Precut Tissue Research Articles

Effect of Donor Preparation-to-Use Times on Descemet Membrane Endothelial Keratoplasty Outcomes

To report the effect of varying donor preparation-to-use times on outcomes of Descemet membrane endothelial keratoplasty (DMEK). Prospective interventional series. DMEK donor tissues prepared at a single center on the day of surgery (group 0), 1 day before the surgery (group 1), or 2 days before the surgery (group 2) were transplanted into 361 eyes for Fuchs dystrophy, pseudophakic bullous keratopathy, or graft failure, with or without combined cataract surgery. When prepared ahead, the donor tissue was stored in refrigerated corneal storage solution until use. Primary outcome measures were air reinjection rate, primary failure rate, and endothelial cell loss. Donor and recipient characteristics did not differ significantly between the groups. In groups 0, 1, and 2, the rate of failure to clear was 1.5%, 1.9%, and 2.8%, respectively (P = 0.78), and the rebubbling rate was 15%, 13%, and 14%, respectively, in the grafts that cleared successfully (P = 0.92). Median endothelial cell loss at 3 months was 28%, 29%, and 29%, respectively (P = 0.56). Having DMEK donor tissue prepared in advance can be logistically advantageous. Tissue preparation in advance with storage for 1 or 2 days in corneal storage solution at 4°C was not associated with any significant difference in the primary failure rate, air reinjection rate, or endothelial cell loss compared with the same-day preparation. The maximum allowable preparation-to-use time and the effects, if any, of different storage media or transportation from off-site locations have yet to be determined for precut DMEK tissue.

Preparing donor tissue for DSEK

AbstractDonor tissue preparation remains a critical step in endothelial keratoplasty technique. Since its introduction in 2008 the use of pre‐cut grafts for Descemet stripping automated endothelial keratoplasty (DSAEK) has become increasingly popular. Pre‐cut tissue enables additional quality control, not readily available in the operating theater, shortens operation time, eliminates intraoperative donor related complications, overcomes surgeon’s learning curve associated with valuable donor tissue loss and allows surgeons who do not have the necessary equipment to perform the procedure. Previous reports suggesting thinner grafts may result in better visual outcomes have driven surgeons to either try and harvest ultra‐thin grafts themselves or request eye banks to do so for them. However, preparation of ultra‐thin grafts is not without challenges. In the current session the literature on the safety and efficacy of precut tissue for (ultra‐thin) DSAEK will be reviewed. The results of our in‐vitro studies on thickness reproducibility and endothelial cell viability of ultrathin precut tissue for DSAEK, using an innovative microkeratome system, as well as our preliminary clinical experience with these grafts will be presented.

Descemet's membrane preparation in eye banks for DMEK

AbstractEventhough Descemet Membrane Endothelial Keratoplasty (DMEK) results in unsurpassed improvement of postoperative visual acuity the complexity of graft preparation in DMEK prevents the wide spread use of this technique. Precut tissue preparation in eye banks for DMEK would make this technique amenable to a larger group of surgeons. Precut preparation of organ cultured corneas was preformed as previously described resulting in incompletely stripped Descemet’s membranes where a small central part was still attached to the corneal stroma. After subsequent culture for up to 5 days the precut grafts were used for DMEK. Visual acuity, central corneal thickness and endothelial cell density were retrospectively analyzed. Stripping was successfully completed in all grafts directly prior to surgery. The average visual acuity (logMAR) improved from 0.47 + 0.11 preoperatively to 0.2 + 0.13 3 months after DMEK. Central preoperative corneal thickness decreased from 632 + 46 µm preoperatively to 471 + 7 µm 3 months after DMEK. Average endothelial cell density was 2326 + 119 cells /mm2 before and 2226 + 150 cells/mm2 3 days after precut preparation (2 days before DMEK). 3 months after DMEK endothelial cell density further decreased to 1519 + 57 cells/mm2. Precut preparation of DMEK tissue, generated by incomplete Descemet stripping, leads to minor endothelial cell loss during subsequent culture and results in a fast visual recovery, only minor additional endothelial cell loss and a rapid decrease of corneal thickness.

A Prospective, Randomized Trial of DSAEK Outcomes Compariing Different Donor Preparation Devices

PURPOSE: To determine whether Descemet stripping automated endothelial keratoplasty (DSAEK) outcomes differ between precut or surgeon-cut donor tissue and the Horizon or Moria systems. DESIGN: This study was a randomized, prospective, double-masked clinical trial. METHODS: Sixty-three consecutive DSAEK surgeries underwent tissue randomization. Thirty-three eyes underwent DSAEK using precut donor tissue prepared with the Horizon system (Group 1) and 30 eyes underwent DSAEK using tissue prepared by the surgeon with the Moria system (Group 2). Main outcome measures included visual acuity, mean endothelial cell loss, graft clarity, and complication rates. RESULTS: The mean patient age was 70 +/- 10 (range, 55-87), with 52 eyes (83%) having Fuchs endothelial corneal dystrophy and 11 eyes (17%) with pseudophakic bullous keratopathy. Mean preoperative best spectacle-corrected visual acuity (BSCVA) was 20/96 (0.68) in Group 1 and 20/130 (0.81) in Group 2 (p value =0.19), and the mean postoperative BSCVA was 20/39 (0.29) in Group 1 and 20/47 (0.37) in Group 2 (p value = 0.25). Mean endothelial cell loss at 12 months was 30.9% in Group 1 and 28.2% in Group 2 (p value = 0.28). Mean induced astigmatism at 6 months was -0.01D in Group 1 and 0.17D in Group 2 (P = 0.59). Group 1 had 3 (9.1%) tissue dislocations and Group 2 had 2 (6.5%) tissue dislocations (P = 0.1). Group 1 had 1 (3.0%) primary graft failure (PGF) and Group 2 had none (P = 0.1). Endothelial graft rejection and pupil block glaucoma were not observed. CONCLUSIONS: No statistical difference was observed in DSAEK outcomes regardless of whether the tissue was precut or surgeon-cut or whether prepared by the Horizon or Moria devices.

Incidence of Presumed Iatrogenic Graft Failure in Descemet Stripping Automated Endothelial Keratoplasty

To evaluate presumed iatrogenic graft failure (PIGF) in Descemet stripping automated endothelial keratoplasty (DSAEK). Deidentified data were collected retrospectively from the Illinois Eye Bank between April 2007 and May 2010. PIGF was defined as cases in which a repeat corneal transplant was performed <8 weeks after an initial DSAEK. Data collected for each case included days between initial DSAEK and regraft, regraft type (DSAEK vs. penetrating keratoplasty), precut versus surgeon-cut tissue, and number of DSAEKs distributed to individual surgeons. Ninety-three cases of PIGF were identified for a group of 46 surgeons who received 2504 corneas. Nine PIGF cases from 4 surgeons in cornea fellowships were analyzed separately. Individual surgeon failure rate and overall failure rate were calculated. Analysis of the overall failure rate was conducted without cases performed by surgeons who train fellows. Effect of surgical experience on PIGF was analyzed. Overall presumed iatrogenic DSAEK failure rate was 3.66% (84 PIGF cases divided by 2294 corneas). Within the group of 4 surgeons that trained fellows, the failure rate was 4.29% (9 cases PIGF divided by 210 corneas). Average time to regraft was 27.5 ± 17.4 days. Initial diagnoses included Fuchs dystrophy, pseudophakic bullous keratopathy, edema, and other disease states. Average donor and recipient ages were 54.3 ± 13.0 and 71.7 ± 11.3 years, respectively. Use of precut versus surgeon-cut tissue did not affect overall failure rates. Failure rates of less experienced surgeons (21.8% ± 10.8%) were higher than more experienced surgeons (1.5% ± 1.4%). Overall, DSAEK failure rates improve as surgeons gain experience. Failure rates in cornea fellowship programs are not excessive.

The Endothelial Safety of Using a Gentian Violet Dry-Ink “S” Stamp for Precut Corneal Tissue

To determine the endothelium damage resulting from the application of "dry" gentian violet (GV) stromal markings on corneas precut for Descemet stripping automated endothelial keratoplasty (DSAEK) using a Moria "S" Stamp. Five precut corneas had the stromal graft bed marked with GV using the Moria "S" stamp and 6 precut corneas were left unmarked as controls. After applying the ink to the stamp, care was taken to allow the alcohol carrier to dry for 10 seconds before applying the dry dye to the stromal surface. Tissue was then trephinated and stained with calcein AM to assess endothelial viability. Grafts were photographed and digital pixel planometry, using an established analysis technique, was used to compare the damage between the control and experimental groups. The mean percent cell damage of corneas treated with GV "S" stamp (n = 5) was 8.6% (range 4.4-12.9), and it was 8.1% (range 3.9-15.1) in the DSAEK control set (n = 6). Median percent cell damage was 6.7% among GV-treated corneas and 7.4% among control corneas. The distributions were not significantly different between groups (Mann-Whitney U test = 15.0, two-tailed P = 1.0). Moreover, no "S" pattern of damage was seen in any study eye. There were no significant differences in endothelial damage between the 2 groups. GV stromal markings may be applied without undue damage to the endothelium using the dry-ink technique described.

Precut Verfahren für Descemet-Membran-Endothelzelltransplantation, Präparation und Aufbewahrung in Kultur

The preparation of the Descemet's membrane (DM) with the endothelial cell layer may be performed directly prior to surgery or as a precut tissue procedure. The purpose of the current study was the evaluation of the preparation technique and the tissue culture of 10 days regarding potential endothelial cell loss. Ten corneoscleral rims with an average age of 64.3 years were dissected to obtain 8.5 mm in diameter endothelial-DM complexes, which subsequently were organ cultured for 10 days. The endothelial cell density (ECD) was assessed during the cell culture period at days 1., 4., 7. and 10. In addition, time of preparation and transplant morphology were evaluated. The DM with the endothelial cell layer could successfully be dissected from all corneoscleral rims. The average preparation time was 8.3 min. The average ECD count was 2183 ± 77 cells/mm2 prior to, 2094 ± 110 cells/ mm2 at day 1, 2078 ± 134 cells/mm2 at day 4, 1977 ± 107 cells/mm2 at day 7 and 1898 ± 170 cells/mm2 at day 10 after preparation, respectively. Endothelial cell loss was 4.1 %, 4.8 %, 9.4 % and 13.1 % after preparation, respectively. None of the transplants exhibited large, centrally-located cell deficits. The isolated storage of DM with the endothelial layer, without any stromal remnants, showed gratifying results under storage conditions in organ culture with a moderate ECD decrease. Hence, the implementation of a precut DMEK is conceivable.

Corneal Donor Tissue Preparation for Endothelial Keratoplasty

Over the past ten years, corneal transplantation surgical techniques have undergone revolutionary changes1,2. Since its inception, traditional full thickness corneal transplantation has been the treatment to restore sight in those limited by corneal disease. Some disadvantages to this approach include a high degree of post-operative astigmatism, lack of predictable refractive outcome, and disturbance to the ocular surface. The development of Descemet's stripping endothelial keratoplasty (DSEK), transplanting only the posterior corneal stroma, Descemet's membrane, and endothelium, has dramatically changed treatment of corneal endothelial disease. DSEK is performed through a smaller incision; this technique avoids 'open sky' surgery with its risk of hemorrhage or expulsion, decreases the incidence of postoperative wound dehiscence, reduces unpredictable refractive outcomes, and may decrease the rate of transplant rejection3-6.Initially, cornea donor posterior lamellar dissection for DSEK was performed manually1 resulting in variable graft thickness and damage to the delicate corneal endothelial tissue during tissue processing. Automated lamellar dissection (Descemet's stripping automated endothelial keratoplasty, DSAEK) was developed to address these issues. Automated dissection utilizes the same technology as LASIK corneal flap creation with a mechanical microkeratome blade that helps to create uniform and thin tissue grafts for DSAEK surgery with minimal corneal endothelial cell loss in tissue processing.Eye banks have been providing full thickness corneas for surgical transplantation for many years. In 2006, eye banks began to develop methodologies for supplying precut corneal tissue for endothelial keratoplasty. With the input of corneal surgeons, eye banks have developed thorough protocols to safely and effectively prepare posterior lamellar tissue for DSAEK surgery. This can be performed preoperatively at the eye bank. Research shows no significant difference in terms of the quality of the tissue7 or patient outcomes8,9 using eye bank precut tissue versus surgeon-prepared tissue for DSAEK surgery. For most corneal surgeons, the availability of precut DSAEK corneal tissue saves time and money10, and reduces the stress of performing the donor corneal dissection in the operating room. In part because of the ability of the eye banks to provide high quality posterior lamellar corneal in a timely manner, DSAEK has become the standard of care for surgical management of corneal endothelial disease.The procedure that we are describing is the preparation of the posterior lamellar cornea at the eye bank for transplantation in DSAEK surgery (Figure 1).

Corneal Donor Tissue Preparation for Endothelial Keratoplasty

Over the past ten years, corneal transplantation surgical techniques have undergone revolutionary changes1,2. Since its inception, traditional full thickness corneal transplantation has been the treatment to restore sight in those limited by corneal disease. Some disadvantages to this approach include a high degree of post-operative astigmatism, lack of predictable refractive outcome, and disturbance to the ocular surface. The development of Descemet's stripping endothelial keratoplasty (DSEK), transplanting only the posterior corneal stroma, Descemet's membrane, and endothelium, has dramatically changed treatment of corneal endothelial disease. DSEK is performed through a smaller incision; this technique avoids 'open sky' surgery with its risk of hemorrhage or expulsion, decreases the incidence of postoperative wound dehiscence, reduces unpredictable refractive outcomes, and may decrease the rate of transplant rejection3-6. Initially, cornea donor posterior lamellar dissection for DSEK was performed manually1 resulting in variable graft thickness and damage to the delicate corneal endothelial tissue during tissue processing. Automated lamellar dissection (Descemet's stripping automated endothelial keratoplasty, DSAEK) was developed to address these issues. Automated dissection utilizes the same technology as LASIK corneal flap creation with a mechanical microkeratome blade that helps to create uniform and thin tissue grafts for DSAEK surgery with minimal corneal endothelial cell loss in tissue processing. Eye banks have been providing full thickness corneas for surgical transplantation for many years. In 2006, eye banks began to develop methodologies for supplying precut corneal tissue for endothelial keratoplasty. With the input of corneal surgeons, eye banks have developed thorough protocols to safely and effectively prepare posterior lamellar tissue for DSAEK surgery. This can be performed preoperatively at the eye bank. Research shows no significant difference in terms of the quality of the tissue7 or patient outcomes8,9 using eye bank precut tissue versus surgeon-prepared tissue for DSAEK surgery. For most corneal surgeons, the availability of precut DSAEK corneal tissue saves time and money10, and reduces the stress of performing the donor corneal dissection in the operating room. In part because of the ability of the eye banks to provide high quality posterior lamellar corneal in a timely manner, DSAEK has become the standard of care for surgical management of corneal endothelial disease. The procedure that we are describing is the preparation of the posterior lamellar cornea at the eye bank for transplantation in DSAEK surgery (Figure 1).

Evaluation of interface quality in organ-cultured lamellar corneal transplants.

BackgroundWith increasing numbers of lamellar keratoplasties, eye banks are challenged to deliver precut lamellar donor tissue. In Europe, the most common technique of corneal storage is organ culture which requires a deswelling process before surgical processing. The aim of this study was to investigate the influence of different deswelling times on the cutting plane quality after microkeratome-assisted lamellar dissection.MethodsEight paired donor corneas (16 specimens) not suitable for transplantation were organ cultured under standard conditions at the Eye Bank of the Ludwig-Maximilians Universität, Munich, Germany. Pairs of corneal buttons were analyzed during the deswelling process in dextrane-containing medium. While one cornea was cut at an early time point during the deswelling process and put back into deswelling medium thereafter, the partner cornea was completely deswollen and dissected after 72 hours. Specimens were then further processed for scanning electron microscopy. Surface quality was assessed both digitally using Scanning Probe Imaging Processing software, and manually by three blinded graders.ResultsThe corneal buttons processed at the beginning of the deswelling process had a smoother surface when compared to the partner cornea that was cut at the end of the deswelling process. In our setting, no relevant difference was detectable between manual and automated microkeratome dissection.ConclusionFor lamellar keratoplasty, organ-cultured corneas should be processed at an early stage during the deswelling process. We interpret the smoother dissection plane during early deswelling as a result of mechanical properties in a highly hydrated cornea.

Endothelial keratoplasty without Descemet's stripping in eyes with previous penetrating corneal transplants

AimsTo evaluate techniques, outcomes and complications of endothelial keratoplasty (EK) without Descemet's stripping in eyes with previous penetrating keratoplasty (PK).MethodsA retrospective, consecutive analysis of patients who underwent EK in eyes...

Comparison of Central Corneal Graft Thickness to Visual Acuity Outcomes in Endothelial Keratoplasty

To evaluate visual acuity outcomes after endothelial keratoplasty (EK) and describe the relationship to postoperative central corneal graft thickness as measured by anterior segment optical coherence tomography (AS-OCT). A retrospective case series of 33 eyes in 28 patients undergoing routine EK using precut eye bank tissue was designed. All patients underwent serial central graft thickness measurements with AS-OCT. Based on the median central graft thickness of all patients, the eyes were divided into 2 groups: thin EK and thick EK. Differences between the groups were compared. The median postoperative graft thickness of all eyes was 131 μm. The eyes were divided into 2 groups based on this median: thin EK (graft thickness: ≤ 131 μm; range: 77-131 μm; average: 109 μm) and thick EK (graft thickness: > 131 μm; range: 138-182 μm; average: 162 μm). There was no statistically significant difference in age, sex, or preoperative best spectacle-corrected visual acuity (BSCVA) between the 2 groups. Average postoperative follow-up was 12.8 months. The thin EK group showed better postoperative BSCVA compared with the thick EK group (P < 0.01). All thin EK eyes had BSCVA greater than or equal to 20/25 with 71% of eyes achieving BSCVA of 20/20. In contrast, only 50% of thick EK eyes reached BSCVA greater than or equal to 20/25 with 19% obtaining BSCVA of 20/20. Thin EK versus thick EK, as measured by AS-OCT in the postoperative period, showed a statistically significant improvement in BSCVA.

Pre-cut donor tissue for Descemet stripping automated keratoplasty: anterior hinged lamella on versus off

AimsTo compare two different techniques for preparation of pre-cut lamellar corneal tissue for Descemet stripping automated keratoplasty.Background/MethodsEight donor lenticules were created with a full pass of the microkeratome blade, which...

DSAEK grafted corneas remain clear with low endothelial cell counts

Abstract Purpose Presentation of observations on endothelial viability and visual outcome in 30 consecutive eyes operated with Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) Methods DSAEK for Fuchs' dystrophy was introduced in October 2006 at the Eye Dept. at Rigshospitalet. The first 7 eyes were grafted with pre‐cut donor tissue, the remaining operations involved tissue preparation with a Moria keratome. All patients were monitored at regular post‐operative intervals for an average of 20 months (range 7 ‐ 34 months). Donor tissue condition was evaluated in terms of detachment rate, primary graft failure and rejection events. Endothelial cell counts (ECC) were done with a digital Topcon SP‐3000P specular microscope camera. Final visual outcome was recorded. Results A fairly large loss of endothelial cells during transplantation was noted. Average cell density of the donor buttons was 2400/mm². At one year follow‐up the recorded ECC had declined to 1129/mm² on average. At two years the average cell density was 1083/mm² indicating a slow progressive cell loss. At the latest follow‐up cell counts ranged from 429 to 2332/mm². Nonetheless all corneas were clear except for one, which was developing secondary bullous keratopathy. Patient satisfaction and visual performance and comfort did not seem correlated to the ECC. Median acuity was 20/40. No case of classical rejection was seen. Conclusion DSAEK is a tempting alternative to PKP in Fuchs' dystrophy. The learning curve, however, is steep even for experienced surgeons at the cost of endothelial cells during the tissue handling. Corneal clarity as well as visual funtion is retained even with very low cell densities.

Precut Tissue for Descemet's Stripping Automated Endothelial Keratoplasty: Vision, Astigmatism, and Endothelial Survival

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. Prospective, noncomparative, interventional case series. We reviewed 100 donor corneas precut for 100 eyes of 90 DSAEK patients. 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. 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. 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). 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. Proprietary or commercial disclosures may be found after the references.

Precut Tissue For Descemet Stripping Automated Endothelial Keratoplasty

Precut Tissue For Descemet Stripping Automated Endothelial Keratoplasty

Precut Tissue For Descemet Stripping Automated Endothelial Keratoplasty

Precut Tissue For Descemet Stripping Automated Endothelial Keratoplasty

Precut Tissue For Descemet Stripping Automated Endothelial Keratoplasty: Complications Are From Technique, Not Tissue

Precut Tissue For Descemet Stripping Automated Endothelial Keratoplasty: Complications Are From Technique, Not Tissue

Randomized, Prospective Comparison of Precut vs Surgeon-Dissected Grafts for Descemet Stripping Automated Endothelial Keratoplasty

To determine whether eye bank predissected corneal grafts provide outcomes comparable to surgeon-dissected grafts for Descemet stripping automated endothelial keratoplasty (DSAEK). Randomized, prospective, double-masked clinical trial. Twenty pairs of donor corneas were harvested. One cornea from each pair was randomized to be precut at an eye bank for next-day use. The surgeon dissected the fellow cornea intraoperatively using a comparable microkeratome and protocol. The corneas were randomly assigned to 40 subjects having DSAEK at a single center. Subjects and evaluators were masked and statistical significance was assessed using the paired t test. Mean subject age was 71 +/- 12 years and 90% had Fuchs dystrophy. Mean endothelial cell loss was 32% at six months and 34% at one year; the two groups did not differ by a statistically significant amount at either time point (P = .10 and P = .79, respectively). Each group experienced two early dislocations (10%), and grafts were repositioned successfully with a second air bubble. At six months, 28 of 35 patients (80%) had best-corrected vision of 20/40 or better, excluding five patients (12%) with preexisting retinal problems (P = .48). Both groups experienced a mild hyperopic shift (P = .82), and neither had a statistically significant increase in mean refractive cylinder (P = .63). Histology from one subject's eye postmortem demonstrated that endothelial cells had migrated over the exposed edge of the donor stroma a year after surgery. Eye bank precut tissue provided similar endothelial cell loss, visual and refractive outcomes, and detachment rates compared with surgeon-dissected tissue.

HIV Incidence Among Men Diagnosed With Early Syphilis in Atlanta, San Francisco, and Los Angeles, 2004 to 2005

To assess surgeon satisfaction with precut corneal tissue from 1 eye bank for Descemet stripping automated endothelial keratoplasty (DSAEK). Surgical techniques and predictors of procedural success were also examined. A 19-question survey was completed by 53 surgeons around the United States for 197 DSAEK cases using prepared corneal allograft tissue from the Iowa Lions Eye Bank. Surgeries were performed between April 1 and December 31, 2006; surveys were completed retrospectively within a few weeks of surgery. Tissue was found to be acceptable in 98% of DSAEK cases reported. Difficulties with precut tissue (eg, lack of anterior cap adherence to the posterior lamella, not visible or decentered central dot, anterior edge undermining) were reported in approximately 10% of cases. A rebubbling procedure was performed in 23% of cases for donor dislocations. The donor lenticule adhered, with resulting corneal deturgescence, in 86% of cases. Surgeons declared a successful procedure in 92% of cases. Of the 14 unsuccessful cases, donor tissue quality was the underlying etiology in only 1 case. Procedural success rates were related to surgeon experience (P = 0.002), lenticule adherence after only 1 anterior chamber air bubble (P = 0.005), no small perforations to release fluid (P = 0.005), and the presence of corneal deturgescence (P = 0.002). The use of precut tissue for DSAEK is not associated with increased risk of complications related to tissue preparation. With standardization of precutting donor tissue, safety of DSAEK surgery may be improved while increasing surgeon efficiency.