Elsevier

Ophthalmology

Volume 120, Issue 9, September 2013, Pages 1769-1777
Ophthalmology

Original article
Reproducibility of Graft Preparations in Descemet's Membrane Endothelial Keratoplasty

https://doi.org/10.1016/j.ophtha.2013.06.038Get rights and content

Purpose

To assess the reproducibility of manual graft preparation and evaluate the incidence rate and nature of structural anomalies of Descemet's membrane (DM) preventing successful graft preparation in DM endothelial keratoplasty (DMEK).

Design

Prospective, single-center, nonrandomized, consecutive case series.

Participants

We analyzed 350 corneoscleral buttons from donors aged 18–95 years stored in Optisol-GS or Dulbecco's modified Eagle's medium and used for DMEK surgery in 343 consecutive patients with Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy.

Methods

Residual endothelial cell–DM complexes obtained after successful DM stripping for DMEK and whole donor corneas obtained after unsuccessful DM stripping were examined by transmission electron microscopy and immunohistochemistry.

Main Outcome Measures

Accuracy of the cleavage plane between DM and corneal stroma and structural abnormalities of the DM–stroma interface.

Results

Uneventful manual separation without any disruption of DM was achieved in 335 of 350 donor corneas (95.7%) by use of a previously established bimanual submerged preparation technique. Correspondingly, the peeled DM specimens revealed a regular and smooth cleavage plane exposing the amorphous interfacial matrix on their anterior surface. Although 8 of 350 donor corneas (2.3%) showed focal adhesions of DM to the corneal stroma and developed isolated tears during stripping, preparation of the graft could be successfully completed. However, 7 of the 350 donor corneas (2.0%) showed extremely strong adhesion and multiple tears of DM, preventing successful preparation of the graft. These specimens revealed either ultrastructural (peg-like interlockings) or biochemical abnormalities (increased staining intensities for adhesive glycoproteins) along the DM–stroma interface.

Conclusions

Using an appropriate technique, manual preparation of grafts for DMEK with reproducible tissue qualities is possible in the vast majority (98%) of donor corneas. Although a relatively rare phenomenon, interindividual variations in DM structure and composition may be responsible for failure of graft preparation in about 2% of donor corneas.

Financial Disclosure(s)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Section snippets

Tissue Specimens

Corneal donor tissue (n = 350) was obtained from various eye banks in Europe and the United States. The corneoscleral buttons of European origin (n = 303) were organ cultured in Dulbecco's modified Eagle's medium containing streptomycin and penicillin (Biochrom, Berlin, Germany) as well as fetal calf serum (Linaris, Bettingen am Main, Germany) at 34°C for 368.9±100.5 hours (range, 48–672 hours). The corneoscleral buttons from US eye banks (n = 47) were stored in Optisol-GS (Bausch & Lomb,

Results

As shown in Table 1, both donor corneas stored under organ culture (n = 303) or short-term culture conditions (n = 47) were used. The ages of the tissue donors ranged from 18 to 95 years (mean, 73.4±11.2 years).

Complete and uneventful manual separation without any disruption of DM was achieved in 335 of 350 donor corneas (95.7%) by use of a previously established bimanual submerged preparation technique.15 Correspondingly, the residual EDM specimens revealed a regular ultrastructure comprising

Discussion

In posterior lamellar surgery of the cornea, DMEK represents the most recent and the ideal patient-oriented development.19 Despite its superior clinical results, as indicated by faster visual recovery, less postoperative astigmatism, and reduced risk of transplant rejection compared with other posterior lamellar procedures,3, 4, 20, 21, 22, 23 DMEK has not yet found widespread application and remains limited to a few clinical centers.19 One of the reasons may be technical challenges in

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    Manuscript no. 2013-249.

    Financial Disclosures: The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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