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Purpose: To compare the outcomes of two techniques, for preparation of microkeratome-assisted ultrathin grafts for Descemet's stripping automated endothelial keratoplasty (DSAEK). Methods: The study involved 20 eyes of 20 patients with pseudophakic bullous keratopathy, randomized into two groups. Group 1 eyes underwent microkeratome-assisted DSAEK using the single-pass technique for lenticule preparation, whereas group 2 eyes underwent microkeratome-assisted DSAEK using the double-pass technique. Patients were followed up till 6 months, postoperatively. Best-corrected visual acuity (BCVA) at final follow-up was considered as the primary outcome measure, whereas graft thickness (GT) contrast sensitivity and endothelial cell loss were considered as the secondary outcome measures. A P value of <0.05 was considered as statistically significant. Results: Baseline characteristics of two groups were comparable. The mean central GT was comparable in both groups at 6 months follow-up [group 1: 98 ± 24.46 μm, group 2: 129 ± 31.46 μm (P = 0.18)]. Both groups fared equally in terms of BCVA (P = 0.33). Contrast sensitivity was significantly better in group 1 eyes (P = 0.045). A statistically significant negative correlation was found between postoperative BCVA and postoperative GT (R = −0.728, P = 0.016). The percentage endothelial cell loss was slightly higher in group 2 eyes, although not statistically significant. Two eyes in group 2 experienced complications during lenticule preparation. None of the eye experienced any complication in the postoperative period. Conclusion: Both techniques provided grafts with comparable thickness and endothelial cell loss and were associated with comparable BCVA, at final follow-up visit. The contrast sensitivity was, however, better in eyes receiving grafts prepared with the single-pass technique.

AimTo evaluate the outcomes and complications of hybrid Descemet membrane endothelial keratoplasty (H-DMEK) using a Descemet stripping automated endothelial keratoplasty (DSAEK) pull-through donor inserter and donor stroma as carrier.MethodsThis was a retrospective interventional case series of eyes with bullous keratopathy (BK) and Fuchs endothelial corneal dystrophy (FECD), which underwent H-DMEK, performed using a bimanual pull-through technique using DSAEK-prepared donor stroma as carrier and the EndoGlide Ultrathin DSAEK donor insertion device. Complex cases with tube shunts, trabeculectomy, aphakia, aniridia, previous vitrectomy, keratoplasty or combined with intraocular lens exchange, were also included. The outcome measures were intraoperative and postoperative complications, best corrected visual acuity (BCVA) and endothelial cell loss after surgery.ResultsOf the 85 eyes from 79 patients, 43.5% (n=37) had BK, 28.2% (n=24) had FECD while 24.7% (n=21) had failed grafts. DMEK was performed in 37 complex eyes (43.5%). Four eyes (4.7%) required rebubbling for graft detachment and two cases of graft failure were observed. A BCVA of 20/25 or better was attained in 44.7% and 57.1% of eyes without pre-existing ocular pathology at 6 and 12 months, respectively. The overall endothelial cell loss was 32.2%±20.5% at 6 months, which improved from 37.2%±20.9% to 24.2%±17.5%, comparing the first 40 and last 45 cases (p=0.012).ConclusionHybrid DMEK offers a controlled ‘pull-through’ technique of donor insertion in the ‘endothelium-in’ configuration, which may be useful especially in complicated eyes. More studies are needed to confirm the long-term endothelial cell loss and graft survival associated with this technique.

PurposeTo design and validate the efficacy of three-dimensional (3D) printed smart storage glide (SSG) which is capable of preserving and delivering posterior lenticules for Descemet stripping automated endothelial keratoplasty (DSAEK).MethodsLaboratory investigation (A) was followed by clinical validation (B). Unsuitable corneas for transplantation (n=20) were used for study A. These tissues were cut using a standard microkeratome, punched and loaded into the SSG and preserved for 7 days in transport media. Endothelial cell density (ECD), Trypan blue and Alizarin red staining for endothelial morphology, thickness measurements and glucose uptake, cell apoptosis and immunostaining post preservation were analysed. For study B, clinical grade corneas (n=14) were preloaded in SSG and grafted in patients with indications of Fuchs’ dystrophy (n=8), pseudophakic bullous keratopathy (n=3), posterior polymorphous dystrophy (n=2), and previous DSAEK failure (n=1). Standard DSAEK included descemetorhexis under air and bimanual delivery of the tissue under infusion of buffered saline solution through an anterior chamber maintainer placed at the 12 o’clock position. Main outcome measures for study B were less surgical time, best spectacle-corrected visual acuity (BSCVA), speed of visual recovery, and ECD.ResultsFor study A, an average ECD loss was 2.30±3.21%, thickness increased by 30.80±20.85% and one-third of glucose was utilised during the preservation phase. Alizarin red showed hexagonality of the cells. Cell apoptosis was not observed and expression of ZO-1 was noted on the preserved tissues. In study B, 25% ECD loss was observed after 6 months. BSCVA improved to 20/25 or better within 3 months after DSAEK. Mean surgical time recorded was 21 min.ConclusionsThis paper describes the development, design, laboratory and clinical validation of a 3D printed SSG which helps to store and deliver posterior lenticules, therefore allowing transportation of quality-controlled precut tissues.

Descemet membrane endothelial keratoplasty (DMEK) is the most desirable corneal transplant surgery as it is associated with the least chances of failure due to endothelial rejection and has the fastest visual recovery among corneal transplants. This technically challenging surgery involves several critical steps such as graft unfolding, positioning and correct orientation. Severe pre-existing corneal oedema limits visibility and prolongs the surgical duration, adversely affecting the success. We present two cases of severe corneal oedema, poor anterior chamber visualisation, wherein we performed endoilluminator-assisted DMEK (E-DMEK). This helped in intraoperative visualisation, reduced the surgical time and reduced graft manipulation. Postoperatively, both patients showed significant improvement in visual acuity (from counting fingers to 20/80 and 20/30) and reduced corneal thickness (556 and 484 microns) at 6 months. The endoilluminator is a practical and cost-effective modification that improves surgical outcomes for both experienced and novice surgeons, expanding the indications for DMEK and ensuring successful postoperative results.

PurposeTo compare endothelial cell loss and complications following Descemet membrane endothelial keratoplasty (DMEK) with use of three commercially available injectors.MethodsFrom 179 consecutive DMEK procedures, 66 cases with uncomplicated graft preparation and completed 12-month follow-up were included in this retrospective study. According to the injector used, 3 groups were formed: group 1 (D.O.R.C. injector, n=16), group 2 (Geuder injector, n=24), and group 3 (Pasteur laboratory pipette, n= 26). Endothelial cell density (ECD) and endothelial cell loss were evaluated preoperatively and at 3, 6 and 12 months postoperatively; surgery-related complications were recorded.ResultsDonor ECD was 2416±179 cells/mm2 (group 1), 2417±164 cells/mm2 (group 2), and 2478±234 cells/mm2 (group 3). At 12 months postoperatively ECD was 1473±403 cells/mm2 (group 1), 1379±317 cells/mm2 (group 2), and 1316±456 cells/mm2 (group 3) (P=0.533, ANOVA). Endothelial cell loss 12 months postoperatively was 39±15% (group 1), 43±13% (group 2), and 47±17% (group 3) (P=0.386, ANOVA). A single case of iris bleeding and reflux of the graft out of the anterior chamber (both in group 3) was noted. Partial graft detachment occurred in group 1 (n=1), group 2 (n=5), and group 3 (n=7) and rebubbling was performed in 6% (group 1), 17% (group 2), and 27% (group 3).ConclusionsTo our knowledge, this is the first clinical study assessing the safety of three different DMEK injectors. Group 1 (D.O.R.C injector) showed the least and group 3 (Pasteur laboratory pipette) the highest endothelial cell loss without reaching statistical significance at 12 months after surgery. Therefore, the graft injector may be chosen according to surgeon's preference.

PurposeThe aim of this study was to investigate the clinical outcome after standardized DMEK using a glass injector.MethodsA total of 254 patients undergoing DMEK surgery using a disposable DMEK borosilicate glass cartridge system were included in this retrospective study. The mean follow-up time was 13.2 months (SD ± 8.1, range 6–36 months). The used glass cartridge system has an aperture diameter of 1.6 mm and a posterior loading orifice of 4.29 mm. Scanning electron microscopy (SEM) was used for estimation of the surface relief of the glass cartridge and comparison with a standard plastic injector cartridge.ResultsMean endothelial cell count of donor grafts was 2465 cells/mm2 (SD ± 199). After 6 weeks of DMEK endothelial cell count decreased by − 28.6% to 1759 cells/mm2 (SD ± 435) (Wilcoxon p = 0.001) and remained stable at the final follow-up at 1735 cells/mm2 (SD ± 442) (Wilcoxon p = 0.89). SEM showed smoother surface of the glass cartridge in comparison with a plastic cartridge.ConclusionThis study showed that this simple and effective DMEK cartridge seems to be a safe and viable device for minimized graft manipulation during DMEK surgery.

Endothelial Keratoplasty (EK) is a corneal surgical procedure that allows a selective transplantation of the posterior layer of the cornea. Descemet's Membrane Endothelial Keratoplasty (DMEK) is one of the EK procedures in which the diseased Descemet's Membrane and the endothelium are replaced with a healthy donor tissue. To achieve this, the donor cornea is cut superficially from the endothelial side and the tissue can be separated using specific instruments like Pierse Notched, Acute or Fogla forceps. However, the pressure required to punch the superficial layer has always been a challenge and therefore a calibrated device to punch and excise the required superficial layer has been designed. This new model of punch will help to identify the peripheral edge of the DMEK lenticule which in turn helps to excise the tissue exclusively, further reducing the donor tissue wastage, as seen with the current tissue preparation methods.

Minimal loss of corneal endothelial cells during corneal transplantation is a major target but remains a point of controversy among specialists. Hence, the available method to best achieve this continues to stir progress in the field. The aim of this study is to evaluate the use of the Endosaver injector device for graft insertion in Descemet's stripping endothelial keratoplasty (DSEK) and compare the visual outcomes and endothelial cell survival between the Endosaver injector and Goosey grasping forceps insertion techniques. This was a retrospective, interventional, consecutive case series undertaken at the University of Southampton Eye Department to assess outcomes of DSEK using the Endosaver injector device compared to noninjector DSEK insertion. Postoperative specular microscopy alongside manifest refraction at 6 and 12 months was evaluated and compared. Mann-Whitney U-test was employed for the statistical analysis of data. Both the Endosaver and Goosey forceps groups showed an improvement in best corrected visual acuity. No significant statistical difference was found in preoperative and postoperative best-corrected visual acuity between the Endosaver and non-Endosaver insertion groups. Mean preoperative endothelial cell count was 2660 (±130) for the Endosaver group and 2608 (±66) for the non-Endosaver group. Postoperative endothelial counts at 6 and 12 months showed a significant difference between the Endosaver: 2104 (±199)-1896 (±226) and the non-Endosaver: 1492 (±207)-1314 (±224) (P < 0.005) groups, respectively. The Endosaver injection device is associated with less trauma to endothelium during graft insertion due to the minimal touch technique employed. A smaller insertion wound of 4.0 mm compared to noninjector cases enabled a more stable system during surgery with no or minimal anterior chamber shallowing. The combination of a stable host with minimal endothelial graft handling and subsequent trauma potentially leads to higher endothelial cell counts when the Endosaver injection device is used compared to forceps insertion.

Objective To study endothelial injury from a newly designed asymmetric double port Descemet Membrane Endothelial Keratoplasty (DMEK) injector, both ex-vivo and in clinical practice. Design Laboratory investigation with an interventional case series study. Method Sixteen rabbit endothelial rolls were tested for injection using a no-touch technique. For each pair of rolls, one endothelial graft underwent injection with a single port Pasteur pipette twice, wheras the other was injected with a novel asymmetric double port injector with a larger diameter entry port than the exit port also twice. Each graft was stained with 4-6-diamidino-2-phenylinidole dihydrochloride and was counted under a fluorescence-inverted microscope before and after injection. The proportion of graft injury was calculated and the differences were analyzed. Subsequently, six patients requiring DMEK underwent surgery using this novel insertion device and endothelial cell loss was calculated 3 months after the surgery. Results After injection, the mean proportion of endothelial cell survival with the single port pipette was 78.8% ( n =8; SD: ±20.9%), whereas the double port injector yielded a survival rate of 96.8% ( n =8; SD: ±8.4%). This difference was statistically significant ( P =0.008), representing less endothelial injury with the double port device. Early endothelial cell loss after 3 months in the DMEK patients was 26.1% (SD: ±6.1%). Conclusion In our injection model, using a double port injector created significantly less endothelial cell damage than with the single port pipette. Clinically, this device yielded early endothelial cell loss comparable to that of the series performed by experienced DMEK surgeons.

To present the clinical outcomes of the Neusidl Corneal Inserter (NCI) (Fischer Surgical, Imperial, MO), a new donor inserter for Descemet's stripping automated endothelial keratoplasty (DSAEK). Six eyes of 6 Japanese patients (mean age = 74.0 years) with endothelial dysfunction were enrolled in this prospective, non-comparative study. All patients had a small cornea of 9.0 mm or less in diameter. A donor was inserted into the eye using NCI. Intraoperative and postoperative complications, postoperative donor endothelial cell densities (ECD), and best-corrected visual acuity (BCVA) were evaluated. Donor loading onto NCI was successful in all cases. No intraoperative or postoperative complications were noted. All cases reached more than 20/63 BCVA within 12 months. Mean ECD was 2,441 cells/mm(2) (mean loss = 22.1%) at 6 months and 2,159 cells/mm(2) (mean loss = 31.0%) at 12 months. Graft insertion with NCI is safe in DSAEK with low endothelial cell loss.