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Purpose: To evaluate the endothelial cell loss at 6 and 12 months after Descemet stripping automated endothelial keratoplasty (DSAEK) using a modified 40/60 underfolding technique and to compare this to the literature on other commonly used implantation techniques, such as the conventional 60/40-fold, gliding, and hitch suture techniques., Methods: Endothelial cell density was measured prospectively, and cell loss was calculated at 6 and 12 months after endothelial keratoplasty using a recently described underfolding implantation technique., Results: In this study, 305 eyes undergoing DSAEK were evaluated. Average endothelial cell loss was 26% at 6 months and 27% at 12 months, all statistically significant reductions from preoperative values (P < 0.01). The decrease in cell count from 6 months to 12 months was not statistically significant., Conclusions: This study demonstrates reduction in endothelial cell loss after DSAEK using the underfold technique when compared with previous reports on conventional folding techniques and similarity to previous reports on glide techniques at 6 and 12 months postoperatively (26% vs. 34% vs. 23% at 6 months). This offers an easy modification to a commonly used existing technique and improves endothelial cell survival after DSAEK.

Purpose: To prospectively assess the impact of a retained open-loop anterior chamber intraocular lens (ACIOLs) on endothelial cell loss after deep lamellar endothelial keratoplasty (DLEK)., Methods: Prospectively gathered central endothelial cell densities of eyes with open-loop ACIOLs after DLEK were examined at 6 months, 1 year, and 2 years., Results: Nine eyes with an open-loop ACIOL were examined. Mean endothelial cell loss was 37% at 6 months (n = 9, P = 0.001), 36% at 1 year (n = 6, P = 0.001), and 41%, at 2 years (n = 5, P = 0.002) after surgery., Conclusion: Postoperative endothelial cell loss over the first 2 years in this small series of patients undergoing DLEK with retention of an open-loop ACIOL may be greater in the first 6-12 months but similar at 2 years when compared with that found in the literature for the DLEK procedure.

Purpose: The purpose of this study was to evaluate outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using anterior stromal flawed (ASF) donor corneas that were unsuitable for use in full-thickness penetrating keratoplasty as a result of stromal scars, pterygia, or previous corneal refractive surgery and to compare results with DSAEK using standard tissue., Methods: We conducted a review of our initial 42 (19 with 6-month follow up) consecutive DSAEK surgeries using ASF tissue compared with 357 (199 with 6-month follow up) time-matched controls using standard tissue. Intraoperative and perioperative complications, including dislocations and primary graft failures, were compared. Six-month best spectacle-corrected vision, incidence of rejection episodes, postoperative refractive astigmatism, keratometric values, pre- and postoperative topography-derived surface asymmetry index, and surface regularity index were compared., Results: One surgeon-cut ASF tissue was perforated before surgery and was discarded. No surgeon-cut standard tissue was perforated. No intraoperative complications and no episodes of primary graft failure or pupillary block glaucoma occurred in either group. One (2.4%) postoperative graft dislocation and one (5.2%) graft rejection episode occurred in the study group. There were 10 (2.8%) dislocations and 8 (2.2%) graft rejection in the controls. A statistically similar significant improvement in best spectacle-corrected vision occurred in both groups. Corneal topography, pachymetry, and manifest astigmatism were not significantly different between groups., Conclusion: Postoperative results of DSAEK using donor tissue excluded from use in penetrating keratoplasty as a result of stromal flaws are equivalent to results using standard donor tissue. Central corneal thickness measurements should be performed before cutting to avoid tissue perforation. The use of ASF tissue for DSAEK will expand the cornea donor pool.

Purpose: To compare a 6-month postoperative vision, endothelial cell loss, and immediate postoperative complications in Descemet stripping automated endothelial keratoplasty (DSAEK) cases performed by an experienced corneal surgeon and his inexperienced fellows using an established technique., Design: Retrospective analysis of prospectively gathered data in 327 consecutive DSAEK cases., Methods: DSAEK cases performed by fellows vs attending surgeons during a concurrent period were compared for 6-month postoperative best spectacle-corrected visual acuity (BSCVA), endothelial cell loss, and immediate postoperative complications. This series represents the initial consecutive cases performed by 3 cornea fellows using a technique identical to that used by the attending., Results: After DSAEK, average BSCVA improved from 20/80 to 20/37 in the attending cases and 20/74 to 20/36 in the fellow cases. There was no statistical difference in endothelial cell loss between groups (32% vs 35%). The dislocation rate was 2% in the attending group and 1% in the fellow group. There were no primary graft failures or cases of pupillary block in either group., Conclusions: This study demonstrates no difference in vision or endothelial cell loss after DSAEK when performed by an experienced corneal surgeon or inexperienced fellows. Postoperative complications also were similar. Results and complications of DSAEK performed by supervised novice fellows can equal those of an experienced DSAEK surgeon.

Objective: To describe a case of retained host embryonic Descemet membrane (DM) after Descemet stripping automated endothelial keratoplasty (DSAEK)., Methods: Review of clinical findings in a case of DSAEK with retention of host embryonic DM., Results: A geographic and patchy haze in the interface involving the visual axis was noted postoperatively as soon as 1 week after DSAEK surgery. This was noted on clinical exam and thought to be retained embryonic DM. Review of pathology on the explanted DM confirmed delamination of DM with absence of the anterior embryonic layer and only patchy areas of full-thickness DM. The haze was followed over time and did not regress over the first 6 months after surgery. It did not seem to affect vision significantly, and the patient achieved best spectacle-corrected vision of 20/30 by 6 months., Conclusions: Endothelial keratoplasty is a relatively new technique for posterior corneal transplantation. Variations in operative technique continue to be described. Delamination of DM during stripping can occur; however, retention of host embryonic DM in DSAEK surgery seems to be compatible with good vision.

Purpose: To report the immediate postoperative complications and the 6- and 12-month clinical results in a large series of cases undergoing the new triple-procedure Descemet's stripping automated endothelial keratoplasty (DSAEK) and concurrent cataract surgery., Design: Prospective, noncomparative, interventional case series., Participants: Three hundred fifteen eyes of 233 patients with Fuchs' corneal dystrophy were evaluated for the complications of dislocation and iatrogenic primary graft failure (IPGF). Two hundred three eyes of 149 patients had 6-month postoperative data available for other outcome analysis., Methods: A standardized technique of DSAEK with extensive use of cohesive viscoelastic was performed in all 315 eyes with Fuchs' dystrophy, and 225 of those eyes had cataract surgery concurrently. Of the 203 eyes with 6-month data, concurrent phacoemulsification with intraocular lens placement (triple procedure) was performed in 149 of those eyes., Main Outcome Measures: The complications of graft dislocation and IPGF were recorded for all eyes. Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive spherical equivalent (SE), and central donor endothelial cell density (ECD) were measured prospectively and then compared with preoperative values for the triple-procedure eyes., Results: There were 4 dislocations (4%) among the 90 straight DSAEK cases and 4 dislocations (1.8%) among the 225 triple-procedure cases (P = 0.327). There was not a single case of IPGF in any of the 315 DSAEK cases. After the triple procedure, the BSCVA in eyes without comorbidity (n = 122) improved with 93% at 20/40 or better at 6 months and 97% at 20/40 or better at 12 months. Refractive SE at 6 months averaged 0.11+/-1.08 diopters (D), with 73% of eyes within 1 D of emmetropia and 95% within 2 D of emmetropia. The postoperative mean ECD was 1955 cells/mm(2) at 6 months (n = 125) and 1979 cells/mm(2) at 12 months (n = 89) and represented a 32% cell loss from that before surgery (P<0.001) for both postoperative time points., Conclusions: The new triple-procedure DSAEK combined with cataract surgery provides rapid visual recovery and allows selection of an appropriate intraocular lens. Dislocations are rare (1.8%) and primary graft failure did not occur.

Purpose: To report 6 and 12 month results using precut tissue for Descemet's stripping automated endothelial keratoplasty (DSAEK) and correlate donor characteristics with clinical outcomes., Design: Prospective, noncomparative, interventional case series., Participants: We reviewed 100 donor corneas precut for 100 eyes of 90 DSAEK patients., Methods: Our first 100 consecutive cases of DSAEK with precut tissue were entered into a prospective protocol. Donor characteristics and the visual, refractive, topographic, and specular microscopy results at 6 and 12 months were analyzed. Correlation analysis comparing donor characteristics with clinical outcomes was performed., Main Outcome Measures: Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive astigmatism, topographic keratometry (K), and specular endothelial cell densities (ECD) were measured prospectively and then compared with preoperative values. Donor characteristics analyzed included death to preservation time, death to surgery time, precutting resection to surgery time, and graft thickness., Results: Six months after DSAEK surgery, BSCVA improved from 20/83 to 20/38. (P<0.01). In eyes with no known comorbidity (n = 60), 92% had a vision of >/=20/40 at 6 months and 20% obtained > or =20/20. Astigmatism changed an average of 0.09 diopters (D) and K changed by +0.09 D, both of which were not significant and were stable to 12 months. The postoperative mean ECD (n = 65) was 1918 cells/mm(2) at 6 months, and represented a 31% cell loss from preoperatively (P<0.001). The mean ECD (n = 61) was 1990 cells/mm(2) at 12 months, and represented a 29% cell loss from preoperatively (P<0.001) with no significant change from 6 to 12 months (P = 0.172). Improvement of visual acuity from preoperative to postoperative in eyes without comorbidity was not correlated with any donor characteristic. Greater endothelial cell loss correlated with higher preoperative ECD levels (P<0.001) and with a trend toward longer precut resection to surgery times at both 6 months (P = 0.049) and 12 months (P = 0.051)., Conclusions: Precut tissue by Eye Banks for use in DSAEK surgery provides an improvement in vision with no significant change in astigmatism. Donor endothelial cell loss from 6 to 12 months is stable and is comparable with reports involving tissue that is cut intraoperatively., Financial Disclosure(s): Proprietary or commercial disclosures may be found after the references.

A 66-year-old man presented with decreased vision and corneal edema after 2 failed Descemet-stripping automated endothelial keratoplasty (DSAEK) graft procedures in the left eye. An uneventful third DSAEK procedure combined with anterior vitrectomy through the previous limbal wound was performed. Postoperative recovery was uneventful. Histopathology of the excised failed graft revealed conjunctival epithelium on the posterior surface of the tissue. At 1 year, the endothelial cell count was 1997 cells/mm(2) and the uncorrected visual acuity was 20/20(-2). At 18 months, the graft remained clear with no signs of epithelial downgrowth. Clinicians should be aware that epithelial downgrowth can occur following DSAEK surgery. Fortunately, excision of the prior DSAEK graft with removal of the active epithelial membrane appears to have been a successful treatment in this patient.

Purpose: To determine the acute endothelial cell damage from trephination and tissue insertion in endothelial keratoplasty (EK) surgery. The influence of insertion technique (forceps insertion vs "pull-through" insertion) of donor tissue and incision size (3 vs 5 mm length) was assessed., Methods: Forty precut 8.-mm-diameter donor posterior buttons were used in this study. Thirty-five buttons were inserted through a limbal incision of either 3 or 5 mm length into the anterior chamber of cadaver eyes and then removed through an open sky technique without further trauma. Five buttons that were trephined but not inserted served as a control group. Vital dye staining and computer digitized planimetry were used to analyze the tissue and quantify the total damaged area over the entire endothelial surface. Five buttons for each of 7 insertion techniques were used. The 8 tissue groups evaluated were as follows: group 1: control group of trephination only, with no insertion; group 2: forceps with folded tissue through 5-mm incision; group 3: suture pull through of nonfolded tissue through a 5-mm incision; group 4: forceps pull through of Busin glide folded tissue through a 5-mm incision; group 5: forceps with folded tissue through a 3-mm incision; group 6: suture pull through with folded tissue through a 3-mm incision; group 7: suture pull through with nonfolded tissue through a 3-mm incision; and group 8: forceps pull through of Busin glide folded tissue through a 3-mm incision., Results: The control group demonstrated 9% +/- 2% peripheral cell damage from simple trephination of the tissue but without insertion. In the 5-mm incision surgeries, forceps insertion (group 2) caused 18% +/- 3% loss, suture pull-through insertion (group 3) caused 18% +/- 2% loss, and Busin glide pull through (group 4) caused 20% +/- 5% loss. There were no significant differences in damage between any of the 5-mm incision group techniques (P > 0.99). In the 3-mm incision surgeries, forceps insertion (group 5) caused a 30% +/- 3% loss, pull through with folded tissue (group 6) caused 30% +/- 5% loss, pull through with nonfolded tissue (group 7) caused 56% +/- 4% loss, and Busin glide pull through (group 8) caused a 28%+/- 5% loss. There was no difference in damage among the 3-mm groups (P > 0.96), with the exception of group 7 where pulling the unfolded tissue through a 3-mm incision was significantly worse than all other techniques (P < 0.001). There was significantly greater cell area damage in the 3-mm groups (36%) than in the 5-mm groups (19%) (P <0.001). Large patterns of striae with cell loss were seen in the 3-mm groups emanating from the peripheral traction site, regardless of whether the traction to pull the tissue through the incision and into the chamber was generated by a suture or cross-chamber forceps. Direct forceps insertion caused circular patterns of injury at the tip compression site regardless of incision size, but this damage was multiplied and exacerbated by insertion through a smaller incision., Conclusions: 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.

Purpose: The purpose of this study was to determine if an association exists between preoperative donor central endothelial cell density (ECD) and the complications of donor dislocation, iatrogenic primary graft failure (IPGF), and endothelial survival at 1 year after endothelial keratoplasty (EK) surgery., Methods: A prospective, nonrandomized, interventional case study was conducted evaluating 629 consecutive EK procedures. The preoperative donor ECD was recorded for each case. The mean preoperative ECD of the group of EK cases with postoperative donor dislocation was compared with the mean ECD of the group of EK cases that did not suffer donor dislocation. The subset of eyes that underwent Descemet stripping automated endothelial keratoplasty (DSAEK) was also evaluated for dislocation, IPGF, and ECD at 1 year., Results: There were 31 eyes that suffered a dislocation in the overall group of 629 eyes (4.9% dislocation rate). The mean preoperative ECD of the donor tissue in this dislocation group was 2769 cells per square millimeter (range = 2147-3454 cells/mm). The mean preoperative ECD of the donor tissue in the group that did not dislocate (n = 598) was 2818 cells per square millimeter (range = 2110-4209 cells/mm). There was no significant difference in preoperative ECD between these groups (P = 0.428). There was a subset of 350 cases of DSAEK, of which 9 cases dislocated (2.6% dislocation rate). The mean preoperative ECD of the donor tissue in this dislocation group was 2604 cells per square millimeter (range = 2323-3175 cells/mm), with 5 of the 9 dislocation donors with a preoperative ECD above 2500 cells per square millimeter. The mean preoperative ECD of the donor tissue in the group that did not dislocate (n = 341) was 2825 cells per square millimeter (range = 2110-4209 cells/mm). There was no significant difference in preoperative ECD between these groups (P = 0.069). There was no significant correlation between preoperative ECD and the ECD at 1 year after DSAEK (n = 90; Pearson correlation = 0.184; P = 0.082). There were no IPGFs in the entire series of 350 consecutive DSAEK cases, and therefore, no statistical analysis is possible for IPGF., Conclusions: Preoperative donor ECD was not associated with donor dislocation for any form of EK surgery. Tissue with donor cell counts below 2500 cells per square millimeter can attach, and tissue with donor cell counts above 2500 cells per square millimeter can detach. Higher preoperative donor ECD was not correlated with higher ECD at 1 year postoperatively. Surgeons' requests for donor tissue with an ECD above 2500 cells per square millimeter for DSAEK surgery for the purpose of avoiding dislocations, IPGF, or improving 1-year ECD are not supported by this data.

Purpose: To describe a technique for insertion of an asymmetrically folded donor graft to minimize endothelial damage during Descemet-stripping automated endothelial keratoplasty., Methods: The tissue is folded in a 40/60 underfold rather than the commonly used 60/40 overfold. It is then grasped with the insertion forceps by using a prone hand position. The hand is rotated clockwise until it is supine, bringing the 60% side of the fold anteriorly, and then the tissue is inserted into the anterior chamber., Results: In 112 eyes, conventional 60/40 overfold insertion technique resulted in a 36% loss in endothelial cell density at 6 months. In 36 eyes, the new 40/60 underfold technique results in a 26% cell loss. This difference of 10% was statistically significant (P = 0.001)., Conclusions: This simple modification to a commonly used folding technique reduces trauma to the exposed peripheral endothelium in a 60/40 overfolded "taco," which is due to contact with the donor trephine block or other surface. It is a slight modification to a commonly used technique for graft insertion and can be easily implemented to reduce postoperative endothelial cell loss.

Purpose: We developed a simple, practical, and inexpensive technique to analyze areas of endothelial cell loss and/or damage over the entire corneal area after vital dye staining by using a readily available, off-the-shelf, consumer software program, Adobe Photoshop. The purpose of this article is to convey a method of quantifying areas of cell loss and/or damage., Methods: Descemet-stripping automated endothelial keratoplasty corneal transplant surgery was performed by using 5 precut corneas on a human cadaver eye. Corneas were removed and stained with trypan blue and alizarin red S and subsequently photographed. Quantitative assessment of endothelial damage was performed by using Adobe Photoshop 7.0 software., Results: The average difference for cell area damage for analyses performed by 1 observer twice was 1.41%. For analyses performed by 2 observers, the average difference was 1.71%. Three masked observers were 100% successful in matching the randomized stained corneas to their randomized processed Adobe images., Conclusions: Vital dye staining of corneal endothelial cells can be combined with Adobe Photoshop software to yield a quantitative assessment of areas of acute endothelial cell loss and/or damage. This described technique holds promise for a more consistent and accurate method to evaluate the surgical trauma to the endothelial cell layer in laboratory models. This method of quantitative analysis can probably be generalized to any area of research that involves areas that are differentiated by color or contrast.

Purpose: Endothelial keratoplasty is an exciting alternative to full-thickness penetrating keratoplasty for replacing the diseased endothelium, yet 3 of the major complications seen are dislocation of the donor tissue, primary graft failure (PGF), and pupillary block from the residual, supportive air bubble. Surgical strategies were developed to reduce the likelihood of occurrence of these complications in our first 200 consecutive Descemet's stripping automated endothelial keratoplasty (DSAEK) cases., Design: Prospective, noncomparative, interventional case series., Participants: Two hundred eyes of 172 patients with corneal edema., Methods: An institutional review board-approved, prospective protocol of endothelial keratoplasty was initiated. Four different surgeons performed DSAEK for the initial 200 consecutive cases using a technique of peripheral recipient bed scraping for donor edge adherence and leaving a residual supportive air bubble, which was freely mobile, and

Purpose: To report 6-month results in a large, prospective study of Descemet-stripping automated endothelial keratoplasty (DSAEK)., Methods: A 5-mm scleral-limbal tunnel approach was created for placement of an automated microkeratome-prepared 8.0-mm endothelial graft after DSAEK in 150 consecutive cases between September 2005 and October 2006. Six-month follow-up data were available on 100 eyes. Intraoperative peripheral scraping was performed to promote adherence of the donor. Preoperative and postoperative visual acuity with and without spectacle correction (BSCVA and UCVA), refractive astigmatism, average topographic keratometry, surface asymmetry index, surface regularity index, and pachymetry were measured prospectively., Results: After DSAEK surgery, average BSCVA improved from 20/86 to 20/38, and average UCVA improved from 20/155 to 20/73, which were both statistically significant (P < 0.05). Excluding 26 eyes with known retinal pathology: 97% of the 74 eyes had a vision of 20/40 or better at 6 months and 14% obtained 20/20 or better. Refractive astigmatism changed an average 0.06 D, and average topographic keratometry changed an average -0.13 D, which were not statistically significant. Surface regularity index and surface asymmetry index improved to normal levels of 0.67 and 1.03, respectively (P < 0.001 and P = 0.002). Pachymetry decreased significantly from 0.70 to 0.66 mm (P = .001)., Conclusions: This large prospective study of DSAEK shows that this surgery provides a significant improvement in vision, corneal thickness, and surface regularity. It does not change refractive astigmatism or average topographic keratometry significantly. This newer technique of endothelial keratoplasty yields many of the benefits of its predecessors, deep lamellar endothelial keratoplasty and posterior lamellar keratoplasty, while improving the visual results.

We describe a case of endothelial graft exchange in a patient who had inadequate vision without a clinically identifiable cause following Descemet-stripping endothelial keratoplasty (DSEK). The initial DSEK was performed with a hand-dissected donor, and the replacement graft was prepared with an automated microkeratome. The best spectacle-corrected visual acuity (BSCVA) improved from 20/50 before replacement to 20/25 after replacement. Although DSEK provides rapid recovery of excellent vision, few patients achieve a BSCVA of 20/20. Some have substandard vision with no clinically identifiable cause. This case demonstrates that replacing a hand-prepared graft with an automated microkeratome-prepared graft may improve vision in patients with no identifiable cause for visual loss.

Objective: To report 3 cases of graft exchange by using a microkeratome-prepared donor tissue in place of a manually prepared donor tissue for inadequate postoperative visual acuity after deep lamellar endothelial keratoplasty and to discuss possible etiologies., Methods: Prospective, observational case series. The patients were 3 consecutive patients who underwent endothelial graft replacement for unsatisfactory vision after initial deep lamellar endothelial keratoplasty. This is a review of clinical findings in 3 cases of endothelial keratoplasty that underwent graft exchange for unacceptable vision after deep lamellar endothelial keratoplasty., Results: Two patients benefited from graft exchange by using a microkeratome-prepared donor in place of a manually prepared donor with improvement in best spectacle-corrected visual acuity and 1 did not because of recipient bed irregularities. Vision improved in this patient with penetrating keratoplasty., Conclusions: Endothelial keratoplasty results in rapid visual recovery and excellent vision. However, fewer eyes achieve 20/20 vision than with full-thickness penetrating keratoplasty. This report shows that some patients with suboptimal vision after endothelial keratoplasty felt to be caused by interface optical problems may benefit from either graft exchange or penetrating keratoplasty.

Purpose: To report the donor endothelial cell loss in the first year after Descemet's stripping endothelial keratoplasty (DSEK) for the treatment of endothelial dysfunction., Design: Prospective noncomparative interventional case series., Participants: Eighty eyes of 78 patients with corneal edema., Methods: Eighty eyes with endothelial failure were entered into a prospective study of endothelial keratoplasty (EK). The donor central endothelial cell density (ECD) was recorded postoperatively at 6 months (n = 80) and 12 months (n = 80) and then compared with the preoperative eye bank measurements. The subsets of eyes with the donor prepared manually (DSEK; n = 19) and the donor prepared with a microkeratome (Descemet's stripping automated EK [DSAEK]; n = 61) were also evaluated and compared., Main Outcome Measures: Preoperative and postoperative central ECDs were prospectively evaluated and the cell loss calculated for each postoperative time point., Results: The average and standard deviation ECD at 6 months was 1908+/-354 cells/mm(2), representing a mean cell loss from preoperative donor cell measurements of 34+/-12%. At 12 months, ECD was 1856+/-371 cells/mm(2) (35+/-13% cell loss). The 1% additional cell loss from 6 to 12 months was not significant (P = 0.233). In the subset of DSEK eyes (n = 19), the cell loss from preoperatively to 6 months was 34%, and at 12 months it was 39%. In the subset of DSAEK eyes (n = 61), the cell loss from preoperatively to 6 months was 34%, and at 12 months it was 34%. There was no statistical difference between the cell loss from DSEK and that from DSAEK at 6 months (P = 0.884) or at 12 months (P = 0.224)., Conclusions: Descemet's stripping EK using our surgical technique has a mean donor endothelial cell loss of 34% at the 6-month postoperative examination, and this average cell loss remains relatively stable up to at least 1 year. We found no difference in cell loss between the DSEK and DSAEK techniques over this 1-year postoperative period.

Purpose: To describe donor characteristics of eye bank-prepared precut tissue used in Descemet's stripping automated endothelial keratoplasty (DSAEK) and report any increase in immediate postoperative complications associated with its use., Design: Prospective, noncomparative, interventional case series., Participants: One hundred donor corneas deemed appropriate for transplant and 100 eyes undergoing DSAEK for endothelial dysfunction., Methods: Precut donor tissue was evaluated in a prospective study of 100 consecutive cases of DSAEK surgery. Donor characteristics and the immediate postoperative complications of donor tissue dislocation and graft failure with the use of precut tissue were recorded and analyzed., Main Outcome Measures: Preoperative donor characteristics (age, time from death to preservation, time from death to implantation, time from cut to implantation, residual stromal bed thickness, pre- and postcut endothelial density), rate of dislocation, and rate of primary graft failure., Results: Average donor age was 57.6+/-10.8 years, average time from death to preservation was 9.8+/-3.2 hours, average time from death to implantation was 94.5+/-33.5 hours, and average time from cut to implantation was 26.0+/-17.4 hours. The average residual stromal bed thickness was 169+/-36 microns. The average endothelial cell density (ECD) after cutting was 2709+/-292 cells/mm(2) (n = 100). In the subgroup of donors in whom pre-resection and postresection endothelial cell densities were available (n = 80), the average ECD before cutting was 2743+/-253 cells/mm(2) and the average ECD after cutting was 2644+/-257 cells/mm(2). This average cell loss of 3.7% was statistically significant (P<0.001). There was only 1 dislocation in this entire series of 100 eyes. There were no primary graft failures., Conclusion: The use of precut tissue in DSAEK had a low rate of early postoperative complications such as graft dislocation (1%) and primary graft failure (0%). A wide range of donor characteristics such as donor age, death to transplantation time, precutting to transplantation time, and donor lenticule thickness resulted in excellent adhesion of the tissue and clear grafts.

Purpose: To report a case of ruptured globe after endothelial keratoplasty., Methods: Review of clinical findings in an 80-year-old man who presented with globe rupture after blunt trauma 3 years after deep lamellar endothelial keratoplasty., Results: The rupture occurred through the temporal scleral tunnel incision with expulsion of endothelial graft and intraocular lens. Primary repair was successful, but the postoperative course has remained complicated., Conclusions: A ruptured globe caused by blunt trauma can occur after endothelial keratoplasty as it can after other intraocular procedures. In this case, the endothelial graft was extruded with separation of the donor-graft interface. The incidence has yet to be determined and whether it is less than that after standard penetrating keratoplasty surgery will require further long-term studies.