Impact of difficult unfolding and attachment of the graft lamella on the long-term outcome after Descemet membrane endothelial keratoplasty

Purpose: Several techniques have been developed for graft unfolding approaches in Descemet membrane endothelial keratoplasty (DMEK). However, despite these techniques, graft deployment and configuration in eyes with deep anterior chambers remain challenging in some cases. Therefore, in this study, we described a modified technique for DMEK, known as the “double-bubble technique assisted by holding forceps.” Methods: This was a retrospective interventional case series. Patients who underwent DMEK between August 2022 and July 2023, including cases with a history of vitrectomy and scleral fixation of intraocular lens, were enrolled in this study. Two experienced surgeons performed DMEK. In brief, after graft insertion into the anterior chamber, the first bubble with a small volume of air was injected above the graft to open the tight roll, and the graft edge was held using a 25-gauge graft manipulator. The second bubble was injected underneath the graft for fixation, while the graft edge was grasped using forceps during gas injection. The graft was released from the forceps. Best spectacle corrected visual acuity, central corneal thickness, endothelial cell density, and incidence of postoperative complications were measured before and after DMEK. Results: Eleven eyes of 11 patients were included in this study (mean follow-up period, 4.5 ± 4.4 months). Best spectacle corrected visual acuity and central corneal thickness significantly improved postoperatively (P < 0.001). Rebubbling was required in 2 eyes; no other postoperative complications or primary graft failure were observed. Conclusions: The present technique enables safe and feasible DMEK surgery in vitrectomized eyes with scleral fixated IOLs and in those with a deep anterior chamber.

mentioning

confidence: 99%

“…3 Longer manipulation time can cause primary graft failure, as in the case of tight graft rolls or postvitrectomy eyes. 4…”

mentioning

confidence: 99%

Double-Bubble Technique Assisted by Holding Forceps: A Modified Technique in Descemet Membrane Endothelial Keratoplasty for Vitrectomized Eyes With Scleral Fixated Intraocular Lens

Igarashi,

Yokogawa,

Shimizu

et al. 2024

“…Prolonged manipulation of donor Descemet membrane (DM) scroll during surgery is usually associated with higher endothelial cell loss, which can affect long-term graft survival or lead to primary graft failure. 4 Most surgeons prefer to insert the donor graft using a glass or plastic insertion device attached to a fluid-filled syringe. During the insertion process, the donor DM scroll can sometimes follow the path of fluid escaping from the pressurized AC, either through the main incision or the side ports, resulting in partial or complete donor expulsion.…”

mentioning

confidence: 99%

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

Fogla

Thazethaeveetil

2021

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.

“…[1][2][3][4] However, DMEK is a more challenging procedure, with graft unfolding considered to be the most demanding and difficult step to master. [5][6][7] Although several well-defined surgical maneuvers for unfolding a DMEK graft inside the anterior chamber have been described, 8 nontraumatic DMEK attachment may be difficult to achieve when the graft is tightly scrolled. 9,10 Tightly scrolled DMEK grafts have been reported after the preparation of tissues from young donors (,50 years old).…”

mentioning

confidence: 99%

“The Spinning Technique” for Unfolding Tightly Scrolled DMEK Grafts

Vasquez-Perez

Phylactou

Din

et al. 2021