Comparison of the Endosaver with noninjector techniques in Descemet's stripping endothelial keratoplasty

Purpose: Minimal loss of corneal endothelial cells during corneal transplantation is a major target but remains a point of controversy among specialists. Hence, the available method to best achieve this continues to stir progress in the field. The aim of this study is to evaluate the use of the Endosaver injector device for graft insertion in Descemet's stripping endothelial keratoplasty (DSEK) and compare the visual outcomes and endothelial cell survival between the Endosaver injector and Goosey grasping forceps insertion techniques. Methods: This was a retrospective, interventional, consecutive case series undertaken at the University of Southampton Eye Department to assess outcomes of DSEK using the Endosaver injector device compared to noninjector DSEK insertion. Postoperative specular microscopy alongside manifest refraction at 6 and 12 months was evaluated and compared. Mann-Whitney U-test was employed for the statistical analysis of data. Results: Both the Endosaver and Goosey forceps groups showed an improvement in best corrected visual acuity. No significant statistical difference was found in preoperative and postoperative best-corrected visual acuity between the Endosaver and non-Endosaver insertion groups. Mean preoperative endothelial cell count was 2660 (+/- 130) for the Endosaver group and 2608 (+/- 66) for the non-Endosaver group. Postoperative endothelial counts at 6 and 12 months showed a significant difference between the Endosaver: 2104 (+/- 199)-1896 (+/- 226) and the non-Endosaver: 1492 (+/- 207)-1314 (+/- 224) (P < 0.005) groups, respectively. Conclusion: The Endosaver injection device is associated with less trauma to endothelium during graft insertion due to the minimal touch technique employed. A smaller insertion wound of 4.0 mm compared to noninjector cases enabled a more stable system during surgery with no or minimal anterior chamber shallowing. The combination of a stable host with minimal endothelial graft handling and subsequent trauma potentially leads to higher endothelial cell counts when the Endosaver injection device is used compared to forceps insertion.