title: Intraocular graft unfolding techniques in descemet membrane endothelial keratoplasty.
abstract: OBJECTIVE
  To define various Descemet graft unfolding techniques in Descemet membrane endothelial keratoplasty.
  
  
  METHODS
  In a retrospective analysis, the surgical videos of 100 consecutive Descemet membrane endothelial keratoplasty cases with at least 6 months of follow-up were evaluated and categorized. The Descemet graft unfolding methods were categorized into 4 basic techniques and 3 auxiliary techniques.
  
  
  RESULTS
  All Descemet membrane endothelial keratoplasty surgical procedures could be completed using (a combination of) 4 Descemet graft unfolding techniques: (1) standardized no-touch graft unfolding using a double roll, (2) carpet unrolling while fixating 1 graft edge (Dirisamer technique), (3) small air bubble-assisted unrolling (Dapena maneuver), (4) the single sliding cannula maneuver. Additional maneuvers included turning over the graft when oriented upside down (flushing); manual graft centration with a cannula; and bubble bumping to unfold peripheral inward folds. In 73% of surgical procedures, technique 1 was used, while a combination of techniques was used in 44% and auxiliary techniques in 62%. None of the techniques showed a correlation with the best-corrected visual acuity, endothelial cell density, or postoperative complication rate (P > .10).
  
  
  CONCLUSIONS
  Descemet membrane endothelial keratoplasty may be further facilitated by using controlled techniques for unfolding the Descemet graft inside the recipient anterior chamber, either as stand-alone techniques or used in various combinations.
authors.affiliation: Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands.
authors.forename: Vasilios S
authors.initials: VS
authors.lastname: Liarakos
authors.forename: Isabel
authors.initials: I
authors.lastname: Dapena
authors.forename: Lisanne
authors.initials: L
authors.lastname: Ham
authors.forename: Korine
authors.initials: K
authors.lastname: van Dijk
authors.forename: Gerrit R J
authors.initials: GR
authors.lastname: Melles
mesh_terms: D000368:Aged; D000867:Anterior Chamber / Q000601:surgery*; D002452:Cell Count; D055954:Corneal Endothelial Cell Loss / Q000473:pathology; D057111:Descemet Stripping Endothelial Keratoplasty / Q000379:methods*; D004728:Endothelium, Corneal / Q000637:transplantation*; D005260:Female; D005642:Fuchs' Endothelial Dystrophy / Q000601:surgery*; D006801:Humans; D008297:Male; D009924:Organ Culture Techniques; D011183:Postoperative Complications; D012189:Retrospective Studies; D014019:Tissue Donors; D014741:Video Recording; D014792:Visual Acuity / Q000502:physiology