A Novel Technique for Donor Insertion and Unfolding in Descemet Membrane Endothelial Keratoplasty

Abstract

To describe a novel technique for insertion and unfolding of donor Descemet membrane (DM) scroll during DM endothelial keratoplasty (DMEK).Methods: DMEK was performed in 20 eyes. The donor DM scroll was loaded into a glass injector, and the fluid column was manipulated to achieve a double scroll configuration. After performing DM stripping and inferior iridectomy, an anterior chamber (AC) maintainer was placed in position. The glass injector was inserted into the AC and the tip rotated to ensure correct orientation of the DM scroll. After disconnecting the IV tubing from the AC maintainer, the donor DM scroll was delivered into the AC. Donor unfolding was performed using surface tapping techniques. An air bubble was injected under the graft to obtain a complete AC air fill. The outcomes of this surgical technique were analyzed.Results: Donor DM insertion and unfolding were performed without any complications in all eyes. Double scroll configuration of donor DM in the injector could be achieved in 17 of 20 eyes (85%). A controlled delivery, maintaining correct scroll orientation, was possible in all eyes. Intraoperative duration from insertion to unfolding was 252.7 6 45.4 seconds. A clear cornea was achieved in all eyes, with 75% of eyes (15/20) achieving corrected distance visual acuity of 20/20 or better, at average follow-up duration of 13.3 6 1.3 months. Endothelial cell loss at 6 months follow-up was noted to be 16.7%. Partial donor detachment was noted in 2 eyes (10%), which resolved spontaneously.Conclusions: Our novel technique of donor DM insertion allows easy donor insertion and unfolding, thereby simplifying the DMEK procedure.

Examination of a Modified Graft Preparation Technique to Induce Double-Scroll Formation and Promote the Use of Younger Descemet Membrane Endothelial Keratoplasty Donor Tissue

“…A single clinical outcome study using the fluid column manipulation technique reported an 85% success rate for achieving the double-scroll conformation, shorter duration of unfolding in double-scrolled grafts compared with single-scrolled grafts, and a low 6- and 12-month ECL (16.7% and 24.9%, respectively) in double-scroll graft recipients. 13 Although this study suggests that use of double-scrolled tissue results in promising clinical outcomes, it was limited by its low sample size and that it reported results of a single, experienced DMEK surgeon. Our study demonstrates that a double-scroll formation technique can be used on younger, tightly rolled, single-scrolled grafts without introduction of additional ECL at the time of processing.…”

“…Veldman and Fogla have demonstrated that a double-scrolled DMEK graft can be formed from a single-scrolled graft inside the injector by manipulating the fluid column immediately before graft ejection into the anterior chamber. 12,13 However, no laboratory studies were presented to detail whether repeated manipulation of the DMEK graft within the fluid column and expulsion of a graft from an injector results in increased ECL. A single clinical outcome study using the fluid column manipulation technique reported an 85% success rate for achieving the double-scroll conformation, shorter duration of unfolding in double-scrolled grafts compared with single-scrolled grafts, and a low 6- and 12-month ECL (16.7% and 24.9%, respectively) in double-scroll graft recipients.…”

“…Clinical studies using a similar technique to form a double scroll in DMEK grafts already loaded into an injector have shown that use of a double-scrolled DMEK graft results in a shorter duration of unfolding and low 6- and 12-month endothelial cell loss (ECL). 13…”

Descemet membrane endothelial keratoplasty: Update on preoperative considerations, surgical techniques, and outcomes

“…The literature search also revealed the use of viscoelastic for descemetorhexis. [ 40 41 ] The author also advised roughening of peripheral 2 mm of the bare stroma with the scraper to facilitate better graft adherence. [ 41 ] In cases with endoglide-assisted insertion of graft, a temporal scleral tunnel making is preferred with a nasal paracentesis for endoglide placement forceps to pull the graft into the anterior chamber.…”

“…A novel technique of donor insertion described by Fogla et al . [ 40 ] uses a glass cartridge attached to the prefilled syringe. The cartridge is inserted into the AC and rotated to orient the graft in the desired orientation.…”