Pupillary Occlusion–Assisted Bubble-Behind-The-Iris Technique For Dmek In Vitrectomized Pseudophakic Eyes

Descemet membrane endothelial keratoplasty (DMEK) in vitrectomized pseudophakic eyes is surgically demanding because loss of vitreous support leads to anterior chamber instability, limited graft control, and risk of posterior dislocation. We describe a modified technique combining temporary intraoperative pupillary occlusion with a posterior chamber air bubble positioned behind the iris to restore anterior–posterior compartmentalization, provide transient posterior support, and improve intraoperative chamber stability and graft manipulation in these complex cases.

Eskişehir Osmangzi Universty, Eskişehir, Türkiye.

This retrospective case series included six vitrectomized pseudophakic eyes undergoing DMEK. Intraoperative pupillary occlusion was achieved using a central iris sliding-knot suture to compartmentalize the chambers. The graft was delivered into the anterior chamber, followed by posterior chamber air injection behind the iris to provide temporary support and allow controlled anterior chamber shallowing. Graft unfolding and positioning were completed, and anterior chamber air tamponade was applied. The suture was removed within two weeks by Nd:YAG laser or manual extraction. Outcomes included posterior dislocation, central 5-mm graft apposition, rebubbling, and early central corneal thickness (CCT) changes.

Four eyes had scleral-flanged IOL fixation, one had a subluxated sulcus IOL, and one had a two-point fixation IOL. No intraoperative posterior graft dislocation, central detachment, or dehiscence occurred. Three eyes (50%) developed limited peripheral detachment outside the central 5-mm zone and required rebubbling; the optical zone remained fully attached in all cases. One eye required repeat rebubbling. Complete graft attachment was achieved in all eyes. CCT decreased by week 1 with further improvement by week 2, and all corneas remained clear with stable centration.

The pupillary occlusion–assisted bubble-behind-the-iris technique provides temporary posterior chamber support and restores anterior–posterior compartmentalization during DMEK in vitrectomized pseudophakic eyes. No posterior graft migration, central detachment, or dehiscence occurred, and the central 5-mm optical zone remained attached in all cases. Peripheral detachments were successfully managed with rebubbling, resulting in complete anatomical attachment.