title: Prevention and management of graft detachment in descemet membrane endothelial keratoplasty.
abstract: OBJECTIVE
  To describe the prevention and management of various types of graft detachment after Descemet membrane endothelial keratoplasty.
  
  
  METHODS
  In 150 consecutive eyes that underwent Descemet membrane endothelial keratoplasty, the incidence and type of graft detachment were studied at 1, 3, 6, 9, 12, and 24 months after surgery in a nonrandomized, prospective clinical study at a tertiary referral center. Four groups of detachments were identified: a partial detachment of one-third or less of the graft surface area (n = 16; group 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); and a free-floating Descemet roll in the host anterior chamber (n = 8; group 4).
  
  
  RESULTS
  Partial or complete graft detachment was found in 36 cases (24%), of which 18 (12%) were clinically significant. All 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 positioned upside down (group 3). Eyes with a free-floating graft (group 4) showed persistent corneal edema. Detachments were associated with inward folds (12 eyes [33%]), insufficient air-bubble support (7 eyes [19%]), upside-down graft positioning (4 eyes [11%]), use of plastic materials (2 eyes [6%]), irido-graft synechiae (1 eye [3%]), poor endothelial morphology (1 eye [3%]), and stromal irregularity under the main incision (1 eye [3%]); 14 (58%) of the partial detachments were localized inferiorly.
  
  
  CONCLUSIONS
  Awaiting spontaneous clearance may be advocated in eyes with a partial detachment. Minor adjustments in surgical protocol as well as careful patient selection may further reduce the incidence of graft detachment after Descemet membrane endothelial keratoplasty to 4% or less.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00521898.
authors.affiliation: Department of Ophthalmology, Allgemeines Krankenhaus Linz, Linz, Austria.
authors.forename: Martin
authors.initials: M
authors.lastname: Dirisamer
authors.forename: Korine
authors.initials: K
authors.lastname: van Dijk
authors.forename: Isabel
authors.initials: I
authors.lastname: Dapena
authors.forename: Lisanne
authors.initials: L
authors.lastname: Ham
authors.forename: Oganesyan
authors.initials: O
authors.lastname: Oganes
authors.forename: Laurence E
authors.initials: LE
authors.lastname: Frank
authors.forename: Gerrit R J
authors.initials: GR
authors.lastname: Melles
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003886:Descemet Membrane / Q000601:surgery; D057111:Descemet Stripping Endothelial Keratoplasty / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D005642:Fuchs' Endothelial Dystrophy / Q000601:surgery*; D006085:Graft Survival; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control* / Q000601:surgery*; D011446:Prospective Studies; D016896:Treatment Outcome; D014792:Visual Acuity