gms | German Medical Science

Objective: To describe re-bubbling techniques in eyes with a visually significant graft detachment after Descemet membrane endothelial keratoplasty (DMEK).

Method: Retrospective observational analysis at a tertiary referral center. A total of 41 eyes (39 patients) received re-bubbling: 39 eyes (37 patients) had a single and two had two re-bubbling procedures. Anterior segment optical coherence tomography and surgical videos were used to determine the best incisional approach for air injection, intraoperative maneuvers, and the success rate (graft re-attachment) at one week postoperatively.

Results: Re-bubbling was performed on average 26 (±21) days (range: 7-92 days) after DMEK. Graft-edge visibility and graft detachment type were important parameters for the area of air injection: either where the graft was attached ('attached area approach') (n=25) or detached ('detached area approach') (n=16). Excluding upside-down grafts (n=3), resulted in a total re-bubbling success rate of 87% (33/38 eyes); ‘attached area approach’ 92% (22/24 eyes) and the ‘detached area approach’ 79%, (11/14). Fourteen eyes were re-bubbled after one month postoperatively; 11 were successful, but in eight eyes the graft appeared too stiff and/or immobile to allow complete unfolding.

Conclusion: Re-bubbling is a feasible procedure to manage graft detachment after DMEK if the graft is correctly oriented. Proper preoperative planning may aid in minimizing intraoperative complications and may increase the success rate. Late interventions (> one month postoperatively) may still produce graft attachment, but increased graft stiffness and/or fibrosis may complicate complete graft unfolding.