100 µm) that is easier to handle but gives slightly slower visual recovery. DMEK (right) transplants Descemet membrane and endothelium only (~15 µm). The choice between DSAEK and DMEK is individualised to each eye by the surgeon. In both, an air bubble in the anterior chamber presses the graft against the cornea for 24–48 hours, which is why the patient lies face-up after surgery.

DSAEK vs DMEK — Which is Used?

Feature DSAEK DMEK
Donor tissue thickness 100–150 µm ~15 µm
Visual recovery 3–6 months 1–3 months
Final visual sharpness Very good Very good
Technical difficulty More forgiving More demanding (donor is fragile and rolls up)
Detachment / re-bubble rate Lower Higher (up to 20% in some series)
Preferred in complex eyes Yes — vitrectomy, glaucoma drainage device, large iris defects Less suitable

Indications

  • Fuchs endothelial dystrophy with visually significant corneal oedema
  • Pseudophakic bullous keratopathy
  • Endothelial decompensation after vitreoretinal surgery, glaucoma surgery or trauma
  • Failed previous endothelial graft (DSAEK after a failed DMEK, or vice versa)
  • Selected congenital endothelial dystrophies

What to Expect

The operation is performed under local anaesthesia, takes 45–60 minutes and is a day procedure. Cataract surgery can be combined with DMEK or DSAEK in a single operation (the triple procedure) when both diseases are present.

After surgery, patients are asked to lie flat (face-up) for several hours so that the air bubble in the anterior chamber floats upwards and presses the graft against the back of the cornea. Topical steroid drops are tapered over many months and continued at low dose for life. Vision improves rapidly over the first weeks for DMEK and over a few months for DSAEK.

Why no sutures? DSAEK and DMEK use no sutures — the graft is held in place by the air bubble for the first day or two, after which the natural endothelial pump action of the donor tissue draws fluid out of the cornea and keeps the graft attached. This is why face-up positioning in the first hours after surgery matters so much.
✔ Endothelial Keratoplasty at Suraj Eye Institute

We perform DSAEK and DMEK for Fuchs endothelial dystrophy and pseudophakic bullous keratopathy, with combined cataract surgery (triple procedure) in selected eyes. Donor tissue is supplied through our partner eye bank, and the air-tamponade attachment is monitored closely with anterior-segment imaging in the first post-operative week.

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Frequently Asked Questions

How is DSAEK different from a full corneal transplant?
A full-thickness corneal transplant (PK) replaces all five corneal layers and is held in place with 16 sutures. DSAEK replaces only the diseased inner layer, is inserted through a small incision and is held in place by an air bubble for the first day or two. Visual recovery is much faster and the eye is less fragile after surgery.

Why must I lie flat after the operation?
An air bubble placed in the anterior chamber pushes the donor tissue upward against the back of the cornea, where it attaches. Air floats upwards, so lying face-up keeps the bubble against the central cornea and the graft well-supported during the critical first 24–48 hours.

What if the graft does not stick?
Detachment of the graft occurs in a minority of cases, especially after DMEK. It is treated by re-injecting an air bubble into the eye in a brief outpatient procedure (“re-bubbling”). In our experience most detachments respond to one or two re-bubbles.

Is rejection still a problem?
Rejection occurs in a small minority of patients and is treated with intensive topical steroids. The rate is lower with DMEK than with PK because much less donor tissue is transplanted. Long-term low-dose topical steroid drops reduce the risk and are continued indefinitely.

Can I have cataract surgery first and an endothelial transplant later?
Yes, and we sometimes prefer that sequence in straightforward Fuchs eyes — cataract surgery alone may stabilise the cornea for years. When the cornea is already swollen at the time of cataract surgery, we usually combine the cataract operation with DMEK or DSAEK in a single procedure.

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