Aphakic DMEK

Aphakic eyes with a large iris defect (unicameral eyes) are typically operated on using DSAEK and a safety suture technique to guard against posterior dislocation. Here we are sharing our experience of techniques for creating a temporary barrier between the anterior and posterior chambers in unicameral eyes to facilitate DMEK. Unicameral eyes have often had multiple previous surgeries, ongoing problems with inflammation and secondary glaucoma, and are therefore at a relatively high risk for rejection. Advantages for DMEK in this context are relatively low graft rejection rates, and relative protection from postoperative posterior dislocation (most DMEK dislocations are partial). We start by showing the use of an ICL as a temporary barrier. This is relatively high cost, and technically difficult. We believe the safety net suture technique, in which a cats cradle of horizontal and vertical passes (3x5 or 5x5) across the anterior chamber is created with a continuous 10/0 polypropylene suture on a double armed straight needle, is a more accessible and technically easier approach. It may be useful where a full anterior segment reconstruction, nicely described by Donald Tan from Singapore in recent presentations, is not indicated; either to minimise risk in a successful contact lens wearer, or as an alternative to a Gundersen flap in eyes with poor visual potential that have had previous retinal or glaucoma drainage surgery (making conjunctival dissection very difficult).