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Arnaiz Camacho, S. Martín Nalda, T. Pablos Jiménez, S. García Hidalgo, A. Pairó Salvador, M.A. Zapata Victori" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Arnaiz Camacho" "email" => array:1 [ 0 => "albert.arnaiz@vallhebron.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Martín Nalda" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Pablos Jiménez" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "García Hidalgo" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Pairó Salvador" ] 5 => array:2 [ "nombre" => "M.A." "apellidos" => "Zapata Victori" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Ophthalmology, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Re-<span class="elsevierStyleItalic">Descemet Membrane Endothelial Keratoplasty</span> (DMEK) con preservación del injerto original tras <span class="elsevierStyleItalic">free roll</span> en cámara anterior: a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3003 "Ancho" => 2925 "Tamanyo" => 898111 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Surgical scheme of re-DMEK with preservation of the original graft. A) De-epithelialization. B) Air bubble infusion. C) Trypan blue infusion. D) Introduction of air bubble. E) Unfolding of the graft. F) Adhesion of the graft to the stroma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Minimally invasive lamellar transplantation techniques such as descemet membrane endothelial keratoplasty (DMEK) have reduced the morbidity associated with penetrating keratoplasty in patients with endothelial dysfunction. Even so, these are complex techniques that are not free of complications and require a long surgical learning curve and an even more demanding experience in postoperative management.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The recent introduction of intraoperative optical coherence tomography (OCT) has had a very positive impact on surgical outcomes, decreasing the rate of graft malorientation (<span class="elsevierStyleItalic">upside down</span>) and facilitating graft manipulation and positioning.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Through a review of the published literature on the subject, we can see that graft detachment constitutes one of the most common post-surgical complications in DMEK surgery. In the first published series, an incidence of around 62% of partial and 30% of complete detachments was identified. However, with surgical learning and perfection of the technique, as well as the introduction of new technologies, the average incidence of debonding is currently estimated at 34–36%, with complete debonding being very infrequent.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In addition to slit-lamp examination, anterior segment OCT (AS-OCT) has established itself as the main diagnostic tool in these cases, and allows planning the most appropriate treatment strategy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> On the one hand, in partial or incomplete detachments, early <span class="elsevierStyleItalic">re-bubbling</span> of the air bubble is the method of choice.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> This technique, carried out under aseptic conditions both in the operating room and in the practice, followed by an interval of rest in the supine decubitus position, is usually sufficient to resolve most sectorial detachments.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand, there are total or complete detachments that cannot be corrected by the <span class="elsevierStyleItalic">re-bubbling</span> technique and in most cases require a new transplantation. The presence of the detached graft in the anterior chamber causes inevitable mechanical damage to the graft and persistent edema in a cornea without an endothelial-descema complex. For this reason, ideally these second surgeries should be performed preferentially and consist of the removal of the free graft and the introduction of a new one. However, the limited availability of donor corneas and adequate processing time by tissue banks condition the therapeutic decision and in some cases repositioning of the original graft has been attempted.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the above described scenarios, both the opacity of the media and the difficulty of manipulating the donor cornea make the surgical technique very difficult. Limited experience in these cases prevents the standardization of a procedure or specific surgical steps and generally leads to greater improvisation on the part of the surgeon with heterogeneous results.</p><p id="par0035" class="elsevierStylePara elsevierViewall">There are few publications and cases in which this type of situation and its management are presented in the literature. However, Menassa et al. described a unique case and proposed a new technique that could become the <span class="elsevierStyleItalic">Gold Standard</span>.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The aim of this text is to shed light on cases of re-DMEK with preservation of the original graft after complete detachment by describing a clinical case in which a management inspired by the technique described by Menassa et al. was used and allowing comparison of the results with the contralateral eye.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Clinical case</span><p id="par0045" class="elsevierStylePara elsevierViewall">The case of an 89-year-old woman with Fuchs endothelial dystrophy is described. She underwent combined cataract phacoemulsification and intraocular lens implantation in sac and lamellar transplant type DMEK successfully in the left eye. A <span class="elsevierStyleItalic">re-bubbling</span> was performed at 24 h due to a small peripheral detachment of the graft. Visual acuity at 8 months after surgery was 0.8 compared to 0.3 at the beginning. Next, it was decided to perform the same combined surgery on the right eye. This was an intermediate nuclear cataract, in an eye with an anterior chamber width (ACD) of 2.52 mm and axial length (AL) of 22.57 mm. The previous visual acuity was 0.3 and abundant endothelial guttae were evident. Peripheral iridotomy with YAG laser was performed in consultation 12 weeks before surgery.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The graft was prepared in the operating room and stained with trypan blue prior to the start of surgery. A 7.75 mm punch was obtained for a recipient cornea with a white-to-white distance (WTW) of 10.9 mm. The cultured donor cornea corresponded to a pseudophakic subject of 81 years of age and endothelial count of 2300 cells/mm<span class="elsevierStyleSup">2</span>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Under retrobulbar anesthesia and sedation, phacoemulsification was performed with subsequent intraocular lens implantation (<span class="elsevierStyleItalic">Alcon SA60WF</span> of +25.0 diopter sphere, according to <span class="elsevierStyleItalic">Carl Zeiss IOLMaster</span>® biometer calculations. Subsequently, descemetorhexis was performed under viscoelastic, and the stained graft was removed and introduced into the anterior chamber. Adequate orientation and centering of the graft was achieved with the help of AS-OCT and by indirect intraocular and extraocular manipulation. Finally, an air bubble was injected to facilitate contact of the graft with the stroma.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient presented 24 h after surgery with diffuse stromal edema and inferior sectorial detachment of the graft measured by AS-OCT. A re-bubbling was performed in consultations, achieving an improvement and partial positioning of the graft ascertained by AS-OCT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). However, 4 days later the patient came for follow-up with worsening edema and the graft was observed coiled and free in the anterior chamber (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Initially, it was considered to reintervene the patient with a new graft, so the blood and tissue bank was contacted to make the request. However, the limited reserve of donor corneas did not allow the availability of a new graft in the short term.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Accordingly, it was decided to perform a re-DMEK with the intention of preserving the original graft (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, Video 1). Under topical anesthesia, subtenon and sedation, the cornea was de-epithelialized with hemostatic (<span class="elsevierStyleItalic">PVA eye spear</span>) and methylcellulose was applied to optimize visualization through the edema.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The intracameral graft was then stained with trypan blue and the posterior stroma was protected with an air bubble. A series of indirect manipulation movements were performed across the corneal surface to orient the graft roller so that it could be accessed through the main incision. Once oriented, the bubble was infused to deploy the graft using the maneuver of Dapena et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The tissue presented a <span class="elsevierStyleItalic">tight roll</span> behavior, which required performing this surgical movement in several attempts.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">With the help of intraoperative OCT, correct orientation of the OCT and complete elimination of bubbles at the interface were ensured. Lastly, an air bubble was infused to apply the graft over the stroma.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Twenty-four hours after surgery, the adherent graft was observed, with a great decrease in stromal edema observed both in slit lamp and AS-OCT. However, after 9 days a new detachment was detected, this time incomplete and sectorial, which was resolved with a new re-bubbling in consultations (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C).</p><p id="par0085" class="elsevierStylePara elsevierViewall">One month later, the patient exhibited a clear cornea, normalization of central thickness measured by pachymetry and AS-OCT showed complete graft adhesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Endothelial count by specular microscopy was 703 cells per mm<span class="elsevierStyleSup">2</span> and polymetastasis, in contrast to the contralateral eye which was 1620 cells per mm<span class="elsevierStyleSup">2</span> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Six months after the re-transplantation, the patient presented a corrected visual acuity of 0.9.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The finding of <span class="elsevierStyleItalic">free roll</span> in the anterior chamber after DMEK surgery is the most complex form of graft detachment. Corneal edema as well as the arrangement of the intraocular structures are determining factors to be taken into account for the surgical resolution of this complication. In many cases surgical repositioning of the graft is feasible, which implies cost savings without the need to use new donor corneal tissues.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The difficulty of visualization generated by stromal edema can be reduced by applying measures that decrease the refractive index of the different media. De-epithelialization and the application of methylcellulose are useful, as well as the use of intraoperative OCT.</p><p id="par0100" class="elsevierStylePara elsevierViewall">On the other hand, loss of staining of the detached graft must be compensated by re-staining. The extraction of the graft and the application of trypan blue in a container, besides being a difficult technique due to poor visualization, can increase the risk of damage to the tissue by excessive manipulation. Intracameral application of trypan blue, on the other hand, can be useful as long as the posterior stroma is protected by an air bubble to prevent unwanted staining at the interface.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the case described, the results obtained in terms of visual acuity and pachymetry support the hypothesis that this series of maneuvers may be useful in situations where repositioning of the original graft is considered.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The contralateral eye, which also underwent combined cataract and DMEK surgery, serves as a control in the same patient. Thus, although the subsequent values obtained in the endothelial count show a decrease in the number of cells with secondary polymimegatism, these do not correspond to a decrease in visual acuity.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical responsibilities</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have obtained the informed consent for the performance and divulgation of the supplementary tests provided in this case.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">No source of funding has been declared by the authors.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">No conflicts of interests were declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2117867" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1804034" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2117868" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1804033" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical responsibilities" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-12-05" "fechaAceptado" => "2024-01-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1804034" "palabras" => array:6 [ 0 => "Transplant" 1 => "Descemet membrane endothelial keratoplasty" 2 => "Graft" 3 => "Detachment" 4 => "Dystrophy" 5 => "Endothelium" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1804033" "palabras" => array:6 [ 0 => "Trasplante" 1 => "<span class="elsevierStyleItalic">Descemet Membrane Endothelial Keratoplasty</span>" 2 => "Injerto" 3 => "Despegamiento" 4 => "Distrofia" 5 => "Endotelio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lamellar keratoplasties have had a great impact in the management of corneal edema due to endothelial dysfunction. Minimally invasive transplant techniques such as Descemet Membrane Endothelial Keratoplasty (DMEK) have helped to reduce the morbidity involved in performing penetrating keratoplasty in this type of patient. Even so, these are complex techniques that are not free of complications and require a long line of surgical learning and an even more demanding experience in postoperative management.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical case</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">An 89-year-old woman suffering from Fuchs endothelial dystrophy and undergoing combined cataract and DMEK surgery presented stromal edema predominantly inferior and sectoral detachment of the graft 24 h after the intervention. After re-bubbling in consultations and 4 days later, the graft was observed rolled and free in the anterior chamber.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">She underwent re-DMEK with preservation of the original graft after 24 h, with de-epithelialization to optimize visualization. The graft was stained with trypan blue and the posterior stroma was protected with air. The graft was reimplanted under intraocular maneuvers and with an air bubble.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">24 h after surgery, the adhered graft was observed, with a great decrease in stromal edema. One month later, the patient had a clear cornea, persistent complete graft adhesion, and visual acuity of 0.9.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The discovery of free roll in the anterior chamber after DMEK surgery constitutes the most complex form of graft detachment. Corneal edema as well as the arrangement of the different intraocular structures are conditions to be considered for the surgical resolution of this complication. In many cases, surgical repositioning of the graft is feasible, which means saving costs without the need to use new donor corneal tissues.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducción</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Las queratoplastias lamelares han supuesto un gran impacto en el manejo del edema corneal por disfunción endotelial. Las técnicas de trasplante mínimamente invasivo como la Descemet Membrane Endothelial Keratoplasty (DMEK) han permitido reducir la morbilidad que suponía la realización de una queratoplastia penetrante en este tipo de pacientes. Aun así, se trata de técnicas complejas que no están exentas de complicaciones y que requieren una larga línea de aprendizaje quirúrgico y una aún más exigente experiencia en el manejo postoperatorio.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso clínico</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Una mujer de 89 años afecta de distrofia endotelial de Fuchs e intervenida de cirugía combinada de catarata y DMEK presentó a las 24 h de la intervención un edema estromal de predominio inferior y un despegamiento sectorial del injerto. Tras un <span class="elsevierStyleItalic">re-bubbling</span> en consultas y 4 días más tarde, se observó el injerto enrollado y libre en cámara anterior.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se intervino de re-DMEK con preservación del injerto original tras 24 h, con desepitelización para optimizar la visualización. Se tiñó el injerto con azul tripán y se protegió el estroma posterior con aire. Se reimplantó el injerto bajo maniobras intraoculares y con burbuja de aire.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">A las 24 h de la cirugía se observó el injerto adherido, con una gran disminución del edema estromal. Un mes después, la paciente presentaba una córnea transparente, una persistente adhesión completa del injerto y una agudeza visual de 0.9.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El hallazgo del <span class="elsevierStyleItalic">free roll</span> en cámara anterior tras cirugía de DMEK constituye la forma más compleja de despegamiento del injerto. El edema corneal así como la disposición de las diferentes estructuras intraoculares son condicionantes a tener en cuenta para la resolución quirúrgica de esta complicación. En muchos casos el reposicionamiento quirúrgico del injerto es factible, hecho que implica ahorrar costes sin necesidad de utilizar nuevos tejidos corneales donantes.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La OCT de segmento anterior resulta una herramienta imprescindible para conocer la situación del injerto y poder planificar de manera óptima la cirugía.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1485 "Ancho" => 2007 "Tamanyo" => 178476 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Optical coherence tomography images of the right eye anterior segment. A) Control 24 h after surgery. B) Control 5 days after surgery. C) Control 24 h after the second surgery. D) Control at one month after the second surgery.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3003 "Ancho" => 2925 "Tamanyo" => 898111 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Surgical scheme of re-DMEK with preservation of the original graft. A) De-epithelialization. B) Air bubble infusion. C) Trypan blue infusion. D) Introduction of air bubble. E) Unfolding of the graft. F) Adhesion of the graft to the stroma.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1133 "Ancho" => 2925 "Tamanyo" => 581298 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Specular microscopy in both eyes. A) Right eye: polymimegatism and count of 703 cells per mm<span class="elsevierStyleSup">2</span>. B) Left eye: 1620 cells per mm<span class="elsevierStyleSup">2</span>.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 17531130 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preliminary clinical results of Descemet membrane endothelial keratoplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.R. 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Original article
Re-descemet membrane endothelial keratoplasty (DMEK) with preservation of the original graft after free roll in anterior chamber: A case report
Re-Descemet Membrane Endothelial Keratoplasty (DMEK) con preservación del injerto original tras free roll en cámara anterior: a propósito de un caso
A. Arnaiz Camacho
, S. Martín Nalda, T. Pablos Jiménez, S. García Hidalgo, A. Pairó Salvador, M.A. Zapata Victori
Corresponding author
Ophthalmology, Hospital Universitari Vall d’Hebron, Barcelona, Spain