1. Prevention and management of graft detachment in DMEK
K. Moutsouris, M. Dirisamer, I . Dapena, K. van Dijk, G.R.J. Melles
Netherlands Institute for Innovative Ocular Surgery
Melles Cornea Clinic
Amnitrans Eyebank Rotterdam
Purpose: To describe the prevention and management of various types of graft detachment after Descemet membrane endothelial Results: Partial or complete graft detachment was found in 36 cases (24%), of which 18 (12%) were clinically significant (TAB. 1). All
keratoplasty. 24 eyes with a partial detachment (groups 1 and 2) showed spontaneous corneal clearance, and all but 6 of these eyes (75%) reached
visual acuity of 20/40 or better (≥0.5). A reversed clearance pattern and interface spikes were observed in eyes with the graft
Materials and Methods: In 150 consecutive eyes that underwent Descemet membrane endothelial keratoplasty, the incidence and type of positioned upside down (group 3) (FIG. 3). Eyes with a free-floating graft (group 4) showed persistent corneal edema. Detachments
graft detachment were studied at 1, 3, 6, 9, 12, and 24 months after surgery in a nonrandomized, prospective clinical study at a tertiary were associated with inward folds (12 eyes [33%])(FIG. 4), insufficient air-bubble support (7 eyes [19%]), upside-down graft
referral center. Four groups of detachments were identified: a partial detachment of one-third or less of the graft surface area (n = 16; group positioning (4 eyes [11%]), use of plastic materials (2 eyes [6%]), irido-graft synechiae (1 eye [3%])(FIG. 5), poor endothelial
1); a partial detachment of more than one-third of the graft surface area (n = 8; group 2); a graft positioned upside down (n = 4; group 3); morphology (1 eye [3%])(FIG. 6), and stromal irregularity under the main incision (1 eye [3%]); 14 (58%) of the partial detachments
and a free-floating Descemet roll in the host anterior chamber (n=8; group 4). (FIG. 1 & 2) were localized inferiorly (TAB. 2).
Conclusions: Awaiting spontaneous clearance may be advocated in eye with a partial detachment. Minor adjustments in surgical
protocol (FIG. 7) as well as careful patient selection may further reduce the incidence of graft detachment after Descemet membrane
endothelial keratoplasty to 4% or less.
Series II
Series I Total
Type (Cases 76-150)
(Cases 1-75) n=150
n=75
n=75
Partial graft detachment ≤ 1/3 6 (8%) 10 (13%) 16 (11%)
Partial graft detachment > 1/3 5 (7%) 3 (4%) 8 (5%)
Graft upside-down 3 (4%) 1 (1%) 4 (3%)
1 (1%)
Complete graft detachment 7 (9%) 8 (5%)
Figure 4. Slitlamp photographs of a transplanted cornea 7 weeks (A), 3 months
Total 21 (28%) 15 (20%) 36 (24%) (B), and 10 months (C) after Descemet membrane endothelial keratoplasty. The
edema (white arrows) overlying the detached Descemet graft (yellow arrows)
Clinically significant 15 (20%) 3 (4%) 18 (12%) resolves with time, and stromal thinning with concomitant corneal clearance
progresses from the periphery toward the corneal center (green arrows).
Furthermore, note that the relatively small inward fold of the peripheral Descemet
graft causes a much larger detachment because the tissue springs away from the
Table 1. Incidence of Graft Detachment recipient posterior stroma. Inset of B, Inward fold at higher magnification.
Figure 5. Slitlamp
photograph of a
transplanted cornea 2
months after
Group III Descemet membrane
Group I Group II Group IV endothelial
Suspected cause
of graft Graft upside- Total keratoplasty.
Partial graft Partial graft Complete graft Gonioscopy showed
detachment down
detachment ≤ 1/3 detachment > 1/3 detachment an adhesion between
the Descemet graft
Inward fold 9 (57%) 2 (25%) -- 1 (12.5%) 12 (33%) (arrows) and the
peripheral iris,
Irregular incision causing a local
1 (6%) -- -- -- 1 (3%)
site traction detachment
because the detached
Irido-Descemet
1 (6%) -- -- -- 1 (3%) part of a Descemet
graft adhesion
graft tends to contract
Poor endothelial
Figure 2. Pachymetry and Scheimpflug images of 3 cell morphology
1 (6%) -- -- -- 1 (3%) over time.
corneas 6 months after Descemet membrane
Figure 1. Detachment patterns observed in our study. endothelial keratoplasty.
Use of plastic
materials
A, In the presence of a partially detached Descemet A, In groups 1 and 2, despite the presence of a contacting donor
-- 1 (12.5%) -- 1 (12.5%) 2 (6%)
membrane endothelial keratoplasty (DMEK) graft, the tissue Figure 3. Slitlamp photographs of a transplanted
detachment of the donor Descemet graft (arrow), the cornea 1 month (A-C) and 12 months (D-F) after
central cornea covered by the graft as well as the host entire cornea shows recovery of corneal clarity
Inadequate air-
peripheral stroma not covered by the graft frequently
bubble support Descemet membrane endothelial keratoplasty. There is
(asterisks) and normal pachymetry values. (vitreous pressure
-- 3 (37.5%) -- 4 (50%) 7 (19%) a reversed corneal clearance pattern with persistent
showed either spontaneous reattachment of the graft B, In group 3, in the presence of a graft positioned
or preceeding
or complete clearance within 1 to 6 months. B, If the vitreo-retinal stromal edema (blue arrows) overlying the area
upside down (with the donor endothelium facing the surgery)
showing graft attachment as well as corneal clearance
Figure 7. Diagram displaying recommendations to prevent detachments in
DMEK graft had been positioned upside down, a recipient posterior stroma), a reversed clearance
Descemet membrane endothelial keratoplasty (DMEK) and a decision tree in the
reversed clearance pattern was observed, ie, the area Descemet graft
-- -- 4 (100%) -- 4 (11%) (green arrows) in the area where the Descemet graft event of a Descemet graft detachment. AC indicates anterior chamber; BCVA,
pattern is seen, ie, a clear cornea in the area of the upside-down
(yellow arrows) is clearly detached. There is fibrous
best-corrected visual acuity; DSAEK, Descemet stripping automated endothelial
not covered by the graft showed complete corneal detachment (white asterisks) but persistent corneal
keratoplasty; DSEK, Descemet stripping endothelial keratoplasty; and PAS,
clearance within 1 to 6 months, whereas the area in Unknown 4 (25%) 2 (25%) 2 (25%) 8 (22%) scarring at the donor-host interface (red arrows) that peripheral anterior synechiae.
edema over the area where the donor tissue is --
may be absent in uncomplicated eyes undergoing
Figure 6. Light microscopy (A), slitlamp (B and C), and specular microscopy (D)
which the graft was attached showed persistent attached (red asterisks).
images of a Descemet graft before (A) and after (B-D) surgery. A, Although the
edema. C, No corneal clearance was seen with a free- 16 (100%) 8 (100%) 4 (100%) 8 (100%) 36 (100%) Descemet membrane endothelial keratoplasty. This endothelial cell layer appears normal during preoperative evaluation in the
C, In group 4, complete graft detachment, ie, a free- reversed clearance pattern with interface fibrosis may
eyebank, Fuchs dystrophy–like changes are seen across the transplant after
floating Descemet roll in the anterior chamber, ie, in floating Descemet roll in the anterior chamber
surgery, while the cell density is virtually normal. B, The arrows indicate the area
the absence of a touch between the graft and the Table 2. Suspected Cause of Graft Detachment be typical for eyes in which the Descemet graft was in which the graft is detached; the overlying cornea cleared despite the
(arrow), is associated with persistent corneal edema. positioned upside down. detachment.
recipient cornea.