Fig. 4

Intraoperative images demonstrating surgical challenges in DMEK in the context of RK and IF-IOL and techniques to overcome them. (A) Inversion of the corneal curvature during anterior chamber shallowing secondary to RK-associated structural weakening of the cornea. (B) Inversion of the corneal curvature during tapping secondary to RK-associated structural weakening of the cornea. (C) Use of a pilot bubble and external pressure on the sclera from a spatula to enable unfurling of the DMEK graft. (D) Use of external pressure on the sclera with a spatula during gas injection to ensure convexity of the graft and host cornea. (E) Full gas fill with DMEK graft unfurled and centered. (F) Final gas fill at the conclusion of the case