Presoaking with BSS used for thin manually dissected DSEK (TMDSEK): a viable option for thin DSEK

Abstract

Aim To describe a novel technique for the safe manual dissection of thin donor lenticules in 10 consecutive patients undergoing DSEK surgery. Methods A key element of our new technique was to presoak the donor cornea in balanced salt solution (BSS) for 30 min before manual dissection. The cornea was placed on an artificial anterior chamber and pressure in the chamber was maintained at 80 mm Hg. The limbus of the donor cornea was incised to the same depth as the central corneal thickness. Lamellar dissection was started with the short side of the Morlet dissector (Duckworth & Kent Ltd) and completed using the lamellar (less sharp) end of the Morlet dissector. Outcomes of 10 consecutive cases of thin manually dissected DSEK (TMDSEK) were prospectively analysed for thickness and visual outcome. Results Mean graft thicknesses measured less than 100 mm at 1 month post surgery (mean thickness 90.7 mm, range 48-137 mm, SD 29.96 mm). Presoaked donor corneal pachymetry was strongly negatively correlated with graft thickness (correlation r ¼ À 0.75, Po0.05). Discussion Our dissection technique achieves consistently thin endothelial donor corneal grafts that can be safely produced with minimal financial investment and no limitations on surgical time. This technique is likely to be of significant importance for a large proportion of the eye centres where microkeratomes may not be routinely available.

Determinants of visual quality after endothelial keratoplasty

“…In our practice, we recently reported 10 consecutive cases of thin manual DSEK (TMDSEK) using tissue pre-soaked in balanced salt solution, achieving a mean graft thickness of 90.7 microns (range 48-137 microns) at one month postoperatively. 125 Busin has also reported better visual outcomes with his ultrathin-DSAEK technique compared with conventional DSAEK, achieving grafts of 73+/-14 microns.…”

Endothelial keratoplasty: is Descemet membrane endothelial keratoplasty the Holy Grail of lamellar surgery? No

“…The challenges when interpreting long-term data in DSEK is that the technique itself has evolved and we have been able to achieve thinner DSEK grafts more consistently. 4 Mean graft thickness in Wacker's cohort was 155 μm, which may or not be representative depending on the institution and technique employed. 20 Busin et al 11 reported 2-year outcomes following UT-DSAEK (mean graft thickness of 78.28 μm) with mean BSCVA at 24 months of 0.04 LogMar, with 48.8% of patients in the entire cohort achieving a visual acuity of 20/20 or better and suggested that outcomes with UT-DSAEK were comparable to DMEK.…”

“…10 Although these numbers are improved in the hands of experienced DMEK surgeons, they are still higher than complication rates reported for DSEK, UT-DSEK, TMDSEK, and PDEK. 4,5,[10][11][12] In a comparative study, graft detachment requiring rebubbling occurred in 3.2% of DSAEK cases and 8.6% of DMEK cases. 12 The deleterious effects of rebbubling and additional surgical manipulation on the graft have been established both in vitro and in vivo.…”

“…15 In contrast to these intraoperative and post-operative challenges faced by the surgeon during and after DMEK surgery, a number of techniques have been described for the safe and reliable dissection of ultrathin DS(A)EK grafts. 2,4,5,16,17 Busin et al 2 described a double-pass technique that allows the creation grafts with central thickness of 100 μm or less in 78.82% of cases and 130 μm or less in 95.6% of the cases. The authors reported intraoperative complications, such as difficulty in graft dissection, in 7.2% of cases and yet only 2.1% of tissue was discarded as a result.…”

“…Posterior lamellar surgery has transformed the management of corneal endothelial disease due to faster visual rehabilitation, minimal refractive change, and maintenance of the ocular structural integrity compared full thickness keratoplasty. Although Descemet's membrane endothelial keratoplasty (DMEK) appears to offer an anatomical repair for endothelial pathology, replacing only endothelium and Descemet's membrane without any posterior stroma, 1 it has yet to supersede Descemet's stripping endothelial keratoplasty (DSEK) and its variations; ultrathin Descemet's stripping automated endothelial keratoplasty (UT-DSAEK), 2,3 thin manual Descemet stripping keratoplasty (TMDSEK), 4 and pre-Descemet's endothelial keratoplasty (PDEK) 5 as the mainstay the treatment of Fuchs endothelial dystrophy or bullous keratopathy. The main reason for this is that DMEK is technically more challenging, requiring prolonged surgical time, associated with a steeper learning curve and possibly more potential complications.…”