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Descemet-Stripping Automated Endothelial Keratoplasty: Effect of Inserting Forceps on DSAEK Donor Tissue Viability by Using an In Vitro Delivery Model and Vital Dye Assay

Ide, Takeshi MD, PhD; Yoo, Sonia H MD; Goldman, James M MD; Perez, Victor MD, PhD; O'Brien, Terrence P MD

doi: 10.1097/ICO.0b013e318142bdde
Clinical Science

Purpose: To qualitatively assess the extent and pattern of endothelial trauma on corneal donor Descemet-stripping automated endothelial keratoplasty (DSAEK) buttons resulting from DSAEK insertion forceps.

Methods: An in vitro model was used with corneoscleral rims, DSAEK quality corneal donor tissue, and DSAEK insertion forceps. After insertion of the donor button through the corneoscleral rim, a vital dye assay was used to identify devitalized and necrotic endothelial cells (with alizarin red S and typan blue).

Results: Corneal buttons evaluated with the forceps delivery model showed that, for each arm of the forceps, there were 2 parallel bands of purple/red staining. In addition, orthogonal wrinkles of scattered blue devitalized nuclei were seen in a parallel arrangement.

Conclusions: The DSAEK insertion forceps resulted in a reproducible pattern of endothelial damage. A thorough understanding of iatrogenic endothelial trauma could result in improved forceps design and perhaps help mitigate the high rate of donor dislocation and graft failure in the future.

From the Bascom Palmer Eye Institute, Miami, FL.

Received for publication May 18, 2007; revision received June 13, 2007; accepted June 13, 2007.

Supported in part by The Osaka Medical Research Foundation for Incurable Diseases, KeraMed, and Japan Eye Bank Association.

Reprints: Sonia H. Yoo, Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136 (e-mail:

© 2007 Lippincott Williams & Wilkins, Inc.