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

Güell, Jose L. MD, PhD*,†,‡; Morral, Merce MD, PhD†,§,¶; Gris, Oscar MD, PhD; Elies, Daniel MD; Manero, Felicidad MD

doi: 10.1097/ICO.0b013e3182933aee
Clinical Science

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.

Author Information

*The Cornea and Refractive Surgery Unit and

Cornea and Refractive Surgery Unit, Instituto de Microcirugia Ocular, Barcelona, Spain;

Department of Ophthalmology, Universitat Autonoma de Barcelona, Barcelona, Spain;

Departments of §Cornea and Anterior Segment Diseases and

Refractive Surgery, Institut Clinic d’Oftalmologia, Hospital Clinic i Provincial, Barcelona, Spain.

Reprints: Jose Luis Güell, Instituto de Microcirugia Ocular (IMO), c/Josep Maria Llado 3, Barcelona 08035, Spain (e-mail:

The authors have no funding or conflicts of interest to disclose.

Received December 24, 2012

Accepted March 20, 2013

© 2013 by Lippincott Williams & Wilkins.