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. 2024 Nov 7;103(3):281–288. doi: 10.1111/aos.16791

Graft detachment rates in surgeon‐cut and pre‐cut tissue for DSAEK transported in different mediums

Thorbjörg Olafsdottir 1, Faisal Hootak 2, Carina Forslund 3, Eydis Olafsdottir 1, Ingemar Gustafsson 1,✉
PMCID: PMC11986399  PMID: 39508714

Abstract

Purpose

To analyse graft detachment rates after Descemet stripping automated endothelial keratoplasty (DSAEK) using surgeon‐cut grafts and pre‐cut grafts transported in different mediums.

Methods

A retrospective study of graft detachment rates including 265 surgeries (240 patients) performed between 2019 and 2023. The DSAEK grafts were either surgeon‐cut (n = 135) or pre‐cut and transported in a dextran‐containing medium (n = 82) or in a dextran‐free medium (n = 48). All surgeries were performed by a single surgeon (I.G.). The surgeries were categorised according to whether the recipients' eyes had, or did not have, factors associated with an increased risk of graft detachment. Detachment rates were compared for all patients receiving the different kinds of graft, and only for those without risk factors.

Results

A significantly higher detachment rate was found among patients receiving pre‐cut grafts transported in a dextran‐containing medium (32.9%), compared to surgeon‐cut grafts (14.1%, p = 0.002), and pre‐cut grafts transported in a dextran‐free medium (6.3%, p = 0.002) for all recipients (those with and without risk factors for graft detachment). When analysing recipients without risk factors for graft detachment, the detachment rate was still significantly higher with pre‐cut tissue transported in a dextran‐containing medium (26.9%), compared to surgeon‐cut tissue (8.3%, p = 0.002) and pre‐cut tissue transported in a dextran‐free medium (3.6%, p = 0.01).

Conclusions

The use of pre‐cut DSAEK tissue transported in a dextran‐containing medium significantly increases the risk of graft detachment requiring re‐bubbling.

Keywords: bullous keratopathy, DSAEK, fuchs dystrophy, lamellar keratoplasty

1. INTRODUCTION

According to the European Cornea and Cell Transplantation Registry, the most common indication for corneal transplantation is primary endothelial failure (Fuchs endothelial dystrophy), followed by re‐graft and secondary endothelial failure (decompensated corneal endothelium after intraocular surgery) (Dunker et al., 2021). Similar findings have been reported in the USA (Mathews et al., 2023). Endothelial transplantation for primary and secondary endothelial failure is commonly performed by Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) or Descemet Membrane Endothelial Keratoplasty (DMEK) (Price et al., 2021). DMEK is gradually increasing as the preferred technique in primary and secondary endothelial failure in the USA (Mathews et al., 2023) and in Europe (Dunker et al., 2021). The frequency of DMEK is also gradually increasing over DSAEK in Sweden, according to data from the Swedish Corneal Transplant Registry (Viberg et al., 2023).

The advantages of DMEK are better visual outcome (Madsen et al., 2023), lower rate of graft rejection (Price et al., 2018), lower risk of secondary graft failure (Price et al., 2023) and higher patient satisfaction (Pavlovic et al., 2017). However, DMEK is considered to be a more challenging surgical technique, with a steep learning curve (Dapena et al., 2011). Furthermore, DMEK has also been associated with a higher rate of early post‐operative complications such as graft detachment requiring re‐bubbling, compared to DSAEK (Li et al., 2017). DSAEK can be more easily performed in recipients with clinical characteristics such as previous vitrectomy and aphakia, than DMEK (Hurley et al., 2023). In addition, the age of the donor has little impact on surgery when the tissue is used for DSAEK, while tissue from young donors used for DMEK can make the surgery challenging due to tight scrolling (Guerra et al., 2011; Tourtas et al., 2012). Thus, DSAEK remains an important technique in clinical practice.

The DSAEK lamella can be cut in the operating theatre (surgeon‐cut) or at a tissue bank (pre‐cut). Pre‐cut tissue is advantageous in terms of time efficiency, and the risk of graft perforation when cutting in‐theatre is avoided. However, when switching from surgeon‐cut to pre‐cut tissue for DSAEK, we observed an increase in the rate of graft detachment requiring re‐bubbling. The aim of this study was, therefore, to compare the detachment rate when using surgeon‐cut and pre‐cut tissues, and to suggest a means of reducing the detachment rate when using pre‐cut tissue.

2. SUBJECTS AND METHODS

This study was conducted at the Department of Ophthalmology and at the Tissue Bank in Lund, Skåne University Hospital, Lund, Sweden, according to the Declaration of Helsinki. The Swedish Ethical Review Authority approved of the study (No. 2023–04528‐01).

2.1. Enrolment

Patients who had undergone DSAEK surgery in 2019 and 2020, when the donor graft was cut by the surgeon in the operating theatre, were identified from the Local Transplantation Registry (LTR) and retrospectively enrolled in the study. Following the introduction of pre‐cut tissue, in 2021 when pre‐cut grafts prepared at the tissue bank were used, all patients undergoing DSAEK between 2021 and 2023 were prospectively evaluated in the study, for reasons of quality assurance. Between January 2021 and November 2022, pre‐cut donor grafts were transported to the operating theatre in a dextran‐containing medium. However, as a consequence of the observed high detachment rate during this period, the dextran‐containing transport medium was replaced in December 2022 by the storage medium without dextran to evaluate its impact on graft detachment rate. To comply with EU‐GDPR an internal register was created at the hospital. The characteristics of the donor tissue were obtained from the LTR, and the clinical characteristics and outcomes were obtained from digital medical records. Only patients undergoing surgery by I.G. were included to avoid the influence of possible differences in surgical technique on detachment rate. A total of 240 patients undergoing 265 surgeries (surgery of the contralateral eye or re‐surgery) were enrolled, and all attended follow‐up visits to determine the need for re‐bubbling. The primary outcome variable was graft detachment requiring re‐bubbling. There were no missing data. The patients were subsequently subdivided in three groups:

Group 1: Those in whom DSAEK was performed with surgeon‐cut tissue, n = 135 (2019–2020).

Group 2: Those in whom DSAEK was performed with pre‐cut tissue transported in a dextran‐containing medium, n = 82 (2021–2022), and

Group 3: Those in whom DSAEK was performed with pre‐cut tissue transported in a storage medium without dextran, n = 48 (2022–2023).

2.2. Grafting procedure

The corneas were prepared by the Tissue Bank in Lund. General donor selection criteria were in accordance with the standards set by the European Eye Bank Association. The minimum endothelial cell density (ECD) was 2000 cells/mm2. The corneo‐scleral rim was dissected and stored in organ culture medium containing compromised minimum essential medium (Life Technologies Europe BV Stockholm, Sweden) supplemented with 12.6 mM HEPES, 8% heat‐inactivated foetal bovine serum, 2 mg/mL piperacillin with 0.25 mg/mL tazocin, 0.2 mg/mL amikacin and 2.5 μg/mL amphotericin B at 31°C until further processing. Microbiological analysis was performed at Clinical Microbiology, Infection Control and Prevention at Skåne University Hospital, 4–7 days after incubation, by injecting 2.5 mL of storage medium into BD Bactec Peds Plus/F culture vials (Becton, Dickinson and Company).

The tissue was stored for at least 10 days after samples were collected for microbiological analysis, when the results of the analysis were available. The storage time varied depending on the availability of donated tissue and surgical capacity. When the storage time exceeded 35 days, the storage medium was replaced with fresh medium. A second evaluation of the corneal cell density was assessed again, prior to surgery. The endothelial cells were stained for 30 s with Trypan Blue (0.4 mg/mL, Eurobio Scientific) and dehydrated for 1–2 min in saline medium (9 mg NaCl/mL, Braun Medical AB) before cell density evaluation in a light microscope (Zeiss AXE 10, Carl Zeiss Meditec AG). If the cell density was >2000 cells/mm2 (mean value = 2680 cells/mm2, Table 2), the cornea was transferred to a new bottle containing dehydration medium (storage medium with the addition of 8% dextran, Pharmacosmos). The tissue was dehydrated for 1 d (mean value = 1.6 days, Table 2) prior to surgery.

TABLE 2.

Donor characteristics.

Group 1 (n = 135) Group 2 (n = 82) Group 3 (n = 48) Total (n = 265)
Age (years)
Mean (SD) 63.1 (17.5) 66.2 (17.1) 69.9 (17.0) 65.3 (17.4)
Median [Min, Max] 69.0 [17.0, 87.0] 73.5 [23.0, 88.0] 75.5 [19.0, 87.0] 72.0 [17.0, 88.0]
Gender
Male 80 (59.3%) 43 (52.4%) 32 (66.7%) 155 (58.5%)
Female 55 (40.7%) 39 (47.6%) 16 (33.3%) 110 (41.5%)
Previous cataract operation
Yes 29 (21.5%) 35 (42.7%) 29 (60.4%) 93 (35.1%)
No 106 (78.5%) 47 (57.3%) 19 (39.6%) 172 (64.9%)
Endothelial cells
Mean (SD) 2730 (346) 2650 (340) 2600 (405) 2680 (358)
Median [Min, Max] 2710 [2090, 3610] 2690 [2060, 3650] 2580 [2020, 3670] 2690 [2020, 3670]
Time from circulatory arrest to storage medium (hours)
Mean (SD) 32.2 (12.1) 37.5 (13.2) 32.9 (10.4) 34.0 (12.3)
Median [Min, Max] 28.8 [11.8, 67.7] 39.3 [10.3, 66.3] 30.7 [11.0, 57.0] 31.0 [10.3, 67.7]
Time in storage medium (days)
Mean (SD) 27.3 (8.79) 23.0 (7.39) 23.8 (7.31) 25.3 (8.34)
Median [Min, Max] 27.0 [14.0, 59.0] 20.0 [15.0, 61.0] 22.0 [12.0, 49.0] 25.0 [12.0, 61.0]
Time from dehydration to surgery (days)
Mean (SD) 1.2 (0.64) 2.1 (0.64) 2.0 (0.93) 1.6 (0.82)
Median [Min, Max] 1.0 [1.0, 5.0] 2.0 [1.0, 4.0] 2.0 [1.0, 6.0*] 1.0 [1.0, 6.0*]
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Note: * In this case, HLA (human leukocyte antigen)‐matched tissue from the Netherlands was used, with a period of 6 days between dehydration and surgery.

Abbreviation: SD: standard deviation.

2.3. Instruments and techniques used for surgeon‐cut and pre‐cut donor grafts

Surgeon‐cut donor grafts were prepared using the Moria ALTK manual microkeratome (Moria). The corneal thickness was measured with an ultrasound pachymeter (Tomey SP‐100, Tomey). If the thickness was >550 μm a 350 μm cutting blade was used, and when the thickness was ≤550 μm a 300 μm cutting blade was used.

Pre‐cut donor grafts were prepared by staff at the tissue bank in grade C cleanrooms using the Moria One‐use plus automated microkeratome. The artificial anterior chamber internal pressure (IP) was set at 200 mm Hg. Corneal thickness was measured with a pachymeter (Sonogage e‐pack™, Sonogage Inc), and the size of cutting blade was chosen in accordance with a nomogram obtained from Moria (Appendix S1) with the aim of achieving transplants with a thickness of 100 μm.

The residual cap (remaining after the cut) was re‐positioned on the cornea and placed in a viewing chamber (Krolman). The chamber was filled with dehydration medium (groups 1 and 2) or with fresh storage medium (group 3) and transported to the operating theatre at the hospital. All groups were treated the same except for which medium was used as a transportation medium. The tissue was cut either on the same day or 1 day before surgery (mean time = 0.3 days).

2.4. Surgical technique

All patients had undergone cataract surgery prior to DSAEK surgery at least 6 weeks earlier. A main 3 mm temporal incision was made, two 1 mm incisions infero‐ and superotemporally, and one 1.5 mm incision nasally. Intracameral lidocaine was administered (lidocaine, Myan). An anterior chamber maintainer (30 G anterior chamber irrigating cannula, Alcon) and balanced salt solution (BSS, Alcon) were used to stabilise the anterior chamber during surgery. Descemet's membrane was stripped using a Descemet stripper (Asico). The donor graft was trephined (Katena), inserted using a pull‐through technique with 23 G Busin DSAEK forceps and a Busin glide spatula (Moria), and centred. The anterior chamber was completely filled with air (using a HEPA filter), and a Lindstrom roll was used to remove fluid from the graft–recipient interface, as this has been suggested to be an important factor in promoting graft adherence (Lehman et al., 2015). High air pressure was then applied for 10 min and then partially shifted to BSS to obtain approximately 60% air fill. Limiting the air fill to 60% eliminates the need for an inferior iridectomy to prevent pupillary block as the air will not cover the lower pupillary margin and this technique can therefore be used in all eyes in a standardised fashion. Also, the post‐surgery air fill could be of less relevance in DSAEK‐surgery as a previous study has demonstrated that a complete same‐day removal of air led to a detachment‐rate of 6.1% (Lehman et al., 2015). In a few cases (n = 9) 20% SF6 was used instead of air in group 2. However, the use of 20% SF6 did not affect the outcomes in terms of graft detachment, and these patients were thus not excluded. Intracameral cefuroxime (Aprokam, Laboratoires Théa) was injected, and topical atropine 10 mg/mL (Atropine, Bausch & Lomb) and phenylephrine100 mg/ml (Phenylephrine hydrochloride, Bausch & Lomb) were instilled to prevent pupillary block. Chloramphenicol 5 mg/mL (Chloramphenicol, Santen Oy) was instilled, and a soft bandage lens was inserted (Air Optix Night and Day, Alcon). Patients were kept in the supine position for 1 h, and then allowed to sit upright. Patients were discharged after 2 h with an air fill of approximately 50% and normotonic intraocular pressure. If the lower pupillary margin was exposed to air, some air was evacuated to prevent pupillary block. Patients were instructed not to lower their gaze below the horizon, and to remain in a supine position for 8 h during daytime for the next 3 days. Follow‐up was performed on days 1 and 7, and then after 1 month (The results of routine follow‐ups at 3, 6, 12 and 24 months were not considered in this study.). Dexamethasone, 1 mg/mL (Dexafree, Laboratoires Théa, France) (one drop six times a day) and Oftaquix, 5 mg/mL (Oftaquix, Santen Oy) (one drop four times a day) were prescribed at the follow‐up on day 1, and the soft bandage lens was removed on day 7. Re‐bubbling was performed if the graft was detached according to the definitions described below.

2.5. Definitions of detachment

The primary outcome variable was graft detachment requiring re‐bubbling. The most common form of detachment was that the donor graft was free floating in the anterior chamber. Partially attached grafts, with ≤25% of the graft surface attached, were re‐bubbled. Partially attached grafts with >25% of the graft surface attached, were observed and re‐examined after 1 week. If improvement was seen, follow‐up was continued weekly. If graft attachment did not improve or deteriorated, re‐bubbling was performed. All cases underwent rebubbling either on day 1, day 7 or day 14. Only one case required re‐bubbling at two occasions.

Clinical features in the recipient associated with an increased risk of graft detachment were denoted ‘risk factors’. The following characteristics were defined as risk factors (Deshmukh et al., 2022): previous vitrectomy with secondary intra‐ocular lens implantation, previous silicone oil after vitrectomy, previous penetrating keratoplasty (PK), presence of glaucoma‐draining devices (shunts and tubes), previous trabeculectomy and iridocorneal endothelial syndrome with iris defects and prior trauma with iris defects.

2.6. Statistical methods and calculations

IBM SPSS Statistics 28 for Windows (IBM Corporation), SAS Enterprise Guide 6.1 for Windows (SAS Institute Inc.) and RStudio (version 2023.12.0 + 369; R Project for Statistical Computing) were used for statistical analyses. Data manipulation was performed in Microsoft Excel (version 16.16.27; Microsoft Corporation). Descriptive statistics are given as the mean with standard deviation and minimum and maximum values for continuous variables, and number with percent for categorical variables. Differences between the surgical techniques were assessed using Fisher's exact test (two‐sided). A p‐value less than 0.05 was considered to indicate a significant difference.

3. RESULTS

Baseline characteristics and detachment rates are presented in Table 1. The mean age of the patients in the three groups was similar, and females were overrepresented in all groups. Secondary endothelial failure was a surgical indication in 31.1% of the eyes in group 1 (the surgeon‐cut tissue group), in 39.0% of the eyes in group 2 (pre‐cut tissue stored in a medium containing dextran) and in 45.8% of the eyes in group 3 (pre‐cut tissue stored in a medium without dextran). In contrast, primary endothelial failure was the surgical indication in 53.3%, 34.1% and 20.8% of the eyes in groups 1, 2 and 3. Group 3 included more patients with risk factors than the other two groups.

TABLE 1.

Recipient characteristics and re‐bubbling rates.

Group 1 (n = 135) Group 2 (n = 82) Group 3 (n = 48) Total (n = 265)
Age (years)
Mean (SD) 74.5 (9.06) 73.1 (10.2) 75.3 (8.87) 74.2 (9.38)
Median [Min, Max] 75.0 [47.0, 91.0] 73.0 [40.0, 96.0] 78.0 [46.0, 87.0] 75.0 [40.0, 96.0]
Gender
Male 63 (46.7%) 37 (45.1%) 17 (35.4%) 117 (44.2%)
Female 72 (53.3%) 45 (54.9%) 31 (64.6%) 148 (55.8%)
Surgical indication
Primary endothelial failure 72 (53.3%) 28 (34.1%) 10 (20.8%) 110 (41.5%)
Secondary endothelial failure 42 (31.1%) 32 (39.0%) 22 (45.8%) 96 (36.2%)
Re‐operation 21 (15.6%) 22 (26.8%) 16 (33.3%) 59 (22.3%)
Risk factors
Number of patients with risk factors 27 (20.0%) 15 (18.3%) 20 (41.7%) 62 (23.4%)
Penetrating keratoplasty 12 (8.9%) 6 (7.3%) 13 (27.1%) 31 (11.7%)
Glaucoma‐drainage devices 2 (1.5%) 0 (0%) 0 (0%) 2 (0.8%)
Trabeculectomy 3 (2.2%) 1 (1.2%) 0 (0%) 4 (1.5%)
Vitrectomy 7 (5.2%) 4 (4.9%) 4 (8.3%) 15 (5.7%)
Trauma 1 (0.7%) 0 (0%) 0 (0%) 1 (0.4%)
Anterior segment malformations 0 (0%) 2 (2.4%) 2 (4.2%) 4 (1.5%)
Two or more factors 2 (1.5%) 2 (2.4%) 1 (2.1%) 5 (1.9%)
No risk factors 108 (80.0%) 67 (81.7%) 28 (58.3%) 203 (76.6%)
Re‐bubbling due to detachment
Total number of patients 19 (14.1%) 27 (32.9%) 3 (6.3%) 49 (18.5%)
Patients with risk factors 10 (37.0%) 9 (60.0%) 2 (10.0%) 21 (33.9%)
Patients without risk factors 9 (8.3%) 18 (26.9%) 1 (3.6%) 28 (13.8%)
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Abbreviation: SD, standard deviation.

The transition from DSAEK with surgeon‐cut tissue to DSAEK with pre‐cut tissue transported in a dextran‐containing medium resulted in a statistically significant increase in the graft detachment rate, from 14.1% to 32.9% (p = 0.002). When considering only the results in eyes without risk factors, the detachment rate increased from 8.3% to 26.9%, which was also statistically significant (p = 0.006). When changing from pre‐cut tissue transported with dextran to pre‐cut tissue without dextran, the detachment rate decreased from 32.9% to 6.3%, which was statistically significant (p = 0.002). When considering only eyes without risk factors, the detachment rate decreased from 26.9% to 3.6%, which was statistically significant (p = 0.01). The detachment rates are illustrated in Figures 1 and 2.

FIGURE 1.

FIGURE 1

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Detachment rates (%) in the three groups including all patients, with and without risk factors.

FIGURE 2.

FIGURE 2

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Detachment rates (%) in the three groups when considering only patients without risk factors.

The baseline characteristics of donors are presented in Table 2. The proportion of donors that had undergone previous cataract surgery was higher in group 2 (pre‐cut tissue with dextran) and in group 3 (pre‐cut tissue without dextran) (42.7 and 60.4%, respectively) than in group 1 (surgeon‐cut tissue) (21.5%). This is due to the increasing number of DMEK surgeries performed over time, and the fact that donors with no history of cataract surgery were prioritised for DMEK to avoid tears in the graft due to previous cataract incisions when preparing the graft.

4. DISCUSSION

DSAEK remains a crucial technique in posterior lamellar surgery, as it can be more easily performed in patients with certain clinical characteristics, such as those with a history of vitrectomy or aphakia (Hurley et al., 2023). DSAEK is also less reliant on air or gas tamponade for graft adherence compared to DMEK, which can be beneficial in eyes with a history of glaucoma drainage device surgery, trabeculectomy or deficiencies in the lens‐iris diaphragm (Lehman et al., 2015). Additionally, the age of the donor has minimal effect on surgery when the tissue is used for DSAEK, whereas tissue from younger donors used in DMEK can pose challenges due to tight scrolling (Guerra et al., 2011; Tourtas et al., 2012). Moreover, in eyes that have undergone previous cataract surgery, a longer main incision can increase the risk of complications when preparing a DMEK graft compared to a DSAEK graft.

The findings of this study show that the rate of graft detachment requiring re‐bubbling increased significantly when transiting from DSAEK with surgeon‐cut tissue to DSAEK with pre‐cut tissue transported in a dextran‐containing medium. However, when the dextran component was excluded from the medium the detachment rate returned to the level of that in patients receiving surgeon‐cut tissue. The reason for adding dextran is to prevent swelling of the DSAEK graft, which could lead to difficulties in inserting the graft, and compression when folding it into the Busin glide spatula causing damage to the endothelium. However, when the DSAEK grafts were cut in the afternoon before surgery or in the morning on the day of surgery, no thickening was observed from a surgical point of view.

Several factors related, for example, to the surgeon's experience, the surgical technique, recipient characteristics, graft‐related characteristics and post‐operative factors, can affect the risk of graft detachment (Deshmukh et al., 2022), complicating its evaluation. This is evidenced by reports on detachment rates ranging from 1% to 43% (Deshmukh et al., 2022). However, a recent publication based on data from the Swedish Cornea Transplant Registry reported a detachment rate of 13% in DSAEK surgery and 22.7% in combined phaco‐DSAEK surgery (Viberg et al., 2023). One strength of the present study is that all surgeries were performed in eyes with pseudophakia. In addition, all surgeries were performed by a single surgeon (I.G.) using the same surgical technique and the same post‐operative instructions. Factors related to the surgery that could have affected the outcome of the study were thus reduced. However, in a small subset of patients (n = 9) in group 2 (receiving pre‐cut grafts when the donor tissue had been transported in a dextran‐containing medium), 20% SF6 was used during surgery instead of air due to its longer residence time in the anterior chamber, in an attempt to reduce the detachment rate (Güell et al., 2015). However, data from these patients did not affect the detachment rate and were therefore not excluded.

It is well‐known that the characteristics of the recipient's eye can affect the detachment rate. In general, eyes in which it is difficult to maintain a sufficiently high air pressure during surgery, or eyes in which the air tamponade is at risk of being spontaneously evacuated too early, can increase the risk of graft detachment. This can occur in cases of previous trabeculectomy (Nahum et al., 2017) and in eyes with glaucoma‐draining devices (Decroos et al., 2012; Kim et al., 2012). It can also occur in aphakic eyes and eyes with large iris defects, as it is difficult to sustain a sufficient air tamponade due to the lack, or partial lack, of an iris‐IOL (intraocular lens) diaphragm(O'Brien et al., 2008). Furthermore, air often escapes to the posterior segment when the patient moves from the supine to the sitting position, with a consequent loss of air tamponade, which increases the risk of detachment (Cardascia et al., 2020). Similarly, eyes that have previously undergone vitrectomy and secondary IOL implantation may be susceptible to a higher detachment rate due to an unstable iris‐IOL diaphragm (Chaurasia et al., 2011; Nahum et al., 2017). Another factor that increases the risk of graft detachment is previous PK. This could be explained by the irregular graft–host interface impeding adhesion (Nahum et al., 2017), or by the mismatch between the curvature of the PK and the inserted graft, which can result in anterior chamber fluid between the grafts, increasing the risk of detachment (Bhogal et al., 2012).

A significant difference was seen in graft detachment rates between patients with and without recipient‐associated risk factors, as described above, which confirms their clinical relevance. It is therefore important to interpret the outcomes of DSAEK in eyes with and without risk factors separately. However, the differences in detachment rate between recipients with risk factors must be interpreted with caution, as specific risk factors may have different probabilities of causing graft detachment. Thus, the uneven distribution of different risk factors in the three groups studied here could have influenced the detachment rate. In addition, some of the patients have more than one risk factor, which could further bias the outcome. We have therefore limited the conclusions of this study to the influence of dextran on the detachment rate in the patients without risk factors.

Among the patients with no risk factors for graft detachment, there were some differences between the groups regarding the surgical indication. Secondary endothelial failure was the surgical indication in 31.1% of the eyes in group 1 (surgeon‐cut tissue, 2019–2020), in 39% in group 2 (pre‐cut with dextran, 2020–2022), and in 45.8% in group 3 (pre‐cut without dextran, 2022–2023). However, no differences were observed in the detachment rate following DSAEK surgery between patients with primary and secondary endothelial failure, which is in line with the results of previous investigations (Nahum et al., 2017; Pagano et al., 2021). It is therefore reasonable to assume that these differences did not affect the outcome of the present study. Furthermore, no statistically relevant inter‐group differences were found in parameters related to donor characteristics or the grafting procedure, and we therefore deem it unlikely that such factors would have affected the outcome. Also, no known donor characteristics have been reported to affect the graft detachment rate (Hood et al., 2013).

Based on the findings of this study, we conclude that the use of 8% dextran in the transport medium increases the donor graft detachment rate. Dextran is a polysaccharide with viscous properties, and has previously been suggested as a causative factor for graft detachment in DSAEK surgery when pre‐cut tissue was transported in a medium containing both chondroitin sulphate and 2.5% dextran, resulting in a 30% detachment rate (Lee et al., 2009). In that study, it was found that pre‐soaking the tissue in BSS reduced the risk of graft detachment. In the present study, detachment rates were not affected, despite leaving the graft in BSS in a trephine followed by flushing on the stromal side with BSS. However, there are some differences between these studies. In the study by Lee et al. (2009), the transport medium contained both dextran (at a lower concentration, 2.5%, compared to 8% in the present study) and chondroitin sulphate, both of which have viscous properties. Also, the tissue in the previous study was stored in cold storage, whereas in the present study the tissue was stored at room temperature. Both of these factors could have affected the detachment rates (Chen & Naseri, 2009; Saethre et al., 2020). However, a previous study (Parekh et al., 2019) found that pre‐loaded DSAEK grafts transported in a medium containing 6% dextran had a higher dislocation rate of 23%, which is comparable to our finding of 27%. Although the study was not comparative, the authors concluded that detachment rates increased with pre‐loaded tissue, speculating that dextran might have a smoothing effect on the stromal side, potentially inhibiting adhesion. Similarly, in DMEK surgery, pre‐cut tissue transported in a dextran‐containing medium showed higher detachment rates compared to surgeon‐prepared tissue, further suggesting that dextran may be deposited on the tissue, impairing adherence (Romano et al., 2022).

In conclusion, excluding dextran from the transport medium leads to a significant reduction in the detachment rate. This is of benefit to both the patient and healthcare organisations as reoperation can be avoided. Furthermore, re‐bubbling could have a negative impact on endothelial cell count (Hayashi et al., 2020) and graft survival in DMEK surgery (Dunker et al., 2023). Future studies should investigate the mechanisms behind the increased detachment rates associated with the use of dextran in the transport medium.

Supporting information

Appendix S1.

AOS-103-281-s001.pdf (297.3KB, pdf)

Olafsdottir, T. , Hootak, F. , Forslund, C. , Olafsdottir, E. & Gustafsson, I. (2025) Graft detachment rates in surgeon‐cut and pre‐cut tissue for DSAEK transported in different mediums. Acta Ophthalmologica, 103, 281–288. Available from: 10.1111/aos.16791

Ingemar Gustafsson is a member of the Nordic Ophthalmological Societies.

Thorbjörg Olafsdottir and Faisal Hootak contributed equally to the manuscript.

REFERENCES

  1. Bhogal, M.S. , Angunawela, R.I. , Bilotti, E. , Eames, I. & Allan, B.D. (2012) Theoretical, experimental, and optical coherence tomography (OCT) studies of graft apposition and adhesion in Descemets stripping automated endothelial keratoplasty (DSAEK). Investigative Ophthalmology & Visual Science, 53, 3839–3846. [DOI] [PubMed] [Google Scholar]
  2. Cardascia, N. , Pastore, V. , Bini, V. , Lategola, M.G. & Alessio, G. (2020) Graft detachment after Descemet's stripping automated endothelial keratoplasty in bullous keratopathy and Fuchs dystrophy. Medical Hypothesis, Discovery and Innovation in Ophthalmology, 9, 15–22. [PMC free article] [PubMed] [Google Scholar]
  3. Chaurasia, S. , Vaddavalli, P.K. , Ramappa, M. , Garg, P. & Sangwan, V.S. (2011) Clinical profile of graft detachment and outcomes of rebubbling after Descemet stripping endothelial keratoplasty. The British Journal of Ophthalmology, 95, 1509–1512. [DOI] [PubMed] [Google Scholar]
  4. Chen, E.S. & Naseri, A. (2009) Presoaking of donor corneas for the reduction of postoperative dislocation after descemet stripping endothelial keratoplasty. American Journal of Ophthalmology, 148, 471 author reply 471‐472. [DOI] [PubMed] [Google Scholar]
  5. Dapena, I. , Ham, L. , Droutsas, K. , van Dijk, K. , Moutsouris, K. & Melles, G.R. (2011) Learning curve in Descemet's membrane endothelial keratoplasty: first series of 135 consecutive cases. Ophthalmology, 118, 2147–2154. [DOI] [PubMed] [Google Scholar]
  6. Decroos, F.C. , Delmonte, D.W. , Chow, J.H. , Stinnett, S.S. , Kim, T. , Carlson, A.N. et al. (2012) Increased rates of Descemet's stripping automated endothelial keratoplasty (DSAEK) graft failure and dislocation in glaucomatous eyes with aqueous shunts. Journal of Ophthalmic & Vision Research, 7, 203–213. [PMC free article] [PubMed] [Google Scholar]
  7. Deshmukh, R. , Nair, S. , Ting, D.S.J. , Agarwal, T. , Beltz, J. & Vajpayee, R.B. (2022) Graft detachments in endothelial keratoplasty. The British Journal of Ophthalmology, 106, 1–13. [DOI] [PubMed] [Google Scholar]
  8. Dunker, S. , Winkens, B. , van den Biggelaar, F. , Nuijts, R. , Kruit, P.J. & Dickman, M. (2023) Rebubbling and graft failure in Descemet membrane endothelial keratoplasty: a prospective Dutch registry study. The British Journal of Ophthalmology, 107, 17–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Dunker, S.L. , Armitage, W.J. , Armitage, M. , Brocato, L. , Figueiredo, F.C. , Heemskerk, M.B.A. et al. (2021) Practice patterns of corneal transplantation in Europe: first report by the European cornea and cell transplantation registry. Journal of Cataract and Refractive Surgery, 47, 865–869. [DOI] [PubMed] [Google Scholar]
  10. Güell, J.L. , Morral, M. , Gris, O. , Elies, D. & Manero, F. (2015) Comparison of sulfur hexafluoride 20% versus air tamponade in Descemet membrane endothelial keratoplasty. Ophthalmology, 122, 1757–1764. [DOI] [PubMed] [Google Scholar]
  11. Guerra, F.P. , Anshu, A. , Price, M.O. & Price, F.W. (2011) Endothelial keratoplasty: fellow eyes comparison of Descemet stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty. Cornea, 30, 1382–1386. [DOI] [PubMed] [Google Scholar]
  12. Hayashi, T. , Schrittenlocher, S. , Siebelmann, S. , Le, V.N.H. , Matthaei, M. , Franklin, J. et al. (2020) Risk factors for endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK). Scientific Reports, 10, 11086. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Hood, C.T. , Woodward, M.A. , Bullard, M.L. & Shtein, R.M. (2013) Influence of preoperative donor tissue characteristics on graft dislocation rate after Descemet stripping automated endothelial keratoplasty. Cornea, 32, 1527–1530. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Hurley, D.J. , Murtagh, P. & Guerin, M. (2023) Ultrathin Descemet stripping automated endothelial keratoplasty (UT‐DSAEK) versus Descemet membrane endothelial keratoplasty (DMEK)‐a systematic review and meta‐analysis. Eye (London, England), 37, 3026–3032. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Kim, P. , Amiran, M.D. , Lichtinger, A. , Yeung, S.N. , Slomovic, A.R. & Rootman, D.S. (2012) Outcomes of Descemet stripping automated endothelial keratoplasty in patients with previous glaucoma drainage device insertion. Cornea, 31, 172–175. [DOI] [PubMed] [Google Scholar]
  16. Lee, J.K. , Eghrari, A.O. , Desai, N.R. , Stark, W.J. & Gottsch, J.D. (2009) Presoaking donor corneas reduces graft detachment rates in descemet stripping endothelial keratoplasty. American Journal of Ophthalmology, 147, 439–441. [DOI] [PubMed] [Google Scholar]
  17. Lehman, R.E. , Copeland, L.A. , Stock, E.M. & Fulcher, S.F. (2015) Graft detachment rate in DSEK/DSAEK after same‐day complete air removal. Cornea, 34, 1358–1361. [DOI] [PubMed] [Google Scholar]
  18. Li, S. , Liu, L. , Wang, W. , Huang, T. , Zhong, X. , Yuan, J. et al. (2017) Efficacy and safety of Descemet's membrane endothelial keratoplasty versus Descemet's stripping endothelial keratoplasty: a systematic review and meta‐analysis. PLoS One, 12, e0182275. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Madsen, M.B.M. , Ivarsen, A. & Hjortdal, J. (2023) Visual function after ultrathin Descemet's stripping automated endothelial keratoplasty or Descemet's membrane endothelial keratoplasty combined with cataract surgery: a randomised controlled clinical trial. The British Journal of Ophthalmology, 108, 654–661. [DOI] [PubMed] [Google Scholar]
  20. Mathews, P. , Benbow, A. , Corcoran, K. , DeMatteo, J. , Philippy, B. & van Meter, W. (2023) 2022 eye banking statistical report—executive summary. Eye Banking and Corneal Transplantation, 2, e0008–e0012. [Google Scholar]
  21. Nahum, Y. , Leon, P. , Mimouni, M. & Busin, M. (2017) Factors associated with graft detachment after primary Descemet stripping automated endothelial keratoplasty. Cornea, 36, 265–268. [DOI] [PubMed] [Google Scholar]
  22. O'Brien, P.D. , Lake, D.B. , Saw, V.P. , Rostron, C.K. , Dart, J.K. & Allan, B.D. (2008) Endothelial keratoplasty: case selection in the learning curve. Cornea, 27, 1114–1118. [DOI] [PubMed] [Google Scholar]
  23. Pagano, L. , Gadhvi, K.A. , Coco, G. , Fenech, M. , Titley, M. , Levis, H.J. et al. (2021) Rebubbling rate in preloaded versus surgeon prepared DSAEK. European Journal of Ophthalmology, 32, 11206721211014380. [DOI] [PubMed] [Google Scholar]
  24. Parekh, M. , Ruzza, A. , Steger, B. , Willoughby, CE. , Rehman, S. et al. (2019) Cross‐country transportation efficacy and clinical outcomes of preloaded large‐diameter ultra‐thin descemet stripping automated endothelial keratoplasty grafts. Cornea, 38(1), 30–34. [DOI] [PubMed] [Google Scholar]
  25. Pavlovic, I. , Shajari, M. , Herrmann, E. , Schmack, I. , Lencova, A. & Kohnen, T. (2017) Meta‐analysis of postoperative outcome parameters comparing Descemet membrane endothelial keratoplasty versus Descemet stripping automated endothelial keratoplasty. Cornea, 36, 1445–1451. [DOI] [PubMed] [Google Scholar]
  26. Price, D.A. , Kelley, M. , Price, F.W., Jr. & Price, M.O. (2018) Five‐year graft survival of Descemet membrane endothelial keratoplasty (EK) versus Descemet stripping EK and the effect of donor sex matching. Ophthalmology, 125, 1508–1514. [DOI] [PubMed] [Google Scholar]
  27. Price, M.O. , Kanapka, L. , Kollman, C. , Lass, J.H. & Price, F.W., Jr. (2023) Descemet membrane endothelial keratoplasty: 10‐year cell loss and failure rate compared with Descemet stripping endothelial keratoplasty and penetrating keratoplasty. Cornea, 43(11), 1403–1409. [DOI] [PubMed] [Google Scholar]
  28. Price, M.O. , Mehta, J.S. , Jurkunas, U.V. & Price, F.W., Jr. (2021) Corneal endothelial dysfunction: evolving understanding and treatment options. Progress in Retinal and Eye Research, 82, 100904. [DOI] [PubMed] [Google Scholar]
  29. Romano, V. , Kazaili, A. , Pagano, L. , Gadhvi, K.A. , Titley, M. , Steger, B. et al. (2022) Eye bank versus surgeon prepared DMEK tissues: influence on adhesion and re‐bubbling rate. The British Journal of Ophthalmology, 106, 177–183. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Saethre, M. , Krekling, E.D. & Drolsum, L. (2020) Lower risk of graft dislocation applying organ cultured corneas compared with cold short‐term cultured corneas during DSAEK surgery. Eye (London, England), 34, 711–716. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Tourtas, T. , Laaser, K. , Bachmann, B.O. , Cursiefen, C. & Kruse, F.E. (2012) Descemet membrane endothelial keratoplasty versus descemet stripping automated endothelial keratoplasty. American Journal of Ophthalmology, 153, 1082–1090. [DOI] [PubMed] [Google Scholar]
  32. Viberg, A. , Samolov, B. & Byström, B. (2023) Descemet stripping automated endothelial keratoplasty versus Descemet membrane endothelial keratoplasty for Fuchs endothelial corneal dystrophy: a national registry‐based comparison. Ophthalmology, 130, 1248–1257. [DOI] [PubMed] [Google Scholar]

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Supplementary Materials

Appendix S1.

AOS-103-281-s001.pdf (297.3KB, pdf)

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