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Endothelial Keratoplasty Operative Sample

DESCRIPTION OF OPERATION:  The Honan balloon was applied to the left eye one-half hour preoperative. General endotracheal anesthesia was established. The left eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted to expose the globe. A 4-0 black silk stay suture was taken beneath the superior rectus muscle insertion. The cornea was measured and marked centrally with an 8 mm corneal marker. A fornix-based conjunctival flap was elevated temporally. Adequate hemostasis was established.

Site for incisions were marked at 0130 and 0430. A vertical 5 mm scleral groove was performed just outside the temporal limbus with 69 beaver blade. The incision was then shelved well into peripheral clear cornea with crescent blade. Side port incisions were performed with 1 mm diamond blade and the anterior chamber was inflated with Healon.

The anterior chamber was entered through the corneal scleral tunnel with 2.8 mm keratome blade. Descemet membrane was stripped over the entire posterior cornea within the corneal marking using Sinskey hook. The corneal scleral wound was temporarily closed with a single 10-0 Prolene suture and the Healon was meticulously removed from the eye with Simcoe needle.

Turning to the donor material, the corneoscleral cap was melted on stores artificial anterior chamber after a small amount of Healon was layered on the endothelium. A peripheral partial thickness incision of 350 microns was performed with Feaster diamond blade. The depth of the incision was confirmed to be adequate.

A lamellar pocket was dissected over the entire extent of the donor cornea with crescent blade followed by straight and curved Devers dissectors. Incidentally, the central cornea was marked on the epithelial surface with surgical marking pen during installation of the cornea in the artificial anterior chamber. The corneal scleral button was removed and a central 8.5 mm button was trephined from the endothelial side with Barron Hessburg donor punch.

The lamellar dissection was confirmed with Calibri forceps. The posterior donor tissue was of excellent thickness. A small amount of Healon was layered across the donor endothelium and the donor cornea was folded slightly over half to give the 60-40 configuration. The Prolene suture was removed from the recipient eye and the donor tissue was inserted into the eye using Rosenwasser shovel.

Attempts to get the donor cornea to unfold in the eye appropriately were frustrated by the fact the donor cornea wanted to unfold upside down. Furthermore, it seemed as though the edge of the donor cornea might be held in the folded position by some adhesions, perhaps from Healon. Eventually, it was possible to physically unfold the cornea within the eye and appropriately orient it endothelial side down. The tissue was adequately centered and held in place with moderate air bubble. The tissue remained in place for 5 minutes' observation.

The corneal scleral wound was closed with three interrupted 10-0 Prolene sutures with the knots buried. The eye was left with approximate 50% air bubble and 50% balanced salt solution in the anterior chamber. The stay suture was removed and subconjunctival gentamicin and Decadron were injected. The eye was dressed with TobraDex ointment, patch and shield. The patient was transferred to postanesthesia care.