April 2006 1/3 My DSAEK/DSEK Surgical Technique by ... - Iogen

My DSAEK/DSEK Surgical Technique
by Francis W. Price, MD (Indianapolis, IN)
Preparation of Donor with Moria CB and Artificial Anterior Chamber
1. Check temperature of artificial anterior chamber (AAC).
2. Hook up infusion line to AAC and run enough fluid through it to remove any air
bubbles.
3. Check donor diameter and trim as needed.
4. Transfer donor tissue to AAC and center cornea. Infusion should be turned on while
placing tissue on AAC to remove air bubbles and turned off once bubbles are gone.
5. Fixate donor on AAC, verify pressure, fixation.
6. Excise excessive conjunctiva, if necessary.
7. Remove epithelium from donor.
8. Place gentian violet reference mark on donor.
9. Measure central corneal thickness of donor. If < 570 microns, use CBm 300 head, if
greater, use CBm 350 head.
10. Inspect blade on microkeratome, inspects tracks on both microkeratome and AAC.
11. Put fluid on donor and make microkeratome pass.
12. Retrieve donor cap from microkeratome, replace on rim and align.
13. Dry gutter.
14. Mark center of donor with gentian violet.
15. Remove microkeratome guide.
16. Open infusion.
17. Rotate collar and allow fluid to push collar and donor rim up.
18. Remove donor from artificial chamber collar.
19. Place donor on Hanna punch block, centering mark on center of block without moving
tissue across block.
20. Apply suction.
21. Place medium on donor.
22. Replace cylinder of the Hanna punch.
23. Cover, and set aside.
Preliminary recipient preparation
1. Return microscope to patient
2. Measure corneal diameter and select donor size (8-9 mm).
3. Place fixation sutures (4-0 Ethicon RB-1 tapered needle #K871) through conjunctiva
and tenons superiorly and inferiorly.
4. Mark patient cornea with Moria marker #19095 when donor size selected in 9 mm.
Donor Trephination
1. Trephine donor, remove cylinder and check trephination.
2. Check gentian violet mark for location of donor disc. The posterior portion of the
donor can come off in the trephine so check that carefully before handing it off. Cover
donor with medium.
3. Replace cylinder of the Hanna punch.
4. Cover and set aside.
April 2006 1/3

Preparation of Recipient
1. Temporal peritomy and use cautery as needed.
2. Make temporal scleral tunnel incision into the clear cornea.
3. Use cautery to ensure there is no bleeding in scleral tunnel.
4. Place stab incision to right of main incision (about 2mm into clear cornea in area that
will be covered by graft using #75 blade).
5. Insert a Moria chamber maintainer #19092 through peripheral cornea into anterior
chamber at 6:00 (left hand) for continuous infusion of anterior chamber during the
stripping and removal of Descemet’s membrane.
6. Use Moria Price hook #19091 to outline in Descemet’s membrane the portion to strip
away. The diameter should be slightly smaller than the size of the planned donor. Be
careful not to overly push up into stroma or to tear tissue as this can lead to
irregularities or loose pieces of stroma which can interfere with good apposition of
donor against recipient.
7. Inject VisionBlue® into the AC. This stains exposed areas of Descemet’s membrane
and allows better visualization of it. The darkest areas of staining will be the scored
area and areas with guttata. (Turn off infusion while injecting the VisionBlue® into
the eye.). If Descemet’s membrane fragments, a second dose of VisionBlue® can be
injected to better see tags and residual pieces of membrane.
8. Strip Descemet’s membrane with Moria Stripper #19077, opening up the temporal
incision as needed. Usually the 90 degree stripper is all that you will need.
9. Place removed Descemet’s on cornea to verify enough, or correct amount of
Descemet’s membrane removed.
10. Extend temporal incision to its full length.
11. Remove the infusion line.
Donor Placement
1. Transfer donor to operative field with spatula if donor on block, or remove from
trephine.
2. Place donor on patient’s cornea.
Preparation of “Taco” (Right-handed)
1. Hold onto right side of donor at epithelial edge and place small amount of viscoelastic
on mid-portion of left side of donor.
2. Use other forceps to fold endothelial side to the left, leaving more donor on the upper
half.
3. Gently slip Moria Goosey forceps #19090 (that grasp only at the tip) around the taco
without overly squeezing the tissue.
Insertion and Unfolding of Donor
1. Gently lift wound and insert “taco” into A/C with donor as close to left side of A/C
angle as possible.
2. Remove Moria Goosey forceps without pulling out or dislodging donor.
3. Optional: place 10-0 nylon fixation suture(s) to completely close scleral tunnel
incision.
4. Fill AC partially with BSS through right paracentesis.
5. Suture edge of donor in eyes with narrow angles, vitrectomy, very thin donors, or
instability of lamellar graft.
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6. Inject air. If air is used to unfold donor, use small bubble and watch that it does not
unfold endothelial side up, or that air goes into and behind pupil.
7. Watch for donor to unfold. If it does not, check to see if it is caught on pupil or iris.
Always keep a close eye on the donor to make sure it does not unfold the wrong way –
endothelial side up.
8. Inject air slowly under left edge of donor to unfold graft (30 gage needle).
9. Watch donor unfold, freeing it from the iris, if required.
10. Fill AC with air.
11. Remove fixation suture, if used.
12. Position donor as needed with roller (do not use unless entire chamber is filled with
air).
13. Make 4 stab incisions with square edge diamond knife to remove fluid trapped in the
interface.
14. Use roller again to position graft and drain fluid.
15. Drain more fluid by opening incisions.
16. In some cases, a stab incision will be needed at limbus on right-hand side to allow a
bent needle into AC to help unfold taco by gently catching the stromal side of lower
portion of taco.
17. Remove epithelium for patients with EBMD.
18. Wait 8 minutes.
19. Inject antibiotics and steroids while waiting.
20. At “end” of case, do not leave the A/C completely filled with air or blocking pupil as
this can cause pupillary block in all but aphakic eyes, those with a total vitrectomy, or
those with filters.
21. If large or moderately large air bubble, use dilating drops. Consider superficial
keratectomy if anterior stromal scarring.
Completion of procedure
1. Rotate eye inferiorly.
2. Create superior paracentesis.
3. Remove most of air and replace with BSS through superior paracentesis with patient
looking down (removal of air not necessary in aphatic eyes, those with vitrectomy or
those with filter).
4. Use dilating drops (homatropine), antibiotic, NSAID, and steroid.
5. Position patient face-up in recovery room.
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