Int Ophthalmol
DOI 10.1007/s10792-014-9941-9
ORIGINAL PAPER
Sutureless clear corneal DSAEK with a modified approach
for preventing pupillary block and graft dislocation: case
series with retrospective comparative analysis
Jeewan S. Titiyal • Sana I. Tinwala •
Himanshu Shekhar • Rajesh Sinha
Received: 28 January 2014 / Accepted: 30 March 2014
Ó Springer Science+Business Media Dordrecht 2014
Abstract The purpose of this study was to describe a
modified technique of sutureless DSAEK with con-
tinuous pressurized internal air tamponade. This was a
prospective interventional case series, single-center,
institutional study. Twenty-seven patients with cor-
neal decompensation without scarring were included.
Aphakic patients and patients with cataractous lens
requiring IOL implantation surgery were excluded.
Following preparation of the donor tissue, a corneal
tunnel was made nasally with two side ports. All
incisions were kept long enough to be overlapped by
the peripheral part of the donor tissue. Descemet
membrane scoring was done using a reverse Sinskey
hook, following which it was removed with the same
instrument or by forceps. The donor lenticule was then
inserted using Busin’s glide. Continuous pressurized
internal air tamponade was achieved by means of a
30-gauge needle, inserted through the posterior lim-
bus, for 12–14 min. At the end of the surgery, air was
partially replaced with BSS, leaving a moderate-sized
mobile air bubble in the anterior chamber. At the
6 month’s follow-up, CDVA improved from counting
fingers at half meter—6/24 preoperatively to 6/9–6/18
postoperatively, and the mean endothelial cell count
J. S. Titiyal (&)
S. I. Tinwala
H. Shekhar
R. Sinha
Cornea, Cataract and Refractive Surgery Services, Dr.
Rajendra Prasad Centre for Ophthalmic Sciences, All
India Institute of Medical Sciences, New Delhi 110029,
India
e-mail: titiyal@gmail.com
decreased: to 1,800 from 2,200 cell/mm2 preopera-
tively (18.19 % endothelial cell loss). Donor lenticule
thickness as documented on AS-OCT was 70–110 l
on Day 1 and 50–80 l at 6 months postoperative.
None of the cases had flat AC or peripheral anterior
synechiae formation. None of the patients required a
second intervention. There were no cases of primary
graft failure, pupillary block glaucomax or donor
lenticule dislocation postoperatively. Our modified
technique is simple and effective with reduction in
postoperative complications associated with DSAEK,
thereby maximizing anatomic and functional out-
comes associated.
Keywords Sutureless DSAEK
Busin’s glide

Pupillary block glaucoma
Graft dislocation
Introduction
Endothelial keratoplasty (EK) is commonly performed
for Fuch’s endothelial dystrophy and bullous keratop-
athy. A variety of surgical approaches for Descemet
stripping-automated endothelial keratoplasty (DSAEK)
have been described [1–3]. These include using scleral
tunnel incisions or clear corneal incisions without donor
folding, often using suture [4], glide devices [5], injector
devices, or a bi-fold or ‘‘tri-fold’’ technique.
The Busin glide (Moria USA, Doylestown, Penn-
sylvania, USA) was designed to avoid folding of the
123

donor endothelium. With this device, the lenticule
usually unfolds spontaneously within the AC, reduc-
ing manipulation and resulting in a less traumatic
insertion with greater endothelial cell survival [6].
EK provides rapid visual rehabilitation for patients.
Despite improvement in the surgical technique for
DSAEK in the recent years, the complications of
donor dislocation and postoperative pupillary block
still pose a challenge. Complete air fill is associated
with an increased risk for postoperative IOP elevation;
conversely, the air bubble is essential for donor graft
adherence to the host stromal surface. Attempting to
decrease the incidence of pupillary block by leaving a
smaller residual air bubble in the anterior chamber
may increase the rate of donor dislocation. Tactful
prevention of both these complications is needed to
optimize outcomes.
We describe a simplified technique of nasal corneal
limbal sutureless DSAEK surgery that eliminates the
use of viscoelastics, surface corneal stab incisions for
interface fluid venting, wound suturing, preoperative
or intraoperative peripheral iridectomies, scraping of
the peripheral cornea or remanipulation of the eye 1 h
after surgery with ‘‘burping’’ of air. Using this
simplified DSAEK technique aimed at maximizing
long-term postoperative anatomic and visual out-
comes, we present the results of DSAEK in a series
of 27 eyes of 27 patients.
Description of the technique
We describe a surgical technique of corneal limbal
sutureless DSAEK via a nasal tunnel keratome entry
wound, coupled with continuous pressurized internal
air tamponade. All surgeries were carried out by a
single surgeon (Prof. JST). Informed consent was
taken from all the patients in accordance with the
declaration of Helsinki.
Donor tissue is prepared by mounting it on an
artificial chamber (Moria ALTK; Moria, Doylestown,
PA), and a free cap is excised using a 400-lm blade.
The remaining donor tissue is placed endothelial side
up on paraffin cutting block and trephined to a suitable
size depending on the vertical white-to-white corneal
diameter. The average donor cut with a Moria ALTK
system is approximately 10 mm. A central trephina-
tion of 8 ± 0.5 mm for DSAEK was taken in all our
cases. This central trephination provides uniform
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Int Ophthalmol
thickness by avoiding the peripheral thicker tissue of
the meniscus-shaped donor lenticule.
Following preparation of the donor tissue, host bed
is prepared under peribulbar local anaesthesia. An
epithelial trephination mark, same size as the donor
lenticule, is centred on the cornea to act as a guide for
scoring of the Descemet membrane–endothelium
complex. A corneal tunnel is made nasally in the
horizontal axis using a crescent knife. The outer lip of
the tunnel is 3.8 mm wide to facilitate lodgement of
the Busin glide at the mouth of the incision, while the
inner lip is approximately 3.2 mm. Care is taken to
keep the tunnel entry into the anterior chamber long
enough for it to be overlapped by the peripheral part of
the donor tissue. Two side ports are made, approxi-
mately 1.5 mm long, directed obliquely, using a
20-gauge micro-vitreo retinal (MVR) (Figs. 1, 2)
blade.
A 23-gauge infusion cannula serving as anterior
chamber maintainer is introduced through the para-
centesis wound. Using a reverse Sinskey hook intro-
duced through the other paracentesis entry, Descemet
membrane scoring is done for 360°, and the membrane
with the endothelium is removed with the reverse
Sinskey hook itself or by forceps. A keratome entry is
now made through the tunnel nasally.
The donor tissue is mounted on a Busin’s glide. A
23-gauge ILM peeling forcep (GrieshaberÒ DSP) is
introduced into the anterior chamber through the same
paracentesis entry as that used for scoring, and brought
out through the keratome entry nasally. The donor
tissue is held by means of this forcep outside the
tunnel, and with the glide now tucked into the wound,
the graft is pulled into the anterior chamber with the
stromal side up. Forcep hold is released when the graft
unfolds completely in the correct orientation.
Air is injected into the anterior chamber through
one of the side ports after the removal of the anterior
chamber maintainer. Graft is centred by stroking with
the aid of a blunt spatula. Continuous pressurized
internal air tamponade is achieved by means of a
30-gauge needle mounted on a 5-cc syringe containing
sterile air, inserted through the posterior limbus. With
the 30-gauge needle in situ, maintaining a complete air
tamponade, the epithelial surface of the host is
massaged externally with the aid of Merocel sponges
for 2–3 min. This manoeuvrer aids in removing any
fluid pockets, while with the 30-gauge needle in the
AC, one can easily replace the air in the event of a leak.
Int Ophthalmol

Fig.1 a Nasal limbal tunnel

using Crescent Blade.
b Side-port incision
approximately 1.5 mm long
and directed obliquely using
micro-vitreo retinal blade.
c Descemet membrane
scoring using reverse
Sinskey hook with a
23-gauge anterior chamber
maintainer in situ. d Nasal
keratome entry following
scoring of Descemet
membrane

After a period of 2–3 min, needle is withdrawn from Results

the anterior chamber. This incision, being self-sealing,
prevents any air leak, maintaining a complete air fill
for a period of 10–12 min.
This 12–14-min period of continuous internal air
tamponade ensures firm adherence of the donor
lenticule to the host tissue. Following this, air is
partially replaced with BSS, and the side ports are
hydrated. This leaves a moderate-sized mobile air
bubble in the anterior chamber eliminating the imme-
diate postoperative intraocular pressure rise associated
with pupillary block glaucoma. It also reduces the
chances of a flat anterior chamber, which may be seen
when partial air removal (‘‘burping’’) is attempted at
the slit lamp in the early postoperative period.
Venting incisions for draining the interface fluid are
not made routinely. The long tunnel entry ensures that
the peripheral part of the donor tissue lies against the
inner lip of the incision, closing it effectively. Anterior
chamber is well formed at the end of the procedure
precluding the need for suturing of the wound.
Of the 27 patients who have undergone DSAEK by
this technique from October 2012, there were 15 males
and 12 females. The mean age of the patients was
62 years (range 35–75 years). The indications for
surgery were pseudophakic bullous keratopathy
(PBK) (n = 16), Fuch’s endothelial dystrophy
(n = 7), corneal decompensation following viral en-
dotheliitis (n = 2), and patients with corneal decom-
pensation following trabeculectomy surgery (n = 2).
Of these, two patients were phakic with clear crystal-
line lens and 25 were pseudophakic.
The preoperative CDVA ranged from counting
fingers (CF) at half meter to 6/24 on Snellen’s visual
acuity chart. The postoperative CDVA ranged from
6/9 to 6/18 at the 6 month’s follow-up. Follow-up
period ranged from 6 to 12 months. Patients with
cataractous lens, requiring a DSAEK-triple procedure
and aphakic patients requiring IOL implantation
surgery, werenot included.

123

Fig. 2 a Busin’s glide-
assisted donor lenticule
insertion. b Air injection
into the anterior chamber
through one of the side ports
after removal of the anterior
chamber maintainer.
c Continuous pressurized
internal air tamponade.
d Moderate-sized mobile air
bubble
Evaluation of the functional capacity of endothelial
cells requires estimation of the endothelial cell density
(ECD) along with the coefficient of variation in cell
size (CV), and percentage of six-sided cells (%
hexagonality). Apart from a good ECD, a normal
healthy cornea should have at least 60 % endothelial
cells with regular shape or hexagonality and should
not have abnormal endothelial cell sizes in more than
30 % of cells.
At our centre, donor tissue is prepared in the
operating room immediately prior to surgery as
facility for pre-cut donor tissue is not available. In
our series, the mean preoperative donor tissue cell
count was 2,200 cell/mm2 (range 2,100–2,650 cells/
mm2). However, preoperative morphological evalua-
tion of cells (CV and % hexagonality) was not
available. Postoperatively, the mean ECD at 6 months
was 1,800 cell/mm2 (18.19 % endothelial cell loss). At
6 months, the mean % hexagonality was 46.1, and the
mean CV was 32.1. Thus, although the cells were
pleomorphic, the cells did not show much polyme-
gathism. This, together with an adequate ECD,
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Int Ophthalmol
maintained clear grafts throughout the follow-up
period.
Donor lenticule was well centred, firmly adherent
to the host stroma, with a clear interface at all follow-
ups as seen clinically on slit lamp examination and
documented on AS-OCT (AS-OCT, Visante; Carl
Zeiss Meditec, Inc., Dublin, CA). The donor lenticule
thickness as documented on AS-OCT was 70–110 l
on Day 1, 60–80 l at 1 month, and 50–80 l at
3 months postoperative.
None of the cases presented with flat anterior
chamber or peripheral anterior synechiae (PAS)
formation. None of the patients required a second
intervention. There were no cases of primary graft
failure or donor lenticule dislocation in the postoper-
ative period. No case of pupillary block glaucoma was
seen in our series.
We retrospectively reviewed our results for DSAEK
performed by the same surgeon (Prof. JST) via a
temporal clear corneal incision (n = 40), requiring
between 2 and 5 sutures for the main wound and side
ports. This technique differed from the above
Int Ophthalmol
described technique in several aspects. Here, the donor
lenticule was prepared using a 350-l microkeratome
blade. A 20-gauge AC maintainer was used as against
the 23-gauge infusion cannula used in the modified
technique. Also, for the main wound, a direct entry
was made into the anterior chamber using a keratome,
rather than a tunnel entry. The side port incisions were
not kept long as in the modified technique. A Descemet
scraper was also made use of in some cases, and the
Descemet–endothelium complex was removed via the
main wound. All the cases required suturing of the
main wound with/without suturing of the side port
incisions. A complete air fill was maintained at the end
of the procedure, requiring ‘‘burping’’ of air 2 h later at
the slit lamp.
The features common to both techniques include
the method of donor lenticule insertion using a Busin
glide and continuous pressurized internal air tampon-
ade for facilitating adherence of the donor lenticule to
the host stroma.
In comparison with our modified technique, it was
seen that the incidences of rise in IOP due to pupillary
block and PAS formation were much higher in these
cases. Pupillary block glaucoma was seen in all eyes
since a complete air fill was maintained at the end of
the procedure. Of these, 90 % patients were given
intravenous mannitol 20 % on the first two postoper-
ative days; 10 % patients required burping of air at the
slit lamp 4 h postoperatively. PAS was noted in five
eyes (12.5 %) on postoperative day 1 requiring
surgical intervention. This can be attributed to several
factors: (1) A complete air fill was maintained at the
end of the procedure with the incisions being air-tight
rather than water-tight; in these cases, partial reab-
sorption of air may be associated with wound leakage
resulting in PAS formation. (2) Maintaining a com-
plete air fill can result in pupillary block glaucoma.
Migration of air in the posterior chamber may result in
peripheral flat AC and PAS formation. (3) In these
cases, a direct uniplanar keratome entry was made in
the AC which may be responsible for wound leaks. (4)
Further, the main incision was made at the start of the
procedure, which may have led to greater wound
manipulation, with the additional use of scraper. In our
present series, keratome entry was made just prior to
donor lenticule insertion, though the tunnel was made
at the start of the procedure. (5) Increased chances of
wound leak in cases of PBK due to re-opening of the
pre-existing temporal cataract surgery wound during
the DSAEK procedure. Therefore, there may be some
leakage of air from the main wound in the immediate
postoperative period resulting in PAS formation. All
these factors were taken care of in our modified
technique.
The preoperative parameters and donor tissue
characteristics were comparable in both techniques.
However, at the 6-month follow-up, the endothelial
cell count in these patients was 1,550 cells/mm2
(29.55 % endothelial cell loss) which is significantly
less than that observed with the modified technique
(p \ 0.05). The donor lenticule thickness at Day 1
was 120–150 l, 110–130 l at 1 month, and
100–130 l at 3 months. The failure rate in this
series was 20 % (8/40).
Discussion
Descemet’s stripping-automated EK is increasingly
being offered as the preferred method for treating
endothelial dysfunction. It is essentially a refractive-
neutral procedure that replaces dysfunctional recipient
endothelium with healthy donor endothelium through
a relatively small (3–5 mm) incision [7–9]. EK
maintains most of the structural integrity of the eye
and retains corneal innervations [10]. Furthermore, no
sutures are required, and so the risk of ocular surface
disease is minimized. In contrast, penetrating kera-
toplasty (PK) permanently weakens the eye; com-
pletely severs the corneal nerves; requires a lengthy
healing period; and can produce large, unpredictable
refractive changes [11–14].
Price and Price reported a significant difference in
endothelial cell loss at 6 months favouring grafts
inserted through 5-mm temporal clear corneal tunnel
incisions as opposed to insertion through a 5-mm
scleral tunnel incision. (27 vs. 36 %); which they
postulated as being due to the decreased internal
compression along the length of the shorter corneal
incision [15]. They also postulated that the scleral
tunnel incision transversed the limbus, and the cornea
and sclera have different radii of curvature which
could account for greater compression of the donor
tissue. However, the 5-mm clear corneal incision
needs to be opposed with sutures.
In our technique, we made a nasal corneal tunnel
using a crescent knife ensuring a longer length of the
tunnel. The paracentesis wounds are also made long
123

and obliquely oriented. When adequately centred, the
donor tissue overlaps the inner lip of the wound, which
is thus closed by the peripheral part of the graft and
acts as self-sealing wound which is water-tight. This
precludes the need for wound suturing.
The nasal location of the wound has several
advantages. It reduces the number of incisions by
eliminating the need for an additional temporal
keratome entry. Also, one of the most common
indications for DSAEK is PBK which follows cataract
surgery. As most phacoemulsification cataract surger-
ies are done via a temporal approach, there may be
scarring or the presence of sutures at that location. A
disadvantage of a temporal incision as seen in some of
our previous cases is the formation of PAS at that
location requiring a repeat surgical intervention,
thereby leading to greater endothelial cell loss. Using
a nasal incision, on the other hand, avoids manipula-
tion of the original wound, leaving it undisturbed.
We also avoid the use of a Descemet scraper in all
our cases, which is a larger gauge instrument com-
pared to the reverse Sinskey hook. Scoring of the
Descemet membrane was done entirely through the
paracentesis entry using the reverse Sinskey hook.
Thus, the microkeratome tunnel entry was not dis-
turbed till the introduction of donor tissue.
In our cases, for insertion of donor lenticule, a
Busin’s glide is used which acts as a means of rolling
the tissue before insertion rather than folding the
tissue, thereby minimizing cell loss. Bahar et al. have
reported lower rates of endothelial cell loss and graft
dislocation with the Busin glide technique compared
with forceps [16]. In the glide techniques, it is
proposed that there is less endothelial cell shock
compared with forceps, and hence it does not diminish
the important pump function of these cells, leading to
reduced dislocation rates [16].
Various techniques for reducing donor dislocation
and preventing pupillary block have been reported
previously. Gorovoy et al. initially described a tech-
nique of placing a supportive air bubble at the end of
surgery completely filling the anterior chamber;
followed by partial air evacuation at the slit lamp
through a previously placed paracentesis site an hour
later [9]. The dislocation rate in this series was 25 %;
pupillary block was not reported in this series of 16
cases. Koenig and Covert reported 4.2 mm incision for
insertion of donor lenticule, with removal of about
50 % of the air bubble at the end of surgery. They
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Int Ophthalmol
experienced a dislocation rate of 35 % (9/26 eyes) [3].
Despite the use of a temporal intraoperative peripheral
iridectomy used in this series, there was one case of
pupillary block that was thought to have led to macular
visual loss owing to an induced branch vein occlusion
[3]. Price and Price have advocated the use of corneal
‘‘fenestration’’ incisions as well as corneal surface
‘‘massage’’ to remove interface fluid before the end of
surgery [8]. The overall dislocation rate was 6 % (4/64
eyes) in this series [10]. They also reported two cases
in a series of 200 eyes with substantially elevated
intraocular pressure, requiring intervention, and one of
these was known to be due to pupillary block by the
residual air bubble [10]. Meisler et al. have described a
technique to promote graft adhesion during DSAEK
using an anterior chamber air–fluid infusion and
exchange to tamponade the graft against the host
stroma [17]. This requires the use of an infusion pump,
which is a component of an air–fluid exchange system
(e.g. Accurus Surgical System, Alcon Surgical used in
this series). The authors attempted to exchange enough
fluid for air such that the temporal edge of the dilated
pupil was just bared or the temporal peripheral
iridotomy was exposed.
Successfully securing the donor lenticule to the
posterior surface of the host stroma is an important
consideration during DSAEK procedure. Our technique
of continuous pressurized internal air tamponade by
means of a 30-gauge needle followed by partial air
removal from the anterior chamber to leave a moderate-
sized mobile air bubble, serves to overcome this
obstacle in multiple ways: it ensures adequate adher-
ence of the donor lenticule to the host stromal bed, and at
the same time prevents pupillary block glaucoma in the
immediate postoperative period. It also reduces the
chances of a flat anterior chamber, which may be seen
when partial air removal is attempted at the slit lamp
post-operatively. No case of flat anterior chamber or
PAS formation was seen in our series.
While maintaining air tamponade, simultaneous
external firm stroking of the host tissue was done by
means of a blunt spatula/Merocel sponge for milking
out the interface fluid. Positive pressure in the anterior
chamber provided counterforce for clearance of the
interface fluid. This manoeuvre precluded the need for
venting incisions which may cause epithelial down-
growth into the interface and interface infections.
Preoperative or intraoperative iridectomy was not
done in any of our cases.
Int Ophthalmol
There is a wide variation in the reported rate of
endothelial cell loss after EK, ranging from 13 % to
61 % at 6–12 months [15, 18–21]. ECL of up to 61 %
has been reported with the taco technique of donor
lenticule insertion, whereas with the Busin glide, the
ECL ranges from 20 % to 30 % [16, 22]. The cell loss
in our series as seen at 6 months was 18.19 % which is
comparable to that reported previously.
This technique can also be used to advantage in
cases of phakic DSAEK. The orientation of the Busin’s
glide and forcep during graft introduction is such that
it does not cross over the pupillary area. Rather, it
remains paracentral, facilitating easy and safe intro-
duction of the donor tissue over the iris, without the
risk of lens touch.
One of the limitations of the nasal wound is the
inability to use this technique for a DSAEK-triple
procedure since a temporal incision would be needed
to perform a phacoemulsification cataract surgery.
However, a similar modification as in our technique
can also be performed through a temporal wound in
cases of DSAEK-triple procedure and aphakic
DSAEK where simultaneous IOL implantation is
planned, although in these cases, an additional nasal
entry would be required for pulling the donor lenti-
cule. Another limitation is the need for longer follow-
up of these patients to know the rate of progression of
endothelial cell loss.
To summarize, by our technique, we have mini-
mized the number of incisions and eliminated the need
for sutures. At the same time, continuous internal air
tamponade ensures a well-formed anterior chamber
without any air leakage. Partial air replacement with
BSS at the end of the procedure prevents the devel-
opment of pupillary block glaucoma in the postoper-
ative period. These manoeuvres coupled with external
firm stroking of the host tissue avoids the need for
venting incisions and ensures adequate adherence of
the donor lenticule.
We have described a simple and effective technique
for sutureless DSAEK with continuous internal air
tamponade, minimizing the rate of postoperative
complications, which may help us improve long-term
anatomic and functional outcomes.
Acknowledgments This study was performed with informed
consent. The authors have not received grant support or research
funding and do not have any proprietary interests in the
materials described in the article.
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