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Minimizing Endothelial Cell Loss Caused by Orientation Stamps on Preloaded Descemet Membrane Endothelial Keratoplasty Grafts

Newman, Lara R., MD*; Tran, Khoa D., PhD; Odell, Kelly, BS; Dye, Philip K., CEBT; Galloway, Joshua, CEBT; Sales, Christopher S., MD, MPH; Straiko, Michael D., MD†,§; Terry, Mark A., MD†,§

doi: 10.1097/ICO.0000000000001809
Basic Investigation

Purpose: To quantify endothelial cell loss (ECL) caused by orientation stamps on prestripped and preloaded Descemet membrane endothelial keratoplasty (DMEK) grafts, and to examine a method for reducing ECL using a smaller stamp.

Methods: Ten prestripped and 10 preloaded DMEK grafts were prepared with S-stamps. Ten additional preloaded DMEK grafts were prepared with both an S-stamp and a smaller F-stamp in different paracentral areas of the graft. The footprint of each stamp was measured using ink on cardstock. DMEK grafts were stored in viewing chambers filled with 20 mL of Optisol-GS for 3 days at 4°C. ECL was quantified using Calcein-AM staining and FIJI Weka Segmentation.

Results: S-stamps on prestripped DMEK grafts contributed an average ECL of 1.1% ± 0.5% (range: 0.6%–2.2%) toward total graft damage, whereas S-stamps on preloaded DMEK grafts contributed approximately twice that amount (average ECL: 2.0% ± 0.7%, range: 1.3%–3.1%, P = 0.004). Overall ECL for prestripped grafts (average: 7.1% ± 3.3%, range: 3.3%–13.7%) and preloaded grafts (average: 11.3% ± 4.2%, range: 6.9%–19.4%) was similar to previous reports. The footprint of the S-stamp was approximately 45% larger than that of the F-stamp. In 10 preloaded grafts marked with both stamps, the S-stamp caused an average ECL of 1.9% ± 0.6% (range: 1.2%–3.2%), whereas the smaller F-stamp caused an average ECL of 1.0% ± 0.2% (range: 0.8%–1.4%, P = 0.0002).

Conclusions: Loss of endothelial cells associated with graft-stamping was greater in preloaded tissue than in prestripped tissue and was less with a smaller F-stamp than with a larger S-stamp. Using a smaller stamp could help minimize ECL in prestripped and preloaded DMEK grafts.

*Central Pennsylvania Eye Institute, Hershey, PA;

Lions VisionGift, Portland, OR;

Weill Cornell Medical College, New York, NY; and

§Cornea Service, Devers Eye Institute, Portland, OR.

Correspondence: Lara R. Newman, MD, Central Pennsylvania Eye Institute, 825 Fishburn Rd, Hershey, PA 17033 (e-mail:

The authors have no funding or conflicts of interest to disclose.

Received July 06, 2018

Accepted September 29, 2018

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