Bimanual Technique for Insertion and Positioning of Endothelium-Descemet Membrane Graft in Descemet Membrane Endothelial Keratoplasty

Purpose:To describe a new bimanual technique for insertion and positioning of endothelium-Descemet membrane (EDM) grafts in Descemet membrane endothelial keratoplasty (DMEK).Methods:Prospective, noncomparative, consecutive interventional case series, including 15 pseudophakic eyes of 15 patients treated with DMEK at the Instituto de Microcirugia Ocular, Barcelona, Spain. A bimanual infusion technique was used to introduce and position donor's EDM. Partial tamponade was achieved with 20% sulfur hexafluoride (SF6). Intraocular manipulation time of EDM grafts, rebubbling rate, and endothelial cell density were evaluated.Results:Six months postoperatively, mean uncorrected visual acuity and best spectacle-corrected visual acuity (BSCVA) improved from 20/100 to 20/50 and from 20/80 to 20/25, respectively (P < 0.001). Six eyes (40%) had 20/20 BSCVA, and 13 (86%) eyes had 20/30 BSCVA. Mean donor cell density decreased from 2690 302 to 1998 +/- 621 cells per square millimeter, representing a mean cell loss of 26% +/- 20%. EDM was stripped successfully in all cases. Mean intraocular manipulation time of donor's EDM (interval between main incision closure and final EDM positioning) was 4.10 +/- 0.5 minutes. Intracameral air reinjection was needed in 1 case (6.6%) with a partial peripheral graft detachment. No episodes of immunologic graft rejection were documented.Conclusions:Insertion and positioning of EDM grafts in DMEK was successfully achieved using this bimanual infusion technique and 20% SF6 partial tamponade, with a low intraocular manipulation time and very low postoperative rebubbling rates, regardless of the preservation method and the donor's age. However, prospective comparative studies are required to demonstrate the long-term safety compared with other approaches.