“Bubble-in-the-Roll” Technique Using the Endoject DMEK Injector: Influence of the Air Bubble on Endothelial Cell Loss

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To evaluate the impact of the air bubble on endothelial cell loss using the “bubble-in-the-roll” technique during Descemet membrane endothelial keratoplasty (DMEK).


Twenty DMEK grafts not suitable for transplantation were manually prepared from organ-cultured corneoscleral discs and injected into culture media using the Endoject DMEK injector (Medicel AG, Wolfhalden, Switzerland). Based on the injection method, the grafts were divided into 2 groups: In group A (n = 10), a small air bubble was placed inside the graft roll while it was in the injector. In group B (n = 10), the grafts were injected without an air bubble inside the graft roll. Main outcome measures included endothelial cell density (ECD) after graft stripping and graft injection.


There were no statistically significant differences between groups A and B in donor age, storage duration, and donor ECD. ECD decreased from 1929 ± 145 cells/mm2 to 1796 ± 303 cells/mm2 after graft stripping in group A and from 1801 ± 226 cells/mm2 to 1709 ± 290 cells/mm2 in group B. ECD after graft injection further decreased to 1683 ± 291 cells/mm2 in group A and to 1651 ± 292 cells/mm2 in group B. Endothelial cell loss after graft stripping and graft injection was not statistically significant between groups A and B (P = 0.29 and P = 1, respectively).


The bubble-in-the-roll technique for injection and unfolding of the graft is a safe method for graft delivery into the anterior chamber guaranteeing orientation of the graft without harming the endothelium.

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