We read with interest the paper by Gangwani and associates comparing Busin glide with EndoGlide insertion of Descemet stripping automated endothelial keratoplasty (DSAEK) grafts. The authors find a significantly higher cell loss using the Busin glide (above 40%) and therefore advocate using the EndoGlide for the delivery of DSAEK grafts.

The 25% cell loss found using the EndoGlide is not a surprising result, as several other authors have reported similar values employing different insertion techniques. What is more surprising is the very high value found with the Busin glide, as various authors have shown, both in experimental models and in patients, much lower endothelial cell loss values. In 2010 Chen and associates found no significant difference in cell loss between insertion with forceps and insertion with the Busin glide through a 5-mm incision. Bahar and associates, Price and associates, and Busin and associates have all shown a similar average endothelial cell loss 6 months after DSAEK graft delivery with the Busin glide, with values below 30%.

What remains to be explained is the 45% cell loss experienced by the authors. The only surgical difference we could identify in the technique described by Gangwani and associates was the use of a clear corneal incision on the temporal side rather than on the nasal side, as we recommend. In fact, insertion of the forceps from the nasal side to pull the tissue through a temporal incision/tunnel is usually difficult and may cause excessive opening of the side entry with flattening of the anterior chamber, and possibly increased damage to the donor endothelium while it is delivered.

Although the authors are to be commended for their work, we think that their paper should have included a more extensive review of other papers dealing with this topic.