Novel delivery method to reduce endothelial injury in Descemet Stripping Automated Endothelial Keratoplasty

PURPOSE: To present a novel technique to deliver the endothelial graft in small incision Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) and to compare graft trauma between forceps delivery and the novel technique. DESIGN: Laboratory investigation with an interventional case report. METHODS: Ten pairs of human donor corneas were sectioned using an automated microkeratome system (Moria ALTK System, Antony, France). The recipient model was prepared by creating a 3 mm clear corneal wound in another human donor cornea. For each pair of corneas, one endothelial graft underwent single,fold delivery with forceps, while the other was delivered with the novel cartridge based technique. Each graft was stained with 0.25% trypan blue and 0.2% alizarin red, and digital photomicrographs were taken. A proportion of graft injury was calculated and differences were analyzed. Subsequently, a patient requiring DSAEK underwent the modified novel insertion technique. RESULTS: After insertion, the mean proportion of graft endothelial injury from forceps delivery through the ex vivo model was 26.02% (n = 10, standard deviation [SD] +/- 14.85%). The mean proportion of graft endothelial injury from cartridge delivery was 9.85 % (n = 10, SD +/- 4.33%). The median difference between the two methods was - 13 %, representing less endothelial injury with the cartridge. This difference was statistically significant (P =.006). The patient who underwent DSAEK with this technique had improved visual acuity and a clear graft at five months. CONCLUSIONS: In our surgical model, inserting an endothelial graft through a small corneal wound using a novel cartridge based technique created significantly less endothelial damage than with forceps insertion. Clinically, this technique was performed without complication.