surgical outcomes from 430 dsek cases performed by a single surgeon in a tertiary eye hospital were compiled and analyzed retrospectively to assess the rate and types of complications with their management . skb ) had undertaken wet - lab and skill transfer courses from accomplished dsek surgeons abroad before starting the procedure . the informed written consent was obtained from all patients after institutional review board approval and the study was in accordance with the declaration of helsinki . four hundred and thirty eyes of 366 patients underwent dsek from july 2006 through june 2011 . the median age of these patients was 59.5 years ( range : 4 - 92 years ) . most eyes had pseudophakic corneal edema and/or bullous keratopathy ( 259 eyes ) of which 225 ( 52.3% ) eyes had posterior chamber intraocular lens ( pciol ) and 34 ( 7.9% ) eyes had anterior chamber intraocular lens ( aciol ) . fuchs dystrophy with different grades of cataract was present in 98 ( 22.8% ) eyes and post - pkp failed graft in 32 ( 7.4% ) eyes . preoperative diagnosis ( no . of eyes=430 ) all the dsek procedures were performed using the similar technique . the preoperative donor endothelial cell density ( ecd ) was 2200 cell / mm ( range 2214 - 3305 cell / mm ; median : 2441 cells / mm ) . the donor dissection was performed manually after mounting the donor tissue on barron 's artificial anterior chamber ( katena , usa ) and 60:40  taco forceps technique was used for donor insertion . the unfolding of the donor tissue was performed by injection of balanced salt solution ( bss ) and air from the sideports . in 98 cases , where the patients presented with moderate to severe fuchs dystrophy with some degree of cataract , the dsek procedure was combined with phacoemulsification ( pe ) or manual small incision cataract surgery ( msics ) with pciol implantation . the detailed description of the surgical technique used by the author was published earlier . the intraocular lens ( iol ) exchange and secondary pciol implantation were performed in seven eyes . early postoperative complications were defined as those complications that happened within 2 months of surgery and late complications were those , which occurred after 2 months . the corneal graft that had not cleared even after 2 months of surgery was classified as pgf . the periodic ecd was analyzed postoperatively for each patient until the last follow - up visit . the follow - up period was between 3 and 60 months ( mean 18.7 months ) . any complication either intraoperative or postoperative , which happened , was managed either medically , or by appropriate surgical means . an excel ( microsoft , redmond , wa , usa ) spreadsheet was used to compile the complications and calculate the results . table 2 shows the operative complications in relation to the donor dissection . in three ( 0.7% ) cases , the donor button was changed with a new one because of poor donor preparation . in 10 ( 2.3% ) cases , additional donor tissue preparation complications such as button - holes or thin donor posterior lenticule ( 0.5% ) cases , donor button was replaced with a new one because of reverse donor unfolding ; and one donor button came out during forcible injection of air while giving air tamponed . so , during operation the overall donor button damage was in six ( 1.4% ) cases , and in all cases the button was replaced with a new button immediately . intraoperative complications during donor dissection ( n=13 ) operative complications during recipient procedure ( n=20 ) table 4 enumerates the important early postoperative complications . the two most common complications in early postoperative period were air - induced pupillary block glaucoma in 12 ( 2.8% ) eyes [ fig . 2a and b ] , one case had interface fungal infection [ fig . 3a and b ] , and one case had postoperative bacterial endophthalmitis . early postoperative complications ( n=50 ) ( a ) air - induced pupillary block ; ( b ) air - induced pupillary block in slit section ( a ) primary graft failure ; ( b ) primary graft failure in slit section ( a ) interface infection  7 day postoperative ; ( b ) interface infection  in slit section air - induced pupillary block glaucoma cases were initially treated with intravenous injection of mannitol and pupillary dilatation . in eight ( 66.7% ) eyes , pupil dilated and air bubble moved anteriorly with releif of pupillary block . but in four ( 33.3% ) cases , under topical or peribulbar anesthesia , air bubble was brought anteriorly by tapping the iris with a sinskey 's hook from the sideports . it is more with aphakic bullous keratopathy cases , aciol cases , and post - pkp - failed graft cases . it is also interesting to note that the incidence is highest in the initial 100 cases and reduced with time . in 18 ( 85.7% ) eyes , donor dislocation occurred within 24 h of surgery , but in three cases , it happened after 7 days after the first follow - up visit . once the donor dislocation was detected , it was immediately treated by repositioning of the donor tissue and rebubbling . in all dislocation cases ,  repositioning and rebubbling table 6 shows the details of donor dislocation management , its success and failures , and repeat procedures . in three eyes , finally they were converted into pkp . in partial non - attachment cases , ( a ) donor dislocation on 2 day ; ( b ) donor dislocation on 2 day in slit section ; ( c ) donor dislocation on 2 day  anterior segment oct picture ; ( d ) donor reattachment after repositioning and rebubbling donor dislocation : overview ( n=21 ) donor dislocation management : success and failures and repeat procedures ( n=21 ) excluding the pupillary block glaucoma , seven eyes had glaucoma in early postoperative period due to other factors such as previous toxic anterior segment syndrome ( tass ) in three cases , past history of glaucoma surgery in three cases , and iridocorneal endothelial syndrome in one case . they were initially treated with oral and topical antiglaucoma medications , but ultimately , in two cases , trabeculectomy with mitomycin - c and in one eye cyclocryopexy was required . the tass occurred in two eyes where dsek was combined with pe and foldable hydrophobic acrylic iol implantation [ fig . they were treated with systemic and frequent topical steroids , cycloplegic , and intraocular pressure - lowering agents . ( a ) toxic anterior segment syndrome at 7 day ; ( b ) toxic anterior segment syndrome  note the anterior uveitis in pgf cases , re - dsek was performed with a fresh healthy donor tissue as early as possible . in case of interface infection , a therapeutic pkp with very good optical quality tissue the culture report was fusarium spp . and the patient was further treated with antifungal agents . the bacterial culture was positive for bacillus cereus . in spite of urgent therapeutic pkp and vitrectomy , the eye could not be saved and evetually it was eviscerated on the 5 day . table 7 shows the overall causes of graft failure in 11 cases in early postoperative period , that is , within first 2 months after the surgery . early graft failure ( within first 2 months ) and final management ( n=11 ) table 8 shows the details of overall complications in the late postoperative period . in this period , the other important complications were late interface opacification in 13 ( 3.1% ) eyes , endothelial graft rejection occurred in five ( 1.2% ) eyes , epithelial ingrowth in two eyes , and late infectious keratitis in two eyes . fourteen ( 3.3% ) patients had late secondary graft failure between 6 and 54 months . late postoperative complications ( of 424 patients ) the most common cause of secondary glaucoma in late postoperative period was steroid - induced glaucoma in 35 ( 8.3% ) eyes . initially , all the secondary glaucoma cases were treated with antiglaucoma medications , and topical steroids were reduced , changed , or withdrawn in selected cases . in one eye , the intervened surgical methods were trabeculectomy with mitomycin - c in five cases and ahmed glaucoma valve ( agv ) in two cases . one was with iridocorneo endothelial ( ice ) syndrome and the other case was with congenital hereditary endothelial dystrophy ( ched ) . among the five cases of late secondary angle closure glaucoma ( acg ) , 360 adhesion was noticed between the iris and the donor lenticular edge [ fig . breaking of adhesion cured the secondary glaucoma ; but in two eyes , as the graft health was not good , repeat dsek procedure was performed after breaking the adhesion . all of these cases are doing fine with clear graft until their last follow - up . causes and number of patients developed late secondary glaucoma ( n=48 ) ( a ) clear graft in dsek after 3 years total cupping ; ( c ) normal optic nerve of the other eye ( a ) 360 peripheral anterior synechia ; ( b ) 360 peripheral anterior synechia  iris bombe five ( 1.2% ) eyes had endothelial graft rejection that occurred between 11 and 36 months after the dsek procedure [ fig . three patients with graft rejection presented with sudden dimness of vision and photophobia ; but in two cases , the rejection episodes were diagnosed during routine examination . all eyes had keratic precipitates and anterior chamber cells , with diffuse corneal edema in three cases . but none of the eyes developed endothelial rejection line . graft rejection cases were treated immediately by intravenous methyl prednisolone injection and frequent topical prednisolone acetate eye drop . in three cases , the rejection episode was reversed with medication and the grafts were cleared [ fig . but , in two eyes graft edema persisted even after maximum medication and re - dsek was eventually required . ( a ) endothelial graft rejection in dsek ; ( b ) endothelial graft rejection in dsek  note corneal edema with descemet 's folds ; ( c ) same eye after two doses of intravenous methyl prednisolone interface opacification was another complication noticed in 13 eyes ( 3.1% ) , and in all cases , it occurred 6 months after the surgery [ fig . this was mostly [ 10 eyes ( 2.4% ) ] with the tass - related pbk cases . ( a ) late interface opacification in the pupillary area ; ( b ) late interface opacification in slit section secondary graft failure occurred in 14 ( 3.3% ) cases between 6 and 54 months after the dsek procedure [ fig . 10a - c ] . of these , eight ( 2.4% ) eyes were with pciol , four ( 11.7% ) eyes had previous aciol , and two ( 13.3% ) eyes were aphakic . in nine eyes , the dsek graft failed 3 years after the surgery . among 14 cases , three cases ( two with aphakia and one eye with aciol ) were treated with pkp and one case was lost to follow - up . ( a ) clear graft 2.5 years after dsek ; ( b ) late graft failure  same eye after 3.5 years ; ( c ) late graft failure in slit section same eye after 3.5 years ; ( d ) re - dsek - same eye  postoperative 3 months epithelial ingrowth was seen in two cases , and in both cases , venting incisions were given during surgery . late infectious keratitis occurred in two cases  one after 8 months and the other after 18 months of the surgery [ figs . 11 and 12 ] . in both the cases , there was history of foreign body entry in the eye one case developed cataract ( of 5 phakic cases where dsek was performed alone without lens extraction ) after 18 months of surgery and treated with pe with pc iol implantation . late infective keratitis with interface hypopyon percentage of periodic endothelial cell loss over last 5 years the overall median ecl after 3 months was 19.7% . it was 32.5% , 38.9% , 42.2% , 47.1% , and 54.2% after 1 year , 2 years , 3 years , 4 years , and 5 years , respectively [ table 10 ] . however , the ecl had not been analyzed independently with different group of patients and with or without complications , such as donor dislocation and rebubbling , secondary glaucoma , rejection episode , etc . periodic endothelial cell loss following manual dsek seven ( 1.6% ) eyes developed cystoid macular edema , between 4 and 11 months after surgery and they were treated with sub - tenon 's injection of triamcinolone acetonide , and nepafenac eye drop - q.i.d . for 3 months . in all cases , the total number of graft failure in this series was 31 ( 7.2% ) cases that occurred between day 1 and 5 years after the surgery [ table 11 ] . eleven ( 2.6% ) of them happened within 2 months of dsek procedures and in 20 eyes graft failed ( 4.7% ) after that . total graft failure following manual dsek procedure ( n=31 ) summary of repeat surgery in failed - dsek cases ( n=31 ) table 2 shows the operative complications in relation to the donor dissection . in three ( 0.7% ) cases , the donor button was changed with a new one because of poor donor preparation . in 10 ( 2.3% ) cases , additional donor tissue preparation complications such as button - holes or thin donor posterior lenticule ( 0.5% ) cases , donor button was replaced with a new one because of reverse donor unfolding ; and one donor button came out during forcible injection of air while giving air tamponed . so , during operation the overall donor button damage was in six ( 1.4% ) cases , and in all cases the button was replaced with a new button immediately . intraoperative complications during donor dissection ( n=13 ) operative complications during recipient procedure ( n=20 ) the two most common complications in early postoperative period were air - induced pupillary block glaucoma in 12 ( 2.8% ) eyes [ fig . 2a and b ] , one case had interface fungal infection [ fig . 3a and b ] , and one case had postoperative bacterial endophthalmitis . early postoperative complications ( n=50 ) ( a ) air - induced pupillary block ; ( b ) air - induced pupillary block in slit section ( a ) primary graft failure ; ( b ) primary graft failure in slit section ( a ) interface infection  7 day postoperative ; ( b ) interface infection  in slit section air - induced pupillary block glaucoma cases were initially treated with intravenous injection of mannitol and pupillary dilatation . in eight ( 66.7% ) eyes , pupil dilated and air bubble moved anteriorly with releif of pupillary block . but in four ( 33.3% ) cases , under topical or peribulbar anesthesia , air bubble was brought anteriorly by tapping the iris with a sinskey 's hook from the sideports . it is more with aphakic bullous keratopathy cases , aciol cases , and post - pkp - failed graft cases . it is also interesting to note that the incidence is highest in the initial 100 cases and reduced with time . in 18 ( 85.7% ) eyes , donor dislocation occurred within 24 h of surgery , but in three cases , it happened after 7 days after the first follow - up visit . once the donor dislocation was detected , it was immediately treated by repositioning of the donor tissue and rebubbling . in all dislocation cases ,  repositioning and rebubbling table 6 shows the details of donor dislocation management , its success and failures , and repeat procedures . in three eyes , finally they were converted into pkp . in partial non - attachment cases ( a ) donor dislocation on 2 day ; ( b ) donor dislocation on 2 day in slit section ; ( c ) donor dislocation on 2 day  anterior segment oct picture ; ( d ) donor reattachment after repositioning and rebubbling donor dislocation : overview ( n=21 ) donor dislocation management : success and failures and repeat procedures ( n=21 ) excluding the pupillary block glaucoma , seven eyes had glaucoma in early postoperative period due to other factors such as previous toxic anterior segment syndrome ( tass ) in three cases , past history of glaucoma surgery in three cases , and iridocorneal endothelial syndrome in one case . they were initially treated with oral and topical antiglaucoma medications , but ultimately , in two cases , trabeculectomy with mitomycin - c and in one eye cyclocryopexy was required . the tass occurred in two eyes where dsek was combined with pe and foldable hydrophobic acrylic iol implantation [ fig . they were treated with systemic and frequent topical steroids , cycloplegic , and intraocular pressure - lowering agents . ( a ) toxic anterior segment syndrome at 7 day ; ( b ) toxic anterior segment syndrome  note the anterior uveitis in pgf cases , re - dsek was performed with a fresh healthy donor tissue as early as possible . in case of interface infection , a therapeutic pkp with very good optical quality tissue was immediately performed . the bacterial culture was positive for bacillus cereus . in spite of urgent therapeutic pkp and vitrectomy , the eye could not be saved and evetually it was eviscerated on the 5 day . table 7 shows the overall causes of graft failure in 11 cases in early postoperative period , that is , within first 2 months after the surgery . table 8 shows the details of overall complications in the late postoperative period . in this period , the other important complications were late interface opacification in 13 ( 3.1% ) eyes , endothelial graft rejection occurred in five ( 1.2% ) eyes , epithelial ingrowth in two eyes , and late infectious keratitis in two eyes . fourteen ( 3.3% ) patients had late secondary graft failure between 6 and 54 months . late postoperative complications ( of 424 patients ) the most common cause of secondary glaucoma in late postoperative period was steroid - induced glaucoma in 35 ( 8.3% ) eyes . initially , all the secondary glaucoma cases were treated with antiglaucoma medications , and topical steroids were reduced , changed , or withdrawn in selected cases . in one eye , developed total glaucomatous optic atrophy inspite of crystal clear graft [ fig . the intervened surgical methods were trabeculectomy with mitomycin - c in five cases and ahmed glaucoma valve ( agv ) in two cases . one was with iridocorneo endothelial ( ice ) syndrome and the other case was with congenital hereditary endothelial dystrophy ( ched ) . among the five cases of late secondary angle closure glaucoma ( acg ) , 360 adhesion was noticed between the iris and the donor lenticular edge [ fig . breaking of adhesion cured the secondary glaucoma ; but in two eyes , as the graft health was not good , repeat dsek procedure was performed after breaking the adhesion . all of these cases are doing fine with clear graft until their last follow - up . causes and number of patients developed late secondary glaucoma ( n=48 ) ( a ) clear graft in dsek after 3 years  secondary glaucoma ; ( b ) glaucomatous optic atrophy  total cupping ; ( c ) normal optic nerve of the other eye ( a ) 360 peripheral anterior synechia ; ( b ) 360 peripheral anterior synechia iris bombe five ( 1.2% ) eyes had endothelial graft rejection that occurred between 11 and 36 months after the dsek procedure [ fig . three patients with graft rejection presented with sudden dimness of vision and photophobia ; but in two cases , the rejection episodes were diagnosed during routine examination . all eyes had keratic precipitates and anterior chamber cells , with diffuse corneal edema in three cases . but none of the eyes developed endothelial rejection line . graft rejection cases were treated immediately by intravenous methyl prednisolone injection and frequent topical prednisolone acetate eye drop . in three cases , the rejection episode was reversed with medication and the grafts were cleared [ fig . but , in two eyes graft edema persisted even after maximum medication and re - dsek was eventually required . ( a ) endothelial graft rejection in dsek ; ( b ) endothelial graft rejection in dsek  note corneal edema with descemet 's folds ; ( c ) same eye after two doses of intravenous methyl prednisolone interface opacification was another complication noticed in 13 eyes ( 3.1% ) , and in all cases , it occurred 6 months after the surgery [ fig . this was mostly [ 10 eyes ( 2.4% ) ] with the tass - related pbk cases . ( a ) late interface opacification in the pupillary area ; ( b ) late interface opacification in slit section secondary graft failure occurred in 14 ( 3.3% ) cases between 6 and 54 months after the dsek procedure [ fig . 10a - c ] . of these , eight ( 2.4% ) eyes were with pciol , four ( 11.7% ) eyes had previous aciol , and two ( 13.3% ) eyes were aphakic . in nine eyes , three cases ( two with aphakia and one eye with aciol ) were treated with pkp and one case was lost to follow - up . ( a ) clear graft 2.5 years after dsek ; ( b ) late graft failure  same eye after 3.5 years ; ( c ) late graft failure in slit section  same eye after 3.5 years ; ( d ) re - dsek - same eye  postoperative 3 months epithelial ingrowth was seen in two cases , and in both cases , venting incisions were given during surgery . late infectious keratitis occurred in two cases  one after 8 months and the other after 18 months of the surgery [ figs . 11 and 12 ] . in both the cases , there was history of foreign body entry in the eye one case developed cataract ( of 5 phakic cases where dsek was performed alone without lens extraction ) after 18 months of surgery and treated with pe with pc iol implantation . late infective keratitis with interface hypopyon percentage of periodic endothelial cell loss over last 5 years the overall median ecl after 3 months was 19.7% . it was 32.5% , 38.9% , 42.2% , 47.1% , and 54.2% after 1 year , 2 years , 3 years , 4 years , and 5 years , respectively [ table 10 ] . however , the ecl had not been analyzed independently with different group of patients and with or without complications , such as donor dislocation and rebubbling , secondary glaucoma , rejection episode , etc . periodic endothelial cell loss following manual dsek seven ( 1.6% ) eyes developed cystoid macular edema , between 4 and 11 months after surgery and they were treated with sub - tenon 's injection of triamcinolone acetonide , and nepafenac eye drop - q.i.d . for 3 months . in all cases , macular edema resolved with improvement of vision . the total number of graft failure in this series was 31 ( 7.2% ) cases that occurred between day 1 and 5 years after the surgery [ table 11 ] . eleven ( 2.6% ) of them happened within 2 months of dsek procedures and in 20 eyes graft failed ( 4.7% ) after that . total graft failure following manual dsek procedure ( n=31 ) summary of repeat surgery in failed - dsek cases ( n=31 ) the most common cause of secondary glaucoma in late postoperative period was steroid - induced glaucoma in 35 ( 8.3% ) eyes . initially , all the secondary glaucoma cases were treated with antiglaucoma medications , and topical steroids were reduced , changed , or withdrawn in selected cases . in one eye , the intervened surgical methods were trabeculectomy with mitomycin - c in five cases and ahmed glaucoma valve ( agv ) in two cases . one was with iridocorneo endothelial ( ice ) syndrome and the other case was with congenital hereditary endothelial dystrophy ( ched ) . among the five cases of late secondary angle closure glaucoma ( acg ) , 360 adhesion was noticed between the iris and the donor lenticular edge [ fig . breaking of adhesion cured the secondary glaucoma ; but in two eyes , as the graft health was not good , repeat dsek procedure was performed after breaking the adhesion . all of these cases are doing fine with clear graft until their last follow - up . causes and number of patients developed late secondary glaucoma ( n=48 ) ( a ) clear graft in dsek after 3 years secondary glaucoma ; ( b ) glaucomatous optic atrophy  total cupping ; ( c ) normal optic nerve of the other eye ( a ) 360 peripheral anterior synechia ; ( b ) 360 peripheral anterior synechia  iris bombe five ( 1.2% ) eyes had endothelial graft rejection that occurred between 11 and 36 months after the dsek procedure [ fig . three patients with graft rejection presented with sudden dimness of vision and photophobia ; but in two cases , the rejection episodes were diagnosed during routine examination . all eyes had keratic precipitates and anterior chamber cells , with diffuse corneal edema in three cases . but none of the eyes developed endothelial rejection line . graft rejection cases were treated immediately by intravenous methyl prednisolone injection and frequent topical prednisolone acetate eye drop . in three cases , the rejection episode was reversed with medication and the grafts were cleared [ fig . but , in two eyes graft edema persisted even after maximum medication and re - dsek was eventually required . ( a ) endothelial graft rejection in dsek ; ( b ) endothelial graft rejection in dsek  note corneal edema with descemet 's folds ; ( c ) same eye after two doses of intravenous methyl prednisolone interface opacification was another complication noticed in 13 eyes ( 3.1% ) , and in all cases , it occurred 6 months after the surgery [ fig . this was mostly [ 10 eyes ( 2.4% ) ] with the tass - related pbk cases . ( a ) late interface opacification in the pupillary area ; ( b ) late interface opacification in slit section secondary graft failure occurred in 14 ( 3.3% ) cases between 6 and 54 months after the dsek procedure [ fig . 10a - c ] . of these , eight ( 2.4% ) eyes were with pciol , four ( 11.7% ) eyes had previous aciol , and two ( 13.3% ) eyes were aphakic . in nine eyes , three cases ( two with aphakia and one eye with aciol ) were treated with pkp and one case was lost to follow - up . ( a ) clear graft 2.5 years after dsek ; ( b ) late graft failure  same eye after 3.5 years ; ( c ) late graft failure in slit section same eye after 3.5 years ; ( d ) re - dsek - same eye  postoperative 3 months epithelial ingrowth was seen in two cases , and in both cases , venting incisions were given during surgery . late infectious keratitis occurred in two cases  one after 8 months and the other after 18 months of the surgery [ figs . 11 and 12 ] . in both the cases , there was history of foreign body entry in the eye one case developed cataract ( of 5 phakic cases where dsek was performed alone without lens extraction ) after 18 months of surgery and treated with pe with pc iol implantation . late infective keratitis with interface hypopyon percentage of periodic endothelial cell loss over last 5 years it was 32.5% , 38.9% , 42.2% , 47.1% , and 54.2% after 1 year , 2 years , 3 years , 4 years , and 5 years , respectively [ table 10 ] . however , the ecl had not been analyzed independently with different group of patients and with or without complications , such as donor dislocation and rebubbling , secondary glaucoma , rejection episode , etc . periodic endothelial cell loss following manual dsek seven ( 1.6% ) eyes developed cystoid macular edema , between 4 and 11 months after surgery and they were treated with sub - tenon 's injection of triamcinolone acetonide , and nepafenac eye drop - q.i.d . for 3 months . in all cases , macular edema resolved with improvement of vision . the total number of graft failure in this series was 31 ( 7.2% ) cases that occurred between day 1 and 5 years after the surgery [ table 11 ] . eleven ( 2.6% ) of them happened within 2 months of dsek procedures and in 20 eyes graft failed ( 4.7% ) after that . total graft failure following manual dsek procedure ( n=31 ) summary of repeat surgery in failed - dsek cases ( n=31 ) the dsek offers an effective and efficient alternative to traditional pkp for the treatment of corneal endothelial dysfunctions . as a relatively new procedure , as previously reported , such complications include pupillary block by air , donor dislocation , graft failure secondary glaucoma , and graft rejection . the potential causes of donor dislocation include the presence of interface viscous fluid or air , patient squeezing , and eye rubbing . there are complications with the preparation , handling , and insertion of donor lamellar tissue into the anterior chamber of the recipient . but most of the reported complications are with automated dissection of the donor tissue , that is , with dsaek and most of the reports did not cover the management of each complication . one with microkeratome - related dissection where four tissues were discarded because of imperfect cut and one with manual dissection where the incidence of donor descemet 's perforation was 4.4% . in this series , there were other problems that have not been reported earlier , such as excessive donor thickness for which the donor tissue was discarded . two other important intraoperative complications happened where the donor tissue were discarded and replaced with a new one . one was reverse unfolding in two eyes during injecting air from the side port , and in another case , the donor tissue came out of the a / c during unfolding . as previously described , pupillary block by air is an important complication of dsek procedure . in fact , the reported incidence of pupillary block varies between 0.5% and 13% in different series . this is due to the displacement of an excessively large air bubble . in this series , but in last 130 cases , it happened only in one ( 0.8% ) eye . the incidence could be prevented drastically by placing a freely mobile air bubble and put a drop of cycloplegic at the end of the surgery as recommended by terry et al . donor dislocation is one of the most important complication and the rates varied from 0% to 82% , with an average dislocation rate of 14.5% . the graft dislocation may represent either fluid in the interface of an otherwise well - positioned graft or complete dislocation into the anterior chamber . in this series , it is interesting to note that the incidence of this unique complication is reduced with experience , and the same author had reported 8% dislocation rate in 2008 . price and price reported a dislocation rate of 50% in the first 10 eyes undergoing dsaek , which was reduced to 13% in the next 126 cases after changing the procedure to include face - up positioning after surgery and smoothening of the corneal surface . several other authors have shown the similar results that , with experience and time , the dislocation rate is reduced . the results of dislocation management are also satisfactory with a success rate of 72.3% that is comparable with other published series . in this study , the donor dislocation was highest in aphakic , aciol , and post - pkp cases compared with uncomplicated pbk and fuchs dystrophy cases . so case selection is an important criteria and special precautions are to be taken in this kind of complicated cases . re - dislocation of donor lenticule , even after rebubbling , is also higher in these cases . the published studies showed rates of pgf from 0% to 29% , with an average pgf rate of 5% . poor surgical technique has been linked to pgf in dsek , with surgeon inexperience and related excessive of iatrogenic intraoperative manipulation donor endothelial as the main factor . in fact , some studies refer to this entity as iatrogenic pgf . in this series , the pgf happened in only three ( 0.7% ) eyes and one of them after donor dislocation and subsequent rebubbling . published reports on secondary glaucoma after dsek was between 0% and 15% , with an average of 3% . in this series , the incidence of secondary glaucoma was 11.8% and the commonest cause of this late secondary glaucoma was topical corticosteroids - induced ( 8.3% ) . most of the patients showed rise in iop after 3 months of surgery . some of the patients had previous history of open - angle glaucoma and also it was more with abk and post - pkp - failed graft cases . as previously reported , patients with a preoperative diagnosis of fuchs endothelial dystrophy did not show a statistically significant increase in iop compared with other group . in this study , two the four eyes with ice syndrome initially remained good , but later failed due to progressive peripheral anterior synechia formation . so , ice syndrome may not be a good indication of dsek , because of continuous nature of the disease . the dsek in ched is often difficult and corneal edema takes long time to clear . in some cases , it is not possible to score and strip the dm , and to work under shallow ac and poor visualization due to thickened edematous cornea . there is also a case report on abandoning the procedure and converting to a pk on operation table due to these technical difficulties . of the four eyes in this series , dm stripping was not possible in two eyes , in one eye it was partial , and only in one eye it was easy . in two eyes , corneal edema cleared after 6 months , and in one eye , there was residual diffuse stromal opacity . one eye developed secondary glaucoma and ultimately the graft failed . among reviewed studies , the endothelial rejection rates varied from 0% to 45.5% , with an average rejection rate of 10% with the follow - up ranging from 3 to 24 months . in this series , the rejection happened with five ( 1.2% ) cases that is low compared with most of the study , although some studies reported the incidence as 0% . allan et al . reported that 15 ( 7.5% ) of 199 eyes had a graft rejection episode within the first 2 years after dsek or deep lamellar endothelial keratoplasty , a rate less frequent than in their series of patients who underwent pkp . in this series , the clinical presentations of endothelial rejection were similar with previous study ; however , no rejection line was noticed in any of the five cases . three cases were reversed with intravenous injection of methyl prednisolone and topical steroids , with two cases progressing to graft failure requiring redo procedure . epithelial ingrowth , interface opacification , and interface hemorrhages are less common complications in this series and these are comparable with reported studies . among these , interface opacity is one of the important reasons for repeat endothelial keratoplasty ( rek ) as reported by letko et al . interface fibrosis was also described histo - pathologically in failed dsaek cases where pkp procedure was performed later on . the incomplete removal of dm as a cause of partial graft detachment in dsaek has been reported . in this series , partial donor detachment happened in three cases and with time they attached completely . in all three cases , the graft was initially attached in more than two - third area . postoperative cystoid macular edema developed in seven ( 1.7% ) eyes , which resolved with topical nonsteroidal anti - inflammatory agent and sub - tenon triamcinolone acetonide injections . two cases of retinal detachment may not be directly related to the dsek procedure : in one case , it was aciol - related pbk , and in the other case , the patient was highly myopic . the corneal surgeon should consult a retinal specialist whenever the patient complains of suboptimal or sudden drop of vision in spite of a clear graft . in this series , the median ecl in manual dsek in different postoperative periods is almost similar to the automated procedure or dsaek of other series using similar donor insertion technique . the dsek grafts experienced more initial cell loss until 1 year , and then a slow and steady cell loss over next 4 years . this is consistent with an earlier finding that cell loss in dsek patients plateaus more quickly . furthermore , the 5-year ecl after manual dsek compared favorably with that measured after pkp in the cornea donor study ( 54.7% versus 70% ) . late secondary donor failure due to the reported late graft failure varies between 0 and 45% after 1 year with an average of 6% in the 1 year . in this series , late secondary donor failure occurred in 14 ( 3.3% ) eyes , which is comparable with other series and it happened between 10 months and 5 years . late graft failure was more in dsek in pseudophakic eyes with aciols than with pciols ( 11.7% versus 2.4% ) . previous studies have also showed that ecl in dsaek in pseudophakic eyes with aciols is higher and the graft failure was 16% up to 30 months follow - up . although dsek surgery in patients with an aciol remains controversial , considering the outcomes from different studies , this is a good surgical option in selected cases . as the published report of dsek beyond 5 years are few in number , so long - term graft clarity with dsek is yet to be determined . showed that only four ( 7.8% ) eyes had late donor failure among 51 cases in their longest follow - up of more than 5 years . the failed dsek cases , early or late can be managed by redo procedure in majority ( 54.8% ) of the cases . the infection following dsek procedure , either in the form of interface keratitis and endophthalmitis in early postoperative period , or delayed keratitis after 3 months is always serious and has already been reported in literature . they were managed either medically or by pkp . in this series , in early period , one interface fungal keratitis with candida , and one fulminant endophthalmitis occurred with b. cereus for which evisceration was required on the 5 day . of these cases , one responded to medical treatment with resolution of the infection and the second case required a therapeutic pkp . as a fairly new procedure , the relative inexperience of surgeons in earlier cases may account for more graft manipulation and ecl during surgery . in addition , the dsek in certain indications have more complications than clean case of pciol - related pbk or fuchs endothelial dystrophy . these eyes are aphakic eyes , aciol - related pbk , post - pkp - failed graft , ched , and ice syndrome . in aphakic cases , there are reports of posterior dislocation of the donor disc into the vitreous cavity with or without retinal detachment . other difficult cases are  vitreous in the anterior chamber , previous large peripheral iridectomy , large yag capsulotomy even in presence of pciol , and a large filtration bleb . an experienced surgeon can perform these difficult cases , but with extra precautions and care , and these cases may require additional procedures . all the surgeries were performed by single surgeon with a maximum follow - up period of 5 years . for late complications , so the long - term delayed complications may not be reflected properly in this series . however , to the best of my knowledge after medline search , this is a compilation of complications of the largest series of manual dissection of dsek performed by single surgeon with the same technique for a period of more than 5 years . in conclusion , the dsek / dsaek is an exciting and promising alternative procedure to the traditional pkp . like other corneal transplantation surgeries , the learning curve is steep and the potential for complications is significant during first few cases . both operative and postoperative complications do occur in dsek and increases with the longer postoperative follow - up , but all very much within acceptable limit . the re - dsek procedure can be easily performed in most of the failed cases with satisfactory results .
purpose : to analyze the complications and their managements in descemet 's stripping endothelial keratoplasty ( dsek ) in consecutive 430 cases by single surgeon in a tertiary eye hospital.materials and methods:430 eyes of 366 patients with endothelial dysfunctions scheduled for dsek , were analyzed retrospectively . in all cases donor dissection 
 was performed manually , and 
 taco insertion and unfolding technique was used . intra - operative and postoperative complications with their managements and outcomes were reviewed retrospectively . 
 periodic endothelial cell density was analyzed for each patient till the last visit . 
 follow - up period was between 3 to 60 months ( mean 18.7 months).results:13 ( 3.0% ) eyes had operative complications during donor dissection and 16 ( 3.7% ) had during recipient procedure . in 7 ( 1.6% ) eyes , 
 donor lenticule was replaced with a new one during the surgery . in early postoperative period , 21 ( 4.9% ) 
 eyes had donor dislocation and 12 ( 2.8% ) eyes had air - induced pupillary block ; and they were managed immediately . 
 2 cases had primary graft failure and in 1 case had postoperative bacterial endophthalmitis requiring evisceration . in late postoperative period , 
 48 ( 11.3% ) eyes had secondary glaucoma and 14 ( 3.3% ) eyes had late secondary graft failure . 
 endothelial rejection occurred in 5 ( 1.2% ) cases . 
 mean endothelial cell loss was 19.7% after 3 months and 54.2% after 5 years . 
 total graft failure in this series was 31 ( 7.2% ) and in 17 cases re - dsek was performed successfully.conclusions:both operative and postoperative complications do occur in dsek . 
 most of these complications can be managed by medical or appropriate surgical means . some of the complications can be avoided and reduced with experience .