First Report of Flipping Endothelial Graft Technique Effectiveness in a Non-Fuchs Patient

Introduction

Descemet membrane endothelial keratoplasty (DMEK) has gained increased importance in the field of corneal endothelial transplantation. As well as being an overall faster procedure, DMEK achieves a more rapid and superior visual outcome. Unfortunately, it remains technically challenging and therefore its adoption worldwide is still pending [1].

One of the main challenges of DMEK for surgeons is the difficulty to correctly ascertain proper graft orientation intraoperatively. This is especially true in cases presenting with corneal edema and reduced anterior chamber (AC) visibility, an S-like graft orientation, or an intraoperative loss of tissue staining agent. Furthermore, intraoperative graft manipulation substantially reduces the quality of the transplanted graft and induces endothelial cell loss [1].

Various techniques exist to ensure proper graft orientation intraoperatively (VisionBlue tissue staining, blue cannula/Moutsouris sign, S or F stamp, peripheral marks, the use of slit beam) as well as intraoperative anterior segment optical coherence tomography (AS-OCT). Nevertheless, graft misorientation remains a possible outcome even for experienced surgeons.

Conventionally, upside-down graft orientation means retransplantation using a new donor corneal graft. In cases of Fuchs endothelial corneal dystrophy (FECD), it could mean waiting for a potential graft colonization by host peripheral endothelial cells. For ethical reasons, the realization of a prospective study in which an upside-down graft left in place is not feasible and waiting for the possibility of an uncertain result in cases of FECD is obviously not ideal. Furthermore, widespread shortage and scarcity of tissue in corneal banks is a known problem, aggravated by lost donor grafts during failed operations [2].

In light of this problem, and in order to assess the viability of upside-down graft reorientation as a means of tackling it, we report a case of DMEK in which an inverted/upside-down graft was observed postoperatively in a patient not presenting with FECD. Successful graft repositioning was carried out during reoperation 1 week after the initial procedure, with a successful 1-year postop follow-up.

Publication History

Received: 18 June 2021

Accepted: 06 February 2022

Article published online:
26 April 2022

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