Eyeworld

66 | EYEWORLD | DECEMBER 2021 C ORNEA by Ellen Stodola Editorial Co-Director About the physicians Amy Lin, MD Associate Professor of Ophthalmology John A. Moran Eye Center University of Utah Salt Lake City, Utah Francis Price, Jr., MD Price Vision Group Indianapolis, Indiana A graft detachment is a fairly common complication that can occur when doing DSAEK and DMEK. Amy Lin, MD, and Francis Price, Jr., MD, discussed when detachments can happen and how to address them. Dr. Lin said that most cornea specialists have likely experienced a graft detachment multiple times in their career. She said it seems to happen more frequently when a physician is first learning to do DSAEK and DMEK. "It has to do with more manipulation of the donor [tissue]," she said, adding that this can lead to a loss of more endothelial cells during surgery. There are instances where there was a known excessive amount of manipulation during sur- gery and there may be a higher chance of graft detachment postoperatively. After the disappear- ance of the air or gas bubble is when a graft will typically detach, Dr. Lin said. With graft detachment in DSAEK, Dr. Price said it's usually almost a complete detachment. "That's something you should be able to head off in most cases, and if it's detaching more, you need to put in air," he said. Dr. Price usually reserves DSAEK for compli- cated cases, those where he's concerned about the DMEK dislocating into the back of the eye. "If we have a case where we're worried about it going into the back of the eye, we will typically put one fixation suture in," he said, noting that he will do this either with a suture pull-in tech- nique, or once the graft is in the eye, he'll put in one stitch. "It's important to remember to never put in more than one fixation stitch," Dr. Price said. Those who initially began to use posterior grafts attempted to use multiple fixation stitches, he said, and that can pull the donor away from the apex of the recipient cornea. It pulls it into a straight line and doesn't curve, so they won't attach properly if you have more than one fixa- tion suture. He also recommended not making the fixation stitch overly tight. When there's a DSAEK dislocation, Dr. Price recommended getting a good air fill. There will typically be a pressure in the 30s for 10 min- utes, then you can get rid of most of the air so you don't get a pupillary block. "If the DSAEK graft is partially detached, it will often reattach on its own if you give it time," Dr. Price said. "That stroma wants to attach." A DMEK detachment is different, he said. If the DMEK graft detaches completely, you'll likely have to take the patient back to the OR, restain with trypan blue, and go through the unfolding process. Dr. Price said he reinjects air with DMEK grafts when the detachment is increasing in size, if it's affecting the vision so you have edema in the center, or if it's an area of ede- ma where you're getting some bullae and it's bothering the patient. "It's very subjective with DMEK as to the percentage of reinjection of air or gas among different surgeons," he added, noting that his practice tends to reinject air more often because they've shown that one reinjection of air doesn't affect cell count. "If we have someone bothered by edema, we reinject, and that's about 20% of the time for virgin eyes," Dr. Price said. Graft detachments in DSAEK and DMEK Complete dislocation of DSAEK graft; arrow points to space between DSAEK and host cornea Source: Amy Lin, MD COMPLICATED CASES

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