OBJECTIVE: To describe long-term outcomes of posterior lamellar [Descemet stripping automated endothelial keratoplasty (DSAEK) and non-Descemet stripping (n-DSAEK)] and the role of microscope-integrated optical coherence tomography (Mi-OCT) in buphthalmic eyes. DESIGN: Retrospective study. METHODS: The medical records of all patients who were diagnosed with buphthalmos and underwent Mi-OCT-guided standard DSAEK/n-DSAEK since 2015 were evaluated. Intraoperative difficulties, graft survival, and complications were recorded. RESULTS: A total of 16 eyes of 16 patients (10 males
6 females) with a mean age of 9.96 + 6.54 years and a mean follow-up of 24.46 + 7.76 months were evaluated. The mean preoperative acuity was 2.03 + 0.39 log MAR, and the mean corneal diameter was 12.89 + 1.0 mm with a corneal thickness of 874.53 + 105 microns. Ten eyes had a clear lens, two had cataracts, three were aphakic, and one was pseudophakic. Descemet membrane scoring was performed in 10 eyes. The mean donor graft size was 9.14 ± 0.30 mm with a lenticule thickness of 135.9 + 44.54 microns. Intraoperatively, all the grafts were attached on Mi-OCT. The final mean acuity was 1.72 + 0.4 log MAR, and the corneal thickness was 596.18 + 89.12. Graft detachment was seen in the immediate postoperative period in 4 eyes that required rebubbling. Two eyes showed pupillary block that was conservatively managed. Following DSAEK, the cornea cleared at 1 month in 81.25% of eyes. One graft failed at the final follow-up. The mean endothelial loss at final follow-up was 29.1%. CONCLUSION: Primary DSAEK is a preferred surgical technique for buphthalmic eyes with compromised corneas. Mi-OCT could be useful in these eyes for various intraoperative maneuvers and to assess graft status thereby improving the outcomes of the procedure.