a 37-year - old male underwent endothelial keratoplasty in the right eye for primary graft failure following large diameter ( 11.5 mm ) therapeutic penetrating keratoplasty . the therapeutic penetrating keratoplasty was done for advanced fungal keratitis 6 months prior to dsaek . following therapeutic keratoplasty the graft was edematous with 10 intact sutures covered by conjunctiva , the anterior chamber was deep with few peripheral anterior synechiae , pupil showed posterior synechiae , and lens showed early nuclear sclerosis . considering the patient 's age and the absence of significant cataract , simultaneous cataract surgery was deferred . the posterior lamellar graft was inserted by the push - in technique using the sheet iol glide ( bd medical - ophthalmic systems , franklin lakes , nj usa ) protecting the endothelium with sodium hyaluronate 1% . the graft clarity recovered in 1 month after the surgery . at 3 months postoperative visit , pre - operative evaluation by confocal microscopy ( nidek , confoscan 4 ) revealed an endothelial count of 1937 cells / mm . biometry was performed using the keratometry readings obtained from orbscan ii ( bausch and lomb 's , florida , usa ) and iol power was calculated for a postoperative targeted refraction of 0.5 diopters of myopia . irrigation was kept off while inserting the phaco handpiece into the anterior chamber to avoid dislodging the graft . during surgery , a dispersive ophthalmic viscosurgical device ( hydroxypropyl methylcellulose 2% , viscomet , sun pharmaceuticals industries ltd . , on the first postoperative day , vision was 20/160 , improving to 20/80 , and the graft was compact [ figs . 1 and 2 ] . he was treated with ofloxacin 0.3% eyedrops 6 times / day for a week and prednisolone acetate 1% eyedrops 8 times / day for the initial 1 week , followed by tapering of one drop a week and finally maintained on 3 times / day . one month after the cataract surgery , his vision was 20/50 . at the last visit , 3 months later , the graft was compact and the best corrected visual acuity was 20/30 with a 0.75 d sph/1.50 d cyl at 160. table 1 shows the visual acuity , donor thickness [ assessed by anterior segment optical coherence tomography ( oct ) , visante : carl zeiss , germany ] and visual acuity pre- and post - cataract surgery . slit - lamp photograph of the right eye after dsaek ( day 1 post op ) post - op day 1 anterior segment oct image showing well - attached , compact graft pre and post - cataract surgery parameters endothelial cell density changes cataract surgery following penetrating keratoplasty is a safe and effective procedure , with a low but definite risk of corneal graft failure . however , the safety and efficacy of intraocular intervention in eyes that have undergone dsaek is not well established . post - dsaek surgical interventions may be fraught with the risk of endothelial cell damage or donor graft detachment or subsequent endothelial rejection . therefore , patients with visually significant cataract often undergo cataract surgery at the time of endothelial keratoplasty . it may be deferred in eyes where the anterior chamber can not be properly visualized . in eyes with crystalline lens or early nuclear sclerosis that have undergone only endothelial keratoplasty , cataract formation may be hastened due to surgical manipulation , air tamponade at the time of surgery and use of postoperative steroid medications . it is likely that all the mentioned factors might have led to accelerated cataract progression in this case . the specific surgery - related issues to be considered in these eyes are : the site of internal incision in relation to the edge of the lamellar graft , turbulence during insertion of the phaco handpiece with irrigation , which can potentially lead to graft dislodgement , reduced working space in the anterior chamber , and endothelial cell loss during surgery . an endothelial cell loss of 14.7% was noted at 3 months after dsaek and an additional loss of 19.3% was noted from the time of cataract surgery to 3 months later . the overall cell loss at 6 months post - dsaek was 31.2% , which is comparable to the endothelial cell density changes reported after dsaek in various series . this case shows that subsequent intraocular surgery with appropriate precautions can be performed safely in post - dsaek eyes . however , the long - term effect on the endothelium and graft survival needs to be better understood .
management of endothelial dysfunction in phakic patients is sometimes a dilemma for corneal surgeons . 
 phakic patients with visually significant cataract and endothelial dysfunction are preferably managed by performing combined cataract surgery with endothelial keratoplasty . 
 however , combined surgery may be deferred in eyes with early incipient cataract , younger age and where anterior chamber is poorly visualized . as cataract formation 
 may be accelerated after endothelial keratoplasty , these eyes may need cataract surgery subsequently . 
 surgical intervention in eyes with endothelial keratoplasty is of concern as this may affect the graft adversely and threaten graft survival . in this report 
 , we describe the intraoperative surgical details and postoperative clinical course of a patient who underwent phacoemulsification with intraocular lens implantation after descemet stripping automated endothelial keratoplasty ( dsaek ) .