How To Tame A Tight Dmek-Roll? The `Bubble-In-The-Roll` Technique

Since its introduction in 2006, Descemet Membrane Endothelial Keratoplasty (DMEK) has become the surgical procedure of choice for endothelial failure. A double roll configuration of the DMEK graft makes subsequent intraocular unfolding easier and is a key step to a short intraocular manipulation time.  Here I present a novel technique to rapidly and reliably create a double roll even from tight single rolls from young donors.

Description of a novel graft preparation technique and retrospective analysis of the first 20 operations.

Donor tissue was purchased from Amnitrans Eye Bank (Rotterdam, The Netherlands). I followed the original `no-touch` procedure except that I avoided the use of a direct flow of BSS on the top of the graft to create a double roll. Instead, I injected a small amount of air with a 30G Rycroft angled air injection cannula (30Gx7.8", 0.3x22 mm, angled 35° 8 mm from tip; Sterimedix, Redditch, UK) into the floating DMEK-roll. The air bubble opened up the roll and rose up subsequently. The DMEK grafts took up a symmetric double roll configuration after the air was gone.

I performed 20 DMEK surgeries with this technique, and it took only a couple of seconds to reach the double roll configuration in all cases. The procedure worked reliably with all kinds of DMEK grafts, also with tight rolls. However, lose rolls had a tendency to regain a single roll configuration. Visual acuity and endothelial cell loss were slightly better than that of the original no-touch technique measured at the 6- and 12-weeks controls. Re-bubbling was needed in one of these cases.

This procedure can accelerate the graft preparation and shorten the operation time. Moreover, it provides a fast and reliable technique to create a double roll DMEK graft under all circumstances and paves the way for the use of younger donor grafts.