Reproducibility of graft preparations in Descemet's membrane endothelial keratoplasty

Ophthalmology. 2013 Sep;120(9):1769-77. doi: 10.1016/j.ophtha.2013.06.038. Epub 2013 Jul 16.


Purpose: To assess the reproducibility of manual graft preparation and evaluate the incidence rate and nature of structural anomalies of Descemet's membrane (DM) preventing successful graft preparation in DM endothelial keratoplasty (DMEK).

Design: Prospective, single-center, nonrandomized, consecutive case series.

Participants: We analyzed 350 corneoscleral buttons from donors aged 18-95 years stored in Optisol-GS or Dulbecco's modified Eagle's medium and used for DMEK surgery in 343 consecutive patients with Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy.

Methods: Residual endothelial cell-DM complexes obtained after successful DM stripping for DMEK and whole donor corneas obtained after unsuccessful DM stripping were examined by transmission electron microscopy and immunohistochemistry.

Main outcome measures: Accuracy of the cleavage plane between DM and corneal stroma and structural abnormalities of the DM-stroma interface.

Results: Uneventful manual separation without any disruption of DM was achieved in 335 of 350 donor corneas (95.7%) by use of a previously established bimanual submerged preparation technique. Correspondingly, the peeled DM specimens revealed a regular and smooth cleavage plane exposing the amorphous interfacial matrix on their anterior surface. Although 8 of 350 donor corneas (2.3%) showed focal adhesions of DM to the corneal stroma and developed isolated tears during stripping, preparation of the graft could be successfully completed. However, 7 of the 350 donor corneas (2.0%) showed extremely strong adhesion and multiple tears of DM, preventing successful preparation of the graft. These specimens revealed either ultrastructural (peg-like interlockings) or biochemical abnormalities (increased staining intensities for adhesive glycoproteins) along the DM-stroma interface.

Conclusions: Using an appropriate technique, manual preparation of grafts for DMEK with reproducible tissue qualities is possible in the vast majority (98%) of donor corneas. Although a relatively rare phenomenon, interindividual variations in DM structure and composition may be responsible for failure of graft preparation in about 2% of donor corneas.

Financial disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Publication types

  • Multicenter Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Biomarkers / metabolism
  • Cell Count
  • Descemet Membrane / metabolism
  • Descemet Membrane / ultrastructure*
  • Descemet Stripping Endothelial Keratoplasty / methods*
  • Endothelium, Corneal / metabolism
  • Endothelium, Corneal / transplantation
  • Endothelium, Corneal / ultrastructure*
  • Extracellular Matrix Proteins
  • Eye Banks
  • Fibronectins / metabolism
  • Fluorescent Antibody Technique, Indirect
  • Graft Survival / physiology
  • Humans
  • Middle Aged
  • Organ Culture Techniques
  • Osteonectin / metabolism
  • Prospective Studies
  • Refraction, Ocular / physiology
  • Reproducibility of Results
  • Specimen Handling / methods
  • Specimen Handling / standards
  • Tissue Donors
  • Tissue and Organ Harvesting / methods
  • Tissue and Organ Harvesting / standards*
  • Transforming Growth Factor beta
  • Visual Acuity / physiology
  • Vitronectin / metabolism
  • Young Adult


  • Biomarkers
  • Extracellular Matrix Proteins
  • Fibronectins
  • Osteonectin
  • Transforming Growth Factor beta
  • Vitronectin
  • betaIG-H3 protein