Various techniques of endothelial keratoplasty explained that is dlek,dsek/dasek,dmek,pdek,femtosecond dsaek,UT-dsaek.

1. ENDOTHELIAL KERATOPLASTY
DR SHREYA BHARGAVA
PG 3RD YEAR

2. HISTORY:
 IN 1956 the first successful human Endothelial Keratoplasty was
done by CHARLES TILLET.
 In 1960 Dr JOSE BARRAQUER described a method of EK using
an anterior approach via LASIK flap.
 IN 1998 MELLE’S et al used air to put a posterior lamellar graft in
place.
 2000:TERRY modified PLK with the introduction of artificial AC
and viscoelastic-DLEK.
 2004: MELLES et al introduced descemetorhexis.
 2005: Dr Francis and Marianne price developed a procedure in
which there is lamellar dissection of stroma,descemet’s and
endothelium was called descemet stripping endothelial
keratoplasty.

3.  2006:Mark Gorovoy introduced the use of microkeratome and thus
DSAEK was introduced.
 2013:Prof.Amar agarwal performed the first innovative PDEK
technique in collabration with Dr Harminder Dua and showed the
significance of Pre-descemet’s layer in corneal transplantation.It
was first performed on a patient with pseudophakic bullous
keratopathy.

4. Anatomy :pre-descemet’s
 Dua’s layer is 15µm thick
 Between corneal stroma and basement
membrane.
 Strong and impervious to air
 It doesnot extend to the periphery.
 Primarily type 1 collagen.

5. Anatomy :descemet’s
membrane
 It is the basal lamina of corneal endothelium;
peripherally ends at schwalbe’s line.
 First appears at 2nd month of gestation and
synthesis continue throughout adult life.
 Thickness at birth (3-4 μm),adult (10 – 12 μm).
 It has two zones- Anterior 1/3 zone - developed
in utero-irregular banded zone; Posterior 2/3 non
banded-developed after birth
 Homogenous fibrillogranular material
 It is a strong resistant sheet,regenerable.usually
stays in tension and curls up when torn.
 -Major protein of DM is Type IV collagen

6. Anatomy:Endothelium
 It is a single layer of hexagonal, cuboidal
cells attached to posterior aspect of DM
 It is neuroectodermal in origin
 Corneal endothelial cells production is
relatively fixed. It is about 500000
(2500cells/mm2)
Endothelial cells density –
 At birth-About 6000 cells/mm²
 26% lost in 1st year
 Further 26% lost over next 11 years
 Rate of cell loss slows and stabilizes
around middle age and then it is about
2500 cells/mm².
 If cell density fall upto 500 cells/mm²
corneal edema develops and transparency
is reduced.

7. Definition:
 Endothelial keratoplasty is the technique in which diseased
endothelium is replaced by healthy donor endothelium.
 Types include: DLEK
DSEK/DSAEK
DMEK
PDEK

8. DLEK:
 Purpose To remove the diseased recipient
endothelium and replace with healthy donor
corneal endothelium.
 In 1998 Dr.Gerritt Melles et al first described
this technique involved large limbal incision
and deep manual lamellar corneal dissection .
 Dr. Mark Terry modified by small incision 5mm
rename the Procedure “Deep Lamellar
Endothelial Keratoplasty (DLEK)”

9. DLEK LARGE INCISION METHOD
STEPS:

10. Continued:

11. DONOR TISSUE
PREPARATION:

12. Graft insertion in DLEK:

13. CLOSURE:

14. SMALL INCISION
TECHNIQUE:

15. CONTINUED:

16. CONTINUED:

17. DLEK vsPKP:
 DLEK procedure preserves the normal corneal topography to allow
faster visual recovery and at 6 months, the average amount of
astigmatism after DLEK surgery was 1.63 ±0.97D* ;after standard
PKP surgery, the average astigmatism is between 4.00 and 6.00D.
 After DLEK the average endothelial cell count at 6 months was
2,218 ±505 cells/mm2 representing only a 22% cell loss from
preoperative donor counts. After PKP, the cell count has been
reported as 1,958 ±718 cells/mm2 which represents a 34% cell loss
from preoperative donor counts.
 The average visual acuity after DLEK surgery at 6 months was 20/40
(6/12). The quality of vision after DLEK appears to be better than
after PKP due to the normal topography and absence of irregular
astigmatism . Topography and vision after PKP are never
considered fully stable until all of the corneal sutures have been
removed, sometimes years after the original surgery.

18. DSEK/DSAEK:
 DSAEK is a partial thickness cornea transplant procedure that involves
selective removal of the patient's Descemet membrane and endothelium,
followed by transplantation of donor corneal endothelium in addition to
donor corneal stroma .
 The transplanted tissue is approximately 100-200 microns thick.
 If the endothelium of the graft makes contact with any surgical
instruments, it will be damaged and the graft may fail.
 A tunneled corneoscleral incision is created, the recipient endothelium
and Descemet membrane is removed, the graft is folded and inserted
with non-coapting forceps (forceps that do not meet at the tips), and an
air bubble is placed in the anterior chamber to support graft adherence.

19. Indications and
Contraindications:
 The procedure is used to treat corneal edema in the setting of
endothelial dystrophies such as:
 Fuchs corneal dystrophy
 posterior polymorphous corneal dystrophy
 pseudophakic bullous keratopathy
 iridocorneal endothelial (ICE) syndrome
 Endothelial failure in the setting of prior intraocular surgery or of a
previous PK graft and other causes of corneal endothelial
dysfunction.
 Contraindications: 1.visual limiting stromal scarring
2.anterior dystrophies
3.corneal ectasias(keratoconus,keratoglobus)
4.hypotony

20. Pre-op evaluation:
 Local anesthesia with peribulbar or retrobulbar block and adjunct
intravenous sedation should be considered. Sometimes even general
anesthesia may be needed.
 Important considerations include the depth of the chamber, severity of
endothelial disease, level of corneal scarring and visibility into the
anterior chamber, status of the other eye, shape of the pupil, and lens
status.
 If the indication for DSEK is a failed graft, knowing the previous size of
the graft will help plan the size for descemetorhexis and graft diameter.

21. .
 With DSEK the shape of the lenticule may produce a hyperopic shift. Targeting a
spherical equivalent of approximately −1.00 when choosing the IOL will generally
minimize a hyperopic surprise.
 The grading of the cataract, endothelial disease, guttae, level of edema, and
scarring should be noted and are critical to use either of two procedures—DSEK
followed by cataract removal, cataract removal followed by DSEK, or a single DSEK-
triple.
 DSEK followed by cataract extraction and IOL implantation performed as two
separate procedures allows for more accurate corneal topography and IOL
measurements and optimizes postoperative visual outcomes. Cataract extraction
and IOL implantation followed by DSEK is the ideal route for mild endothelial
disease, where a DSEK may not be needed.
 DSEK-triple is elected in the presence of endothelial dysfunction and a cataract and
has been shown to be as effective as DSEK alone;cataract extraction alone is
attempted only if endothelial compromise and corneal guttata are minimal, in the
setting of Fuchs.
 Cases with anesthesia risks or the patient experiences difficulty in remaining in the
supine position for prolonged periods DSEK-triple use is lowered.

22. DONOR PREPARATION:
 MOUNTED ON AN ARTIFICIAL ANTERIOR CHAMBER
(DSEK)
 MANUALLY OR SEMI AUTOMATED
MICROKERATOME (DSAEK)
 FEMTOSECOND LASERS

23. GRAFT INSERTION AND
POSITIONING:
 Forceps – charlie 2, goosey ,kelman.
 Sheets glide – sheets intraocular lens.
 Busin glide-reusable funnel glide.
 Insertors/injectors- endosertor, endoglide.
 After graft is inserted—air BUBBLE—10-12 MINS
 Anterior chamber and wound is closed by 3 interrupted nylon sutures.
 Donor disk is uniformly adherent to the patient’s cornea.

24. DSEK/DSAEK:
 Creation of a 5-mm scleral tunnel .
 Descemet‘s membrane is scored
&stripped using a reverse Terry-Sinskey
hook under Healon : Descemetorhexis .
 Inferior iridectomy performed.
 Graft is inserted by endoglide by pull
through technique.
 Air is injected for graft attachment.
 Opening of venting incision to release
fluid from graft host interface.
 Tunnel sealed with 3 10-0 nylon sutures.

25. Taco technique:
 The tissue is folded in a 40/60 underfolded taco.
 Charlie II noncoapting insertion forceps are used to insert the graft into
the AC
 BSS injected to partially unfold of the graft f/b slow air injection
beneath the endothelium for complete unfolding.
 The cornea is compressed with the AC full of air to center the graft
and milk fluid out of the interface.
 The air is exchanged with BSS & reinjected & pt. lies supine for 24 hrs.

26. DSEK/DSAEK TRIPLE
PROCEDURE:phaco+lens
implant+dsaek

27. Modified DSAEK:CONTINUOUS
AIR PUMPING TECHNIQUE:

28. ULTRA-THIN DSAEK:
 In 2009, at the annual meeting of the Cornea Society
in San Francisco a new approach to DSAEK surgery
aimed at utilizing "ultra-thin" (UT) DSAEK grafts.
 In this procedure, the surgical technique differs
substantially from conventional DSAEK, both in the
preparation and in the manipulation and delivery of
the graft.
 UT graft is created with two microkeratome passes,
the first one to debulk the donor tissue and the second
one to cut down the final thickness to about 100
micrometers.

29. DONOR GRAFT PREPARATION
UT-DSAEK:
 FIRST CUT : remove approximately 2/3 of
the anterior stroma, using a disposable
300- or 350-micrometer cutting head,
which should be passed for at least 4
seconds.
 SECOND CUT :The second cut (the
refinement cut) is made with a 90- to
200-micrometer microkeratome head,
depending on the tissue thickness, with
the goal of ultimately creating a graft
that is approximately 100 micrometers or
less .
PACHYMETRY RANGES
•<150 micrometers :No second cut
• Between 150 and 180
micrometers: Use 50 micrometers
• Between 180 and 210
micrometers :Use 90 micrometers
• Between 210 and 230
micrometers :Use 110
micrometers
• Between 230 and 250
micrometers :Use 130
micrometers

30. CONTINUED:
 By starting the two cuts from opposite directions, the second cut is
deeper exactly where the first cut was shallower. Thus the risk of
perforation is minimized and the final shape of the graft is planar .
 Mark stromal side by trypan blue, mark the periphery with a 9.0
round marker to visualize extension of the dissection. Then, mark
asymmetrically (i.e., "F") the central stroma for proper positioning.
 Extend the dissection by hand into the periphery .Remove tissue.
 punch donor tissue to a size that would leave 0.5 mm of free
recipient bed peripherally to the donor tissue (usually graft diameter
varies between 8.25 and 9 mm).
 UT grafts obtained this way are very similar to grafts used for DMEK,
which consist only of Descemet's and endothelium. Despite the
presence of a layer of deep stroma, donor tissue cut extremely thin
tends to curl and manipulation with forceps becomes extremely
difficult.

31. DONOR GRAFT
PREPARATION:
•Pull-through delivery of UT-DSAEK graft.
•The tip of the modified Busin glide is
inserted into a 3 mm nasal clear cornea
incision and a 23-G forceps is entered from
the temporal side and used to grasp the
tissue and pull it into the anterior chamber.
• Modified Busin glide with side platform
allowing scooping of UT-DSAEK graft
•UT grafts obtained this way are very similar to
grafts used for DMEK, which consist only of
Descemet's and endothelium.

32. ADVANTAGES and Disadvantages
OF UT-DSAEK.
 ADVANTAGES:
 The speed of visual recovery is faster than conventional DSAEK and
equivalent to DMEK and the proportion of patients who achieve final
acuity of 20/20 is higher than conventional DSAEK and perhaps also
DMEK.
 This procedure offers the potential to achieve the visual results of DMEK
with the ease of handling and tissue preparation of DSAEK.
 DISADVANTAGES:
 Despite the presence of a layer of deep stroma, donor tissue cut
extremely thin tends to curl, and its manipulation with forceps becomes
extremely difficult.

33. FEMTOLASER DSAEK:
 The laser uses an infrared wavelength (1053nm) to deliver closely
spaced, 3 microns spots that can be focused to a preset depth to
photodisrupt the tissue within the corneal stroma.
 Femtosecond laser is used to create a dissection plane on the donor
cornea mounted on artificial anterior chamber.
 ADVANTAGES:
1. Offers a potential advantage over microkeratome with regards to better
sizing of the posterior lenticule.
2. Obtains a smooth surface and precise stromal cuts SUTURELESS
CORNEAL ADHESION .

34. DISADVANTAGES
DSEK/DSAEK
 Steep learning curve
 Higher endothelial cell loss rate in initial post op period
 Graft dislocation
 Pupillary block
 Reports of graft dislocation in vitreous cavity in aphakics
 Interface haze limiting 20/20 vision
 More hyperopic shift compared to DMEK

35. DMEK:
 Transplantation of isolated donor endothelium and
Descemet’s membrane.
 Steps – Isolation of donor DM and endothelium , recipient
descematorhexis followed by donor insertion and positioning
 Donor preparation :DM isolated by direct peeling(SCUBA) or
by injection of air to create a Big Bubble
 Donor tissue over 50 years of age is preferred.
 Insertion – glass pipette or IOL catridge and injector,
through 2.8mm corneal incision—unwrapping--air fill.

36. DONOR TISSUE
PREPARATION:
 The DMEK graft is ideally prepared in an eye bank prior to surgery by
stripping the tissue from a donor corneoscleral button with a
minimum cell count of 2,300 cells/mm2.
 The tissue is stored for 1 or 2 weeks in a glass vial in organ culture at
31 deg C.At the time of surgery, the content of the glass vial is poured
into a glass bowl, and a glass pipette is used to drain the culture
medium from the bowl, avoiding any contact with the graft.
 In the bowl, the DMEK roll is thoroughly rinsed (two to three times)
with balanced saline solution (saline).
 The DMEK roll is then stained with trypan blue dye 0.06% for about 30
seconds, rinsed with saline, and again stained with trypan blue dye to
obtain an intense blue tissue coloration.
 The DMEK roll is then rinsed again with saline to remove all excess
dye.

37. DM PEELING TECHNIQUES:
 The most commonly performed technique for DM peeling is the manual
peeling method described by Melles et al wherein the donor corneoscleral
rim is immersed in Balanced Salt Solution and the DM is peeled with 1-point
fine non-toothed forceps.
 Giebel and Price described the SCUBA (submerged corneas using
backgrounds away) where the donor tissue is submerged in Optisol or BSS
during tissue peeling to minimize the surface tension on the donor tissue
allowing the DM to settle back onto the stroma. Microfinger (moria) used for
dissection.
 SUBHY’S technique:0.3 ml organ culture is injected in posterior stroma to
create a liquid bubble.Bubbled cornea mounted on AAC then trephination
performed.

38. DM PEELING:BIMANUAL
TECHNIQUE

39. DM PEELING TECHNIQUES:
 Yoeruek et al. described the use of a curvilinear forceps with a half-moon shape
non- toothed that can equally distribute the forces needed for DM separation .
 Venzano et al. described the use of an artificial anterior chamber (AAC) to
harvest the Descemet-endothelium complex with the Anwar air-bubble
technique.
 Zarei-Ghanavati et al. used a reverse big-bubble technique for DMEK tissue
preparation
 The technique of pneumatic dissection was further modified by Busin et
al. where the donor tissue is mounted on AAC and superficial keratectomy is
done with a 300-micron microkeratome head prior to air injection.

40. DM PEELING:
 Muraine et al. reported a technique in which the cornea is mounted on an
AAC with the endothelium side up and a 330° superficial trephination is done
with a trephination blade that is first broken to generate a fragment 3-4 mm
long.
 The peripheral endothelium is detached with a spatula or jaws of a Troutman
forceps on either side of the zone where Descemet membrane is attached.
 A cannula is then inserted beneath the flap through which BSS is injected
with a 27 gauge cannula mounted on a syringe to detach the DM by
hydrodissection .

41. SUCCESS RATE ACCORDING TO DM
PEELING TECHNIQUES:

42. DM MARKING:
 Mark the EDM complex to ensure correct orientation of the donor tissue
when injected into the eye.
 Misidentification of the graft orientation in the anterior chamber can lead to
eventual primary graft failure. The stromal bed of the donor cornea is
punched with a 2 mm punch. Following this the EDM complex is reposited
over the stromal bed and the donor tissue is inverted with the epithelium
side up. Through the 2 mm window the stromal side of the EDM complex is
marked with a S stamp stained with gentian violet paint.
 Bachmann et al. introduced asymmetric marking on the edge of the graft
using a 1-millimetre-diameter dermatological biopsy punch at 3 sites at the
edge of donor tissue from the endothelial side to ensure proper anterior
posterior orientation of the donor tissue.
 Bhogal et al. described a Single triangular marking technique using a 30-
degree incision knife for DM marking.
 Matsuzawa et al described the four asymmetric semicircular marking
technique with 1.0- and 1.5-mm diameter dermatomal punch at the edge of
the donor from endothelial side. The small and large marks are paired and
the two pairs are placed at the opposite ends of the graft diameter

43. DONOR PUNCHING:
 After marking the donor tissue the EDM complex is punched with 7.5-8.0
mm trephine. The tissue is then carefully peeled avoiding peripheral rip
off.
 ROLL PREPARATION:AUTHOR’S MODIFICATION:SHARP TECHNIQUE

44. GRAFT INSERTION:

45. MOUTSOURIS SIGN:
 The sign indicates correct graft orientation. If the graft is oriented
correctly (A), the tip of the cannula turns blue (B); if not (C), the tip does
not turn blue

46. GRAFT POSITIONING IN
DMEK:

47. SURGICAL OUTCOME:
 Visual acuity-6/9 to 6/18 with DSEK DMEK has faster and better visual
recovery DMEK – 6/9 or better vision.
 Refractive results- mean hyperopic shift of 0.75 to 1.5D due to changes in
posterior corneal curvature and increase in thickness in DSEK.
 DMEK– 0.25 to 0.50 D hyperopic shift.
 Endothelial cell loss- at 6months- 18-35 % , 54% at 5years .
 Graft survival-55-100% in various studies.

48. DMEK ADVANTAGES:
 Reduction of interface haze
 Less incidence of graft dislocation
 Shorter visual recovery as total corneal thickness remains
same
 Larger donor surface provides more viable endothelial cells
 Less strong host graft apposition at interface allows easier
removal of failed/rejected donor lenticule
 No costly instruments for donor lenticule preparation
disadvantages

49. DISADVANTAGES:
 Difficult and more traumatic manipulation of
rolled DM.
 Higher endothelial cell loss rates with current
techniques.
 Not suitable for 1. Aphakics
 2. Large iris defects
 3. Previous pars plana
vitrectomy

50. Continued:
 DMEK>DSEk Management-scraping, venting
incisions, air, supine position, rebubbling .
 Epithelial down growth- donor epithelial
entrapment
 Interface abnormalities- thickness irregularities
due to manual dissection— folds and wrinkles in
EK, incomplete removal of visco Haze due to
proteoglycan deposition
 Infections
 Graft rejection- Lower in EK compared to PK,
rejection PK>DSEK>DMEK
 Late endothelial graft Failure
 Steroid induced glaucoma

51. PDEK:
 Dua et al. identified a novel pre-Descemet's layer
(PDL) or a Dua's layer.
 Although pneumatic dissection has been described
before, Dua et al. distinctly described the Type-1,
Type-2, and mixed bb, highlighting and
scientifically proving their individual existence and
significance.
 Pre-Descemet's EK (PDEK) is a newer variant in the
arena of EK and it involves the separation of PDL
along with DM-endothelium as a donor lenticule.

52. GRAFT PREPARATION

53. PDEK GRAFT PREPARATION:
 A .30-gauge needle connected to a syringe with air enters the cornea from the edge of
the sclera. The donor cornea is kept endothelial side up.
 B: The needle is gradually passed to the center of the cornea, taking care not to perforate
the endothelial side. Once it reaches the center of the cornea, air is injected into the
corneal layers.
 C: A type 1 big bubble is formed. The air is now between the pre-Descemet’s layer and
stroma. Big bubble does not reach the periphery of the cornea because there are firm
adhesions between the pre-Descemet’s and stroma in the periphery.
If a bubble is created to the edge of the cornea, it is a type 2 big bubble i.e between the
Descemet’s membrane and the pre-Descemet’s layer. So we will have to do DMEK.
 D: Trypan blue is injected into the type 1 big bubble as the bubble has been perforated.
This helps to stain the tissue and also helps the surgeon get a clear view of the lenticule.
 E: A trephine is taken, matching the size of the type 1 big bubble and trephination done.
 F: Any area that has not been clearly cut is cut with Vannas scissor, and the entire
lenticule is lifted. This graft now contains endothelium, Descemet’s membrane and pre-
Descemet’s layer.
 The final size of the graft after cutting may be slightly larger than the trephine. The graft
is loaded into an injector when ready for insertion.

54. CONTINUED:
 A type 1 big bubble is a PDEK graft. It is a well-circumscribed, central
dome-shaped elevation measuring 7 mm to 8.5 mm in diameter. It
always starts in the center and enlarges centrifugally, retaining a
circular configuration.
 Creation of a type 1 big bubble is similar to an Anwar’s big bubble
created for DALK except that air is injected from the endothelial side.
 A type 2 big bubble is a DMEK graft. It is larger, up to 10.5 mm, and
extends from the periphery.
 The bursting pressure of the PDEK graft is higher than that of the
DMEK graft. The type 2 bubble collapses on attempting to peel the
Descemet’s membrane off whereas it can be peeled off a type 1
bubble without the bubble collapsing, proving the inclusion of the
pre-Descemet’s layer in the PDEK graft.

55. PDEK STEPS:

56. PDEK SURGICAL STEPS:
A: Preop photo of pseudophakic bulbous keratopathy.
B: After marking the cornea with a trephine, Descemet’s membrane is
scored and stripped.
C: Pupilloplasty is done.
D: Pupilloplasty is completed. Pupil is now round.
E: The PDEK graft is injected into the anterior chamber with the help
of the injector.
F: The graft is unrolled once correct orientation is checked. Air is
injected under the graft to fix it to the cornea. PDEK graft is
attached. Air is filling the anterior chamber.

57. PUPILLOPLASTY:
 It is often performed to prevent the escape of air from the AC to the
vitreous cavity.
 specially indicated in cases with iris defects that can be surgically
corrected.
 Along with secondary IOL fixation, it helps to compartmentalize the eye
into AC and posterior chamber, thereby acting as a diaphragm. It also
helps to create an adequate air pressure in the AC that facilitates graft
adhesion to the recipient bed.
 The surgical procedure of choice for performing pupilloplasty is single-
pass four throw technique (SFT)[

58. PUPILLOPLASTY:

59. PDEK ADVANTAGES:
 The presence of PDL in the donor graft provides it with splinting
effect and this results into less curling of the donor tissue.
 The difference is more evident in young/infant donor corneas
where the PDEK graft can be handled comparatively in a stable
way.
 DMEK does not allow the use of donor tissue younger than 40
years of age due to the inability to unscroll the edges of the graft.
Also, PDEK allows usage of young and infant donor corneas,thereby
increasing the virtual pool of potential donors.
 Theoretically, due to increased ECD count in young corneas, the
results should be better as compared to transplantation performed
with adult or older donor corneas. Although this aspect needs to
be evaluated, the potential loss of ECD in the postoperative period
can be partially compensated with the initial high ECD count of the
young donor cornea.

60. POST-OP CARE PDEK:
 All the patients undergo pressure patching and supine positioning.
 Postoperatively, all the patients are advised to lie supine for 1–2 hours
and also to lie supine for the most part during the 1st postoperative day.
 From the 1st postoperative day, 0.1% dexamethasone sodium phosphate
and moxifloxacin eye drops are administered every 2 hourly for 1 week
and then every 4 hourly for the next 3 weeks.
 Topical steroid drops are then tapered slowly over a period of the next 3
months and are then instilled once daily from the 4th month onward.

61. PDEK VS DMEK
 The graft size that is achieved in PDEK is approximately 7.6 ± 0.22 mm in
diameter that is comparatively less as compared to DMEK grafts that are
around 10 mm in diameter.
 This occurs due to peripheral adhesions between the PDL and the DM
that prevents the extension of air bb far into periphery.
 As the DMEK graft is larger, it tends to cover more area of the recipient
bed as compared to PDEK graft that is comparatively smaller. However, a
smaller graft undergoes less compression while being injected inside the
AC.
 endothelial cell density loss to be almost identical in both PDEK and
DMEK procedures when prepared by pneumodissection, and that PDEK
graft preparation is a viable technique.[

62. COMPLICATIONS OF
ENDOTHELIAL KERATOPLASTY:
EARLY :
1.Graft dislocation 1st postoperative
week(>30%).Treatment:Rebubbling.Total disloction then regrafting is
done.
2.Primary graft failure
3.Ocular hypertension
4.Pupillary block

63. Continued:
 LATE:
 Graft rejection: Khodadaust line
 Epithelial ingrowth:

64. SUMMARY: