J. Brian Foster, MD No Financial Disclosures
Keith Walter, MD Patent for Endosaver,
consultant for Allergan, Alcon, Oculus, Inspire
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.
Current Methods of DSEK delivery
 3mm Incision
 Injectors- Endosaver, NCI, Endoshield
 Trifold
 Pull through
 Folded
 Unfolded
 5mm Incision
 Bifold
 Busin glide
 Pull through
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.
Trifold
Supinate
Endo
S
S
Endothelial
side up
Stroma
Forceps
on stroma
side
S
Trifold
Endosaver
Injector
(See Video)
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.
6 Month Visual Acuity
Eyes without Ocular Co-morbidities
100%
98%
100%
Exclusion Criteria
Glaucoma
8
ION
1
Macular Edema
8
Macular
Ischemia
1
50%
Trauma
1
40%
AMD
13
30%
Corneal Scar
6
20%
CRAO
1
10%
Vit. Hemorrhage
1
90%
80%
72%
70%
70%
60%
40
0%
Trifold
20/40 or better
Endosaver
20/60 or better
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.