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Part ix Keratoplasty
Section 6 Endothelial Keratoplasty
Chapter 131
c00131 Surgical Technique for DMEK
Kevin J. Shah, Michael D. Straiko, Mark A. Greiner
Key Concepts
p0045 • A closed-system injector is ideal for controlled delivery
of a DMEK graft.
u0050 • Creating a recipient stromal bed of slightly greater
diameter than the donor graft improves graft
attachment.
u0055 • Creating a peripheral iridotomy is vital in preventing
pupillary block.
u0060 • Obtaining correct graft orientation is critical for a
successful outcome.
u0065 • The primary techniques used to unfold and center a
DMEK graft include fluid or air injection, corneal
tapping, and/or anterior chamber depth modulation.
u0070 • The use of sulfur hexafluoride 20% has decreased graft
detachment rates.
s0010 Introduction
p0080 Descemet membrane endothelial keratoplasty (DMEK) is the
only surgical procedure that provides a true anatomic
exchange of diseased endothelium and Descemet membrane
with healthy donor tissue. There are several advantages of
DMEK compared to Descemet stripping endothelial keroto-
plasty (DSEK), including faster visual recovery, lower rejec-
tion rate, and higher quality of vision. However, graft
preparation, iatrogenic graft failure, and previously reported
high rates of graft detachment are obstacles that have pre-
vented many corneal surgeons from adopting this surgery.
With eye banks now preparing DMEK tissue, more corneal
surgeons are beginning to adopt DMEK as the risk of pre-
operative tissue loss has been eliminated.
p0085 Similar to DSEK, all corneal surgeons will experience a
learning curve with DMEK and should select their first
patients keeping this in mind. This chapter discusses the
authors’ experiences performing DMEK and provides a
literature-based review of surgical techniques that have been
implemented with DMEK. While the techniques necessary
to perform DMEK are different than DSEK, successful out-
comes can be achieved routinely. This chapter outlines a
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sequential approach to this technique and highlights several
vital intraoperative techniques that can make DMEK a
reproducible, predictable, and successful procedure.
Injectors s0015
One of the key steps in DMEK surgery is the safe and con- p0090
trolled delivery of the fragile DMEK scroll into the anterior
chamber. The ideal DMEK injector should have multiple
features including:
• A closed system that prevents backflow from the anterior u0075
chamber and is capable of maintaining anterior chamber
volume
• A material that is safe for the endothelium u0080
• No need for viscoelastic u0085
• Easy loading with minimal handling of the graft u0090
• An adequate caliber to avoid compression of the graft u0095
• A tapered tip to seal the surgical incision well. u0100
Currently there are no FDA-approved DMEK injectors.
American surgeons have found many creative off-label
methods around this obstacle. Many surgeons use modified
intraocular lens injection cartridges for this purpose.1–4 The
Staar microinjector (Staar Surgical Company, Monrovia, CA)
was one of the most common inserters initially used for
DMEK in the US (Fig. 131.1B). The Staar injector is an open
system with a foam plunger and requires a viscoelastic agent
to help deliver the tissue. This technique risks the introduc-
tion of viscoelastic into the anterior chamber during tissue
injection, which can impede graft attachment.5 Another
popular IOL cartridge based system is the Viscoject IOL injec-
tor (Bausch & Lomb, Aliso Viejo, CA) (Fig. 131.1A). The Price
group reported improved rebubble rates when transitioning
from the Staar injector with the use of viscoelastic to the
Viscoject, which does not require viscoelastic and is a small
closed-system inserter.6
A similar closed-system injector can be created with the p0125
AMO Emerald One Series IOL cartridge (Abbot Laboratories
Inc., Abbot Park, IL), with a few key differences compared to
other IOL cartridge injectors (Fig. 131.1D). Assembled with
a standard Luer-Lok syringe filled with BSS and 14-French
gauge nasogastric tubing, the Emerald One Series IOL car-
tridge is large enough that it can be used to aspirate the
graft into the injector and small enough to be used through
a 2.75 mm clear corneal incision. Similar to other injectors
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CHAPTER 131
Surgical Technique for DMEK

Chapter Outline
u0010 Introduction
u0015 Injectors
u0020 Recipient Preparation
u0025 Wound Creation
u0030 Graft Orientation
u0035 Unscrolling and Centering
u0040 Graft Tamponade With Air or Sulfur Hexafluoride 20%

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PART ix Keratoplasty

Section 6 Endothelial Keratoplasty

A a

B b

C c

D d

A: Viscoject IOL injector and tip (a)

B: The staar microinjector and tip (b)
C: DMEK jones tube and tip (c)
D: Modified AMO emerald IOL injector and tip (d)
E
f0010 E: Alcon B cartridge
Fig. 131.1 (A–E) DMEK injectors. Multiple closed-system injectors have been used to deliver the DMEK graft into the eye. To date, there is no
FDA-approved DMEK injector system in the US.

made of clear or translucent materials, graft orientation can
often be maintained during injection. The authors suggest
using a 1 mL or 3 mL Luer-Lok syringe with this injector
to further enhance controlled delivery into the anterior
chamber. An optional 3-way stopcock can also be added to
the injector for safety to remove air bubbles and refill the
syringe without disturbing the loaded graft (Fig. 131.1D).
p0130 Glass injectors have been promoted in the European
literature.7–9 Several European techniques utilize glass injec-
tors such as the curved glass pipette made by the Dutch
Ophthalmic Research Center (DMEK surgical disposable set;
DORC, Zuidland, The Netherlands) or the Geuder glass
injector (Geuder AG, Heidelberg, Germany). Glass poten-
tially offers a smoother surface than plastic and may cause
less endothelial cell damage. Surgeons have also adopted
off-label use of a glass Jones tube (DMEK Jones tube #80000-
DMEK, Gunther Weiss Scientific, Portland, OR). Jones tubes
are FDA approved for lacrimal surgery. Similar to the modi-
fied AMO injector, the Jones tube can be used to aspirate the
graft into the inserter, reducing forceps contact with the
graft and the risk of endothelial cell trauma. Coupled with
14-French gauge nasogastric tubing, the Jones tube is
attached to a 3 mL or 5 mL syringe full of BSS, creating a
closed system with a fluid reservoir for tissue injection and
chamber maintenance (Fig. 131.1C). The technique also
allows slow, controlled delivery of tissue with optimal ante-
rior chamber maintenance. An additional feature of the
DMEK Jones tube is a central dilation, which results in
decreased fluid velocity in the central portion of the injector
relative to the tip. This differential in velocity helps to
prevent excessive graft aspiration and maximize control of
graft delivery.
With all closed-system DMEK injectors, care must be p0135
taken to avoid over-pressurization of the anterior chamber.
Injection of excess BSS creates an unfavorable pressure gradi-
ent that can result in ejection or incarceration of the graft
when the injector tip is withdrawn. To avoid this situation,
the authors recommend releasing fluid from a paracentesis
prior to withdrawing the injector, or at any time the surgeon
feels the eye is becoming over-pressurized. Additionally,
shallowing the anterior chamber after graft insertion and
prior to injector removal can maintain graft orientation and
simultaneously begin the unfolding process. Another tech-
nique for reducing graft ejection is by pressing a second
instrument (e.g. 30-G cannula) atop the main incision while
withdrawing the injector, essentially creating a “trap door”
at the wound. It is also helpful in many situations to
position the graft near the opening of the injector so that
it is introduced into the eye with minimal influx of BSS
(Video 131.1).

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CHAPTER 131
Surgical Technique for DMEK

p0140 Akin to DSAEK surgery, there are multiple ways to insert
DMEK graft tissue. Whether the injector material is a key
component as suggested by Dapena et al.7 or the injector
design is more important as suggested by Kim et al.1 remains
to be seen. Interestingly, in their small series, Kim et al.
found a postoperative endothelial cell loss (ECL) of 28 ± 16%
with an Alcon B cartridge attached to a syringe of BSS. This
finding compares favorably to the ECL of 12–29% found by
Ham et al. in their larger study using a closed-system glass
injector.9 These data suggest that the design features of an
injector (e.g. a closed system) may prove more important
than its material properties. Further clinical trials and labora-
tory work with vital dye staining for endothelial damage will
be required to better inform this important topic.
of the incisions with a surgical marking pen so that the
paracenteses can be located and accessed easily during the
surgical procedure. The internal opening of the paracenteses
should not overlap with the area where the graft will be
placed. After the paracentesis incisions are made, the primary
incision is created. The primary incision is sized to fit the
injector chosen by the DMEK surgeon (Table 131.1). The
primary incision should allow a snug fit with the DMEK
injector and prevent fluid egress, which could risk flushing
the graft out of the main incision during graft injection.
Although a self-sealing stable incision is ideal, the authors
recommend suturing even the smallest main incisions to
avoid any potential loss of the graft, air, or gas during later
maneuvers.

Endothelium-Descemet membrane resection s0030

s0020 Recipient Preparation
p0145 Preparation of the recipient eye for successful DMEK surgery
involves creation of surgical incisions, removal of the
recipient’s Descemet membrane and corneal endothelium,
constriction of the pupil, and creation of a peripheral
iridotomy.
s0025 Wound Creation
p0150 The authors prefer a temporal approach, in the widest
corneal dimension, to help ensure the primary incision will
not interfere with graft implantation. The number of total
incisions needed for DMEK surgery varies based on surgical
technique. The majority of DMEK surgeons will create two
to four paracentesis incisions in addition to the primary
incision. Paracentesis incisions of 1 mm are created superior
and inferior to the main temporal incision. All wounds for
DMEK should be self-sealing, as this aids greatly in chamber
stability and subsequent positioning of the graft. Making the
incisions parallel to the iris plane facilitates the creation of
self-sealing paracenteses. It is helpful to mark the entrance
After creating the surgical incisions, the diseased endothelium- p0155
Descemet membrane complex (EDM) is stripped from the
host cornea. This step can be accomplished in numerous
ways but it is widely agreed that the creation of a smooth
area of resection without residual Descemet membrane (DM)
or stromal fibrils is of utmost importance.10 Residual tags of
DM and stromal fibrils may allow fluid to collect between
the graft and the recipient stroma, thereby preventing
attachment of the graft. It may also result in a suboptimal
interface, which can compromise the visual quality in DMEK
patients. Kruse was the first to report a lower rate of graft
separation and subsequent re-bubbling when the graft does
not overlap with host DM.10 To avoid overlap, the area of
stripping on the host cornea should be slightly larger than
the diameter of the planned DMEK graft (Fig. 131.2). This
results in a small area of bare posterior stroma devoid of any
DM coverage. Initially, there may be corneal edema overly-
ing the uncovered areas; the edema typically resolves over
days to weeks, likely as donor endothelial cells migrate to
cover the bare stroma.11 The potential increase in graft
attachment may result in a loss in cell density as donor cells

t0010 Table 131.1 Characteristics of various DMEK injectors

Injector Incision Materials needed Unique properties

Viscoject IOL injector 2.4 mm Viscoject IOL injector Need to remove spring
Graft is loaded like an IOL, not aspirated

Staar Microinjector 3.0 mm Requires viscoelastic Graft is loaded like an IOL, not aspirated

DMEK Jones tube 3.2 mm Gunther Weiss DMEK modified Jones Tube Glass material may be safer for endothelium
14-French gauge nasogastric tubing 3 mL syringe for controlled injection and chamber maintenance
3 mL syringe Central dilation to control fluidics

Modified AMO Emerald One
Series injector
2.75 mm AMO Emerald One cartridge 1 mL syringe for controlled injection
1 mL Luer-Lok syringe A backup 3-way stopcock valve for removing air bubbles and
14-French gauge nasogastric tubing refilling injector if necessary (useful in leaking wounds)
Optional Safety additions
3-way stopcock
3 mL Luer-Lok syringe

Alcon B cartridge 2.8 mm 3 mL Luer-Lok syringe Can be difficult to create a watertight closed system between
Various adapters to join to a syringe the cartridge and the syringe

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PART ix Keratoplasty
Section 6 Endothelial Keratoplasty
2 5
1
3 4
2 synechiae. Due to the importance of a small pupil in DMEK,
6
1- Limbus
2- 1 mm paracentesis incisions
3- Temporal incision to fit injector
4- Well-centered DMEK graft (blue)
5- Edge of desmetorrhexis
f0015 6- Thin rim of bare stroma (orange)
Fig. 131.2 Host preparation for DMEK. Note the absence of overlap of
graft and the host Descemet membrane.
migrate to cover areas of bare stroma. A small decrease in
endothelial cell density may be a salient trade if it is accom-
panied by a lower rate of graft detachment. Regardless of
the planned area of resection, the authors recommend an
optical zone marker or calipers be used to mark the area of
resection. These marks facilitate precise graft centration after
unfolding.
p0160 A stable anterior chamber facilitates stripping of the EDM.
This stability can be accomplished with a cohesive viscoelas-
tic, air, or BSS using an anterior chamber maintainer. The
use of viscoelastic affords the most stable anterior chamber,
but requires extra supplies including an irrigation and aspi-
ration unit. Some have raised concerns that viscoelastic
devices may impede donor attachment.12 However, a cohe-
sive viscoelastic facilitates grasping and removing the EDM
from the recipient stromal bed, can be used to prevent and
control bleeding, and can also be removed completely from
the anterior chamber. In the authors’ experience, using air
provides a less stable anterior chamber but improves visual-
ization of DM as it is scored and removed. No matter what
method of support is used, a blunt tipped instrument such
as a reverse Sinskey hook is used to score a circle in the
recipient EDM. After establishing this initial break, the host
EDM tissue is pulled carefully in toward the center of the
eye and removed through the main incision. As mentioned
previously, great care must be taken to avoid disturbing the
underlying stroma, especially in cases of pseudophakic
bullous keratopathy in which this maneuver is more difficult
compared to Fuchs endothelial corneal dystrophy. It is of
utmost importance that the cohesive viscoelastic, if used, is
removed in its entirety prior to insertion of the graft.
s9000 Pupillary modulation
p0165 After the recipient EDM is removed, attention is directed
toward pupillary modulation to prepare the eye for graft
insertion. A small pupil is advantageous in DMEK surgery.
The iris serves to protect the graft from contact with the
intraocular lens implant, which can damage the endothe-
lium, or the crystalline lens in phakic DMEK cases, which
can be damaged by intraocular maneuvers. Prior to graft
injection, acetylcholine is injected into the anterior chamber
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to cause miosis. Gentle stroking of the iris surface with a
blunt instrument can also be used to augment the miotic
effect; however, this may predispose the patient towards
greater intraocular inflammation and development of cystoid
macular edema postoperatively. The authors recommend
against application of carbachol and pilocarpine as the
prolonged effect may encourage development of posterior
some have advocated for staged surgery only, and avoidance
of the triple procedure when visually significant cataracts are
present concurrently with endothelial decompensation.
For DMEK triple procedures, adequate visualization of the p0170
lens is necessary for the cataract surgery portion of the case.
The authors avoid preoperative NSAIDs and exclude dilating
agents from the irrigating solution as both prolong dilation.
Dilation for the cataract surgery portion of a DMEK triple
procedure can be achieved with intraocular epinephrine
alone, or with preoperative instillation of topical phenyleph-
rine 2.5% drops and a topical cycloplegic agent such as a
single drop of mydriacil 0.5%. The authors recommend
avoidance of more potent topical cycloplegic agents, as their
effects are not readily reversible.
There are several additional considerations when perform- p0175
ing DMEK surgery in conjunction with cataract surgery.
Following DMEK surgery there is a hyperopic shift, likely due
to deturgesence of the cornea. Ham et al. have reported a
hyperopic shift of 1/3 of a diopter on average.13 When select-
ing an IOL, the authors target mild myopia of −0.5 D to
−0.75 D to accommodate this shift and achieve a favorable
emmetropic or slightly myopic result in the majority of
patients. DMEK triple procedures can provide additional
challenges, especially early in the surgeon’s learning curve.
The intraocular lens is not fully stabilized just after insertion,
which can make the procedure challenging. A smaller cap-
sulorhexis can help keep the lens implant from prolapsing
and improve lens implant stability. In a highly myopic eye,
the anterior chamber will be considerably deeper after the
cataract portion of the case and can contribute to difficulty
unscrolling the graft tissue. In such cases, consideration may
be given to staging the surgery instead of a combined pro-
cedure. Additionally, it is possible to inadvertently fill the
entire capsular bag and anterior chamber with air or gas in
DMEK triple procedures. Should this occur, all of the air or
gas can be evacuated and replaced with BSS and a smaller
bubble left in the anterior chamber at the conclusion of
surgery. This situation can be best avoided by refilling the
eye with BSS prior to placing the final air or gas bubble.
Peripheral iridotomy s0035
Pupillary block is a reported complication of all types of p0180
endothelial keratoplasty.14,15 With DSEK surgery, pupillary
dilation is often employed to prevent pupillary block.16
However, with DMEK surgery, pupillary constriction is used
during surgery to prevent graft damage. Pupillary constric-
tion increases the risk of pupillary block from an air or gas
bubble in the anterior chamber. As pupillary dilation is not
desired during DMEK surgery, it is of great importance that
the recipient eye has a patent peripheral iridotomy. This can
be accomplished in many ways. The authors prefer to create
the peripheral iridotomy as inferior and peripheral on the
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patient’s iris as possible. This ensures that the peripheral
iridotomy will be uncovered by gas when the patient sits
upright. A peripheral iridotomy can be created preopera-
tively with a YAG laser, but it is critical to pass an instrument
through the PI intraoperatively to assure its patency. A
peripheral iridotomy may also be created at the time of
DMEK surgery. The authors prefer to bend the tip of a
30-gauge needle, then pass it through the pupil behind the
iris, and scratch down on top of the needle with a Sinskey
hook to establish an opening. The opening can be stretched
using a bimanual technique to assure its patency. For phakic
DMEK cases in which this maneuver cannot be performed,
a peripheral iridectomy can be created using a fine-toothed
forceps to grasp the peripheral iris through a fairly vertical
paracentesis incision, and Vannas scissors to resect the
peripheral iris tissue. It is important to ensure that the iri-
dectomy is full thickness. A risk of all intraoperative periph-
eral iridotomy techniques is bleeding. Techniques that use a
cohesive viscoelastic to maintain the anterior chamber can
be advantageous in this setting as this device can be used to
tamponade any bleeding that may occur during creation of
the peripheral iridotomy (Video 131.2).
s0040 Graft Orientation
p0185 When separated from the stromal surface, DMEK grafts typi-
cally scroll with the endothelial cell side facing outwards.
Correct graft orientation occurs when the curls of the scroll(s)
face the posterior stroma. Achieving correct orientation
before unfolding and inflating the anterior chamber is vital
for successful DMEK surgery. Depending on the characteris-
tics of the scroll and visibility through the host cornea,
this task can present several challenges. Several techniques
have been described to facilitate and confirm proper graft
orientation.
s0045 Orientation before insertion
p0190 Injecting a DMEK graft in the correct orientation is ideal and
should be attempted in all cases. Several steps can be taken
to aid in confirming graft orientation prior to injection.
Before loading into the desired injector, staining the graft
Correct side up
1 overlapping edges of a DMEK graft stained with trypan blue
2 2
2 2
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CHAPTER 131
Surgical Technique for DMEK
with trypan blue 0.06% (VisionBlue, Dutch Ophthalmic
USA, Exeter, NH) is essential to increase contrast and maxi-
mize visibility of the graft edges. The authors recommend
between 1 and 3 minutes of graft immersion in trypan blue
for adequate staining. When the stained graft is loaded into
an injector, a double or single scroll will form. In cases with
a double scroll, orientation can often be confirmed by direct
visual inspection and the graft should be injected with the
scrolls facing up (e.g. facing the posterior stroma). The ori-
entation of a single scroll is more difficult to ascertain, but
can be accomplished by observing the movement of the
overlapping areas of the scroll when rotating the tip. In the
correct position, the overlapping edges of the graft will be
on the top of the scroll and will appear to move in the same
direction as the tip is rotated (e.g. rotating the tip clockwise
will result in rightward movement of the overlapping area).
If the graft is upside down, the overlapping edges will move
in the opposite direction of the tip (e.g. rotating the tip
clockwise will result in leftward movement of the overlap-
ping area). After rotating the tip to position the graft in the
correct orientation, the tissue is injected into the anterior
chamber. This graft orientation technique was first described
by Peter Veldman, and named the “Veldman Venn” tech-
nique. The overlapping DMEK graft edges are similar in
appearance to a Venn diagram (Fig. 131.3).
Kruse et al. described creating three semicircular marks at p0195
the edge of the graft in an identifiable order.17 The marks are
created in succession with a small round punch blade, but
the distances between the marks vary. The order of the three
marks changes when looking from the corrected orientation
versus the inverted position. The loss of endothelial cells in
the marked areas and the potential increase in peripheral
detachments has limited its use.
Recently, eye banks have begun to place an S-stamp on p0200
the stromal side of Descemet membrane when preparing
DMEK tissue. Similar to the orientation markings made on
the stroma on DSAEK grafts, the stamp provides definitive
graft orientation regardless of scroll characteristics. The
S-stamp remains visible for days to weeks after being placed
at the eye bank. One concern is the loss of endothelial
cells with this technique from the markings itself and
the additional manipulation required by the ophthalmic
Fig. 131.3 Veldman Venn technique. The movement of the
Up side down
can be observed to determine orientation prior to insertion.
131-5
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PART ix Keratoplasty
Section 6 Endothelial Keratoplasty
technicians. A recent study conducted at the Devers Eye
Institute compared the rate of ECL in 19 patients who
received DMEK tissue with the S-stamp with 32 patients who
received a standard DMEK graft. At 6 months postopera-
tively, equivalent rates of ECL were found in both groups.18
The initial studies are promising for its safety and efficacy
compared to previous methods of ascertaining graft orienta-
tion. Use of the S-stamp is increasing among surgeons and
eye banks throughout the US.
s0050 Orientation after insertion
p0205 When the graft is injected into the anterior chamber, graft
orientation can change and can be difficult to assess. An
edematous host cornea or a poorly stained graft can further
impede visualizing graft orientation.
p0210 A technique using a cannula in the lumen of a double
scroll to confirm graft orientation has been described.19,20
When the graft is oriented correctly with the scrolls facing
up, the tip of the cannula will appear blue when moved
towards the scroll edge because of the overlying stained
graft. If the graft is positioned upside down (e.g. scrolls
facing down), the tip of the cannula will not change
color when moved to the edge of the scroll. Coined the
Moutsouris sign, this technique is useful, but can also
cause cell loss with inadvertent touch of the cannula to the
endothelium (Fig. 131.4).
p0215 Several no-touch techniques have been described to detect
graft orientation. Burkhart described using a handheld slit
lamp to enhance visualization of the scrolls.21 When the slit
beam is placed over a correctly oriented double scroll (e.g.
scrolls facing up), two adjacent arcs can be seen (two scrolls)
with a distant slit beam connecting the two arcs. If the graft
is inverted, only one continuous beam is noted. Agarwal
et al. described the use of an endoilluminator or light probe
to aid in graft orientation.22 Typically used in retinal cases,
a 20-, 23-, or 25-gauge light probe is placed obliquely on the
corneal epithelium to enhance visualization. The probe is
f0025
Fig. 131.4 Moutouris sign. The instrument is placed on top of the graft
and moved side to side. If it disappears under a scroll and looks blue
(as in the picture above), correct graft orientation has been confirmed.
(Courtesy of Mark A. Terry, MD.)
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rotated around the limbus and gentle tapping of the cornea
is performed. The operating microscope light is turned down
or completely off. The dynamics of the graft is observed and
light reflexes from graft folds and edges provide information
to assess graft orientation. This technique is particularly
useful in edematous corneas.
The use of intraoperative optical coherence tomography p0220
(iOCT) during DMEK surgery is increasing in popularity.23
Handheld devices and integrating the OCT into the opera-
tive microscope have been described. High-resolution images
from iOCT provide very accurate and detailed information
about graft positioning (Fig. 131.5). In addition, iOCT can
be used to evaluate graft attachment to the posterior stroma.
While the cost of iOCT is prohibitive in most settings, its
accuracy in ascertaining graft orientation and versatility
in obtaining real-time details about graft position and
attachment makes it a unique and useful adjunct for DMEK
surgeons.
Changing orientation after insertion s0055
If a graft is inverted after insertion, several steps can be used p0225
to flip the tissue back to its correct orientation. First, fill the
anterior chamber with BSS. This deepening of the anterior
chamber will provide space for the graft to rotate. Next,
move the graft toward the center of the pupil with gentle
tapping (See Unscrolling and centering section). Finally,
through a paracentesis site, use a burst of BSS to create an
internal fluid wave to rotate the graft in the desired direc-
tion. For example, if the graft is oriented on its side akin to
the letter “C”, a burst of fluid towards the superior aspect
of the “C” will cause the superior edge to move in the
direction of the fluid wave and the graft will subsequently
rotate counterclockwise. While this technique can be used
with the graft near the angle, centering the graft and deepen-
ing the anterior chamber can facilitate this technique.
Unscrolling and Centering s0060
After achieving proper orientation of the DMEK graft, the p0230
surgeon can proceed with a set of unfolding and centering
maneuvers to unscroll and position the graft tissue with the
endothelium facing the iris, in correct anatomical conforma-
tion. Just as obtaining the correct graft orientation is essential
to preventing graft detachment, unscrolling and centering
the graft using prescribed techniques are essential to mini-
mize postoperative stromal edema due to endothelial cell
traumatization during surgery, graft decentration, or both.
Generally, unfolding of the graft is achieved with the p0235
assistance of BSS, an air bubble, or a deliberately shallowed
anterior chamber. All three approaches manipulate the effec-
tive force of fluid (liquid or gas) within the unscrolled graft
tissue, and result in the application of force perpendicular
to the DM surface of the unscrolled graft to open up the graft
leaflets. This principle also governs the efficacy of corneal
tapping and stroking maneuvers – external compression
forces applied to the anterior corneal surface with a cannula
– that virtually all DMEK surgeons use at some point during
surgery to assist with graft unfolding. Each approach aims
to eliminate direct contact between the graft tissue and
metal instrumentation to minimize donor endothelial cell
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CHAPTER 131
Surgical Technique for DMEK

A B

C D
f0030
Fig. 131.5 Intraoperative OCT. While the surgeon’s view is similar in both photos on the left, iOCT reveals that the graft in the top photo is upside
down (scrolls down), while the bottom is in the correct orientation (scrolls up).

damage. Additionally, a shallow chamber frequently is
helpful during the unfolding process, as reduced force
outside the graft leaflets will encourage the graft to unfold
and the reduced chamber area will help prevent the graft
from rescrolling. These basic principles provide a conceptual
foundation for the various approaches to unfolding the
DMEK graft practiced by surgeons at major DMEK centers
(Fig. 131.6).
s0065 Fluid assisted unscrolling
p0240 Short bursts of BSS from a 30-gauge cannula on a syringe
can be used to open the graft scrolls. With the graft posi-
tioned so a cannula tip can be placed within or aimed at
the edge of the scrolled graft, irrigation is applied to the
scrolled portion(s) of the graft to unfold its leaflets. During
this process, a shallow anterior chamber can be helpful in
keeping the newly unfurled edges of the DMEK graft from
rescrolling.
Güell et al. have described a systematic approach using p0245
BSS fluid to unfold the donor graft.24 In their technique, a
Gills cannula is connected to an automated irrigation-
aspiration system (Constellation, Alcon Laboratories Inc.,
Fort Worth, Texas). The instrument tip is introduced through
the main incision after suturing it closed. Continuous irriga-
tion is set high at 60–100 mmHg, but the actual fluid pres-
sure is much lower due to the small caliber of the Gills
cannula. Low-pressure irrigation flow is used both to center
the graft scroll, and to unfold the leaflets. As described
above, the instrument tip is placed within the overlapping
graft leaflets, and the irrigation is applied from within the
scrolled graft to open the leaflets. As grafts from younger
donors are more tightly scrolled and unfolding generally is
more difficult in this setting, higher flow pressures can be
required. This technique can be combined with injection of
an air bubble within the scroll prior to complete unfolding,
or with gentle cannula-assisted compression of the anterior
corneal surface while low-flow irrigation is applied.

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PART ix Keratoplasty

Section 6 Endothelial Keratoplasty

A B C

D E F

G H I
f0035
Fig. 131.6 Unfolding and centering a DMEK graft using corneal tapping assisted by a shallow anterior chamber. (A) The graft is positioned in proper
orientation, with overlapping edges facing upward. (B, C) The graft is unfolded by tapping on the anterior corneal surface with a 30-gauge cannula.
(D–G) The graft is centered, prior to complete unscrolling of the graft, by tapping on the limbus and/or peripheral cornea. (H) Additional corneal taps
are used to unfurl the peripheral edges. (I) The DMEK graft is fully unscrolled and properly centered. (Courtesy of the University of Iowa.)

s0070 Bubble-assisted unscrolling
p0250 Small volumes of air from a 30-gauge cannula on a 1 mL
syringe can also be used to open the graft. Although this can
be achieved in several ways, fundamentally, air is injected
either above the graft or below the graft to facilitate its
unfolding. In the technique described by Price et al., after
the edges of the graft are partially unscrolled with irrigating
jets of BSS, a small volume of air can be placed underneath
the graft, floating it upward so that the Descemet surface is
apposed to the recipient stroma. An initial air bubble of
approximately 0.02 mL or less injected beneath the graft is
used to secure its orientation, yet is small enough to allow
the graft to continue to be unfolded and moved as needed
for proper centering. BSS can be injected into the interface
between the Descemet surface of the graft and the recipient
stroma, as needed, to help center and fully unscroll the
donor tissue. Subsequently, a cannula can be used to stroke
or tap the anterior corneal surface to help unfolding the
graft edges.25 Again, as noted with fluid-assisted maneuvers,
a shallow anterior chamber during bubble-assisted unscroll-
ing is helpful in keeping the edges of DMEK graft from
recurling.
Tight scrolls can present several challenges and the use of p0255
air can facilitate atraumatic unscrolling in these cases. The
tight scroll can be positioned so a cannula tip can be placed

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within the lumen of the scrolled DMEK graft. A small air
bubble is then delivered within the scroll(s) such that the
bubble will be on top of the Descemet surface of the graft
during the unscrolling process.20 Alternately, as long as the
graft is positioned with the scroll(s) facing upward, a small
air bubble can be placed on top of the graft tissue, so that
with external application of a cannula it becomes trapped
with the scrolled graft. External taps are used to begin the
unscrolling process. Then, external strokes on the anterior
corneal surface are used to direct the bubble to unfold the
graft. As the bubble is pushed along the DM toward a curled
edge of the graft, that edge becomes unscrolled. The air
bubble is enlarged subsequently as needed to help facilitate
graft unscrolling, until the central endothelium of the DMEK
graft is flattened over the iris surface. Once unscrolling is
complete, the bubble on top of the graft is evacuated, and
the graft can be recentered as needed using corneal taps on
the peripheral cornea, limbus, or anterior sclera if needed.
Of note, as described by Kruse, an air bubble can be preloaded
in the scrolled DMEK graft and the tissue is then injected
with the “bubble in the roll” to facilitate unscrolling.
p0260 In the event a small edge is not unfolded completely, it
is possible to utilize an air bubble equal to or smaller than
the graft diameter to maintain the graft’s position while
unfolding the curled graft edge. Termed “bubble bumping,”
the folded edge is submerged in BSS, while the anterior
corneal surface overlying the folded edge is tapped with a
cannula.25 Grasping the limbus with a 0.12 forceps and rotat-
ing the eye toward the unscrolled edge, to ensure its complete
submersion in fluid, can be helpful.
s0075 Chamber assisted unscrolling
p0265 Tapping on the anterior cornea of an eye with a very shallow
anterior chamber can also be used to open the DMEK graft.
Neither irrigation with BSS nor injections of air are used to
assist with unfolding the graft in this technique, first
described by Yoeruek et al.26 After confirming the graft’s
orientation and releasing aqueous from the paracentesis
incisions, a 30-gauge cannula is used to tap on the anterior
corneal surface to unfold the graft. Whether the graft leaflets
are overlapping (single scroll) or nonoverlapping (double
scroll), typically the initial corneal taps are applied centrally
with the long axis of the cannula parallel to the long axis of
the graft. Corneal tapping increases the pressure of fluid
trapped within the unscrolled graft tissue, and redirects the
fluid force perpendicular to the Descemet surface within the
unscrolled leaflet(s) to open them. Once one leaflet is
opened, a bimanual technique can be used, wherein one
cannula applies pressure over the unscrolled graft and
another cannula is used to tap the anterior cornea to unfold
the curled graft edge. In order to recenter the graft (whether
fully or partially unfolded) during the process, a 30-gauge
cannula is used to tap the limbus or stroke the peripheral
cornea, usually toward the desired location. External maneu-
vers have greater effect, and result in greater graft movement,
in a shallow chamber than a fully formed chamber.
p0270 This chamber assisted unscrolling technique requires
that the anterior chamber is sufficiently shallow to prevent
rescrolling of the tissue. In order to maintain a shallow
chamber during the unscrolling process, fluid is released or
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CHAPTER 131
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aspirated from the paracentesis incisions as often as needed.
Additionally, if needed, pressure can be applied at the
equator of the globe using a digit or a larger-bore cannula
to displace the lens–iris diaphragm anteriorly and shallow
the chamber further.
Centering and centration s9005
Surgeons may need to recenter the graft several times prior p0275
to injecting the final air bubble. This centration can
be accomplished whether the graft is fully or partially
unscrolled, as long as a layer of fluid is bathing both sides
of the graft. In the bubble-assisted techniques, BSS first is
injected into the anterior chamber, either into the interface
between the recipient stroma and DM (if the bubble is
beneath the graft) or beneath the graft to make it float up
(if the bubble is on top of the graft). Reducing the volume
of the air bubble may achieve the same effect. Then, the graft
is reposition by tapping or stroking gently on the anterior
corneal surface, the limbus, or the anterior sclera with a
cannula, tapping or swiping the graft toward the desired
location. In addition, slow limbal indentation followed by a
rapid release of the indentation can be very effective in
moving a graft towards the direction of the cannula. For
example, if a graft is nasally displaced, indenting the tem-
poral limbus will deepen the chamber nasally. A quick release
of this indentation will result in an internal fluid wave
traveling temporally that will reposition the graft in the
desired temporal direction. As noted above, a shallow
chamber will accentuate the effect of external compression
forces and result in greater graft movement compared to a
deep anterior chamber.
It is ideal for the final graft position to be centered within p0280
the area of stripped DM on the recipient cornea. Tourtas
et al. have shown that the absence of overlap between the
DMEK graft and host Descemet membrane correlates with
reduced edge detachments and lower rebubble rates.27
Regardless of the surgeon’s strategy for sizing the graft and
performing the descemetorhexis, it may be of particular
importance to minimize edge overlap at the inferior quad-
rant, as this edge is least protected by air or gas tamponade
in the early postoperative period. Conversely, gaps of uncov-
ered recipient stroma between a slightly decentered graft and
host DM are more acceptable. Such gaps will result in stromal
edema that will generally subside, as donor endothelium
and/or recipient endothelial cells migrate to repopulate the
uncovered stroma.28 As long as the central cornea is covered,
slight decentration of a DMEK graft does not seem to impact
the final visual outcome.
Graft Tamponade With Air or Sulfur s0080
Hexafluoride 20%
Immediately after unscrolling and positioning the DMEK p0285
graft, a bubble of air or sulfur hexafluoride 20% is placed in
the anterior chamber. The purpose of the bubble is to main-
tain apposition of the graft tissue with the posterior stroma
of the host, while the pump function recovers and the graft
can maintain its adherence in aqueous humor. A variety of
technical considerations to avoid complications of air or gas
131-9
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PART ix Keratoplasty

Section 6 Endothelial Keratoplasty

A B C

D E F
f0040
Fig. 131.7 Graft tamponade with air or sulfur hexafluoride 20%. After the 30-G cannula tip is centered beneath the graft, a slow, controlled inflation of
the anterior chamber is performed. Rapid inflation or inflating prior to centering the cannula tip can move and dislodge the graft. (Courtesy of the
University of Iowa.)

tamponade, chiefly pupillary block, are employed during
and sometimes before surgery.
p0290 To instill the air or gas bubble once the graft is unscrolled,
the surgeon slides a small bore cannula or needle (typically
30-gauge) along the anterior iris beneath the graft tissue. The
chamber volume typically is low at this point. Once the
cannula tip is centered beneath the graft in the pupillary
axis, the surgeon inflates the anterior chamber. The initial
bubble can be small or large, depending on the surgeon’s
needs. Ultimately, once the graft is positioned, the bubble is
enlarged to occupy nearly the entire anterior chamber (Fig.
131.7). Some surgeons will insufflate the chamber to a higher
intraocular pressure and use a second instrument to com-
press the cornea externally and evacuate any fluid trapped
between the thin DMEK graft and the recipient corneal
stroma. After a period of time, typically 10 minutes, the
bubble is reduced to 80–90% of the anterior chamber volume
so that it encompasses the entire graft.
p0295 The primary complication of air or gas tamponade is
pupillary block. Pupillary block can occur when the anterior
chamber is overfilled with air or gas and causes impedance
of aqueous flow from the posterior chamber across the pupil-
lary margin and into the anterior chamber. To prevent this
potentially blinding complication, a peripheral iridotomy in
the inferior iris is created prior to insertion of the graft,
either intraoperatively or preoperatively (see section on host
preparation). Care should be taken to ensure that a cuff of
aqueous is present in the peripheral anterior chamber that
encompasses the peripheral iridotomy at the end of surgery.
This will ensure free communication of fluid across the
peripheral iris. The surgeon should also attend to the cre-
ation of a sufficiently large iridotomy to maintain patency;
stretching the peripheral iris with blunt instruments such
as Sinskey and/or reverse Sinskey hooks can be helpful.
Some surgeons will utilize topical dilating drops (phenyleph-
rine 2.5% and cyclopentolate 1%) intraoperatively, typically
after the graft is unscrolled and centered, to dilate the
pupil and minimize the risk of developing pupillary block.
Additionally, some surgeons perform a gas-fluid exchange
after the initial period of tamponade, prior to placement of
the final bubble, to ensure no air or gas is trapped behind
the iris.
DMEK detachment s0085
Graft detachment is the most frequent complication of p0300
DMEK and remains a challenge for surgeons performing
and considering adoption of this surgical technique. Reports
from surgeons early in their surgical experience with DMEK
indicate there is a high rate of graft dislocations requiring
reinjection of air to support the graft (a “rebubble” procedure),
ranging from 20% to 82%.29–32 As surgeons gain experience
the graft detachment drops, ranging from 4.4% to 14% after
passage of a “learning curve” period.30,33,34 This complication
has prompted surgeons to make additional modifications
to initial graft tamponade strategies. For example, Dapena

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et al. attribute their reduced graft dislocation rate, in part,
to an increase in the duration of complete air fill postop-
eratively, from 30 minutes to 45–60 minutes.30 However,
it is important to note that the centers most experienced
with DMEK have used room air as the tamponade agent. In
order to reduce the risk of graft detachment and need for
rebubble procedures, other centers have adopted the use of
sulfur hexafluoride (SF6) at a 20% concentration, rather than
room air, to increase the duration of the bubble and graft
tamponade in the early postoperative period. Detachments
after DMEK tend to start with lifting of a graft edge – often
the inferior edge – and can be observed as early as the first
postoperative day. Because edge lifts can progress over days
to weeks to a complete dislocation of the graft, increasing
the duration of the anterior chamber bubble in the early
postoperative period is advantageous.
p0305 Longer lasting gases have been attractive alternatives to
air to support and achieve tissue tamponade. SF6, first syn-
thesized in 1902, is an inert, inorganic, water-insoluble gas
first described in the ophthalmic literature for use in retinal
detachment repair by Norton in 1973.35 It is used routinely
in modern retinal detachment and macular hole surgeries.36
Vitreoretinal surgeons successfully utilize SF6 at a non-
expansile concentration of 20%,37 which effectively doubles
the period of postoperative tamponade compared to air in
vitreoretinal surgery.38 SF6 was first described for use in
anterior segment surgery in 1987, in the repair of Descemet
detachments after cataract surgery, and has since been
reported on extensively for this indication.39,40 SF6 has also
been described for the treatment of acute hydrops in kera-
toconus as well as complex DSAEK surgery. Most recently,
Güell et al. have reported on the use of SF6 20% for the initial
graft tamponade in their initial series of 15 cases of DMEK.
They report good resultant corneal clarity, mean ECL com-
parable to other groups, and rate of rebubble of 6.6%.24 The
authors routinely use SF6 20% as the initial agent to achieve
graft tamponade, with similar results as reported by Güell.
When the anterior chamber is filled to 80–90%, an air bubble
lasts approximately 3–5 days, while a SF6 20% bubble lasts
approximately 6–10 days. It is vital that a concentration
greater than 20% is not used as this will result in an expansile
gas that can lead to pupillary block despite placement of a
peripheral iridotomy.
p0310 SF6 has been shown to be nontoxic by inhalation in rats,
mice, guinea pigs, rabbits, and humans, and nontoxic in the
intraperitoneal cavity of humans.41–43 Clinically and histo-
logically, the effects of air and sulfur hexafluoride on the
corneal endothelium have been under investigation since
the 1970s. Histological analyses of corneal endothelium in
rabbit and cat models have demonstrated that both air and
SF6 cause ultrastructural damage and ECL.44,45 In Van Horn
et al.’s landmark investigation of the in vivo effects of air
and sulfur hexafluoride on rabbit corneal endothelium, both
air and SF6 were shown to cause proliferation of rabbit
endothelium. SF6 did not appear to have any specific toxic
effect on the corneal endothelium when compared with
air.46 These results appear to be as valid in a cat model – a
species, like humans, without regenerative endothelium – as
shown by Foulks.47 Of note, in an updated investigation of
the effects of SF6 20% compared to air in cats, greater ECL
was noted in the group exposed to SF6 20% compared to air,
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especially in the superior corneal endothelium. That study
could not control for positioning, and unlike in humans,
both air and SF6 exposed groups demonstrated substantial
intraocular inflammation beginning on day 1.48 Taken alto-
gether, the literature suggests that SF6 appears to be as toxic
to the corneal endothelium as air, and that sequestration of
the corneal endothelium from nutrients in aqueous likely
contributes to cell damage and cell loss.47 Repositioning and
normal patient movement should help ensure that the
corneal endothelium is exposed to aqueous and mitigate
possible damage.
Positioning strategies to maintain support of the air or gas p0315
tamponade in the postoperative period vary substantially. A
common practice is for the patient to be instructed to main-
tain a supine position for 45 to 60 minutes after surgery in
the postoperative unit. Some surgeons will recheck the
patient at that time to ensure appropriate intraocular pres-
sure and perform an air-fluid exchange routinely or as
needed.49,50 The authors currently keep the patient’s eye
shielded and do not examine the patient until the first
postoperative visit the following day. Patients are often
instructed to maintain supine positioning for some time
postoperatively, ranging from as little as 24 hours postopera-
tively to as much as every 2 hours for up to 1 week postop-
eratively, with practices again varying from surgeon to
surgeon. The postoperative positioning regimen described
by Güell – in which patients are asked to position their head
in various positions for 15 minute intervals while awake for
the first week postoperatively – demonstrates the concept of
using the bubble to tamponade the entirety of the graft
surface.51 While the bubble is still present in the anterior
chamber, should an edge lift present, the patient’s head can
be positioned such that the bubble can be directed toward
the area of concern (e.g. with the head hanging backward
slightly to tamponade an inferior edge lift).
References
1. Kim EC, Bonfadini G, Todd L, et al. Simple, inexpensive, and effective
injector for Descemet membrane endothelial keratoplasty. Cornea 2014;
33(6):649–52.
2. Kruse FE, Laaser K, Cursiefen C, et al. A stepwise approach to donor
preparation and insertion increases safety and outcome of Descemet
membrane endothelial keratoplasty. Cornea 2011;30(5):580–7.
3. Gorovoy IR, Gorovoy MS. Descemet membrane endothelial keratoplasty
postoperative year 1 endothelial cell counts. Am J Ophthalmol 2015;
159(3):597–600, e592.
4. Price MO, Price FW Jr. Descemet’s membrane endothelial keratoplasty
surgery: update on the evidence and hurdles to acceptance. Curr Opin
Ophthalmol 2013;24(4):329–35.
5. Nieuwendaal CP, Lapid-Gortzak R, van der Meulen IJ, et al. Posterior
lamellar keratoplasty using descemetorhexis and organ-cultured donor
corneal tissue (Melles technique). Cornea 2006;25(8):933–6.
6. Feng MT, Price MO, Price FW Jr. Update on Descemet membrane endo-
thelial keratoplasty (DMEK). Int Ophthalmol Clin 2013;53(2):31–45.
7. Dapena I, Moutsouris K, Droutsas K, et al. Standardized “no-touch”
technique for Descemet membrane endothelial keratoplasty. Arch Oph-
thalmol 2011;129(1):88–94.
8. Arnalich-Montiel F, Munoz-Negrete FJ, De Miguel MP. Double port injec-
tor device to reduce endothelial damage in DMEK. Eye (Lond) 2014;
28(6):748–51.
9. Ham L, van Luijk C, Dapena I, et al. Endothelial cell density after Des-
cemet membrane endothelial keratoplasty: 1- to 2-year follow-up. Am J
Ophthalmol 2009;148(4):521–7.
10. Kruse FE, Schrehardt US, Tourtas T. Optimizing outcomes with Descemet’s
membrane endothelial keratoplasty. Curr Opin Ophthalmol 2014;25(4):
325–34.
131-11
8/23/2016 4:34:30 PM
To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s), editor(s), reviewer(s), Elsevier and
typesetter Toppan Best-set. It is not allowed to publish this proof online or in print. This proof copy is the copyright property of the publisher and is confidential until formal publication.
PART ix Keratoplasty
Section 6 Endothelial Keratoplasty
11. Jacobi C, Zhivov A, Korbmacher J, et al. Evidence of endothelial cell
migration after Descemet membrane endothelial keratoplasty. Am J
Ophthalmol 2011;152(4):537–42, e532.
12. Nieuwendaal CP, Lapid-Gortzak R, van der Meulen IJ, et al. Posterior
lamellar keratoplasty using descemetorhexis and organ-cultured donor
corneal tissue (Melles technique). Cornea 2006;25(8):933–6.
13. Ham L, Dapena I, Moutsouris K, et al. Refractive change and stability
after Descemet membrane endothelial keratoplasty. Effect of corneal
dehydration-induced hyperopic shift on intraocular lens power calcula-
tion. J Cataract Refract Surg 2011;37(8):1455–64.
14. Maier AK, Gundlach E, Gonnermann J, et al. Retrospective contralateral
study comparing Descemet membrane endothelial keratoplasty with
Descemet stripping automated endothelial keratoplasty. Eye (Lond) 2015;
29(3):327–32.
15. Suh LH, Yoo SH, Deobhakta A, et al. Complications of Descemet’s strip-
ping with automated endothelial keratoplasty: survey of 118 eyes at one
Institute. Ophthalmology 2008;115(9):1517–24.
16. Terry MA, Shamie N, Chen ES, et al. Endothelial keratoplasty a simplified
technique to minimize graft dislocation, iatrogenic graft failure, and
pupillary block. Ophthalmology 2008;115(7):1179–86.
17. Bachmann BO, Laaser K, Kruse FE, et al. A method to confirm correct
orientation of Descemet membrane during Descemet membrane endo-
thelial keratoplasty. Am J Ophthalmol 2010;149:922–5.
18. Veldman PB, Mayko Z, Straiko MD, et al. Descemet membrane endothe-
lial keratoplasty: early complications and 6-month endothelial cell loss
in a comparative series of unstamped and stromal sided S-stamped tissue
in 101 consecutive cases. Paper presented at: AAO Annual Meeting;
October 19, 2014; Chicago, IL.
19. Liarakos VS, Dapena I, Melles GRJ, et al. Intraocular graft unfolding
techniques in Descemet membrane endothelial keratoplasty. JAMA
Ophthalmol 2013;131:29–35.
20. Dapena I, Moutsouris K, Melles GR, et al. Standardized “no-touch”
technique for Descemet membrane endothelial keratoplasty. Arch Oph-
thalmol 2011;129(1):88–94.
21. Burkhart ZN, Feng MT, Price FW, et al. Handheld slit beam techniques
to facilitate DMEK and DALK. Cornea 2013;32:722–4.
22. Jacob S, Agarwal A, Agarwal A, et al. Endoilluminator-assisted transcor-
neal illumination for Descemet membrane endothelial keratoplasty:
enhanced intraoperative visualization of the graft in corneal decompen-
sation secondary to pseudophakic bullous keratopathy. J Cataract Refract
Surg 2014;40(8):1332–6.
23. Steven P, Le Blanc C, Velten K, et al. Optimizing Descemet membrane
endothelial keratoplasty using intraoperative optical coherence tomog-
raphy. JAMA Ophthalmol 2013;131:1135–42.
24. Güell JL, Morral M, Gris O, et al. Bimanual technique for insertion and
positioning of endothelium-Descemet membrane graft in Descemet
membrane endothelial keratoplasty. Cornea 2013;32(12):1521–6.
25. Price MO, Giebel AW, Price FW Jr, et al. Descemet’s membrane endo-
thelial keratoplasty: prospective multicenter study of visual and refrac-
tive outcomes and endothelial survival. Ophthalmology 2009;116(12):
2361–8.
26. Yoeruek E, Bayyoud T, Hofmann J, et al. Novel maneuver facilitating
Descemet membrane unfolding in the anterior chamber. Cornea 2013;
32(3):370–3.
27. Tourtas T, Schlomberg J, Kruse FE, et al. Graft adhesion in Descemet
membrane endothelial keratoplasty dependent on size of removal of
host’s descemet membrane. JAMA Ophthalmol 2014;132(2):155–61.
28. Jacobi C, Zhivov A, Kruse FE, et al. Evidence of endothelial cell migration
after Descemet membrane endothelial keratoplasty. Am J Ophthalmol
2011;152(4):537–42.
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29. Ham L, Dapena I, van Luijk C, et al. Descemet membrane endothelial
keratoplasty (DMEK) for Fuchs endothelial dystrophy: review of the first
50 consecutive cases. Eye (Lond) 2009;23:1990–8.
30. Dapena I, Ham L, Droutsas K, et al. Learning curve in Descemet’s mem-
brane endothelial keratoplasty: first series of 135 consecutive cases.
Ophthalmology 2011;118:2147–54.
31. Price MO, Giebel AW, Fairchild KM, et al. Descemet membrane endothe-
lial keratoplasty: prospective multicenter study of visual and refractive
outcomes and endothelial survival. Ophthalmology 2009;116:2361–8.
32. Tourtas T, Laaser K, Bachmann BO, et al. Descemet’s membrane endothe-
lial keratoplasty versus Descemet stripping automated endothelil kerato-
plasty. Am J Ophthalmol 2012;153:1082–467.
33. Dirisamer M, Ham L, Dapena I, et al. Efficacy of Descemet membrane
endothelial keratoplasty; clinical outcome of 200 consecutive cases after
a learning curve of 25 cases. Arch Ophthalmol 2011;129:1435–43.
34. Feng MT, Price MO, Price FW. Update on Descemet membrane endothe-
lial keratoplasty (DMEK). Int Ophthalmol Clin 2013;53:31–45.
35. Norton EWD. Intraocular gas in the management of selected retinal
detachments. Trans Am Acad Ophthalmol Otolaryngol 1973;77:OP85–98.
36. Km SS, Smiddy WE, Feuer WJ, et al. Outcomes of sulfur hexafluoride
(SF6) versus perfluropropane (C3F8) gas tamponade for macular hole
surgery. Retina 2008;28:1408–15.
37. Abrams GW, Edelhauser HF, Aaberg TM, et al. Dynamics of intravitreal
sulfur hexafluoride gas. Invest Ophthalmol Vis Sci 1974;13(11):863–8.
38. Thompson JT. Kinetics of intraocular gases. Disappearance of air, sulfur
hexafluoride, and perfluoropropane after pars plana vitrectomy. Arch
Ophthalmol 1989;107(5):687–91.
39. Gault JA, Raber IM. Repair of Descemet’s membrane detachment with
intracameral injection of 20% sulfur hexafluoride gas. Cornea 1996;15(5):
483–9.
40. Zusman NB, Waring GO, Najarian LV, et al. Sulfur hexafluoride gas in the
repair of intractable descemet’s membrane detachment. Am J Ophthalmol
1987;104:660.
41. Greenberg LA, Lester D. The toxicity of sulfur hexafluoride. Arch Ind Hyg
Occup Med 1950;2:348–9.
42. Swalbach WS, Schwarz SI, Rhan W, et al. Use of a new gas, sulfur hexa-
flouride, SF6, in pneumoperitoneum. Am Rev Tuberc 1957;76:1063–70.
43. Specht H, Brubach HF. Inhalation of sulfar hexafluoride. Science 1951;
114(2973):662–3.
44. Leibowitz H, Laing R. Corneal endothelium: The effect of air in the
anterior chamber. Arch Ophthalmol 1974;92(3):227–30.
45. Olsen RJ. Air and the corneal endothelium: an in vivo specular microscopy
study in cats. Arch Ophthalmol 1980;98(7):1283–4.
46. Van Horn DL, Edelhauser HF, Aaberg TM, et al. In vivo effects of air and
sulfur hexafluoride gas on rabbit corneal endothelium. Invest Ophthalmol
Vis Sci 1972;11:1028–36.
47. Foulks GN, de Juan E, Hatchell DN, et al. The effect of perfluoropro-
pane on the cornea in rabbits and cats. Arch Ophthalmol 1987;105:
256–9.
48. Landry H, Aminian A, Hoffart L, et al. Corneal endothelial toxicity of air
and SF6. Invest Ophthalmol Vis Sci 2011;52(5):2279–86.
49. Dirisamer M, van Dijk K, Dapena I, et al. Prevention and management
of graft detachment in Descemet membrane endothelial keratoplasty.
Arch Ophthalmol 2012;130(3):280–91.
50. Guerra FP, Anshu A, Price MO, et al. Descemet’s membrane endothelial
keratoplasty: prospective study of 1-year visual outcomes, graft survival,
and endothelial cell loss. Ophthalmology 2011;118(12):2368–73.
51. Güell JL, Morral M, Gris O, et al. Bimanual technique for insertion and
positioning of endothelium–Descemet membrane graft in Descemet
membrane endothelial keratoplasty. Cornea 2013;32(12):1521–6.
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