Standardized DMEK Technique: Reducing Complications Using Prestripped Tissue, Novel Glass Injector, and Sulfur Hexafluoride (SF6) Gas

Cornea. 2015 Aug;34(8):845-52. doi: 10.1097/ICO.0000000000000479.


Purpose: To report low complication rates in Descemet membrane endothelial keratoplasty (DMEK) using sulfur hexafluoride (SF6) gas, a novel glass injector, and donor tissue prestripped by an eye bank technician.

Methods: A standardized technique of DMEK was performed in 80 consecutive Fuchs corneal dystrophy cases using technician-prestripped tissue, a novel glass injector, a modified Yoeruek tap technique, and an SF6 gas (20% concentration) bubble for prolonged tissue support. Twenty-five donors were premarked with an "S" stamp for intraoperative orientation. Surgery was performed by 2 experienced DMEK surgeons and 2 inexperienced cornea fellows. Complications were recorded, and the percent endothelial cell loss was calculated at 6 months postoperatively.

Results: There were 5 cases that received an air bubble injection postoperatively (6% rebubble rate). There were 6 grafts that immediately failed, 2 because of excessive surgical trauma, and 4 because of upside-down graft placement documented by optical coherence tomography. None of the 25 cases with an S stamp failed. Recipient corneas cleared quickly with no clinical evidence of toxicity from the SF6 gas bubble, and the grafts experienced a mean endothelial cell loss of 27% at 6 months.

Conclusions: Tissue prestripped by an eye bank technician can be safely used for DMEK surgery. SF6 gas for prolonged tissue support may reduce the rebubble rate in DMEK, with no apparent acute toxic effect. An unrecognized upside-down graft was the primary cause of graft failure in this series. Upside-down grafts may be eliminated by the use of donor tissue premarked by the eye bank with an S orientation stamp.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Descemet Stripping Endothelial Keratoplasty / instrumentation
  • Descemet Stripping Endothelial Keratoplasty / methods*
  • Descemet Stripping Endothelial Keratoplasty / standards
  • Endotamponade
  • Eye Banks
  • Female
  • Fuchs' Endothelial Dystrophy / surgery*
  • Humans
  • Intraoperative Complications
  • Male
  • Middle Aged
  • Postoperative Complications
  • Sulfur Hexafluoride / administration & dosage*
  • Tissue Donors
  • Tissue Transplantation / instrumentation*
  • Tissue and Organ Harvesting / methods*


  • Sulfur Hexafluoride