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Standardized DMEK Technique

Reducing Complications Using Prestripped Tissue, Novel Glass Injector, and Sulfur Hexafluoride (SF6) Gas

Terry, Mark A. MD; Straiko, Michael D. MD; Veldman, Peter B. MD; Talajic, Julia C. MD; VanZyl, Cor FC Ophth(SA); Sales, Christopher S. MD; Mayko, Zachary M. MS

doi: 10.1097/ICO.0000000000000479
Clinical Science

Purpose: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

*Cornea Service, Devers Eye Institute, Portland, OR; and

Lions VisionGift, Portland, OR.

Reprints: Mark A. Terry, MD, Devers Eye Institute, 1040 NW 22nd Ave, Portland, OR 97210 (e-mail:

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

This article discusses the off-label use of SF6 gas, a modified glass Jones tube, and trypan blue solution.

Received March 01, 2015

Received in revised form March 20, 2015

Accepted April 07, 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.