title: Descemet-stripping automated endothelial keratoplasty: insertion using a novel 40/60 underfold technique for preservation of donor endothelium.
abstract: OBJECTIVE
  To describe a technique for insertion of an asymmetrically folded donor graft to minimize endothelial damage during Descemet-stripping automated endothelial keratoplasty.
  
  
  METHODS
  The tissue is folded in a 40/60 underfold rather than the commonly used 60/40 overfold. It is then grasped with the insertion forceps by using a prone hand position. The hand is rotated clockwise until it is supine, bringing the 60% side of the fold anteriorly, and then the tissue is inserted into the anterior chamber.
  
  
  RESULTS
  In 112 eyes, conventional 60/40 overfold insertion technique resulted in a 36% loss in endothelial cell density at 6 months. In 36 eyes, the new 40/60 underfold technique results in a 26% cell loss. This difference of 10% was statistically significant (P = 0.001).
  
  
  CONCLUSIONS
  This simple modification to a commonly used folding technique reduces trauma to the exposed peripheral endothelium in a 60/40 overfolded "taco," which is due to contact with the donor trephine block or other surface. It is a slight modification to a commonly used technique for graft insertion and can be easily implemented to reduce postoperative endothelial cell loss.
authors: Devers Eye Institute, Portland, OR 97210, USA. eschen37@hotmail.com
authors: Edwin S
authors: ES
authors: Chen
authors: Mark A
authors: MA
authors: Terry
authors: Neda
authors: N
authors: Shamie
authors: Paul M
authors: PM
authors: Phillips
authors: Daniel J
authors: DJ
authors: Friend
authors: Stephen D
authors: SD
authors: McLeod
mesh_terms: D000867:Anterior Chamber / Q000601:surgery*; D002452:Cell Count; D002470:Cell Survival; D003316:Corneal Diseases / Q000601:surgery*; D016039:Corneal Transplantation / Q000379:methods*; D003886:Descemet Membrane / Q000601:surgery*; D004728:Endothelium, Corneal / Q000637:transplantation*; D006085:Graft Survival; D006801:Humans; D014021:Tissue Preservation