Table of Contents

Table of Contents

Case Report

Specular Microscopic Imaging Results May Be Deceiving, as Demonstrated by Vital Dye Staining

Global Perspectives

The Eye Bank Association of Australia and New Zealand: Origins, History, Activity and Future.

Original Research

Potential Adverse Effects on the Cornea Donor Pool in 2031

Donor Endothelial Specular Image Quality in Optisol GS and Life4˚C

Picture Challenge

Picture Challenge: What is This?

Specular Microscopic Imaging Results May Be Deceiving, as Demonstrated by Vital Dye Staining


Hisham A. Saad, MD, Christopher Stoeger, CEBT


endothelial keratoplasty, microkeratome, vital stain, slit lamp, specular microscopy


PURPOSE: To describe a case where specular microscopy data relayed misleading information regarding the quality of a cornea processed in an eye bank for endothelial keratoplasty.

METHODS: A cornea was prepared by microkeratome for endothelial keratoplasty and was evaluated with routine slit lamp and specular microscopy. In addition, the tissue was stained with trypan blue and alizarin red S to demonstrate the efficacy of the preliminary evaluation with endothelial viability studies. The stained cornea was photographed, and the percent cell death was calculated using Adobe Photoshop analysis.

RESULTS: The preresection central endothelial cell density was 2608 cells/mm2. In comparison, the post-cut density was 2978 cells/mm2, a figure that represents a 14.19% cell gain. Viability staining with analysis showed 43.77% cell damage.

CONCLUSIONS: Reliance on specular microscopy for determination of endothelial viability can lead to misleading conclusions, as demonstrated in this case study.



Claesson M, Armitage WJ, Fagerholm P, et al. Visual outcome in corneal grafts: a preliminary analysis of the Swedish Corneal Transplant Register. Br J Ophthalmol. 2002;86(2):174-80. Doi:10.1136/bjo.86.2.174.

Pineros OE, Cohen EJ, Rapuano CJ, et al. Triple vs nonsimultaneous procedures in Fuchs’ dystrophy and cataract. Arch Ophthalmol. 1996;114(5):525-528. Doi: 10.1001/archaopth.1996.01100130517002.

Melles, GR, Eggink, FA, Lander F, et al. A surgical technique for posterior lamellar keratoplasty. Cornea 1998;17(6):618-626. PMID: 9820943.

Melles GR, Lander F, Nieuwendaal C. Sutureless, posterior lamellar keratoplasty: a case report of a modified technique. Cornea 2002 21(3):325-327. PMID: 11917186.

Melles GR, Wijdh RH, Nieuwendaal, CP. A technique to excise the descemet membrane from a recipient cornea (descemetorhexis). Cornea 2004 23(3):286-288. PMID: 15084862.

Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea 2006;25(8):886-889. Doi: 10.1097/01.ico.0000214224.90743.01.

Price MO, Price FW. Descemet’s stripping with endothelial keratoplasty: Comparative outcomes with microkeratome-dissected and manually dissected donor tissue. Ophthalmology 2006;113(11):1936-1942. Doi:10.1016/j.ophtha.2006.05.034.

Terry MA. Endothelial Replacement Surgery. In: Krachmer JH, Mannis MJ, Holland EJ, eds. Cornea: Surgery of the Cornea and Conjunctiva. 2nd ed, St. Louis, MO: Elsevier Mosby; 2005:1707-1718. ISBN 0323023150.

Price FW, Price MO. Descemet’s stripping with endothelial keratoplasty in 200 eyes: Early challenges and technique to enhance donor adherence. J Cataract Refract Surg 2006;32(3):411-418.

Terry MA, Ousley PJ. Deep lamellar endothelial keratoplasty (DLEK): Visual acuity, astigmatism, and endothelial survival in a large prospective series. Ophthalmology. 2005;112(9):1541-1549.

Ousley PJ, Terry, MA. Stability of vision, topography, and endothelial cell density from 1 year to 2 years after deep lamellar endothelial keratoplasty (DLEK) surgery. Ophthalmology. 2005;112(1):50-57.

] Van Dooren B, Mulder PG, Nieuwendaal CP, et al. Endothelial cell density after posterior lamellar keratoplasty (Melles techniques): 3 years follow-up. Am J Ophthalmol 2004;138(2):211-217.

Fogla R, Padmanabhan P. Initial results of small incision deep lamellar endothelial keratoplasty (DLEK). Am J Ophthalmol. 2006; 141(12): 346-351.

Wilson SE, Bourne WM. Corneal preservation for penetrating keratoplasty. In: Kaufman HE, Barron BA, McDonald MB, eds. The Cornea. 2nd ed. Boston, MA: Butterworth-Heinemann; 1998:781-803.

Spense DJ, Peyman GA. A new technique for the vital staining of the corneal endothelium. Invest Ophthalmol. 1976; 15(12): 1000-1002.

Taylor MJ, Hunt CJ. Dual staining of corneal endothelium with trypan blue and alizarin red S: importance of pH for the dye-lake reaction. Br J Ophthalmol. 1981;65(12):815-819.

Saad HA, Terry MA, Shamie N, et al. An easy and inexpensive method for quantitative analysis of endothelial damage by using vital dye staining and Adobe Photoshop software. Cornea. 2008; 27(7):818–824. Doi: 10.1097/ICO.0b013e318705ca2.

Terry MA, Saad HA, Shamie N, et al. Endothelial keratoplasty: the influence of insertion techniques and incision size on donor endothelial survival. Cornea. 2009;28(1):24–31. Doi: 10.1097/ICO.0b013e318182a4d3.

Terry MA, Saad HA, Shamie N,et al. Peripheral endothelial cell damage after trephination of donor tissue. Cornea. 2009;28(10):1149-1152. Doi: 10.1097/ICO.0b013e3181a87a28.

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