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Graft Injection

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90° Counter Counter Clockwise Rotation

Rotate Straiko-Jones Tube Clockwise

The Dance Before the Dance: Reorient the Graft for an Efficient Unfolding

Scroll (in injector) → Irrigate and Aspirate Syringe
Double Scroll (in injector) → Controlled injection
Double Scroll (in eye) → Central tapping
Bouquet → Central tapping
Edge Fold → Fluid release, tapping, push and release, removal of injector

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Scroll

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To Open:

  • Try tapping perpendicularly to the end of the scroll. Sending fluid waves into scroll to open it.
  • Tap vertically and centrally, aligned with the long axis of the scroll. Skew your tapping to the more open or more peripheral end.
  • If the scroll is tight, consider using a cannula/BSS to “flip open” one edge. Alternatively, a Fogla cannula (opening on sides) can be inserted into scroll and BSS used to push the graft open.

Most likely next conformation(s):

  • Simple Fold (most likely)
  • Bouquet
  • Double Scroll
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Simple Fold

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To Open:

  • Use a two cannula Dirisamer technique.
  • The Red Cannula is stationary and mildly compressing the cornea.
  • The Green Cannula is dynamic. Tap just to the open side of (not on top of) the folded edge. You can direct your taps slightly toward the fold.
  • Continue to advance your dynamic cannula (Green) until the graft has opened completely, taking breaks to recenter as needed.
  • No alternative option here as this “always” works.

Most likely next conformation(s):

  • Edge Fold
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Inverted

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Video provided by Michael Straiko, M.D.

To Flip:

  • Note the confirmation of the graft (backwards S).
  • Inject small and sequential bursts of BSS along the iris plane.
  • Use the BSS to “push” the folded edge around and thus roll the graft over.
  • If a shallow AC is maintained, the graft will remain unscrolled.

Most likely next conformation(s):

  1. Scroll
  2. Simple Fold
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Double Scroll

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To Open:

  • Tap directly down on the center of the graft along the long axis.

Most likely next conformation(s):

  1. Simple Fold (most likely)
  2. Bouquet (if eccentric tapping)
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Bouquet

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Video provided by Michael Straiko, M.D.

To Open:

  • Tap directly down on the center of the graft along the long axis. Skew tapping toward the more open end, treating it as if it were a double scroll.
  • Tap at open end, perpendicular to long axis and march taps centrally as graft opens. This maneuver takes advantage of the asymmetry of this conformation.

Most likely next conformation(s):

  1. Simple/edge Fold(s)
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Edge Fold

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To Open:

  • Slowly indent the cornea peripheral to the edge fold and then quickly release. This will “pull” the edge open.
  • Use a Dirisamer technique or simple tapping (without static/red cannula) to open the fold.
  • Burp aqueous from an existing wound (ideally a para) to “pull” the edge open. This may require rotating the graft (sweep the cornea along edge of graft in a path that is tangential to the limbus).
  • If the fold is very small and the graft is centered, just go ahead and place a moderate size gas bubble.

Most likely next conformation(s):

  1. Done!
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Origami

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To Resolve:

  • Deepen the anterior chamber with BSS through a para, using the BSS current and space created to help re-orient the graft.
  • Tap along apex or inside of the fold and it should straighten out into a scroll (deep chamber required).

Most likely next conformation(s):

  1. Scroll
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Taco

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It Depends:

  • Smaller side on the top (40/60)
    • This is a (slightly more difficult) Simple Fold
    • Open with Dirisamer (see Simple Fold)
  • Smaller Side on bottom (60/40)
    • This graft is Inverted.
    • Jet BSS along iris surface (see Inverted) to roll the graft over.
  • 50/50 Taco
    • No way to open a 50/50 with tapping.
    • Jet BSS along iris surface (see Inverted) to roll the graft over.

Most likely next conformation(s):

  1. Simple Fold
  2. Scroll (if deepen AC with BSS)
  3. Origami
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Let's Dance! - One Step Back, Three Steps Forward

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50/50 Taco → Attempted Roll with BSS
Origami → Tap (Already Deep)
Simple Fold → Dirisamer Technique
Edge Folds → Release Fluid, Indent and Release, Simple Tapping

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Try to Open the Graft Prior to Removing the Injector

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Smaller side on the top (40/60)

  • This is a (slightly more difficult) Simple Fold
  • Open with Dirisamer (see Simple Fold)

Smaller Side on bottom (60/40)

  • This is Inverted
  • Jet BSS along iris surface (see inverted) to roll graft over

50/50 Taco

  • No way to open a 50/50 with tapping
  • Jet BSS along iris surface (see inverted) to roll graft over/reorient

Most likely next conformation(s):

  1. Simple Fold
  2. Scroll (if deepen AC with BSS)
  3. Origami

The Dance Before the Dance: Reorient the Graft for an Efficient Unfolding

Scroll (in injector) → Irrigate and Aspirate Syringe
Double Scroll (in injector) → Controlled injection
Double Scroll (in eye) → Central tapping
Bouquet → Central tapping
Edge Fold → Fluid release, tapping, push and release, removal of injector

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The above content was created by Peter Veldman, MD with the support of Lions VisionGift, and may not be reproduced without express permission from the author. Permission will not be granted for commercial uses.

Peter Veldman, MD
Assistant Professor
Vice Chair for Education
Residency Program Director

University of Chicago
Department of Ophthalmology and Visual Science

5841 S. Maryland Avenue MC 2114
Chicago, IL 60637

p. 773.702.5984
f. 773.926.0685
e. pveldman@bsd.uchicago.edu

DMEK Conformation Handout (PDF)