PMC5816860_01
Photographs showing the modified DSAEK surgical technique using OVDs. (a) After securing the wound with interrupted 10-0 Nylon sutures, air was injected under the graft to fill the anterior chamber as much as possible. Injection was stopped when air began to migrate from the sclera flap into the bleb space (black star). (b) Then we penetrated the conjunctiva apart from the bleb by inserting a 30 G needle into the bleb and injecting Healon V. (c) Healon V was injected into the bleb until the encapsulated space was completely filled and the shape of the air bubble in the anterior chamber (AC) became deformed (arrows). (d) The DSAEK graft became firmly attached due to the pressure of the injected air, which also facilitated the draining of the remaining interface fluid. After 15 min, we confirmed that adequately high IOP was maintained by the air bubble in the AC (white star).
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fig1
The injection continued until the encapsulated space was completely filled and the shape of the air bubble in the anterior chamber became deformed (Figure 1). The pressure provided by this air-filling procedure pushed the remaining fluid from the interface between the graft and the back surface of the cornea, allowing it to drain through the stab incisions, which resulted in firm graft attachment.
Representative slit-lamp microscopy photographs and anterior-segment optical coherent tomography images of Case 1. (a, b) Advanced bullous keratopathy with functional bleb before the secondary DSAEK surgery. (c, d) Six months after the first DSAEK surgery, the edematous DSAEK graft is observed on the back surface of the corneal stroma. The entire cornea shows remarkable edema. (e, f) One month after the secondary modified DSAEK procedure, the cornea became clear. An anterior-segment optical coherent tomography image shows that the graft was completely attached; no edema was observed.
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fig2
Optimal graft attachment was achieved without bleb leakage or microbial infection (Figure 2).
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