Intraoperative fibrin formation during Descemet membrane end
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Endothelial keratoplasty has become the primary surgical approach for treating disorders of the corneal endothelium, and Descemet membrane endothelial keratoplasty (DMEK) is gaining popularity as the preferred technique over Descemet stripping automated endothelial keratoplasty (DSAEK) because of its rapid visual recovery, superior visual outcomes, and lower risk of rejection. The challenges of DMEK include graft insertion and positioning due to the thinness and scrolling properties of the donor tissue. Various techniques have been described for inserting, unfolding, and positioning the graft tissue in a controlled and reproducible manner, and these steps can be made even more challenging when complicated by the unexpected formation of fibrin in the anterior chamber.

In this review of 868 cases of standardized DMEK surgery with surgical peripheral iridotomy, 32 eyes of 29 patients (3.7%) were complicated by the formation of intraoperative fibrin formation, including 3 patients that developed fibrin in both eyes. Three of the 32 grafts failed (9.4%). None of the mate corneas transplanted developed complications related to fibrin. The donor age ranged from 51 to 75 years and recipient age ranged from 49 to 82 years. Unscrolling time ranged from 1 to 105 min. Nine eyes required one rebubble procedure. No eyes had vision-limiting comorbidities, and the 6-month BSCVA was 20/40 in all eyes. Six-month ECL ranged from 19% to 73%.

In conclusion, intraoperative fibrin formation during DMEK surgery is an uncommon but important complication that can make graft unscrolling and positioning more difficult and potentially more damaging to the tissue. This reaction may have deleterious effects on endothelial cell loss and graft survival that are likely related to additional graft manipulation. Attention to intraoperative minimization of hypotony may be important in limiting fibrin occurrence during DMEK surgery.