Authors: Maya Tong, David Ellis, Bonnie Kissick, Khaliq Kurji, Dean Mah, David Climenhaga.

Disclosure Block: M. Tong: None. D. Ellis: None. B. Kissick: None. K. Kurji: Membership on advisory boards or speakers’ bureaus; Name of for-profit or not-for-profit organization(s); Shire Ophthalmics, Labtician Ophthalmics. Membership on advisory boards or speakers’ bureaus; Description of relationship(s); Advisory board member. D. Mah: None. D. Climenhaga: None.

Purpose: In collaboration with Edmonton’s Comprehensive Tissue Centre (CTC), the purpose of this project is to create a sustainable, cost effective program where Descemet membrane endothelial keratoplasty (DMEK) grafts can be made and used locally, instead of purchased from American eye banks.
Study Design: Prospective cohort study
Methods: Two operators were trained to make DMEK grafts. For DMEK grafts made between October 1, 2018 and October 15, 2020, local donor corneas accepted as suitable for DMEK underwent slit lamp evaluation at the Comprehensive Tissue Centre (CTC). When local tissue could not be procured, pre-stripped DMEK grafts were purchased from American eye banks. Donor characteristics including age, medical history of diabetes mellitus, and pre- and post-DMEK preparation endothelial cell density (ECD) were compared using unpaired T-test or chi-square analysis where appropriate. The cost of each locally made graft was calculated and compared to the cost that would otherwise have been accrued if each graft had been bought from an American eye bank.
Results: 125 DMEK surgeries were completed over 24.5 months. 60 (48%) of these were purchased from an American eye bank. 68 (54%) DMEK grafts were prepared locally, 3 (2.4%) of which failed the preparation process. There was no statistically significant difference in average donor age (p = 0.29) or number of donors with a diagnosis of diabetes mellitus (p = 0.39) between the purchased and home cut DMEK groups. The average endothelial cell density (ECD) pre-stripping was 2834 cells/mm² (±178) in the purchased group and 2743 cells/mm² (±216) in the home cut group. Post-stripping ECD was 2845 cells/mm² (±230) in the purchased group and 2657 cells/mm² (±264) in the home cut group. There was no significant endothelial cell loss between the two groups (p = 0.9). There was no significant difference in graft failure between the two groups at 6 months postoperatively (p = 0.14) The cost of making a DMEK graft locally was calculated based on initial purchase of re-sterilizable instruments ($2864.63 one-time investment), disposable instruments ($72.58 per graft), and additional transportation costs ($6.50 per graft). The cost of purchasing 60 DMEK grafts was $240 000. The cost of making 68 DMEK grafts locally was $8242.07. The cost of 125 DMEK grafts was $248 242.07, resulting in a savings of $254 882.93 over 24.5 months.
Conclusions: Training local operators to make high quality DMEK grafts with local donor corneas is extremely cost effective and an efficient use of local tissues.