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Lessons learnt and observations from incorrect DMEK orientation

Poster Details

First Author: A.Barua UK

Co Author(s):    E. Sykakis   D. Lake   S. Hamada              

Abstract Details


During the learning curve of DMEK surgery, we present several observations which would aid in early recognition of graft orientation, complications of DMEK surgery and behaviour of endothelial cells with an inverted graft.


The case presented had DMEK surgery at our tertiary corneal unit. During the post-operative period the findings presented were noted, and slit lamp photographs along with anterior segment imaging were utilised.


A 56 year old male underwent DMEK surgery for Fuch's endothelial dystrophy, The donor preparation just prior to surgery was unremarkable with good DM stripping and minimal trauma. A Melles glass injector was used to insert the graft into the anterior chamber, and the case was prolonged due to difficulty with unfolding of the donor tissue. The graft was attached after unfolding with a 10 minute air fill reduced to 80 percent and dilation with face up posture. The graft was not fully attached despite re-bubbling with air a week later. Several observations were made during the post-operative period.


Despite attempting to re-bubble the graft, it remained partially detached. In the areas of detachment, the cornea overlying seemed to clear with time, and a suggestion of endothelial cell migration would explain this finding. The host DM was completely stripped from prior to DMEK, and the vision had improved to 6/19 Snellen despite detachment of the graft around the pupillary axis. In areas of attachment, the overlying cornea was oedematous. The patient had successful redo surgery with a DSAEK procedure as the area of clear cornea was limited and the surrounding oedematous cornea may have affected his long-term outcome.


During the early post-operative period, it is difficult to determine if the donor tissue is correctly orientated. OCT imaging may show general areas of detachment not just peripherally. We also suspect endothelial migration from the donor tissue to the host explaining increasing clarity of the cornea in areas of non-attachment. This may allow simple removal of the non attached graft and avoid redo procedures if endothelial migration is sufficient. In areas of attachment of the inverted donor tissue, the cornea became increasingly oedematous. Early recognition may allow repositioning to correct orientation.

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