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The Mystery beneath the Cornea

The Mystery beneath the Cornea (DMEK + Phacoemlsification) Welcome to a transformative journey into the world of ophthalmology! In this comprehensive video, we unravel the mysteries behind one of the most groundbreaking advancements in eye surgery: DMEK, or Descemet Membrane Endothelial Keratoplasty. Descemet’s membrane endothelial keratoplasty (DMEK) is a partial thickness posterior cornea transplant where the host descemet membrane (DM) and endothelium are replaced by donor DM and endothelium. This is different than Descemet’s stripping endothelial keratoplasty (DSEK) where donor DM, endothelium, and posterior stroma replace the host DM and endothelium. A 65yr old female presented with progressive diminution of vision with photophobia in both eyes. Her UCVA RE- 3/60 LE 6/18 On Slit lamp examination,there were multiple diffuse corneal opacities/lesions at the level of Endothelium.Senile cataract in both eyes. we ordered AS-OCT and Specular microscopy AS-OCT shows prescence of deposits over the endothelium layer and specular microscopy shows presence of guttae. Fundus is WNL and IOP is Normal. Since the patient had overlapping features of PPMD and Fuch's.we wonder if we are dealing with an atypical variant of PPMD.Since the deposits were in the centre and causing her visual disturbance we planned to do DMEK+ phaco for this patient. A) donor preparation - peeling of DM -after staining with trypan blue,donor tissue partially punched with 10mm trephine -sinskey hook used to delineate ledge between DM and stroma 360degrees -edges stained with trypan blue again -DM held from one side and peeled off gradually upto 2/3rd tissue circumference. -full thickness stromal punch with 3mm trephine . -DM fold rolled back using BSS B) Descemetorhexis:it's done under viscoelastic in two parts scoring and scraping . scoring- (pressure just more than touch) done 360° using reverse sinskey.A more peripheral approach is taken with the aim of removing the DM in one go. scraping done to remove DM entirely but it didnt come off easily rather it was tearing up in parts along with the deposits.these deposits have a gritty feel to them.tried removing the deposits with single port aspiration but it wasnt effective.main entry made with 2.8mm keratome and visco expression is tried.the bigger deposits could come out with this method.Tried to remove the residual deposits with single port aspiration cannula but it again was not effective.next we tried to remove the remaining deposits with bimanual irrigation and aspiration cannulas.With this the remaining deposits could be cleared effectively.we ensure that the anterior chamber is cleared of all the debris. C) Phacoemulsification: routine phaco is performed and foldable iol is implanted in the bag. D) peripheral iridectomy done at 5 och using vitrector(cut rate -60) -epithelial debridement done with 15no. blade -infero temporysideport is made -residual DM tags removed using single port aspiration cannula -full chamber air injected -graft size measured with castroviejo's callipers E)donor prep part 2: stamping and graft roll -graft placed on flat side of teflon block with endothelial side facing downwards -bed dried using merocel sponge -p-mark placed using p-marker -stromal button placed back -donor tissue flipped back with endothelial side up -desired partial trephination of donor tissue done and trypan blue instilled -peripheral rim of DM removed -complete DM peeling done -trypan blue instilled and left for 2 minutes -bss injected drop by drop as DM rolls up and aspirated in injector D)graft insertion: -air replaced with bss -DM roll injected in correct orientation (empty side of triangle up) -gentle taps done on the cornea to unfold the graft -2 cannula technique used to unfold the graft graft centration achieved by tapping on limbus with cannula -full chamber air injected. -BCL placed. The patient achieved BCVA of 6/9 at 1month post op. Histopathological examination of the deposits revealed PAS +ve DM along with guttae and few Endothelial cells with focal amorphous deposits. Immunohistochemistry revealed cytokeratin deposits along the line of DM. These findings confirmed it to be a rare case of PPMD with guttae.