Comparative Analysis of Corneal Morphological and Optical Parameters in Predicting DSAEK Surgery Outcome

<i>Background and Objectives</i>: Descemet stripping automated endothelial keratoplasty (DSAEK) is a widely used surgical technique for treating corneal endothelial dysfunctions such as Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK). This study aimed to investigate the association between postoperative visual acuity and various corneal morphological and optical parameters, including corneal densitometry (CD) and higher-order aberrations (HOAs), measured using the Pentacam (OCULUS Optikgeräte GmbH, Wetzlar, Germany), as well as graft thickness, which was assessed by anterior segment optic coherence tomography (AS-OCT), (Optovue Inc., Fremont, CA, USA), and corneal thickness, assessed by both AS-OCT and Pentacam. <i>Materials and Methods</i>: This prospective, observational cohort study included 17 eyes from 13 patients who underwent DSAEK. Data on preoperative visual acuity were collected, while postoperative parameters were assessed during follow-up visits. Corneal measurements included the total corneal and corneal graft thickness, corneal densitometry in 20 defined subregions, and corneal higher-order aberrations. Associations between these parameters and postoperative visual acuity were evaluated using nonparametric statistical tests. <i>Results</i>: The postoperative visual acuity improved significantly (<i>p</i> < 0.001). Strong correlations were found between poorer visual acuity and higher CD values. The strongest correlations with visual acuity were found for CD 2-6 mm total (Rho = 0.795; <i>p</i> < 0.001), CD central 2-6 mm (Rho = 0.791; <i>p</i> < 0.001), and CD central 0-2 mm (Rho = 0.730; <i>p</i> < 0.001). Significant associations were also observed with anterior and posterior HOAs (Rho = 0.624, <i>p</i> = 0.01; and Rho = 0.556, <i>p</i> = 0.02, respectively). No correlation was found between visual outcomes and graft thickness measured by AS-OCT (Rho = 0.051; <i>p</i> = 0.85), nor with total corneal thickness measured by AS-OCT (Rho = -0.227; <i>p</i> = 0.38) or Pentacam (Rho = -0.369; <i>p</i> = 0.14). <i>Conclusions</i>: This study demonstrates that CD and HOAs are more strongly associated with postoperative visual acuity after DSAEK than traditionally monitored parameters such as graft or corneal thickness. The results highlight the value of detailed corneal imaging and support the use of advanced optical diagnostics in postoperative evaluation.