Endothelial keratoplasty (EK) carries a higher success rate than full-thickness penetrating keratoplasty (PKP) in children because of its faster visual recovery, stronger structural stability, and decreased risk of immunologic rejection.¹

Use the EK technique you are most comfortable with; most techniques can be adapted to pediatric cases taking into account the smaller anterior chamber, floppy iris, and likely phakic status. Also plan to stay in the operating suite longer under sedation to allow time for the graft to attach as sustained positioning in young children is difficult once they are awake.

If the patient is phakic, consider pilocarpine preoperatively to protect the lens during graft insertion.

General anesthesia is recommended for all pediatric patients.

Position patient and yourself as you feel most comfortable taking into account any synechiae or glaucoma devices; EK can be performed sitting temporally or superiorly.

Measure the cornea and decide on the size of the graft. Mark the size of the graft on the epithelium.

Note: The epithelium can be removed for better visualization if needed. Some centers may have access to MIOCT (microscope-integrated OCT) that can be of great assistance in cases with poor visibility.

Make two paracentesis wounds aimed slightly posteriorly.

Instill cohesive viscoelastic agent into the anterior chamber (AC).

Make a triplanar main wound.

Prior to removing endothelium, it is best to ensure the readiness of your graft. We prefer precut thin DSEK tissue, which we trephine to our desired size (˜8 mm) prior to removing endothelium, then store safely in BSS

Note: Err on the side of smaller graft for your first few cases. This will make it easier to unfold in a small AC.

Score the endothelium 360 degrees using your predetermined epithelial markings. There are several methods for scoring Descemet membrane (DM); our preferred method is the use of a reverse Sinskey hook (a bent 27G needle can also be used) to apply gentle but consistent pressure to the DM. The correct pressure will produce a light “snail track” behind your instrument but should not encounter any resistance against stroma. Once 360 degrees have been scored, remove DM with a stripping instrument (Gorovoy stripper) pulling centrally and trying to remove endothelium and DM in one sheet.

Note: Pediatric patients have a stronger adhesion of DM to stroma; if the endothelium and DM does not remove easily (or at all), you can still proceed and place the graft over their existing DM.

Remove all viscoelastic agent, fill AC with air to ensure smooth surface, and visualize any remaining tags of DM. Again, irrigate the AC to remove the air bubble and any possible remaining viscoelastic agent.

Insert the graft.

Note: Our preferred method of insertion is using a single-use inserting device that provides irrigation which helps maintain the AC depth and prevent iris prolapse and lenticular touch. Other methods of insertion include Sheets glide, suture pull through, or Busin glide, etc.