Transcorneal Suture Fixation of Posterior Lamellar Grafts in Eyes With Minimal or Absent Iris–Lens Diaphragm AMIT K. PATEL, SAVERIO LUCCARELLI, DIEGO PONZIN, AND MASSIMO BUSIN ● PURPOSE: To describe a technique that uses a transcor- neal suture for safe delivery and fixation of donor tissue during Descemet stripping automated endothelial kerato- plasty in patients that are at risk of graft dislocation into the vitreous cavity as a result of minimal or absent iris–lens diaphragm. ● DESIGN: Interventional case series. ● METHODS: Thirteen eyes with endothelial decompen- sation and inadequate iris–lens diaphragm underwent modified Descemet stripping automated endothelial ker- atoplasty surgery. A 10-0 Prolene suture (Ethicon Inc) was passed through the endothelial graft and used to pull the graft into the eye and anchor it onto the recipient cornea. Best-corrected visual acuity, refraction, and com- plications were recorded. ● RESULTS: Preoperative best-corrected visual acuity was less than 20/200 in all cases. Eleven patients had a pre-existing comorbidity (glaucoma, n  8; previous retinal detachment, n  2; epiretinal membrane n  1). Average follow-up was 11.3 months (range, 3 to 36 months). No graft dislocation occurred during surgery. After surgery, graft detachment was noted in 2 cases and rebubbling succeeded in achieving reattachment. All patients had successful attachment of the endothelial graft. Postoperative best-corrected visual acuity im- proved in 11 of 13 patients and remained unchanged in 2 patients. ● CONCLUSIONS: In patients with insufficient iris–lens diaphragm, this technique allowed safe graft delivery, prevented intraoperative and postoperative graft disloca- tion, and facilitated successful rebubbling in case of postoperative graft detachment. (Am J Ophthalmol 2011;151:460 – 464. © 2011 by Elsevier Inc. All rights reserved.) S TANDARD DESCEMET STRIPPING ENDOTHELIAL KER- atoplasty (DSAEK) surgery involves stripping of Descemet membrane from the recipient cornea fol- lowed by the introduction of a posterior lamellar graft into the anterior chamber. The graft is usually delivered by means of an injector or via a pull-through technique using forceps or sutures. Once inside the eye, the donor tissue floats freely in the anterior chamber above the iris–lens diaphragm. Air is injected under the graft to fixate it against the recipient cornea. 1,2 The air bubble is trapped in the anterior chamber by the iris–lens barrier. However, if such a barrier is partly or totally breached, the graft cannot be safely delivered because it may dislocate into the vitreous cavity during insertion or intraoperative manipulation. In addition, even if the surgeon succeeded in primarily attaching the donor tissue, the air can escape into the vitreous cavity after surgery, resulting in loss of the tamponading effect and risk of graft detachment and dislocation. 3–5 Suture and viscoelastic-assisted techniques have been de- scribed previously to aid DSAEK surgery in case of partial or total absence of the iris–lens barrier. 3,4,6 We describe herein a modified technique that uses a transcorneal Prolene suture to allow safe graft delivery and anchoring onto the recipient cornea. This technique aims to eliminate the intraoperative and postoperative risk of posterior graft dislocation, while facilitating the management of postoperative graft detach- ment. The outcomes of this technique in 13 patients with endothelial decompensation and minimal or absent iris–lens diaphragm are reported. METHODS THIS PROSPECTIVE STUDY WAS UNDERTAKEN IN AN INSTI- tutional setting at the Department of Ophthalmology, Villa Serena Hospital, Forlì, Italy. Thirteen patients with corneal decompensation and minimal or absent iris–lens diaphragm were recruited into the study, which was aimed at evaluating the results of an anchoring transcorneal suture in DSAEK surgery. The diaphragm was deemed absent in the event of aphakia or when the plan was to leave the patients aphakic after surgery (ie, removal of anterior chamber intraocular lens [IOL]). Eyes with zonu- lar dehiscence in the presence of a fixed mydriasis or an iris defect of 120 degrees or more (i.e., deemed unsuitable for pupilloplasty) were classified as having a minimal dia- phragm. Iridoplasty before DSAEK surgery was not feasible (iris defect  120 degrees, n = 5; iris atrophy with fixed pupil Supplemental Material available at AJO.com. Accepted for publication Aug 31, 2010. From the Department of Ophthalmology, “Villa Serena” Hospital, Forlì, Italy (A.K.P., S.L., M.B.); and the Fondazione Banca degli Occhi del Veneto, Venice, Italy (A.K.P., D.P., M.B.). Inquiries to Amit K. Patel, Villa Serena Hospital, Via Camaldolino 8, 47100 Forlì, Italy; e-mail: amitpatel@doctors.org.uk © 2011 BY ELSEVIER INC.ALL RIGHTS RESERVED. 460 0002-9394/$36.00 doi:10.1016/j.ajo.2010.08.043