Purpose: To determine the change in anterior corneal high-order aberrations (HOAs) after Descemet's stripping endothelial keratoplasty (DSEK) for Fuchs' dystrophy, and to compare the HOAs with those of age-matched controls. Design: Prospective cohort and cross-sectional study. Participants and Controls: Forty-eight eyes with Fuchs' dystrophy were examined before and after DSEK, and were compared with 52 eyes of age-matched controls with normal corneas. Methods: Corneas of patients with Fuchs' dystrophy were examined prospectively before and at intervals through 2 years after DSEK. Wavefront errors from the anterior corneal surface were derived from corneal topograms and were expressed as Zernike polynomials through the sixth order. Best-corrected visual acuity (BCVA) was measured by the electronic Early Treatment of Diabetic Retinopathy Study protocol, and subepithelial haze was measured from the brightness of confocal images. Total HOAs were compared before and after DSEK, and with those of age-matched controls, by using generalized estimating equation models. Relationships between HOAs, BCVA, subepithelial haze, and recipient age were determined. Main Outcome Measures: Anterior corneal HOAs, BCVA, and subepithelial haze (backscattered light). Results: In Fuchs' dystrophy before DSEK, total HOAs (4 mm optical zone) from the anterior corneal surface (0.29±0.13 μm) were higher than those of controls (0.17±0.08 μm; P<0.001). At 2 years after DSEK, total HOAs (0.26±0.13 μm) did not differ from preoperative aberrations (P = 0.99), and remained higher than in controls (P<0.001). At 2 years, total HOAs were correlated with BCVA (r = 0.59; P<0.001; n = 27), with subepithelial haze (r = 0.41; P = 0.01; n = 25), and with recipient age (r = 0.59; P<0.001; n = 27). Conclusions: Anterior corneal HOAs are higher in Fuchs' dystrophy than in controls, and remain higher through 2 years after DSEK. The aberrated anterior surface might be related to anterior corneal ultrastructural changes and haze formation in Fuchs' dystrophy, and should not be ignored as a source of decreased visual acuity after DSEK. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.
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