Descemet Membrane Endothelial Keratoplasty Using a Pull-Through Technique With Novel Infusion Forceps

Abstract

Purpose: To describe a surgical technique of Descemet membrane endothelial keratoplasty (DMEK) using an endothelium-in pull-through technique with novel infusion forceps and report 6-month clinical outcomes. Methods: This is a retrospective case series of 33 cases with Fuchs endothelial corneal dystrophy who underwent either DMEK alone (n = 5), DMEK combined with phacoemulsification (n = 27), or DMEK combined with intraocular lens exchange (n = 1) performed by surgeons at the beginning of the DMEK learning curve. Best-corrected visual acuity (BCVA), manifest refraction, central corneal thickness, endothelial cell density, intraoperative and postoperative complications, and need for additional surgeries including rebubbling were evaluated through 6 months postoperatively. Results: Preoperative BCVA was 0.37 ± 0.34 logarithm of the minimum angle of resolution and improved to 0.09 ± 0.10 logarithm of the minimum angle of resolution at 6 months (P < 0.001). Eighty-two percent of eyes obtained a BCVA of 20/25 or better. Central corneal thickness decreased significantly at 6 months (P < 0.001). Endothelial cell loss was 29.1% at 6 months (available for 20 of 33 eyes). All surgeries were uneventful. Six eyes required rebubbling for graft detachments. There were no primary or secondary graft failures at 6 months. Conclusions: DMEK with infusion microforceps is efficacious and safe in eyes with Fuchs endothelial corneal dystrophy and could offer a more controlled surgery, making it suitable for both novice and experienced DMEK surgeons.

New forceps free injection technique for delivering descemet membrane endothelial keratoplasty preloaded endothelium-in grafts

“…Additionally, the need for an ACM and the bimanual manipulation of the graft may prolong the learning curve and the surgical time. 17 Our technique has the main advantage to avoid the use of a forceps to deliver the DMEK tissue reducing the risk of ECL. At the same time, it guarantees a very good control of the graft orientation during the injection step, allowing the insertion of the tissue with the correct endo-in configuration and thus facilitating its natural unscrolling.…”

“…14 Further, it has been suggested that DMEK surgery using preloaded endothelium-in grafts could be easier in challenging situations like AC IOL, large iris defects, and vitrectomized eyes. 17 In 2016 Busin et al 7 presented their pull-through technique to facilitate the delivery of the graft into the eye recipient. This method has the advantage to improve the surgeon's control over the DMEK membrane during the injection step, and to allow the delivery of the graft maintaining its endo-in configuration.…”

Safety-Net Suture for Aphakic Descemet Membrane Endothelial Keratoplasty

“…This may be more difficult where no anatomical or surgically created barrier is present to protect from donor scroll conformation reversal. Trifold techniques may also require both specialized instrumentation 12 and input from a skilled surgical assistant.…”

Descemet membrane endothelial keratoplasty in complex eyes

“…DMEK grafts can be configured in an endothelium in or tri-fold configuration. Jabbour et al [28 ▪▪ ] have reported on a pull through technique with tri-fold grafts which would theoretically place the graft in a correct orientation for bubbling with minimal manipulation. This method has potential to assist in eyes with soft and deepening anterior chamber dynamics (Fig.…”

“…Given the attractive visual acuity outcomes of ultrathin DSAEK [3 ▪ ,53 ▪▪ ], this may continue to be a preferred option in eyes where iris and or lens are absent. Optimization and standardization of pull through and endothelium-in scrolls may become a tool for predictable positioning of DMEK grafts in these complex eyes in the future [28 ▪▪ ].…”