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Small-Incision Descemet Stripping Automated Endothelial Keratoplasty: A Comparison of Small-Incision Tissue Injector and Forceps Techniques

Foster, John Brian MD; Swan, Kevin Roy MD; Vasan, Ryan Anthony MD; Greven, Margaret Ashley BS; Walter, Keith Andrew MD

doi: 10.1097/ICO.0b013e3182120f9d
Clinical Science

Purpose: To describe a novel, small-incision, no-fold Descemet stripping automated endothelial keratoplasty (DSAEK) graft injector and to compare complications, visual acuity, and endothelial cell loss with a forceps technique.

Methods: An Institutional Review Board–approved, interventional, nonrandomized, consecutive case series analysis of 175 eyes undergoing DSAEK for Fuchs dystrophy and bullous keratopathy. The injector arm is prospective, and the forceps arm is retrospective. Seventy grafts were performed with a DSAEK graft injector, and 105 grafts were performed using a small-incision forceps technique. Preoperative and postoperative visual acuities at 3 and 6 months, 6-month endothelial cell counts, and complications, including graft dislocation, failure, and rejection, were recorded. Fifty-seven of 232 eyes met exclusion criteria for previous incisional corneal or glaucoma surgery.

Results: There were 4 eyes (5.7%) in the injector group and 29 eyes (27.6%) in the forceps group that required a re-bubble procedure because of graft detachment. One graft (1.4%) failed in the injector group and 7 grafts (6.5%) failed in the forceps group. Excluding eyes with other ocular comorbidities (43), in the injector group 74% were 20/40 or better at 6 months and 100% were 20/60 or better. In the forceps group, 72% were 20/40 or better at 6 months and 98% were 20/60 or better. Six-month postoperative endothelial cell counts were available for 84 (46 injector and 38 forceps) eyes, with an average cell loss of 28.3% in the injector group and 44.1% in the forceps group.

Conclusions: DSAEK is an effective treatment of endothelial dysfunction. Surgical technique is important to limit endothelial cell loss and prevent complications, such as graft dislocation. The injector device has several advantages over the trifold forceps technique, including decreased endothelial cell loss, graft dislocation rate, and graft failure rate, and it reduces the DSAEK learning curve. DSAEK graft injectors likely will have a role in the future of endothelial keratoplasty.

From the Wake Forest University Eye Center, Winston-Salem, NC.

Received for publication July 13, 2010; revision received January 11, 2011; accepted January 21, 2011.

J. B. Foster, K. R. Swan, R. A. Vasan, and M. A. Greven state that they have no financial or conflicts of interest to disclose.

K. A. Walter is a patent holder for injector device (OSI, Winston-Salem, NC) and a consultant for Allergan, Oculus, and Inspire.

Reprints: John Brian Foster, Wake Forest University Eye Center, 6th Floor, Janeway Tower, Medical Center Boulevard, Winston-Salem, NC, 27157 (e-mail:

Copyright © 2012 Wolters Kluwer Health, Inc. All rights reserved.