Trifolded Endothelium-In Dmek With Pull-Through Technique For A Peripherally Torn Graft

To describe the successful management of a peripherally torn graft using tri-folded endothelium-in Descemet membrane endothelial keratoplasty (DMEK) with pull-through technique.

Tertiary Eye Care Referral Center (Ospedali Privati Forlì “Villa Igea”, Forlì, Italy)

A 79-year-old female underwent triple DMEK for Fuchs dystrophy. Upon inspection of the pre-stripped donor tissue prepared by the eye bank, a 5-mm radial tear was noted extending towards the periphery of the graft. The graft was positioned on the punch block, stained with Trypan blue and punched to 8-mm. The DMEK graft was then tri-folded endothelium-in by orienting the tear parallel to the unfolded base of the tri-folded tissue. In order to maintain the tri-fold configuration, the intact edge of the unfolded portion of the graft opposite to the radial tear was grasped and transferred onto the contact lens and into an IOL cartridge filled with BSS. Despite the presence of the tear, the bimanual pull-through technique ensured control of the graft upon delivery into the anterior chamber under continuous irrigation. Gentle tapping on the surface of the cornea allowed unfolding of the DMEK tissue in the proper orientation. 

One week postoperatively, a partial graft detachment was noted inferiorly around the radial tear. This was successfully managed with a single rebubbling with air. Six months postoperatively, the cornea was clear, Snellen BCVA was 20/20 and ECD was 1511 cells/mm².

Tri-folded endothelium-in DMEK is technically feasible in grafts with large peripheral tears.   The bimanual pull-through technique results in less manipulation and facilitates the unfolding of the graft in the proper orientation.