Modified DSAEK technique reduces endothelial cell loss

NEW ORLEANS — A modified technique for performing Descemet-stripping automated endothelial keratoplasty, or DSAEK, that involves less graft manipulation may reduce rates of postoperative endothelial cell loss and improve graft survival, according to a study presented here.

In performing DSAEK, many surgeons make a "taco" fold of the donor graft tissue and pull it through an incision before unfolding it and suturing it to the host cornea. However, unfolding the graft with forceps may kill a large number of endothelial cells, said Massimo Busin, MD, professor of ophthalmology at the Villa Serena Hospital in Forli, Italy.

"What counts is the way you insert your graft into the anterior chamber and how you unfold it," Dr. Busin said in a presentation at the American Academy of Ophthalmology annual meeting. "Grabbing with the forceps is deadly for the endothelium ... . If you fold the graft, when you try to unfold it in the eye, it's difficult, especially if you have a shallow chamber or a phakic IOL."

To reduce damage to the graft, Dr. Busin and colleagues developed a "sliding" donor graft insertion technique for performing DSAEK. The new technique involves using "crocodile" vitreous forceps to pull the graft, which is mounted on a funnel-shaped glide, into the anterior chamber. With this no-touch technique, the graft unfolds automatically, with minimal trauma and cell loss, Dr. Busin said.

In a study involving 27 consecutive patients who underwent the modified DSAEK technique, endothelial cell loss averaged 23% at 12 months follow-up, similar to rates of cell loss seen for penetrating keratoplasty, he said.

One patient achieved a visual acuity of about 20/30 at 1 month postop, he noted.

"That was a refraction that was unimaginable for PK," Dr. Busin said.