DSAEK Evolution: A comparison of Small Incision Graft Insertion Methods

J. Brian Foster, MD No Financial DisclosuresKeith Walter, MD Patent for Endosaver, consultant for Allergan, Alcon, Oculus, Inspire

IntroductionDescemet’s Stripping Endothelial

Keratoplasty DSEK has been established as the treatment of choice in the treatment of Fuchs’ Dystrophy and Bullous Keratopathy

Current graft insertion techniques have been shown to decrease endothelial integrity of the donor cornea, reducing the efficacy of the transplant.

Current Methods of DSEK delivery3mm Incision

Injectors- Endosaver, NCI, EndoshieldTrifoldPull through

FoldedUnfolded

5mm IncisionBifoldBusin glidePull through

MethodsAn interventional case series analysis of 213 eyes

undergoing DSAEK for Fuchs' endothelial dystrophy and bullous keratopathy.

40 eyes met exclusion criteria of prior penetrating keratoplasty, incisional glaucoma, or retinal surgery.

105 eyes were performed with a small-incision forceps "trifold" insertion technique and 68 eyes were performed with a no-fold DSAEK graft injector.

We noted pre and post-operative visual acuity at 3 and 6 months, pre and post-operative endothelial cell counts, and complications, including graft detachment, failure, and rejection rates.  

SEndothelial side up

Forceps on stroma

side

Endo

Stroma

SupinateTrifold

Trifold

Endosaver Injector

(See Video)

ResultsAverage post-operative endothelial cell loss

at 6 months was 27.7% (n=27) for the injector group and 54.8% (n=51) for the forceps group.

There were three post-op graft dislocations in the injector group (4.4%) and 29 (28%) for the forceps group.

There were 5 graft failures in the forcep group and none in the injector group.

There were no cases of graft rejection.

Trifold Endosaver0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

72% 70%

98% 100%

6 Month Visual AcuityEyes without Ocular Co-

morbidities

20/40 or better 20/60 or better

Exclusion CriteriaGlaucoma 8

ION 1

Macular Edema 8Macular Ischemia 1

Trauma 1

AMD 13

Corneal Scar 6

CRAO 1

Vit. Hemorrhage 1

40

ConclusionsPreservation of donor endothelium is

important for long-term graft survival and speed of visual rehabilitation after DSAEK.

Our injector device permits a no-fold graft insertion through a 4mm incision with a lower graft dislocation rate and endothelial cell loss than a small incision forcep technique.