BlueCross BlueShield of Tennessee Medical Policy Manual

Endothelial Keratoplasty


Endothelial keratoplasty, also referred to as posterior lamellar keratoplasty, is a form of corneal transplantation in which the diseased inner layer of the cornea, the endothelium, is replaced with healthy donor tissue. The cornea, a clear, dome-shaped membrane that covers the front of the eye, is a key refractive element of the eye. Layers of the cornea consist of the epithelium (outermost layer); Bowman’s layer; the stroma, which comprises approximately 90% of the cornea; Descemet’s membrane; and the endothelium. The endothelium removes fluid from the stroma and limits its entry, thereby maintaining the ordered arrangement of collagen and preserving the cornea’s transparency. Diseases that affect the endothelial layer include Fuchs’ endothelial dystrophy, aphakic and pseudophakic bullous keratopathy (corneal edema following cataract extraction), and failure or rejection of a previous corneal transplant.

Specific techniques for preparing donor tissue include Descemet stripping endothelial keratoplasty (DSEK), Descemet stripping automated endothelial keratoplasty (DSAEK), or Descemet’s membrane endothelial keratoplasty (DMEK). Laser procedures called femtosecond laser-assisted corneal endothelial keratoplasty (FLEK) or femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK) have also been proposed for utilization in tissue preparation.





The evidence is insufficient to determine if Femtosecond laser-assisted corneal endothelial keratoplasty (FLEK) and femtosecond and excimer lasers‒assisted endothelial keratoplasty (FELEK) improve health outcomes.


American Academy of Ophthalmology. (2018, February). Ophthalmic technology assessment: descemet membrane endothelial keratoplasty: safety and outcomes. Retrieved January 28, 2021 from

BlueCross BlueShield Association. Evidence Positioning System. (4:2020). Endothelial keratoplasty (9.03.22). Retrieved January 28, 2021 from  (25 articles and/or guidelines reviewed)

Kim, S., Lim, S., Byun, Y., & Joo, C. (2016). Comparison of long-term clinical outcomes between descemet’s stripping automated endothelial keratoplasty and penetrating keratoplasty in patients with bullous keratopathy. Korean Journal of Ophthalmology, 30 (6), 443-450. (Level 4 evidence)

Li, S., Liu, L., Wang, W., Huang, T., Zhong, X., Yuan, J., Liang, L. (2017). Efficacy and safety of descemet’s membrane endothelial keratoplasty versus descemet’s stripping endothelial keratoplasty: A systematic review and meta-analysis. PLoS One, 12 (12), e0182275. (Level 1 evidence)

Matsou, A., Pujari, R., Sarwar, H., Rana, M., Myerscough, J., Thomson, S.M., et al. (2020). Microthin descemet stripping automated endothelial keratoplasty versus descemet membrane endothelial keratoplasty: A randomized clinical trial. Cornea, doi: 10.1097/ICO.0000000000002601. Abstract retrieved January 28, 2021 from PubMed database.

Nanavaty, M., Wang X., & Shortt, A. (2014). Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy. Cochrane Database System Review, 2:CD008420. Doi.10.1002/14651858.CD008420.pub3 (Level 2 evidence)

National Institute for Health and Care Excellence. (2009, June). Interventional procedure guidance: Corneal endothelial transplantation. Retrieved July 13, 2016 from

Nielsen, E., Ivarsen, A., Kristensen, S., & Hjortdal, J. (2016). Fuchs’ endothelial corneal dystrophy: a controlled prospective study on visual recovery after endothelial keratoplasty. Acta Opthalmologica, 94 (8), 780-787.  Abstract retrieved July 13, 2016 from PubMed database.




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