Intraocular Graft Unfolding Techniques in Descemet Membrane Endothelial Keratoplasty

Abstract

To define various Descemet graft unfolding techniques in Descemet membrane endothelial keratoplasty. In a retrospective analysis, the surgical videos of 100 consecutive Descemet membrane endothelial keratoplasty cases with at least 6 months of follow-up were evaluated and categorized. The Descemet graft unfolding methods were categorized into 4 basic techniques and 3 auxiliary techniques. All Descemet membrane endothelial keratoplasty surgical procedures could be completed using (a combination of) 4 Descemet graft unfolding techniques: (1) standardized no-touch graft unfolding using a double roll, (2) carpet unrolling while fixating 1 graft edge (Dirisamer technique), (3) small air bubble-assisted unrolling (Dapena maneuver), (4) the single sliding cannula maneuver. Additional maneuvers included turning over the graft when oriented upside down (flushing); manual graft centration with a cannula; and bubble bumping to unfold peripheral inward folds. In 73% of surgical procedures, technique 1 was used, while a combination of techniques was used in 44% and auxiliary techniques in 62%. None of the techniques showed a correlation with the best-corrected visual acuity, endothelial cell density, or postoperative complication rate (P > .10). Descemet membrane endothelial keratoplasty may be further facilitated by using controlled techniques for unfolding the Descemet graft inside the recipient anterior chamber, either as stand-alone techniques or used in various combinations.