Unfolding The Taco: Dmek Challenges In Complicated Eyes With Difficult Anterior Chamber Visualization

To present the method in which we were able to overcome intraoperative challenges like taco graft shape unscrolling, fibrin formation and poor visualization  and perform endothelial keratoplasty in an eye with decompensated Fuchs endothelial dystrophy. 

Clinical Emergency Eye Hospital Bucharest

Sequential cataract surgery and DMEK was performed in a patient known with Fuchs endothelial corneal dystrophy. Endothelial cell count could not be evaluated in either eye. Intraoperative OCT was used to aid in intraoperative visualization and unscrolling of the corneal graft. 

During unscrolling, the graft acquired a taco configuration, which proved significantly more challenging to unscroll, due to the small anterior chamber and fibrin formation. 

By using tapping movements and inflation of the anterior chamber using BSS and Enoxaparin, we were able to rescroll the graft. 

We have placed a small air bubble to partially fixate the graft to avoid it reassuming a taco configuration. Using the movement of the air bubble and the eye, full graft unscrolling, centration and attachment was achieved.

Despite a longer manipulation of the graft, full attachment with good restoration of the endothelial pump, corneal transparency and excellent visual acuity recovery were attained.

Anterior segment parameters and corneal graft dimensions should be carefully assessed preoperatively. Intraoperative OCT greatly aids the surgeon in visualizing and unscrolling the graft in eyes with hazy corneas and small anterior chamber depth. Fluidics are a key step in achieving good results in challenging DMEK surgeries.