Background
Currently, the standard care for patients with endothelial dysfunction is a posterior lamellar graft which can be performed either as Descemetʼs stripping automated endothelial keratoplasty (DSAEK) or Descemetʼs membrane endothelial keratoplasty (DMEK). Posterior lamellar keratoplasty (PLK) is nowadays preferred over penetrating keratoplasty (PK) because of quicker visual recovery, less astigmatism and lower rate of rejection [1]. However, longstanding stromal edema in patients with endothelial dysfunction can lead to temporary or even persistent subepithelial haze or scarring [2]. Espana et al. studied confocal microscopic features in patients with Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy who underwent DSAEK and correlated these findings witha the post operative visual acuity. They concluded that the most important limiting factor for improvement of best-corrected visual acuity (BCVA) was subepithelial haze [2]. These opacities can cause irregular anterior corneal surface and visual distortions, which may persist even after DSAEK [3]. To date, the only way to treat this was to perform a PK.
In this case report, we describe a new technique to manage this condition. The so called „Sandwich graft“, is a combination of a posterior lamellar graft (DSEAK) with an anterior lamellar graft (ALTK: automated lamellar therapeutic keratoplasty). This type of „double graft“, preserving an intermediate layer of the recipient stroma, has theoretically the same advantages as a lamellar keratoplasty with rapid visual recovery, but a lower immunological rejection risk.
