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‘Acute-angled bevel’ sign to assess donor lenticule orientation in ultra-thin descemet stripping automated endothelial keratoplasty
  1. Jeewan S Titiyal,
  2. Manpreet Kaur,
  3. Farin Shaikh and
  4. Aafreen Bari
  1. Cornea, Cataract & Refractive Surgery Services, RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
  1. Correspondence to Professor Jeewan S Titiyal, titiyal{at}


A 6.5-year-old boy with congenital hereditary endothelial dystrophy underwent clear corneal ultra-thin descemet stripping automated endothelial keratoplasty (DSAEK). After graft insertion, it was difficult to assess graft orientation due to hazy cornea. Intraoperative optical coherence tomography (iOCT) showed a well-attached graft and the bevelled edge of donor lenticule made an acute angle with the overlying stroma. Postoperative anterior segment OCT confirmed the presence of acute-angled bevel sign. A wetlab experiment was performed with experimental corneoscleral tissues to confirm the findings. Donor lenticule was injected in the artificial chamber with stromal-side up as well as stromal side-down. ‘Acute-angled bevel sign’ was observed on iOCT in the experimental cases with stromal-side up. In inverse graft, the acute-angled bevel was not observed, instead the configuration was obtuse angled. Identifying the ‘acute-angled bevel sign’ on iOCT confirms correct graft orientation after unfolding and is extremely useful for hazy corneas and ultrathin DSAEK lenticules.

  • ophthalmology
  • anterior chamber

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  • Contributors JST and MK made substantial contributions to the conception or design of the work. AB and FS were responsible for acquisition, analysis or interpretation of data. MK and FS undertook drafting the work. JST and MK were responsible for revising it critically for important intellectual content. MK, JST, FS and AB gave final approval of the version published. MK, JST, FS and AB were in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Guardian consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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