Contact lens-assisted pull-through technique for delivery of tri-folded (endothelium in) DMEK grafts minimizes surgical time and cell loss

Purpose To evaluate the feasibility and outcomes of contact lens-assisted bimanual pull-through delivery of Descemet membrane endothelial keratoplasty (DMEK) tissue trifolded with the endothelium inward. Design Prospective, noncomparative, interventional case series. Participants Forty-two consecutive eyes of 42 patients with Fuchs endothelial dystrophy with or without cataract. Intervention Standardized DMEK was performed as a single procedure (n = 9) or in combination with phacoemulsification and implantation of a posterior chamber intraocular lens (n = 33) using prestripped donor tissue punched to a diameter of 8.25 mm and then trifolded with the endothelium in. Using a sterile soft contact lens as scaffold, the tissue was loaded in this configuration into a disposable cartridge and delivered into the anterior chamber under continuous irrigation using a bimanual pull-through technique to facilitate spontaneous proper unfolding. Main Outcome Measures Surgical time, intraoperative and postoperative complications, visual acuity 3 and 6 months after surgery, and endothelial cell loss 6 months after surgery. Results Surgery was uneventful in all cases and the time required for the DMEK procedure (from Descemet scoring until final air filling) never exceeded 20 minutes (average, 17.1±1.6 minutes). The only complication observed after surgery was graft detachment (10 of 42 eyes [23.8%]), successfully managed in all cases by single rebubbling within 6 days from surgery. In all eyes with a minimum postoperative follow-up of 6 months (n = 20), best spectacle-corrected visual acuity was 20/25 or better and the average endothelial cell density (±standard deviation) was 2363.8±82.7 cells/mm2(range, 2258-2490 cells/mm2). The cell loss calculated as a percentage of the preoperative value determined at the eye bank (range, 2500-2700 cells/mm2) was 9.9±2.1% (range, 4.1%-11.9%). Conclusions Delivering DMEK tissue, trifolded with the endothelium inward, reduces surgical trauma to donor cells and facilitates spontaneous unfolding, thus minimizing surgical time.