Beyond keratoplasty: The role of Descemet stripping only in the management of Fuchs endothelial dystrophy-a systematic review and meta-analysis

Abstract

The clinical role of Descemet stripping only (DSO) in treating Fuchs endothelial corneal dystrophy (FECD) re mains uncertain. The literature varies regarding patient selection, timing of intervention, and use of additional therapies. We evaluate the efficacy and safety of DSO through a systematic review and meta-analysis, focusing on visual outcomes, corneal clearance, and the need for subsequent keratoplasty. It was conducted following PRISMA guidelines and registered with PROSPERO (ID: CRD420251160540). Comprehensive searches of MEDLINE, Scopus, Web of Science, and Embase were performed from inception to August 2025. Eligible studies included prospective or retrospective clinical series with at least 5 patients who underwent DSO for FECD and had a minimum follow-up of 6 months. Data extraction focused on best-corrected visual acuity (BCVA), corneal clearance rates, complications, and reoperation rates. Risk of bias was assessed using the Newcastle-Ottawa Scale and the Egger test. After a multistage screening process, 15 studies meeting the inclusion criteria were included. The pooled mean difference in BCVA, estimated using a random-effects model, was 0.23 LogMAR (95% Confidence Interval [CI] − 0.30 to − 0.17). The corneal clearance rate after DSO was found to be 0.91 (95% CI, 0.85–0.96). Subgroup analysis based on postoperative Rho-kinase inhibitor (ROCKi) use showed that the corneal clearance rate was higher in the group that used ROCKi prophylactically than in the group that did not (96% vs. 85%), with a statistically significant difference (p = 0.0012). The need for secondary endothelial keratoplasty (EK), considered surgical failure after DSO, was 10 % (95% CI, 0.05–0.15). In conclusion, DSO presents a promising alternative to EK in certain FECD patients, decreasing dependence on donor tissue and eye banks, reducing immunological risks, and minimizing the need for complex surgeries. Although the results generally support its clinical value, the variation in outcomes emphasizes the importance of patient selection and complementary therapies. We consolidate the available evidence and underscore the ne cessity for prospective studies to establish standard indications for DSO and enhance its clinical application.