The American Journal of Ophthalmology

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3 AQ: 2 AQ: 1 AQ: 3 Preliminary Clinical Results of Descemet Membrane Endothelial Keratoplasty GERRIT R. J. MELLES, SAN NG, BB VERVERS, AND JACQUELINE VAN DER WEES PURPSE: To describe the preliminary clinical results of selective transplantation of organ cultured donor Descemet membrane (DM) carrying autologous corneal endothelium through a 3.5-mm incision, tentatively named Descemet membrane endothelial keratoplasty (DMEK), for the management of corneal endothelial disorders. DESIGN: Nonrandomized clinical study. METHDS: In 10 patients with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy, DMEK was performed. A 3.5-mm clear corneal tunnel incision was made, the anterior chamber was filled with air, and DM was stripped off from the posterior stroma. A 9.0-mm diameter DM roll was harvested from an organ cultured donor corneo-scleral rim, and inserted into a recipient anterior chamber. The donor tissue was gently unfolded, positioned onto the posterior stroma, and secured by completely filling the anterior chamber with air for 30 minutes. RESULTS: At one month, six eyes had a best-corrected visual acuity of 0.5 (20/40) or better, and three eyes reached 1.0 (20/20). At six months, the endothelial cell density averaged 2030 ( 373) cells/mm 2 (n 7). Three eyes showed a complete detachment of the donor tissue in the early postoperative course that was managed by removal of the transplant and a secondary Descemet stripping endothelial keratoplasty procedure. CNCLUSIN: DMEK may have potential to become the most preferable technique to manage corneal endothelial disorders, because it provides quick and nearly complete visual rehabilitation. Because the donor tissue required can be prepared from organ cultured corneoscleral rims, the procedure may be readily accessable to most corneal surgeons. (Am J phthalmol 2007;xx: xxx by Elsevier Inc. All rights reserved.) IN RECENT YEARS, WE DESCRIBED VARIUS CNCEPTS for posterior lamellar keratoplasty that allowed replacement of the corneal endothelium without corneal surface incisions or corneal sutures in the management of Fuchs endothelial dystrophy and pseudophakic or aphakic bullous keratopathy. In 1998, we introduced a technique in which an unsutured, 7.5-mm diameter, posterior lamellar disk could be transplanted through a 9.0-mm sutured scleral incision. 1 3 Since 2001, the technique has been popularized in the United States as deep lamellar endothelial keratoplasty (DLEK). 4 In 2000, we reported a sutureless modification of the technique: a folded, tacoshaped 9.0- to 9.5-mm diameter posterior transplant was inserted through a self-sealing 5.0-mm scleral tunnel incision and unfolded in the anterior chamber. 5 Since 2005, this technique has been popularized in the United States as small incision DLEK. 6 In 2003, we reported how the insertion of folded donor posterior disk was combined with a descemetorhexis for removing the recipient endothelial layer and its Descemet membrane (DM). 7,8 The latter technique is currently referred to as the descemet stripping endothelial keratoplasty (DSEK). 9,10 Although the various techniques designed and developed by us showed the feasibility of transplanting an unsutured donor posterior corneal disk, selective transplantation of only DM and the endothelium may be expected to provide the best possible restoration of the visual performance of a cornea with an endothelial disorder. 11,12 Recently, Tappin described the clinical transplantation of 7.5-mm diameter DM through an 8.0-mm scleral incision using a flat carrier device, 13 and Pavel reported the transplantation of DM with a peripheral stromal rim (Studeny P, Descemet s membrane with stromal hem transplantation, Winter ESCRS 2007). The current study describes the preliminary clinical results of isolated DM transplantation through a self-sealing 3.5-mm clear corneal incision that may be referred to as Descemet membrane endothelial keratoplasty (DMEK). 14,15 METHDS THE DMEK WAS PERFRMED IN FUR MALE AND SIX FEMALE patients, 45 to 87 years of age, with Fuchs endothelial dystrophy (Table). Accepted for publication Sep 17, From the Netherlands Institute for Innovative cular Surgery, Rotterdam, The Netherlands (G.R.J.M., S.., B.V.); Melles Cornea Clinic Rotterdam, The Netherlands (G.R.J.M., S.., B.V.); and Amnitrans EyeBank Rotterdam, The Netherlands (G.R.J.M.). Inquiries to Gerrit R. J. Melles, Netherlands Institute for Innovative cular Surgery, Rotterdam, The Netherlands; [email protected] DNR TISSUE: From seven donor globes less than 36 hours post-mortem, corneo-scleral buttons were excised and stored by organ culture in modified minimum essential medium (EMEM) at 31 C. 16 Donor age averaged 71.3 years (SD, 6.1 years); and the donor endothelial cell count averaged 2,610 ( 147) cells/mm 2 (Table). After two weeks of culture, the endothelial cell morphology and viability were evaluated and the corneo AQ: T /07/$ BY ELSEVIER INC. ALL RIGHTS RESERVED. 1 doi: /j.ajo

4 No. TABLE. Preliminary Clinical Results of Descemet Membrane Endothelial Keratoplasty Patient Preoperative Donor Age (yrs) Gender D/S Indication Surgery Concomitant Disease BCVA scleral buttons were mounted, endothelial-side up, on a custom-made holder with a suction cup. The DM was stripped from the posterior stroma, so that a 9.0-mm diameter flap of posterior DM with its endothelial monolayer was obtained. 11,12,17 Due to the elastic properties of the membrane, a Descemet-roll formed spontaneously, with the endothelium at the outer side. Each Descemetroll was then stored in organ culture medium until the time of transplantation. SURGERY: In recipient eyes, a 9.0-mm diameter epithelial mark was made to outline the area of DM excision. A 3.5-mm tunnel incision was made just within the limbus, entering the anterior chamber just at the mark. With a custom-made scraper (Melles scraper; D..R.C. International, Zuidland, The Netherlands), a circular portion of DM was stripped from the posterior stroma, so that a 9.0-mm diameter descemetorhexis was created, and the central portion of DM was removed from the eye. 7,8 The donor Descemet-roll was stained with a 0.06% trypan blue solution (VisionBlue, D..R.C. International), and sucked into a custom-made injector (Hippocratech, Rotterdam, The Netherlands), namely, a fine transparant plastic tube with a suction device to transfer the tissue from the culture medium vial to the anterior chamber. 11,12 Using the injector, the donor Descemet-roll was inserted into the anterior chamber and the graft was oriented endothelial-side down (donor DM facing recipient posterior stroma) by careful, indirect manipulation of the tissue with air and fluid. While maintaining the anterior chamber with fluid and air, the graft was gently spread out over the iris. Then, an air bubble was injected underneath the donor DM to position the tissue onto the recipient posterior stroma. 11,12 The anterior chamber was completely filled with air for 30 minutes followed by an air liquid exchange to pressurize the eye. ENDTHELIUM EVALUATIN: Donor endothelial cell viability was evaluated with an inverted light microscope (Axiovert 40, Zeiss, Göttingen, Germany). After provoked swelling with sucrose 1.8% and staining with trypan blue 0.04%, digital photographs were made (PixeLINK PL- A662, Zeiss, Göttingen, Germany). 16 In patient eyes, the endothelium was photographed and evaluated using a Topcon SP3000p noncontact autofocus specular microscope (Topcon Corp, Tokyo, Japan). Images of the central corneal window were analyzed and manually corrected and three measurements of endothelial cell density were averaged. 16,18,19 RESULTS Age (yrs) ECD (cells/mm 2 ) 1 64 M S FED (pseudophakic) None 0.3 (20/60) F D PPBK None FC F S PPBK Immobile pupil & RPE changes 0.1 (20/200) after complicated phaco 4 86 F D FED (pseudophakic) Superficial stromal scar 0.3 (20/60) M D FED (pseudophakic) Subepithelial central corneal scar 0.1 (20/200) M S FED (pseudophakic) None 0.3 (20/60) F S FED (pseudophakic) None 0.3 (20/60) M D BK eci (phakic) None 0.8 (2025) F S FED None 0.3 (20/60) F D FED (phakic) SLE 0.5 (20/40) AMD age-related macular degeneration; DSEK descemet stripping endothelial keratoplasty; PPBK pseudophakic bullous keratopathy; BCVA best-corrected visual acuity (Snellen); ECD endothelial cell density; RPE retinal pigment epithelium; DM descemet membrane; FED Fuchs endothelial dystrophy; n.r. not relevant. IN THREE EYES THE IMPLANTATIN F THE DNR DM WAS traumatic attributable to complicated donor tissue insertion, vitreous pressure, and incomplete unfolding of the tissue (Cases 2, 4, and 10, respectively; Table). In Case 2, the graft was inadvertently positioned halfway the tunnel incision, due to reflux of fluid from the anterior chamber immediately after the injection of the tissue. In Case 4, the AQ: AMERICAN JURNAL F PHTHALMLGY MNTH 2007

5 C L R AQ: 6 TABLE. Preliminary Clinical Results of Descemet Membrane Endothelial Keratoplasty (Continued) Surgery Diameter (mm) Complications BCVA at 1 Week BCVA at 1 Month FIGURE 1. Slit-lamp photograph of a cornea one month after Descemet membrane endothelial keratoplasty (DMEK). Note that the transplanted cornea is clear with an invisible anatomical interface between the donor and host tissues. anterior chamber showed a strong tendency to collapse throughout the procedure. Although the tissue was carefully manipulated using side port incisions, the unfolding process proved difficult. In Case 10, tissue insertion was uneventful and the anterior chamber was stable, but we failed to unfold the tissue attributable to the intrinsic tendency of the isolaged DM to roll-up. In all of these eyes, the extended or complicated manipulation of the tissue may have resulted in irreversible endothelial cell damage. In the other seven eyes, the surgical procedure was uneventful. In all 10 eyes, the donor DM kept its position BCVA at 6 Months Postoperative Slit-lamp ECD (cells/mm 2 ) following a complete air fill of the anterior chamber for 30 minutes. At the first postoperative day, all donor DM showed complete attachment onto the recipient posterior stroma. At one week, the DM transplant was in situ in seven eyes (Figure 1). In the three remaining eyes (Cases 2, 4, and 10), a donor DM roll was seen floating in the anterior chamber, that is, a complete detachment of the graft was seen. In the latter eyes, an uncomplicated DSEK was performed 7 10 two to three weeks after the initial DMEK surgery. A best-corrected visual acuity (BCVA) of 0.5 (20/40) or better was reached by four of the seven DMEK eyes at one week, and by six eyes at one month after surgery (Table). At six months, the endothelial cell density averaged 2620 ( 348) cells/mm 2 before, and 2030 ( 373) cells/mm 2 after manual correction (n 7) (Figure 2; Table). The preoperative endothelial cell density for these eyes averaged 2600 ( 179) cells/mm 2 (n 7) (Table). At early time intervals, it proved difficult to visualize the donor tissue. Confirmation that the donor tissue was in situ was obtained by visualizing its peripheral edge, the presence of a reflective sheen over the donor DM, and specular microscopy to identify the (para)central donor endothelial cells (Figure 3). In some eyes, Descemet tags were seen in the far corneal periphery, namely, the presence of micro-detachments or doubled DM at the outer edge of the transplant. ver time these peripheral tags were stable and did not increase in size. Remarks 9.0 None 1.0 (20/20) 1.0 (20/20) 1.25 (20/15) Attached 1750 None 8.5 Complicated insertion donor Donor detached n.r. n.r. n.r. n.r. Uncomplicated DSEK 2 weeks after initial DMEK 9.0 None 0.25 (20/80) 0.25 (20/80) 0.4 (20/50) Attached 1760 None 9.0 Vitreous pressure Donor detached n.r. n.r. n.r. n.r. Uncomplicated DSEK 3 weeks after initial DMEK 9.0 Eccentric position donor 0.25 (20/80) 0.5 (20/40) 0.6 (20/30) Attached; small paracentral DM roll 1790 None 9.5 None 0.8 (20/25) 1.0 (20/20) 1.0 (20/20) Attached 2270 None 9.0 None 0.6 (20/30) 0.6 (20/30) 0.8 (20/25) Attached 2180 None 9.0 None 0.6 (20/30) 1.0 (20/20) 1.0 (20/20) Attached 1790 None 9.0 None 0.3 (20/60) 0.6 (20/30) 0.7 (20/30) Attached 2730 None 9.0 Incomplete unfolding donor Donor detached n.r. n.r. n.r. n.r. Uncomplicated DSEK 3 weeks after initial DMEK F1 AQ: 7 F2 F VL. XX, N. X PRELIMINARY RESULTS F DMEK 3

6 C L R C L R FIGURE 2. Image of endothelial cell density analysis (manually corrected) six months after DMEK. FIGURE 3. Slit-lamp photograph of a cornea six months after DMEK. In the far periphery, small tags (thick arrows) are visible consisting of folded or doubled donor Descemet membrane. The transplant overlaps the residual peripheral edge of the recipient Descemet membrane (thin arrows) from which the central part has been stripped off during the surgery. DISCUSSIN IN 1998, WE REPRTED THAT TRANSPLANTATIN F DM was technically feasible in a human cadaver eye model. 11,12 At that time however, harvesting DM from a donor corneo-scleral rim was considered too challenging in the absence of supporting eyebank facilities. Because stripping DM may sometimes be complicated by inadvertent tearing of the membrane, the surgical preparation of a donor DM sheet may preferably be performed in an eyebank prior to the surgery rather than as a part of the surgical routine itself. With the start of the Amnitrans Eyebank Rotterdam in January 2004, all facilities and logistics could be set up for routine preparation of a DM transplant, the evaluation of its endothelial cell layer, and microbiological checks to ensure sterility of the tissue. Since then, extensive laboratory studies have been performed to simplify the procedure for harvesting the tissue. 14,17 In addition, we designed various modifications for the surgical implantation of a donor DM sheet into the recipient eye and the manipulation of the tissue inside the anterior chamber to obtain complete adherence of the graft onto the posterior recipient stroma (Melles GRJ, unpublished data, 2005). 14,15 Recently, the feasibility of transplanting an isolated DM was also shown by Tappin and Pavel using different approaches. Tappin designed a carrier device to insert a 7.5-mm diameter donor DM into the anterior chamber through an 8.0-mm sutured incision (Melles GRJ, personal communication, 2006). 13 Pavel reported the transplantation of a donor DM still attached to a peripheral stromal rim to facilitate tissue handling (Studeny P, Descemet=s membrane with stromal hem transplantation, Winter ESCRS 2007). In the current study, we transplantatied DM with autologous endothelium through a small corneal tunnel incision, as previously described. 11,12 With regard to the popular nomenclature to distinguish the various surgical procedures for posterior lamellar keratoplasty, 4,6,9,10,15 the procedure currently described, that is, the transplantation of isolated donor DM carrying a viable endothelial cell layer, was tentatively named DMEK. 14,15 The challenge with designing any type of posterior lamellar keratoplasty procedure may be to provide an endothelial cell density high enough to provide long-term graft survival. In the current study, both objective and subjective measurements indicated that DMEK may have potential to reach short-term cell densities of 2000 to 2600 cells/mm 2, which compare to those after DLEK and DSEK. 6,19 In comparison with the techniques for posterior lamellar keratoplasty previously designed by us, that is, DLEK and DSEK, 15 DMEK may have five major advantages. First, the present study suggests that visual rehabilitation after DMEK may be much faster than after DLEK or DSEK, because six of the seven succesful DMEK eyes achieved a BCVA of 0.5 or better within the first month after surgery AMERICAN JURNAL F PHTHALMLGY MNTH 2007

7 AQ: 8 (Table). In contrast, DLEK and DSEK procedures have been reported to give an average BCVA of 0.5 (20/40) or better at an average time interval of six months or more. 6,9,20 This difference in restoration of the visual acuity may suggest that it is the presence of (cultured) donor posterior stroma in DLEK and DSEK rather than secondary changes or edema in the recipient corneal stroma that primarily determines the rate of visual rehabilitation, because no donor posterior stroma is transplanted in DMEK. Second, a near perfect anatomical restoration of the recipient cornea in DMEK may provide a better optical quality of that cornea, which may be expected to result in a more complete visual rehabilitation. 11,12 In DMEK, the final visual performance of the eye may be limited only to the preoperative condition of the recipient anterior cornea that is left in situ. Third, in DMEK the diameter of the graft may be as large as 9.0 mm to 11.0 mm, so that a larger endothelial cell surface is transplanted as compared to DLEK (7.5 mm to 8.0 mm) or DSEK (8.5 mm to 9.5 mm). Although to our knowledge, a correlation between graft diameter and graft survival has not been reported, a larger graft in DMEK may be expected to benefit long-term graft survival. 16 Fourth, DMEK may better fit the current requirements of modern anterior segment surgery, because the donor DM can be transplantated through a clear corneal tunnel incision as is widely used in phacoemulsification surgery, and that is known to induce minimal postoperative astigmatism. 16,21,22 Although various carriers have been described as a supportive means for the insertion of a donor DM, 13,23,24 a carrier may have the disadvantage of limiting the final graft diameter to 6.0 mm to 7.5 mm, and requiring a relatively large entry incision. Fifth, in contrast to DLEK and DSEK (for which most surgeons would need to use a microkeratome or femtosecond laser), donor DM sheets can be stripped off directly from a corneo-scleral rim in DMEK. With our technique of stripping 9.0-mm DM sheets from donor corneo-scleral (concave) rims, we previously reported that the amount of cell damage as expressed in the percentage of damaged endothelial surface area averaged 3.4%. 11,12,17 Similar results were found by Ignacio and associates, who stripped DM transplants from convex rims, 25 and Zhu and associates, who harvested rectangular strips from concave rims. 26 From a logistic point of view, it may be important to note that all studies used preserved tissues, either by cold storage or organ culture. If viable grafts can be routinely obtained from preserved tissues, DMEK may be far more accessible to most corneal surgeons than DLEK or DSEK. In all types of posterior lamellar keratoplasty, immediate donor attachment is mandatory because suture fixation of the graft is not performed. In our experience, the single most important factor in obtaining complete attachment of the donor is to avoid the use of a visco elastic during the entire procedure. 16 As in DSEK, visco elastics may also be avoided in DMEK, because obtaining donor attachment is even more critical. 16 Furthermore, in vitro experiments showed that at least a 30-minute air-fill of the anterior chamber was required to obtain complete donor attachment in DMEK, whereas a 15-minute air-fill seemed sufficient in DLEK and DSEK. 8,15,16 ur preliminary experience with DMEK suggests that transplantation of an isolated donor DM carrying viable endothelium for the management of corneal endothelial disorders provides near perfect anatomical restoration and a high level of visual rehabilitation. As in DLEK and DSEK, the only major drawback of the procedure is the risk of detachment of the graft in the early postoperative course. When the rate of detachments in DMEK can be lowered by futher improvement of the eyebank logistics and the surgical technique, the project on posterior lamellar keratoplasty may near its completion. THE AUTHRS INDICATE N FINANCIAL SUPPRT. DR MELLES IS A CNSULTANT FR D..R.C./DUTCH PHTHALMIC USA. Involved in design of study (G.M., J.v.d.W.); conduct of study (G.M., B.V., S.., J.v.d.W.); data analysis (G.M., J.v.d.W.); collection, management, and interpretation of the data (?); and preparation, review, or approval of the manuscript (?). This study was conducted in compliance with the Institutional Review Board and Informed Consent requirements, in adherence to the tenets of the Declaration of Helsinki at The Netherlands Institute for Innovative cular Surgery (Study registration no. N.05.14). REFERENCES 1. Melles GRJ, Eggink FAGJ, Lander F, et al. A surgical technique for posterior lamellar keratoplasty. Cornea 1998;17: Melles GRJ, Lander F, Beekhuis WH, Remeijer L, Binder PS. Posterior lamellar keratoplasty for a case of pseudophakic bullous keratopathy. Am J phthalmol 1999;127: Melles GRJ, Lander F, van Dooren BTH, Pels E, Beekhuis WH. Preliminary clinical results of posterior lamellar keratoplasty through a sclerocorneal pocket incision. phthalmology 2000;107: Terry MA, usley PJ. Deep lamellar endothelial keratoplasty in the first United States patients: early clinical results. Cornea 2001;20: Melles GRJ, Lander F, Nieuwendaal C. Sutureless, posterior lamellar keratoplasty. Cornea 2002;21: Terry MA, usley PJ. Small-incision deep lamellar endothelial keratoplasty (DLEK): six-month results in the first prospective clinical study. Cornea 2005;24: Melles GR, Wijdh RH, Nieuwendaal CP. A technique to excise the descemet membrane from a recipient cornea (descemetorhexis). Cornea 2004;23: VL. XX, N. X PRELIMINARY RESULTS F DMEK 5

8 AQ: 9 AQ: Melles GRJ, Kamminga N. Techniques for posterior lamellar keratoplasty through a scleral incision. phthalmologe 2003; 100: Price FW Jr, Price M. Descemet s stripping with endothelial keratoplasty in 50 eyes: a refractive neutral corneal transplant. J Refract Surg 2005;21: Price FW Jr, Price M. Descemet s stripping with endothelial keratoplasty in 200 eyes. Early challenges and techniques to enhance donor adherence. J Cataract Refract Surg 2006; 32: Melles GRJ, Rietveld FJR, Pels E, Beekhuis WH, Binder PS. Transplantation of Descemet s membrane carrying viable endothelium through a small scleral incision. Invest phthalmol Vis Sci 1998;39:S Melles GRJ, Rietveld FJR. Transplantation of Descemet s membrane carrying viable endothelium through a small scleral incision. Cornea 2002;21: Tappin M. A method for true endothelial cell (Tencell) transplantion using a custom made cannula for the treatment of endothelial cell failure. Eye Forthcoming. 14. Melles GRJ, ng TS, Ververs B, van der Wees J. Descemet membrane endothelial keratoplasty (DMEK). Cornea 2006; 25: Melles GRJ. Posterior lamellar keratoplasty: DLEK to DSEK to DMEK (editorial). Cornea 2006;25: Nieuwendaal CP, Lapid-Gortzak R, van der Meulen IJ, Melles GRJ. Posterior lamellar keratoplasty using descemetorhexis and organ cultured donor corneal tissue (Melles technique). Cornea 2006;25: Lie JT, Van der Wees J, Melles GRJ. Donor tissue preparation for Descemet membrane endothelial keratoplasty (DMEK). Submitted. 18. van Dooren BTH, Mulder P, Nieuwendaal CP, Beekhuis WH, Melles GRJ. Endothelial cell density after posterior lamellar keratoplasty (Melles technique): three years followup. Am J phthalmol 2004;138: van Dooren BTH, Mulder P, Nieuwendaal CP, Beekhuis WH, Melles GRJ. Endothelial cell density after deep anterior lamellar keratoplasty (Melles technique). Am J phthalmol 2004;138: Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea 2006;25: Holweger RR, Marefat B. Corneal changes after cataract surgery with 5.0 mm sutured and 3.5 mm sutureless clear corneal incisions. J Cataract Refract Surg 1997;23: lsen T, Dam-Johansen M, Bek T, Hjortdal J. Corneal versus scleral tunnel incision in cataract surgery: a randomized study. J Cataract Refract Surg 1997;23: Lange TM, Wood TM, McLaughlin BJ. Corneal endothelial cell transplantation using Descemet s membrane as a carrier. J Cataract Refract Surg 1993;19: Shimmura S, Miyashita H, Konomi K, et al. Transplantation of corneal endothelium with Descemet s membrane using a hyroxyethyl methacrylate polymer as a carrier. Br J phthalmol 2005;89: Ignacio TS, Nguyen TT, Sarayba MA, et al. A technique to harvest Descemet s membrane with viable endothelial cells for selective transplantation. Am J phthalmol 2005;139: Zhu Z, Rife L, Yiu S, Trousdale MD, Smith RE. A technique for preparation of the corneal endothelium-descemet s membrane complex for transplantation. Cornea 2006;25: AMERICAN JURNAL F PHTHALMLGY MNTH 2007

9 Biosketch Gerrit R. J. Melles, MD, PhD, attended medical school and interned at the University of Leyden, The Netherlands, and did his phthalmology residency at the University of Nijmegen, The Netherlands. He completed a Research fellowship in San Diego with Perry S. Binder, MD, who also supervised his PhD dissertation. Dr Melles is currently director of the Netherlands Institute of Innovative cular Surgery ( and head of Amnitrans Eyebank, in Rotterdam, The Netherlands VL. XX, N. X PRELIMINARY RESULTS F DMEK 6.e1

10 Preliminary clinical results of Descemet membrane endothelial keratoplasty. Gerrit R. J. Melles, San ng, Bob Ververs, and Jacqueline van der Wees Early results of DMEK, that is, the isolated transplantation of Descemet membrane carrying viable endothelium, through a 3.5-mm clear cornea tunnel incision are reported. The study shows that DMEK may provide a visual rehabilitation to 0.5 (20/40) or better within the first month, and an average endothelial cell density of 2000 cells/mm 2 at six months. DMEK may be more accessible to surgeons than previous endothelial keratoplasty techniques

11 JBNAME: AUTHR QUERIES PAGE: 1 SESS: 1 UTPUT: Fri ct 26 20:42: /tapraid3/zrx ajopht/zrx ajopht/zrx00108/zrx6952d08z AUTHR QUERIES AUTHR PLEASE ANSWER ALL QUERIES 1 AQ1 Please provide affiliations for author van der Wees. AQ2 Please provide complete mailing address for corresponding author. AQ3 Please clarify the phrase organ cultured donor Descemet membrane (DM) This is unclear. AQ4 Disc changed to Disk per journal style. AQ5 Something is missing here: halfway *within*? AQ6 Do you mean isolated here? AQ7 In the latter eyes is ambiguous. Please clarify. AQ8 Please complete the involvement sentence. AQ9 Please update reference 13. AQ10 Submitted manuscripts not acceptable in AJ References. If this paper has been published, please update the info. If not, please change it to an in-text citation and renumber all subsequent cites, per AJ style.