Pre-Descemet’s Endothelial Keratoplasty

Injection of Graft, Identifying Orientation of Graft, Unfolding and Flotation of Graft

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This segment details the injection of the graft, identification of the orientation of the graft, unfolding and flotation of the graft.


  • graft
  • recipient eye
  • anterior chamber
  • E-DMEK
  • E-PDEK
  • Descemet’s membrane
  • cornea

Conflict of Interest

The author declares no conflict of interest.

About this video

Soosan Jacob
First online
01 April 2020
Online ISBN
Springer, Cham
Copyright information
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020

Video Transcript

This video deals with injection of the graft, identification of orientation of the graft, unfolding and flotation of the graft. As we saw earlier, the recipient eye has already been prepared, and the graft has already been loaded into a cartridge and put onto the injector.

Now, you verify that the graft is oriented right side up within the cartridge itself by using the endoluminator technique, as demonstrated earlier. All the air bubble is removed from the recipient eye, and the graft is injected in such a manner that the graft is delivered the right side up into the anterior chamber. It’s important to hold the lip of the incision while pulling the cartridge out to prevent a backflush our reflux of the graft out through the main port.

We now switch off the microscope light and check the orientation of the graft using the endoluminator light, and this is the E-DMEK technique or the E-PDEK technique that was described by me. This utilizes the reflections from the oblique light of an endoluminator to identify that the graft is facing the right side up.

Since the Descemet membrane is elastic, the graft always goes towards the Descemet membrane side, and therefore the correct orientation is when the graft is curled facing upwards. This, as described earlier, can be easily confirmed with the E-PDEK or the endoluminator assisted technique.

It is now time for the graft to be opened up. And as you can see here, two blunt instruments are used. The graft is held at one edge, and the other fold is opened outwards. And this can be assisted by shallowing the anterior chamber out.

There are various ways to unfold the graft, and the viewer is directed to look at the further reading section to understand these in much greater detail. In this case, as seen here, we first center the graft and moved it to the center of the anterior chamber. And once that’s done, one of the limbs is opened up by again using these gentle tapping movements. It is very helpful to also keep the anterior chamber shallow at the same time.

And once the graft is mostly opened up, you can see that there might be some small edge folds at one side or both sides. If these edge folds are substantially large, they can be opened out as seen here further by using these gentle tapping movements. But if they are very small edge folds, you can just go ahead and inject air to float the graft up.

A 27-gauge cannula is then introduced through the side port or the main port carefully in such a way that it goes under the graft and over the iris. And once it reaches near the center of the pupil, air is injected to float the graft up against the overlying cornea.