1. Venting Incisions in DSAEK Patients: Is It an Absolute Necessity?
Authors
Johanna Choremis, Silvin Bakalian, Michele Mabon
The authors have no financial interests to disclose

2. Introduction Venting incisions were first described by Price
They are commonly used in Descemet’s stripping automated endothelial keratoplasty (DSAEK) to remove fluid from the donor-recipient interface to enhance donor graft adherence(1)
Studies show that corneal venting incisions and higher IOP values seemed to facilitate DSAEK donor graft lenticle adhesion to the recipient cornea(2)
First described by Price, venting incisions are commonly used in Descemet’s stripping automated endothelial keratoplasty (DSAEK) to remove fluid from the donor-recipient interface to enhance donor graft adherence1.
1. Price FW Jr, Price MO. Descemet’s stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence. J Cataract Refract Surg. 2006;32(3):411–418.
Corneal venting incisions and higher AC IOP values seem to facilitate DSAEK donor graft lenticle adhesion to the recipient cornea 2.
2. Vaddavalli PK, Diakonis VF, Canto AP et al: Factors Affecting DSAEK Graft Lenticle Adhesion: An In Vitro Experimental Study. Cornea: June Volume 33 - Issue 6 - p 551–554

3. Purpose
The aim of this study is to assess the role of venting incisions during Descemet striping automated endothelial keratoplasty (DSAEK) to assure graft adhesion to the corneal stroma
The aim of this study is to assess the role of venting incisions during Descemet striping automated endothelial keratoplasty (DSAEK) to assure graft adhesion to the corneal stroma.

4. Materials & Methods
A pilot study with a small prospective case series from a tertiary referral surgical center
A total of 40 consecutive eyes that underwent DSAEK surgery were included in the study
One experienced surgeon using the same DSAEK technique (insertion with forceps and incision size of 5,2mm) completed all the surgeries, either without venting incisions (group 1) or with venting incisions (group 2)
Clinical data recorded : age, gender, eye, clinical diagnosis, donor graft endothelial cell density (ECD)
A pilot study with a small prospective case series from a tertiary referral surgical center. A total of 40 consecutive eyes that underwent DSAEK surgeries were included in the study. One experienced surgeon using the same DSAEK technique (insertion with forceps and incision size of 5,2mm) completed all the surgeries, either without venting incisions (group 1) or with venting incisions (group 2). Clinical data including, age, gender, eye, clinical diagnosis donor graft endothelial cell density (ECD) were recorded. In addition, intraoperative and postoperative data including complications, venting incisions (with or without), graft detachment, graft dislocation and rebubbling were noted. Patients with only posterior chamber intraocular lens were included in the study. Patients with repeat DSAEK due to graft failure were excluded from the study. The relationship between venting incisions and graft adherence was evaluated for both groups of patients.

5. Materials & Methods
Intraoperative and postoperative data including complications, venting incisions (with or without), graft detachment, graft dislocation and rebubbling were noted
Patients with only posterior chamber intraocular lens were included in the study
Patients with repeat DSAEK due to graft failure were excluded from the study
The relationship between venting incisions and graft adherence was evaluated for both groups of patients

6. Results
The number of cases were equal for both groups of patients, comprising of 20 cases for each one (group 1=20 cases and group 2=20 cases)
The mean age of patients who underwent DSAEK surgery was 60 years old for group 1 and 59 years old for group 2
The mean donor graft ECD was very similar for both groups of patients (group 1=2729 and group 2=2753)
No intraoperative and postoperative complications were noted for both groups of patients
The number of cases were equal in both groups comprising of 20 cases for each one (group 1=20 cases and group 2=20 cases). The mean age for group 1 and 2 were 60 and 59 years old respectively. The mean donor graft ECD was very similar for both groups (group1=2729 and group 2=2753). No intraoperative and postoperative complications were noted for both groups of patients. All the grafts adhered and remained attached to the stroma. There was no need to do a rebubbling post-operatively for both groups of patients. None of the grafts were detached or dislocated in either group of patients.

7. Without venting incision
Results
Without venting incision
Group 1
With venting incision
Group 2
Mean age 60 59
Donor graft ECD
2729
2753
Rebubbling
None of the grafts were detached or dislocated in either group of patients
There was no need to do a rebubbling post- operatively for both groups of patients

8. Discussion
DSAEK with venting incisions may be an entry site for different microorganisms, leading to corneal and intraocular infections (3-4)
DSAEK with venting incisions can facilitate epithelial ingrowth leading to graft failure (5)
DSAEK with venting incisions can cause irregular corneal astigmatism that may affect post operative visual outcomes (6)
Venting incisions can induce irregular corneal astigmatism
DSAEK venting incisions can cause irregular corneal astigmatism that may affect visual outcomes
Moshirfar M, lependu MT, Church D, et al. In vivo and in vitro analysis of topographic changes secondary to DSAEK venting incisions. Clin Ophthalmol. 2011;5:
Moshirfar M, Lependu MT, Church D, et al.
Clin Ophthalmol. 2011; 5: 1195–1199.
Published online 2011 Aug 25. doi:  /OPTH.S23867
Corneal venting incisions in DSAEK surgery may be a portal of entry for microorganisms, leading to corneal and intraocular infection, and a high index of suspicion is warranted in the presence of stromal infiltrates or inflammation at venting sites.
Cornea: March Volume 29 - Issue 3 - pp
Fungal Endophthalmitis After Descemet Stripping Automated Endothelial Keratoplasty-A Case Report
Chew, Annabel C Y; Mehta, Jodhbir S; Li, Lim et al.
Cornea: February Volume 30 - Issue 2 - pp
Late-onset Deep Infectious Keratitis After Descemet Stripping Endothelial Keratoplasty With Vent Incisions
Hannush, Sadeer B; Chew, Hall F; Eagle, Ralph C Jr
Cornea: May Volume 30 - Issue 5 - pp
Epithelial Ingrowth After Descemet Stripping Automated Endothelial Keratoplasty: Description of Cases and Assessment With Anterior Segment Optical Coherence Tomography
Suh, Leejee H; Shousha, Mohamed Abou; Ventura, Roberta U

9. Discussion
The goal of venting incisions is to reduce the graft lenticule dislocation rate
Even though our sample size was small we did not notice any difference in dislocation rate for both groups of patients
We believe that venting incisions are not advantageous in preventing graft dislocations

10. Conclusion
Our study suggest that doing DSAEK without venting incisions seems to have no effect on graft detachment and dislocation postoperatively
The limitation of our study is the small sample size
Further studies with larger sample size are needed to validate our results
Our study suggest that doing DSAEK without venting incisions seems to have no effect on graft detachment and dislocation postoperatively. The limitation of our study is the small sample size. Further studies with larger sample size are needed to validate our results. We are aiming to increase our sample size by continuing our study.

11. References
Price FW Jr, Price MO. Descemet’s stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence. J Cataract Refract Surg ;32(3):411–418.
Vaddavalli PK, Diakonis VF, Canto AP et al: Factors Affecting DSAEK Graft Lenticle Adhesion: An In Vitro Experimental Study. Cornea: June 2014 – Vo Issue 6 - p 551– 554.
Hannush SB, Chew HF, Eagle RC JrLate-onset Deep Infectious Keratitis After Descemet Stripping Endothelial Keratoplasty With Vent Incisions. Cornea: February 2011 – Vol Issue 2 - pp
Chew ACY, Mehta JS, Li L et al. Fungal Endophthalmitis After Descemet Stripping Automated Endothelial Keratoplasty-A Case Report. Cornea: March Vol 29 - Issue 3 - pp
Suh LH, Shousha MA, Ventura RU, et al. Epithelial Ingrowth After Descemet Stripping Automated Endothelial Keratoplasty: Description of Cases and Assessment With Anterior Segment Optical Coherence Tomography. Cornea: May Vol 30 - Issue 5 - pp
Moshirfar M, lependu MT, Church D, et al. In vivo and in vitro analysis of topographic changes secondary to DSAEK venting incisions. Clin Ophthalmol. 2011;5: