on the day of surgery , all donor tissues are dissected in the operating room prior to the start of the first dsaek surgery .
dissection is performed using a microkeratome ( altk cbm ; moria japan kk , tokyo , japan ) equipped with a 300 m head .
after microkeratome - dissection , the donor - endothelial lamella ( with the repositioned , dissected cap ) is transferred to a punching system , and cut with an 8.0 mm diameter punch ( barron donor cornea punch ; katena products inc , denville , nj ) .
the busin glide surface is then wetted with several drops of balanced salt solution ( figure 2a ) .
after the composite of donor - endothelial lamella and microkeratome - dissected cap is punched out , several drops of dispersive ophthalmic viscosurgical device are placed onto the endothelial surface ( figure 2b ) .
next , hydrodissection of the potential space between the donor - endothelial lamella and the microkeratome - dissected cap is carefully performed , using ophthalmic irrigation solution ( bss plus ; alcon , fort worth , tx ) to enable smooth detachment of these two lamellae ( figure 2d ) .
this technique enables smooth detachment of the composite , without causing the formation of any wrinkles or folds ( figure 2e ) .
the donor lamella is then pulled into the busin glide opening , using a 25-gauge anterior - capsular forceps ( cat # mf801l ; inami co , ltd , tokyo , japan ) ( figure 2f ) .
we reported herein a modified surgical technique , prewetting of the glide , and hydrodissection of the donor lamella aimed at optimizing the use of the busin glide for dsaek surgery .
hydrodissection of the donor lamella enables the smooth detachment of the composite of donor - endothelial lamella and microkeratome - dissected cap on the busin glide without the formation of any wrinkles or folds .
this technique is quite useful when the dsaek is performed using pre - cut tissue , as these tissues are usually distributed with the cap adhered to the dissected stromal bed . in ten out of ten consecutive cases
, we saw that simply dragging donor - endothelial lamella directly onto the glide caused macroscopic wrinkling or folding of the donor lamella .
it has been shown previously with in vitro vital dye staining9 that folding of the donor endothelial lamella resulting from the forceps manipulation can cause endothelial cell damage .
we too , have preliminary vital dye staining data ( not shown here ) that wrinkling or folding of the donor lamella as it is dragged onto the busin glide causes endothelial cell damage . to date
, we have used this modified technique in more than 50 consecutive dsaek cases , and no wrinkles or folds were caused during loading of the donor lamella onto the busin glide .
furthermore , prewetting of the glide enabled quite smooth pull - through of the donor lamella in all cases .
we strongly believe that this technique eliminates additional endothelial - cell loss caused by wrinkle formation , during donor manipulation .
however , care should be exercised in using viscoelastic materials over the graft , especially on the stromal side , because of the increased risk of donor dislocation . currently , these modifications are our preferred endothelial keratoplasty technique during busin glide use .
 we describe a modified technique for loading donor corneal endothelial lamella onto a busin glide without causing wrinkles , as part of the procedure of descemet - stripping automated endothelial keratoplasty . briefly , after punching out a composite of the donor - endothelial lamella and a microkeratome - dissected cap , several drops of dispersive ophthalmic viscosurgical device are placed onto the endothelial surface . 
 the busin glide surface is then wetted with several drops of balanced salt solution . 
 after the composite is transferred onto the busin glide , hydrodissection of the potential space between the donor - endothelial lamella and the microkeratome - dissected cap is carefully performed to enable smooth detachment of these two lamellae . whereas simply dragging the donor - endothelial lamella directly onto the glide can cause wrinkling or folding of the donor lamella , this technique enables smooth detachment of the composite without wrinkle or fold formation , and results in less endothelial cell damage . 
Surgical technique
Discussion