Rebubbling Techniques for Graft Detachment After Descemet Membrane Endothelial Keratoplasty

To describe rebubbling techniques in eyes with a visually significant graft detachment after Descemet membrane endothelial keratoplasty (DMEK).

Retrospective observational analysis at a tertiary referral center. A total of 41 eyes (39 patients) received rebubbling: 39 eyes (37 patients) had 1 and 2 eyes had 2 rebubbling procedures. Anterior segment optical coherence tomography and surgical videos were used to determine the best incisional approach for air injection, intraoperative maneuvers, and success rate (graft reattachment) at 1 week postoperatively.

Rebubbling was performed on average 26 (±21) days (range: 7-92 days) after DMEK. Graft edge visibility and configuration of graft detachment were important parameters for the incisional approach for air injection: the air cannula was introduced in the area of graft attachment (attached area approach) (n = 25) or detachment (detached area approach) (n = 16). After excluding upside-down grafts (n = 3), the rebubbling success rate in total was 87% (33/38 eyes); in the attached area approach, it was 92% (22/24 eyes); and in the detached area approach, it was 79% (11/14). Of 14 eyes that had rebubbling later than 1 month postoperatively, 11 were successful; in 8 eyes, the graft seemed too stiff and/or immobile to allow complete unfolding.

Rebubbling 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 (>1 month postoperatively) may still produce graft reattachment, but increased graft stiffness and/or fibrosis may complicate complete graft unfolding.