. Purpose:  To describe a standardized ‘no‐touch’ harvesting technique of anterior and Descemet membrane (DM) grafts for use in deep anterior lamellar keratoplasty (DALK) and Descemet membrane endothelial keratoplasty (DMEK), which provides undamaged anterior and posterior corneal grafts. Methods:  A retrospective evaluation was performed of our standard method for harvesting DM grafts and DALK grafts (Technique I; n = 31) versus a newly designed ‘no‐touch’ technique (Technique II; n = 31), in which a peripheral ring of trabecular meshwork tissue is left in‐situ, and the DM graft is trephined on an underlying soft contact lens. Endothelial cell density (ECD) before and immediately after DM stripping was used as the main outcome parameter. Results:  Endothelial cell density did not differ within Techniques I and II (before versus after DM stripping) (p = 0.75 and p = 0.54, respectively) or among Techniques I and II (p = 0.61). With the latter technique, anterior corneal grafts and posterior DM grafts could be harvested with negligible damage to the endothelial cell layer or the posterior stromal bed. All 93 grafts (62 DM grafts) were eligible for transplantation, and six months post‐operatively all transplants used were functional. Conclusion:  The new technique offers the following advantages: (i) production of ‘undamaged’ grafts for DALK and DMEK, (ii) better controlled tissue handling of the thin DM graft during DM stripping and (iii) an increase in availability of corneal grafts obtained from the same donor tissue pool.

DMEK may be a viable option to manage secondary PK graft failure with acceptable outcomes in many cases. Rebubbling for graft detachment may be anticipated, especially because of preexisting glaucoma conditions (severe decompensation, hypotony, and tubes from glaucoma-draining devices). Graft reattachment may occur through interface scarring.

n the past decade, various techniques for endothelial keratoplasty, including Descemet membrane endothelial keratoplasty (DMEK), have been introduced. 1 To further refine this technique, we assessed the clinical outcome of the first 500 consecutive DMEK eyes at the Netherlands Institute for Innovative Ocular Surger y (NIIOS), Rotterdam, the Netherlands. 1 In that study, various outcome parameters did not seem to correlate with surgical difficulty or donor tissue preparation error. For example, some eyes showed a decrease in endothelial cell density (ECD) that could not be attributed to surgical trauma or a postoperative (partial) graft detachment. 1 If preparation or surgical trauma would not (solely) explain a higher-than-average ECD decrease and/or postoperative graft detachment, donor-and/or recipientrelated factors may influence DMEK surgical outcomes or its complications. Therefore, the aim of the current study was to assess whether donor-and tissue-related parameters correlated with short-term ECD reduction and/or detachment rate. Methods To test this hypothesis, the clinical outcome of the same cohort of 500 consecutive DMEK eyes was matched to the donor and tissue information available in our eye bank (Amnitrans EyeBank, Rotterdam, the Netherlands) for statistical analysis. All donor tissue was stored under organ culture conditions. The 500 cases evaluated were cases 26 to 525 from a total of 525 consecutive DMEK surgical procedures performed at our institute between October 2007 and September 2012. The first 25 DMEK eyes were excluded to eliminate a potential start-up effect. 1 Retrospective analysis was performed between August 2013 and March 2015. This study was approved by the institutional review board of the Netherlands Institute for Innovative Ocular Surgery. All patients signed an institutional review board-approved informed consent form. IMPORTANCE After retrospectively evaluating the clinical outcome of 500 consecutive cases after Descemet membrane endothelial keratoplasty (DMEK), we extended the analysis in this study by assessing the effect of donor-related parameters on endothelial cell density (ECD) decline and detachment rate in this group. OBSERVATIONS This retrospective case series included 500 cases who had undergone DMEK from October 2007 to September 2012 at the Netherlands Institute for Innovative Ocular Surgery (NIIOS), Rotterdam, the Netherlands. Logistic regression analysis (n = 332 eyes) showed that donor age might be associated with a 3% increase in the risk for a detachment (odds ratio, 0.97; 95% CI, 0.94-1.00; P = .049) (ie, higher donor age seems to be associated with lower chances of a detachment). In addition, linear regression analysis indicated that graft storage time in medium was associated with ECD decrease (ie, the longer the storage time, the larger the decrease at 6 months after DMEK) (P = .01). CONCLUSIONS AND RELEVANCE We showed an association between graft storage time and ECD decline after DMEK and possibly between donor age and graft detachment. Therefore, donor...

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ABSTRACT.Purpose: To evaluate the feasibility of two novel 'heavy' dye solutions for staining the internal limiting membrane (ILM) and epiretinal membranes (ERMs), without the need for a prior fluid-air exchange, during macular surgery. Methods: In this prospective nonrandomized multicenter cohort study, the high molecular weight dyes ILM-BlueÔ [0.025% brilliant blue G, 4% polyethylene glycol (PEG)] and MembraneBlue-DualÔ (0.15% trypan blue, 0.025% brilliant blue G, 4% PEG) were randomly used in vitrectomy surgeries for macular disease in 127 eyes of 127 patients. Dye enhanced membrane visualization of the ILM and ERMs, 'ease of membrane peeling', visually detectable perioperative retinal damage, postoperative best-corrected visual acuity (BCVA), dye remnants and other unexpected clinical events were documented by 21 surgeons. Results: All surgeries were uneventful, and a clear bluish staining, facilitating the identification, delineation and removal of the ILM and ERMs, was reported in all but five cases. None of the surgeries required a fluid-air exchange to assist the dye application. BCVA at 1 month after surgery improved in 83% of the eyes in the MembraneBlue-DualÔ group and in 88% in the ILM-BlueÔ group. No dye remnants were detected by ophthalmoscopy, and no retinal adverse effects related to the surgery or use of the dyes were observed. Conclusion: The 'heavy' dye solutions ILM-BlueÔ and MembraneBlue-DualÔ can be injected into a fluid-filled vitreous cavity and may facilitate staining and removal of the ILM and ⁄ or ERMs in macular surgery without an additional fluid-air exchange.

Purpose/Aim: Evaluating the suitability of bioengineered collagen sheets and human anterior lens capsules (HALCs) as carriers for cultivated porcine corneal endothelial cells (pCECs) and in vitro assessment of the cell-carrier sheets as tissue-engineered grafts for Descemet membrane endothelial keratoplasty (DMEK). Materials and Methods: pCECs were isolated, cultured up to P2 and seeded onto LinkCell™ bioengineered matrices of 20 µm (LK20) or 100 µm (LK100) thickness, and on HALC. During expansion, pCEC viability and morphology were assessed by light microscopy. ZO-1 and Na + /K +-ATPase expression was investigated by immunohistochemistry. Biomechanical properties of pCEC-carrier constructs were evaluated by simulating DMEK surgery in vitro using an artificial anterior chamber (AC) and a human donor cornea without Descemet membrane (DM). Results: During in vitro expansion, cultured pCECs retained their proliferative capacity, as shown by the positive staining for proliferative marker Ki67, and a high cell viability rate (96 ± 5%). pCECs seeded on all carriers formed a monolayer of hexagonal, tightly packed cells that expressed ZO-1 and Na + /K +-ATPase. During in vitro surgery, pCEC-LK20 and pCEC-LK100 constructs were handled like Descemet stripping endothelial keratoplasty (DSEK) grafts, i.e. folded like a "taco" for insertion because of challenges related to rolling and sticking of the grafts in the injector. pCEC-HALC constructs behaved similar to the DMEK reference model during implantation and unfolding in the artificial AC, showing good adhesion to the bare stroma. Conclusions: In vitro DMEK surgery showed HALC as the most suitable carrier for cultivated pCECs with good intraoperative graft handling. LK20 carrier showed good biocompatibility, but required a DSEKadapted surgical protocol. Both carriers might be notional candidates for potential future clinical applications.

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