Descemet Stripping Automated
Endothelial Keratoplasty with a
Graft Insertion Device :
Technique and Early Results
Dr Wei-Boon KHOR, MRCS(Ed),
Dr Jodhbir S MEHTA, FRCS(Ed),
Prof Donald TH TAN, FRCS(G)
Singapore National Eye Centre (SNEC)
and Singapore Eye Research Institute (SERI)
WB Khor has no financial interests.
Jodbir Mehta and Donald Tan have financial interests
in the EndoGlide (Network Medical Products)
Singapore National Eye Centre
Singapore Eye Research Institute
Introduction
►
►
Descemet Stripping Automated Endothelial Keratoplasty
(DSAEK) is a form of selective corneal lamellar transplant
surgery with many advantages over penetrating
keratoplasty (PK)
However, there is concern over the degree of endothelial
cell loss in DSAEK
 a recent review reported an average loss of 37% (range 25%-54%)
at 6 months, and 42% (range 24%-61%) at 12 months1
►
►
Graft insertion through a small incision with the current
“taco-fold” technique may be a major cause of endothelial
cell damage
New inserters are now emerging which are designed to
minimize surgical trauma and reduce loss in endothelial
cell density (ECD)
1. Lee, W.B., et al., Descemet's stripping endothelial keratoplasty: safety and outcomes: a report
by the American Academy of Ophthalmology. Ophthalmology, 2009. 116(9): p. 1818-30.
Purpose
► This
poster describes the use of the EndoGlide
(Network Medical Products, North Yorkshire, UK),
a new graft insertion device for use during DSAEK
► We
also report the early clinical results of the
Singapore National Eye Centre (SNEC) EndoGlide
Trial
► The
SNEC EndoGlide Trial is an IRB-approved
prospective clinical trial aimed at evaluating the
use of the EndoGlide in 100 eyes
The EndoGlide
Glide Capsule
Glide Introducer
Glide Capsule
Preparation Base
Glide Introducer
EndoGlide consists of three components – the
Glide Capsule, the Glide Introducer, and the
Preparation Base
► The
Diagram on the left is courtesy of Network Medical Products.
Central Ridge
►
A central ridge within the Glide
Capsule (Figure A) enables
automatic coiling of the donor tissue
into a ‘double-coil’ configuration
when pulled into the chamber
►
Double-coiled graft outlined from the
front (Figure B) and the top (Figure
C); the endothelial surface is on the
inside of the double-coil
►
The Capsule can hold a doublecoiled graft without endothelium to
endothelium touch
A
B
C
 accomodates a graft of up to 10 mm in
diameter and 250 um in thickness
Surgical Technique
►
Microkeratome lamellar dissection of
the donor cornea is performed and
then trephined to the desired
diameter
►
Figure D: Leading edge of the
posterior lenticule can be inked on
the stromal edge for easy
visualization
►
Figure E: The internal lumen of the
Glide Capsule is lubricated with
balanced salt solution (BSS)
►
Figure F: Both anterior cap and
posterior donor lenticule are gently
separated with BSS and then
transferred (endothelial side up) onto
the Preparation Base
D
E
F
Forceps introduced here
►
Figure G: Straight forceps are
introduced through the anterior
opening of the Capsule to
grasp the leading edge of the
graft
►
Figure H: As the graft is drawn
into the Capsule, it rolls into the
double-coil configuration when
the lateral edges of the donor
encounter the central internal
ridge
►
Figure I: The graft is drawn
completely into the Capsule
G
H
I
J
►
Figure J: The purple Glide
Introducer is inserted into the
posterior opening of the Capsule
and locked into place
►
The assembled EndoGlide is
removed from the Preparation
Base and inverted for insertion
►
Figure K: The anterior glide
surface of the EndoGlide is
inserted into the eye through a
4.5mm scleral tunnel and
advanced fully in the AC
►
Figure L: Through a nasal
paracentesis, forceps are
passed over the glide surface
and used to grasp the stromal
edge of the graft
K
L
►
Figure M : The graft is simply pulled out
of the EndoGlide and into the AC
►
Figure N : Within the AC, the graft will
uncoil, endothelial surface down.
Moderate BSS flow from a pre-placed
AC maintainer will facilitate unfolding.
Gentle movements of the graft with the
forceps will also aid in the full uncoiling
process
►
Figure O: Whilst still holding the graft
with forceps, the EndoGlide is removed
and a small air bubble is injected
beneath the graft to float it against the
recipient stromal surface
►
The surgery is then completed in the
usual manner
M
N
O
Results
►
The EndoGlide has been used in 26 eyes of 26 patients so
far (performed by 2 surgeons – DTHT and JSM)
►
Diagnosis :
- 11 Pseudophakic/Aphakic Bullous Keratopathy
- 9 Fuchs Endothelial Dystrophy
- Others : Post-Laser PI Bullous Keratopathy, Descemet
Detachment, PPMD, Failed DSAEK
►
Procedures performed: - 12 DSAEK
- 11 Phaco-DSAEK
- 3 DSAEK + IOL exchange
►
►
Median donor diameter: 8.75 mm (range 8.25-9.5)
Mean donor thickness: 187 microns (SD+32)
►
►
We found that coiling of the graft and graft insertion were
easily achieved in all cases
For donor coiling, the use of a BSS cannula or Sinskey
hook to gently stroke up the stromal edges of the graft was
useful to achieve a perfect double-coil configuration
►
Immediate post-op results
 No primary iatrogenic graft failures
 No donor dislocations
►
13 patients have completed 6 months follow-up (and 4
have completed 1 year follow-up)
 Best corrected VA : range from 6/7.5 to 6/45
 No patient has lost any lines of vision
 Mean ECD : 2528 (SD + 337) at 6 months
 Mean ECD loss : 17.6% at 6 months
Discussion
► The
EndoGlide enables graft insertion through a
4.5mm incision with ease, minimal graft
manipulation, and with full control of the graft at all
times during DSAEK
► Early
results show that it is safe in clinical use; no
immediate endothelial complications such as
primary graft failure or graft dislocation so far
► Initial
6 months ECD results are promising, but
more patients and longer follow-up times are
required to determine the long-term ECD loss with
EndoGlide use
Comments? Email <khor.wei.boon@singhealth.com.sg>