ASCRS-ASOA

2018
DR.ASHVIN
AGARWAL
( M.B.,B.S.; M.S. OPHTHALMOLOGY )

ENDOTHELIAL
KERATOPLASTY:
( DSEK / DMEK / PDEK )
HANDOUTS

DR.AGARWAL’S GROUP OF

EYE HOSPITAL
DSEK
GRAFT PREPARATION :
Requirements :
Artificial chamber, donor cornea, 5/2 ml syringes, 8 mm trephine, Crescent knife,
DSEK disectors (Straight and curved)
1.Donor cornea is fixed onto artificial chamber with epithelial side facing up
2.Epithelium is debrided, with Wexel sponge
3.Partial trephine mark is done. Small incision made to 2/3rd depth of cornea.
4.Using straight and curved dissectors manual dissection is made
5.Donor cornea is then placed on teflon block with endothelium side facing up
6.Full thickness punch is then made and stromal side of the graft is marked and
tissue is preserved in preservative media
DMEK
GRAFT PREPARATION :
Requirements :
Teflon block, Donor cornea, 8 mm Trephine, tryphan blue
1.Donor cornea with endothelium facing upwards is placed on teflon block
2.8mm trephine is used to punch the graft, this step gives sharp margins for
the graft with out tags
3.Graft edges is stained with tryphan blue
4.Using non toothed forceps graft is harvested by gently peeling away from
stroma, SCUBA (Submerged Cornea Using Backgrounds Away) technique
makes it more easier (Donor tissue is submerged with fluid above and below,
making tissue easier to visualize and handle )
5.Harvested graft is stained with tryphan blue and preserved in preservative medium
PDEK
GRAFT PREPARATION :
Requirements :
30 G needle,5 ml syringe, Teflon block, Donor cornea, 15 degree knife, Vanas
scissors, tryphan blue
1.30 G needle is bent to 45 degree angle with bevel facing up and is fixed to 5 ml
air filled syringe
2.Donor cornea with endothelium facing upwards is placed on teflon block
3.Needle is passed into posterior stroma starting from limbus
4.Air is injected slowly
5.Small multiple bubbles starts forming in the centre which joins to form type I big
bubble (PDEK Bubble)
6.Entry into bubble is made using 15 degree knife at the base of bubble
7.Tryphan blue is injected into bubble to stain the graft
8.Vanas scissors is used to cut the bubble at the base al around
9.Harvested graft is stained with tryphan blue and preserved in preservative medium
DSEK/DMEK/PDEK
RECIPIENT PREPARATION :

Recipient preparation is same for all 3 procedure

1.Two side ports (10 and 2 ‘O clock ) and a main wound is made
2.Descematorhexis is done using reverse sinskey hook and diseased descemets
membrane is removed. Removed descemets membrane is checked to asses it is
removed intotal
3.This step is much easier with continuous flow of air into anterior chamber. This
can be achieved by fixing an Trocar Anterior Chamber maintainer into anterior
chamber connected to a air pump
DSEK
GRAFT INSERTION AND UNROLLING :

1.Graft is injected into anterior chamber in many different methodsGraft is

folded into 60/40 taco fold and placed into anterior chamber using Goosey
forceps and graft is unfolded by injecting small jet of saline
2.Graft is loaded into Busin glide and placed into anterior chamber
3.10’ O nylon suture is tied on 2 opposite ends and graft is placed into anterior
chamber by pulling one suture end by a forceps passed through side port made
at 6 ‘o clock
4.Air is injected under the graft which pushes graft against the stroma
DMEK
GRAFT INSERTION AND UNROLLING :

1.Graft is loaded into a cat ridge and fixed into a IOL injector
2.Before injecting graft into anterior chamber, air is removed from the anterior chamber
3.Graft is injected into AC and the main wound is sutured
4.Correct orientation of graft is identified, the scroll facing up. Presence and its orientation
is well appreciated by placing an ENDOILLUMINATOR tangentially over the cornea.
5.Graft is unrolled by gentle taping on the cornea and by injecting short jets of fluid into
the graft
6.After the graft is unrolled air is injected under the graft and air pushes the cornea
towards stroma
7.Graft centration and unrolling should be done before injecting air underneath then graft
PDEK
GRAFT INSERTION AND UNROLLING :

1.Graft is loaded into a cat ridge and fixed into a IOL injector
2.Before injecting graft into anterior chamber, air is removed from the anterior chamber
3.Graft is injected into AC and the main wound is sutured
4.Correct orientation of graft is identified, the scroll facing up. Presence and its orientation
is well appreciated by placing an ENDOILLUMINATOR tangentially over the cornea.
5.Graft is unrolled by gentle taping on the cornea and by injecting short jets of fluid into
the graft
6.After the graft is unrolled air is injected under the graft and air pushes the cornea
towards stroma
7.Air pump is turned on and graft cent ration and unrolling the edges is done
DSEK/DMEK/PDEK

DSEK DMEK PDEK

Predescemet’s membrane +
Surgical layers Stroma + DM + Endothelium DM + Endothelium
DM + Endothelium

Technical difficulty Moderate Difficult Moderate

Special instruments Required Not required Not required

Induced hyperopia Yes No No

Graft unrolling Easy Difficult Moderate

Tissue handling Good Difficult Good

Visual recovery Slow Fast Fast

Donor age dependency Independent Dependent Independent