Endothelial Keratoplasty: The Influence of Insertion Techniques and Incision Size on Donor Endothelial Survival

Abstract

Smaller size (3 mm) incisions for EK surgery result in greater acute endothelial area damage than larger size (5 mm) incisions. Pull-through insertion techniques through a 5-mm incision seem equivalent in the amount of induced area damage to that of forceps insertion. Compressive injury from the incision appeared less when the tissue was folded than when not folded. Insertion with any technique through a 3-mm incision resulted in larger areas of endothelial damage. All these iatrogenic death zones outside the central endothelial area would be missed clinically by standard early specular microscopy after EK surgery.

Management and Outcomes of Descemet Stripping Automated Endothelial Keratoplasty With Intraocular Lens Exchange, Aphakia, and Anterior Chamber Intraocular Lens

“…2,12 With the proven success with a variety of donor insertion techniques, 13,14 even novice surgeons 15,16 have reported excellent outcomes in routine cases. In challenging scenarios with a failed PK or glaucoma, graft dislocation and failure rates are higher, 17-20 especially in those cases with a history of previous glaucoma surgery.…”

In Vitro Evaluation of Endothelial Cell Loss Using the Neusidl Corneal Inserter

“…Directly across from the insertion site, a 180-degree clear corneal incision was formed and then closed with 10-0 nylon sutures to create a watertight seal. This flap was opened after each tissue insertion to allow for atraumatic removal, per the earlier study by Terry et al 2 …”

“…2 In that study, the use of non-coapting forceps to insert a folded graft through a 5.0 mm incision resulted in a mean ECL of 18.4%. This study was only powered to determine "noninferiority," meaning that we can only conclude whether ECL resulting from DSAEK with the NCI is comparable with and not worse than DSAEK with Charlie forceps.…”

Evaluation of equine corneal endothelium after exposure to 0.5% indocyanine green - in vitro study

“…Among the methods used for assessing cell death or damaged areas, is a vital staining technique using trypan blue and alizarin red (PARK et al, 2012;RUÍZ et al, 1991;SAAD et al, 2008;SPERLING, 1977;TAYLOR;HUNT, 1981;TERRY et al, 2009). Many studies on endothelial evaluation for corneal transplantation, and studies on the effects of substances to the endothelium, intraocular administration of anesthetics and other vital staining using this technique to analyze, by means of photographic images, to quantitatively and qualitatively analyze cell loss (CHANG et al, 2005;EGGELING et al, 2000;LIOU et al, 2004;SAAD et al, 2008;TERRY et al, 2009;WERNER et al, 1998). This in vitro technique has been used in the laboratory to determine acute cell trauma and death from surgical manipulations.…”

“…The most common method of determining cell death or injury, in the areas not seen by specular microscopy, is through the use of vital dye such as trypan blue and alizarin red (PARK et al, 2012;RUÍZ et al, 1991;SAAD et al, 2008;TERRY et al, 2009). The toxicity of vital dyes to the corneal endothelium has been evaluated in humans and in rabbits (CHANG et al, 2005;CHUNG et al, 2005;RODRIGUES et al, 2009).…”