Descemet Membrane Endothelial Keratoplasty Technique Research Articles

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

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." 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. 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. The present technique enables safe and feasible DMEK surgery in vitrectomized eyes with scleral fixated IOLs and in those with a deep anterior chamber.

Challenges of DMEK Technique with Young Corneal Donors' Grafts: Surgical Keys for Success-A Pilot Study.

To report on the surgical maneuvers recommended for a successful unfolding of very young donors in order to accomplish an uneventful Descemet Membrane Endothelial Keratoplasty (DMEK) surgery. Five patients (three females and two males, mean age 71.2 ± 6.7 years) with Fuchs endothelial cell dystrophy who underwent DMEK with very young donors (between 20 and 30 years old) were included. The following demographic data were assessed: donor's age, donor's endothelial cell density (ECD), preservation time, recipient's age and sex and unfolding surgical time. Best-corrected visual acuity (BCVA; decimal system), ECD and corneal central thickness (CCT) were assessed preoperatively and at 6-month follow-up. Donors' mean age was 23.6 ± 3.6 years (range 21 to 30) and the mean ECD was 2748.6 ± 162.6 cells/mm2. All of them underwent an uneventful DMEK as a single procedure performed by one experienced surgeon (MAG) with a mean unfolding time of 7.2 ± 4.9 min (range 4 to 15). The essential steps, including patient preparation as well as DMEK graft implantation, orientation, unrolling and centering are detailed. At 6 months, BCVA was 0.6 ± 0.2, ECD was 1945.0 ± 455.5 cells/mm2 and CCT was 497.0 ± 19.7 microns. We hereby present the keys to overcome tightly scrolled grafts of very young donors, which prove perfectly suitable for DMEK surgery. The graft shape tends towards a double-roll and specific maneuvers are strongly recommended.

Outcomes and Early Complications Using an Endothelium-in Pull-Through Descemet Membrane Endothelial Keratoplasty Technique With Preloaded Versus Surgeon-Loaded Donor Tissue in Fuchs Patients.

This study aimed to compare outcomes and early complications using an endothelium-in pull-through Descemet membrane endothelial keratoplasty (DMEK) technique with preloaded versus surgeon-loaded donor tissue. Data from 163 eyes of 125 patients at the Wilmer Eye Institute diagnosed with Fuchs endothelial corneal dystrophy who underwent DMEK with or without cataract extraction using surgeon-loaded tissue (n = 83) or preloaded tissue (n = 80) were reviewed. Best-corrected visual acuity and early postoperative complications including small graft detachment (less than one third of the graft area), large graft detachment (more than one third), graft failure, and rebubbling were compared. Baseline characteristics including age, sex, and visual acuity were not statistically different between the groups. Small graft detachment was observed in 18.1% of the surgeon-loaded and 22.5% of the preloaded group ( P = 0.48), whereas large detachment occurred in 12.0% and 5.0%, respectively ( P = 0.11). Among these, rebubbling was performed in 18 (21.7%) in the surgeon-loaded compared with 12 (15.0%) in the preloaded group ( P = 0.27). The rebubbling rate of the combined procedure (cataract surgery and DMEK) was 21.8% and of DMEK alone was 7.7% ( P = 0.048). Primary graft failure occurred in 2 surgeon-loaded cases (2.4%) and 1 preloaded case (1.3%) ( P = 0.58). There was no difference in postoperative best-corrected visual acuity at 1 year (logarithm of the minimum angle of resolution 0.21 ± 0.25 for the surgeon-loaded vs. 0.16 ± 0.16 for the preloaded group, P = 0.23). DMEK surgery using preloaded endothelium-in tissue has comparable outcomes with surgeon-loaded endothelium-in tissue. However, there was a trend toward the lower rebubbling rate in DMEK alone compared with combined procedures.

Comparison of the Modified Jones Tube Technique and the DMEK EndoGlide Technique With and Without Viscoelastic Material for DMEK Tissue Preparation.

The aim of this study was to compare endothelial cell loss for DMEK (Descemet membrane endothelial keratoplasty) tissue preparation techniques using the modified Jones tube and the DMEK EndoGlide with and without viscoelastic material to protect the endothelium. This ex vivo study included 10 DMEK grafts prepared using each of the 3 abovementioned techniques. After tissue preparation, transport conditions were simulated for a minimum of 45 hours before deployment of the DMEK tissue and quantification of endothelial cell loss. Comparisons between preparation technique groups were made using the Wilcoxon rank-sum test. The Jones tube group had a mean endothelial cell loss of 11.0 ± 4.8% compared with the EndoGlide group with 12.9 ± 6.7% and the EndoGlide with viscoelastic group with 25.7 ± 15.0%. The differences between the EndoGlide with viscoelastic group and the other 2 were statistically significant both before (P < 0.01 and P = 0.01) and after (P = 0.01 and P = 0.02) adjusting for baseline characteristics. The difference between the EndoGlide and Jones tube groups was not significant (P = 0.73 and P = 0.53 after adjustment). Microscopy revealed endothelial cell loss in the area of viscoelastic use for the EndoGlide with viscoelastic group. Both the Jones tube and DMEK EndoGlide resulted in similar low rates of endothelial cell loss after tissue preparation, transport, and deployment. However, use of viscoelastic material to protect the endothelium using the DMEK technique actually resulted in increased cell loss in the area of its application resulting in overall higher rates of cell loss across the DMEK tissue.

Cooperation between the department of ophthalmology at the University of Düsseldorf (Germany) and the Fundación Visión in Asunción (Paraguay) as an example of the German hospital partnerships programm

HintergrundSeit 2014 besteht auf der Basis eines Memorandum of Understanding eine Partnerschaft zwischen der Universitätsaugenklinik Düsseldorf (UAK Düsseldorf) und der Fundación Visión (FV) in Asunción, die eine führende Rolle in der augenärztlichen Behandlung sowie der Prävention von Erblindung in Paraguay einnimmt. Seit 2016 existiert ein Programm zur Förderung internationaler Klinikpartnerschaften der Bundesregierung.Material und MethodenDie Klinikpartnerschaft Düsseldorf–Asunción wird nach schriftlichem Antrag im Jahr 2016 durch das Ministerium für wirtschaftliche Zusammenarbeit gefördert. Im Rahmen der Projektlaufzeit sollen mithilfe mehrerer Aktivitäten in einem definierten Zeitplan moderne, minimal-invasive Hornhauttransplantationstechniken, die eine schnellere postoperative Rehabilitation und weniger Nachsorge erfordern, in Paraguay etabliert werden. Zusätzlich sollen erste Prävalenzdaten von Augenerkrankungen erhoben und die Basis für moderne Hornhautbanktechniken geschaffen werden.ErgebnisseZunächst erfolgte die Ausbildung eines paraguayischen Operateurs in der Durchführung von DMEK-Transplantationen in Deutschland. Zeitgleich wurden die instrumentellen Voraussetzungen für die Etablierung der DMEK-Technik in der FV geschaffen. Im September 2018 wurden unter Supervision eines erfahrenen OP-Teams aus Düsseldorf die ersten lamellären Hornhauttransplantationen durch das Team der FV erfolgreich in Paraguay durchgeführt. In der Folge wurden in Asunción auch die Verwendung einer Spenderhornhaut für je ein Transplantat für eine hintere und eine vordere lamelläre Keratoplastik (DMEK und DALK) umgesetzt. Im November 2019 erfolgte eine epidemiologische Datenerhebung zu Augenerkrankungen im Rahmen einer Feldkampagne der Fundación in einer ländlichen Region Paraguays. In deren Zug erlernte der datenerhebende Mitarbeiter der Universitätsaugenklinik Düsseldorf die Technik der manuellen Kleinschnittkataraktchirurgie. Im März 2019 wurde ein Mitarbeiter der FV in Düsseldorf in den Techniken der Hornhautgewebekultur und der Herstellung von Amnionmembrantransplantaten in der Lions-Hornhautbank NRW geschult.SchlussfolgerungMithilfe einer geförderten Klinikpartnerschaft können moderne minimal-invasive Hornhauttransplantationstechnik erfolgreich in die Augenklinik eines Schwellenlandes transferiert und im Gegenzug chirurgische Fertigkeiten für in Ausbildung befindliche Operateure aus Deutschland vermittelt werden. Damit stellt eine effiziente Klinikpartnerschaft die Grundlage für einen wechselseitigen Austausch dar und ist keine reine Einbahnstraße.

Long-Term Outcomes of Descemet Membrane Endothelial Keratoplasty in Postvitrectomized Eyes With the Use of Pars Plana Infusion.

To evaluate the use of pars plana infusion as part of Descemet membrane endothelial keratoplasty (DMEK) in eyes of patients who underwent vitrectomy. A retrospective chart review was conducted of patients at Toronto Western Hospital (Toronto, Canada) who had undergone DMEK with pars plana infusion, with a minimum follow-up of at least 12 months. Collected data included postoperative best-corrected visual acuity (BCVA), intraoperative complications, and postoperative complications such as graft detachment, rejection and failure, and rate of endothelial cell loss. Fifteen eyes of 14 patients were included in this study. The mean follow-up time was 23.9 ± 5.7 months. Four grafts required rebubbling within the first month of surgery, and one graft required repeat DMEK right away. Two grafts failed secondarily at 24 months, and there was one episode of graft rejection. Five eyes had retinal complications including retinal detachment, retinoschisis, and cystoid macular edema. BCVA improved significantly from 1.7 ± 0.77 logarthim of the minimum angle of resolution (LogMAR) (mean Snellen 20/1000) preoperatively when compared with postoperative BCVA at 6 months (0.95 ± 0.74 LogMar, mean Snellen 20/180, P = 0.02, n = 10), 12 months (0.93 ± 0.6,P = 0.01, mean Snellen 20/170, n = 11), and 24 months (1.01 ± 0.68, mean Snellen 20/200 P = 0.046, n = 7). Although pars plana infusion is a helpful technique for DMEK in vitrectomized eyes, such cases are still quite difficult to perform compared with standard DMEK and use of an infusion may increase the risk of retinal complications. Descemet Stripping Automated Endothelial Keratoplasty may be the preferred technique in these challenging vitrectomized eyes.

Update on Descemet membrane endothelial keratoplasty.

To provide an update on new perspectives on Descemet membrane endothelial keratoplasty (DMEK). Preloaded DMEK grafts allow optimization of DMEK surgery time and reduce costs of the procedure, which is allowing the procedure to become more easily performed as reflected in the increasing number of cases. The surgical technique in the United States differs from the technique in Europe, but outcomes have been similar. Hemi-DMEK and quarter-DMEK have shown similar outcomes to conventional DMEK with respect to corneal transparency and visual acuity. Three-year follow-up of hemi-DMEK has also shown stability in endothelial cell count while maintaining corneal transparency. DMEK is becoming more accepted as the procedure of choice for treating endothelial failure. However, challenges with the surgical technique have limited wider implementation of this lamellar corneal transplantation. Preloaded DMEK provides one solution for the surgical challenges associated with the procedure while also reducing costs. Variations in the surgical technique for DMEK, including hemi-DMEK and quarter-DMEK, allow for central corneal clarity similar to traditional DMEK, but both result in lower endothelial cell density (ECD).

Sinsky hook assisted roll preparation (SHARP): A modified technique for Descemet membrane endothelial keratoplasty donor preparation

PurposeTo describe a simple technique of sinsky hook assisted roll preparation (SHARP) for Descemet membrane endothelial keratoplasty (DMEK) donor preparation. MethodsThis experimental study was conducted at National Eye Bank, India with 40 optical grade human donor corneoscleral tissues found not suitable for surgery. 25 tissues were initially used to standardize the technique and remaining 15 for establishing the final technique. Donor corneal tissues were initially placed on a sterile Teflon block partially filled with tissue culture media. Initially, a partial thickness trephination was done followed by sinsky assisted 360° separation of the Descemet membrane (DM) from the underlying stroma (2 mm from the edge). The separation was further extended by 3–4 mm from the edge for 4–5 clock hours followed by bimanual peeling of the DM. This was followed by central 8 mm trephination. The primary outcome measures were a complete success (8 mm roll without peripheral edge tears) and partial success (8 mm roll with peripheral edge tears). ResultsDMEK roll was successfully peeled in 86.6% tissues (n = 13/15). Complete success was obtained in 66.6% tissues while partial success was obtained in 20% tissues. The median age of donor tissue was 45 years. The donor age of tissues, from which DMEK roll could not be obtained (2/12) was 15 days and 18 years. ConclusionSHARP is a simple technique of DMEK that does not require any sophisticated instruments.

Technique of Descemet membrane endothelial keratoplasty (DMEK) : Video article

Descemet membrane endothelial keratoplasty (DMEK) selectively removes diseased corneal endothelium and Descemet membrane and replaces them with healthy donor tissue. The DMEK technique represents the current gold standard for the treatment of corneal endothelial dysfunction. In this article the surgical technique for DMEK is presented by means of avideo. The indications for surgery, patient education, anesthesia and patient positioning, postoperative treatment as well as possible complications and their management are described. The DMEK can be applied for the treatment of awide range of corneal endothelial disorders. In addition to the operative implementation, the basis for the outstanding results of the surgical procedure are careful donor-patient allocation, thorough examination and follow-up of all patients and experience of the surgeon. The use of DMEK is asafe and effective procedure for the treatment of corneal endothelial dysfunction. Astandardized and individualized procedure provides the basis for optimal results compared to all previous transplantation procedures.

Новая стратегия кератопластики: расслоение и разделение роговицы донора.

Purpose: to report the first case of the same day use of a single donor cornea tissue for 5 consecutive transplantations in patients with endothelial dystrophy and keratoconus. Material and methods. The Descemet membrane (DM) and the endothelium were fully detached from the stroma of the donor on the endothelial side, using first a circular and then a direct corneal cutter, forming four partial triangle-shaped Descemet grafts (each constituted a 1/4 Descemet graft). The stroma of the donor's cornea was separated by a circular cutter of a preset diameter. One patient with keratoconus underwent deep anterior lamellar keratoplasty (DALK) using the big bubble technique. Then, each of the four Descemet grafts was sequentially transplanted by the Descemet membrane endothelial keratoplasty (DMEK) method to 4 patients with Fuchs dystrophy and pseudophakia. Results. During and after the surgery, there were no complications requiring additional intervention. Six months after DALK, the best corrected visual acuity (BCVA) was 0.66. Six months after four operations each using ¼ DMEK the average BCVA was 0.95 ± 0.1 (from 0.8 to 1.0) and the endothelial cell density was, respectively, 2839 after DALK and 1680 ± 254 cells/mm2 (from 1492 to 2039 cells/mm2) after ¼ DMEK. Conclusion. One donor cornea can be successfully transplanted to at least 5 patients. Despite the fact that the implementation of DALK and several operations using the ¼ DMEK technique within one day is technically difficult, this approach can contribute to a drastic reduction in the deficit of donor tissue. This approach requires a thorough selection of patients and an extensive surgical experience. For citation: Oganesyan O.G., Makarov P.V., Grdikanyan А.А., Getadaryan V.R. A new strategy of keratoplasty: laminating and splitting the donor cornea. Russian ophthalmological journal. 2018; 11 (3): 11-8 (In Russian). doi: 10.21516/2072-0076-2018-11-3-11-18. The full English version is available online at http://roj.igb.ru/eng/issues

Standardizing Descemet Membrane Endothelial Keratoplasty Graft Preparation Method in the Eye Bank-Experience of 527 Descemet Membrane Endothelial Keratoplasty Tissues.

To share the experience and provide a standardized protocol for Descemet membrane endothelial keratoplasty (DMEK) graft preparation. A retrospective study based on 527 prestripped DMEK tissues that were prepared between 2014 and 2017. The experience of using different instruments and techniques has been described, and a standardized technique for preparing DMEK grafts has been identified. The tissues in general were prepared by superficially tapping the endothelial side with a Moria trephine (9.5 mm diameter). The plane of cleavage was identified using a cleavage hook, and the DMEK graft was deadhered from the trephined site throughout the circumference for ease of excising the graft. The DMEK graft was peeled using either one or multiple quadrant methods depending on the challenges faced during excision. The graft was finally marked with the letter "F" to identify the orientation during surgery. Data on endothelial cell loss (ECL) and challenging cases were observed, monitored, and recorded during this period. Less than 1 percent trypan blue-positive cells with tissue wastage of <6% was observed during the study period. Our standardized stripping technique has resulted in an overall ECL of 4.6%. Marking Descemet membrane showed 0.5% cell mortality. Standardizing DMEK technique using specific tools and simple techniques would help new surgeons to decide the instruments and improve their tissue preparation skills also in challenging cases such as previous cataract incisions or horseshoe-shaped tears, further reducing ECL or tissue wastage.

Vent Incisions to Facilitate Peripheral Unfolding of the DMEK Graft.

To present the results of 15 cases in which a modified technique of Descemet membrane endothelial keratoplasty (DMEK) with vent incisions was used to assist unfolding of tight peripheral inward folds. This is a retrospective case series of 15 consecutive eyes that underwent a modified vent incision technique for DMEK. Six oblique, small-size (1 mm) vent incisions parallel to the limbus and 3.5 mm from the center were performed after descemetorhexis. The graft was opened with standard no-touch techniques and was partially attached to the stroma with air injection. Then, in cases with remaining tight inward folds despite gentle corneal tapping, jets of balanced salt solution were pulsed through the vent incisions directed at the peripheral folds to achieve complete unfolding. Descemet membrane endothelial keratoplasty was performed in 2 phakic eyes (14%) and 13 pseudophakic eyes (86%). Six cases (40%) required fluid injection through the vent incisions: 3 corresponded to grafts from younger donors (54, 41, and 29 years old), and 3 had a 9.0-mm-sized graft. Complete graft unfolding was successfully achieved in 14 cases (93%), and in 1 case (7%), peripheral folds remained because of spontaneous bleeding in the anterior chamber. A clear cornea was achieved in all cases, and there were no postoperative complications associated with the vent incisions. This technique provides a different DMEK no-touch approach that could be used in challenging cases of graft unfolding such as young donors and/or large-sized grafts. It may also avoid excessive unfolding times and direct manipulation that are related to higher endothelial cell loss.

Enhancing Descemet Membrane Endothelial Keratoplasty in Postvitrectomy Eyes With the Use of Pars Plana Infusion.

To present a modified surgical technique to perform Descemet membrane endothelial keratoplasty (DMEK) in previously vitrectomized eyes and to analyze its safety and efficacy. A retrospective analysis of previously vitrectomized eyes that underwent DMEK at Toronto Western Hospital was performed. The modified DMEK technique that was used included placement of a posterior pars plana infusion to reduce fluctuations in the anterior chamber depth and its excessive deepening. Twelve eyes of 12 patients (5 females and 7 males) aged 65.3 ± 21.5 years were included. Mean best-corrected visual acuity improved significantly from 1.72 ± 0.62 logMAR (mean Snellen ∼20/1040) preoperatively to 1.01 ± 0.64 logMAR (mean Snellen ∼20/200) at 6 months postoperatively (P = 0.017). Mean donor endothelial cell density was 2658 ± 229 cells/mm preoperatively and 1732 ± 454 cells/mm at 6 months after the procedure (mean percentage cell loss of 31.8%) (P = 0.046). There were no significant intraoperative complications, and no graft failures. One eye had graft detachment, which resolved after 2 rebubbling procedures. One eye had retinal detachment, which was corrected surgically. The use of posterior pars plana infusion in previously vitrectomized eyes stabilizes the anterior segment during DMEK, allowing for performance of DMEK surgery, and can potentially reduce intraoperative and postoperative complications.

Validation of an endothelial roll preparation for Descemet Membrane Endothelial Keratoplasty by a cornea bank using "no touch" dissection technique.

Descemet Membrane Endothelial Keratoplasty (DMEK) selectively replaces the damaged posterior part of the cornea. However, the DMEK technique relies on a manually-performed dissection that is time-consuming, requires training and presents a potential risk of endothelial graft damages leading to surgery postponement when performed by surgeons in the operative room. To validate precut corneal tissue preparation for DMEK provided by a cornea bank in order to supply a quality and security precut endothelial tissue. The protocol was a technology transfer from the Netherlands Institute for Innovative Ocular Surgery (NIIOS) to Lyon Cornea Bank, after formation in NIIOS to the DMEK "no touch" dissection technique. The technique has been validated in selected conditions (materials, microscope) and after a learning curve, cornea bank technicians prepared endothelial tissue for DMEK. Endothelial cells densities (ECD) were evaluated before and after preparation, after storage and transport to the surgery room. Microbiological and histological controls have been done. Twenty corneas were manually dissected; 18 without tears. Nineteen endothelial grafts formed a double roll. The ECD loss after cutting was 3.3% (n=19). After transportation 7days later, we found an ECD loss of 25% (n=12). Three days after cutting and transportation, we found 2.1% of ECD loss (n=7). Histology found an endothelial cells monolayer lying on Descemet membrane. The mean thickness was 12±2.2µm (n=4). No microbial contamination was found (n=19). Endothelial roll stability has been validated at 3days in our cornea bank. Cornea bank technicians trained can deliver to surgeons an ECD controlled, safety and ready to use endothelial tissue, for DMEK by "no touch" technique, allowing time saving, quality and security for surgeons.

Standardization of the Descemet membrane endothelial keratoplasty technique: Outcomes of the first 450 consecutive cases

ObjectivesTo evaluate the clinical outcome of the first 450 consecutive cases after Descemet membrane endothelial keratoplasty (DMEK), as well as the effect of standardization of the technique. Material and methodsComparison between 3 groups: Group I: (cases 1–125), as the extended learning curve; Group II: (cases 126–250), transition to technique standardization; Group III: (cases 251–450), surgery with standardized technique. Best corrected visual acuity, endothelial cell density, pachymetry and intra- and postoperative complications were evaluated before, and 1, 3 and 6 months after DMEK. ResultsAt 6 months after surgery, 79% of eyes reached a best corrected visual acuity of ≥0.8 and 43% ≥1.0. Mean preoperative endothelial cell density was 2530±220cells/mm2 and 1613±495 at 6 months after surgery. Mean pachymetry measured 668±92μm and 526±46μm pre- and (6 months) post-operatively, respectively. There were no significant differences in best corrected visual acuity, endothelial cell density and pachymetry between the 3 groups (p>0.05). Graft detachment presented in 17.3% of the eyes. The detachment rate declined from 24% to 12%, and the rate of secondary surgeries from 9.6% to 3.5%, from group I to III respectively. ConclusionsVisual outcomes and endothelial cell density after DMEK are independent of the technique standardization. However, technique standardization may have contributed to a lower graft detachment rate and a relatively low number of secondary interventions required. As such, DMEK may become the first choice of treatment in corneal endothelial disease.

Standardized DMEK Technique: Reducing Complications Using Prestripped Tissue, Novel Glass Injector, and Sulfur Hexafluoride (SF6) Gas.

To report low complication rates in Descemet membrane endothelial keratoplasty (DMEK) using sulfur hexafluoride (SF6) gas, a novel glass injector, and donor tissue prestripped by an eye bank technician. A standardized technique of DMEK was performed in 80 consecutive Fuchs corneal dystrophy cases using technician-prestripped tissue, a novel glass injector, a modified Yoeruek tap technique, and an SF6 gas (20% concentration) bubble for prolonged tissue support. Twenty-five donors were premarked with an "S" stamp for intraoperative orientation. Surgery was performed by 2 experienced DMEK surgeons and 2 inexperienced cornea fellows. Complications were recorded, and the percent endothelial cell loss was calculated at 6 months postoperatively. There were 5 cases that received an air bubble injection postoperatively (6% rebubble rate). There were 6 grafts that immediately failed, 2 because of excessive surgical trauma, and 4 because of upside-down graft placement documented by optical coherence tomography. None of the 25 cases with an S stamp failed. Recipient corneas cleared quickly with no clinical evidence of toxicity from the SF6 gas bubble, and the grafts experienced a mean endothelial cell loss of 27% at 6 months. Tissue prestripped by an eye bank technician can be safely used for DMEK surgery. SF6 gas for prolonged tissue support may reduce the rebubble rate in DMEK, with no apparent acute toxic effect. An unrecognized upside-down graft was the primary cause of graft failure in this series. Upside-down grafts may be eliminated by the use of donor tissue premarked by the eye bank with an S orientation stamp.

Multicenter study of descemet membrane endothelial keratoplasty: first case series of 18 surgeons.

Surgeons starting to perform Descemet membrane endothelial keratoplasty (DMEK) should be informed about the learning curve and experience of others. To document the clinical outcome of standardized "no-touch" DMEK and its complications during the learning curves of experienced surgeons. Retrospective multicenter study. A total of 431 eyes from 401 patients with Fuchs endothelial dystrophy (68.2%) and bullous keratopathy (31.8%) underwent DMEK performed by 18 surgeons in 11 countries. Descemet membrane endothelial keratoplasty. Best-corrected visual acuity (BCVA), endothelial cell density, and intraoperative and postoperative complications. Of 275 eyes available for BCVA pooled analysis, BCVA improved in 258 eyes (93.8%), remained unchanged in 12 (4.4%), and deteriorated in 5 (1.8%). Two hundred seventeen eyes (78.9%) reached a BCVA of at least 20/40 (≥0.5), 117 (42.5%) at least 20/25 (≥0.8), and 61 (22.2%) at least 20/20 (≥1.0). Eyes with at least 6 months of follow-up (n = 176) reached similar BCVA outcomes. Mean (SD) decrease in endothelial cell density at 6 months was 47% (20%) (n = 133 [P = .02]). Intraoperative complications were rare, including difficulties in inserting, unfolding, or positioning of the graft (1.2%) and intraoperative hemorrhage (0.5%). The main postoperative complication was graft detachment (34.6%); 20.4% underwent a single rebubbling procedure, occasionally requiring a second (2.6%) and a third rebubbling (0.7%), and 17.6% underwent a second keratoplasty. Our multicenter study showed that the standardized no-touch DMEK technique was feasible in most hands. The main challenges for surgeons starting to perform the procedure may be (1) to decide whether graft preparation is outsourced or performed during surgery, (2) to limit the number of graft detachments and secondary procedures, and (3) to obtain organ cultured donor corneal tissue.

Endothelial Keratoplasty: Fellow Eyes Comparison of Descemet Stripping Automated Endothelial Keratoplasty and Descemet Membrane Endothelial Keratoplasty

To evaluate patients' perspectives and outcomes of 2 different endothelial keratoplasty (EK) techniques performed in the fellow eyes of the same patients: Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). In this fellow eye, comparative, retrospective case series, the records of 15 patients who underwent DSAEK in 1 eye and DMEK in the fellow eye and completed at least 1 year of follow-up after the second procedure were reviewed. Visual outcomes and endothelial cell density were assessed. Patient satisfaction was evaluated using a subjective questionnaire. At 12 months postoperatively, the mean best spectacle-corrected visual acuity (BSCVA) in the DMEK group was 0.07 logarithm of the minimum angle of resolution (20/24) and 0.20 logMAR (20/32) in the DSAEK group (P = 0.004). The majority of the patients (85%) perceived better visual quality in the DMEK eye. Furthermore, 62% preferred or would recommend DMEK to a friend or relative, whereas 15% preferred DSAEK and 23% reported no preference between the surgical procedures. The 1-year endothelial cell loss and the perceived discomfort level during the postoperative period were comparable for the 2 procedures. The majority of the patients preferred or would recommend the DMEK procedure. Faster visual recovery and better final visual acuity were the main benefits of the DMEK technique.