Current concepts and recent trends in endothelial keratoplasty.

Endothelial keratoplasty (EK) is defined as an umbrella term comprising methods for selective surgical replacement of corneal endothelium and adjacent corneal tissue, which retains healthy portions of a patient's cornea while replacing diseased innermost corneal layer(s) with healthy donor tissue, to achieve corneal dehydration and transparency before the onset of irreversible stromal edema and permanent loss of corneal clarity. Recently, the pathophysiology of corneal decompensation is increasingly being researched upon. Consequent improvement in pharmacotherapy is progressively leading to reduction in the indications of EK. In addition, EK techniques have progressed towards using thinner tissue, optimizing visual outcomes. Improvements have enabled better donor tissue formulation, usage, and attachment, and surgical modifications have enhanced the tissue utilization in difficult clinical scenarios lowering failure and rejection. However, challenges are encountered in various complex clinical scenarios including eyes with prior intraocular surgery, complex anterior chamber anatomy, glaucoma, ocular surface disease etc. These complexities demand tailored surgical strategies, including modifications in graft handling, instrumentation, and postoperative management to ensure success. Attention to these details and addressing patient-specific factors can help improve outcomes in these difficult cases. The choice of procedure depends on multiple factors, including the surgeon's experience, patient's ocular anatomy, and the specific clinical scenario. This review article encompasses the recent developments in this field presenting a comprehensive picture of our modern understanding of the indications, contraindications, surgical techniques, clinical situations, community aspects and future directions pertaining to EK.