 So we've got Dr. Pooley presenting on DMACC. I'm just going to go over some of the basics of DMACC and how endothelial carotid plastiae evolved into DMACC. And we'll show a little bit of the surgical technique. I have some videos here. So DSEC, which was first performed in the US in 2003. And the automated form of DSEC involves using a micro-carotome cut posterior stromal tissue and decimase membrane. And usually that tissue is about, with ultra-thin DSEC, it's less than 100 sometimes. But it's usually between 100 and 140 microns of tissue thickness. DMACC was done in Germany in 2006 for the first time. And that just involves inserting the stripped decimase membrane for endothelial failure. So there are some advantages that a lot of things are being published. And I have a couple recent studies I'll show you too. But some of the advantages potentially to DMACC over DSEC are very rapid visual recovery. Sometimes it's a little bit more predictable. And the replacement of the tissue, some people think that that's because it's anatomic replacement. There is less shift in refraction, less hyperopic shift since the tissue is thin. And there's the potential for better post-operative visual acuity and likely less higher order aberration since there is no stromal interface. And similar to DSEC, and some studies show potentially even less rejection than with DSEC, but substantially better than penetrating care to plastic. So this is a study that came out this month showing the visual potential after DMACC. This was done by an experienced DSEC surgeon who'd done over 200 transplants. And he compared his last 100 DSECs to his first 100 DMACC surgeries. And the best spectacle corrected visual acuity was near 2020 with the DMACC and around 2030 with the DSEC, which is pretty consistent with what's been shown in other studies as well. One of the more impressive differences is over 50% of those DMACC patients were 2020 or better. And that's sometimes a little harder to achieve with DSEC. And a lot of people think it's that stromal interface that's limiting the visual potential with the DSEC. DSEC graphs in this study were 13% or 2020 or better. One thing people worry about with DMACC is the level of endothelial cell loss, which is probably a little bit more than DSEC. And in this study, this person did a pretty good job because 31% is a pretty reasonable rate of endothelial cell loss initially after the surgery in the first month compared to 20% for the DSEC. So this was another study on long term outcomes after DMACC. And this involved 310 patients. And they had a 95% five-year graph survival. We don't have a lot of data beyond five years at this point just since it's such a new surgery. But they also showed 42% endothelial cell loss at one month. And that stayed really stable over the first five years. And they only had 44% endothelial cell loss. I'm freezing up, too. I'm really happy. Wasn't just the old guy who came from the computer. There we go. So this also came out this month from Mellis in Germany who did the first DMACC in 2006. And he followed this patient over the last 10 years. And he showed that this particular DMACC, which is very likely representative of the experience people are going to be having with DMACC, they had a 70% decrease in endothelial cell count over 10 years, which is similar to what's been published for DSEC. And this patient had better than 2020 visual acuity on most of their visits. They were usually between 2025 and 2017. So this shows the trend of transitioning to DMACC. And just for historical interest, here in 2005, only 4 and 1 half percent of transplants in the US were endothelial keratoplasty. So there's been a really rapid rise. This kind of shows now they're in 2015, there are more endothelial keratoplacies being done than penetrating. And you can see just over the last several years how quickly DMACC is taking over. Here we go again. So I have just some videos on the technique. So this is showing after we use a 3.2 millimeter temporal incision. And this is after stripping of the decimase membrane. So you have to make an inferior peripheral aerodotomy. We've been doing it with a vitrector. This isn't a fake patient. That's because we inject gas at the end of the surgery that stays there for a while. We use 20% SF6. These are a couple short videos of the tissue preps. And usually we stain the tissue before we lift it up. So this is pre-stripped tissue that's one of the big things that's allowed this surgery to be adopted is that eye banks now are pre-stripping the tissue. So they kind of lift it up most of the way and then lay it back down on the bed. So then here we're staining. And so this is after the initial stain. So it's a little bit hard to see. Can we turn these lights in the front off? It might be a little bit easier to see. So this is after we cut the tissue. And then we remove the rim of decimates around the central punch. And so then we're just lifting the tissue up here. And this one turns into a pretty tight scroll. And they always scroll with the endothelial side out. And then we restain it so it has a deep blue stain so you can see it in the anterior chamber after it's injected. You'll be able to see the scroll in a second here. You have to be really careful when you're removing the tri-pan blue because that graft is just floating around. And there are definitely cases where people have gotten it stuck to the Wexel with that endothelial side out. That's not ideal, obviously. So there you can see the graft over there in the corner. It's kind of close to the wek. And we're just removing the rest of the fluid from the notch there. So there are different kinds of injectors. Some people use plastic injectors, but we've been using a modified glass Jones tube. So then we draw that up into the Jones tube. You have to be really careful not to get air bubbles in there. And this is injecting the graft. So it's important to maintain a really shallow chamber when you're doing this so the graft stays in there. And there are also a number of people who have reported the graft shooting right back out when they remove the injector right out through that temporal incision. And so probably the most challenging part of DMACC surgery is getting that graft to unscroll, which every tissue acts differently. But what most people are doing is this tapping technique that uses fluid waves. And you have to constantly shallow the anterior chamber to help with unscrolling. These are the tissue that we're using is pre-stamped with an S-stamp that allows you to tell if it's endothelial sub aside in the correct orientation. You kind of have to keep the graft centered over your dysmetoreaxis at the same time. This one unscrolls fairly easily. Sometimes it's a lot more challenging than this. But it's a little bit difficult to see. The S-stamp is in the wrong orientation in this case. And so we had to flip the graft around so you can use a fluid burst to kind of flip the graft, which I did there, and then tap it back out into the correct orientation. It's a little difficult to see, but the S-stamp's now in the correct orientation there. And so then after that, we inject 20% SF6 underneath the graft to push it up against the stroma. And usually that dissolves over seven days or so, or five to seven days. So a few of the challenges, stripping the tissue is definitely one of the early limiting factors. And that's a lot easier now that iBanks are doing pre-stripped tissue. Because that was a big risk if you're trying to strip that decimates membrane in the OR right before your case that it can tear pretty easily. There's less predictability just because every tissue behaves really differently with DMEC. And some of these might take 40 minutes to get them to unscroll or be really difficult. Every anterior chamber's different. Some are really hard to shallow enough to unscroll the graft. The re-bubbling rate is higher with DMEC than VSec. And those rates are sometimes pretty high. And studies report between one and a half and 50% in some studies for early experience. And primary graft failure rate is probably also higher, especially with the initial experience. But this is actually the patient that was in the videos. So she had a detachment. And if it's over 30%, then usually it needs re-bubbling. And so the top OCT anterior segment OCT, here you can see that detachment there that's probably 45 or 50%. So that was seven days after then we did re-bubbling on this day. And this is her. This is her graft a few days later. It was nicely attached. And we saw her for post-op month one a couple of weeks ago. She was 2025 uncorrected with her suture still in. So she may end up close to 2020 uncorrected. So just a few things that are important in the early stages with DMEC shallowing. Having a patient that you can shallow the anterior chamber that has a small pupil using retro bulbar anesthesia or general anesthesia for the early cases. This is easier in fuchs dystrophy because it's easier to strip the tissue. And if you have strimmel tags, it can be really difficult to get these to attach well. And then picking donor tissue is also important. The pre-strip tissue from the eye bank is very beneficial. And some people only use donors between specific ages because they think the tissue behaves better. And some people only use 60 to 65 year old tissue or most people don't like tissue that's younger than 55 years old. And most people like to have an endothelial cell count that's 3000 or higher. So it's usually not a great option in patients that are post-patrectomy because you can't shallow the chamber very easily if they have glaucoma filters or tubes. It can be done. And some people are doing DMEC in these patients but there obviously are more risks of doing that kind of surgery. ACIOL is a problem since you're using that shallow chamber and the endothelium is rubbing all over the ACIOL. Hey, fake is a problem since that tissue can go right behind the pupil easily. And it's not good if they live at really high altitude. And we always ask patients about this if they're gonna be traveling up at 10,000 feet or something like that with that SF-6 gas. This is really cool stuff. I really love the fact that they're getting thinner and thinner and thinner than we're really just doing now. That's a good memory of the endothelial cells. Garrett Mellis would be very perturbed if you'd call him in German as he's Dutch. Oh, sorry about that, yeah. You kind of akin to calling me, you thought you'd grab some? Yeah, sorry. I think he practices in Germany partially. The second thing is there's an issue with the gas and hydro-filling acrylic lenses. So all that really ought to come in on that. Yeah, so just as a reminder, if you have these procedures done in a specific patient with a human-bag hydro-filling acrylic lens and you have to re-inject a lot of gas or air as we attached to that, there's chance for most of the patients actually to get in for a second. And if you plan, because I have, we've got our surgery, we're not for the... What if they usually revoke it? People mostly use air, they use SF-6. I think most people use air because they're doing it in the clinic, but some people will probably use SF-6. Some people use air primarily, though, and that's an option, too, for people that are gonna be at high altitude. No, we've mostly been doing it if they're edematous or we're concerned about a problem. It's really hard to see the tissue, so without the anterior segment OCT, it's really hard to tell if it's detached or anything. With the DSEC, you can often tell, but with DMACC tissue, it's so thin you can barely see the tissue and usually they still have a little bit of edema. But they recover very quickly after this. And we've had some combined FACO DMACCs that we've done now and some of those patients are, they're 20-20 uncorrected at one month after surgery. So the results in the visual recovery are very impressive. Two questions, why not do a YAG PI pre-op and second question? Has the disome stripping with no graft gone away entirely, that K-series of the idea? The just primary dysmetoreaxis. So that has not gone away, but I think the problem is then you're leaving the patient edematous for months and probably most people are not gonna be happy with that. You can do, some people do YAG PI's before, but I think we like the Traktor PI just because it's big and open and you don't want them to get a big pressure spike. Do you feel like in the developing world dysmetoreaxis with that graft is a reasonable option for patients with that other? Yeah, yeah, potentially. And in other countries, in other countries in Europe, especially they're doing quarter DMACC grafts where they do a dysmetoreaxis and they'll cut a single piece of tissue into four segments or two segments and just put that in the middle and then let the rest fill in with endothelial cells. But the concern I have about that though is you see that there's a pretty substantial rate of endothelial cell loss and it can even, in some studies, they even report problems with when there isn't a big graft put in there that they think that it's gonna fail earlier because there aren't enough endothelial cells left. So that'll be my concern with doing these quarter grafts is that they're gonna wear out a lot sooner, which may be okay for some patients, but. There's one patient at Moran that has a dysmetoreaxis and it took like four to six months for his central edema to go away. The procedure was done, he ended up about 20, 30. So, and I think they did, they did endothelial cell counts and it did decrease kind of paracentrally as his edema result. Are there certain indications for that? I mean, is it the sort of thing where PBK does better than Fuchs or, which is primary dysmetoreaxis? Well, probably, I mean, Fuchs would be probably the easiest since the decimates comes off so easily, I would think, but. Katherine Colby, who's like, she was at the University of Chicago, she's probably done the most in the country who went to a meeting with her and she, they have not seen any success in PBK just because they think that you toast it off the edema field. So, mainly doing for Fuchs and tons of discussion with patients that you can have really blurry vision for months and months and months. I think most people are, because these patients are often, they're 20, 40, some people are doing 20, 30 patients with DMEC now since the visual results are so good. I mean, I think, I've heard Mark Terry say he'll even consider doing like 20, 25 patients because they're, even if their acuity's not, not that bad, I think their quality of vision is pretty bad with the light scatter from the Goutte, but I would think that somebody who's 20, 25 is not gonna be very happy with that. Even 20, 40 or 20, 50, they're not gonna be very happy with that.