CORRESPONDENCE
Technique to F mark Descemet-stripping endothelial keratoplasty graft Pietro Viola, MD, Sandro Soldati, MD, Romeo Altafini, MD, Roberto Cian, MD Endothelial keratoplasty has evolved into a popular alternative to penetrating keratoplasty (PKP) for the treatment of endothelial dysfunction.1 Since its introduction, endothelial keratoplasty has progressed toward a graft thickness as thin as possible. During this progression, various technical and surgical challenges had to be overcome. Although the earliest iterations were challenging and were not widely adopted, the iteration known as Descemet-stripping endothelial keratoplasty (DSEK) has gained widespread acceptance. Studies show that a newer endothelial keratoplasty iteration, Descemet membrane endothelial keratoplasty (DMEK), provides an even faster and better visual recovery than DSEK. In addition, DMEK significantly reduces the risk for immunologic graft rejection episodes compared with the risk in DSEK or PKP. Although the DMEK donor tissue, consisting of the bare endothelium and Descemet membrane without any stroma, is more challenging to prepare and position in the recipient eye, recent improvements in instrumentation and surgical techniques are increasing the ease and the reliability of the procedure.1–3 In 2013, Muraine et al.4 described a reliable technique that significantly improved the safety and repeatability of donor graft preparation, which also led to some improvement in donor graft management once inside the anterior chamber. The proper orientation of the graft remains a matter of surgeon experience. The technique we describe would fill this gap and although it has been derived from Muraine et al.’s technique,4 it might be applicable to some of the previous techniques. According to Muraine et al.’s technique,4 the donor graft is obtained by hydrodissecting a donor cornea placed on an artificial anterior chamber filled with air, endothelium side up. After this is completed, the Descemet–endothelium complex will be lying on the inverted corneal stroma. The lamella is now folded in 3 parts, envelope style, to fold the graft with the endothelium inside. At this point, the original technique is modified. The stroma next to the folded graft is gently pressed and a straight flat spatula painted with gentian violet on the inferior side is slid under the graft to obtain a straight groove running underneath the folded graft with a violet line painted on the stroma. After the Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
Figure 1. Second short segment parallel to the shorter meridian to finish inverted F.
spatula is removed, the stroma will return to its original shape. The gentian violet will be transferred by contact from the stroma to the graft's descemetic side, obtaining an effective indirect coloration. This procedure is repeated 3 times to obtain an inverted F letter. The longer segment of the F should be performed parallel to the longer meridian of the folded graft and the other 2 segments, parallel to the shorter meridian (Figure 1). At this point, the technique returns to that of Muraine et al.4 The graft is loaded in the cartridge, the cartridge is turned upside down, and the graft is injected. The surgeon can easily and unequivocally tell whether the graft is correctly oriented by looking at the F in the paracentral part of the lamella (Figure 2). Many other techniques have been used to visualize the proper orientation of the graft, such as shapecutting the edge of the lamella,4 handheld slit beam,5 intraoperative optical coherence tomography,6 and Moutsouris sign.7 The one we are proposing is a Descemet-stripping automated endothelial keratoplasty (DSAEK)-style technique that is diffusely used and therefore more familiar to most corneal surgeons. It is easy and inexpensive compared with most of the previous orientation
Figure 2. The F mark.
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.08.011
1743
1744
CORRESPONDENCE
techniques. Our marking maneuver is basically the same as the maneuver used to fold the graft, performed right after the folding itself, but in a paracentral zone, which will be highly visible even through a cloudy cornea at almost every moment during the positioning phase; it does not matter whether there is a peripheral opacity such as gerontoxon or a partially rolled graft. The safety of gentian violet has been proven on DSAEK grafts8 and according to our experience, indirect DMEK graft coloration will not be visible 2 days after the surgery. On the contrary, direct painting of the graft provides a color deposit and could result in a descemetic permanent tattoo.
REFERENCES 1. Price FW Jr, Price MO. Evolution of endothelial keratoplasty. Cornea 2013; 32(suppl 1):S28–S32 2. Melles GRJ, Ong TS, Ververs B, van der Wees J. Preliminary clinical results of Descemet membrane endothelial keratoplasty. Am J Ophthalmol 2008; 145:222–227 3. Price MO, Giebel AW, Fairchild KM, Price FW Jr. Descemet’s membrane endothelial keratoplasty; prospective multicenter study of visual and refractive outcomes and endothelial survival. Ophthalmology 2009; 116:2361–2368 4. Muraine M, Gueudry J, He Z, Piselli S, Lefevre S, Toubeau D. Novel technique for the preparation of corneal grafts for Descemet membrane endothelial keratoplasty. Am J Ophthalmol 2013; 156:851–859 5. Burkhart ZN, Feng MT, Price MO, Price FW. Handheld slit beam techniques to facilitate DMEK and DALK. Cornea 2013; 32:722–724 6. Steven P, Le Blanc C, Velten K, Lankenau E, Krug M, € ttmann G, Cursiefen C. Oelckers S, Heindl LM, Gehlsen U, Hu Intraoperative optical coherence tomography. JAMA Ophthalmol 2013; 131:1135–1142 7. Dapena I, Moutsouris K, Droutsas K, Ham L, van Dijk K, Melles GRJ. Standardized “no-touch” technique for Descemet membrane endothelial keratoplasty. Arch Ophthalmol 2011; 129:88–94. Available at: http://archopht.jamanetwork.com/ data/Journals/OPHTH/10230/est05009_88_94.pdf. Accessed May 26, 2014 8. Stoeger C, Holiman J, Davis-Boozer D, Terry MA. The endothelial safety of using a gentian violet dry-ink “S” stamp for precut corneal tissue. Cornea 2012; 31:801–803
Lessons from implementation of an intraocular lens timeout
innovations such as intraoperative aberrometry aim to improve the accuracy of IOL selection, this added information makes it even more critical to verify that the intended IOL is the one inserted. Although multiple IOL checklists are publicly available, there are scant data on the success of their implementation. At the University of Washington, an IOL timeout was mandated in July 2012. The protocol requires the circulator to verify the patient's name on the IOL sheet preoperatively and cross off the nonoperative eye. It also requires the surgeon and circulator to pause during the case before the IOL is opened to check the IOL sheet and to confirm the patient, eye, and IOL type and power. Approximately 6 months after timeout implementation, all resident and attending physicians (other than the first author) who perform cataract surgery at the Eye Institute were invited to take an online survey as part of the department's quality improvement process. Another survey was sent to all staff who take part in cataract surgery. RESULTS The response rate was 100% for attending surgeons (n Z 8), 75% (6/8) for residents, and 100% for staff identified by the nurse manager as most frequently involved in cataract cases (n Z 15). Many more staff members give occasional breaks in the hospital operating room setting, so 107 in total were invited to participate (23.3% response rate). Surgeons All attending surgeons agreed or strongly agreed that they performed the timeout consistently, and 79% agreed it was useful. Thirty-six percent of attendings did not identify the patient and 21% the operative eye as essential timeout elements, and 43% did not agree they felt adequately trained (Table 1). However, 1 attending decided to change the IOL power in 1 case during the timeout, and 1 resident reported that the supervising attending changed the resident's IOL selection during the timeout. Operating Room Staff
Bryan S. Lee, MD, JD, Philip P. Chen, MD In both the medical and lay literature, use of checklists and timeouts has gained wide support as an adaptation of safety processes from airlines and other industries.1,2 One of the most common errors in ophthalmology is insertion of the wrong intraocular lens (IOL), which is a major source of patient dissatisfaction and malpractice litigation.3,4 Although
Ninety-two percent of staff agreed the timeout was useful and 84% that it was always performed (Table 2). However, 48% did not agree it was performed consistently. Twenty-eight percent did not identify the patient and 24% the operative eye as essential timeout elements, and 64% had difficulty identifying the intended IOL from the calculation sheet. Multiple respondents indicated that standardization of specifying the intended IOL would be
J CATARACT REFRACT SURG - VOL 40, OCTOBER 2014
Technique to F mark Descemet-stripping endothelial keratoplasty graft Pietro Viola, MD, Sandro Soldati, MD, Romeo Altafini, MD, Roberto Cian, MD Endothelial keratoplasty has evolved into a popular alternative to penetrating keratoplasty (PKP) for the treatment of endothelial dysfunction.1 Since its introduction, endothelial keratoplasty has progressed toward a graft thickness as thin as possible. During this progression, various technical and surgical challenges had to be overcome. Although the earliest iterations were challenging and were not widely adopted, the iteration known as Descemet-stripping endothelial keratoplasty (DSEK) has gained widespread acceptance. Studies show that a newer endothelial keratoplasty iteration, Descemet membrane endothelial keratoplasty (DMEK), provides an even faster and better visual recovery than DSEK. In addition, DMEK significantly reduces the risk for immunologic graft rejection episodes compared with the risk in DSEK or PKP. Although the DMEK donor tissue, consisting of the bare endothelium and Descemet membrane without any stroma, is more challenging to prepare and position in the recipient eye, recent improvements in instrumentation and surgical techniques are increasing the ease and the reliability of the procedure.1–3 In 2013, Muraine et al.4 described a reliable technique that significantly improved the safety and repeatability of donor graft preparation, which also led to some improvement in donor graft management once inside the anterior chamber. The proper orientation of the graft remains a matter of surgeon experience. The technique we describe would fill this gap and although it has been derived from Muraine et al.’s technique,4 it might be applicable to some of the previous techniques. According to Muraine et al.’s technique,4 the donor graft is obtained by hydrodissecting a donor cornea placed on an artificial anterior chamber filled with air, endothelium side up. After this is completed, the Descemet–endothelium complex will be lying on the inverted corneal stroma. The lamella is now folded in 3 parts, envelope style, to fold the graft with the endothelium inside. At this point, the original technique is modified. The stroma next to the folded graft is gently pressed and a straight flat spatula painted with gentian violet on the inferior side is slid under the graft to obtain a straight groove running underneath the folded graft with a violet line painted on the stroma. After the Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
Figure 1. Second short segment parallel to the shorter meridian to finish inverted F.
spatula is removed, the stroma will return to its original shape. The gentian violet will be transferred by contact from the stroma to the graft's descemetic side, obtaining an effective indirect coloration. This procedure is repeated 3 times to obtain an inverted F letter. The longer segment of the F should be performed parallel to the longer meridian of the folded graft and the other 2 segments, parallel to the shorter meridian (Figure 1). At this point, the technique returns to that of Muraine et al.4 The graft is loaded in the cartridge, the cartridge is turned upside down, and the graft is injected. The surgeon can easily and unequivocally tell whether the graft is correctly oriented by looking at the F in the paracentral part of the lamella (Figure 2). Many other techniques have been used to visualize the proper orientation of the graft, such as shapecutting the edge of the lamella,4 handheld slit beam,5 intraoperative optical coherence tomography,6 and Moutsouris sign.7 The one we are proposing is a Descemet-stripping automated endothelial keratoplasty (DSAEK)-style technique that is diffusely used and therefore more familiar to most corneal surgeons. It is easy and inexpensive compared with most of the previous orientation
Figure 2. The F mark.
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.08.011
1743
1744
CORRESPONDENCE
techniques. Our marking maneuver is basically the same as the maneuver used to fold the graft, performed right after the folding itself, but in a paracentral zone, which will be highly visible even through a cloudy cornea at almost every moment during the positioning phase; it does not matter whether there is a peripheral opacity such as gerontoxon or a partially rolled graft. The safety of gentian violet has been proven on DSAEK grafts8 and according to our experience, indirect DMEK graft coloration will not be visible 2 days after the surgery. On the contrary, direct painting of the graft provides a color deposit and could result in a descemetic permanent tattoo.
REFERENCES 1. Price FW Jr, Price MO. Evolution of endothelial keratoplasty. Cornea 2013; 32(suppl 1):S28–S32 2. Melles GRJ, Ong TS, Ververs B, van der Wees J. Preliminary clinical results of Descemet membrane endothelial keratoplasty. Am J Ophthalmol 2008; 145:222–227 3. Price MO, Giebel AW, Fairchild KM, Price FW Jr. Descemet’s membrane endothelial keratoplasty; prospective multicenter study of visual and refractive outcomes and endothelial survival. Ophthalmology 2009; 116:2361–2368 4. Muraine M, Gueudry J, He Z, Piselli S, Lefevre S, Toubeau D. Novel technique for the preparation of corneal grafts for Descemet membrane endothelial keratoplasty. Am J Ophthalmol 2013; 156:851–859 5. Burkhart ZN, Feng MT, Price MO, Price FW. Handheld slit beam techniques to facilitate DMEK and DALK. Cornea 2013; 32:722–724 6. Steven P, Le Blanc C, Velten K, Lankenau E, Krug M, € ttmann G, Cursiefen C. Oelckers S, Heindl LM, Gehlsen U, Hu Intraoperative optical coherence tomography. JAMA Ophthalmol 2013; 131:1135–1142 7. Dapena I, Moutsouris K, Droutsas K, Ham L, van Dijk K, Melles GRJ. Standardized “no-touch” technique for Descemet membrane endothelial keratoplasty. Arch Ophthalmol 2011; 129:88–94. Available at: http://archopht.jamanetwork.com/ data/Journals/OPHTH/10230/est05009_88_94.pdf. Accessed May 26, 2014 8. Stoeger C, Holiman J, Davis-Boozer D, Terry MA. The endothelial safety of using a gentian violet dry-ink “S” stamp for precut corneal tissue. Cornea 2012; 31:801–803
Lessons from implementation of an intraocular lens timeout
innovations such as intraoperative aberrometry aim to improve the accuracy of IOL selection, this added information makes it even more critical to verify that the intended IOL is the one inserted. Although multiple IOL checklists are publicly available, there are scant data on the success of their implementation. At the University of Washington, an IOL timeout was mandated in July 2012. The protocol requires the circulator to verify the patient's name on the IOL sheet preoperatively and cross off the nonoperative eye. It also requires the surgeon and circulator to pause during the case before the IOL is opened to check the IOL sheet and to confirm the patient, eye, and IOL type and power. Approximately 6 months after timeout implementation, all resident and attending physicians (other than the first author) who perform cataract surgery at the Eye Institute were invited to take an online survey as part of the department's quality improvement process. Another survey was sent to all staff who take part in cataract surgery. RESULTS The response rate was 100% for attending surgeons (n Z 8), 75% (6/8) for residents, and 100% for staff identified by the nurse manager as most frequently involved in cataract cases (n Z 15). Many more staff members give occasional breaks in the hospital operating room setting, so 107 in total were invited to participate (23.3% response rate). Surgeons All attending surgeons agreed or strongly agreed that they performed the timeout consistently, and 79% agreed it was useful. Thirty-six percent of attendings did not identify the patient and 21% the operative eye as essential timeout elements, and 43% did not agree they felt adequately trained (Table 1). However, 1 attending decided to change the IOL power in 1 case during the timeout, and 1 resident reported that the supervising attending changed the resident's IOL selection during the timeout. Operating Room Staff
Bryan S. Lee, MD, JD, Philip P. Chen, MD In both the medical and lay literature, use of checklists and timeouts has gained wide support as an adaptation of safety processes from airlines and other industries.1,2 One of the most common errors in ophthalmology is insertion of the wrong intraocular lens (IOL), which is a major source of patient dissatisfaction and malpractice litigation.3,4 Although
Ninety-two percent of staff agreed the timeout was useful and 84% that it was always performed (Table 2). However, 48% did not agree it was performed consistently. Twenty-eight percent did not identify the patient and 24% the operative eye as essential timeout elements, and 64% had difficulty identifying the intended IOL from the calculation sheet. Multiple respondents indicated that standardization of specifying the intended IOL would be
J CATARACT REFRACT SURG - VOL 40, OCTOBER 2014
