Cornea Preference Request

Custom cut corneal tissue can be prepared based on your unique specifications. Please indicate your preferences below.

To understand the markings of our tissue and further explanation please see DSAEK Tissue guide and DMEK and Pre-Loaded DMEK Tissue Guide.

NOTE: All fields should be filled in. If a question does not apply, write N/A.

Physician Name

Phone

Email

Surgery Scheduler

Surgery Scheduler Email

How do you prefer to receive your tissue requests? How do you prefer to receive your tissue requests? Phone Call Text Message Email

Death to Surgery (how many days)

Death to Preservation (how many hours)

Age Range of Donor

Cell Count Range

DSAEK Thickness Preference DSAEK Thickness Preference Less than 60 (specify minimum) 61 - 90 microns 91 - 120 microns 120 - 160 microns

Other: Specify min. and/or range

Would you like your DSAEK pre-loaded in the Coronet Endoglide Ultrathin? Would you like your DSAEK pre-loaded in the Coronet Endoglide Ultrathin? Yes No

DSAEK Trephination Diameter DSAEK Trephination Diameter 7.25mm 7.5mm 7.75mm 8mm

DSAEK Orientation Markings DSAEK Orientation Markings Centration Dot Exit Mark Peripheral Gutter Markings (4 quadrant markings placed) F Stamp S Stamp

Other: Please specify

What DMEK pre-loader do you prefer? What DMEK pre-loader do you prefer? STRAIKO (3.2mm incision) LEITR (2.2mm incision) Stephen's (2.2mm incision)

DMEK Preferences DMEK Preferences F Stamp S Stamp

Pre-Loaded DMEK Diameter Pre-Loaded DMEK Diameter 7.25mm 7.5mm 7.75mm 8mm

Other: Please specify

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