Case 5 was that of a REFractive Descemet's stripping endothelial keratoplasty (DSEK) surgery (REFEK) procedure. A patient from Texas was referred for endothelial failure and corneal decompensation after cataract surgery with a premium toric implant in a cornea with multiple RK incisions.
Here again, leaving the patientâs toric IOL in place and following my 5S system, my only desire was how to maintain her own cornea (of course deep anterior lamellar keratoplasty/penetrating keratoplasty was a back-up option and part of informed consent) despite the RK since there was history of improved vision close to emmetropia after her cataract surgery before eventual corneal decompensation.
I planned on performing my modified Descemet's stripping automated endothelial keratoplasty (DSAEK) technique (Gulani single instrument DSAEK) trying my best to avoid sutures and also keep my surgery as non-invasive as possible with thin graft, focused centration and secure incision. My goal was to restore her potential vision with minimal distortion of vision due to the surgical procedure. This goal was achieved successfully as I named this technique REFEK or REFractive DSEK surgery) for future similar situations, which involved a central small diameter endothelial graft and sutureless incision.
Many such examples can be seen where you can work refractively with visual impact either to enhance or at least maintain emmetropic vision while corrected corneal disease. In some cases, I use ReSure sealant (Ocular Therapeutix, Inc.) to further secure their incisions especially in patients travelling back to their surgeons.