title: Contact Lens-Assisted Pull-Through Technique for Delivery of Tri-Folded (Endothelium in) DMEK Grafts Minimizes Surgical Time and Cell Loss.
abstract: OBJECTIVE
  To evaluate the feasibility and outcomes of contact lens-assisted bimanual pull-through delivery of Descemet membrane endothelial keratoplasty (DMEK) tissue trifolded with the endothelium inward.
  
  
  METHODS
  Prospective, noncomparative, interventional case series.
  
  
  METHODS
  Forty-two consecutive eyes of 42 patients with Fuchs endothelial dystrophy with or without cataract.
  
  
  METHODS
  Standardized DMEK was performed as a single procedure (n = 9) or in combination with phacoemulsification and implantation of a posterior chamber intraocular lens (n = 33) using prestripped donor tissue punched to a diameter of 8.25 mm and then trifolded with the endothelium in. Using a sterile soft contact lens as scaffold, the tissue was loaded in this configuration into a disposable cartridge and delivered into the anterior chamber under continuous irrigation using a bimanual pull-through technique to facilitate spontaneous proper unfolding.
  
  
  METHODS
  Surgical time, intraoperative and postoperative complications, visual acuity 3 and 6 months after surgery, and endothelial cell loss 6 months after surgery.
  
  
  RESULTS
  Surgery was uneventful in all cases and the time required for the DMEK procedure (from Descemet scoring until final air filling) never exceeded 20 minutes (average, 17.1±1.6 minutes). The only complication observed after surgery was graft detachment (10 of 42 eyes [23.8%]), successfully managed in all cases by single rebubbling within 6 days from surgery. In all eyes with a minimum postoperative follow-up of 6 months (n = 20), best spectacle-corrected visual acuity was 20/25 or better and the average endothelial cell density (±standard deviation) was 2363.8±82.7 cells/mm(2) (range, 2258-2490 cells/mm(2)). The cell loss calculated as a percentage of the preoperative value determined at the eye bank (range, 2500-2700 cells/mm(2)) was 9.9±2.1% (range, 4.1%-11.9%).
  
  
  CONCLUSIONS
  Delivering DMEK tissue, trifolded with the endothelium inward, reduces surgical trauma to donor cells and facilitates spontaneous unfolding, thus minimizing surgical time.
authors.affiliation: Department of Ophthalmology, Ospedale Privato "Villa Igea", Forlì, Italy; Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy. Electronic address: mbusin@yahoo.com.
authors.forename: Massimo
authors.initials: M
authors.lastname: Busin
authors.affiliation: Department of Ophthalmology, Ospedale Privato "Villa Igea", Forlì, Italy; Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy.
authors.forename: Pia
authors.initials: P
authors.lastname: Leon
authors.affiliation: Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy; Department of Ophthalmology, University of "Magna Graecia", Catanzaro, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Scorcia
authors.affiliation: Fondazione Banca degli Occhi del Veneto (FBOV), Venezia, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Ponzin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002452:Cell Count; D003261:Contact Lenses; D055954:Corneal Endothelial Cell Loss / Q000503:physiopathology; D057111:Descemet Stripping Endothelial Keratoplasty / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D005642:Fuchs' Endothelial Dystrophy / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications; D019654:Lens Implantation, Intraocular; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D018918:Phacoemulsification; D011183:Postoperative Complications; D011446:Prospective Studies; D054457:Tissue Scaffolds; D014792:Visual Acuity / Q000502:physiology