PRESS & ROLL Technique for Descemet Membrane Endothelial Keratoplasty Graft Unfolding in Vitrectomized Eyes

Purpose: Unfolding a Descemet membrane endothelial keratoplasty (DMEK) graft in vitrectomized eyes is technically demanding because of the characteristic deepening of the anterior chamber seen in these patients. The PRESS & ROLL technique was developed for use in this challenging scenario to facilitate graft unfolding by combining central corneal indentation with controlled rolling of a small air bubble. Methods: After insertion of the DMEK graft through the main incision, proper graft orientation is first confirmed. A small air bubble is then injected above the graft. Central corneal indentation is gently applied using a blunt instrument to shallow the space between the graft and the pupillary area. While maintaining central indentation, the surgeon rolls the air bubble circumferentially around the corneal depression, gradually unfolding the graft toward the periphery in all directions. Once the graft is completely unfolded, air is fully injected beneath the graft while simultaneously releasing the indentation pressure. Result: In both cases, conventional unfolding maneuvers were unsuccessful because of repeated anterior chamber deepening. The PRESS & ROLL technique enabled complete and controlled graft unfolding without intraoperative complications. At 3 months, both eyes showed successful graft attachment with improved resolution of corneal edema and visual acuity, along with reduced corneal thickness. Conclusions: The PRESS & ROLL technique offers a practical and effective method for DMEK graft unfolding in vitrectomized or complex eyes with deepening of the anterior chamber. It enhances intraoperative control and predictability in challenging surgical environments.