1. DSAEK Evolution: A comparison of Small Incision Graft Insertion Methods
J. Brian Foster, MD No Financial Disclosures
Keith Walter, MD Patent for Endosaver, consultant for Allergan, Alcon, Oculus, Inspire

2. Introduction
Descemet’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.

3. Current Methods of DSEK delivery
3mm Incision
Injectors- Endosaver, NCI, Endoshield
Trifold
Pull through
Folded
Unfolded
5mm Incision
Bifold
Busin glide

4. Methods
An 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.  

5. Trifold Supinate Endo Forceps on stroma side Endothelial side up
In contrast to traditional penetrating keratoplasty in which the entire corneal thickness is replaced, our DSEK technque utilizes a tri-fold that allows for insertion of donor endothelium in a small incision. The donor cornea is placed endothelial side up. The graft is folded and then grasped with non-compressing forceps. It is turned over, creating the tri-fold. The graft is then inserted through a 3mm incision.
Endothelial side up

6. Trifold

7. Endosaver Injector
(See Video)

8. Results
Average 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.

9. Exclusion Criteria Glaucoma 8 ION 1 Macular Edema Macular Ischemia
Trauma
AMD 13
Corneal Scar 6
CRAO
Vit. Hemorrhage 40

10. Conclusions
Preservation 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.