Wheel Spokes Technique for Endothelial Keratoplasty for Extremely Mydriatic Bullous Keratopathy Eyes without Capsular Support

We describe a new technique to prevent an endothelial donor graft from dropping into the vitreous cavity during non-Descemet stripping automated endothelial keratoplasty (nDSAEK) for extremely mydriatic bullous keratopathy (BK) eyes without capsular support. The patient was a 79-year-old woman who underwent nDSAEK for an extremely mydriatic BK eye with an incomplete barrier between the anterior and posterior chambers. She had undergone argon laser iridotomy for acute glaucoma at the age of 59 years and cataract surgery 3 years later. The pupil was extremely mydriatic as a result of iris sphincter muscle damage associated with an acute glaucoma attack and cataract surgery. After cataract surgery, the dislocated intraocular lens (IOL) sometimes touched the corneal endothelium. Despite simultaneous surgery to remove the dislocated IOL and lens capsule, vitrectomy, and intrascleral IOL fixation, her corneal endothelial decompensation progressed to BK. During nDSAEK, three 9-0 Prolene suture threads were placed through the recipient's cornea, limbus-to-limbus, resembling wheel spokes, to prevent the graft from dropping into the vitreous cavity. With the aid of these pre-placed sutures, the graft was inserted safely and was well attached to the host's posterior cornea by air tamponade without suturing. The wheel spokes technique prevented the endothelial graft from dropping during intraoperative manipulation, suggesting that nDSAEK is possible even in an extremely mydriatic aphakic BK eye without capsule support.