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  1. Siamak Zarei-Ghanavati1,
  2. Mehran Zarei-Ghanavati1,
  3. Arturo Ramirez-Miranda2
  1. 1Cornea Department and Eye Research Center, Khatam-al-Anbia Eye Hospital, Mashhad University of Medical Sciences (MUMS), Mashhad, Iran
  2. 2Department of Cornea and Refractive Surgery, Institute of Ophthalmology “Conde de Valenciana”, National Autonomous University of Mexico, Mexico DF, Mexico
  1. Correspondence to Dr Siamak Zarei-Ghanavati, Mashhad University of Medical Sciences (MUMS), Khatam-al-Anbia Eye Hospital, Cornea Department and Eye Research Center, Abootaleb Blvd, Mashhad, Iran; zareis{at}

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We thank Busin et al1 for their letter regarding our article ‘Reverse big bubble: a new technique for preparing donor tissue of Descemet membrane endothelial keratoplasty’2 and would like to answer briefly the main questions raised.

Regarding their claim of novelty, we recently read their study regarding air-assisted donor preparation for Descemet membrane endothelial keratoplasty (DMEK) published in August 2010,3 but we were not aware of their presentation at the American Academy of Ophthalmology meeting in Atlanta. We also used an air-assisted technique (reverse big bubble)2 to prepare the Descemet membrane (DM) for DMEK. We presented the videograph of our technique at the 19th Iranian Congress of Ophthalmology, 2009.

We think their technique needs some modifications. They use ‘peripheral cornea approximately 1 mm from the limbus’ for insertion of the needle. Puncture of the DM at peripheral cornea might cause an air leak or DM rupture during the injection and bubble formation. We think the preferred entry point for the needle should be outside the Schwalbe's line (a pigmented trabecular meshwork is used as a marker) which makes this technique more atraumatic.

Busin et al1 reported a 5% failure with their technique. In our experience, we found that air-assisted DM dissection is more difficult in young patients (<40 years old) and sometimes the attempt to make a complete detachment may lead to DM rupture. In these cases, we prefer to use a 2 cc air-filled syringe and restrict DM dissection up to 8–9 mm diameter, to reduce the possibility of DM rupture. In our first 10 cases, with an average age of 32 years, we had two patients with incomplete detachment (<8 mm diameter) and one case of DM rupture. Therefore, the high rate of success in the Busin et al3 study might be related to the older age of donors (average=63 years).

We would like to add that we intentionally make a DM roll at the end of the procedure as it allows us to inject the DM through a small corneal incision, which is one of the obvious advantages of DMEK over Descemet stripping automated endothelial keratoplasty.



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  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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