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 .